Embedding Quality Improvement Skills into an Organization Through a Green Belt Certification Program

Abby Kim, PharmD BCOP
Supervisor of Clinical Pharmacy Services
Children’s Hospital Colorado
Denver, CO

 The focus on quality processes, care, and outcomes has never been more prevalent than it is today, particularly in the oncology world, given the rapidly rising cost of care. The opportunity to read, hear, and learn about efforts related to quality has been a focus for HOPA in recent years. In a recent issue of HOPA News, we learned about the efforts of HOPA’s Quality Oversight Task Force to increase members’ knowledge and equip them with tools and resources related to quality.1 Those who attended HOPA’s 2019 Practice Management program had multiple opportunities to learn and engage in quality-focused discussion—both at the American Society of Clinical Oncology (ASCO) Quality Training Program’s 1-day preconference workshop and in the conference sessions related to value-based care. Several members who attended the ASCO workshop asked how others incorporate quality work into their day-to-day activities and gain buy-in from senior leadership.

Beginning in 2016, one senior leader at Children’s Hospital Colorado identified the need to embed quality improvement skills into his team members. This leader partnered with the Process Improvement Department to brainstorm ways to root the Six Sigma methodology into his organization. The Process Improvement Department, which consists of team members who hold Green Belt, Black Belt, and Master Black Belt certifications, knew they could effectively complete up to three quality improvement projects per year on their own. This was not enough, given their goals related to quality work and the pace of value-based health care. A new idea was needed, and thus an internal organizational Green Belt Certification Program was born, allowing up to 12 quality improvement projects to be completed each year. In addition, those who complete the program are called upon to return to their departments and continue embedding the quality skills they have acquired through continued project work and mentorship of others.

Each director in the Professional Support Services Division identifies and nominates two leadership-level or frontline team members to participate in the Green Belt Certification Program each year. The director works with the Green Belt mentee to identify possible projects and sponsors the mentee and project throughout the certification. Each Green Belt mentee is matched with a Black Belt or Master Black Belt, who provides mentorship for quality improvement skills and the identified project. The program leads two cohorts of a total of 12 Green Belt mentees per year and is designed as follows:

 Green Belt Classroom (Week 1)

  • Process improvement history and overview of define, measure, analyze, improve, and control (DMAIC) tollgates
  • Define: project charter, SIPOC (suppliers, inputs, process, outputs, and customer), voice of the customer, stakeholder analysis, communication plan, project timeline
  • Measure: process mapping, data collection plan, measurement system analysis, working with data, change leadership
  • Analyze: 5 whys, cause and effect, fishbone, failure modes effect analysis, lean simulation

Green Belt Mentee and Mentor Work (Weeks 2–4)

  • Meet with Green Belt mentor weekly
  • Complete define tollgate

Green Belt Classroom (Week 5)

  • Improve: hypothesis testing, facilitation basics, generating solutions, implementing solutions, improve risk analysis, working with data
  • Control: control plan, transition plan, lessons learned

Green Belt Mentee and Mentor Work (Weeks 6–36)

  • Complete tollgates with multidisciplinary core team and Master Black Belt mentor
  • DMAIC tollgate readouts to cohort and senior leadership
  • Green Belt Certification graduation

The Pharmacy Department has participated in the program by sending an operational and clinical supervisor to complete department-level projects, and additional pharmacy team members have been nominated for the upcoming 2020 cohorts. The program also engages other departments in the organization, including nursing, nutrition, imaging, and finance, and has successfully graduated 12 Green Belts; an additional 12 are currently nearing project completion and graduation. Their projects have focused on creating safety for magnetic resonance imaging, decreasing anesthesiology same-day conversions for all imaging, optimizing total fluid management, improving scheduling and prior authorization processes, and improving documentation of opioid waste.

I had the privilege of participating in the Green Belt Certification Program, working on a project that focused on the workflow of our clinical and operational oncology pharmacists in our pharmacy satellite. Analysis revealed that the oncology pharmacy team was performing manual calculations to prepare chemotherapy; this did not allow the team to work at the fullest scope and resulted in double and triple work by both pharmacy technicians and pharmacists. Although error in the process was near zero, the opportunity for error existed, and the risk was extremely high if error did occur. A multidisciplinary core team that included providers, clinical and operational pharmacists, pharmacy technicians, and workers in patient safety, information technology, and clinical applications was identified. The core team participated in completing each tollgate and is championing change in the oncology pharmacy satellite. The project is currently in progress, and work in several areas is nearing completion: eliminating manual chemotherapy calculations, building standard electronic medical record oncology drug files for commercial and investigational agents, improving real-time dispense preparation, eliminating 22 steps in the process of preparing a chemotherapy agent for administration, and returning as much as 30 minutes per day to clinical pharmacists so they can focus on direct patient care!

The impact of quality work completed has been recognized across the organization, and the program is continuing to grow. The process improvement team is now offering Lean Bootcamp Training, Lean Simulations, Change Management Training for Sponsors, and Black Belt Certification. The organization also holds a yearly Quality Improvement Poster Symposium that highlights quality improvement work from all departments. The 2019 symposium will have 65 poster presentations, including seven completed by pharmacists and one poster that was previously presented at the 2019 conference of the Association of Pediatric Hematology/Oncology Nurses; that poster discusses improving the admission process and decreasing the length of stay for high-dose methotrexate admissions. That quality improvement team will be saving the organization up to $600,000 annually because of its work on decreasing the length of stay for both osteosarcoma and leukemia patients secondary to bundled reimbursement.2

This Green Belt Certification Program is just one example of how to integrate quality improvement skills and principles into an organization from the front line to senior leadership. As evidenced by the lively participation at ASCO’s Quality Training Program 1-day workshop, many of you are completing similar quality improvement programs and learning new skills related to quality improvement that help optimize care for patients. I challenge each of us as HOPA members to continue to find opportunities to build our quality improvement skills and put these skills to work on a daily basis in our organizations. Ask your senior leadership about expanding your own internal quality improvement program, or learn about external programs such as ASCO’s. We have nothing to lose and so much to gain for our patients and our organizations!


  1. Seung AH. Oncology pharmacists’ role in value- and quality-based patient care. HOPA News. 2019;16(2):6-7.
  2. Stokes C, Kaiser N, Merrow M, et al. Improving admission process and decreasing the length of stay for high-dose methotrexate admissions. Association of Pediatric Hematology/Oncology Nurses, 43rd annual conference; September 2019, San Jose, CA.