An overview of six sigmaapplications in healthcare

industryMehmet Tolga Taner and Bulent Sezen

Gebze Institute of Technology, Kocaeli, Turkey, and

Jiju AntonyCaledonian Business School, Glasgow, UK

Abstract

Purpose – Delays, measurement and medical errors and variability often undermine the delivery ofsafe, effective patient care. However, it is possible to minimize them by applying six-sigma. Thismethodology aims to focus on the root causes of healthcare problems, analyses them by flowchartsand fishbone diagrams and produces near-perfect healthcare services.

Design/methodology/approach – Five case studies in healthcare are designed to show theperformance improvement accomplished by six sigma. The DMAIC (Define-Measure-Analyse-Improve-Control), i.e. a road-map for problem solving and service/process improvement, isimplemented.

Findings – The findings in this paper show that the healthcare organization has a greater ability toaddress challenges across the system. Resource utilization has been maximized. Fewer redundancies,waste and rework have been observed. Bottle-necks related to scheduling have diminished. Workingconditions have improved for healthcare personnel. Increased patient and physician satisfaction aswell as cost savings have been achieved. These will enable the healthcare organization to increase itsmarket share in the long run.

Originality/value – The application of six sigma in healthcare services is relatively new topic andvery little research has been performed in this area. The paper will be extremely valuable toresearchers and practitioners who are currently engaged in six sigma research.

Keywords Six sigma, Health services

Paper type Research paper

IntroductionHealth care today is a vast web of complexity and contradiction. It offers astoundingadvances in technology and treatment, but is often overburdened by inefficiencies,errors, resource constraints and other issues that threaten the accessibility andsafety of patient care. In 1998, the Institute of Medicine released an assessmentstating that 98,000 people die each year as a result of medical errors, highlightingthe necessity for quality improvements (Lazarus and Neely, 2003). An estimated£400 million is being paid in clinical negligence claims and adverse incidentsresulted in approximately £2 billion per annum (Department of Health, 2001;Milligan and Robinson, 2003).

Over the past decade, the need and desire for healthcare institutions to operate moreefficiently has been driven largely by financial concerns. With decreasingreimbursements and the rising cost of labour and supplies, healthcare organizationshave been driven to look within to find savings. Generally, the accepted rule has beenthat there are two primary areas to find savings, either through reductions in labour

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International Journal of Health CareQuality AssuranceVol. 20 No. 4, 2007

pp. 329-340q Emerald Group Publishing Limited

0952-6862DOI 10.1108/09526860710754398

costs or by reducing the high cost of supplies. With the continuing shortage ofqualified healthcare professionals, registered nurses, registered radiologictechnologists, etc., the opportunities to reduce expenses solely by reducing labourcosts can play an important role in causing bottlenecks in healthcare services.

Today’s health care organizations are complex dynamic systems. They are morefocusing to improve quality of care and meet stringent guidelines. Thus, re-examiningthe method of evaluating the service performance has become necessary. All qualityimprovement activities should focus on improvements in:

. clinical outcomes;

. satisfaction; and

. efficiency.

These are determined by system characteristics.Improving levels of patient satisfaction is very critical to a healthcare organization’s

long-term success. To improve patient satisfaction, healthcare providers must focus onquality improvement strategies. That is, healthcare professionals must demonstrateattributes consistent with organizational culture. Six attributes for a quality healthcaresystem are identified as follows:

(1) Safe.

(2) Effective.

(3) Patient-centred.

(4) Timely.

(5) Efficient.

(6) Equitable.

Monitoring these attributes is a crucial element of organization’s philosophy andshould be part of the quality improvement initiative.

Much effort has in the past and in some places still is directed at imposing qualityrather than concentrating on optimizing the healthcare system. Sigma methodology isan optimization tool that focuses on developing and delivering near-perfect services. Itis one of the most powerful performance improvement methodologies that arechanging the face of modern healthcare delivery. The DNA of the six sigmamethodology can be felt while reducing variation that leads to safer, quicker and moreco-ordinated care, less mortality and morbidity, better response to needs and bettervalue from resources.

Up-to-date, six sigma projects in healthcare industry have focused on direct caredelivery, administrative support and financial administration (Antony et al., 2006). Sixsigma projects can be executed in the following healthcare processes:

. increasing capacity in X-ray rooms;

. reducing avoidable emergency admissions;

. improving day case performance;

. improving accuracy of clinical coding;

. improving patient satisfaction at Emergency Room (ER);

. reducing turn around time in preparing medical reports;

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. reducing bottle necks in emergency departments;

. reducing cycle time in various inpatient and outpatient diagnostic areas;

. reducing number of medical errors and hence enhancing patient safety;

. reducing patient falls;

. reducing errors from high-risk medication;

. reducing medication ordering and administration errors;

. improving active management of personnel costs;

. increasing productivity of healthcare personnel;

. increasing accuracy of laboratory results;

. increasing accuracy of billing processes and thereby reducing the number ofbilling errors;

. improving bed availability across various departments in hospitals;

. reducing number of post-operative wound infections and related woundproblems;

. improving MRI exam scheduling;

. reducing lost MRI films;

. improving turn-around time for pharmacy orders;

. improving nurse or pharmacy technician recruitment;

. improving operation room throughput;

. increasing surgical capacity;

. reducing length of stay in ER;

. reducing ER diversions;

. improving revenue cycle;

. reducing inventory levels;

. improving patient registration accuracy; and

. improving employee retention.

Theoretical backgroundHigh performance is essential in every healthcare process. Sigma is a Greek letter of thealphabet used to describe variability, or in mathematical terms, standard deviation. Sixsigma offers a way of measuring the performance capability of existing systems orprocesses. It is a statistical unit of measure that reflects the likelihood that an error willoccur. Six-sigma relies on rigorous statistical methods, and implements controlmechanisms, in order to tie together quality, cost, process, people, and accountability. Itbegins with an understanding of customer requirements, and values (Riebling, 2005).The six-sigma goal is to reduce both variance and control processes in order to assurecompliance with the critical specifications.

The higher the sigma level, the higher the performance of the healthcare system. Forexample, a 3s process has a defect rate of 6.7 percent whereas a 6s process has 3.4defects per million opportunities. An Institute of Medicine (IOM) report states thatdeaths attributable to anaesthesia have fallen to 5.4 per million, which approaches 5s

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and added that medical errors are responsible for the deaths of 44,000 to 98,000hospital patients every year (Bion and Heffner, 2004). In addition, reducing medicalerrors can also result in significant financial savings, reporting that total national costsof preventable medical errors resulting in injury account for between $17 billion and$29 billion per year. The study noted that preventable adverse drug reactions canincrease average hospitalization costs by $4,700 per admission (Bion and Heffner,2004). Also, the average of doctor prescription writing has been found to be betweenthree and four-sigma (Rudisill and Druley, 2004). These examples can be improved bymeans of applying the six-sigma philosophy.

Organizations need to improve what they are currently doing as well as changingoperations to what they should be doing, and after measuring the outcomes theyshould search for improvements on other new activities. Every improvement requires achange, either in small scale or in large scale, and every change requires an act ofcreation (Sommers, 1998).

Patient satisfaction, physician satisfaction, reduced overtime, reduced patient waittimes, increased revenues and an enhanced quality of life for healthcare personnel aresome of the outcomes of moving to the higher sigma level. The goal is to move from thecurrent state to a future, more productive state.

By means of adopting six-sigma philosophy, the healthcare organization canachieve a cultural change. This will lead in realizing sustainable bottom-line results inthe hospital. Having committed and being supportive, the top management must selectquality strategies that tie projects to organization imperatives. Thus, it can identifymeaningful performance metrics (see Figure 1).

From emergency room to boardroom, six-sigma can reduce variability and waste bytranslating to fewer errors, better processes, improved patient care, greater patientsatisfaction rates, and happier, more productive employees. To achieve these goals, theDMAIC must be implemented.

The DMAIC is a five-step improvement cycle with the aim to continuously reduceerrors: Define the project by identifying problems, clarifying scope, defining goals.

Figure 1.The core of six sigmaapplications in healthcare,i.e. patient satisfaction

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Measure the current performance against requirements, gather and compare data,refine problems/goals. Analyse by developing hypotheses, identifying sources, gapsand root causes, analysing best practices. Improve by conducting experiments toeliminate root cause, testing solutions, measuring results, standardizing solutions,implementing new processes by designing creative solutions to fix and preventproblems. Control the performance of the process by institutionalizing improvementsand putting a mechanism for ongoing monitoring in place.

Healthcare organizations implementing six-sigma using the DMAIC methodology,should later add the DFSS (design for six sigma) methodologies when theorganizational culture and experience level permits. However it is always advised tolook at the improvement aspects of existing processes using DMAIC methodology andthen apply Design for six sigma methodology either to re-design existing processes forfurther improvement or to design and develop a new service from scratch.

At its core, six-sigma revolves around the following key concepts:. Critical to quality: Attributes most important to the patient.. Defect: Failing to deliver what the patient wants. In terms of impact to the

patient, a defect in the delivery of healthcare can range from relatively minor tosignificant. In a worst-case scenario, the defect can be fatal, as when a medicationerror results in the patient’s death.

. Process capability: What the healthcare process can deliver.

. Variation: What the patient sees and feels.

. Stable operations: Ensuring consistent, predictable processes to improve whatthe patient sees and feels.

. Design for six sigma: Designing to meet patient’s needs and process capability.

. Lean six sigma: integration of Lean Thinking (that means speed and better flowof the processes by eliminating waste) and Statistical Thinking (that meansunderstanding data, process and variation in processes).

Some key challenges and barriers in the implementation of six sigma inhealthcareThe first and foremost challenge is the initial investment in six-sigma Belt Systemtraining. The absence or difficulty to obtain the baseline data on process performanceis another major challenge while applying six-sigma in health care sector. There will belots of data available in the health care sector, however, most of the time these data arenot readily available for its analysis. For health care industry, it is often a struggle toidentify processes, which can be measured in terms of defects or errors per millionopportunities (Lanham and Maxson-Cooper, 2003). Another barrier to six-sigmadeployment in health care industry is the psychology of the workforce. Last but not theleast, it is important to present recommendations using the business language ratherthan the statistical language.

Sample applications of six sigma methodology in healthcare industryIn this paper, the following five case studies of six sigma applications are suggested:

(1) Decreasing unnecessary laboratory tests.

(2) Improving Magnetic Resonance (MR) image quality.

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(3) Decreasing waiting times before surgery.

(4) Reducing catheter infections.

(5) Decreasing excess length of stay in hospitals.

Case 1: Decreasing unnecessary laboratory testsMany blood tests and urinalyses requested in the pediatric andobstetrics-gynecology wards must be repeated due to procedural errors. Theresult is delay in getting final results to the physician and unnecessary costs dueto rework.

While human error is an important cause in the majority of cases, importantbackground factors may exist which need to be understood. These includecomplexity, exhaustion, distraction, and inadequate supervision by senior staff.

A Quality Improvement Team was formed to analyze the process. The first part ofthe analysis comprised a flowchart to examine the current process, beginning with theordering of a laboratory test by a physician all the way through to the reporting of theresults to the doctor. Once the process was flowcharted, the team developed a fishbonediagram to speculate on possible reasons for errors (Figure 2).

This was followed by a data-collection to measure the frequency of actual errors bytype. The team focused on potential errors related to personnel actions, equipmentproblems, and systematic procedural impediments to minimize errors. Hence, two maincategories of problems have been examined by the team: those related to samplecollection, transport and storage of samples.

Development of standards and job aids for collecting blood samples and fortransporting and storing the samples, followed by a review and discussion of thestandards with the nurses and technicians for these activities have been practised. In

Figure 2.Possible causes ofunnecessary repeatlaboratory tests

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addition, quality management principles which often lead to cost savings have beentaught.

Case 2: Improving MRI image qualityMany imaging technologies are introduced to the healthcare market each year. Thesemodalities deliver increased image quality and provide diagnostic confidence tophysicians to more accurately treat patients. However, this is generally achieved onlyat considerable additional expense. Redesign for cost and medical management havebecome necessary (Taner and Antony, 2000). Six sigma tools can be used in optimizingdesign protocols in radiology.

In diagnostic imaging, there is always the risk of variation since the reading maychange from observer to observer. By superior imaging techniques, this problem canbe overcome.

The image quality of MRI depends on many parameters such as the technicalvariables, processing conditions, calibration of the equipment, observer’s performanceetc. as illustrated in Figure 3. The bias in observer’s performance has the utmostimportance and must be improved by training. The other parameters should beimproved by giving training to the technician and providing the maintenance to theMRI equipment when necessary.

Case 3: Decreasing waiting time before surgeryPatients often register their dissatisfaction while they wait for surgery. From hospital’sviewpoint, this resulted in wasted resources, increased costs, and additional risk to thepatient. As for the patients, they complain that their time has been wasted, and addedthat there has been great inconvenience to the family. Moreover, the protractedanticipation of surgery has been distressing.

Figure 3.Factors affecting image

quality of MR

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A Quality Improvement Team was formed. To identify possible nodes in the processwhere significant delay might have been incurred, the team developed a flowchart ofthe process by which patients were admitted to the hospital and then proceed tosurgery (Figure 4).

Following this, the team developed a fishbone diagram (Figure 5) to speculate onhow and why time might be lost at these points during the process.

Data are collected by modifying the medical record to show delays in surgery andthe reasons for the delay as noted by the attending personnel. Substantial delay hasbeen found to be due to the laboratory tests to be reported and for the ECG(Electrocardiogram) unit to become available.

Case 4: Reducing catheter infectionCatheter infection is one of the serious problems that patients face after surgery. Theneed to reduce the occurrence of catheter infection has become a major issue in both thequality improvement and patient safety arenas.

To accomplish this project, patients with catheter infections were identified byinterviewing nurses and physicians, by the review of an established documentationform kept on all nursing stations, and by direct observation. An Infection ControlTeam was formed. This team organized a series of meetings with key representativesfrom medicine and surgery, nursing staff from both medical and critical care units,anesthesiology, the ER, materials management, and performance improvement.Information needed to identify factors influencing the occurrence of catheter infectionwas gathered through this working team; through assessment sessions conducted andvia observations conducted during the catheter insertion and maintenance procedures.

Figure 4.Flowchart of thewaiting-time beforesurgery

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This process resulted in the development of the fishbone diagram, which highlightedthe patient, equipment, healthcare personnel and environment which impact thecatheter infections (Figure 6).

This process was also beneficial in identifying various needs: the need for staff tounderstand the nature and severity of the problem; a uniform education program fornurses and physicians; selection of insertion site to reduce infection risk; standards foraseptic practice during catheter insertion and replacement; standardization ofskin-antisepsis; standardization of sterile attire and compliance with its use. A masterplan was developed by this team. At the core of this plan was giving educationprimarily to the caregiver.

Case 5: Decreasing excess length of stay in hospitalMedical errors and adverse events in healthcare organizations are mostly common andmany of them are potentially avoidable. In addition to their capacity to harm patients,these potentially avoidable outcomes can increase the length of stay addingconsiderably to economic difficulties of healthcare organizations.

However, if the primary goal is to decrease the length of stay in hospital and therebyimproving the level of efficiency, it is essential that changes do not result in a decreasedlevel of safety or effectiveness of the care provided.

There were many patients waiting in the admissions department to be placed in aroom. To analyze where the bottleneck was, a Quality Improvement Team was formed.To identify possible nodes in the process where significant delay might have beenincurred, the team developed a flowchart and fishbone diagram (Figure 7).

The team determined that excess length of stay in the hospital was greatlyinfluenced by discharge planning process. Discharge planning was the critical linkbetween treatment received in hospital by the patient, and post-discharge care

Figure 5.Potential causes of waiting

time before surgery

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Figure 6.Possible causes of catheterinfection

Figure 7.Possible causes of excesslength of stay in hospital

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provided by the community. Thus, the team prepared an effective discharge planningthat would enable a smooth transaction from hospital to home, producing betteroutcomes for the patient, and reducing the likelihood of readmission to hospital.

ConclusionsHealthcare industry is still in the early stages of evolution with regard to six-sigma.Therefore, healthcare personnel should seek guidance for training and implementationby the support of the top management. Successful execution of simple projects inhospitals can enable practitioners to tackle tougher initiatives in the future and createclinical change on a broad scale.

Integrating the six-sigma culture into entire organizations by the commitment andinvolvement of top management can multiply the positive effects and make asignificant impact at all levels. High level of internal communication is also necessaryto facilitate the implementation of six sigma. The established Quality ImprovementTeam should collaborate with outside quality facilitators who can train them indeploying implementation and to provide necessary training for all project participantsin system deployment, project management, and utilization of quality tools.

Appropriately implemented, six sigma clearly produces benefits in terms of betteroperational efficiency, cost-effectiveness and higher process quality. In addition, it alsohas an impact in clinical areas such as infection control and medication delivery.

Impeding factors to the implementation of six sigma in healthcare organizations areas follows:

. lack of financial resources;

. lack of human resources;

. lack of time;

. lack of leadership;

. poor training;

. poor project selection; and

. internal resistance.

The authors believe that six sigma as a business strategy allows health care sector todeliver a truly high-class service to patients. Think of the true impact that six sigmacould have if we focus on the core issues of health care and improving the quality oflives of patients. In authors’ opinion, the application of six sigma in health careindustry will continue to grow, especially here in Europe over the next five years or so.

References

Antony, J., Antony, F. and Taner, T. (2006), “The secret of success”, Public Service Review: Tradeand Industry, Vol. 10, pp. 12-14.

Bion, J.F. and Heffner, B.J. (2004), “Challenges in the care of acutely”, The Lancet, Vol. 363No. 9413, pp. 970-7.

Department of Health (2001), Organisation with a Memory: Report of an Expert Group onLearning from Adverse Events in the NHS chaired by the Chief Medical Officer, TheStationery Office, London.

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Lanham, B. and Maxson-Cooper, P. (2003), “Is six sigma the answer for nursing to reduce medicalerrors?”, Nursing Economics, Vol. 21 No. 1, pp. 39-41.

Lazarus, I. and Neely, C. (2003), “Six sigma raising the bar”, Managed Healthcare Executive,Vol. 13 No. 1, pp. 31-3.

Milligan, F and Robinson, K (2003), Limiting Harm in Future Health Care – the Role of Nursing:A Nursing Perspective, Blackwell Publishing, Oxford, pp. 255-73.

Riebling, N. (2005), “Six sigma project reduces analytical errors in an automated lab”, ClinicalIssues, June, pp. 20-3.

Rudisill, F. and Druley, S. (2004), “Column: back to basics: which six sigma metric should I use?”,Quality Progress, Vol. 37 No. 3, pp. 104-10.

Sommers, P.A. (1998), Medical Group Management in Turbulent Times, The Haworth Press, NewYork, NY, p. 26.

Taner, T. and Antony, J. (2000), “The assessment of quality in medical diagnostic tests:a comparison of ROC/Youden and Taguchi methods”, International Journal of Health CareQuality Assurance, Vol. 12 No. 7, pp. 300-7.

Further reading

Committee on Quality of Health Care in America (2001), Crossing the Quality Chasm: A NewHealth System for the 21st Century, National Academy Press, Washington, DC, pp. 41-2.

Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. (2000), To Err Is Human: Building a Safer HealthSystem, Institute of Medicine, National Academy Press, Washington, DC.

Corresponding authorMehmet Tolga Taner can be contacted at: mtaner@ gyte.edu.tr

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