A Six Sigma Black Belt gets a personal tour of health care inefficiencies when his father enters the hospital. He applies his quality-control experience to pinpoint the source of the problems.
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| Peter J. Sherman |
We all read and hear about how wasteful the U.S. health care system is, but what exactly does this mean? Unnecessary tests and procedures? Administrative red tape? Overpriced pharmaceuticals? Where is the waste? In September 2007, I received at least partial answers to these questions when my father entered the hospital.
Our Hospital Experience
My father, who is 84 years old, was admitted to the emergency department of our local hospital with extremely low blood pressure and pulse rate. It’s my job to coordinate and attend his physician visits, order prescription refills for all 13 of his medications, perform quality checks on the weekly pill box, take his daily blood pressure and pulse readings, administer his monthly B-12 injections, manage all his Medicare expenses and so on. So when he entered the hospital, I gave his medication table, blood pressure and heart pulse logs, and all my notes to the attending ED nurse.
I am a Certified Six Sigma Black Belt, and I have applied the discipline of thorough quality assurance and quality control processes to help my father enjoy steady, reliable and predictable health. During the hospital stay, three episodes occurred that might, if gone unchecked, have resulted in significant cost overruns and adversely affected my father’s health:
Episode 1. After my father was moved to the regular part of the hospital, the on-duty nurse came by to review his medications. The questions she asked made it clear she had not seen the medication log the ED nurse put into my father’s three-ring medical binder. The on-duty nurse and I then painstakingly compared the cardiologist’s notes with my medication log to arrive at the right medications. But even after all this, the on-duty nurse inadvertently missed the medication my father takes for stress and anxiety. Had I not been there to monitor the process, who knows what medications my father would have taken, and how his heart condition would reacted?
Episode 2. On Friday at 10 a.m., my father’s nurse called the transport technician to move my father down to the cardiogram room. She gave specific, written instructions that he was to have an echocardiogram and a renal ultrasound. After the technician completed the echocardiogram at around 10:45 a.m., she ordered the transport technician to take my father back up to his room. I explained that my father was supposed to have both procedures. The transport technician said “OK,” and moved my father to the ultrasound department. The ultrasound technician told us we were lucky to have arrived before 11 a.m. because if not, we would have had to wait until Monday to complete the procedure. This would have meant two additional nights in the hospital, costing an extra $1,750. The technician went on to complete a kidney Doppler echogram—not the test the cardiologist had ordered. A kidney Doppler is a more detailed kidney procedural analysis that costs $959.75. At the time, my father and I were unaware of this.
Episode 3. After the attending technician completed the kidney Doppler echogram, she wheeled my father to the radiology department to perform a renal ultrasound procedure. The attending technician examined the charts and instructions for nearly 10 minutes, and then called us in. She was unclear why a renal ultrasound had been ordered since my father just had a kidney Doppler echogram performed. I told the technician I remembered hearing that the cardiologist wanted to see if the arteries in the kidney might be clogged and thus ordered a renal ultrasound. Nevertheless, she began to prepare my father for the renal ultrasound—a procedure that costs $600. I recommended to the technician that she contact the cardiologist to confirm before proceeding. She did and was advised not to proceed since the kidney Doppler had already been performed.
The total cost of my father’s four-day hospital stay was $6,684.75. The extra cost of these three episodes could have been an additional $2,709.75 and possibly some adverse health effects.
Analysis
I did not feel the hospital nurse was intentionally skipping the medicine charts. Nor was the technician purposely delaying the second test to force my father to stay an extra two nights. And the renal Doppler technician was not intentionally ordering an extra test. It was simply a breakdown in communication and process.
A close examination of the hospital stay reveals, first of all, that all of the episodes are process related—not a personnel issue (understaffing) nor a technology issue (poor functioning equipment, lack of technology). Second, all the episodes reflected breakdowns in quality control. In other words, they were more reactive in nature; discovered through inspection or customer complaints. Third, all episodes’ outcomes were easily within the hospital’s ability to control. (See figure 1 below for a summary.)
Faulty processes upstream have a tendency to create bottlenecks and costly gaps downstream. For example, the on-duty nurse was not aware that the complete list of my father’s medications had been inserted into the three-ring binder by the emergency department nurse the day before. In another example, the transport worker probably never realized how much incremental cost ($1,750 for two extra nights in the hospital) she would have caused by returning my father to his hospital room after the echocardiogram instead of performing both tests back to back. Lastly, if the ultrasound technician had the opportunity to see the end-to-end process, she would have realized that a renal ultrasound effectively duplicates the kidney Doppler echogram my father had just received.
The key takeaway from this simple analysis is that these issues could easily be corrected through cost-effective process improvements such as improved methods and procedures, regular training, and clarity of roles and responsibilities. From my own experience in quality and process improvement as a Six Sigma Black Belt, I have found that 85 percent of errors and mistakes are process related. This is significant because process-related issues encourage employees to more freely raise issues or problems. Equally important, process-related issues generally require less capital and have a high ROI.
Building Quality into the Process
The magnitude of waste in our health care system is staggering. Waste comes in the form of duplication, rework, lack of consistency, lack of supplies, waste of resources and money, overuse of antibiotics in children with ear infections, underuse of mammograms, and so forth. According to Sister Mary Jean Ryan, president and CEO of SSM Health Care in St. Louis, “I think there’s still 40 percent waste in the system, and it is wasted time, it is wasted energy. It wastes people’s creativity, their innovation. It wastes everything about the human person. That could possibly be the worst waste. People get so dragged down or pulled into this. It’s very demoralizing.” (See Louis M. Savary and Clare Crawford-Mason, “The Nun and the Bureaucrat—How They Found an Unlikely Cure for America’s Sick Hospitals,” CC-M Productions Inc., 2006.)
I see ample opportunities to leverage a variety of proven, cost-effective quality practices for building quality into the process. These include:
Quality circles. Started in Japan during the early 1960s, quality circles are grass-roots, volunteer efforts by small groups of workers trying to improve workplace conditions: safety, product design, production processes. Quality circles have the advantage of continuity: The circle remains intact from project to project.
Kaizen. Japanese quality circles have evolved into kaizen, or continuous improvement. A kaizen event is a dedicated and concerted effort by everyone (line supervisors, employees and management) involved in a process to improve an area of the business. The principle of kaizen is that the person doing the job has the most knowledge about the requirements and how to improve it. Kaizen events generally last only two days. Most are small in scale, low in cost and relatively low tech.
Six Sigma or lean practices. Originating out of Motorola in the mid-’80s, Six Sigma is a customer-centric, problem-solving methodology supported by powerful statistical tools. The chief goal is to reduce variation in a process to make it more stable and predictable—achieving a Six Sigma level of performance translates into 99.9997 percent error-free process (see figure 2 below). A variation of Six Sigma is known as lean, which focuses on reducing waste and streamlining processes.
Hospitals are fast-paced and dynamic work environments that are often stressful and involve long hours. Lives are literally at stake. Seamless handoffs from one department to another or one shift to the next shift are critical to achieving steady, reliable and predictable outcomes. Based on my experience at the hospital and background in quality and process improvement, the central issues appeared to be more lack of communication and breakdowns in the process—not understaffing, improper staffing or lack of technology. Process issues can generally be evaluated and resolved quickly and cost effectively through techniques such as quality circles, kaizen approaches or even Six Sigma, which build quality into the process. As one of the largest components of our GDP, the U.S. health care industry is too critical to America’s future prosperity for us to allow it to fail.
Peter J. Sherman is lead instructor at Emory University’s Six Sigma Certification Program, Atlanta.
Figure 1. Issues We Encountered at the Hospital
| No. | Episode | Type Issue (People, Technology or Process) |
Quality Assurance vs. Quality Control |
Controllable or Uncontrollable | Potential Impact |
| 1 | Not reviewing medical binder for prescription medications | Process | QC | Controllable | Adverse health implications; lawsuits |
| 2 | Not performing two procedures back to back to reduce time | Process | QC | Controllable | Wasted time in hospital; incremental costs; inconvenience for patient |
| 3 | Lack of follow-up on questionable procedures | Process | QC | Controllable | Extra cost for hospital and patient; wasted time on uncecessary procedure |
Figure 2. Key U.S. Medical Statistics for Quality: Reality versus Potential
The following statistics show the differences between the current reality of surgical deaths and faulty prescriptions when compared to what is possible at Six Sigma levels of quality.
| Category | Current Status | Six Sigma Level (99.997% Error Free) |
| Annual Surgical Deaths | 98,000 | 98 |
| Annual Incorrect Prescriptions | 150,000,000 | 9,000 |
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