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Mike Richman

Health Care

Interview: Dr. Tomas Gonzalez of Valley Baptist Health System

An award-winning Black Belt speaks about how to instill DMAIC in a health care environment

Published: Wednesday, February 6, 2008 - 22:00

Dr. Tomas Gonzalez, senior vice president and chief quality officer for Valley Baptist Health System of Harlingen, Texas, is a busy man. Not only does he direct quality process improvement at Valley Baptist’s two hospitals, he’s also a physician and a certified Master Black Belt. Valley Baptist had a banner year in 2007, including the achievement of a No. 1 U.S. ranking for the management of heart failure by the Centers for Medicare and Medicaid Services. In addition, in October, Valley Baptist received multiple awards from WCBF during their Global Six Sigma Awards ceremony; Dr. Gonzalez himself was named as WCBF’s Six Sigma vice president of the year.

The following interview appears in a truncated form in the News Digest section of Quality Digest’s February 2008 issue www.qualitydigest.com/currentmag/news.shtml#8.

Quality Digest: How did Valley Baptist first learn about Six Sigma?
Tomas Gonzalez: Six Sigma came to Valley Baptist Health System in 2001, along with James G. Springfield, who at that time was named chief operating officer for Valley Baptist Medical Center, Harlingen. Almost immediately upon his arrival, it became apparent that Mr. Springfield was bringing not only new administrative expertise, but a whole new way of doing business that would amount to nothing less than a cultural change. This cultural change was Six Sigma, which Mr. Springfield had learned about through his studies of successful corporations, in particular General Electric. In 2002, Six Sigma was adopted as the operating system of the organization, and in January, 2003, Mr. Springfield was named CEO for Valley Baptist Health System.

More than 340 Valley Baptist employees have undergone Six Sigma training. Mr. Springfield and Six Sigma Master Black Belts at Valley Baptist have been invited to speak at national Six Sigma and quality conferences across the country. In August, 2007, Valley Baptist hosted its own conference, titled “Achieving Excellence in Health Care Through Six Sigma” at South Padre Island, Texas.

Today, eight waves of initiatives later (with each wave lasting six months), there are over 100 ongoing Six Sigma initiatives throughout the health system, in addition to more than 350 Work-Outs, which have been completed in nearly every hospital department.

QD: How do you get physicians to “buy into” quality improvement?
TG: By including them. In fact, I am a physician and Master Black Belt who serves as senior vice president and chief quality officer for the health system. In addition, 27 doctors have been trained as Six Sigma Yellow Belts after having completed a high-level four-day overview of Six Sigma’s define, measure, analyze, improve, and control (DMAIC) methodology. Sixteen of these doctors serve on the Six Sigma Physicians’ Council.

We believe that physicians should feel right at home with Six Sigma’s processes, because DMAIC formalizes what physicians have always done with their patients—define (or diagnose) the problem, measure and analyze the problem, improve it, and control it. The art of medicine is not lost with Six Sigma. Six Sigma is disciplined and data-driven, but it never interferes with the sacred physician-patient relationship. It gives physicians the data they need to help support the decision making process.

QD: How do you initiate new projects?
TG: Each fiscal year, there is an opportunity for ideas on quality improvement projects to be proposed at the grassroots level—from our physicians, nurses, staff, and medical students. This open door global process helps ensure that quality improvement projects are responsive to community needs—as well as weaknesses in our organization as gauged by those at the very point of care. Meanwhile, the commitment to Six Sigma at the top of our organization ensures that our quality improvement projects address national, state, and local priorities—for example, those national priorities identified by the Institute for Healthcare Improvements, the Joint Commission, and the U.S. Centers for Medicare and Medicaid Services.

The process of choosing Six Sigma projects continues with a list of ideas presented to our senior leadership, who discuss the proposals and ultimately decide what our quality improvement priorities will be for the next fiscal year. Valley Baptist’s quality initiatives department also has a voice in determining whether quality improvement proposals can be effectively implemented using the organization’s DMAIC process.

Key caregivers and staff are involved from the beginning of each Six Sigma project, because Six Sigma initiatives require the input and participation of those closest to the care or procedure. Patients, family members, physicians, and other customers provide input through the voice of the customer, the starting point for any Six Sigma initiative. Nurses, physicians, pharmacists, suppliers and others who are closest to the process provide input through four-hour Six Sigma Work-Outs, designed to quickly elicit effective, doable improvement ideas, and to develop a who, what, when, and why (4W) plan for implementing change. For the more-extensive initiatives, physicians, pharmacists, nurses, respiratory therapists, and other front-line staff serve on the initiative team, under the leadership of a Six Sigma Green Belt and Master Black Belt. Frontline caregivers are involved in developing the multifaceted improvement efforts; the process control plans and control methods; determining ways to engrain accountability for the standard operating procedures for individual nurses and staff; and calculating the effect on patient care.

Processes are measured long before any solution is implemented, to obtain the baseline statistics on how often a standard is being met under the current procedures. Solutions are tried and re-tooled in the pilot phase. Once success is achieved, the improvements are applied on a larger scale in the control phase, and eventually rolled out throughout the hospital and health system. Solutions and ideas for improvement are rewarded, but an even greater emphasis is placed on day-to-day execution of the improved procedures to ensure continuous success. Decision support tools are employed continuously, including electronic spread sheets which divide, measure, and analyze every step in the process in great detail. This helps in eliminating or consolidating unnecessary steps until only truly value-added steps are left in the process.

An example of how a project is initiated involves our Six Sigma initiative on heart failure management. During the “define” phase of the initiative, the focus was placed on improved compliance with national core measures for treatment of heart failure patients. A team of two “Green Belts in Training,” the nurse manager of cardiac rehab for Valley Baptist and the ED [emergency department] nurse manager, along with cardiologists, family practitioners, cardiac ED physicians, medical-surgical staff, cardiac rehab, CHF clinic and ED nurses, pharmacists, case managers, and documentation specialists tackled this clinically critical initiative. During the “measure” phase of the project, Valley Baptist staff reviewed 300 medical records and created an aggregate score for each measure. The baseline data review showed a sigma score of 1.7 or a 58-percent yield for complying with heart failure core measures and a defect per million opportunities (DPMO) of 420,000. During the “analyze” phase, the team employed Six Sigma analysis tools to identify the greatest variances in the process, and used brainstorming to assess barriers to uniformity and to identify ideas for improvement. Ideas included staff and physician education, a process to identify heart failure patients on admission, and documentation tools and reminders to facilitate compliance. Physicians on Valley Baptist’s cardiac care committee were made aware of the importance of their involvement. The team then developed a new standard procedure to address heart failure patients. The initiative reached 100-percent compliance with heart failure core measures in 2005, and this result has been sustained over time at the near-perfect six sigma level. From October 2005 to August 2006, the improvements affected 626 patients. The improvements are projected to affect as many as 7,000 patients over the next ten years in Harlingen alone.

QD: What’s your personal vision for improvement at Valley Baptist?
TG: For our organization as a whole, my vision is for Valley Baptist to be an international leader in promoting quality health care and in teaching other health-care institutions how to achieve success through Six Sigma and other quality improvement tools. We have already taken the first steps in this leadership role by holding our own conference, where we showed more than 130 people how Six Sigma can be successfully applied to health care.

We have been contacted by other organizations interested in having us present this methodology on-site to their personnel—both in the United States and Mexico—and we have been invited to speak at quality improvement conferences and gatherings literally across the globe, from London to Harvard. I see what we started here at Valley Baptist—deep in South Texas—as having national implications. Health-care administrators, quality managers, office managers, physicians, and nurses can learn creative new strategies that will allow them to enhance quality of care, transform business processes, and maximize savings, which would go a long way in helping our country to meet the challenges it faces in health care today and into the future. My vision is that we will continually improve to the point that every patient will know that every time they are admitted to the hospital we will do everything possible, according to evidence-based medicine, every time, to deliver the best possible care.

QD: What’s next for Valley Baptist? Have you considered applying for the Malcolm Baldrige National Quality Award?
TG: Yes, we are working on applying for the Baldrige Award. In addition, we have another wave of initiatives underway at both hospitals, and we are refocusing our quality initiatives department to achieve greater participation and input from nurses, physicians, and board members in selecting and implementing our quality improvement initiatives. We will seek to continually raise the bar as we strive to deliver the highest quality of care to each and every patient and to be at the very top of the nation when it comes to delivering quality health care.

Our efforts at quality improvement were recently recognized when Valley Baptist, Harlingen, was named one of the Thomson top 100 hospitals in the nation for cardiovascular care. In addition, Valley Baptist, Brownsville, has been recognized by the Alliance for Cardiac Care Excellence for making significant improvements in cardiac care. More than 95 percent of the patients at Valley Baptist, Brownsville, received care according to 12 quality measures in 2006. This national recognition is from a coalition which includes the American College of Cardiology, the Centers for Medicare and Medicaid Services, the American Health Quality Association and the American Heart Association.


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Mike Richman