Six Sigma boosts quality with ongoing analysis

QI strategy promises to improve quality, finances

Quality managers in health care are hearing more about Six Sigma, the quality improvement strategy that has been taking hold in other industries for years now, and the statistics-focused techniques promise great improvements for hospitals and other providers.

One of the greatest benefits, proponents say, is that you can improve quality while improving your employer’s bottom line.

Chances are good you’ve heard of Six Sigma, but unless you’ve actually employed it already, you might not know much about what it can do in a health care setting. The basic concept won’t be foreign to peer review professionals who have used quality improvement/total quality management (QI/TQM), but Six Sigma is different in some significant ways. In a nutshell, Six Sigma is a quality initiative that tries to reduce variation in a system or process, says Mary Williams, vice president of AON Management Consulting in East Hartford, CT, which takes the Six Sigma process to health care clients. Six Sigma started out in more nuts-and-bolts industries, so some health care leaders balk at using a process designed to reduce variations, she says.

"They say health care isn’t the same as manufacturing widgets, so you can’t standardize the process to eliminate variation," she says. "But in fact, with Six Sigma, we’re trying to reduce the unnecessary variation so you get a more standardized procedure that reduces costs and time while improving quality."

The whole Six Sigma strategy is aimed at reducing errors, and the name actually is an analytic term that means having 3.4 defects per million opportunities, the ultimate for most processes.

"So you’re talking about a very low defect rate," Williams says. "That is definitely a goal that health care providers are striving for already, and Six Sigma is proving to be an effective way to reach that goal."

Though the concept is based on that ultimate goal of 3.4 defects per million, not every Six Sigma project has to strive for that level of near-perfection. Depending on the particular process, it might be sufficient to work toward four sigma or five sigma — in which each lower level represents a tenfold increase in the error rate.

Heavy on statistics

The process is focused on statistical analysis, more so than QI/TQM or other quality improvement efforts, says Andy Mayfield, managing director with North Highland, a business performance and technology consulting company, in the Atlanta office.

"Six Sigma is a very disciplined tool that puts a much higher degree of emphasis on both measurement of processes and the improvements being made on those processes," Mayfield says. "Two things are unique about Six Sigma. The first is the emphasis on the customer and how processes impact the customer. The second is the high degree of rigor around how we design measurement systems for processes. Those measurement systems are geared around identification of defects that inhibit both the customer experience and the process performance."

Six Sigma is based on the idea that if you measure how many "defects" you have in a process, you can systematically determine how to eliminate them and get as close to "zero defects" as possible. Six Sigma training levels are similar to those in karate, with a "black belt" and "master black belt" being the two highest levels of training and the green belt level being the starter level.

Most Six Sigma projects are either process improvement or process redesign. Mayfield explains that for process improvement — used when a product or service is not meeting customer expectations or performing adequately — the major steps are:

  • Define the project. Clarify the project’s purpose and scope and get background on the process and customer.
  • Measure the current situation. Focus the improvement effort by gathering information on the current situation.
  • Analyze to identify causes. Identify root causes and confirm them with data.
  • Improve. Implement solutions and evaluate results. Develop, try out, and implement solutions that address root causes. Use data to evaluate both the solutions and the plans used to carry them out.
  • Control. Standardize and make future plans. Maintain the gains by standardizing work methods or processes. Anticipate future improvements and preserve the lessons from this effort.

For process redesign — used to design a new process or redesign a process that cannot meet customer requirements through improvement — the steps are define, measure, analyze, define, and verify. Those steps are similar to the steps for improving a process, but they include developing alternative concepts and transitioning the new process into the organization.

Data are everything for Six Sigma. As Williams says, "If it doesn’t get measured, it doesn’t get managed." She offers this example of how Six Sigma can be used in health care: The first step in any project is defining the problem. In this case, the organization determines that the cost of hip replacement procedures is too high. The "customers" — clinicians are the internal customers, and patients are the external customers — don’t want to sacrifice any quality when you cut costs. So the next step in the Six Sigma process is to measure what you’re doing so far. The Six Sigma team, made up of either your internal Six Sigma experts or the consultants who will work with your quality professionals, start by measuring what you currently do with hip replacements.

"We’ll look at costs and outcomes over the past year and ask why costs are so high," she says. "We’ll look for the major drivers and brainstorm, saying we think these are the primary reasons for the high cost. But then we’ll go and collect data to see if the data support what we think."

In this example, the team finds that room costs and operating costs are the major drivers. Then the team asks how it can get the cost to where it should be. Creative solutions are found and implemented, and analyzed to see if they worked. Then the final step, control, comes into play. Unlike some other quality initiatives, Six Sigma emphasizes ongoing analysis after the implementation, after it seems that the problem has been solved.

"We want to keep the gains," Williams says. "We may have reduced the costs and kept quality high, but we don’t want to come back a year later and see higher costs. So we determine what needs to measured on an ongoing basis." 

One key difference from other quality improvement efforts is that using Six Sigma can be a major undertaking. Unless you have special training yourself, you almost certainly will have to bring in consultants who specialize in the kind of sophisticated statistical analysis that makes up the bulk of Six Sigma work.

To really make Six Sigma work, senior leadership in the health care organization should support the effort, Williams says. Six Sigma can take a good deal of time, effort, and money, so it helps if senior leadership staff are involved in designating projects and assigning resources, she says.

"This can be a fairly major undertaking, so you want to be sure that you’re using the resources wisely," she says. "We like to see senior leadership involved so that we’re addressing the problems that will really have an impact on the organization. You don’t need to use Six Sigma to clean the back stairs."

Six Sigma is a quality improvement tool, but Mayfield says it can have a significant impact on the organization’s financial health. The key, he says, is to link the quality improvement goals to the organization’s strategic goals.

"The Six Sigma measurement tools give you a clear path so you can begin to link the strategic direction of the overall organization, and the goals associated with that, to the process improvement activities of the project you’re working on today," he says. "The tools help you determine whether your process improvement is aligned with that larger strategy, misaligned, or not affecting the overall strategy at all."

Mayfield says financial savings should be a significant component of every Six Sigma project in health care, even though that may not be the goal initially. The statistical analyses help you find a way to achieve your initial, immediate goal while also positively impacting the organization’s overall financial health, he says.

"When you can bring that component along with the other goals, it’s easier to get the leadership support you need, because finance is such a big component of their responsibilities," Mayfield says. "They can see patient satisfaction increasing all the time, but if it doesn’t have a connection to the financial, it loses some of its value. You can satisfy customers all the way to bankruptcy."

For those who have never used Six Sigma before, Mayfield says how you start will depend on your situation. In the first scenario, the Six Sigma idea is highly supported by the leadership team, and the quality improvement leaders are willing to drive the Six Sigma process. The organization’s culture is ready for a significant change. "That’s what you find when an organization is facing significant financial difficulty, or a problem in the industry," he says. "Everyone has their attention focused on survival. The leadership is willing to drive this, rather than just support it."

In that situation, Six Sigma can be implemented on a wide scale, training a large number of organization leaders and tackling large problems right away. On the other hand, your organization might not be too eager to embrace Six Sigma. If you think it’s a good tool but not sure Six Sigma can really take hold in your organization, Mayfield says the best approach is to be very focused. Start with a highly critical process, one that you know can be improved with the right focus and one that will have a material impact on customers and on process performance.

"Focus on people within that business who are the known quantities, the ones you know you can rely on and who know the process, people who are willing to support the effort," he says. "Do those projects one at a time, build people’s skills in Six Sigma, and move on to the next one. Build credibility with each project."

Mayfield says the biggest mistake he sees with Six Sigma is trying to bite off more than you can chew. "Beginners sometimes try to tackle something far too big, something with multiple root causes that they’re not prepared to address," he says. "Without some experience in Six Sigma, it’s difficult to take those apart and address them in small enough chunks to manage them through completion. You end up doing the work without really solving the problems."

Another common mistake is attacking symptoms without finding the root causes. "You never get done because you treat the symptoms and then something else pops up because you haven’t addressed the root cause," Mayfield says.

Six Sigma consultants specialize in the statistical tools that are key to the strategy, but many will train you in those analytical skills so that you can carry on after they leave.

"What we do typically is go in and train the people in a hospital who need to work on these projects," Williams says. "It’s usually four weeks of training, working with whoever is involved with the process at hand, people from all levels of the organization. Part of the Six Sigma culture is that you become skilled in using these statistical tools, and you progress through levels."

Williams and Mayfield both say that Six Sigma is not something you can tackle on your own if you have no experience with it, but it certainly is something you can learn with help from experts. You may have to hire consultants at first, but eventually any quality improvement professional can become the in-house expert on Six Sigma and direct projects without outside help.

"Our goal is to transfer the technology," says Williams. "You can’t just go and read a book and do this, but we train others to become the in-house expert. Ideally, that should be someone considered for senior leadership, with good leadership skills and able to persuade people to do things differently. Six Sigma black belts are usually in the top 10% of their organizations, either because they started out there or because Six Sigma helped them get there."

[For more information, contact:

  • Mary Williams, Vice President AON Management Consulting, Commerce Center One, 333 East River Drive, Suite 404, East Hartford, CT 06108-5018. Telephone: (860) 282-6700.
  • Andy Mayfield, Managing Director, North Highland, 550 Pharr Road, Suite 850, Atlanta, GA 30305. Telephone: (404) 233-1015.]