The art and science of winning physician support for Six Sigma change - Six Sigma

Physician Executive, Sept-Oct, 2003 by Walter Ettinger, Mark Van Kooy

Six Sigma is a process improvement methodology that is remarkably effective across many industries.

As hospitals face mounting regulatory burdens, calls for improved quality and safety, serious budget challenges and extraordinary capital requirements for infrastructure and new technology, many are implementing or considering Six Sigma to simultaneously improve clinical quality and reduce operating costs.

When deploying SIX Sigma, it's important to have strong buy-in and involvement of key stakeholders across the organization. Without acceptance by stakeholders of proposed improvement initiatives, failure is almost assured.

The physician relationship with hospitals is unique. Although physicians often are not employed by hospitals, they are critical drivers of hospital performance. Hospitals have limited influence over physicians given their independent status, technical expertise, political influence and, at times, different business objectives.

Physicians often complain about the difficulty of making improvements in hospitals. They may be skeptical of management's ability to deliver results, perceive meetings as a waste of time and see process improvement initiatives as endless--or as "flavors of the month" that will quickly pass.

Moreover, physicians perceive hospital improvement efforts largely as a way to reduce staff and services, while physicians want improvements in clinical quality.

The physician relationship with hospitals is unique in another way since physicians are simultaneously stakeholders and customers. They are stakeholders in that the quality of care they can provide is highly determined by how the hospital functions. Through medical staff committees, physicians greatly influence the operations of the organization.

On the other hand, as customers, physicians evaluate the hospital as a workplace and choose to practice in one system over another. When trying to enlist their support in change efforts, it is important to recognize this dual nature and address their needs in both roles.

Both physicians and hospital staff can bring destructive preconceptions with them when they try to collaborate on process improvement.

* Physicians may believe significant change is unlikely, that hospital managers are insensitive to the constraints on their time and that the only important goal is to save money.

* Management often feels that physicians veto initiatives without being involved, that they can circumvent institutional procedures to get what they want and that they are generally uninvolved unless an issue directly affects their practice.

* There is a sense that physicians undervalue the efforts of hospital managers and that there is no such thing as medical staff consensus.

Developing supporters from skeptics

The application of the Six Sigma performance improvement methodology can help bridge the chasm between the medical staff and management of a hospital.

Since it is highly quantitative, physicians find Six Sigma attractive and can appreciate the nuances of sampling, hypothesis testing and statistical relationships. The structured phases allow physicians to efficiently monitor the progress of a particular project.

Six Sigma projects are based on solid data that is carefully validated for accuracy. Such validation is necessary for physicians who are trained to be critical of the validity and reliability of data. They regularly evaluate clinical information in a precise manner, so inaccurate information destroys the credibility of improvement efforts.

Conversely, when data stands up to vigorous challenges by physicians, they become interested in understanding the data and its implications.

Finally, the Six Sigma methodology achieves lasting results. It explicitly acknowledges that without continuous monitoring and fundamental changes in systems and structures, problems will always recur and improvements will always deteriorate.

Physicians justifiably are skeptical of change initiatives that have not produced sustained improvements. The latter is a recurrent problem in many hospitals across the country.

Tools and techniques for physician buy-in

Since physicians are likely to be skeptical, how should they be introduced to Six Sigma? Physicians may be customers, stakeholders, sponsors, team members, process owners or champions. It is important to be clear about the level of participation needed and the role physicians should fill.

For example, it is usually unrealistic to expect--and unnecessary for physicians to attend--weekly team meetings. Instead, determine what is needed from physicians up front and how best to obtain it and get agreement on these points with physicians. Sometimes the need is simply for physicians to refrain from active opposition.

Other situations may require a decision or specific technical information. Careful planning can lead to efficient use of physician time and increase their support.

Six Sigma provides techniques for identifying the level of participation required. Teams can use tools such as Stakeholder Analysis and ARMI (Approver, Resource, Member, Interested Party analysis) to determine the level of participation needed from physicians. Think creatively.