professional practice Health Updates

Six Sigma
by Pam Carter, RN, COHN-S, FAAOHN

When I was first introduced to the Six Sigma process, I resisted it with every ounce of energy I had. I continuously fabricated reasons so that I was unable to complete the training that my company required. When it came time for my performance review, I could not hide the truth from my manager; I had not completed the required training. It was then that I began my journey into the world of Six Sigma. Once I understood that a black belt and a green belt certification had nothing to do with karate, I felt much better.

xactly what is Six Sigma? Sigma, a Greek letter used in statistics, represents the amount of variation in a process, a set of data, or anything measurable. The Six Sigma process is used to eliminate defects and inefficiencies in a process or service. The process has adopted the belt system used in karateblack belt, green belt, and yellow beltto signify the level of training and performance an individual has completed. The Six Sigma method was introduced in the mid-1980s at the Motorola Corporation when the company began to focus on strategies to reduce product defects. As a result of those efforts, Motorola won the Malcolm Baldridge National Quality Award in 1988. Today, Motorola holds the trademark for Six Sigma. In the mid-1980s, Motorola partnered with several other companies, including AlliedSignal, Kodak, IBM,
ABOUT THE AUTHOR

Ms. Carter is Occupational Health, Safety and Wellness Manager, Albemarle County, Charlottesville, VA. The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Pam Carter, RN, COHN-S, FAAOHN, 122 Mohican Trail, Ruckersville, VA 22968. E-mail: pcarter@albemarle.org. doi:10.3928/08910162-20101124-02

Texas Instruments, and ABB (Asea Brown Boveri), to found the Six Sigma Research Institute. General Electric increased the popularity of Six Sigma when Jack Welch committed to achieving Six Sigma capabilities for the company. One of the primary goals of the process is to eliminate anything that does not meet customers needs. Phrases such as the voice of the customer or customer delight are often heard. Often, process owners may think they know what their customers want and expect; in reality, however, process owners and customers may not be in agreement. Therefore, one of the essential tasks of Six Sigma is to establish what is important to customers. What is critical to the quality of the product or process from the customers standpoint? This information is referred to as CTQ (critical to quality). The Six Sigma process uses two defined methodologies, DMAIC and DMADV. DMAIC involves five steps: define, measure, analyze, improve, and control. It is used to improve an existing process. DMADV (define, measure, analyze, design, and verify), on the other hand, is used when a new process or service is needed. This article focuses on DMAIC.

Define Once a process or service has been identified as needing improvement, the next step is to identify potential team members who are familiar with and knowledgeable about the elements of that process or service. Often, a master black belt discusses the project with the leadership of the organization to determine the value of the project and identify the appropriate individual to lead the team. Responsibilities are generally divided into four areas: 1. Team sponsorA representative from the leadership of the organization who has the power to dedicate necessary resources to the project and also insight about the value of the project. 2. Team coachThis individual is often a master Six Sigma expert, having extensive training in the Six Sigma process and providing technical support to the team. The team coach is often the person who suggests which type of tools would best support the analysis. 3. Team leaderThis individual has received training in the Six Sigma process, but not to the degree of a master black belt. The team leader is responsible for meeting the goals of the project and providing continuous direction to keep the team moving forward. 4. Team membersThese are the individuals who are most familiar with the process or service needing improvement. They execute the work of the project. A cross-functional team is important (e.g., including an individual familiar with the financial aspects of the process to add financial importance to the project). Once the team has been identi-

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fied, the project must be defined. To accurately focus on the correct issue, the team must understand customers expectations and needs. Meeting with customers to clarify their needs and expectations can be beneficial. Without a clear understanding of customers needs and values, the teams work may be useless. It may also be beneficial to identify measurements that would assist the team and customers in evaluating progress toward improvement. Measure Next, the problem is investigated in detail. Data are used to determine when, where, and how the problem is occurring. Accurate and appropriate data are essential because all decisions are data driven. Data can have numerous sources. Customers can provide data supporting their complaints. Individuals involved with executing the process or service can offer data. A request for data often leads to additional requests for data. The team may find that some of the data have already been collected. Data should be collected over a sufficient period of time to provide an accurate representation of the process being investigated. A process map may be beneficial for identifying each step in the process and the data actually needed. If data do not accurately reflect the problem, the process begins again with the team clearly defining how to gather the desired data. Analyze Now, the team seeks to understand the data that have been collected and make sense of the existing process. In the analysis phase, the problem is clearly identified and confirmed. The team looks for trends and patterns based on the data and identifies the problems root cause. The team must use the data, not individual opinions, to reach conclusions. Improve In the improvement phase, solutions are identified and implemented to address the root cause of the prob-

Examples of Tools and Visual Aids Used Throughout the Six Sigma Process
Pareto charta bar graph used to identify which issues will yield the greatest improvements. Most effective when analyzing data regarding the frequency of a problem. May also be used to display the relative significance of the differences between groups of data. Cause-and-effect diagramoften referred to as a fish bone because it resembles a fish skeleton. The problem is the head of the fish, and the various causes are the bones of the fish. It helps the team identify which causes need to be investigated by collecting additional data. Scatter plotused to determine if a relationship exists between two variables. Assists in determining a hypothesis. The data used are often those collected by the cause-and-effect diagram. Histogramused to graphically summarize and display the distribution of a process data set. For statistically sound data, 50 to 100 data points are needed to identify reliable patterns. A histogram will identify any outliers or if the data are symmetrical.

Table

Examples of the Practical Meaning of Six Sigma

99% Good (3.8 Sigma)
Incorrect surgeries per week Incorrect medication prescriptions per year Time without electricity Lost pieces of mail per hour 5,000 200,000 7 hours per month 20,000

99.99966% Good (6 Sigma)

1.7 68 1 hour every 34 years 7

lem. Creativity may be necessary to identify new approaches or best practices with a demonstrated record of success. Some team members may wish to continue using current practices; however, the teams analysis has demonstrated that those methods are inadequate, so the team must identity new ways to operate. Once new strategies are identified, an implementation plan is needed. Other associated processes may be impacted by this change, so these processes may also require evaluation. Control In the last phase, controls are developed to prevent the problem from reoccurring and to ensure that fixes are maintained over time. These controls may include retraining or devel-

oping and implementing a monitoring or auditing system to ensure that improvements continue. CASE STUDY An example of using Six Sigma methodologies in health care could be applied to reducing medication errors. The first step is to obtain approval and support from senior leadership. Once this support has been obtained, the next step is team formation. Possible team members might include nursing staff, physicians, risk managers, and pharmacy staff. Once the team has formed, the project must be defined. Medication errors and opportunities for medication errors would need to be defined to compute Six Sigma levels. Be-

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cause errors and opportunities can be classified into three categoriesprescription errors, dispensing errors, and administration errorsthe team may choose to work on just one category or all three. The problem and customers expectations must be clearly understood. In this case, customers may include patients, the pharmacy, or risk managers. The expectation would be to properly dispense the correct medication at the correct time to the correct patient. The next step is measurement. This would be accomplished by collecting data such as number of medication errors, categories of errors, when and where errors occurred, method of administration, ordering physicians, and administering personnel. Now, collected data are analyzed. During this step, the team may find that additional data are needed. When analyzing the data, trends must be identified. Perhaps a specific physicians orders are one common

denominator in errors, or errors may be originating from a particular nurse who has been administering medications. Next, the team identifies ways to improve or solve the problem. In this case, a policy change may be needed, with all medication orders being entered into a computerized system, thus eliminating hand written orders. The last step is the control process. In this case, use of computerized medication orders may need to be monitored. Conclusion Throughout the process, numerous tools and visual aids, including Pareto charts, cause-and-effect diagrams, scatter plots, and histograms (Sidebar), are used. The types of data collected determine the tools best suited for the needed analysis. Sound project management principles are also used to achieve success. Health care professionals use

the Six Sigma process routinely in practice. They may not refer to it by name, but they have been trained to make decisions using a scientific or evidence-based process. The benefits of Six Sigma methodologies are numerous (Table). Six Sigma provides structure and an objective method for identifying and addressing business problems. Using Six Sigma ensures quality, which in turn ensures that defined customer needs are met. Customer satisfaction is the foundation of profitable businesses. BIBLIOGRAPHY
Barry, R., Murcko, A. C., & Brubaker, C. E. (2002). The Six Sigma book for healthcare. Chicago: Health Administration Press. Brassard, M. (1994). The Six Sigma memory jogger II. Salem, NH: GOAL/QPC. Esimai, G. (2005, April). Lean Six Sigma reduces medication errors. Quality Progress, 51-57. Harry, M. J. (1994). The vision of Six Sigma. Phoenix, AZ: Sigma Publishing. iSixSigma. (n.d.). iSixSigma.com. Retrieved from www.isixsigma.com

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