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While national guidelines for community-acquired pneumonia (CAP) care exist, research has demonstrated that they are not followed consistently throughout many hospital settings. Many patients with CAP are not treated with the core measures that have been identified by national guidelines; there is a wide variance in how care is being provided.

Six Sigma practices are widely used in the manufacturing industry in an effort to improve performance in organizations. These practices can be used the same way in healthcare as they are in technology and auto industries; they can help eliminate non–value-added steps in processes and reduce defects and variation. When the performance improvement system has been used in hospitals, studies show that the development of more efficient processes provides significant benefits for hospitals, staff, and patients.

Big Rewards Are Possible

In 2007, my colleagues and I from Mercy Medical Center presented a study at the annual international scientific assembly of the American College of Chest Physicians demonstrating that Six Sigma performance improvement practices may help hospitals decrease in-patient mortality, length of hospital stay, and healthcare costs associated with CAP. Six Sigma practices also improved compliance with JCAHO Core Measures as they relate to CAP, leading to decreased patient mortality. Physicians and nurses also benefited because the practices facilitated our ability to provide the most appropriate, evidence-based, guideline-directed care possible. Furthermore, Six Sigma resulted in benefits for our hospital as it led to decreases in lengths of stay and costs.

In our study, we implemented the Six Sigma performance improvement project to ensure that each JCAHO CAP Core Measure of care was met. These included:

• Checking oxygenation.

• Checking blood cultures before antibiotics are administered.

• Administering antibiotics within 4 hours of arrival to the hospital.

• Ensuring that antibiotics were provided based on guideline recommendations.

• Ensuring that smokers received smoking cessation.

• Ensuring that influenza vaccinations were provided when appropriate.

Critical processes and key stakeholders in patient care were identified, and specific tools for process flow, cause/effect matrices, and outcomes analysis were utilized. Several full-time positions were dedicated to the new methodology, and the staff was thoroughly trained in the Six Sigma program. If deviations from protocols occurred, timely feedback was provided.

After the Six Sigma program was implemented, compliance scores for each JCAHO Core Measure improved from 70% to over 90%. CAP order usage improved from 40% to 73% and lengths of hospital stay decreased from 5.9 days to 5.1 days. These findings correlated with a cost savings of over $300,000. At the end of the study period, in-hospital mortality rates decreased by almost half.

The Increasing Prevalence of Six Sigma

Six Sigma practices aren’t being used everywhere, but they are becoming more prevalent, especially in larger institutions. When implementing Six Sigma practices, it’s important to recognize that changing behaviors can be challenging. The strategy has worked well in our experience, but may not be the best methodology for everyone. The key is to initiate it positively and to gain staff acceptance. Close collaboration and constant communication with all stakeholders are other important considerations. Six Sigma can help organizations evaluate the effect of departmental and system-wide processes and address gaps in patient care. Improvements in these processes may ultimately improve the delivery of patient care.

Neil R. Horning, MD, FCCP has indicated to Physician’s Weekly that he has or has had no financial interests to report.