Nearly two years ago, Virtua Health adopted six sigma to achieve goals in the organization's improvement program, known as the STAR initiative. We are using six sigma to ensure better financial performance, increase productivity and measurably improve patient safety and clinical quality.
Virtua Health spends about $1.5 million a year on its six sigma program. We have three master black belts (including one physician) and six black belts, all working only on six sigma projects, and 21 green belts doing six sigma part-time. Another 21 green belts will be trained this year.
Through a structured, five-phase process in six sigma known as DMAIC (Define, Measure, Analyze, Improve and Control) and the use of data tools and change-management techniques, providers are able to prevent adverse medical events and reduce the defects per million opportunities (DPMO) to just 3.4.
One of the ways Virtua is using six sigma involves prevention of infrequent but serious injuries from medication errors associated with anticoagulants, chemotherapy and the infusion pump.
The Oncology Nurse Practice Committee documented a variety of processes in delivering chemotherapy to patients in the hospitals. In attempting to judge best practice, errors in chemotherapy were assessed.
The baseline data collected from our risk management and pharmacy clarification systems in 2001 have yielded a 0.6% error rate in five distinct categories: prescribing, transcribing, dispensing, administering and monitoring.
Using Pareto analysis, we found that 80% of the errors were related to prescribing and dispensing medication.
We established a multidisciplinary team consisting of nursing, pharmacy and physician champions to utilize the six sigma methodology for improvement strategies. Tools we've used are:
- 15 Words to establish the goals and expected outcomes.
- Elevator speeches to communicate the outcomes and reasons for the project to staff and patients.
- Stakeholders analysis and role definition to identify who is involved in the process and the phases of DMAIC.
- Threat opportunity matrix to determine the importance of applying resources and focusing on chemo errors.
- Process flow charts to demonstrate the complexity of the chemotherapy delivery system. Variations in practices were clearly identified in the various hospital divisions.
Even system communication failures were revealed. For example, nursing process flow included the "faxing of orders to pharmacy," when in fact the pharmacy had recently mandated that only original orders were to be accepted for chemotherapy agents.
We also are able to link the process flow charts back to the errors and determine which practices have reduced errors. For example, one division has the nurses go directly to the pharmacy to pick up doses of chemo, where a check between nursing and pharmacy takes place.
- L2 spreadsheet to calculate Z scores, i.e., the number of "sigmas" (standard deviations) between the process output average and the closest specification limit. With Z scores, the higher the better. Virtua has demonstrated a system-wide Z score of 3.86. The chemotherapy dispensing process had a better Z score at 4.10.
- Cause-and-effect diagram to identify the "X" in the project. Examples include use of a standardized order sheet and a dedicated chemo unit. An interesting finding was that one error in calculating an infusion rate was due to a nurse misreading a Taxol bottle. The IV bottle has two volume grades, one for the bottle standing upright and one for the bottle hanging.
Though still in the early phases of the chemotherapy project, we are already gaining valuable insights and beginning to implement positive changes.
One lesson we have learned is that, as is probably the case with most providers, medical errors are inherently underreported and our methods for capturing this information have been inadequate. With heightened awareness from the project and a clear definition of error and improved data collection methods, we are actually experiencing a higher rate of error (2.5%) in the first quarter 2002.
Since the science behind six sigma is evidence-based, physicians seem to respond favorably to the approach. The process affords clinicians the ability to focus on specific areas for improvement and then monitor changes through control tools.
Walter Ettinger Jr., M.D., is executive vice president of Virtua Health, a four-hospital system based in Marlton, N.J. He has an MBA from Wake Forest University. Jane Slaterbeck, assistant vice president of Programs of Excellence at Virtua, is a registered nurse with an MBA from Temple University.
