Lean Six Sigma: Louisiana Department of Health's quality improvement quest

By KEVIN LITTEN | LDH Communications Specialist

For the Louisiana Department of Health’s Mendy Richard, a passion for quality began at the State Police Crime Lab in 2010, where there was a massive backlog of DNA tests that waited as long as 260 days for analysis.

Richard was given a challenge: eliminate the 1,700-case backlog with no additional staffing and no outsourcing. She and her team did it in a matter of months, using a conveyor belt-type process using strict standards for the pace of all activities. The project cut the turnaround time to 14 days.

While the project was a lot of work, Richard said, it was made easier using a process first perfected in the manufacturing sector called Lean Six Sigma. This process aims to eliminate waste while accepting no defects.

Mendy Richard, the deputy assistant secretary of the Office of Public Health,
holds a box of green and yellow karate belts. The belts are awarded to
trainees who successfully complete different levels of training in the Lean Six
Sigma quality improvement program.

Now Richard, the deputy assistant secretary of the Office of Public Health’s Center for Community Preparedness and Health Protection, is deploying Lean Six Sigma across the Louisiana Department of Health with advanced training for team members. The training empowers its participants to lead their own teams, finding solutions to problems in their bureaus. The 14 advanced Lean Six Sigma graduates are now using their skills to reorganize processes, eliminate rework and rethink how Department of Health team members do their jobs.

Continuous quality improvement

The “Six Sigma” system was first developed at Motorola to ensure quality of products, and “Lean” was developed at Toyota to reduce waste. After the State Crime Lab experience, Richard realized that the Lean Six Sigma methodology, which had been combined into a single improvement program, could apply to government as well.

Richard landed at the Louisiana Department of Health after completing improvement projects across state government, and began using the same methodology for new challenges that had some pretty serious consequences: The Office of Public Health was at risk of rejecting many of the specimens it was receiving from across the state because of tightened federal standards around temperatures in specimen storage and transport.

Federal authorities were holding Public Health officials accountable for keeping specimens within their prescribed storage temperatures, with some ranges between 2 and 6 degrees Celsius. If the temperature went higher or lower during transport to the lab, the specimens weren’t valid.

With those specimens being driven across the state in courier vehicles, Richard quickly realized that she needed to use Lean Six Sigma and let the data drive the improvements. In the midst of the search for the perfect procedure, she and the team launched a search for the ideal ice chest. In the end, Richard discovered that the most reliable and affordable ice chest to travel across the state — sometimes in blindingly hot temperatures — plugs into a cigarette lighter.

The discovery allowed Richard and her team to reduce rejections from 15% to less than 3% within a few months.

Richard is certified as a Master Black Belt in Lean Six Sigma, which allows her to successfully execute projects and oversee a quality improvement training program that can be used throughout the Department.

The push for continuous quality improvement is coming from the highest levels — particularly Department of Health Secretary Dr. Rebekah Gee and Deputy Secretary Mark Thomas. Gee said she has long wanted to create a culture of continuous quality improvement, but said it can’t really be done without leadership being fully on board.

Mendy Richard works with a human resource team to identify process steps
to understand where bottlenecks occur and where the greatest delay happens.

“What’s different about continuous quality improvement is that it’s strategic action versus strategic planning,” Gee said. “People are used to planning and coming up with our objectives and key goals, but what a lot of organizations don’t do is act.” 

MendyThe Department wanted to implement a more formal process that would improve efficiency and streamline processes: “Lean Six Sigma is a methodology that has been used in both the public and private sectors very successfully,” Thomas said.

Department leaders selected 14 Department of Health team members to begin what’s known as Green Belt training, a course that teaches how to define a problem and how to collect data and measure progress as possible solutions are worked out. The course also schools trainees in how to analyze various parts of the problem and to design a solution in response.

Following training, each Green Belt team member took on their own project and put together a team that helped analyze and implement solutions.

Problems and solutions

Clara Hudson, a quality assurance program monitor in the Department’s Office of Aging and Adult Services, took on a project that looked at why the Department was missing goals for approving Medicaid applications for people entering nursing homes across the state. The end goal was to ensure that people who apply for Medicaid to cover long-term care get a timely decision.

Hudson said her team was able to identify the problem fairly quickly: Application decisions depend on paperwork being scanned into the Department’s system, and scanning takes time — sometimes a couple of hours per application. But rather than hire more staff to mitigate that problem, Hudson said the team wanted to think more creatively, so it came up with a pilot program to bypass the need to hire more people.

“We created a partnership with some Medicaid analysts and a small group of nursing facilities that allowed the facilities to tell the analyst which application needed to be worked,” Hudson said. The analyst would become the single point of contact for the nursing home, and if the facility needed a decision on a patient more quickly, it could call the analyst directly and have that application located and scanned.

A key step in the process was identified as taking too long: 91% of the time, that step wasn’t being completed in five days or less. After the team completed the pilot program, that step only missed the five-day goal 5% of the time.

Christina Bolton, the quality management and improvement director at Pinecrest Supports and Services Center in Pineville, helped lead a project to improve talent recruitment and retention at the Department of Health. The Department had noted high turnover among nursing and direct care employees, and leaders knew that it was “very important to hire and maintain the right employees to improve quality and continuity of care.”

Bolton’s team created a tool that rated the quality of applications and then examined how the posting was written when there were a greater number of high-quality applications. The team found that because of nuances in the way that job postings were being presented online, some of the job titles were “vague and non-descript,” and other postings were not clear enough about required certifications.

Natalie Istre, a program manager in the Bureau of Nutrition Services at the
Louisiana Department of Health, goes over a plan for a pilot program that
was designed to improve quality in the Women, Infants & Children program.

The team decided to sculpt a new way for departmental leaders to advertise job postings by using a “working job title.” For example, if the Civil Service required a technical job title such as “Sanitarian I,” a manager could add something more descriptive in the title in parentheses, like “health inspector.”

They also improved the quality of job postings around certifications, linking potential applicants to ways they could receive a required certification.

“We wrote the job posting to appear more user-friendly to applicants: We show the required job qualifications and then let them know what steps to follow in order to become qualified if they are not already qualified,” Bolton said. ”We also worked with the Louisiana Civil Service Commission on improving how we are identifying the most effective job recruitment strategies.”

The strategy has been working, and by the end of the year, Bolton said her team projects its can scale up the pilot program to the point where it can train human resources staff to do what the team is doing with job postings. The results are projected to shave hours of time off the application-filtering duty of a hiring manager.

A transformative process

Both Bolton and Hudson said Lean Six Sigma training has transformed how they see things in everyday life as well as in their regular day-to-day work. Bolton said she’s even been doing housework differently according to principles learned in Lean Six Sigma.

“You begin to readily identify and avoid rework mishaps by properly sequencing steps,” Bolton said.
Richard said that while Lean Six Sigma stresses goals that can be applied throughout the Department — accept no defects is a common mantra, for example — the Department also sees the program as an important retention tool for retaining employees.

“Dr. Gee and Mark Thomas have whole-heartedly supported building this culture of quality,” Richard said. “It takes courageous leaders to invest in, engage in and promote this approach. Quite simply, having top-down support is the difference between mediocre and excellence in effective, sustainable improvements.”