The Use of Six Sigma inHealthcareJayanta K. BandyopadhyayAnd Karen CoppensCentral Michigan UniversityMt. Pleasant, Michigan, U.S.A.

International Journal of Quality & Productivity ManagementVolume 5, No. 1 December 15, 2005Bandyopadhyay andCoppensSix Sigma Approach to Healthcare Quality and Productivity ManagementByJayanta K. Bandyopadhyay and Karen CoppensCentral Michigan UniversityAbstract:For decades the U.S. health care industry has been operating on its own way ignoringemerging factors such as competition, patient safety, skyrocketing health care cost, liability,malpractice insurance cost and use of DRG for Medicare and insurance payment. However, asthese factors became more prevalent and competition within the industry intensified, many U.S.hospitals have been becoming increasingly aware of the critical needs of controlling theoperating costs and meet and even exceeds the expectations of patient care quality. This paperpresents a model of Six Sigma approach to health care quality management for hospitals in theU.S. and abroad.Keywords: six sigma, quality and productivity management in healthcareIntroductionThe health care industry in the U.S has been operating on its own traditional economicdomain ignoring current emerging factors such as competition, patient safety, skyrocketinghealth care cost, liability from malpractice lawsuits and more government control on Medicarepayment.( Hansson, 2000). But in recent years, these factors have become more prevalent andcompetition within the industry has been intensified, and many U.S. hospitals has beenbecoming increasingly aware of the critical needs of controlling their operating costs and meetthe expectations of patient care quality (Chow-Chua,2000). In current competitiveenvironment, many health care organizations are taking steps to ensure that they are providingthe "absolute best care at the lowest possible costs". However, many hospital administrators stillhave to learn how to lower operating costs without compromising on providing consistent goodquality patient care (Griffith, 2000).In 1993, Chaufournier et al. reported that 44% of 1,083 hospitals surveyed in the U.S.were embracing some kind of quality management approach such as CQI (Continuous qualityimprovement), Kaizen, and TQM (Total Quality Management) to improve health care quality(Choufournier, 1993). Also, in 1994, Hertz, et. al suggested that Malcolm Baldrige NationalQuality Award (MBNQA) concepts could help stimulate health care quality improvement ( 1994). In 2001, Leggit, and Anderson reported that the Malcolm Baldrige National QualityAward (MBNQA) assessment criteria for performance excellence developed by NationalInstitute of Standards and Technology has been successfully applied for organizational-wideperformance improvement at Hartford Hospital at Hartford, Connecticut (Leggit, 2001).Under the current environment which contains many forces such as increased customerexpectations, steeper competition, and government agency pressures the health care deliverysystem has been undergoing formidable challenges since early 1990s (Chow-Chua 2002),V-1

International Journal of Quality & Productivity ManagementVolume 5, No. 1 December 15, 2005Bandyopadhyay andCoppensand this paper presents a Model of a Six Sigma approach to quality management to improveproductivity and quality in a health care delivery system.Six Sigma approach to quality improvementSix Sigma approach to improve quality has been used in many organizations since itsinception. at Motorola Corporation in the 1980s to measure and improve product andservice quality. Six Sigma is focused on defects per million opportunities,. Six Sigma isbased on a quality statistic that equates to 3.4 defects per million opportunities. This isthe target level of performance for a process.Six Sigma DMAIC Quality Improvement ModelThe Six Sigma quality improvement model as applied by Robert Galvin at Motorola,Inc refers to the five step process problem solving approach known as DMAIC:(Define,Measure, Analyze, Improve and Control ) as explained below Define: this step defines who the customers are, what the customers want, the processcapabilities, and provides objectives for project-based improvement efforts. Measure: this step measures the quality characteristics that reflects improvement incustomer satisfaction and product performance and provides the metrics of data onwhich the improvement efforts will be based. Analyze: in this step, data collected in previous steps are analyzed using analyticaltools such as Pareto analysis, process flow diagram, fish-bone diagram, statisticalprocess control charts, for identifying necessary design and process modifications forachieving customer satisfaction and performance objectives. Improve: in this step resources are allocated so that design and process modificationsneeded for improvement can be implemented. Control: in this step the process is monitored using quality management tools such asPareto charts, and statistical process control charts to ensure that the performanceimprovements are maintained.The Six Sigma process is highly measurement and data driven. Data has to be gatheredto determine the baseline performance of a process in order to validate that animprovement has been made. Decisions are made on statistics and facts, rather thaninstinct or past history. Six Sigma projects can be lead by Black Belts or Green Belts.ninjas (experts) who are trained for quality problem solving. The Master Black Beltninjas usually serve as advisors to the project leaders while local champions promote SixSigma in their organizations. All of these roles require extensive training to becomefamiliar with the tools of Six Sigma. Six Sigma projects that focus on improving/solvingexisting quality problems follow the process of DMAIC (Define, Measure, Analyze,Improve, and Control) as described above. While projects that involve developing a newproduct, process or procedure follow the DFSS (Design for Six Sigma) process that focuson meeting customer needs and expectation, on time and on budget.V-2

International Journal of Quality & Productivity ManagementVolume 5, No. 1 December 15, 2005Bandyopadhyay andCoppensSix Sigma’s ability to reduce errors, improve customers satisfaction, and bring infinancial gains has lead many companies such as General Electric, Texas Instruments,3M, IBM, Citibank, Xerox, The Dow Chemical , and Boeing Aircraft to adopt the SixSigma process.Six Sigma approach to service industryCitibank is a service based company, used Six Sigma approach to reduce cycle timeswithin the company. Service based industries usually struggle with Six Sigma approachbecause of its intense data focus. There are three main challenges to overcome forimplementing Six Sigma approach in service industries (Lanser,2000). First, it is sometimes difficult for service industries to identify an indicator tomeasure the performance level of a service in their organization. Manufacturingplants can use measures such as no of defects per million parts produced. But itdoes not always translate into service industries. Customer variability also needsto be considered when using Six Sigma in service industries. A service might beacceptable to one customer but viewed as sub-par by another customer. A second issue to overcome in service industries is the difficulty in creatingcultural changes for empowering Six Sigma leaders. The final challenge service organizations face in Six Sigma implementation is thatit fails to capture the benefits of Six Sigma application immediately. Cost savingsfrom Six Sigma projects may take time to realize, and frequently, managers giveup too soon before cost savings are realized.Six Sigma approach to healthcare industryThe challenge for health care industry to benefit from the use of Six Sigma isparamount. Patient care significantly involves human element as compared to machineelements, in which the variability is subtle and very difficult to quantify. Therefore,challenge in adopting Six Sigma approach to healthcare is to find a way to leverage thedata from Six Sigma to drive human behavior. Success will come only when the SixSigma technical strategy is combined with a cultural strategy for change acceleration anda sound operational mechanism (Lasarus, Ian, and Neely, 2003)There are usually four metrics (indicators) that can be used by singly or incombination to define level of performance of a healthcare organization. These metricsare service level, service cost, customer satisfaction, and clinical excellence. While thesemetrics are applicable in healthcare organizations, they are also very difficult to apply ina health care setting. Despite the challenges in using Six Sigma in the healthcareindustry, many hospitals within the healthcare industry is beginning to use Six Sigmaapproach to improve patients’ satisfaction (Lasarus, Ian, and Neely, 2003).V-3

International Journal of Quality & Productivity ManagementVolume 5, No. 1 December 15, 2005Bandyopadhyay andCoppensImproving patient satisfaction in health careIn healthcare organizations, patients may be considered as customers. Keepingpatients satisfied are considered as a top priority by many healthcare organizations Thetraditional concept, that people need healthcare and will continue to use the same healthcare providers out of necessity, even if they are not happy with their services they receive,has been changing rapidly. A patient can now access more information on healthcareproviders and can make more informed choices about their treatment. Quality is nowplaying a more important role as patients have started choosing healthcare providersbased on quality of care and their level of satisfaction with the organization from theirprevious experiences At the same time many hospital administrators have already startedusing the views and perceptions of their patients to organize their service and staff andfor continuous improvement in the overall organizational performance.Three approaches to improve patient satisfactionTorres et, al (2004) reported three approaches to quality improvement in thehealthcare industry to improve patient satisfaction. They are measuring the patient’s perspective, improving patient outcomes, and using Six Sigma approach.Regardless of which approach or approaches are used, support of senior levelmanagement is critical to the success of such programs.Measuring the patient’s perspectiveIt is important to measure patient’s perspective to the health care services. Theservices that patients receive is intangible, can’t be physically viewed or touched like amanufactured product. There are three ways to measure patient perspective. First method is to determine patients’ preferences. This method involvesqualitative measures, such as focus group, interviews, and surveys, to determinepatients’ desires and expectations about various health care services. The second method is patient’s evaluation of the services they received Thismethod involves a questionnaire survey given to patients after they have receivedhealthcare services to measure their level of satisfaction to the services received. The final method is to measure patient’s perspective through reports of objectiveobservations from the patient, such as how many times they were seen by adoctor during their stay in a hospital or how long they waited in the waiting roomfor seeing a doctor etc.V-4

International Journal of Quality & Productivity ManagementVolume 5, No. 1 December 15, 2005Bandyopadhyay andCoppensAll three of these methods can provide valuable insight into patients’ expectations ofhealthcare and their evaluations of services received. Patient views can be used toimprove quality and gain business for healthcare organizations.Improving patient outcomesImproving patient outcomes, can also increase patient satisfaction. One exampleof this was in Dayton, Ohio where a community based approach was used to improvepatient outcomes. In this community, five competing hospitals worked together todetermine the best way to treat certain illnesses. The theory is that if many people worktogether, a better solution can be found than if one hospital works alone. In Dayton, themortality rate from acute myocardial infarction declined from 9.68 percent in 1999 to 6.3percent in 2002 after the community based approached was implemented (Crane,2000).Using Six Sigma approachSix Sigma is a powerful approach to quality improvement that can be used inhealthcare organizations to meet needs and expectations of patients as well as to improveprofitability and cash flow. A model of Six Sigma approach to health care qualityimprovement is presented in figure 1, which involves a six step process as describedbelow: Define the goal and scope of the project, for example, improve patient satisfaction,reduce average patient waiting time, etc Create a performance baseline to compare data evidencing errors, for example,develop a quantifiable Upper and Lower Control limits the average level ofperformance indicator of patient satisfaction ( average performance level ( /-)Six Sigma of std deviation )against which performance can be measured., and forpatient waiting time, determine average waiting time expected by average patient,and its upper and lower limit. Continuously, monitor performance and collect performance related data usingpatient satisfaction survey, and for waiting time, design the patient appointmentscheduling and patient waiting line system, implement the system, andcontinuously monitor the performance of the patient waiting line system. If the level of performance goes below the lower limit of expected performancelevel, then analyze root causes of the problem, solve (not just fix) the problem byremoving the root cause. Implement procedures to remove the root cause of the problem and improveperformance level of the systemV-5

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