A Large Scale Implementation of Six Sigma at the

Skaraborg Hospital Group

Svante Lifvergren1, Alexander Chakhunashvili1, Ida Gremyr2, Bo Bergman2, Andreas

Hellström2
1
Centre for Healthcare Improvement, Chalmers University of Technology, 412 96
Gothenburg, Sweden and Skaraborg Hospital Group, 541 85 Skövde, Sweden,
svante.lifvergren@vgregion.se, 2Division of Quality Sciences and Centre for
Healthcare Improvement, Chalmers University of Technology, Sweden

Abstract
The Skaraborg Hospital Group (Skas) has a long history of quality improvement. The
strategy of Skas is to excel at quality development to be able to constantly orientate
towards and take actions to fulfill the need and expectations of its patients. Various
initiatives related to quality management are in place at SkaS. The Six Sigma initiative
here presented has been added to the current quality initiatives and has to date resulted
in more than 20 completed improvement projects. Experiences from those projects form
the basis of this paper.

Keywords: Six Sigma, Healthcare, Process Management

Introduction
The challenges of today’s healthcare are monumental. The proportion of elderly people
in the population is growing. Proportionately more people are developing multiple and
complex diseases and more treatment possibilities are available. As a result of this, the
cost of healthcare is increasing while cost containment is a pressing goal (OECD, 2007).
New ways of organizing health care systems are required to provide high quality care in
line with patient expectations. Future health systems must have a capacity for ongoing
improvement, innovation and development from within to meet the challenges. Specific
targeted areas for improvement are patient safety, accessibility, increased patient focus,
and improved efficiency and efficacy (IoM, 2001).
Unfortunately, many change efforts in the health care sector are neither successful
nor sustainable (Olsson et al., 2003). Surprisingly, it is not until recently that the
potential of utilising concepts from the industrial quality movement has been recognised
in healthcare. One such concept is Six Sigma aiming at improvement of various
processes and the achievement of strategic objectives through a systematic, data-driven
approach supported by an organisation of Six Sigma experts (Zu et al., 2008; Schroeder
et al., 2008). Reported applications of Six Sigma from healthcare contexts often concern
experiences from individual projects (van den Heauvel et al., 2004; Simmons et al.,
2004; Scalise, 2003). However, studies of Six Sigma in healthcare limited to the entity
of single projects do not seem as a feasible strategy to explore its applicability in this
context. On the contrary, Six Sigma affects an organisation on a broad scale as it e.g.

1
encompasses a parallel organisation of improvement experts and focus on solving
problems of strategic importance.
In this collaborative research initiative we explore experiences from a Swedish
hospital group involved in a large-scale implementation of Six Sigma. The case
presented in this paper is that of a Six Sigma implementation at the Skaraborg Hospital
Group (Skas). The strategy of Skas is to excel at quality development to be able to
constantly orientate towards and take actions to fulfill the need and expectations of its
patients. Various initiatives related to quality management are in place at SkaS e.g.
balanced scorecards, process improvement initiatives, breakthrough improvements and
Six Sigma. The Six Sigma initiative has to date resulted in more than 20 completed
improvement projects. Experiences from these projects form the basis of this research.
Before reporting on the practical experiences the following section provides a brief
theoretical background to Six Sigma and its applications in healthcare. The theoretical
background is followed by a description of the research method, and the remainder of
the paper is devoted to the empirical data and a discussion thereof.

Theoretical Background

Six Sigma
Many authors have described the story of Six Sigma and its development at Motorola as
well as its anticipated savings in various types of industries (Goh, 2002; Magnusson et
al., 2003; Prabhushankar et al., 2008). Others have identified Six Sigma as the latest fad,
encompassing nothing new but merely being a re-package of quality management
practices (Clifford, 2001). However, Zu et al. (2008) identify three practices of Six
Sigma that are new as compared to other quality management initiatives and that are
critical for Six Sigma implementation. These practices are the Six Sigma role structure,
the structured improvement procedure and the focus on metrics.
The role structure is often referred to as the ‘belt system’ and could be seen as a way
to standardize the improvement competences in an organization. The Black Belt role
signifies a co worker with advanced improvement knowledge, working fulltime as an
improvement expert. Green Belt competence is suitable for middle managers,
supervisors, engineers and improvement project members. The Green Belt role requires
the completion of a medium sized improvement project, in which a theoretical course of
four to six days is incorporated. Finally, the White Belt course leading to White Belt
competence is equivalent to the participation in a one day introductory improvement
course.
The systematic problem solving process in Six Sigma – DMAIC – is used to assess
the problems and search for root causes in the projects (Magnusson et al., 2001). In the
Define phase, the actual quality problem – the y - is formulated. Project and team
charters are developed. The underlying process is mapped and the y is then quantified.
In the Measure phase, possible root causes – xs – are assembled using fishbone
techniques. In the Analyze phase, the xs that influence the y are identified. In the
Improvement phase solutions are designed and implemented and cost/benefit analyses
are carried out. Finally, in the Control phase the solutions are documented,
institutionalized and verified.
In the Six Sigma measurement system, the quality results in the process to be
improved (the y metrics) are quantified and followed over time to ensure that suggested
solutions result in real improvements.
Based on case study data and literature, Schroeder et al. (2008, p 540) define Six
Sigma as ‘an organized, parallel-meso structure to reduce variation in organizational
2
processes by using improvement specialists, a structured method, and performance
metrics with the aim of achieving strategic objectives.’ Thus, an emphasis is put on the
parallel structure as well as on the application of Six Sigma in existing and established,
organizational processes. If those processes needs to be identified and/or developed, Six
Sigma proponents advocate the use of the sister concept for product and process
development – Design for Six Sigma (Antony, 2002; Berryman, 2002).

Six Sigma in Healthcare

In the health care area Six Sigma applications have been reported to shorten the patient
visiting time in hospitals, improve quality of care and contribute to more efficient
administrative processes (van Heuvel et al., 2004)). Practical applications of Six Sigma
in health care are described in e.g. van Heuvel et al. (2004), Woodard (2005) and Frings
and Grant (2005).
Stahl et al. (2003) argue that processes in the health care area often are poorly
designed compared to industrial processes. Hence, Stahl et al. (2003) believe that the
limitations of improvements in health care will be experienced earlier than in industrial
processes. Further, the need of a defined process owner and a process management
system has been identified as a key factor for sustained long-term improvements from
Six Sigma implementation in healthcare (Simmons et al., 2004).
In their review of quality improvement efforts in healthcare, Boaden et al. (2008)
conclude that ‘given the relatively unobjective accounts of Six Sigma in healthcare to
date, it is not possible to give independent views on the reported outcomes’.

Research Method
In the study, we have followed the Six Sigma program at SkaS for three years by
closely monitoring and participating in more than twenty larger improvement projects
using an action research approach.
Action research could be described as an orientation to inquiry where the intention to
improve the studied system plays a central role. Researchers and co
workers/practitioners share a participative community, in which all members are equally
important when generating actionable knowledge. Practitioners are thus considered to
be co researchers. Iterating action loops are central to the knowledge generating process
(Lewin, 1945; Aagaard Nielsen et al., 2006; Lewis, 1929).
In this particular context the first and second author could be considered to be inside
action researchers i) participating in and coaching the different projects, ii) leading
network activities to encourage knowledge sharing between the projects, iii)
quantitatively assessing the results of the projects and iiii) frequently discussing the
program with outside researchers, the third and the fourth author of this article.

Actionable knowledge in the individual projects

Many similarities reveal themselves when comparing the action-reflection loops central
to the knowledge generating process of action research (Lewin, 1945) with the learning
cycles (DMAIC) underpinning improvement efforts in Six Sigma. The iterative
DMAIC-loops could thus be seen as pragmatic action research reflection loops in which
practitioners and researchers also share experiences in order to identify critical success
factors and barriers to change, thus generating actionable knowledge (Aagaardh Nielsen
et al., 2006; Bradbury et al., 2008).

3
Project assessment
Two types of project results have been monitored throughout the program. First of all,
the goal fulfilment in every project has been assessed using line diagrams – did the
project reach its intended goals? We have assembled the reports from the projects after
nine months (at the official project closure time) and after eighteen months. On each
occasion, the project result – the improvement in y – has been compared with the
expressed aim of the project. If the aim was fulfilled, the project has been ranked as
successful; otherwise the project has been labelled ‘not yet’ successful. Secondly, in the
eighteen month follow up, the project manager together with the economist of the actual
clinic has estimated the net profit for each project during its first eighteen months.
In the nine month and eighteen month written project reports, the project managers
have formulated critical lessons learned during the different phases of their project.
These experiences have then been discussed conjointly on monthly knowledge sharing
meetings involving all the project managers. The intention of the meetings has been to
highlight important lessons from the individual projects in order to gradually refine the
common problem solving process used in the projects.

Six Sigma at the Skaraborg Hospital Group

The Skaraborg Hospital Group

The Skaraborg Hospital Group (Skas) is situated in the Western Region of Sweden and
serves a population of 260 000. The group consists of four hospitals – the hospitals of
Lidköping, Skövde, Mariestad and Falköping. The services offered by Skas include
acute and planned care in 30 different medical specialities. In total Skas has over 800
beds and approximately 4 700 employees. The hospitals annually handle 41 000
inpatient episodes, 204 000 outpatient doctors visits, 19 300 surgical procedures and
2300 births.
The hospital director is the executive officer of the four hospitals. The hospital group
is organized in a vertical structure that is typical of Swedish hospitals, with four
divisions – the divisions of Medicine and Psychiatry (MP), Surgery (S), Women and
Children Care (WCC) and the Lidköping Hospital (LH). Each division is headed by a
division manager and has a number of departments – so called clinics. Each clinic is
lead by a clinical manager, most often a physician. The annual turnover of the hospital
group is three billion SEK.

Quality Management at the Skaraborg Hospital Group

In the mid and late 1990s, ‘process improvement’ found its way into Swedish healthcare
(Kammerlind et al., 2007). As in most Swedish hospitals at that time, process mapping
at Skas was the tool preferably used to solve local problems in care processes. The
concept of process orientation was not considered to be a management idea but was
seen rather as a useful improvement tool. Nevertheless, using mapping processes to
identify problems in important patient flows often proved successful. The process
initiatives resulted in several successful improvement projects, although many outcomes
did not prove to be sustainable over time (Eriksson, 2005).
The Balanced Scorecard (BSC) was introduced as the main management system at
Skas in 2003. The use of BSC shifted the strategic discussion from a dominating
economic discourse towards a more balanced dialogue containing patient, process and
learning perspectives as well. The initiative can be viewed as a TQM strategy that
focuses on customer and process orientation together with continuous improvement

4
(Lifvergren et al., 2008). From then on, the strategy at SkaS has been expressed as ‘the
ability to excel at quality development’.
In 2005, SkaS combined its TQM approach with Six Sigma (ibid, 2008) to reach
breakthrough improvement. For the last three years, many improvement projects using
the DMAIC roadmap of Six Sigma have been carried through. Simultaneously, 45 black
belts and 200 green belts have been trained. As of today there are 25 process
managers/black belts at SkaS working full time with quality improvement. Almost 3000
co workers have participated in a two day white belt course.

The Six Sigma program

Twenty two larger improvement projects have been accomplished from 2005 to 2008.
Every participating clinic have had a standardized method to identify critical quality
gaps in core processes, thereby collecting its own improvement ideas suitable for Six
Sigma methods. Co workers and managers with a role in the projects have received a 3-
day education in Six Sigma methods. The projects have been managed by a certified
black belt or a black belt in training. For every project, a steering committee consisting
of the concerned clinical managers of the process to be improved has been formed. The
main purpose of the committee has been to continuously supervise the project to ensure
that it reaches its intended results. The members of every steering committee have
received a one day white belt course.

Results

Quantitative results
In Table 1, completed or soon to be completed projects are shown. The columns
describe in which clinical area the projects were carried out; in what years(s) the project
was (were) run, the project purpose, if the project reached its intended results (eighteen
month follow up) and what the net profit savings was the first year after implementation
of suggested solutions.

Table 1 – Overview of 22 Six Sigma projects at Skas

Project Clinical area Project purpose Year Goal Net profit,
number fulfillment; SEK
Yes/No/Not
completed
1 Psychiatry Improve cooperation 2007-08 Yes 150 000
between institutional and
non-institutional care
2 Medicine Lower blood sugar levels 2006-07 Yes 0
in patients with diabetes
3 Psychiatry Reduce unwanted variation 2006-07 Yes 220 000
in hours used for
supervising suicidal
patients at different
psychiatric wards
4 Medicine Reduce the number of leg 2008 Not -
ulcers completed

5 Emergency Reduce haemolysis in 2006-07 Yes 180 000

blood tests

5
6 Surgery Reduce variation in length 2006-07 No 0
of hospital stay for patients
with hip fractures
7 Surgery Reduce unnecessary 2006 Yes 244 000
cancellations of
orthopaedic operations
8 Surgery Minimize the number of 2007-08 No 0
patients that select other
hospitals than Skas for
elective orthopaedic care
9 Emergency Reduce the flow of 2007 No 0
patients to the emergency
department (SH)
10 Skas (Hospital Reduce the waiting times 2008-09 Not -
wide) for elective patient completed
transportation
11 Emergency Reduce the length of stay 2008-09 Not -
for patients at the completed
emergency ward
12 Women’s/ Lower the rate of 2006-08 Yes 0
children’s care Caesarean sections
13 Women’s/ Reduce the proportion of 2007 Yes 600 000
children’s care institutional care at the
Children’s Clinic
14 Women’s/ Reduce medication costs at 2007 Yes 1 400 000
children’s care the Children’s Clinic
15 Care support Optimize resource 2007-08 Yes 0
utilization in occupational
therapy process
16 Care support Optimize resource 2007-08 Yes 1 700 000
utilization in medical aid
process
17 Medicine Optimize resource 2008 Yes 1 000 000
utilization in obstructive
sleep apnea process
18 Skas (Hospital Reduce variation in lead 2008 No 0
wide) times to IT service support
19 Emergency Reduce waiting times at 2006 No 0
the emergency ward in
Lidkoping (LH)
20 Medicine Reduce variation in 2005-06 Yes 0
waiting times to the elderly
care homes in Lidköping
(LH)
21 Care support Reduce absence due to 2007-08 Yes 1 200 000
illness among co workers
22 Skas (Hospital Reduce variation in INR of 2005-06 Yes 100 000
wide) patients undergoing blood
thinning treatment as a
way to eventually decrease
mortality and morbidity

6
The assessment shows that the percentage of completed projects reaching their intended
goals within 18 months from project start equals 74 % (14 out of 19 projects). Twenty
of the twenty two projects here accounted for are educational projects, where the project
leader has been a black belt in training. Most projects have been selected from a patient
safety’s perspective and not from a cost of poor quality perspective. In spite of this, the
mean net profit savings per project amounts to 340 000 SEK It is also important to note
that we in this table have had a square-shaped approach to the assessment of the results.
Many of the ‘not succeeded’ projects have been the most valuable projects from a
learning perspective.

Action research - qualitative results

In the reflexive action-learning loops that have characterized both the individual
projects and the network meetings, many insights have gradually evolved and been
added to the problem solving process.
We can certainly support earlier Six Sigma healthcare experiences insofar as poor
process maturity seems to be a common cause of poor quality in many cases. The lack
of distinct responsibilities for important patient flows contributes to unnecessary
variation in process outcomes.
Our experiences also show that the DMAIC – roadmap is especially beneficial when
the root causes are unknown and the relationships are thought to be linear. However, in
some of the projects, it has been obvious that the processes to be improved are part of a
complex non-linear system, where the logic is more of dynamic complexity logic
(Senge, 1995; Stacey, 2007) than of linear cause-effect logic. The toolkit accompanying
Six Sigma does not include the archetypes that e.g. Senge (ibid.) recommends when
trying to improving complex systems.
The project managers have often worked in pairs with two projects at a time. The
approach has proved to be efficient when it comes to time utilization. On the other hand,
being two project managers carries a risk of not involving the actual project group to a
full extent.
Another point of departure in the network dialogues has been the project timetable.
Experiences from industry show that a project time of six to nine months is often
sufficient. In healthcare, the timetable appears to be critically different. Most often, the
implemented solutions seem to bear fruit after twelve months or more. Maybe this
phenomenon illustrates the complexity typical of healthcare systems – it takes time for a
solution to diffuse throughout the system (Fraser, 2002).
Many projects show that, although many root causes of unwanted variation can be
detected in or within groups of patients in the process, a principal variation factor not
present in industrial processes is the individual patient variation over time. This source
of variation seems to be one of the most important root causes to the aggregated process
variation.
The systematic, data-driven approach seems particularly attractive to physicians,
thereby reducing resistance to change. As expressed by one of the black belt project
managers:
‘The difficulties that I encountered at the beginning of the project were primarily due to
the problem of getting the doctors involved. Some of the doctors were very much against
the whole project. They know best themselves! And why should they put effort into an
improvement project when their hands are needed in the daily care of the patient? But a
great deal of the resistance could be eliminated by showing significant results. The
DMAIC problem solving process is excellent in this respect. A doctor rarely contradicts
a significant p-value! There aren’t that many arguments against that.’
7
Concluding discussion
This is the first large Six Sigma initiative in a Swedish healthcare context so far. We
believe that a prerequisite for its implementation can be found in the long history of
quality improvement at Skas – e.g. the use of process improvement and balanced
scorecards. The results show that Six Sigma is a useful concept when trying to improve
healthcare processes. We believe that a success rate of 70% proves that the problem
solving method should be added to the set of improvement tools used in common
healthcare development initiatives.
Our experiences from the recurrent dialogues when sharing lessons learned with co
workers and projects leaders, but also drawing conclusions from the project results,
have inspired us to design a revised Six Sigma management model more suitable for
healthcare systems. This model has been in use since 2007 at Skas. In the model, we
have added a sixth phase – L – which stands for Learn (figure 1 below). We believe that
it adds time for implementing solutions, but that it also creates the space and time for
reflection, a prerequisite for cultivating creative solutions that encourage the adoption of
new mental models.

D M A I C L

Define Measure Analyze Improve Control Learn

Formulate Measure the Analyze the Improve the Control and Summarize
the problem process, data and process by monitor the the project
determine determine designing new peocess and reflect on
Identify current state root causes alternative as well as your own
improvemen and quantify of the solutions and standardize learning
t areas the problem problem by selecting and integrate process.
Define the one you it into daily Continue to
project goals want to go work integrate
on with solutions into
the daily work

Figure 1 .The refined Six Sigma roadmap at Skas – DMAICL.

We believe that the Six Sigma program in a convincing way and from a bottom up
perspective has highlighted how process immaturity leads to severe problems in critical
patient processes. These insights have, in many cases, resulted in the swift creation of
distinct process roles for the actual patient flow after the completion of the projects.
Cronemyr (2007) describes similar experiences from an industrial context.
In other words, the Six Sigma projects have contributed to process maturity by
creating an awareness of process immaturity and catalyzing process design and
improvement work. In that respect, the program has created better conditions for the
next generation of improvement projects but also simultaneously stimulating other
continuous improvement activities. Another outcome of the increased awareness of
process immaturity is the decision to embark on DFSS work. Simply stated the aim of
Six Sigma can be summarized as minimizing variation in processes, whereas DFSS is
about designing products and processes that allow for more variation without
unintended outcomes. The experiences from this program supports earlier studies
8
indicating that the design of processes capable of Six Sigma performance is an urgent
need in healthcare, and that to sustain long-term improvements it is crucial that the
project result are handed over to a process owner (Stahl et al., 2003; Simmons-Trau et
al., 2004; Cronemyr, 2007).

References
Aagaard Nielsen, K., Sevensson, L. editors, (2006). Action Research and Interactive Research. Shaker
Publishing, Maastricht.
Antony, J. (2002). Design for six sigma: a breakthrough business strategy for achieving competitive
advantage.Work study 21(1): 6-8.
Berryman, M. L. (2002). DFSS and Big Payoffs. Six Sigma Forum Magazine 2(1): 23-28.
Boaden, R., Harvey, G., Moxham, C., and Proudlove, N. (2008). Quality Improvement: theory and
practice in healthcare. NHS Institute for Innovation and Improvement, Coventry
Bradbury, H., Reason, P. (2008). The Sage Handbook of Action Research. Sage Publications, London.
Cronemyr, P. (2007). Six Sigma Management. Göteborg: Chalmers University of Technology
Fraser, S (2002) Accelerating the spread of good practice: a workbook for health care, Chichester:
Kingsham Press.
Goh, T. N. (2002) “A strategic assessment of Six Sigma” Quality and Reliability Engineering
International, 18 (5) pp 403-410
Institute of Medicine. (2001). Crossing the Quality Chasm. National Academy Press, Washington DC.
Kammerlind, P, Kollberg, B. (2007), Kvalitetsmetoder inom svensk hälso- och sjukvård. In Elg, M,
Gauthtereau, Witell, L. Att lyckas med förbättringsarbete. Studentlitteratur, Polen.
Lewis, C. (1929). Mind and the world order. Dover Publications, New York.
Lifvergren, S et al. (2008). Lean Six Sigma i sjukvården. Sveriges Kommuner och Landsting, Stockholm.
Magnusson, K., Kroslid, D., and Bergman, B. (2003). Six Sigma, the pragmatic approach. 2nd ed,
Studentlitteratur, Lund.
OECD. (2007). OECD Health Data: Statistics and Indicators for 30 Countries. OECD, Paris.
Olsson J., Kammerlind P., Thor J., Elgh M. (2005). Surveying Improvement Activities in Health Care on
a National Level – The Swedish Internal Collaborative Strategy and Its Challenges. Quality
Management in Healthcare; Vol 12, 2005 No 4, pp 202-216
Prabhushankar, G. V., and Devadasan, S. R. (2008) ”The origin, history and definition of Six Sigma: a
literature review”, International Journal of Six Sigma and Competitive Advantage, 4(2) pp 133-
150
Revere, L., & Black, K. (2003). Integrating Six Sigma with Total Quality Management. Journal of
Healthcare Management (48), 377-391.
Frings, G. W. and L. Grant (2005). "Who Moved My Sigma. Effective Implementation of the Six Sigma
Methodology to Hospitals." Quality and Reliability Engineering International 21 (3): pp 311-328.
Scalise, D. (2003) “Six Sigma in quality put theory into practice”, Hospitals and Health networks, 77 (5)
pp 57-60
Schroeder, R. G., Linderman, K.,Liedtke, C., and Choo, A. S. (2008) “Six Sigma: Definition and
underlying theory”, Journal of Operations Management 26(4) pp 536-554
Senge, P.M. (1995). The fifth disciplin. Stockholm: Thomson fakta
Simmons, D., Cenek, P., Counterman, J., Hockenhury, D., and Litwiller (2004). “Reducing VAP with 6
Sigma – use quality improvement methodologies to enhance core patient care process”, Nursing
Managament, 35 (6) pp 41-45
Stacey, R. D. (2007). Strategic Management and Organisational Dynamics - The Challenge of
Complexity (Fifth Edition). China: Prentice Hall
Stahl, R., B. Schultz, et al. (2003). From incremental improvement to designing the future. Six Sigma
Forum Magazine; 2(2). Pp 17-26
van Heuvel, J., R. Does, et al. (2004). "Six Sigma in a Dutch Hospital: Does it Work in a Nursing
Department?" Quality and Reliability Engineering International 20 (5):pp 419-426.
Woodard, T. D. (2005). "Addressing Variation in Hospital Quality: Is Six Sigma the Answer?" Journal
for Healthcare Management 50(4): pp 226-236.
Zu, X., Fredendall, L. D., and Douglas, T. J. (2008) “The evolving theory of quality management: the role
of Six Sigma”, Journal of Operations Management 26(5) pp 630-650