Six Sigma in Healthcare Delivery

SIX SIGMA IN HEALTHCARE DELIVERY
Matthew J. Liberatore, Villanova University, 610-519-4390, matthew.liberatore@villanova.edu
ABSTRACT
This paper reviews and assesses the extant literature on the application of six sigma in health
care delivery, focusing on the areas of application, process changes initiated and outcomes,
including improvements in process metrics, cost, and revenue. The reported six sigma
applications were classified using a two-dimensional framework: area of application within
health care delivery and key process metrics improved. The findings suggest that although six
sigma has been effective in improving health care delivery, more emphasis needs to be placed on
improving the process of identifying and evaluating alternatives, and verifying that the changes
implemented offer significant and sustainable improvements.
INTRODUCTION
The United States continues to devote substantial amounts of its resources to health care. U.S.
health care spending growth decelerated in 2008, increasing 4.4 percent compared to 6.0 percent
in 2007. Hospital spending growth increased 4.5 percent to $718.4 billion compared to 5.9
percent growth in 2007. Health spending growth for state and local and private sources of funds
also slowed while federal health spending growth accelerated in 2008. Total health expenditures
reached $2.3 trillion in 2008, which translates to $7,681 per person and an increase to 16.2
percent of the nation’s GDP or Gross Domestic Product [132].
While health care spending continues to rise, so do concerns about health care quality. A major
impetus toward recognizing the need to improve health care quality and patient safety occurred
when the Institute of Medicine (IOM) released a report in November 1999 estimating that as
many as 98,000 patients die as the result of medical errors in hospitals each year [65]. Through
process and quality improvement efforts, the quality of health care for millions of Americans
improved in 2007 but significant variations in performance continue to leave many people
receiving substandard care [86].
The IOM report and the ongoing interest in improving operational cost and quality led a number
of authors to recommend the application of six sigma to health care in the US and elsewhere [6]
[21] [48] [60] [64] [68] [83] [92] [127]. Carrigan and Kujawa [16] states that six sigma is an
effective strategy tool that can be used to establish and sustain competitive advantage and
facilitate achievement of long-term strategic goals in health care. Physician participation is
critical, and strategies to support their engagement are discussed in [42].
Some authors suggest that Six Sigma grew out of the total quality management (TQM)
movement. TQM had a number of shortcomings, including not providing evidence of better
patient outcomes, increased satisfaction, or improved financials. These factors, along with its
inability to remove root causes of problems and demonstrate a strategic importance, led to
TQM’s eventual decline. In contrast, Six Sigma offers time and money deliverables; the sigma

2011 Northeast Decision Sciences Institute Proceedings - April 2011 Page 440
metric to indicate the current state of process, outcome, or service quality; and a focus on
improving the “critical to quality” (CTQ) characteristics vital to internal and external customers
[11]. Woodard [143] describes evolution of quality control methods and compares them to six
sigma, and ultimately advocates for six sigma. However, Landek [76] argues that six sigma is a
useful tool that may not be effective in hospitals because of the cash and resources required.
Neff (2003) states that six sigma can be overwhelming in scope if not broken down into
manageable pieces, and requires significant investment in time.
The purpose of this paper is to review and assess the extant literature on the application of six
sigma in health care delivery, focusing on the areas of application, process changes initiated, and
outcomes, including improvements in process metrics, cost, and revenue. Those areas that have
seen the most successful application are identified, and suggestions for other application areas
and improved usage of six sigma are discussed.
OVERVIEW OF SIX SIGMA
Six sigma is credited with helping Motorola win the Malcolm Baldridge Award in 1988. Six
sigma is a process improvement goal that was developed by Motorola in the early 1980s and
subsequently has been adopted by many organizations. Traditionally a capable process was one
in which its natural variation of plus or minus three standard deviations, or sigma, from the mean
was less than the target specifications. Under the assumption of normality, this translates to a
process yield of 99.73 percent. Motorola's Six Sigma asks that processes operate such that the
nearest target specification is at least plus or minus six sigma from the process mean. This
translates into an error rate of 2 parts per billion. Often, an error rate of 3.4 parts per million is
associated with Six Sigma quality, under the assumption that the process mean can shift 1.5
standard deviations on either side of the mean [80].
Six Sigma projects are undertaken to improve the process of interest, focusing on the CTQ. A
structured approach is used to uncover the root cause of problems using the DMAIC (Define-
Measure-Analyze-Improve-Control) methodology:
Define the problem within a process
Measure the defects
Analyze the cause of defects
Improve the process performance to remove causes of defects
Control the process to make sure defects do not recur.
DMAIC is a data-driven process that uses various quality and process improvement tools that
have been developed over time, including: statistical analysis, cause and effect diagrams
(fishbone, Ishikawa), control charts, design of experiments, Pareto Analysis, process mapping,
Failure Modes and Effects Analysis (FMEA), Quality Function Deployment (QFD)/House of
Quality, and Suppliers, Inputs, Process, Outputs, and Customers (SIPOC diagrams), among
others.
Organizations that use Six Sigma emphasize employee participation and training through three
levels:
Green belts: individuals that have completed basic training and participate in Six Sigma projects

Black belts: individuals competent to serve as on-site consultants and lead project teams
Master black belts: individuals who have mastered the Six Sigma process and are capable of
teaching it to others and acting as resources for project teams [35] [93].
Six sigma is sometimes combined with lean management, which is based on the principles of the
Toyota Production System [141] [142], and the resulting method is called lean six sigma. A
kaizen event may be used, which is a focused, intensive, short-term project targeted to improve a
process. Jacobson and Johnson [67] argue that the combined implementation of lean and six
sigma drives effective results in healthcare, when DMAIC and the lean principles of speed,
efficiency, and immediate action are applied. Daley [28] addresses the most common
misconceptions regarding lean six sigma using several mini cases to provide anecdotal evidence.
LITERATURE REVIEW
There are some studies that have attempted to assess the implementation of six sigma in health
care. Martin and McLennan [82] surveyed health care organizations and found that six sigma
was the most common approach utilized by nearly one in five (18.5%) of the respondents
followed closely by lean processes (13.3 %). Antony et al. [6] include a summary of outcomes
and financial savings from ten health care organizations having six sigma programs. Of the ten
firms, six were able to estimate cost savings and/or revenue increases. Revere et al. [105]
provide a summary of some six sigma applications, while Gras and Philippe [54] review the
application of six sigma in some clinical laboratories. All of the specific applications mentioned
in these reviews are included in our application review if sufficient information was found in
either these or other articles.
RESEARCH METHODOLOGY
To identify those journal articles that describe the application of six sigma in healthcare, an
extensive literature search was conducted. The research process used the keyword “six sigma,”
in combination with the keywords “healthcare,” “health care,” and “hospital.” We searched Pub
Med, ABI/Informs Proquest (business), Compendex (engineering), CINAL (The Cumulative
Index to Nursing and Allied Health Literature), and PsycINFO using these keywords.
The topics of the articles that were uncovered in the database searches were screened to
determine if the six sigma methodology had either been recommended for application or actually
applied in a health care context. Our search excluded conference proceedings and doctoral
dissertations since we assume that important research will eventually appear in academic or
professional journals. We also exclude non-English language publications from our search.
Applications were included in this review if they provide sufficient details concerning the study
approach, process changes initiated, and the results achieved, often including improvements in
metrics.
RESULTS
Ninety-seven six sigma applications were identified, and address a variety of application within
health care delivery, as shown in Table 1. At the highest level, area of application was defined to

include inpatient care, therapeutic support, emergency care, ambulatory care, and administrative.
Inpatient care includes the processes associated with the major flow of patients through a
hospital or medical center, including admission, medical/surgical, critical/intensive care, hotel
services, and discharge. For example, hospital admission and pre-registration processes and the
time required to obtain subsequent treatment are areas that have been addressed using six sigma.
These studies indicate that six sigma has been effective in improving admission-related
processes, and is an area of application that might be considered by more hospitals.
Table 1: Six Sigma Applications in Health Care Delivery
Inpatient
Admissions
 Registration process
 Pre-registration system
 Bed assignments for patients needing to be isolated
 Development of kidney transplant list
Medical/Surgical
 Catheters: infection, UTIs, groin injuries, insertion
 Cardiac surgery infections
 Insulin, heparin, breast milk administration
 Correct blood transfusions
 Double stapling technique (surgical procedure)
 Incidence of falls pressure
 Medication errors, timing, compliance, usage
 CHF, COPD, Ventilator, Delivery Room LOS
 Surgery, OR TAT & productivity
 Pain management, nursing efficiency
Intensive/critical care
 Ventilator days spent, incidence of pneumonia
 Transfer time to regular patient unit
 Compliance with hand hygiene regulations
Hotel services/discharge/other
 TAT for bed assignment
 Time to complete patient discharge: routine, SNF, Medicare
 Centralized equipment delivery
 Removal of old inventory
 Unresolved work orders
Therapeutic Support
Laboratory
 TAT for ED laboratory orders
 TAT for MCI test

 Pneumatic tube system wait/travel time
 Laboratory requisition errors
 Phlebotomists’ efficiency
Diagnostics/Radiology
 Defect rate of X-ray films
 Communicating findings without defects
 Test wait time
 Report creation time
 Stress test TAT
 Mammography screening cycle time
 Radiology scheduling process
 CT capacity
Pharmacy
 Medication safety, errors
 In-hospital drug sales
 Pharmacy call backs to physicians
Emergency Care
 Physician turnover
 Reduce patient “walk out” rate: improve flow; add capacity, reduce staff turnover
 Patient flow: throughput rate, LOS
 Door-to-doctor time
 Patient wait time for treatment
 Patient wait time for a bed
Ambulatory Care
Ambulance
 Best hospital destination, response time
Home health
 Prospective payment system – process automation
 reduce low utilization payment adjustments
 use of telehealth device
Outpatient/Surgical Clinics
 LOS for post-anesthesia and ambulatory surgery
 Medicine dispensing errors
 Patient access to OB/GYN clinic
 Delays in starting treatments for oncology patients
 Wait time from lab order placement to specimen collection
 Reduce rate of follow-up to new patient in Genitourinary Medicine clinics

Administrative
Billing/Employee Management
 Billing accuracy
 Number of invoice mistakes from temporary employment agencies
 Employee recruitment process time
 Employee vaccination rate
 Develop tool for staff effectiveness
Figure 1 shows the number of reported six sigma applications over time. Note that the initial
applications coincided with the publication of the IOM report. After a period a rapid growth,
the number of reported six sigma applications has remained steady since 2004, the year when the
first lean six sigma application appeared. Interestingly, the number of reported lean six sigma
applications has remained at a steady level since 2005, perhaps indicating that those health care
organizations that are adopting lean principles are not necessarily combining their efforts with
six sigma.
Figure 1: Reported Six Sigma Applications in Health Care Delivery Over Time
16
14 14 14 14
13 13
12 12 12 12
10 10
Count of Applications
8 8 8 8
6 6
4 4 4 4
1 1 1 1
0 0 0 0 0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Six Sigma Lean Six Sigma Total
ANALYSIS
To obtain a better understanding of the extent of successful Six Sigma implementation, the
reported applications were classified using a two-dimensional framework: area of application
within health care delivery (as described above) and key process metrics improved (Table 2).
The second dimension, process metric, includes defect rate, medication error, process time,
compliance rate, and productivity. We note whether data on the level of improvement of the
metric(s) are provided, whether cost and revenue improvements were obtained, and whether the
application is six sigma or lean six sigma.
Focusing first on the rows in Table 2, we see that of the 97 applications reviewed, the health care
delivery areas receiving the most attention are medical/surgical (33), diagnostics (14), and
emergency care (11). These applications offer useful information and guidance to other health

care organizations facing similar problems. A limited number of applications were found in
inpatient areas such as admission, discharge, and hotel services, which should be amenable to six
sigma process and quality improvement efforts. Also, limited applications were found in
ambulatory care areas such as surgery and clinics, which face issues similar to those in the
medical/surgical area. In addition, there were no reported applications in other support areas
within the hospital such as respiratory therapy and rehabilitation, as well as in physician
practices, an important area of primary care. These findings suggest that six sigma can see much
more widespread application in health care delivery.
Second, nearly all of the reported applications indicate the level of improvement of the key
process metric after implementation. Only about one-third of the applications translate the level
of process improvements into cost savings or revenue enhancement to demonstrate value and
significance. The value of six sigma applications need to be clearly demonstrated to help
maintain commitment to the process changes implemented. Along the same lines, only three of
the applications discussed the sustained improvement in the key metrics. The control process is
critical, so that the process and quality improvements are maintained.
Six sigma focuses on reducing process variation and errors, so it is clear why over one-third of
the reported applications have error rate (defect rate, medication errors, or compliance rate in
Table 2) as their driving metric. Of the remaining applications, about one-third focus on process
time (e.g., cycle time, TAT, LOS, wait time) and slightly less than one third focused on
productivity (e.g., resource utilization, throughput, capacity) metrics. Selection of the key metric
is a critical task that directs six sigma process improvement efforts.
CONCLUSIONS
In this paper we have reviewed the reported applications of six sigma in health care delivery and
presented a two-dimensional framework that has categorized the applications by area and the
metrics improved. Our research demonstrates that many health care organizations have reported
the application of six sigma or lean six sigma. Across the reported health care delivery
applications, DMAIC is widely used to implement six sigma, and a number of hospitals have
utilized consultants, including GE Healthcare Systems. Over time, the number of reported six
sigma applications has remained at a steady rate. Hospitals that have not implemented six sigma
or lean six sigma can learn from the successful applications discussed in this paper.

Table 2: The Six Sigma Applications in Health Care Delivery Literature Classified Using a Two‐Dimensional Framework
Functional Area Defect Rate Medication Error Process Time Compliance Rate Productivity Total
Inpatient Care
C C R C
Admission [111**],[43* ], [46** ] [115** , 58** ] 4
R C CR C
[1** ], [109***], [122** , 41**, [135** , 30 ,134], [32],
[47**, 120], [33*], [84*], [27*, [109**], [9**], C C
C 52** ], [98**], [121**], [10 , C [44**], [50** ], [111**],
55*, 90**], [57**], [59***], [40** ], [77, 99, [125 ], [25*],
C C C
Medical/ Surgical [116**], [88**], [29], [137**] 144], [37] 135 , 134 ], [95**] [102***] [73**], [140** ], [34**] 33
C
Intensive/ Critical [118**] [4**], [69** ] [38**] 4
Hotel Services [100**] 1
C
Discharge [123**], [5*] [12** ] 3
C C
Other [110**] [30 ], [78 , 117**] 3
Therapeutic Support
C C
Laboratory [75**], [91** ], [117**] [106**], [128** ] 5
R R C
[79** , 119** ], [7** ],
[19**], [71*], [139**], [117**,
C C C C
Diagnostics [23** ], [53**] [104** ], [18*], [51**], [138**] 26* ], [8, [39** ] 14
C
Pharmacy [97**], [17*] [85**] [61** ] 4
Emergency Care
C
[81**], [124**], [45**], [111* ],
C R R
Emergency Care [63** ], [129** ], [113**] [24**], [74], [96*], [78** ] 11
Ambulatory Care
C
Ambulance Operations [126** ] 1
C C
Home Health [37 ], [82** ] [108***] 3
Surgical [62**] 1
R
Clinic [19*] [14** ], [66] [2**, 56**, 3], [107**, 26**] 5
Administrative
C C
Billing [117** ], [30 ] 2
Employee Management [117**] [72**], [91*] 3
C
Legend: []articles in brackets relate to the same applicatio n, *beginning o r ending metric, **beginning and ending metirc, ***beginning, ending and sustained metric, co st savings,
R
revenue generated, bo ld Lean Six Sigma applicatio n

For those applications applying DMAIC, statistical analysis is sometimes used to identify the
sources of process variation. Process and other changes typically are developed in response to
the major drivers of variation, but are sometimes implemented without statistical or other proof
that the change is valid. On the other hand, in some cases we have sufficient statistical power so
that even miniscule differences of no practical value will be seen as significant. More attention
needs to be directed to make certain that the changes implemented are of statistical and practice
significance.
Generally, mathematical, computer, or statistical modeling are not used to help identify the best
course of action, or to predict the change in behavior before implementation. There are
opportunities to increase the use of modeling to improve the analysis phase of DMAIC.
Overall, six sigma has made important contributions in improving health care delivery, and
should find increased application, often in conjunction with lean management.
ACKNOWLEDGEMENT
The author would like to thank his graduate assistants, Kristin Miller and Donald Morris, for
their assistance in completing this research.
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SIX SIGMA IN HEALTHCARE DELIVERY

Matthew J. Liberatore, Villanova University, 610-519-4390, matthew.liberatore@villanova.edu

OVERVIEW OF SIX SIGMA

Table 1: Six Sigma Applications in Health Care Delivery

Six Sigma Lean Six Sigma Total

[3] Ahmed-Jushuf, I., and V. Griffiths. B., "Reducing Follow-Ups: An Opportunity to

[8] Benedetto, A. R., "Adapting Manufacturing-Based Six Sigma Methodology to the

[14] Bush, S. H., M. R. Lao, K. L. Simmons, J. H. Goode, S. A. Cunningham, and B. C.

[18] Cavagna, E., R. Berletti, F. Schiavon, B. Scarsi, and G. Barbato, "Optimized

[25] Christopher D. A., A. Campbell, and J. Dateshidze, "Working Smarter with

[38] Eldridge, N. E., S. S. Woods, R. S. Bonello, K. Clutter, L. Ellingson, M. A. Harris, B. K.

[55] Griffin, B., H. Cooper, C. Horack, M. Klyber, and D. Schimmelpfenning, "Best-

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[68] James, C., "Manufacturing's Prescription for Improving Healthcare Quality,"

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[88] Neri, R. A., C. E. Mason, and L. A. Demko, "Application of Six Sigma/CAP

[95] Parker, B. M., J. M. Henderson, S. Vitagliano, B. G. Nair, J. Petre, W. G. Maurer, M. F.,

[116] Shukla, P. J., S. G. Barreto, and M. S. Nadkarni, "Application of Six Sigma

[118] Simmons-Trau, D., P. Cenek, J. Counterman, D. Hockenbury, and L. Litwiller,

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