On November 16, 1960, at 3:00 A.M., I was being strangled by my umbilical cord. A doctor asked how my mother was feeling. She explained that she was feeling better after some minor discomfort she had been experiencing. Fortunately, the doctor decided to check my fetal heartbeat in utero just in case. The doctor determined that my heartbeat was extremely slow and that I was about to die. The doctor rushed my mother to the operating room for an emergency cesarean section. My life was saved. I am thankful that the system worked in this instance. Many other babies have not been as fortunate. In fact, witnessing the preventable deaths of two babies was so painful that it triggered a career change and a passion to improve healthcare processes and systems for one of this book’s coauthors.
Fast forward 20 years: I was an intern in the engine room of a commercial cargo ship in the summer of 1980. In a three-month period, almost every piece of equipment had failed in that engine room. We even had a major fire. I felt that there had to be a better way to maintain ships such as mine to at least diminish the seemingly never-ending failures. That experience brought me to the University of Michigan to better understand reliability and maintenance of ship machinery and how to improve them.
Then, at a maintenance conference, I heard about Six Sigma, which was developed by a reliability engineer. After studying it further and implementing it to improve the availability of shipyard cranes, I realized the power of Six Sigma. Yes, I was aware of most of its tools before. However, using those tools within the discipline of the Six Sigma roadmap, combined with the soft skills of change management and project management, brought much more powerful, sustainable results. This was when Lean, Six Sigma, and Constraints Management were like competing professional sports teams where each practitioner believed that his or her method was the best.
Then I saw a trend to integrate Lean and Six Sigma. A growing number of practitioners recognized that the methodologies were complementary. The U.S. Navy provided a research grant to my team at the University of New Orleans to pioneer Lean Six Sigma integration in shipbuilding at Northrop Grumman Ship Systems. The success of that project gave birth to NOVACES, which was founded by the project’s researchers. Next, we were invited to the core contractor team to truly integrate Constraints Management with Lean Six Sigma in the largest supply-chain network in the world: the U.S. Naval Aviation Enterprise. The synergy between the methodologies was even more apparent than the differences. Subsequently, we had the opportunity to adopt and apply the integrated approach first to Navy hospitals and clinics and then to other health systems worldwide. Our passion to improve healthcare performance brought us together to write this book. Our diverse backgrounds allowed us to bring the latest methodologies to healthcare from various perspectives. In this journey, my path first crossed that of coauthor Dan Chauncey. Here is his story:
After more than 10 years in law enforcement, I found myself serving as a trainer and quality-assurance leader for the U.S. Air Force Corrections Facility in Denver, Colorado. In this role, I had the opportunity to have my position audited by the local personnel office. I was absolutely astonished to find that the auditor assessed that all the effort I put into my long workdays was worth only one-half of a full-time equivalent (FTE). I immediately balked at this finding and asked for help in understanding how such a conclusion was reached. I was amazed that once I understood the rules and operational definitions, I could not refute the findings. I was so intrigued that I made the decision to change careers and transferred to the Air Force Management Engineering Agency to work on performance improvement and staffing analysis.
After attending the Air Force training course in Biloxi, Mississippi, I relocated to Albuquerque, New Mexico, to work within the Air Force security and law enforcement community. One of the things I realized was that the approach being applied required 26 months to complete and not a single one had been approved and implemented in three years. In my first meeting with my new commanding officer, I asked why we even bother when we get results such as these. Luckily, he had an open mind and asked if I had a solution. I stated that I “would get some smart cops (subject-matter experts) in a room and figure out how to improve the way the work was done and then cost it out.” At the time, I viewed this as common sense and knew virtually nothing about facilitation and teams. After the commanding officer told me to “run with it,” I started learning about facilitation and teams—quickly!
The first project I lead thereafter was completed within 13 months. Not only was it completed in half the time of the average project, but it also actually was approved and implemented immediately and even resulted in significant savings. The project’s success led to my transfer to San Antonio, Texas, to document and standardize the approach across the Air Force. After publishing the Air Force Regulation, I was directed to develop a curriculum and begin training practitioners across the Air Force management engineering community. I ran the training program for around two years, and then I was assigned to be the quality advisor to the Air Force Management Engineering Agency leadership team. This was when Total Quality Management was emerging within the Air Force. It was at an extensive training program at the Air Force Quality Institute (which since has been disbanded) that I was first really exposed to the quality profession.
My next career transition was to spend three years as the manager of management engineering for the claims-processing center of the health insurance agency Humana. This experience gave me an opportunity to hone some data-analysis skills in a healthcare setting. After Humana, I moved to the University Health System as a quality trainer. My role was to develop training for all employees on the systems approach to process improvement. After 18 months of training delivery, it became apparent to me that training was not enough and that my team was not receiving any return on the investment. I submitted a plan to change course and was promoted to a newly developed position of Director of Performance Improvement and Organizational Development. My plan included the deployment of Six Sigma throughout the system and my attendance of Black Belt training. However, it quickly became apparent that a proper deployment of Six Sigma did not have the leadership support that was necessary for it to succeed.
I decided to move into consulting, where I reasoned that there would be more support of leadership. Since consultants are hired for the explicit purpose of improving client organizations, implicit in my role would be the vested support of the managers who brought me in and wanted a change from the status quo. I wound up working at Rath and Strong, the oldest continuously operating management consulting firm in the United States. I began working with a team of Master Black Belts deploying Six Sigma—later expanding to include Lean—to Fortune 500 companies. What a growth opportunity for me. I was exposed to virtually every industry, working with such companies as Johnson & Johnson, Pfizer, Alstom, Schneider Electric, and Aon not only in the United States but also in France, Great Britain, and Bermuda. It was this role, along with my healthcare experience, that brought me to NOVACES.
At NOVACES, I was exposed to Constraints Management and began to understand that the best way to drive improvement was to apply the right tool at the right time to the right problem—but always from a systems perspective. The natural extension of this principle was the development of SystemCPI and the integrated approach to performance improvement. When I look back at my younger days, I believe that my time in law enforcement, where I was trained to handle challenging situations and people—including certification as a hostage negotiator—balanced with my time in management engineering—learning the math—has positioned me well for my current role. Even my education—a master of arts in resource development and a master of business administration—contributed to a balance between hard and soft skills; a firm grasp of the balance between costs and benefits, theory and reality, and data and people; and a strong grounding in real-world practicality. Now I go to work every day (luckily some days it is right down the hall to my home office) knowing that I can contribute to making a difference in the delivery of healthcare not only in the United States but across the world.
When Dan joined NOVACES in 2006, he was passionate about Six Sigma—he still is, but he greatly appreciates its synergies with other methodologies. During the course of writing this book, we had lively debates about how to best integrate Constraints Management with Lean, Six Sigma, and other points of view to provide the best value for performance improvement in healthcare. Working on both the hospital and insurance sides of the system has given him a unique perspective and an ability to understand the highly complex relationship among people and processes in healthcare. Along the way, in 2007, Vickie Kamataris joined us. Here is her story:
I became a nurse because I wanted to make a difference. In early 1996, I was working as the patient care coordinator in a large family birth center in a large Midwestern city. My staff was well trained, disciplined, and dedicated. I ran a “tight ship” and was constantly benchmarking and seeking ways to improve performance and service to our customers. Still, bad things happened despite the best people working extraordinarily hard. Two bad outcomes occurred within a short period of time. In both cases, no one was to blame. Procedure was followed. No one did anything wrong. Still, two babies died, and I was stunned.
During this time, my husband was coming home from work every day complaining about the “latest, next best thing” at General Electric. At that time, he was manager of one of GE’s major aircraft engine lines. I will never forget looking over his shoulder and reading the binder he had laid out on the table. Still, even after so many years, I get goose bumps. I knew that Six Sigma could change the world. My world! I determined right then to find a way to get my hands on this methodology and apply it to healthcare processes.
I resigned from the hospital and took a position at GE as an independently contracted occupational health nurse. My objective was to learn as much about Six Sigma as possible. As a contractor, I was not eligible for training. So I watched and learned, asked questions, ... and waited. When, six months later the human resources manager came to me and asked what it would take for me to accept a GE position as the site occupational health and safety manager, my response did not surprise him. He laughed when I said, “Six Sigma training!” I was enrolled in the next wave of Green Belt training. My objective was to become certified as a Green Belt and return to the hospital with this powerful new tool.
This was early in GE’s Six Sigma deployment. It was the second wave of Green Belts trained at the site. All my fellow students were managers and engineers. My Black Belt trainers were engineers. Everyone (except me) agreed that Six Sigma did not apply to transactional processes and certainly not to health and safety. It was agreed that I would need to complete a “real” training project in addition to the one I had submitted for approval. My certification project was intended to reduce the cost of handling scrap parts from one of the engine lines. The objective of my pet project was to reduce the incidence of upper extremity repetitive-stress injuries (RSI) in a rework shop.
I knew that the rework shop had a high incidence of upper extremity RSI because I had treated these injuries in the clinic, managed the medical care and disability of those who suffered from them, and reported the cost associated with lost work days and worker’s compensation. I knew that the company had invested in every conceivable ergonomic improvement, including vacuum lift devices, vibration-dampened tools, and ergonomically designed tables and chairs. I had implemented exercise and nutritional programs. Still, the incidence of RSI continued to increase in this one area of the facility. I did not believe that it was a function of demographics alone (mostly women over age 50).
The engine scrap project was a success. I learned to use the tools and improved the process, saving a modest amount of money. The RSI project identified a previously unsuspected cause for RSI, and once it was corrected, the incidence of new cases and aggravation of existing cases decreased dramatically, with savings estimated at more than $170,000 per year. Soon after the project was entered into the company database, I was contacted by the medical director of GE’s Corporate Healthcare and Medical Programs and invited to showcase my project at the annual medical conference in Toronto. The project was recognized as an innovation (the first healthcare-related project at GE) and a best practice (using Six Sigma to solve a clinical problem). In September, I was invited to join the corporate team in Fairfield as a project leader. I would create a balanced scorecard for GE’s global network of more than 200 occupational health clinics and lead nurses and physicians to use Six Sigma to improve compliance, quality, and patient satisfaction while reducing costs.
My professional vision was to translate Six Sigma and balanced scorecard and, later, other quality tools and methods for application to healthcare processes and problems. I led clinical teams to improve performance and meet corporate objectives. I was certified as a Black Belt and then a Master Black Belt and promoted to quality leader for corporate healthcare and medical programs. In this role, I had the opportunity to present at national and international conferences, teaching nurses and other healthcare professionals beyond GE what I had learned. I created tools and templates for healthcare, including a “Define-Measure-Analyze-Improve-Control (DMAIC) in a Box” that would allow contracted nurses to improve performance without formal training. Constantly researching emerging trends and tools, I was inspired by the work being done at Virginia Mason to add Lean to my toolset well before the method was accepted by the company at large. Healthcare was beginning to see the light! In 2007, I saw my advancing career at GE evolving farther and farther away from clinical healthcare. Nursing is not what I do—it’s who I am. The time had come for me to take the skills and knowledge I had acquired back to the hospital and clinic, pharmacy, and lab. The means by which to do this in the broadest possible sense was as a consultant.
As a NOVACES consultant, I have had the opportunity to learn from colleagues with varied backgrounds and areas of expertise to use Constraints Management, TRIZ (which is a Russian acronym for Teoriya Resheniya Izobretatelskikh Zadatch, commonly known as the Theory of Inventive Problem Solving), and other methods to solve healthcare problems in innovative and unusual ways. I have led performance-improvement teams in military and civilian hospitals and health systems in the United States and abroad. I have trained and mentored healthcare practitioners from cooks to surgeons and touched virtually every healthcare process. I have had the opportunity to lead deployments, projects, and events from the Bureau of Medicine in Washington, DC, to Anadolu in Gebze, Turkey. I am able ... every day ... to make a difference.
And Vickie indeed makes a big difference with her passion, dedication, and unwillingness to rest on her laurels. Even after she was a pioneer, applying Six Sigma to healthcare when even GE did not believe it could be done, she continues to have the courage to try new tools and push the methodology farther than it has ever gone before. She was convinced to join the Healthcare Division of NOVACES because it allowed her an unparalleled opportunity to achieve real clinical and organizational improvements for patients. Today, Vickie works closely with Charles Mount, a veteran of not only the U.S. Navy but also of quality improvement in healthcare. Here is his story:
While stationed at the Naval School of Health Sciences in Bethesda, Maryland, I had an outstanding opportunity to teach the Navy Medicine’s leadership and management education and training (LMET) curriculum for midlevel healthcare professionals in Navy hospitals throughout the nation. It was a two-week, competency-based course taught on the road at the hospitals and medical centers, training newly promoted department heads, division officers, and special assistants in how to lead and manage highly skilled experts effectively in healthcare. During a coffee break, my boss, a senior Navy captain, rushed upstairs and yelled, “Charles, we need a TQM [Total Quality Management] bibliography on Dr. Deming’s work for the senior class, and we need it now!”
While I had heard about TQM and W. Edwards Deming, at that time, I had only peripheral knowledge of his work. I asked the captain where he thought I should start. He quickly replied, “Call his office at George Washington University and see if you can talk with him.” I called George Washington University and was unable to actually talk with Dr. Deming, but I did talk with his administrative assistant, who sent me his bibliography. Little did I realize the extraordinary journey I had embarked on in process improvement.
At the time, the Navy used the term Total Quality Management (TQM) synonymously with Continuous Process Improvement. (The Chief of Naval Operations later changed it to Total Quality Leadership to highlight the Navy’s emphasis on leadership rather than management.) On transfer to the Naval Medical Center in San Diego (NMCSD), the Navy’s largest healthcare system, I was appointed as the special assistant for TQM to the commanding officer, Rear Admiral Robert Halder. Dr. Halder was a highly respected admiral, physician, and leader throughout the Navy. My first goal at Dr. Halder’s command was to learn as much as I could about Continuous Process Improvement (CPI) and to do so as quickly as possible. The admiral believed in the immersion style of learning and sent me to six TQL-CPI courses in seven weeks. I was literally drenched in all the tools, methods, concepts, and skills of CPI, including the Hospital Corporation of America’s model of find-organize-clarify-understand-select (FOCUS)–plan-do-check-act (PDCA).
Dr. Halder fully understood the power of CPI, having just returned from attending the Navy Surgeon General’s conference on CPI for all his admirals. During that conference, the audience heard a presentation by Dr. Donald Berwick regarding National Demonstration Project (NDP) efforts to implement the industrial tools of TQM in healthcare. What Dr. Halder heard resonated with his style of medical practice. Additionally, he believed wholeheartedly in the top-down approach at NMCSD and wanted to accelerate the implementation of TQM himself. In order to accomplish this effectively, he asked me to quickly meet with San Diego area hospitals and create a coalition with which he could then bring Dr. Berwick’s presentation to San Diego. I met with the performance-improvement coordinators at two large medical centers and created the Southern California Coalition for Improving Healthcare Quality.
I served as president of the Southern California Coalition for Improving Healthcare Quality for six years. At its peak, 24 hospitals from San Diego and Orange County attended its meetings and conferences. The coalition sponsored numerous healthcare conferences and workshops, all with one primary intent: to help the hospitals and their medical, nursing, administrative, and allied staff implement the principles and practices of CPI. Thus the coalition became a support group, a mentoring team, and an accelerator for healthcare’s deployment of CPI throughout San Diego. Coincidentally, on my arrival in San Diego, I was introduced to the San Diego Deming User Group (DUG). The group had been started by Dr. Deming himself when he was asked to assist the North Island Naval Rework Facility, which repaired the engines on the Navy’s fighter jets. Dr. Deming contributed his own money to create the group and conducted the first meetings.
Starting as the education director, I later became vice president and then president of this group. The DUG also sponsored numerous CPI training programs and conferences and enabled many members to attend Dr. Deming’s famous four-day conferences. With the combination of the coalition and the DUG, San Diego’s healthcare system quickly embraced CPI and saw a remarkable impact on its hospitals’ delivery of healthcare. At NMCSD, the results included over 50 process action teams and savings well into the millions of dollars.
As my knowledge and involvement in CPI grew, so did my career in Navy Medicine. While stationed at the Navy Bureau of Medicine and Surgery (BUMED) as a captain, I saw the impact of process improvement on headquarters-level policy development and execution firsthand. It is one thing for a hospital CEO or a Navy senior executive to say that he or she wants CPI to be implemented; it is far different to create the push, the drive, or the motivation for it when the hospital staff is overwhelmed with the everyday work of taking care of patients. That drive or powerful motivation must come from on high. If the executive leadership doesn’t create the buy-in and make it important, no one else will either.
BUMED understood its role and responsibility in the top-down leadership for Navy Medicine. This later served me well as I progressed to executive officer and then commanding officer in Navy Medicine. It became my responsibility to walk the talk and use my own top-down approach to accelerate CPI throughout my commands. I was keenly aware that the moment I stopped leading the effort—the moment I downplayed its importance—every physician, registered nurse, technician, and administrator on my staff would know that my words had been hollow. Fortunately, I was true to my words, and the staff expanded their CPI efforts to as many areas as possible. The results were impressive: Processing of administrative work was reduced by 50 percent, turnaround times for implementing specialty work was reduced by at least 45 percent, and orientation of new staff was accelerated by at least 35 percent, thus enabling them to begin their work far sooner than previously. I learned firsthand never to underestimate the power of senior leadership in leading anything that is important. The staff wants to do what is right, especially as it affects their work and their patients. Staff members need to know that their leader cares and will take the time, effort, and commitment to actually be a leader. My experience of 44 years in healthcare has been that in the eyes of employees, anything less is unacceptable!
As I transitioned to private-sector healthcare executive leadership, everything that I learned while in government became even more pronounced. Everyone is short on time: physicians, nursing staff, technicians, and administrators alike. Everyone is overloaded with work responsibilities. It was my job as a senior executive, working with other members of the executive suite, to not waste people’s time. Serving as a champion for a performance-improvement team takes concentrated time, effort, and discipline. I knew that teams would not have unlimited time to use the tools to solve the tough problems they had been handed. It became my job to maximize whatever time was available—to focus the team’s efforts as diligently as possible. What I learned from the private sector is that instilling teamwork, developing a common goal, and using the right people from the start are my job. As a senior executive, I could not delegate that work. Nor did I want to. The team’s success was my success, and vice versa.
NOVACES has taken me farther than I ever dreamed. My recent work has enabled me to expand my skills and knowledge to fully understand the rigor and discipline of performance improvement, especially in the areas of Lean, Six Sigma, and Constraints Management. Improving healthcare’s processes incrementally may be fine for solving the easy problems. Tackling the difficult ones, however, requires the diligent use of all three of these methodologies in a highly refined manner that leads to long-term sustainment.
One of several great lessons I have learned from my early days in TQM is that sustainment must be pursued vigorously. In other words, never let up! Another equally important lesson is about the use of data. Physicians, nurses, administrators, technicians, and executive leaders all use data to make decisions in their daily work. Along with my fellow colleagues, I, too, must continually use data to solve the tough, stubborn problems that we all face in today’s healthcare environment. To not treat data with the importance it is due reduces my chances of success. In summary, what I’ve witnessed is the tremendous impact we can have by using the tools and methods of process improvement on our hospitals, patients and their families, our staff, and the entire healthcare community.
Captain Charles Mount shares his invaluable point of view based on his unique experience in military and civilian healthcare. Having spent almost four decades in military healthcare, Charles served at all four of Navy Medicine’s large regional medical centers as the commanding officer of the Navy’s Medical Sciences Training Command before he went on to become a for-profit hospital’s chief nursing officer. His unrelenting optimism and positive energy combines with his leadership savvy to tackle the problems plaguing healthcare systems effectively.
In the course of writing this book, each of us has been a patient more than once. We have observed the vast numbers of inefficiencies, bottlenecks, and mistakes and the huge amounts of waste as both patients and practitioners. Every doctor, nurse, technician, administrator, and staff member is a patient at some point. Every year when health insurance renewal time comes, we all continue to be frustrated with rising costs and diminishing benefits, from individual consumers to small business owners and large corporations. There are few issues that touch so many lives as the importance of quality healthcare.
We are all on the same boat. The state of healthcare today is not unlike the engine room of that cargo ship I was aboard over 30 years ago, where everything was breaking down. Putting out the fire is no longer enough, for each spark alights a new blaze. It does not have to be this way. Proven tools and methods are now available to attack root causes of systemic problems rather than putting Band-Aids on symptoms. These techniques empower teams to develop practical solutions to achieve better quality of care while containing costs. And just as critical as achieving those improvements is the sustainment of those gains, lest all the effort expended in the name of performance improvement be for naught. What it will take to make this happen is described in this book. There is a better solution on the horizon—and in the pages ahead.
Bahadir Inozu, Ph.D.
Chief Executive Officer and Cofounder