10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital?

Objective: This article demonstrates how Duke University Hospital has taken three widely diverse quality management initiatives and melded them into a comprehensive approach to achieve our strategic goals. Methods: The Balanced Scorecard (BSC) is a management system focused on developing a mission, strategic goals, and key metrics and linking these to specific operational initiatives. Six Sigma provided a solid performance improvement framework utilizing the DMAIC approach: Define, Measure, Analyze, Improve, and Control. Team Training translated aviation’s Crew Resource Management principles to a health care-specific methodology. Results: Utilization of the BSC has led to an increase in net margin by 236 percent. Six Sigma reduced the risk score in moderate sedation from 11.94 to 4.94 and event probability score from 3.31 to 1.34. Team Training increased awareness of safety processes by 26 percent, communication as a team by 29 percent, and independent observations of overall teamwork by 72 percent. Conclusion: The BSC consolidates strategic initiatives; Six Sigma facilitates focused improvement within operations; and Team Training improves communication across disciplines. Understanding these differences and building upon each approach’s individual strengths is essential to success. Introduction A number of quality management and performance improvement (PI) methodologies are readily available for use in the hospital setting. 2, 3, 4 However, these models consist of differing frameworks and flow processes, which often compete for resources and may even have conflicting goals. Many of these methodologies have been used in business and then translated to health care. 2, 4 One concern with this translational approach is that the goal of business is primarily to improve shareholder value, whereas the primary goal in medicine is to improve patient care. As a result, the direct translation of these business principles to health care can result in confusion as to which strategy is best for what problem. In addition, as new methodologies are introduced, the questions become: