Improving Patient Safety with Six Sigma: An Interview with Dr. Denise Remus, Chief Quality Officer of BayCare Health System

It's been no easy feat for health care organizations to juggle reducing costs with improving patient safety and care. It's been particularly difficult in light of the ever shifting changes that the industry now faces. Achieving greater operational excellence can go a long way in helping health care organizations to accomplish this task. In this Six Sigma & Process Excellence IQ interview, Dr. Denise Remus, chief quality officer of BayCare Health System, discusses how her organization is using Six Sigma to improve patient safety and stay on top of the growing health care industry demands.

How does Six Sigma provide a structured quality process for improving patient safety?

BayCare’s Quality Model (right; click on image to enlarge) provides the framework and direction for all quality measurement and improvement efforts. Six Sigma expanded existing quality improvement efforts by providing additional statistical methodologies and tools to support our processes and enhance our ability to apply our quality philosophy and process to business (operational and clinical) challenges.

You joined BayCare Health System as chief quality officer in 2007. What Six Sigma deployment strategy have you put in place to drive improved patient safety? How does this strategy compare to or build upon the program prior to your time at the organization?

In 2005, BayCare established the Six Sigma (SS) Department and began training Black Belts, Green Belts, Yellow Belts and Master Black Belts using external resources. Black Belts were trained in waves consisting of a two-year assignment to the SS Department; then transitioning to another role in the organization. In 2007, we contracted with the International Society of Six Sigma Professionals (ISSSP) and conducted an external evaluation to identify strengths and opportunities for improvement.

Their report identified multiple strengths including the comprehensive training program and strong leadership support. Several enhancements were proposed, and as a result, the program was restructured in 2008.

Key adjustments included:

• Changing the Department name to Performance Improvement (PI);
• Organizing all process improvement methodologies — DMAIC, Lean SS, DFSS, Workout, Plan-Do-Study-Act (PDSA) and others — under one umbrella;
• Assuming responsibility for training using internal resources;
• Creating dedicated, full-time positions for Black Belts and decentralizing them from health system-based roles to positions in the hospitals;
• Increasing focus on aligning projects to business needs;
• Enhancing project prioritization and selection process;
• And implementing new software to assist in managing project data and information.

What is BayCare’s strategy for selecting projects that will have the most impact on patients’ safety?

BayCare’s performance improvement projects are aligned with the organization’s quality and safety goals, specifically key performance indicators, quality and safety goals, team award goals, strategic directions and department quality goals. Project ideas may be submitted by any team member using our intranet-based tool. Part of the submission process is to identify which goal(s) the project is proposed to address. Project ideas are then reviewed by Performance Improvement managers and prioritized by members of our Quality Leadership Task Force.

Please tell us about your most recent Six Sigma initiatives that have been the most successful in helping to improve quality and patient safety. What impact did they have on patients and the organization? Why were they so successful?

BayCare celebrates our quality improvement efforts annually at our Quality Sharing Day. Quality Sharing Day celebrates BayCare’s commitment to quality and is an opportunity for team members to learn more about best practices that have been implemented elsewhere in the health system that may help achieve higher performance in their individual departments. In 2009, Quality Sharing Day attracted a record number of team members and participants as approximately 450 registered to see the 67 projects. Twelve of the project teams presented summaries of their successful process improvements.

For the first time in 2009, we implemented the BayCare Quality Award for the project that has the greatest impact on quality; best supports BayCare’s mission to improve the health of all we serve through community-based health care services that set the standard for high-quality, compassionate care; and best supports BayCare’s values of trust, respect and dignity and reflects our responsibility to achieve health care excellence for our communities.

The first BayCare Quality Award was presented to the Morton Plant Hospital "Indigent Diabetic After Care" DFSS (Design for Six Sigma) project team. The objectives were to ensure consistent follow-up care for indigent diabetic patients discharged from Morton Plant Hospital, to improve patient outcomes including management of diabetes, reduced ER utilization and reduced hospitalizations through coordination of care and improved access to key services. The project exceeded all projected goals. The number of indigent diabetic patients who attended their first follow-up appointment increased significantly and there was a considerable reduction in the 30-day re-admission rate.

What have been some of the trickiest initiatives to implement and why? What has BayCare learned from these experiences?

The challenges facing BayCare’s quality improvement efforts are similar to other large community-based, multi-hospital, not-for-profit health care systems. Improvement opportunities that cross multiple departments, clinical settings, involve multiple processes or challenge cultural norms require careful planning and coordination. Six Sigma methodologies provide a structured, disciplined approach to address complex problems and create sustainable solutions.

Six Sigma provides tools to define the problem with a focus on the "voice of the customer"; map out current processes, potential failure modes, defects and waste; define and analyze measures; test and implement solutions; and monitor for success. Over the years, we’ve integrated concepts of change management, particularly creating a sense of urgency, and focused more on the need to fully engage Champions and process owners in leading team activities, removing barriers and ensuring access to sufficient resources. The Black Belt is the team facilitator and expert in process improvement but the problem and solutions must be owned by the team for success to be achieved.

How will BayCare's Six Sigma program continue to evolve in order to further address quality and patient safety in the future?

Health care is under considerable pressure to improve quality and reduce costs. The implementation of high-tech solutions such as electronic medical records is transforming the way we provide care. In this rapidly changing environment, understanding and improving our processes is more important than ever.

BayCare is committed to improving the health of all we serve, but we have to challenge the "status quo." We must continue to leverage all tools within our performance improvement toolkit, increase the pace of improvements, and ensure we can sustain the benefits achieved. It’s critical we evaluate the needs of our organization against the benefits provided by our Performance Improvement structure and evolve as needed to remain effective and efficient. Six Sigma training remains a critical component as we move toward the goal of all team members achieving an understanding of the importance of process improvements.

Interview by Genna Weiss