According to The Joint Commission, hand hygiene is instrumental for preventing healthcare-associated infections (HAI).1 However, compliance with hand hygiene practices among healthcare workers has been low, historically averaging around 39%.2 Despite clinical research to improve behaviors and practices, healthcare processes have been unreliable because clinicians are not trained in the methods of process improvements such as Six Sigma, Lean, and change management. The Joint Commission Center for Transforming Healthcare was created to help healthcare organizations apply these tools and methods, which are referred to as Robust Process Improvements® (RPI®).3
In the Center’s first improvement project, it focused on improving and sustaining hand hygiene compliance.4 Eight hospitals participated in the project over a 22-month period. The participants used RPI methods to measure rate of hand hygiene noncompliance, assess specific causes plus develop and test interventions to target failures and sustain performance improvement levels. As the project began, a baseline rate of hand hygiene compliance averaged 47.5%. At the end of the project, compliance increase to 81%, a 70.5% increase in compliance and sustained for 11 months.5
RPI methods and tools allowed each hospital to customize its improvements efforts by focusing causes of failures that were specific to its facility. In a similar manner, the power of Six Sigma RPI method can also be applied to other projects to improve procedures that have been resistant to change.
The Six Sigma process is comprised of five improvement steps. All these steps are mandatory and must be followed in the given order6:
- Define: Identify the problem and the end goal of the project. This includes determining the scope of the project, defining metrics, resources to be used and the timeline.
- Measure: Taking inventory of the process as it currently exists and objectively establish current baselines as the basis for improvement. The performance metric baseline from the will be compared to the performance metric at the conclusion of the project to determine objectively whether significant improvement has been made. Thorough documentation of everything related to the process is essential for drawing conclusions.
- Analyze: Identify where the problems lie within the process. The top 3-4 potential root causes can be selected for further validation.
- Improve: Identify, test, and implement creative solutions with the aim to eliminate the key root causes in order to fix and prevent future problems. Brainstorming or techniques like Six Thinking Hats and Random Word can be used to identify potential solutions.
- Control: Devise ways to monitor implementation of the new process to sustain gains. Documentation and periodic training sessions discourage reversion to the old habits.
The “Define, Measure, and Analyze” steps in Six Sigma focus on studying the issue in depth to obtain high-quality data before implementing process improvement and instituting controls. These steps may make this process especially suitable for patient safety improvement initiatives because it addresses the lack of reliable baseline data in patient safety.
While the link may be obvious between patient safety and behavioral improvements, such as hand hygiene compliance, patient safety can also be improved by removing operational. For example, a project focused on streamlining workflow in the perioperative period may allow nurses to spend more time on patient care and less time on supply acquisition or completing redundant documentation.7 Projects that deliver cost savings may free up capital that can be used to hire additional healthcare workers or to invest in new technologies. In short, clinical and operational management concerns are not mutually exclusive, making a strong business case for implementing Six Sigma techniques.
When Six Sigma is implemented appropriately, it provides healthcare workers with a common set of tools and skills that empower them to use a team-based approach to solve issues. This culture change lays a strong foundation for sustainable change and continuous improvement.