clipboard april - december 2010

A Quarterly Update on Management Issues from the

Administrators Section of the Christian Medical Association of India

ClipboardIssue 54, 55 & 56 April- December 2010

Dear MembersDear MembersDear MembersDear MembersDear Members ,,,,,

Biblespeak

Stephen Victor

Secretary, Administrators' Section

[email protected]

Health is a state of complete physical, mental and social well-being, andHealth is a state of complete physical, mental and social well-being, andHealth is a state of complete physical, mental and social well-being, andHealth is a state of complete physical, mental and social well-being, andHealth is a state of complete physical, mental and social well-being, andnot merely the absence of disease or infirmitynot merely the absence of disease or infirmitynot merely the absence of disease or infirmitynot merely the absence of disease or infirmitynot merely the absence of disease or infirmity.....

- World Health Organization

Greetings from the Administrators Section of CMAI!

Hospital Administration is poised for major challenges. In the traditional

model of health care, the doctor came in every day and sat for hours as

patients flocked the place. A typical patient spends mainly on purchasing

medicines. That is no longer the case. Doctors are aplenty in cities, but for a cost.

In rural areas only a few doctors are available and even they have to depend on

several diagnostic tools using laboratories and radiographic techniques. This

increases the cost of medical care. This cost increase makes health care inacces-

sible to the common man and people below the poverty line (BPL) in particular.

The solution to this problem lies in the hands of the administrator. The challenge

is to find suitable finance in the form of health insurance, government grants (E.g..

Rashtriya Swasthya Bima Yojana – RSBY, Kalaignar Kapitu Thittam – KKT of

Tamilnadu and Arogyashree of Andhra Pradesh) health savings account, health

loans etc. A lot of work is involved in going for any of these options. A knowledgeable

administrator will be able to arrive at the right decisions to make the health care

facility economically viable.

Another challenge facing the administrator is ensuring quality. The National

Accreditation Board for Hospitals & Healthcare Providers (NABH) has prescribed

important standards. The administrator should not only be conversant with the

standards but should be able to make the necessary corrections within the institution

to ensure that the quality of health care is excellent.

At the recently concluded National Conference of the Administrators Conference,

there were some admirable presentations. In this edition of Clipboard I am presenting

two of the presentations. Their details are listed below

1. Training and Development: A Key to Excellence Mr Samuel N J David2. Brief overview on governance Dr Ashok Chacko

Further to the above I have covered in this issue an article regarding Six Sigma

in health care and the regular Legal Watch column.

Please send in you comments and suggestions.

Staying FOCUSEDStaying FOCUSEDStaying FOCUSEDStaying FOCUSEDStaying FOCUSED

We find loads of information all aroundus. Who can assimilate all the informa-tion that is available today? Are we ata loss if we don’t know it all?

Instead we should be actually lookingfor Wisdom and Knowledge. The Godwho is the Creator of all things says inthe Bible in Proverbs 9:10 that “Thefear of the LORD is the beginning ofwisdom, and knowledge of the HolyOne is understanding.” God has re-vealed Himself to us through His Wordand His Son Jesus Christ.

I have come to understand how invalu-able it is to be able to hear when God isspeaking to us. Such a man can easehimself from desperately seeking everybit of the ever-increasing informationthat is in this world.

He can stay focused because he knowswhere he got his guidance. It is from theOne who is perfect in Wisdom.

- Dr John Thomas

Secretary, Doctors Section, CMAI

2

Clipboard Issue 54, 55 &56

Training and Development:A Key to Excellence

The health industry is the fastest growing industry in the

world. Once associated with missionaries and philanthro-

pists this industry has become a multi- billion one with

many players in the market.

In any industry, as competition increases the product and

services move from the sellers market (where seller is the king)

to the buyers market (where customer/buyer is the king). In the

hospital industry also, patients/customers have big expecta-

tions and are well informed. Governments, organisations and the

laws of the land also support and facilitate this process. As

competition increases hospitals are forced to improve their

service, failing which redundancy or closure is inevitable (more

and more mission hospitals have been closed down since they

have not been able to withstand the onslaught of aggressive

competition by managing their hospitals professionally)

The hospitality sector, which includes hospitals, is growing at

a very fast race in India. Skilled employees are always in great

demand. Employees require a huge range of competencies

which range from core/professional/technical competencies to

basic competencies which can be defined as

� intellectual competencies (communication, creativity, anal-

ytical ability, planning and organising)

� social competencies (team work, interpersonal skills,

responsibility, customer satisfaction)

� emotional competencies (initiative, optimism, self-confidence,

leadership, managing stress and managing change) and

� motivation competencies (continuous learning, persever-

ance, achievement orientation and time management).

In a hospital (service provider), a customer/patient has numer-

ous service encounters where he meets various members of

the service provider belonging to different levels and profes-

sions. Even if one staff in the organisation is not aware of the need

to be customer focused in his communications and dealings with

the patients, it could be detrimental to the organisation and its

repute, while increasing the dissatisfaction level. It is absolutely

vital that all employees be made aware of the purpose statement

of the organisation and have a right attitude towards the patient.

In short skilled and trained human resource is invaluable. With

patients and customers being the focus, it is crucial that hospitals

gear up to address the training needs of their staff.

National Accreditation Board for Hospitals

and Health care Providers

National Accreditation Board for Hospitals & Health care Provid-

ers (NABH) is a constituent board of Quality Council of India, set

up to establish and operate accreditation programme for health

care organisations. The board has been structured to cater to the

needs of the consumers and to set benchmarks for the progress

of the health industry in India.

The standards require a documented training and develop-

ment policy for the staff which shall cover the following aspects:

19 standards and 23 objective elements pertaining to training

and development from the NABH standards is summarised

below.

� Proper induction of the staff which covers orientation of the

staff to the services and the service standards being deliv-

ered by the organisation

� The staff shall be well acquainted to the policies and

procedures of the institution and of the respective depart-

ments

� Inductive and ongoing training programmes in critical areas

such as infection control, disaster management, drug safety,

patient safety, end of life care, employee/patients rights and

responsibilities

� Ongoing programme for professional training and develop-

ment of the staff

� Maintenance of training and development records in the

employee portfolio

� Monitoring and evaluation of the training programme

including objective evaluation of the training outcome

Categories of training and development needs

The training and development requirements of the hospital staff

can be divided into the following three tiers keeping the core/

professional/technical and basic competencies in mind:

PPPPP Tier I: Critical Areas

PPPPP Tier II: Soft Skills

PPPPP Tier III: Functional/Technical Skills

Tier I: Critical Areas

This competency development area includes all those skill sets

and required knowledge which are directly associated with

quality of health care delivery. Many accreditation standards

recognise these skills and mandate the existence of training

and development programmes to impart them and document the

delivery.

Tier II: Soft Skills

In this era of patient-centric health care services, it is prudent

3

Clipboard Issue 54,55 & 56

A suggested administrative structure incorporating the Training and DevelopmentDepartment (Human Resource Development) for hospitals

* HRM – core HR functions such as appointments, confirmations, transfers, promotions, retirements etc.

**HRD – Training and development aspects of Human Resource as distinct from HRM

to develop positive behavioural skills in our employees. In

addition to service delivery, good soft skills are also important

for the success of the organisation as a whole. Organisations

across the globe have realised that professionals with just

technical skills only partly complement the essentials of being

a ‘complete professional’.

Tier III: Functional/Technical Skills

These skills form the core of the services provided by health care

service providers. A major chunk of these skills are imparted as

functional/ technical education before the employee joins the

organisation. But the organisations have the responsibility to

tweak these skills to their needs and ensure that acceptable

acumen is maintained by the provision of continued education

and on-the-job training.

Roles and Responsibilities

Employee

The Training and Development department (HRD) has the right

to expect of each member of staff:

� To develop his/her competence and capability in accor-

dance with Training and Development Policy and strategic

objectives

� To participate in all the mandatory training and development

activities

� To participate in the annual training and development

review process – this includes opportunities for appropri-

ate ongoing support, undertaking an annual review of the

individual’s past development and identification of plans

for the future

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� To become committed and take personal responsibility to

agree on an individual training plan, which will address

personal development as well as specific expertise, on a

regular basis

� To contribute to the nurturing and growth of an emotionally

safe, enjoyable and fulfilling working environment

� It will be mandatory for the staff to complete all the

prescribed modules in the stipulated time period

� Individuals will have to undergo pre and post training

assessment

� The staff will have to submit a completed signature sheet

& checklist to the Department of Training and Development

after the training cycle.

Training and Development Department (HRD)

- The Department will be responsible for the implementation

of the Training and Development Policy and administration

of the programme in the hospital

- The content, administration and responsibility of the follow-

ing aspects of the training and development programme will

lie with the Training and Development Department:

o Mandatory institutional induction programme

o Mandatory ongoing training in critical areas and soft

skills

o Need based training in Critical Areas and Soft Skills

o The records of all staff training and development partici-

pation to be maintained in the training portfolio

o Induction and training programme compliance reports

will be sent at the end of each training cycle to the

appointing authority as per the relevant staff categories

they are responsible for

o The score sheet of pre and post training assessment will

be formulated and forwarded to individual departments to

be included as a criterion in the performance appraisal

Training Cell Advisory Committee (TCAC)

� The Training Cell Advisory Committee (TCAC) consists of

representatives from different appointing authorities and

various other departments. This committee meets as and

when required to discuss and dialogue with representatives

from various appointing officers with regard to their training

needs and how best this can be incorporated into the training

schedule

Appointing Authority

� The above departments will send a monthly new starter list

with relevant details to the Department of Training and

Development

� To receive compliance reports from the Training and

Development department; and take suitable action against

the staff not complying with the training and development

policy of the institute

Individual Departments� The content, administration and responsibility of the

following aspects of the training and development

programme will lie with the individual departments

o Mandatory Departmental Induction Programme

o Mandatory ongoing Functional/Technical Training

- The departments will be required to perform

regular Training Needs Assessment to recognise

any gaps in employee performance

- The training and development scores and attendance will

be forwarded at regular intervals by the Training and

Development Department to the individual departments

which shall be used as a criterion for performance

appraisal

Quality Management Cell- The quality management cell will recognise any gaps in

training and development to meet the quality standards by

means of quality audits and communicate them to the

Training and Development department.

ConclusionIn today’s world where there is greater degree of awareness,

there is a stronger need for hospitals to develop its human

resources. Training is considered an integral part of HRD. No

HRD initiative can be conclusive without involving training at

one or other stage. Proper continuous training would greatly

contribute to the existing need for skilled human resource in the

health sector.

Samuel N J David

Sr Manager (Mgt Studies & HR) & Head

Department of Hospital Management Studies & Staff

Training and Development

Christian Medical College Hospital, Vellore

Dr Sandeep Moolchandani &

Dr Lawrence Tozoe

2nd year MHA students, Tata Institute of Social

Sciences

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Training and Development Process Flow

6


Brief Overview of GovernanceDefinitions of “Governance”

� Governance is the effective management of an organisation’s resources in a manner that is open and transparent, legally correct,

accountable, equitable and responsive to people’s needs.

� Governance is a process by which a governing body (the Board) ensures that an organisation is effective and runs smoothly.

� Governance is not about doing but about ensuring that things get done.

Balance of Power Between Governance & Management

Power is real & good but must be balanced between Governance

(Chair & Board) and Management (ES & Staff). The GB fails

when it cannot balance the power and cannot hold the ES & staff

accountable. The ES fails when the GB finds him/her incompe-

tent or unaccountable and then sacks him/her.

Two Types of Governing Models1. Guideline Based Model: This model has a set of standards

or a list of best practices prescribed by someone putting into

place rules that NGOs must follow. In this model, governance

problems are solved by looking to the rule book. The solutions

are straight-forward and cut through internal squabbles. But they

provide solutions in a blanket sort of way. They address every

governance situation and every board meeting at every time in

the same way.

John Carver’s Policy Governance has become the standard

textbook for governing NGOs. At its heart, is the principle that

boards must focus on ends and management must focus on

means. Boards achieve this by developing and approving

policies and then holding management accountable for effec-

tively operating the organisation within these parameters. Man-

agement implements these policies and acts on them. Thus,

there is a definite need for standards, guidelines and rules in

governance.

2. Principle Based Model: Here the focus is on identifying an

umbrella of governing principles and encouraging boards to

evolve their own best practices using these principles as their

framework. There are normally ten principles:

(i) Ethical Leadership & Stewardship: This is essentially

servant leadership with personal and social transfor

mation as its purpose. It puts the welfare of the group first

and lays down selfishness and ego issues. It includes

the moral responsibility to investigate truth and apply it.

It also plans for succession and renewal.

(ii) Strategic Planning & Direction: It visualises the future

and predicts where the potential lies ahead for the NGO

and will steer it towards this strategic direction.

(iii) Internal Control or Audits: (Financial and Project Evalua-

tion). This raises efficiency, provides safeguards, in

spires confidence among donors and gives everybody

timely and reliable information.

P O W E R

P O W E R

GOVERNING BODY

CHAIRPERSON

EXECUTIVE SECRETARY

(IES)

STAFF

The GB focus is on:

− the outcome of all activities and not on its details

− the ends and not the means

− strategic goals & direction

− executive accountability

The Chairperson:

− plays a legislative role

− works closely with the ES

The Executive Secretary

− plays an executive role

− works closely with the Chair

− makes operational decisions

− is concerned with staff performance & efficiency.

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(iv) Accountability: This has no meaning if a person doesn’t

know clearly what is expected of him, what his respon-

sibilities are, who he is accountable to and who the people

accountable to him are. Hence job descriptions and

skills required must be clearly stated and must be accom-

panied by a clear organisation structure, showing different

levels of authority, responsibility and accountability.

(v) Transparency: Information is the key to growth and must

be shared freely but responsibly because confusion will

result if information is carelessly handled and passed on

to those to whom it matters little. Nevertheless transpar-

ency is based on a free flow and availability of information

to those that want to examine it.

(vi) Communications: Reporting must be encouraged at all

levels for it is good process through which an NGO is able

to document, seek information, analyse results and make

suitable decisions for effective management. Reports also

serve as a mirror that reflects the NGO’s image and builds

credibility both in terms of its ministry and financial

accountability.

(vii) Organisational Sustainability: Involves not only adequate

financial resources but also human resources and de-

velopment to sustain its vision, mission and strategic

goals in an ever changing environment.

(viii) Systematic & Periodic Evaluation: It includes monitoring

management, evaluating GB, ES &staff and selecting

appropriate performance measures of all activities.

(ix) Ensuring Equity & Justice: This does not mean that an

immediate redistribution of resources or power will take

place. But it means that good governance will provide

necessary conditions that will give everyone access to

a level playing field that provides equal access to oppor-

tunities and resources to improve one’s capabilities.

(x) Continuous Learning & Growth: It includes the develop-

ment and training of Board members, Directors, Manag-

ers, Executives & other Staff.

The Principles for Functioning of the Governing

Body

1. Some boards are “rubber stamp” boards that give inadequate

attention to the running of their organisations. Other boards are

micro-managers of their organisations.

2. Harold Gensen, a management guru, said, “95% of boards

cannot carry out their purposes”.

Biblical Basis & Practice of a Christian Board

On behalf of the moral owners of the board / GB (who is our Lord

Jesus Christ, His universal Church, the City Church, the members

of the organisation, the donors and the community at large), the

GB will govern by taking pains to do what is right thus bringing

much glory to God

- Positively: The GB is accountable to the moral owners to

accomplish its purpose - which is the reason for the

existence of the organisation (e.g. what would happen if

this organisation was not there at all).

- Negatively: The GB is accountable to the moral owners

to avoid unacceptable means of operation (i.e. avoid any

illegal, unethical, imprudent ways of operation to accom-

plish the purpose).

Purpose of a Christian Board

(To take pains to do what is right)

1. To guard the vision, mission and direction of the organisation

2. To fulfill all government mandates

3. To organise itself to accomplish its governance work

effectively

4. To select senior leadership consistent with the practice of the

organisation

5. To deal with non-performing members of the Board

6. To decide when to meet and what to discuss and decide

upon

Distinguish Between Purpose (ENDS) & Opera-

tions (MEANS)Generally, the purpose (ends or vision & mission) of the Organ-

isation is the responsibility of the Board; whereas the operations

(means) are the responsibilities of the Executive staff.

A. Main job of the Board is to:

- determine the appropriate purpose (ends) of the organi-

sation, i.e. its vision, mission and reason to exist. The

overall purpose may not change drastically, but must be

fine tuned annually to meet changes in environment

- to hold the executive staff accountable to reach those

ends

- to be occupied with ends & macro governance. In fact, the

more time the board spends here to think out issues with

clarity, the easier becomes the job of the Executive

B. Main job of the Executive (ES or CEO & staff) is:

- everything that helps to accomplish the organisation’s

ends

2 Cor 8:20-21 We want to avoid any criticism of the

way we administer this liberal gift. For we aretaking pains to do what is right, not only in the

eyes of the Lord but also in the eyes of men.

The biggest problem in the functioning of a Board

(GB) is that the board members do not know what is

expected of them.

8


- to be occupied with efficient ministry, operations,

administration, hiring and firing staff (other than the ES),

accounting, planning, etc.

- to be occupied with Operations (means) and Micro man-

agement.

How a Board Operates

The Board members have no individual authority over the staff.

Their authority comes only through the process of deliberation

and prayer in which individual opinions are developed into a

single corporate voice expressed in policies and resolutions.

Diversity in view point is to be encouraged. But once a decision

through voting is taken, all members must support the final

agreement.

- Policies: are written standing instructions to the ES of

what he may or may not do.

- Resolutions: are also written instructions to the ES about

what he may do or not do

a. On a one time basis (e.g. buy land on a one time basis)

b. Updating or establishing new policies of what the ES

may or may not do

Four Main Categories that a Board Needs to Discuss &Decide:

1. Purpose or Ends (this is the most important of the four). This

will include the mission, vision, goals and objectives includ-

ing strategic goals of the organisation.

2. Governance Structure & Process: This will include the

governance style, the board responsibilities, write policies,

the criteria for Board members, brief new Board members,

define the role of the Chairman of the Board, how to conduct

Board meetings, Board member term of service and stand-

ing committees' principles.

3. Board/ES & Staff Relationship: This will include-delegation

by the Board to the ES (CEO), the ES’s job description, ES’s

accountability & reporting to the Board, ES’s performance

review by the Board & staff treatment.

4. Executive Parameters: This will include-financial opera-

tions, ministry operations, resource development and miscel-

laneous topics like external affairs.

Dr Ashok Chacko

Regional Director, EHA

[email protected]

Quality Council of India (QCI) and its National Accredi-

tation Board for Hospitals and Health care providers

(NABH) have designed an exhaustive set of standards

for health care delivery by professionals in medicine, dentistry,

nursing, pharmacy and allied health areas in hospitals and

health care institutions in India. The NABH manual consists of

10 stringent chapters comprising of 100 standards and 500+

objective elements for the hospital to achieve in order to get the

NABH accreditation.

To comply with these standard elements, the hospital will need

to have a process-driven approach in all aspects of hospital

activities – from registration, admission, pre-surgery, peri-

surgery and post-surgery protocols, discharge from the hospital

to follow-up with the hospital after discharge. Not only the clinical

aspects but the governance aspects are to be process-driven

based on clear and transparent policies and protocols. In a

nutshell, NABH aims at streamlining the entire operations of a

hospital.

NABH is equivalent to JCI and other international standards

including Australian Council on Health care Standards, SHQS

of Finland, Japan Council for Quality in Health Care and National

Committee for Quality Assurance (NCQA) of USA. The NABH

standards have been accredited by ISQUA, the apex body

Ripple in Health Care Through Six Sigmaaccrediting the accreditations hence making NABH accredita-

tion at par with the world’s leading hospital accreditations.

Why Six Sigma in health care?

In the present health care scenario, the requirement that the

customer is not only satisfied but delighted with the services

plays a very significant role in the highly competitive health care

market. Presently a major chunk of health care organisations is

going through the NABH accreditation process and some of them

have been accredited by the QCI and JCI. Six Sigma (6-Sigma)

comes into play once the standard processes or policies are

implemented in the hospital and it has started monitoring the

process capabilities or indices to root out the problems of the

customer. Once the standard operating processes are imple-

mented in the organisation, it is to be looked into, whether the

SOPs implemented in the organisation are capable of tackling

the problem of the process or not and whether the analysis of

indices is up to the mark or not. You may find the trend of the

problem but the root cause may still exist in the organisation and

to find out the root cause of the problem one needs to apply the

Six Sigma tools.

Benefits

Six Sigma concepts and methods enable a health care

organisation to offer improved health care services to patients

9


by streamlining business processes. In the health care industry,

the quality of services rendered depends a lot on human skills,

which is often very difficult to measure and control. Six Sigma

is effective as it is based on a comprehensive

approach that focuses on improving both human and

transactional aspects of a process. Although

implementing Six Sigma concepts in the health care

industry is a challenging task, it does help in getting

quick results.

In the health care industry, the factors that deter-

mine the quality and efficiency are usually the flow

of information and interaction between people. Six

Sigma helps in streamlining the flow of information

and achieving strategic business results by initiat-

ing cultural shifts throughout the organisation. 6-Sigma focuses

on improving processes rather than just concentrating on the

task, which helps in increasing the scope of improvements. It

provides the necessary tools and methodologies that help in

analysing and transforming human performance necessary for

achieving significant long-term improvements.

The Process

Six Sigma helps in defining a vision for the future, identifying

specific goals, and establishing quantitative measures for turning

that vision into reality. It helps in formulating goal plans and

setting timelines for moving from current performance levels to

Six Sigma performance levels. The plans are defined only after

documenting their effects on the organisation’s work processes

that may include flow of information, surgical site procedures,

handling patients and others.

The basic requirements for successfully implementing Six

Sigma programs are usually long-term vision, commitment,

leadership, management and training. It is important to provide

the requisite training to doctors, nurses and the administrative

staff for making them aware of the various concepts and meth-

odologies. The training may initially appear to be expensive, but

is often worth the cost when one considers the benefits such as

improved quality of services and increased efficiency. It is

necessary for employees working in a health care organisation

to develop an understanding about the various Six Sigma

concepts. This will help them in integrating new techniques into

the Six Sigma processes for improving quality and effective-

ness.

What is Six Sigma?

The term “Six Sigma process” comes from the notion that if

one has six standard deviations between the process mean and

the nearest specification limit, as shown in the graph, practically

no items will fail to meet specifications. This is based on the

calculation method employed in process capability studies.

Capability studies measure the number of standard deviations

between the process mean and the nearest specification limit in

sigma units. As the process standard deviation goes up, or the

mean of the process moves away from the center of the tolerance,

fewer standard deviations will fit between the mean and the

nearest specification limit, decreasing the sigma number and

increasing the likelihood of items outside specification.

Six Sigma is a business management strategy originally

developed by Motorola, USA in 1981. As of 2010, it is widely

used in many sectors of industry, including health care.

Six Sigma seeks to improve the quality of process outputs by

identifying and removing the causes of defects (errors) and

minimising variability in manufacturing and business processes.

It uses a set of quality management methods, including statis-

tical methods, and creates a special infrastructure of people

within the organisation (“Master Black Belts”,” Black Belts”,

“Green Belts” etc) who are experts in these areas.

Six Sigma methodologies aim at improving the overall quality

by eliminating defects and achieving near perfection by restrict-

ing the number of possible defects to less than 3.4 defects per

million. Six Sigma methodologies were originally developed for

implementation in the manufacturing sector but with time, their

use has spread to the services sector as well. In the services

sector, Six Sigma concepts are used mainly for eliminating

transactional errors. Today, the concepts and methodologies of

6-Sigma are increasingly being used in the health care industry

for improving the quality of services rendered, increasing effi-

ciency and eliminating human errors that can often prove fatal.

However, the use of 6-Sigma in the health care industry is a

relatively new phenomenon as compared to other service indus-

tries that have undergone some type of data-supported, system-

atic, quality-improvement process. With medical and techno-

logical advancements, the demand and expectations for im-

proved medical care are continuously increasing. However, due

to lack of effective management systems, inefficiency is in-

creasing, which often leads to congested emergency rooms,

customer complaints, and lost revenues.

Bill Smith (known as the Father of Six Sigma) first formulated

the particulars of the methodology at Motorola in 1981. Six

Sigma was heavily inspired by six preceding decades of quality

improvement methodologies such as quality control, TQM, and

Zero Defects, based on the work of pioneers such as Shewhart,

Deming, Juran, Ishikawa, Taguchi and others.

10


Six Sigma has been used to address many of the most

common challenges facing health care, including patient safety,

technology optimisation, market growth, resource utilisation,

length of stay and throughput. In some cases, it has been used

to focus on a specific department or process, and in other cases,

it has been implemented on an enterprise-wide basis to achieve

a cultural transformation.

The figures in the table below illustrate several health care

processes by sigma level. They also illustrate that sometimes

being 99 per cent effective is just not good enough in health care

delivery. And the figures show the value in striving for a Six

Sigma level of excellence.

Role of Six Sigma with 1.5 Sigma shift

Experience has shown that processes usually do not

perform as well in the long term as they do in the short

term. As a result, the number of Sigmas that will fit

between the process mean and the nearest specifica-

tion limit may well drop over time, compared to an initial

short-term study. To account for this real-life increase

in process variation over time, an empirically-based

1.5 Sigma shift is introduced into the calculation.

According to this idea, a process that fits six Sigmas

between the process mean and the nearest specifica-

tion limit in a short-term study will in the long term only

Sigma level DPMO Per cent

defective

Percentage

yield

Short-term

Cpk

Long-term

Cpk

1 691,462 69% 31% 0.33 –0.17

2 308,538 31% 69% 0.67 0.17

3 66,807 6.7% 93.3% 1.00 0.5

4 6,210 0.62% 99.38% 1.33 0.83

5 233 0.023% 99.977% 1.67 1.17

6 3.4 0.00034% 99.99966% 2.00 1.5

7 0.019 0.0000019% 99.9999981% 2.33 1.83

Source: GE Health care

Sigma Level

Patients With

Misplaced Personal Items

Coding Errors

Requiring Correction

Phone Calls Exceeding the

Two-Minute-on-Hold Limit

Defects/Million

Opportunities

Per cent Yield

3 Sigma 3,660 Every Day 770 Per Day 257 Each Day 66,800 93.32000

4 Sigma 340 Every Day 72 Per Day 24 Each Day 6,210 99.34900

5 Sigma 12 Every Day 13 Per Week 5 Each Week 230 99.97700

6 Sigma 6 Every Month 10 Per Year 3 Each Year 3.4 99.99966

fit 4.5 Sigmas – either because the process mean will

move over time, or because the long-term standard deviation of

the process will be greater than that observed in the short term,

or both.

Hence the widely accepted definition of a Six Sigma process

as one that produces 3.4 defective parts per million opportunities

(DPMO). This is based on the fact that a process that is normally

distributed will have 3.4 parts per million beyond a point that is

4.5 standard deviations above or below the mean (one-sided

capability study). So the 3.4 DPMO of a “Six Sigma” process in

fact corresponds to 4.5 Sigmas, namely 6 Sigmas minus the 1.5

Sigma shift introduced to account for long-term variation. This

takes account of special reasons that may cause deterioration

in process performance over time and is designed to prevent

underestimation of the defect levels likely to be encountered in

real-life operation.

Sigma levels

The table below gives long-term DPMO values corresponding

to various short-term Sigma levels. Presently most of the health

care organisations or the market use the Six Sigma for the

analysis and root cause find out purpose but almost at the door

is the Seven Sigma, which has more excellence in doing the job

with less DPMO than the Six Sigma as shown below.

11


� 5 Whys·

� Analysis of variance (ANOVA) Gauge R&R

� Axiomatic design

� Business Process Mapping

� Cause & effects diagram (also known as fishbone or

Ishikawa diagram)

� Chi-square test of independence and fits

� Control chart

� Correlation

� Cost-benefit analysis

� CTQ tree

� Design of experiments

� Failure mode and effects analysis (FMEA)

� General linear model

� Histograms

Quality management tools and methods used in Six Sigma

Within the individual phases of a Define, Measure, Analysis Improvement and Control (DMAIC) or Define, Measure, Analysis DESIGN

and Verify (DMADV) project, Six Sigma utilises many established quality-management tools that are also used outside of Six Sigma.

The following table shows an overview of the main methods used.

� Quality Function Deployment (QFD)

� Pareto chart

� Pick chart

� Process capability

� Quantitative marketing research through use of Enterprise

Feedback Management (EFM) systems

� Regression analysis

� Root cause analysis

� Run charts

� SIPOC analysis (Suppliers, Inputs, Process, Outputs,

Customers)

� Taguchi methods

� Taguchi Loss Function

� TRIZ (Russian)

Conclusion

There is no doubt that six sigma can cause ripples in the health

care sector. It is high time that many health care organisations

adopt measuring techniques to measure important parameters

to find whether they meet the required standards. This would not

only help them to save valuable cash but also deliver error free

health care services.

Mithleshwar Hembrom

MHA (TISS Mumbai)

[email protected]

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12


A

Q

A

Q Christian

Medical

Association of

India

ClipboardClipboardClipboardClipboardClipboardA CMAI publication focussing on issues

related to hospital administration

Published by

The General Secretary

CMAI, Plot no. 2, A-3 Local

Shopping Centre, Janakpuri

New Delhi 110 058

Tel: (011) 2559 9991/2/3

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Editorial Committee

Dr Vijay Aruldas

Dr Jeyakumar Daniel

Mr Innocent Xess

Sr Vijaya

Mr Samuel NJ David

Mr Edward David

Dr CAK Yesudian

Ms Jaya Philips

Editor

Mr Stephen Victor

Editorial Coordinator

Ms Jaya Philips

Design & Production

Susamma Mathew

Printer: New Life Printers Pvt Ltd

LEGAL WATCH

A doctor examines a person who

was brought to him and finds him

dead. The person does not belong

to the State where the hospital is

situated but to a very far-off place.

Those who brought the person are

not his relatives but strangers who

found him at the site of a road

accident. In this situation, to whom

should the doctor send the MLC; to

the local police where the hospital

is situated, or to the place where

the dead person belongs?

Whatever be the situation, for a

doctor who examines a person and

finds him dead, the cause of action

arises only from the hospital itself.

Therefore, jurisdictionally speak-

ing, the doctor has to inform the

local police station where the hos-

pital is situated. If the local police

do not take up the matter, then the

doctor can take the help of the

Superintendent of Police or the

Public Prosecutor.

A group of 20 people bring a person

to the hospital at odd hours, and

subsequently he is declared dead

by the doctor. The doctor feels that

the death occurred under mysteri-

ous/ suspicious circumstances.

But, the group threatens the doctor

not to intimate the police but re-

lease the body. How does the doc-

tor act in such a situation?

The doctor has to handle such

situations in a diplomatic most mis-

sion / rural hospitals are situated in

remote areas where the rule of law

cannot be enforced. Therefore, the

best way out for the doctors is to:

a. Release the body forthwith

b. Subsequently

and simultaneously, intimate the

police about the case as soon as

the group leaves the hospital. It is

up to the police to investigate the

matter. The liability of the doctor

A

Q

will be absolved if the doctor inti-

mates the police even though he

did not detain the body because he

does not have any magisterial pow-

ers to detain a dead body.

A person, who met with a road

accident, is brought in an uncon-

scious state to an emergency unit

for immediate treatment. But no

relatives or guardians are present

to give consent for treatment. In

this situation, from whom should

the doctor get consent for provid-

ing emergency treatment?

According to law, in such situa-

tions, only those people who

brought the person to the hospital

can be considered as local parents

(in loco parentis) and they can be

asked to sign the consent form. As

soon as the relatives/parents /

guardians come to the hospital, the

doctor / hospital can get their post

approval for the treatment already

given to save the patient’s life. All

courts accept this position because

it is the stated law.

Note: The term in loco parentis,

Latin for in the place of a parent,

refers to the legal responsibility of

a person or organisation to assume

some of the functions and respon-

sibilities of a parent.

***

***

clipboard april - december 2010

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