As the corporate director of process excellence at Citrus Valley Health Partners—a family of facilities that serves nearly a million residents of California’s East San Gabriel Valley—Denise Ronquillo plays a key role in improving quality and ensuring that patients receive excellent and safe care. Two years ago, the organization adopted the Joint Commission Center for Transforming Healthcare’s Robust Process Improvement (RPI) methods, which include Lean Six Sigma, change management, and other tools for high reliability. Since then, Ronquillo and her colleagues have achieved substantial successes while overcoming resistance and skepticism, and are beginning to see a new culture of quality emerge in their organization. Ronquillo, who never expected to be using statistics on a daily basis, has found Minitab Statistical Software makes it easy to analyze data, and to validate and sustain the improvements project teams make. We asked her to share some of the insights she’s gleaned during the previous two years.
How did you get started with data-driven quality improvement?
One of our physicians, Dr. William Choctaw, started learning about Lean Six Sigma through the Joint Commission’s Center for Transforming Healthcare. Through his initiative and his work with Robert H. Curry, our CEO, we began implementing the Center’s Robust Process Improvement framework. He’s now our Chief Transformation Officer, and I report to him. Early on, a group of us including our CEO, visited Sharp Memorial Hospital in San Diego. They’re about 10 years into implementing Lean Six Sigma and Robust Process Improvement, and they’ve even received the Malcolm Baldrige Award. When we saw their process and what their projects achieved to improve patient care and safety, we knew that we were on the right path.
But Lean Six Sigma is a culture change, and it has to start with leadership buy-in and commitment. Fortunately, our leadership team is very committed and involved. The Center for Transforming Healthcare first trained our leaders on the methodology and on some key tools. Then the leadership team selected 24 individuals to go through the Center’s Green Belt training, and two individuals for Black Belt training, and the real work began. I was one of the Black Belt trainees, and Dr. Choctaw was the other.
What was the training like?
When our Green Belt training started, we’d already been assigned real improvement projects to work on. The project I worked on focused on improving work flow and documentation with our Electronic Health Record because we knew that was an issue in our Labor and Delivery area. That first week of Green Belt training really helps you understand the basics of the Robust Process Improvement methodology and change management. What is the problem we are trying to solve, and how can we better understand it? What is the voice of our customers? How are we going to formulate our core team? Who are key stakeholders? What frontline staff are involved? Staff from the Center returned several times that year to deliver more specific training sessions centered around the DMAIC (Define, Measure, Analyze, Improve, Control) methodology. We earned our Green Belt certifications by showing statistically validated improvements from our projects. A year later, I was certified as a Black Belt, and that included more in-depth statistical training—what is hypothesis testing, what is regression analysis, why is it important to identify root causes, what kind of data do you need, and are you sure you’re collecting the right data? And we learned how to use Minitab to find out what the data means. It’s difficult in healthcare to really wrap yourself around Lean Six Sigma and data. Statistical analysis seems complicated to a lot of people, and they’re intimidated by it. But you can really break it down to be simpler than you can imagine.
Don’t healthcare organizations already have a lot of data available?
We have more data than we know what to do with, but data is meaningless until we can put a story behind it—and to be sure we’re really improving quality, that story has to be validated statistically. How are we defining those data fields? What kind of data are we collecting? Are we sure it’s correct?
Foothill Presbyterian Hospital is one of four facilities that make up Citrus Valley Health Partners, which serves nearly a million residents of California’s East San Gabriel Valley.
Could you use your existing data to improve quality?
Yes and no. For example, one Green Belt project looked at heart failure re-admissions. We had data that told us if a patient was readmitted…but what about all those other variables that we needed to look at? That wasn’t so easily available. Another project looked at emergency department flow, and the number of patients leaving without being seen. We had that number, and we were thinking, “Great, we’re not going to need to do massive data collection.” And we were able to use some existing data—but then we ran into challenges. When validating the data, we found different operational definitions. How do we define “left without being seen?” If one registration person has entered patients differently than another, then how valid is that data? So we learned that it’s really important to clearly define data, establish a data collection plan, and make sure you’re collecting the right data.
What role has Minitab played in your efforts?
Without Minitab there’s no way that we could do these analyses. I encountered a pharmacist in a meeting a few of weeks ago. She’d performed a study on the effectiveness of a care continuum program, and was talking about statistics and P-values. I asked if she used Minitab and she said, “No, I do it by hand.” I couldn’t even fathom that. I could do it by hand, too, but why would I when I have a tool like Minitab?
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Can staff at Citrus Valley Health Partners get involved without becoming a Green Belt?
Absolutely! Anybody who gets approval from their director can become a Certified Lean Agent. They receive four hours of training, and they have to complete a Lean project within three months. The Lean program is great because it really affects more frontline staff, those doing the work and knowing it best. You’re empowering them, and you’re teaching them the methodology. I’m not sure everyone has really grasped how important that is, but we call it our “secret weapon.” We have over 100 Lean agents, most of whom are frontline staff, and many of them later become involved in Green Belt projects. The more that happens, the more you can see our culture beginning to change.
That’s a great way to get people on board for more involved projects. Has your Lean program led to more buy-in from stakeholders or frontline staff?
Most definitely yes! But, change management is challenging and there is always skepticism. You’ll have people who have “always done it this way” and resist change. You can have the best plan, the best process, and involve the best people, but if you cannot get the frontline people to see what’s in it for them, you can’t succeed. So you want to know your stakeholders, target those resisters, and get them on board.
One Green Belt project’s goal was to get 0730 scheduled surgeries to start on time—defined as the wheels going into the operating room. We had some resistance from surgeons, who would say, “When I’m on time, you’re never ready, anyway.” That was beyond our control, but we could focus on processes that were under our control: are we ready as a team, or do we have some improvements to make? Initially some nurses and orderlies were not buying into this project. Fortunately, the Director really focused on engaging, encouraging the staff and helped them see what was in it for them. Starting with, if they improve this process, surgeons who arrive after 7:30 can no longer claim the team’s not ready. The Director was creative and also offered some incentives— for example if 50% or more of surgeries started on time for three months, we’d celebrate. That was done specifically to overcome that resistance, and it worked. If you don’t engage those people doing the work, then you’re going to fail.
How is Robust Process Improvement changing the culture at Citrus Valley?
In the past, we’d used control charts. We might look at the data, see if a certain number went up or down, and then say we had an improvement. But did we look at relationships and validate them statistically? Did we look at proportioning data out to different subgroups? Was there a statistically significant difference in our readmission rate for patients in a certain care program compared to those who weren’t? We never answered those kinds of questions. We didn’t statistically validate root causes to pinpoint where the real problem lies.
Now that we have learned the methodology and how to collect the right data, analyze our data appropriately, our improvements really are validated and data-driven. There’s a growing awareness that says, “Don’t just show me numbers—show me valid data and improvements.” We’re hearing that more and more in the organization, and that’s really exciting.
What would you tell somebody just starting this journey?
Know that it is possible and that it will be an exciting journey to take. Do a lot of research, learn, and talk to other organizations. Look for those successes in high reliability—the Sharp Medical Centers, the Memorial Hermanns, the Virginia Masons—and use their examples to make your case to the leaders within your own organization who will support the journey and help bring it to fruition. Most importantly be relentless. You will have successes and failures but stay the course and remember that we are all striving to achieve the highest quality and safest care for our patients.
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