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177 7 Two Methods of Quality Improvement: Six Sigma and Lean Theory KEENE/BSIP/SuperStock Learning Objectives After reading this chapter, you should be able to do the following:

• Evaluate Six Sigma and its role in quality improvement.

• Describe the Six Sigma Belts and metrics used.

• Analyze the five steps that define Six Sigma.

• Compare and contrast the successes and limitations of Six Sigma.

• Describe the origin and evolution of lean theory from the manufacturing industry.

• Summarize core principles of lean theory implementation.

• Explain fundamental concepts and methods used in lean methodology.

• Discuss examples of lean projects in healthcare. fin81226_07_c07_177-222.indd 177 10/30/14 7:26 PM What is Special Education? 1 iStockphoto/Thinkstock Pre-Test 1. You can use the terms disability and handicap interchangeably. T/F 2. The history of special education began in Europe. T/F 3. The first American legislation that protected students with disabilities was passed in the 1950s. T/F 4. All students with disabilities should be educated in special education classrooms. T/F 5. Special education law is constantly reinterpreted. T/F Answers can be found at the end of the chapter. Introduction Introduction Compared to other developed countries, such as the United Kingdom, France, or Canada, the United States spends more money on healthcare but has poorer healthcare outcomes (Col - laborators, U.S. Burden of Disease, 2013; Squires, 2011). In 2012, healthcare spending in the United States was $8,895 per capita, the third highest in the world (only Norway and Swit - zerland had a higher per capita rate, at $9,055 and $8,980 respectively; see Table 7.1) (World Bank, 2012).

Table 7.1: The top 15 countries for healthcare expenditure per capita Country Expenditure per capita Norway $9,055 Switzerland $8,980 United States $8,895 Luxembourg $7,452 Monaco $6,708 Denmark $6,304 Australia $6,140 Canada $5,741 Netherlands $5,737 Austria $5,407 Sweden $5,319 Japan $4,752 Belgium $4,711 France $4,690 Germany $4,683 Source: World Bank. (2012). Health expenditure per capita (current US$). Retrieved from http://data.worldbank.org/indicator /SH.XPD.PCAP/countries Despite this higher investment, the United States struggles with lower quality healthcare, fin - ishing far worse than many of its counterparts on various health outcomes. These outcomes include higher infant mortality rates, higher rates of hospital admissions for most chronic diseases, and the highest rate of foot amputations for patients with diabetes (see Table 7.2) (Squires, 2011). fin81226_07_c07_177-222.indd 178 10/30/14 7:26 PM Introduction Table 7.2: A comparison of healthcare outcomes for common chronic diseases Hospital admissions for chronic diseases per 100,000 population, age 15 and older Diabetes lower extrem - ity amputations per 100,000 population, age 15 and older Asthma Chronic obstructive pulmonary disease Congestive heart failure Hypertension Diabetes acute complications Canada 18 190 146 15 23 11 Denmark 43 320 165 85 20 21 France 43 79 276 —e —e 13 Germany 21 184 352 213 14 —e Netherlands 26b 154 b 171 b,d 19b 8b 11b New Zealand 73 308 206 16 1 12 Norway 42 243 188 70 20 11 Sweden 25 192 289 61 19 12 Switzerland 32a 100 a 155 a 55a 12a 16a United Kingdom 76 236 117 11 32 9 United States 120 a,c 203 a,c 441 a,c 49a,c 57a,c 36a,c Median (countries shown) 42 192 188 52 19.5 12 Age-sex standardized rates. Data not available for Australia.a 2006.b 2005.c U.S. does not fully exclude day cases.d Netherlands includes admissions for additional codes, which marginally elevates rates.e Data not available. Source: Squires, D. A. (2011). The U.S. health system in perspective: A comparison of twelve industrialized nations.

Journal of Operations Management , 16, 14. Reprinted by permission of The Commonwealth Fund. fin81226_07_c07_177-222.indd 179 10/30/14 7:26 PM Section 7.1 Definition and History of Six Sigma A 2013 report published in the Journal of the American Medical Association confirmed that overall mortality rates in the United States still lag behind many countries, including sev - eral with much lower gross domestic product and healthcare spending, such as Chile, South Korea, and Slovenia (Collaborators, U.S. Burden of Disease, 2013).

Improving healthcare quality and efficiency, while simultaneously curbing rising medical costs, is a major goal for U.S. healthcare organizations (Toussaint & Berry, 2013). To achieve a higher level of quality, healthcare organizations must use a systematic approach to improve - ment. First, they need to recognize healthcare problems within their organization. Next, they must determine their goals for improvements in quality, as well as the changes required to achieve them. Finally, they need to measure the impact and monitor to ensure that enhance - ments in quality are appreciable and sustained.

Many of the widely accepted methods to improve quality originated in the manufacturing world and are now increasingly being applied to healthcare. In this chapter, we will examine two popular methods of quality improvement—Six Sigma and lean theory—and how they can be used to improve healthcare operations.

Methods of quality improvement have some basics in common. Process improvement meth - odologies provide an established and systematic approach to improving processes. Usually these methodologies include a step-by-step guide to help organizations identify problems, implement interventions, measure the impact of changes, and monitor processes so that improvements in care are sustained.

The overarching goal for any quality improvement method is to reduce the number of defects in a product or process as much as possible. Defects are deficiencies in the process being eval - uated—in other words, a result that is outside of the established parameters or benchmarks.

Some of the common healthcare organizational processes that might be the target for quality improvement include improving waiting room times, surgery scheduling, and patient satis - faction. A secondary goal is to reduce costs or save the organization money. The added goal of sustaining improvements is also critical to quality improvement methods. This is emphasized because organizations need to avoid the natural tendency to revert back to old processes, which can lead to variability in quality over time. Let’s take a look at the details of two process improvement methodologies: Six Sigma and lean theory.

7.1 Definition and History of Six Sigma Six Sigma is one of the most well-known process improvement methodologies, and it has been adopted by many healthcare organizations over the last 20 years. It has been described as a disciplined and quantitative approach to process improvement methodology (Hahn, Hill, Hoerl, & Zinkgraf, 1999; Markarian, 2004). Central features of Six Sigma include (Antony, 2004; Schroeder, Linderman, Liedtke, & Choo, 2008): 1. A clear focus on measurable financial results; 2. Emphasis on data collection and analyses; 3. A defined structure with specified steps and tools; 4. Use of dedicated Six Sigma specialists within the organization; and 5. Emphasis on leadership support and engagement. fin81226_07_c07_177-222.indd 180 10/30/14 7:26 PM Section 7.1 Definition and History of Six Sigma Six Sigma History In 1987, Motorola Company formally introduced Six Sigma as a new way to decrease the number of defects in manufacturing (Schroeder et al., 2008). Soon after, the methodology was adopted by some of the country’s leading companies, including Honey - well (which was acquired by AlliedSig - nal) in 1994 and GE in 1995.

In the early 1990s, the healthcare industry began to embrace process improvement methodology and qual - ity management approaches. In 1993, one study showed that 44% of 1,083 U.S. hospitals surveyed applied some form of quality management approach (Choufournier & St. Andre, 1993).

Beginning in 2000, reports were published on the successful implementation of Six Sigma at hospitals across the United States, signifying a new chapter in Six Sigma history. One of the most cited examples came from Heidi L. Frankel, MD, and colleagues who used Six Sigma methodology to reduce catheter-related bloodstream infections at Yale New Haven Hospital (Frankel et al., 2005). Other applications of Six Sigma in healthcare include Stanford Medical Center in California and the Red Cross Hospitals in the Netherlands (Koning, Verver, Heuvel, Bisgaard, & Does, 2006).

While healthcare organizations are adopting Six Sigma techniques, it is not clear if they are using the process correctly. In 2013, a comprehensive literature review found over 300 articles published on the use of Six Sigma in healthcare management (Dellifraine, Wang, McCaughey, Langabeer, & Erwin, 2013). Among these, 55 articles were peer reviewed, but only 16 reported correct use of Six Sigma. Based on these findings, the authors concluded that the evidence that Six Sigma is being used correctly in healthcare remains “weak” (Delli - fraine et al., 2013). This review also reported the increasing number of hybrid models, which include combined elements of Six Sigma and lean quality improvement methodologies (lean will be discussed later in this chapter). Together these are referred to as lean Six Sigma; they can be used as complementary tools for quality improvement.

A brief timeline of major events in the history of Six Sigma is included in Table 7.3. AP Photo/LM Otero Motorola Company formally introduced the concept of Six Sigma as a new way to decrease the number of defects in manufacturing in 1987. fin81226_07_c07_177-222.indd 181 10/30/14 7:26 PM Section 7.1 Definition and History of Six Sigma Table 7.3: Historical timeline of major events in Six Sigma history Year Milestone 1985 Motorola needs to make major changes to deal with growing competition from Japan and begins to create Six Sigma. 1987 Six Sigma concept formally introduced by Motorola. 1988 Motorola wins the Malcolm Baldrige Award for Quality and reports $940 million in savings from Six Sigma. 1994 Honeywell (acquired by AlliedSignal) adopts Six Sigma. 1995 GE adopts Six Sigma. 1997 Honeywell reports successful implementation of Six Sigma, resulting in less than 3.4 defects per million products manufactured. 1999 GE reports net income from Six Sigma exceeding $2 billion. 2003 Reports of successful implementation of Six Sigma in several healthcare organizations, includ - ing Good Samaritan Health System in Kearney, Nebraska; the Charleston Area Medical Center (CAMC) in West Virginia; and Mount Carmel Health System in Columbus, Ohio. 2013 A total of over 300 articles (to date) published on the use of Six Sigma in healthcare. Sources: Antony, J. (2004). Some pros and cons of Six Sigma: An academic perspective. The TQM Magazine , 16(4), 303–306; Schroeder, R. G., Linderman, K., Liedtke, C., & Choo, A. S. (2008). Six Sigma: Definition and underlying theory. Journal of Operations Management, 26 (4), 536–554. While rooted in manufacturing, Six Sigma is helping healthcare organizations to improve their processes and patient care.

Six Sigma Explained The technical definition of Six Sigma is to strive for less than 3.4 defects per million opportu - nities (DPMO), in any process, product, or service (Hahn et al., 1999; Linderman, Schroeder, Zaheer, Choo, & Carlson, 2003). Sigma refers to the Greek letter (represented by the Σ in lower case Greek) that is used in statistics to measure how far something deviates from per - fection. The “six” refers to a statistical calculation worked out by the creators of Six Sigma, which aims for a very high percentage of defect-free products.

At Motorola, William Smith, John Mitchell, and Robert Galvin are credited as the masterminds behind the Six Sigma concept (Hahn et al., 1999). They combined two rules to derive the now infamous 3.4 DPMO value. The first is the well-known empirical rule in statistics, which states that nearly all values (or 99.7%, to be exact) lie within three standard deviations of the mean.

The second rule was an assumption based on the creators’ experiences in the manufacturing world (Hahn et al., 1999; Kumar, Nowicki, Ramírez-Márquez, & Verma, 2008). Their assump - tion was that even the most controlled manufacturing processes eventually vary, or drift away from perfection (specifically 1.5 standard deviations) over time.

In the case of a hospital seeking to improve hand hygiene among staff members to reduce the number of infections and therefore achieve healthier outcomes for patients and reduced recovery times, the organization can expect compliance to be high after the initial launch of its initiative. As part of the roll-out, staff members will receive training on hand hygiene fin81226_07_c07_177-222.indd 182 10/30/14 7:26 PM Section 7.2 Six Sigma Quality Improvement Questions to Consider 1. What are two specific examples of ways to improve quality of care in a clinic, hospital, pharmacy, or outpatient laboratory setting? 2. What are some important points to consider when applying quality improvement pro - cesses in healthcare? protocols during meetings on each hospital floor. They will be reminded about the hand hygiene policy at regular staff meetings. Supervisors will monitor to see if staff members are following the protocols.

However, after six months, there may be less emphasis on hand hygiene. Supervisors may be focused on other priorities. Some staff members may become less vigilant about following the protocols and slip into old habits. While infection rates may have dropped because of hand hygiene, the hospital may now see a gradual increase in these numbers. Therefore, over the long term, it may become increasingly difficult to maintain the same level of quality. This variation in process over the long term is what the originators of Six Sigma tried to capture mathematically.

How do you calculate the now-infamous 3.4 DPMO, which is one of the key measurements of a Six Sigma quality system? A process is said to be operating at Six Sigma if the DPMO is 3.4 or less. If a defect means, for instance, a patient acquiring an infection, then for every mil - lion patients, fewer than four would acquire a healthcare-associated infection. Of course, in healthcare, even one patient with an infection is one too many.

As they did with manufacturing, the Six Sigma concept can improve healthcare quality, enhance patient satisfaction, and allow an organization to compete with others in a competi - tive market.

7.2 Six Sigma Quality Improvement Just as some of the largest and most successful U.S. companies have adopted Six Sigma, the healthcare industry provides numerous examples of successful Six Sigma implementation.

Numerous studies have tried to dissect the inner workings of the most notable Six Sigma organizations to reveal the secrets of their success (Hahn et al., 1999; Schroeder et al., 2008; Senapati, 2004). These studies have shown that many manufacturing companies employ the use of parallel-meso structures to support Six Sigma activities (Schroeder et al., 2008). Paral - lel structures operate outside of and do not directly interfere with daily operations. Thus, to ensure success, Six Sigma activities are usually supported in ways that do not alter “normal” operations of an organization.

An example of parallel support for Six Sigma activities include dedicated Six Sigma specialists within the organization. These individuals are specifically trained in Six Sigma methodology and work with existing personnel and processes to improve quality. The significant time com - mitment to manage and move quality improvement projects forward lies on the shoulders of fin81226_07_c07_177-222.indd 183 10/30/14 7:26 PM Section 7.2 Six Sigma Quality Improvement these specialists so that daily processes and routines are minimally disrupted. In a healthcare setting, the Six Sigma specialists, who might be physicians, nurses, and others in the organiza - tion, would oversee quality improvement projects, while other personnel remain focused on their daily responsibilities. Healthcare organizations can implement Six Sigma by bringing in experts in this improvement process from outside the organization and teaching them about how healthcare works or by sending their own personnel to learn the Six Sigma methods. For instance, an organization can send physicians, nurses, and other leaders to seminars to train in Six Sigma and bring their knowledge back to the facility.

Additionally, meso theory describes the integration of data at multiple levels, ranging from micro- to macro-level (Schroeder et al., 2008). Micro level data is very detailed and can include information about individual steps in a process (e.g., the amount of time it takes to register a patient). Macro level data is less detailed and can include information about the process as a whole (e.g., the average length of stay for patients admitted to the hospital).

Six Sigma projects require the connection of multiple pieces of information within one orga - nization. This can occur in several ways. Examples include the engagement of participants from various levels within the organization (i.e., from front line workers to leadership) to col - laborate on one project and the integration of various pieces of data from different steps within the process to improve one final product or service (Schroeder et al., 2008). Six Sigma Belts The use of full-time Six Sigma specialists within organizations is a unique attribute of this method - ology. It is not unusual to have dedicated Six Sigma specialists who spend 50% to 100% of their time on Six Sigma-related activities (Hahn et al., 1999; Schroeder et al., 2008). Different companies use var - ious names to describe the individuals working on Six Sigma projects, but the most widely known are the Black Belts , who typically run these improve - ment projects. While others with less training in Six Sigma may be involved in projects and collect data, the structure, reports, and number analysis is typi - cally done by Black Belts. In the Six Sigma methods, white, yellow , and green belt describe individuals with less intense training.

Black Belts are typically selected to attend at least four weeks of intense Six Sigma training, which provides review as well as hands-on application of quantita - tive methods (including statistical programs) (Hoerl, 2001). Qualitative skills in the areas of team leader - ship and communication are also usually covered, but are emphasized less (Hahn et al., 1999; Hoerl, 2001). The number of Six Sigma belts will vary depending on the available resources, size of the com - pany or organization, and scope of projects. As a general guideline, most companies aim to have AndreyPopov/iStock/Thinkstock “Black Belts,” the most widely used name to describe individuals working on Six Sigma projects, are typically selected to attend at least four weeks of intense Six Sigma training. fin81226_07_c07_177-222.indd 184 10/30/14 7:26 PM Section 7.2 Six Sigma Quality Improvement 1% of their workforce trained at the Black Belt level (North Carolina State University Lean Six Sigma, n.d.). Most Six Sigma projects take an average of four to six months to complete. Black Belts should be able to support three to four large-scale projects annually. Thus, it is estimated that two to three full-time Black Belts are needed to support quality improvement activities in a typical acute care hospital with 150 to 300 beds (Caldwell Butler & Associates, n.d.).

When Six Sigma is adopted within an organization, individuals are usually first trained by external experts. Trainees typically have the opportunity to progress through belt levels.

It is important to note that the Six Sigma certification and training processes are not stan - dardized across organizations. Currently, there is no single society or council that provides Six Sigma certification. A survey of businesses found that companies with fewer than 500 employees were reporting an average of $10,000 or less in total costs of Six Sigma implemen - tation each year (Dusharme, 2004). Additionally, companies that have adopted Six Sigma over many years eventually provide internal training and certification programs that are tailored to the company as needed. Thus, studies have demonstrated that the skills and expertise developed by Black Belts are inconsistent among companies (Antony, 2004).

Executive leadership plays a key role in all Six Sigma activities. Leadership must first provide adequate support for these activities in the form of funding. It is impossible to implement Six Sigma methods without spending money to certify employees and paying the salaries to retain experienced Black Belts and higher level Master Black Belts. Leadership may also need to provide additional resources for a particular project. As an example, the use of informa - tion technology (IT) support services to assist with data collection, monitoring, and analysis would require leadership approval.

Additionally, leadership must align Six Sigma activities with company priorities and values.

Leadership must encourage participation and enthusiasm around Six Sigma activities at all levels. Leadership should also promote a culture that empowers employees to seek oppor - tunities to improve quality, rather than being content with the status quo. Senior executives’ continuous support and engagement is necessary to successfully carry out Six Sigma projects (Schroeder et al., 2008). Thus, involvement of executive leadership is critical to the success of Six Sigma in any organization.

Six Sigma Metrics Metrics are specialized measures that play a central role in all Six Sigma improvement proj - ects. They are measureable factors that provide useful information about the performance of a process. A variety of metrics can be employed in Six Sigma projects; they will generally fall under one of two categories: 1) customer-oriented metrics and 2) financial metrics . Customer-Oriented Metrics Customer-oriented metrics are measurements of performance from the customer’s perspec - tive. Also referred to as critical-to-quality (CTQ) characteristics , these metrics are defined as key measurable characteristics of a process or product that are essential for customer sat - isfaction (Antony, 2004). Healthcare organizations may consider medication errors or emer - gency room throughput as examples of customer-oriented metrics. It is easy to imagine the impact on patient satisfaction, not to mention patient well-being, if medication doses were fin81226_07_c07_177-222.indd 185 10/30/14 7:26 PM Section 7.2 Six Sigma Quality Improvement erroneously mixed up or emergency room wait times were too long. Examples of metrics are included in Table 7.4.

Table 7.4: Examples of two CTQ projects Project Example Example CTQ Metric Wait times to obtain new obstetrical visits Patient time spent in obstetrical clinic Benefits Reduced from 38 to 8 days 52% reduction Sources: Kwak, Y. H., & Anbari, F. T. (2006). Benefits, obstacles, and future of Six Sigma approach. Technovation, 26 (5–6), 708–715; Bush, S. H., Lao, M. R., Simmons, K. L., Goode, J. H., Cunningham, S. A., & Calhoun, B. C. (2007). Patient access and clinical efficiency improvement in a resident hospital-based women’s medicine center clinic. American Journal of Managed Care, 13 (12), 686–690. Customer-oriented metrics can provide a picture of how well a healthcare organization is performing in the eyes of its patients.

Financial Metrics Six Sigma projects are usually selected based on their potential to improve specified met - rics and have a financial impact. Financial metrics are measurements of monetary impact.

Examples include the amount of money saved when processes are made more efficient or the additional amount of money generated. For instance, a healthcare organization can bring in increased revenues by performing more surgeries with high reimbursement levels or attract - ing more patients. While businesses may select improvement projects that will generate high levels of annual savings or benefits, it may not be realistic for many healthcare organizations to expect such high levels of return. Many large organizations routinely monitor and report their financial results; therefore, the incorporation of a financial analyst on their Six Sigma teams is common (Schroeder et al., 2008).

Financial analysts collect data in real time as projects unfold, but also track outcomes beyond just one project cycle (this can vary depending on the project but typically could include tracking results several months to one year pre-project and one year post-project). Examples of reported financial metrics are provided in Table 7.5.

Table 7.5: Examples of financial metrics from Six Sigma healthcare organizations Healthcare organization Savings Women and Children’s Hospital (Charleston Area Medical Center) Gross obstetrics and gynecology clinic revenue increase of 73% in the first 6 months of 2006 (Bush et al., 2007) Radiology Department in a Hospital (Taiwan) Savings of $36,000 from reduced hospital lengths of stay (Chan, Chiu, Chen, Lin, & Chu, 2005) Mount Sinai Medical Center (New York) Savings of $75,000 by switching from IV to oral antibiotics (DuPree et al., 2009) Froedtert Hospital (Milwaukee, WI) Increase in revenue of $1.2 million by improving commu - nication and documentation of radiology reports (Gor - man, Donnell, Hepp, & Mack, 2007) fin81226_07_c07_177-222.indd 186 10/30/14 7:26 PM Section 7.2 Six Sigma Quality Improvement In healthcare, where organizations are always trying to save money while at the same time improving patient care, managers who can show a potential savings from implementing a new project are more likely to receive approval from top leaders. However, healthcare orga - nizations are not only focused on quality improvements that can save them money. Their rev - enues, or earnings, may be directly tied to quality improvements. For instance, the Centers for Medicare & Medicaid Services (CMS) has begun to penalize hospitals with high readmission rates related to heart attacks, heart failure, and pneumonia. CMS will add more conditions in the future. The government program reduces Medicare costs but also makes hospitals focus on preventing patient health problems. Hospitals with higher-than-average 30-day readmis - sion rates—where patients are admitted back into the hospital shortly after being released— will face reductions in their Medicare payments. That becomes an incentive for hospitals to reduce readmissions and avoid losing those payments. It’s also an incentive to focus on qual - ity of care. For instance, hospitals are looking more closely at why heart attack patients are being readmitted and in some cases changing their practices to improve patients’ outcomes.

They are working with patients while they are in the hospital, for example, ensuring they understand what their medications are for and why they need to take them, and following up with outpatient care when they leave the hospital.

One large health system took on the task of reducing heart failure readmissions. After review - ing the causes for readmissions, they outlined specific interventions based on best practices that would move them toward this goal (Brown, 2014). Their interventions included: • Medication reconciliation. Within 48 hours after a patient discharge, a physician reviews the list of the patient’s medications with explicit instructions on how to take them properly. • Post-discharge appointments. Prior to discharge, patients’ follow-up care is sched - uled. For patients at high risk of readmission, appointments are scheduled within seven days of discharge when possible. • Post-discharge telephone calls. Within a set time following discharge, a care team member calls patients to assess how they are doing and answer their questions. Just six months after implementing these improvements, the health system achieved a 21% seasonally adjusted reduction in 30-day readmissions for heart failure, a 14% seasonally adjusted reduction in 90-day readmissions, and a 63% increase in post-discharge medication reconciliation.

Another healthcare system also took on the challenge of reducing admissions of heart fail - ure patients. Partners HealthCare Systems is a not-for-profit, integrated healthcare system in Boston, Massachusetts, that was founded by Brigham and Women’s Hospital and Massachu - setts General Hospital, two leading academic medical centers. Partners HealthCare developed its Connected Cardiac Care Program (CCCP), a home monitoring program for heart failure patients at risk for hospitalization. Core components include care coordination, education, and development of self-management skills through the use of telemonitoring. Patients use home monitoring equipment to submit their weight, blood pressure, heart rate, and symptom information on a daily basis. The results have been better care and lower costs. For instance, Partners HealthCare saw a 51% reduction in hospital readmissions for heart failure patients, amounting to $8,155 in savings per patient for more than $10 million in savings total as of 2012 (Cosgrove et al., 2012). fin81226_07_c07_177-222.indd 187 10/30/14 7:26 PM Section 7.3 DMAIC Six Sigma Projects Six Sigma projects are selected using a formal process to improve performance or meet speci - fied metrics and generally fall into either the customer-oriented or financial categories. Proj - ect selection occurs “top-down,” meaning that project prioritization or initiation is at the dis - cretion of senior management, rather than front line workers.

This has raised some criticism because project selection may be vulnerable to the preferences of senior management (Antony, 2004). Because senior management is usually several steps removed from the front line, they may be less informed about the real day-to-day happenings, problems, and potential solutions. In contrast, front line workers are intimately involved in most processes and may be in a better position to identify the most significant issues and potential impact of changes being considered. For this reason, some argue that a top-down approach to project selection may be less desirable (Antony, 2004).

Some companies refer to the senior management involved in project selection as project hoppers (Schroeder et al., 2008). The hopper’s role is to sort through and filter out projects without financial or strategic implications (Schroeder et al., 2008). As with belt certification, project selection is not standardized, so the criteria company leaders may use to filter proj - ects can vary between companies. Questions to Consider 1. Why are both quantitative and qualitative skills included in Black Belt training? Provide an example of a quality improvement project that would require both. 2. What are some examples of customer-oriented metrics in each of the following health - care settings: an outpatient family medicine clinic, an inpatient pediatric ward, and a typical surgical operating room? 7.3 DMAIC Six Sigma projects typically follow five process steps: 1) Define, 2) Measure, 3) Analyze, 4) Improve, and 5) Control. These steps help standardize and structure project execution. The acronym DMAIC (pronounced “duh-maic”) is commonly used to refer to this process (Arthus, 2011; Dahlgaard & Dahlgaard-Park, 2006; Glower, 2006; Nave, 2002). In each of the five steps (see Figure 7.1), there are specific goals that must be met for overall project success (Arthus, 2011; Dahlgaard & Dahlgaard-Park, 2006; Glower, 2006; Nave, 2002). fin81226_07_c07_177-222.indd 188 10/30/14 7:26 PM Define Define the opportunity fromboth businessand customerperspectives Measure Understand theprocess and itsperformance Analyze Search for the keyfactors (critical Xs)that have thebiggest impacton process performance anddetermine theroot causes Improve Developimprovementsolutions forthe critical Xs Control Implement thesolution andcontrol plan Section 7.3 DMAIC We will consider a sample clinical scenario to illustrate DMAIC. Suppose that patient satis - faction has been very low in a general health clinic for the past two years. Clinic leadership is motivated to address this issue and opts to use the Six Sigma methodology to improve the quality of care in their clinic.

Define The purpose of the first step is to define the problem or defect that needs improvement. This involves identifying key pieces of information that help set the stage for steps to follow. In our sample scenario, patient satisfaction is very low in a health clinic but it is not enough to define the problem this broadly. Since many things impact patient satisfaction, it is more useful to define the specific problems that have led to low satisfaction. A key piece of information to review in this case is feedback from patient surveys, which might reveal that long wait times are a main driver of dissatisfaction. This more specific definition of the quality problem— dealing with long wait times—provides needed focus for steps to follow.

Or take the case where an employee survey shows a high rate of dissatisfaction with the job a healthcare organization’s maintenance crew is doing. Why is that the case? Are maintenance staff unfriendly? Do they have the knowledge to complete the tasks assigned to them? Do they take too long to respond to calls for assistance? Do they have poor communication skills?

Depending on which problems are causing the dissatisfaction, the organization can decide what solutions will work. Perhaps maintenance staff need more training or the department needs a better work order system so staff members can be dispatched more quickly to handle requests to change a burned-out light bulb or repair a broken sink.

Or a health system has a problem with the number of insurance claim forms submitted with errors to insurance companies. Is this a system-wide problem or is it confined to a particular group? It may be that the problem is with insurance claim forms originating at one hospital’s emergency department. What is the result? Are the mistakes causing a loss of revenue, costs to rework the claim forms, and delayed payments to the health system?

Figure 7.1: Six Sigma DMAIC Goals identified within each of the five steps must be met to achieve project success.

Source: Six Sigma. (2011, December 19). Six Sigma: Streamlining the way of business. Lean Six Sigma Blog. Retrieved from h t t p : // leanapplied.com/blog/?tag=dmaic . Copyright © Lean Applied Blog. Reprinted by permission Define Define the opportunity fromboth businessand customerperspectives Measure Understand theprocess and itsperformance Analyze Search for the keyfactors (critical Xs)that have thebiggest impacton process performance anddetermine theroot causes Improve Developimprovementsolutions forthe critical Xs Control Implement thesolution andcontrol plan fin81226_07_c07_177-222.indd 189 10/30/14 7:27 PM Section 7.3 DMAIC In the define step, the general scope of the project and estimated return on investment are considered. It is important to consider the goals, available resources, timeline, and potential gains. In the case of long wait times, improvement must be defined (e.g., is it enough to reduce average wait time by 10 minutes or must it be 25 minutes?), staff who can work with project team members to provide insight into the existing issues must be identified, and the benefits of improving wait times must be determined (e.g., increases in patient satisfaction, increases in the number of patients seen, or increases in referrals to the clinic).

The define step should also include identifying pertinent information about potential cus - tomers, including who they are and what they want (Bandyopadhyay & Coppens, 2005).

For long wait times, it would be helpful to know if patients have preferred times for their appointments (e.g., if they preferred morning visits, the clinic could look into the possibility of increasing services/staff during those hours) or what they feel are reasonable wait times (e.g., patients may not consider a 10-minute wait significant).

Key questions to ask at the define step include: • What is the existing problem, defect, or deviation? • How do we define improvement in this case? • What is the potential business opportunity? • How do customers view this process or product? Measure The purpose of this second step is to measure the problem. The goal is to collect data to help understand the process and outcomes of interest. Data is collected about the existing process, creating specific metrics that are readily measurable. These metrics then serve as benchmarks of interest and provide tangible means of measuring future improvement. Recall from Section 7.2 that most Six Sigma projects will include measurements about customer- oriented and financial metrics.

In the sample scenario, the clinic may measure the amount of time patients spend at each step in their clinic visit, including how long it takes to check in upon arrival, how long they sit in the waiting room, and how long they wait in the visit room for a nurse, then the provider, and so on. By studying the existing process, they can better understand where the delays or bottlenecks may be. This information can then be used to later create targeted solutions and gauge improvements as they progress through the following steps. For instance, if the prob - lem is that patients sit in the waiting room because there are not enough nurses or assistants to do the preliminary work before the provider visit, the clinic may need to hire more staff.

In the case of the health system experiencing problems with insurance claim forms contain - ing errors, the quality team needs to determine how extensive the problem is. What percent of the claim forms have errors? What is the average of defects or mistakes per form? When did the problem begin? Was there a change in the way the claims were processed? Has claims processing recently been moved to a different office or group of employees? fin81226_07_c07_177-222.indd 190 10/30/14 7:27 PM Frequency Cumulative percent Cause 100% Section 7.3 DMAIC Key questions to ask at the measure step include: • What is the existing process? • What are the key metrics in the existing process? • What are the outcomes of interest? Analyze The purpose of the third step is to analyze the root cause(s) of the problem. This involves a detailed examination of the data collected in the two prior steps using analytic tools (Ban - dyopadhyay & Coppens, 2005), which identify and organize the plan of action. Examples of analytic tools include the Pareto analysis , process flow diagrams , fishbone diagrams, and statistical process control charts (see Figure 7.2). Many of these analyses use statistical software. Figure 7.2: Examples of analytic tools Analytic tool Brief description Pareto analysis This technique uses combinations of lines and graphs to visually dem- onstrate the relative frequency of root causes for a defect or problem. Since there may be several competing reasons for one defect, this technique is used to identify and organize the issues that must be addressed. This type of chart can be drawn by hand or created using standard statistical soft - ware. The limitation with Pareto is the potential loss of detail, since the focus is on the main causes and not on the variety of contributing factors that lead to each cause. In the sample scenario, for example, one main cause of long wait times could be lack of physician promptness, which would be included on this graph. However, several factors may contribute to physician prompt- ness, such as a conference call that runs long, limited number of parking spots outside the clinic, or interrup - tions to workflow by frequent pages, and these would not be listed. Frequency Cumulative percent Cause 100% (continued) fin81226_07_c07_177-222.indd 191 10/30/14 7:27 PM Flow Chart Customer Step Do Plan Who Group 1 Group 2 Requestfor product Activity 1 Activity 2 Decision? Document Copy and paste textand objects to createyour own flowchart Select Drawing toolbarfrom Options (Mac) or View (PC) To copy all Flowchart “objects”Use Ctrl-Shift-A Y N Group 3 Section 7.3 DMAIC Analytic tool Brief description Process flow diagram Source: QI Macros. (n.d.).

Flow chart template in Excel.

Retrieved from http://w w w.qimacros .com/qualit y-tools/f lowchart /. Created using QIMacros™ SPC Software for Excel, http://www .qimacros.com . Reprinted by permission. This technique maps the general flow in a process. It visually links dif - ferent steps that happen over time and helps uncover redundancies or inefficiencies. These types of diagrams can be drawn by hand or through simple computer programs. Various software programs can be used to draw a process flow chart. For example, Microsoft Word has a flowchart section. In our sample scenario, it might be difficult to fully appreciate the inefficiency of the back and forth movement of nurses without a process flow diagram. When a process flow diagram is used to graphically connect the steps in the process, it may become apparent that nurses are spending a great deal of time walking back and forth to their station dur - ing a patient encounter, which adds to wait times to deliver patient care. The process flow diagram illustrates potential improvements in nursing efficiency that could be achieved by relocating the nurses’ stations or redesigning nursing workflow to decrease redundancy. Flow Chart Customer Step Do Plan Who Group 1 Group 2 Requestfor product Activity 1 Activity 2 Decision? Document Copy and paste textand objects to createyour own flowchart Select Drawing toolbarfrom Options (Mac) or View (PC) To copy all Flowchart “objects”Use Ctrl-Shift-A Y N Group 3 Figure 7.2: Examples of analytic tools (continued) fin81226_07_c07_177-222.indd 192 10/30/14 7:27 PM Equipment Cause Effect Methods Problem People Time Environment Metrics Quality Characteristic Sample 11. 0 9.0 3 6 9 12 15 UCL = 10.860 LCL = 9.256 Center line = 10.058 10.0 Section 7.3 DMAIC Analytic tool Brief description Fishbone (Ishikawa) diagram This technique examines cause-and-effect relationships to identify root causes of a problem. The major categories of a fishbone diagram are explored individually, usually leading to several sub-analyses. The atten - tion to detail in this technique is one of the advantages compared to the other analytic tools. In our sample scenario, physician promptness and all the contributing factors that lead to physician late arrivals would be included in a fishbone diagram. The titles of the diagonal lines will change based upon the situation. Fishbone diagrams are usually drawn by hand or typed onto a pre-formatted template. The name is derived from the resemblance to a fish skeleton. Statistical process control charts Source: Retrieved from http://w w w.isixsigma.com/tools-templates/control-charts/a-guide -to-control-charts/ . Copyright © iSixSigma. Reprinted by permission. This technique helps visually track quality over time. The metric of inter - est is followed over time and used to calculate a mean value (represented by a central line). Upper and lower control limits are also designated. Fluctuations in the process can then be tracked in a time sequential man - ner. Computer software programs are used to create SPCCs. In our sample scenario, overall clinic visit wait time could be estimated and tracked over time using this method. Equipment Cause Effect Methods Problem People Time Environment Metrics Quality Characteristic Sample 11. 0 9.0 3 6 9 12 15 UCL = 10.860 LCL = 9.256 Center line = 10.058 10.0 Figure 7.2: Examples of analytic tools (continued) fin81226_07_c07_177-222.indd 193 10/30/14 7:27 PM Section 7.3 DMAIC Analytic tools may be used alone or in combination. All four tools from Figure 7.2 could be applied in our sample clinical scenario. A process flow map would help the clinic outline the steps involved in a typical visit. By visually examining the flow of patients, the clinic may consider reorganizing the physical layout of the clinic to improve efficiency (e.g., having three small nurses’ stations spread evenly down the main clinic hallway instead of one larger sta - tion at the end of the hallway to decrease nurses’ walking time).

A fishbone diagram could be used to conceptually organize all the root causes of long wait times. It is likely that several issues contribute to long wait times, such as overbooking of patients during preferred appointment times, inadequate staffing at check in, physicians who routinely arrive late, and the distance to and from the nurses’ station. Understanding the root causes of each contributing issue will inform the types of interventions needed. For example, relocating the nurses’ station, increasing staffing at check in, and correcting scheduling issues are important, but long wait times may persist until interventions to increase physicians’ promptness are incorporated as well.

A Pareto chart would demonstrate the frequency with which each root cause contributes to long wait times. This analytic tool could help the clinic prioritize the ideal order with which to make changes. For example, if physician promptness contributed to a greater majority of the wait time problems, then this would be a priority to resolve. Pareto charts are particularly helpful if the clinic has limited resources and can only choose a subset of problems to fix at any one time.

Lastly, a statistical process control chart could be used to track wait times before and after interventions. The chart helps to visually display what is considered normal variation and the desired measure for a particular process through the designation of upper and lower control limits. The upper control limit is about three sigma levels over the mean and the lower con - trol limit is about three sigma levels below the mean. Each additional data point that is mea - sured is expected to fall within the upper and lower limits 99% of the time. If additional data points fall outside the designated limits, deviation from normal processes becomes a concern, which, in turn, can impact quality. For example, with upper and lower limits of control for a clinic wait time example, we can easily detect whether wait times are improving over time or trending upward in the wrong direction (toward the upper control limit).

Key questions to ask at the analyze step include: • What is the root cause of the problem at hand? • Which analytic tool(s) can be used to examine this process? • What do we know about the existing process? • What types of changes are necessary for improvement? Improve The purpose of the fourth step is to improve the defect or problem. The goal of this step is to organize and allocate available resources so that the design and process modifications required for improvement can be implemented. The idea is to figure out what can be done to reduce the defect or correct the problem. In the long wait time example, relocating the nurses’ stations and increasing staffing at check in may be straightforward ways to resolve scheduling fin81226_07_c07_177-222.indd 194 10/30/14 7:27 PM Section 7.3 DMAIC issues. Solutions to increase physician promptness may be more difficult to choose, as inter - ventions could range from mild to harsh punitive measures.

In cases where several potential solutions exist, it is not unreasonable to consider testing a few interventions to see which yield the best results. This type of evaluation could include several small pilot tests of one potential solution at a time. Data on wait times can be collected with each test. After several pilots are conducted, the resulting effect on wait times can be compared to see which of the potential solutions yields the lowest wait times and is also the best fit for daily clinic operations. It’s important for organizations not to jump to conclusions when looking for solutions to a problem and to test various interventions to select the one that will be most effective.

Key questions to ask at the improve step include: • What type of intervention is needed to correct the defect or problem? • What are the available resources? • How can we reduce variability? Control The purpose of this final step is to control the process after it has been improved. Recall that Six Sigma is based on an assumption that even with the best of controls there is drift, or vari - ability, that occurs over time. The goal of this step is to continue to monitor performance to ensure that improvement is sustained. Analytic tools such as Pareto charts and statistical pro - cess control charts may once again be used. A statistical process control chart, for example, could track changes in wait times over the following year and highlight a trend toward longer wait times. In that case, the organization can take steps to stop this trend. What has happened to cause the longer wait times? Has the organization maintained the number of staff avail - able to check-in patients or have staff members left and not been replaced? Have physicians slipped back into old habits of arriving late, delaying the start of appointments?

Key questions to ask at the control step include: • How can we continue to monitor this process? • Are results sustainable over time? • What modifications are needed to maintain improvement? • How do we avoid drift? Reporting In addition to the five DMAIC process steps, some experts have advocated the addition of a reporting step at the end of the DMAIC framework (Senapati, 2004), which adds an R to the commonly used acronym, making it DMAICR . The goal of this step is to report the benefits of the improved process. Although this step was not part of the original framework, most companies have routinely included internal reporting of Six Sigma results. Internal reporting helps inform employees and leadership about progress that is being made. These results are sometimes considered proprietary and may not always be publically available. fin81226_07_c07_177-222.indd 195 10/30/14 7:27 PM Define What is theproblem? Measure What data isavailable? Analyze What are theroot causes ofthe problem? Improve Do we havethe rightsolutions? Control What do werecommend? What is thescope? Is the dataaccurate? Have the rootcauses been verified? How will weverify the solutions work? Is there support for our suggestions? Which keymetric isimportant? How should westratify thedata? Where shouldwe focusour efforts? Have thesolutions been piloted? What is ourplan toimplement? Who are thestakeholders? What graphsshould wemake? What clueshave weuncovered? Have wereducedvariation? Are resultssustainable? Section 7.3 DMAIC One way healthcare organizations are improving quality is by putting in place evidence-based protocols for managing the diagnosis and treatment of various health conditions. Intermoun - tain Healthcare, a non-profit health system based in Salt Lake City, Utah, has applied evidence protocols and process improvement methods to more than 60 clinical processes that consti - tute roughly 80% of care delivered. One example is the elective induction of labor in preg - nant women versus waiting until the patients go into labor naturally. When women arrive at the Intermountain labor and delivery facility, nurses using the electronic medical record review nine criteria established by the American College of Obstetrics and Gynecology for appropriate elective induction. The patient must meet all criteria for an elective delivery of the baby for the procedure to proceed. If the criteria are not met, including the appropriate gestational age of the baby, approval/consultation is required to proceed. The result has been a reduction in the rate for inappropriate elective inductions from 28% to less than 2%, with women spending 750 fewer hours in delivery per year. Intermountain’s C-section rate has also dropped and is approximately 40% lower than the national average, producing cost sav - ings of $50 million (Cosgrove et al., 2012). One way to get physicians to buy into the use of evidence-based protocols is to show them the improved clinical results from following these standardized methods of care. It’s hard to argue with success.

Figure 7.3 provides a brief review of the original DMAIC process steps, including an abbrevi - ated set of questions to consider at each step.

The DMAIC steps are sequential and build on one another. If one step is inadequately or par - tially completed, there are implications for the project as a whole. For example, if the problem Figure 7.3: DMAIC steps By design, the DMAIC steps are sequential and build upon one another.

Source: Rever, H. (2011, October 12). Ask Harry: Six Sigma and sustainability business survival in a challenging economy. International Institute for Learning (allPM). Retrieved from http://w w w.allpm.com/index.php/free-resources/94-article /newslet ter-ar ticle/176 -askharrysixsigmaandsustainabilit ybusinesssurvivalinachallengingeconomybyharryreverpmp -directorofsixsigma . Copyright © Lean Six sigma. Reprinted by permission of Harry Rever. Define What is theproblem? Measure What data isavailable? Analyze What are theroot causes ofthe problem? Improve Do we havethe rightsolutions? Control What do werecommend? What is thescope? Is the dataaccurate? Have the rootcauses beenverified? How will weverify the solutions work? Is there support for our suggestions? Which keymetric isimportant? How should westratify thedata? Where shouldwe focusour efforts? Have thesolutions been piloted? What is ourplan toimplement? Who are thestakeholders? What graphsshould wemake? What clueshave weuncovered? Have wereducedvariation? Are resultssustainable? fin81226_07_c07_177-222.indd 196 10/30/14 7:27 PM Section 7.3 DMAIC is inadequately defined in the first step, then subsequent steps are unlikely to yield interven - tions that will truly resolve the quality issue.

Application to Healthcare Over the last two decades, the focus on quality improvement in healthcare has increased greatly and various quality improvement methodologies, including Six Sigma, have been embraced across the healthcare industry. Many healthcare organizations have used Six Sigma to improve their processes and outcomes. As such, several models of Six Sigma in health - care quality improvement are available in the existing literature (Bandyopadhyay & Coppens, 2005). Table 7.6 outlines two healthcare projects presented within the DMAIC framework.

Table 7.6: DMAIC examples in healthcare Part A: Improving patient satisfaction DMAIC steps Healthcare application Define The goal of the project is to improve in-patient satisfaction. Measure Monitor performance and collect data using patient satisfaction survey. Analyze Develop quantifiable upper and lower control limits for the average level of performance indicator (average performance level +/- standard deviation against which performance can be measured). Use process flow diagrams to understand the patient experience from admission to discharge. Improve Implement procedures to remove the root cause(s) of the problem and improve patient satisfaction. Control Continuously monitor performance and collect satisfaction data. If the level of performance goes below the lower limit of expected performance level, then go back to re-analyze root causes. Part B: Decreasing patient waiting times DMAIC steps Healthcare application Define The goal of the project is to reduce average patient waiting time. Measure Measure average waiting time using the patient scheduling system. Analyze Determine average waiting time expected by patient, along with the upper and lower limits. Use a Pareto chart and fishbone diagram to help identify the root causes of long waiting times. Improve Implement procedures to remove the root cause of the problem and decrease wait times. Control Continuously monitor performance and collect data on wait times. If the level of performance goes below the lower limit of expected performance level, then go back to re-analyze root causes. Source: Bandyopadhyay, J. K., & Coppens, K. (2005). The use of Six Sigma in healthcare. International Journal of Quality & Produc - tivity Management, 5 (1), 12. fin81226_07_c07_177-222.indd 197 10/30/14 7:27 PM Section 7.4 Successes and Limitations of Six Sigma By following the DMAIC steps, healthcare organizations can get a handle on a quality prob - lem they want to address, find a solution, and ensure their efforts continue to be effective in improving quality. Questions to Consider 1. Hospital-associated infections are a major cause of morbidity and mortality for hospital - ized patients, so this issue is a priority in healthcare quality improvement efforts in the United States.

a. How would a typical hospital define, measure, and analyze this quality issue? b. Which analytic tool(s) would best help tackle this quality issue? 2. Why is the control step important in Six Sigma projects? 7.4 Successes and Limitations of Six Sigma Healthcare organizations have successfully used Six Sigma to improve quality. Six Sigma has been used to address a wide variety of issues that affect healthcare. However, there are some limitations to the method and its application in healthcare.

Successful Six Sigma Implementation There are numerous examples of successful Six Sigma implementation in various healthcare settings (Bandyopadhyay, 2009; Dellifraine et al., 2013). The majority of studies have focused on the use of Six Sigma to improve processes of care, such as patient satisfaction, wait times, length of hospital stay, and operating room throughput, followed closely by its use in improv - ing clinical outcomes or processes that directly affect patient health, like hand hygiene prac - tices or reducing inappropriate use of medications (Dellifraine et al., 2013). Six Sigma has also been used to improve personnel-related issues, including employee needle stick events and nursing satisfaction.

Descriptions of Six Sigma implementation at a larger scale U.S. health system (Mount Carmel Health), a smaller scale U.S. hospital (Good Samaritan Health Systems), and a health system outside the United States (Red Cross Hospitals) are provided in the following sections.

Six Sigma at Mount Carmel Health System (Banyopadhyay & Coppens, 2005; Sehwail & DeYoung, 2003) Mount Carmel Health System is a three-hospital system with 7,300 employees located in Columbus, Ohio. In 2000, the health system experienced financial difficulties, which led fin81226_07_c07_177-222.indd 198 10/30/14 7:27 PM Section 7.4 Successes and Limitations of Six Sigma leadership to seek viable solutions. Six Sigma was implemented and ultimately led to the cre - ation of a team comprised of 44 Black Belts. Projects focused on a variety of issues, including operational inefficiencies and patient safety. Financial savings of $3.1 million were reported just over the first five years of Six Sigma implementation.

Although Mount Carmel initially chose many of its quality improvement projects based on financial reasons, it later began to prioritize projects based on their impact on patient safety, patient satisfaction, and staff interests. One project focused on a high ambulance diversion rate because of back-ups in the emergency department. While the project team thought these delays originated in the ER, they discovered that bed management practices were actually to blame.

Good Samaritan Health Systems (Bandyopadhyay & Coppens, 2005; Lazarus & Neely, 2003) Good Samaritan Health System is a 287-bed hospital located in Kearney, Nebraska. The health system adopted Six Sigma to improve frequent delays and cancellations in their operating rooms. The project’s goal was to identify the root causes for the delays and cancellations.

The hospital began collecting data and used this to improve scheduling and throughput in the operating rooms. The hospital found that most cancelled surgeries were cancelled within 48 hours of the scheduled time, making it difficult to schedule other surgeries in the avail - able time. The result was that other patients awaiting surgery had to wait longer for their procedures to be performed. Often failure to have the necessary diagnostic tests completed is responsible for the cancellation of surgeries. Patients are then forced to reschedule their procedures, resulting in delays that can affect outcomes and patient satisfaction.

Six Sigma at Red Cross Hospital (Bandyopadhyay & Coppens, 2005; Van den Heuvel, Does, & Bisgaard, 2004) The Red Cross Hospital is a 384-bed hospital with 930 staff located in Beverwijk, Nether - lands. Prior to Six Sigma implementation, the hospital invested significant resources in qual - ity assurance, but hospital management was seeking to formalize quality management within the organization. They sought the assistance of an external consulting company to imple - ment Six Sigma and successfully implemented several projects, with total annual savings of $440,000 (see Table 7.7).

Among the projects successfully completed were an effort to shorten the length of stay of patients with chronic obstructive pulmonary disease (COPD) and providing accommodations for parents to stay with their hospitalized children, which resulted in the children being able go home earlier. Another project focused on reducing the number of patients on intravenous antibiotics. The hospitals developed a standard operating procedure for administering antibi - otics. The projects not only saved money, but resulted in happier, healthier patients. fin81226_07_c07_177-222.indd 199 10/30/14 7:27 PM Section 7.4 Successes and Limitations of Six Sigma Table 7.7: Six Sigma projects at Red Cross Hospital Project # Focus Annual savings 1 Shorten the length of stay of patients with chronic airway disease $40,000 2 Reduce errors in invoices from temp agencies $75,000 3 Standardize payment policies for the hospital suppliers $35,000 4 Reduce mistakes in invoices Percentage of invoice errors decreased from 9% to 1% $200,000 5 Decrease length of stay for hospitalized children Parents were provided accommodations to stay with their hospitalized children $30,000 6 Standardize use of IV antibiotics $25,000 Six Sigma at Women and Infants Hospital of RI The Women and Infants Hospital of Rhode Island has successfully implanted a Six Sigma project that allowed it to increase rates for women undergoing fertility treatment. Using the methodology, the hospital standardized its procedures for embryo transfer, which increased pregnancy rates by 24%.

The goal of the project was to improve the “take home baby” rate for infertility parents. The hospital obtained and collected data on possible factors that stood in the way of achieving pregnancy. Project members tested potential factors for their significance and built a model describing the relationships between the probability of achieving a pregnancy and those fac - tors. They focused on the embryo transfer procedure and developed standard operating pro - cedures, which reduced variation and increased overall pregnancy rates. Variation among implantation rates dropped dramatically and has remained low, suggesting interventions in standardizing and optimizing the embryo transfer procedure played an important role in the change.

While many quality improvement projects result in savings and improving the financial health of healthcare organizations, quality strategies are also focused on improving patient outcomes. Six Sigma projects have targeted patient safety, reduction of medical errors, clinical process improvement, patient satisfaction, and outcomes.

Limitations of Six Sigma There are several limitations of Six Sigma applications in healthcare that must be considered.

One of the main criticisms involves the general acceptance of up to 3.4 defects per million opportunities. Foremost in this concern is that not all errors are created equal. Although 3.4 defects per million opportunities may be a goal in manufacturing, there may be cause for alarm if this is widely applied to healthcare (Bandyopadhyay & Coppens, 2005; Dellifraine et al., 2013).

Picture, for example, the millions of prescription medications that are filled in hospitals across the United States; consider how many lives could be at stake if even one defect or error fin81226_07_c07_177-222.indd 200 10/30/14 7:27 PM Section 7.5 Definition and History of Lean Theory per million were considered acceptable. Critics argue that since healthcare deals with human lives, as opposed to machine parts, the stakes are higher (Bandyopadhyay & Coppens, 2005).

In fact, the idea that some tolerable errors can be expected in healthcare is disregarded by many (Dellifraine et al., 2013). Most healthcare leaders would agree that the goal, however difficult, should always be to strive for perfection, or zero defects/errors, when human lives are involved.

Additionally, many have argued that the human element may produce variability that is much more subtle and difficult to quantify (Bandyopadhyay & Coppens, 2005). Six Sigma may be particularly weak in dealing with behavioral processes, which are critical in healthcare.

According to some experts, improvement in decision making, communication, and learning processes may be difficult to achieve with Six Sigma projects because these issues may be less amenable to direct measurement (Parast, 2011). Because Six Sigma was designed to handle specific, quantifiable, and measurable improvement goals, less tangible processes may prove particularly challenging (Parast, 2011).

The empirical evidence of Six Sigma use to improve healthcare quality is increasing (Del - lifraine et al., 2013). However, as mentioned in Section 7.1, there is concern that Six Sigma is being incorrectly applied. Of 55 articles published between 1999 and 2012 that were included in a review, only about half reported correct use of DMAIC (n=30/55), even fewer calculated sigma values (n=16/55), and very few reported results of statistical tests (n=7/55) (Dellifraine et al., 2013). Thus, while the number of Six Sigma studies in healthcare settings is rising, questions about the fit of this structured approach to quality improvement and its long-term impact in the healthcare industry remains to be seen. Questions to Consider 1. In what ways would it be reasonable to adapt Six Sigma core concepts within healthcare settings to overcome some of the proposed limitations? 7.5 Definition and History of Lean Theory Many healthcare experts and leading organizations, including the Institute for Healthcare Improvement (IHI), are advocating that lean theory , another quality improvement method, can be successfully applied to healthcare to improve quality and efficiency, while curbing costs (IHI, 2005). Lean is a type of process improvement methodology that was derived from Toyota manufacturing and is now helping to transform many healthcare organizations across the United States.

Jidoka Sakichi Toyoda was a successful Japanese businessman who had built a renowned automatic loom company known as Toyoda Automatic Loom Works (Holweg, 2007). In 1929, Sakichi sold the patents to his loom company to help his son, Kiichiro, pursue his dream of automobile fin81226_07_c07_177-222.indd 201 10/30/14 7:27 PM Improvements incorporated into the standard workflow. A situation deviates from the normal workflow. Manager/supervisor removes the cause of the problem. A machine detects a problem and communicates it. The line is stopped. Daily Improvements Section 7.5 Definition and History of Lean Theory manufacturing. Kiichiro traveled to Europe and the United States to study automobile pro - duction, and then returned home, determined to mass-produce automobiles that could rival foreign cars in performance and price (Holweg, 2007). His first automobile prototypes were manufactured through a subdivision of the Toyoda Automatic Loom Works. In 1937, the fam - ily formally established the Toyota Motor Company.

Lean theory developed over decades within the Toyoda family businesses and is often referred to as “Toyotism.” Lean concepts emerged in the way business was conducted at the Toyoda Loom Company and grew as the family transitioned into the automobile industry. The Toyo - das built a strong tradition of problem solving and constant pursuit of perfection (or zero defects) beginning with their loom industry. The concept of jidoka , or rapid identification and correction of mistakes in a manufacturing process to prevent defects, was first applied in the family’s automatic loom operations. Sakichi’s automatic loom machines had the ability to detect and correct their own operating problems, which was unique at that time.

To prevent damage to fabrics, the loom would automatically stop if operating problems, such as a break in the thread or underlying tension, were detected. By creating automatic stops, defects or faults in the final fabric product were prevented. Therefore, the concept of jidoka was to detect problems in real time and to remove or correct the cause of the problem, leading to improvements in the process (see Figure 7.4).

Figure 7.4: The concept of jidoka Daily improvements can be achieved through real-time detection and corrections of problems.

Source: Toyota. (2013a). Jidoka—Manufacturing high-quality products. Retrieved from http://w w w.toyota-global.com /company/vision_philosophy/toyota_production_system/jidoka.html . Reprinted by permission of Toyota Motor Corporation. All rights reserved. Improvements incorporated into the standard workflow. A situation deviates from the normal workflow. Manager/supervisor removes the cause of the problem. A machine detects a problem and communicates it. The line is stopped. Daily Improvements fin81226_07_c07_177-222.indd 202 10/30/14 7:27 PM Section 7.5 Definition and History of Lean Theory Jidoka is considered one of the main pillars of lean theory and is just one example of a lean concept that began in the loom company and was transitioned to the automobile industry. It was a novel concept in manufacturing, which later became known as intelligent automation, or “automation with a human touch” (Toyota, 2013a).

The Toyota Production System In 1965, the Toyota Production System (TPS) was officially documented (Holweg, 2007). TPS was the formal description of core concepts that were integral to the way Toyota con - ducted daily activities. These core concepts included rigorous problem solving, teamwork, standard work, zero defects, and elimination of waste.

The concept of rigorous problem solving included detailed assessments of the current state of affairs, a testable plan for improvement, and engagement of employees at all levels in improvement processes. The belief was that input from leaders and front line workers was essential for the best results. Collaboration and exchange among employees from all levels was considered an essential part of daily operations. Teamwork, or the ability for employees to effectively work together in small teams toward a common goal, was heavily emphasized.

Standard work was a uniform way of approaching a task, no matter how simple. It increases efficiency while decreasing variation when possible. Tasks as mundane as tightening four screws on a car door were standardized so that workers always tightened the screws the same way; that is, workers followed a well-defined clockwise sequence as opposed to allow - ing each worker to approach the task in slightly different ways (Spear & Bowen, 1999). Simi - larly, members of a surgical team will go through a standardized checklist before the start of every surgery. In its guidance for healthcare professionals, The Joint Commission urges conducting a “time-out” before starting any procedure so that all concerns and questions are resolved before beginning a surgical or invasive procedure. The Joint Commission says this step is essential for preventing wrong-site, wrong-procedure, or wrong-person surgery. A time-out is a short meeting with the entire operating room team immediately before starting a procedure.

Efficiency is highlighted by the just-in-time approach to manufacturing processes, which describes the concept of making “only what is needed, when it is needed, and in the amount needed” (Toyota, 2013b). Essentially, this is the goal of perfectly matching supply to demand to ensure that products are not underproduced (which can decrease customer satisfaction) or overproduced (which can increase surplus and cost).

TPS also emphasized the goal of the ideal and pursuit of perfection. The aim was to continually create products with zero defects. Management acknowledged that mistakes were inevitable but set up systems to support successive checks, also known as poka-yoke or error proofing (Shingo & Dillon, 1989). These checks would occur during a task, just after, and right before the next step to ensure mistakes were detected and corrected. When front line workers were not able to solve a problem, they were empowered to “pull the line,” which meant they pulled a cord situated above each station that would halt the entire assembly line. Managers would immediately respond and try to resolve the issue. If the problem could not be resolved, the entire car would be pulled off the assembly line. TPS strongly emphasized real-time assess - ment and resolution of problems as they occurred. fin81226_07_c07_177-222.indd 203 10/30/14 7:27 PM Section 7.6 Implementation of Lean Theory 7.6 Implementation of Lean Theory In 1988, engineer John Krafcik first coined the term “lean.” This was the focus of his master’s thesis at Massachusetts Institute of Technology (MIT) and was based on his work experience as a quality engineer at Toyota (Spear & Bowen, 1999). In 1990, James Womack, Daniel Jones, and Daniel Roos published a book describing the system of lean production and the positive results it created for Toyota. Their book became a bestseller that was translated into 11 lan - guages, bringing international recognition to lean theory (Spear & Bowen, 1999). For several decades now, lean principles have been widely applied in various business sectors. The out - comes have included significant strides across different industries. Questions to Consider 1. Poka-yoke is regularly applied to healthcare. As an example, consider an outpatient pharmacy, where medication orders are entered by one pharmacist and rechecked by a second pharmacist to confirm the correct dosage or amount prior to dispensing the medication. What is an example of poka-yoke for an outpatient clinic or an inpatient hospital ward? 2. Just-in-time is also applied to healthcare. Consider an operating room where several cases are booked in one day. To ensure operation scheduling occurs just-in-time, aver - age case times can be used to approximate the time needed for each operation and creation of daily schedules that minimize delays between cases. This would help ensure that the room is used efficiently all day (i.e., cases are not backed up). What is an exam - ple of just-in-time for an outpatient pharmacy and an emergency room? Poka-yoke can be used whenever something can go wrong or an error can be made. It can be applied to any type of process. An example of an error is “missing parts,” which in healthcare might be not having all the equipment needed for a particular procedure. Another example is a “processing error,” which in healthcare could be a process not performed per the standard operating procedure.

Elimination of waste was also a major goal. Waste referred to anything that did not add value from the customer’s perspective. One example of waste was waiting, or idle time not used productively. An example in healthcare is when physicians in the emergency room must wait an extraordinarily long time for a patient’s test results, delaying the diagnosis of the patient’s condition and the ability to transfer him or her to a hospital ward or discharge the patient from the ER.

All of the core concepts employed by TPS were made available to others and not regarded as top-secret information for Toyota use only. To this day, leaders from various industries travel to Toyota plants to learn these methods firsthand. Ultimately, the main elements of TPS were formalized under lean methodology. fin81226_07_c07_177-222.indd 204 10/30/14 7:27 PM Section 7.6 Implementation of Lean Theory In 1996, a book titled Lean Thinking described a five-step process for guid - ing implementation of lean techniques (Poksinska, 2010; Womack & Jones, 1996). These five steps serve as the basic requirements for an organiza - tion wishing to adopt lean. They are based on core philosophies at Toyota that were later formalized under lean theory. The five basic steps of lean implementation are (Spear & Bowen, 1999; Toussaint & Berry, 2013; Wom - ack & Jones, 1996): 1. Specify value from the stand - point of the customer Enhancing quality, or value , from the customer’s perspec - tive is a main focus in lean (Toyota, 2013b). Value can also be considered as the right product or service, at the right time. It is what the customer wants and is willing to pay for. It is critical to understand what the customer desires or feels in order to adequately meet those needs.

In healthcare, value from the patient’s perspective can vary depending on the situa - tion. Generally speaking, however, most patients rate a physician’s communication skills and bedside manner as very important. Studies have shown that patients are more likely to be dissatisfied with care if a provider’s communication style lacks warmth or if he or she uses medical jargon that makes it difficult to understand the information (Korsch, Gozzi, & Francis, 1968). Therefore, value is placed on health - care providers who communicate with warmth and avoid medical jargon in order to meet patient needs and improve patient satisfaction. 2. Map the value stream A value stream is a detailed map of the steps or activities that are required to cre - ate a product or service (Toussaint & Berry, 2013). Studying each step allows better understanding of an existing process and identifies the steps that add value from the customers’ perspective. A clear understanding of the current situation is necessary in order to make improvements. The following questions can be posed for each step in a process: (Toussaint & Berry, 2013) • Why is this step necessary? • Would customers pay for this step? • How can this step be more efficient? Any step that is not necessary or customers would not pay for should be eliminated.

For example, a patient’s physician or specialist orders lab tests, including blood tests. The patient then goes to the hospital for pre-operative testing and has blood drawn again. The patient has blood drawn twice for the same blood tests, a redun - dancy that can be eliminated (Figure 7.5). Richard Drew/Associated Press Engineer John Krafcik was the first to coin the term “lean” in 1988. fin81226_07_c07_177-222.indd 205 10/30/14 7:27 PM Phlebotomistchecks requisitionsat nursing station Phlebotomist printsschedule for blooddraw (3 times/shift) Phlebotomistwalks to scheduled floor Phlebotomistwalks topatient room Phlebotomistwalks totransport boxat nursing station Transportercarries bloodsample tocore lab 4 Mins 1 Min 1 Min N.A. 2 Mins 5 Mins 1 Min N.A. Blood draw orderis entered in POE Phlebotomistrecieves page Stat call Stat call Phlebotomistcalls back Nurse/Physician MICYSsystem Lab results Phlebotomistdraws bloodfrom patient Phlebotomistdrops blood samplein transport box Phlebotomist carries blood sample to lab Core lab testsblood sample Section 7.6 Implementation of Lean Theory 3. Create flow Creating flow means that each step involved in creating a product or service is as efficient as possible. Work should occur continuously from start to finish and any bottlenecks, or areas where work slows down or is halted, should be eliminated. In other words, products “flow” seamlessly to the customer without delay.

Flow in an operating room is important. Operating rooms are costly to maintain and require large support staff. If case times are underestimated, significant delays and back-up can result. If case times are overestimated, then operating rooms are not efficiently used, which increases cost and lost revenue for the hospital. Understand - ing the appropriate mix and timing of cases is critical. Additionally, efforts before a surgery (i.e., items handled in the preoperative waiting area) and after a surgery (i.e., items handled in the postoperative care units) must be coordinated and accounted for to make the entire process as efficient as possible. 4. Establish pull Pull is allowing the customer’s need for the final product or service to guide how much of that product or service is to be generated or offered (Toyota, 2013b).

In healthcare, there is a lot of waiting in between steps in care processes. The time patients spend from first contact with a provider until diagnosis can take weeks, if not longer. From the perspective of a patient, care processes are often a stop-and-go Figure 7.5: Value stream map A value stream map presents all of the steps and activities required to create a product or complete a service.

Source: Agency for Healthcare Research and Quality (AHRQ). (2005, September). Figure 6. Sample value stream map: Phlebotomy. A toolkit for redesign in health care: Final report. Retrieved from http://w w w.ahrq.gov/professionals/qualit y-patient-safet y /patient-safety-resources/resources/toolkit/tkfig6.html Phlebotomistchecks requisitionsat nursing station Phlebotomist printsschedule for blooddraw (3 times/shift) Phlebotomistwalks to scheduled floor Phlebotomistwalks topatient room Phlebotomistwalks totransport boxat nursing station Transportercarries bloodsample tocore lab 4 Mins 1 Min 1 Min N.A. 2 Mins 5 Mins 1 Min N.A. Blood draw orderis entered in POE Phlebotomistrecieves page Stat call Stat call Phlebotomistcalls back Nurse/Physician MICYSsystem Lab results Phlebotomistdraws bloodfrom patient Phlebotomistdrops blood samplein transport box Phlebotomist carries blood sample to lab Core lab testsblood sample fin81226_07_c07_177-222.indd 206 10/30/14 7:27 PM Section 7.6 Implementation of Lean Theory experience, with each step in the care process taking time. Healthcare organiza - tions can work to improve that process. Rather than pushing patients from one step to another, pulling them from the end of one step to the beginning of a next may be more effective.

Does the process allow patients to “pull” value? For instance, does the emergency room “push” patients from registration, only to require that they wait again to be seen by a provider? In a “pull” system, once an empty bed is ready, a patient is brought from the waiting room to make sure the bed does not sit idle while patients wait for attention.

Pull means that you perform work as it is needed. For example, a baby is transferred from surgery to the neonatal intensive care unit (NICU). If the baby arrives at the unit and the respirator and respiratory therapist are not waiting for the patient, there is a problem. The baby has been “pushed” to the unit without the appropriate services and staff on hand to provide care. Pull works to ensure that the respirator, therapist, and nurse are ready and waiting when the baby arrives at the NICU. 5. Strive for perfection through continuous improvement Lean emphasizes the need to seek perfection or aim for zero defects when generat - ing products or services. This is in contrast to other process improvement method - ologies, including Six Sigma, that have a built-in acceptable rate of defects. Perfection also necessitates that quality improvement is continuous and not a temporary activ - ity to address one specific issue. In lean, there is no finish line and each successive quality improvement initiative moves a product or service closer to absolute perfec - tion (Toussaint & Berry, 2013).

At St. Jude Medical Center in Fullerton, California, perfect care is translated into specific initiatives and measures for inpatient, outpatient, and support areas. The focus on the critical care floor is the elimination of ventilator-acquired pneumonia.

Before analyzing the problem, critical care staff thought they were doing everything possible to prevent this condition. But analysis showed that wasn’t the case. Staff implemented a visual management board outside each room of a patient who was on a ventilator. On the board, staff flip red and green magnets every two hours as they execute prevention measures—steps such as oral care or changing respiratory equipment when it is soiled or malfunctioning. The system enables staff to quickly determine whether they have missed any prevention steps.

The care team meets regularly to review clinical evidence and discusses any misses in the prevention measures. The critical care unit has had zero preventable cases of ventilator-acquired pneumonia for more than three years (Touissant & Berry, 2013).

The program saves patients from ventilator-acquired pneumonia, which significantly increases the risk of death in critically ill people. Patients also spend less time on the ventilator, and their length of stay in the hospital and cost of care decreases. Specifying value, mapping value, creating flow, establishing pull, and striving for perfection are considered five basic steps for lean implementation. These steps are in no way inclusive of all lean concepts and principles, but rather a basic foundation for organizations wishing to implement lean. fin81226_07_c07_177-222.indd 207 10/30/14 7:27 PM Section 7.7 Overview of Lean Concepts and Methods Questions to Consider 1. What is the importance of identifying value from the customer’s perspective and how might this be different from identifying value from the organization’s perspective? 2. How can the concept of pull be applied in an emergency room and a chemotherapy infu - sion center? 7.7 Overview of Lean Concepts and Methods In addition to the five main principles of implementation, lean theory includes essential concepts and methods to support an organization’s improvement activities. Core concepts include changing company culture, widespread engagement in improvement activities, and emphasis on respect, as well as the identification and elimination of waste (Simon & Canacari, 2012; Toussaint & Berry, 2013). The core lean methods include Kaizen, gemba, the five Ss, visual management/control, standard work, and A3.

Lean Concepts Lean theory is a system based on six principles. An organization that does not to take into account each and every one of these principles will miss out on the full benefit of lean.

Change in Organizational Culture Many experts argue that lean is not just a quality improvement program or set of tools but that it involves cultural transformation that changes how an organization works (Toussaint & Berry, 2013). Lean principles must be engrained in all day-to-day operations, at all levels within the company. Leadership support is integral to the success of lean in any organiza - tion (Simon & Canacari, 2012). Company leaders must emphasize the importance of quality improvement and customer satisfaction as priorities. Employees must be assured that prob - lems are opportunities for improvement rather than blame or finger pointing.

Medicine has traditionally treated errors as failings on the part of individual providers. For instance, the error was blamed on a physician who didn’t have adequate knowledge or skill.

By contrast, the systems approach takes the view that most errors are the result of poorly designed systems. The errors result from predictable human failings; for instance, humans will make mistakes if they are required to put in long, unreasonable work hours or if inexpe - rienced staff are put into complex situations. Instead of punishing or remediating individuals, the systems approach identifies situations or factors likely to give rise to human error. The goal is to change the systems of care to reduce the occurrence of errors or to minimize the impact on patients (AHRQ, 2012).

For instance, to ensure medication safety, organizations must recognize and the correct the failures in the system. They must look beyond blaming individuals and focus on the multiple underlying system failures that create the conditions under which medication errors occur. fin81226_07_c07_177-222.indd 208 10/30/14 7:27 PM Section 7.7 Overview of Lean Concepts and Methods In healthcare, a change in organizational structure conducive with lean would be the elimi - nation of identifying and punishing one employee if a patient receives the wrong dose of a medication. A lean hospital would examine a medication error from a systems perspective and hold the entire organization accountable. There are many steps between when a medica - tion is ordered and ultimately given to a patient (e.g., physician initial order entry, pharmacy processing) that could be improved to prevent this type of error from occurring. Improving the process as a whole would be the main goal of lean. Eliminating blame has the added ben - efit of making employees more inclined to report errors because they are less fearful of the consequences for themselves or their co-workers (Leape, 1997).

The culture of an organization is not always easy to change. However, one way to persuade people to modify their behaviors is when they observe leaders in their organization acting differently. Organizations also reward new behavior with promotions, choice assignments, or praise and feedback from the top of the organization. For instance, if an organization wants to encourage its staff members to propose and implement changes that might result in better care for patients, it must ensure that employees have the ability to influence change and are rewarded for their ideas and efforts. Staff members must believe that change is worthwhile and the responsibility of everyone, otherwise, they will become discouraged and not moti - vated to undertake process improvements.

An organization must decide what principles it values and convey that message throughout the organization. If teamwork is valued, the organization must build trust among its manag - ers so they will collaborate. Similarly, it must build trust between the managers and the staff members working for them.

Companywide Engagement in Improvement All individuals, regardless of their level within the organization, should be involved with improvement projects. Unlike some process improvement theories that rely heavily on selected “champions,” such as Six Sigma, lean emphasizes the importance of hands-on involvement of all levels to ensure identification of the best and most sustainable solutions.

However, teams usually have assigned leaders who are ultimately responsible for project success (Simon & Canacari, 2012). Project leaders keep teams focused, obtain additional resources, assign tasks, and report on project progress. Projects can also have a facilitator who works closely with the leader but has the distinct responsibility of making sure meetings and discussions are productive and focused (Simon & Canacari, 2012).

Typically, a facilitator focuses on asking people their opinions, listening, and building consen - sus among the meeting participants. The facilitator should ensure everyone has the chance to participate, avoid too much or too little contribution from individuals, and keep the meeting flowing in the direction to meet the team’s goals. The facilitator can summarize the discussion and recommendations when an agenda topic is completed, and move on to the next item.

Companywide engagement means that all employees are involved in improvement activities.

In an outpatient cardiology clinic improvement project, for example, the front desk scheduler, nurse, cardiologist, and cardiology clinic administrator would be asked to work together to improve clinic flow issues. Hospital leadership, such as a division chief or chief medical offi - cer, could also be represented on this team. Even members of the housekeeping or medical fin81226_07_c07_177-222.indd 209 10/30/14 7:27 PM Section 7.7 Overview of Lean Concepts and Methods supplies staff may be asked to join the team. Making sure that everyone in the organization is engaged and working together to drive improvement is a key emphasis in lean.

Respect for People One of the core lean principles is respect for people who are doing the work (i.e., front line employees). This means recognizing that these are the individuals who understand existing problems and are best suited to provide sustainable improvement solutions (Kruskal, Reedy, Pascal, Rosen, & Boiselle, 2012; Toussaint & Berry, 2013).

Some improvement methodologies rely heavily on leadership to identify or select improve - ment projects. With lean, however, the goal is to empower front line employees to identify problems and create potential solutions. This can be considered a bottom-up approach to improvement. When workers gain confidence in their problem solving skills and witness pos - itive results, their drive for improvement may increase (Toussaint & Berry, 2013).

This principle also highlights the importance of teamwork and collaboration in order to improve day-to-day operations. Respect for people reflects an understanding that individuals within the organization are of equal value. Input from front line providers, such as nurses’ aides or physician assistants, is considered as important as the input provided by physicians or hospital leadership in driving improvement goals and processes.

Waste Waste is defined as anything that does not add value. Elimination of waste is strongly empha - sized as a core principle in lean (Simon & Canacari, 2012). TPS identified seven sources of waste, including 1) waiting, 2) motion, 3) inventory, 4) transportation, 5) over processing, 6) overproduction, and 7) defects. Although these sources were originally identified for man - ufacturing processes, they easily transfer to healthcare. The definitions for each source of waste and healthcare examples are listed in Table 7.8.

Table 7.8: Seven sources of waste in lean Waste Definition Example Waiting Idle time not used productively; waiting for the next event of work activity • Lag between surgical cases in an operating room • Patient waiting for a physician during a clinic visit Motion Unnecessary movement of people or employees in the system. Poor design of a work area or workflow • Nursing station placed at the end of a hallway (as opposed to centrally across from patient rooms) Transporting Unnecessary movement of parts in a system • Hospitalized patients being transported down to radiology for chest x-rays (as opposed to the use of a portable x-ray machine) fin81226_07_c07_177-222.indd 210 10/30/14 7:27 PM Section 7.7 Overview of Lean Concepts and Methods Waste Definition Example Inventory Shortage of the parts that make up the final product • Missing medical supplies needed for a pending procedure Overproduction Excess supply of product (i.e., that which exceeds customer demand); doing more than what is needed • Excess number of physicians staffing a medical clinic with high no-show rates Over processing Redundant work; doing work that is not valued by the customer • Duplicate charting • Multiple forms with the same information Defects Errors or mistakes that are not caught and corrected • Medication errors Sources: Teich, S. T., & Faddoul, F. F. (2013). Lean management—The journey from Toyota to healthcare. Rambam Maimonides Medical Journal, 4 (2), e0007; Simon, R. W., & Canacari, E. G. (2012). A practical guide to applying lean tools and management principles to health care improvement projects. AORN Journal, 95 (1), 85–100; Toussaint, J. S., & Berry, L. L. (2013). The promise of Lean in health care. Mayo Clinic Proceedings, 88 (1), 74–82. Lean is an approach that has proven successful in healthcare organizations. Lean transforms an organization’s culture and offers both challenges and opportunities to improve quality and efficiency.

Lean Methods Now that you understand the principles that underlie lean theory, it’s important to under - stand the methods to carry out this quality improvement process. Lean is an approach to quality improvement that has tangible benefits to healthcare organizations.

Kaizen and Kaizen Events Kaizen means to improve ; the literal translation in Japanese is gradual change (Protzman, Mayzell, & Kerpchar, 2011). Kaizen is the notion that everyone understands the importance of continuous improvement that should be part of day-to-day operations.

A Kaizen event involves assembling a small team of individuals to collaborate on a project to improve a process or service. Kaizen events are usually composed of six to eight workers who dedicate 100% of their time over a short time period, such as 7 to 10 days (Protzman et al., 2011). Kaizen events usually involve one day of training, one or more days of active observation and data collection about the process being improved, and one or more days of implementing changes and reporting results. Traditionally, Kaizen events also included one day of celebration at the end of the improvement project.

Kaizen events may take place during a typical work week. The team is responsible for meet - ing daily to discuss and conduct the improvement project. It would be comprised of employ - ees from different levels within the healthcare organizations, such as nurses, physicians, and administrators, who would be freed of their weekly tasks to attend the Kaizen event. Once the project is completed, team members return to their regular roles.

Table 7.8: Seven sources of waste in lean (continued) fin81226_07_c07_177-222.indd 211 10/30/14 7:27 PM Section 7.7 Overview of Lean Concepts and Methods Gemba and the Importance of Observing the Workplace Lean also emphasizes the importance of communication and interaction between leaders and front line employees. This is highlighted by the concept of gemba , or direct observation of work where it actually occurs (also known as “going to the gemba,” “gemba walk,” or “gemba rounds”) (Kruskal et al., 2012; Simon & Canacari, 2012). Gemba demonstrates the need for leadership (or anyone without firsthand experience of a particular process) to observe pro - cesses and interact with employees who actually complete the work to gain knowledge about day-to-day operations.

During a Kaizen event, for example, the assigned team may spend time directly observing a process to inform potential opportunities for improvement. Senior hospital leadership, such as the chief medical officer, may use gemba as an opportunity to interact with employees on the front lines. This could occur with daily rounds on the hospital wards and speaking with nurses, physicians, and support staff about daily operations and areas in need of improvement.

Visual Management Lean heavily emphasizes visualization of problems and processes. The idea is that informa - tion is communicated visually to facilitate regular and real-time exchange of information. This can be used to increase efficiency, recognize issues with products or services, and real-time testing of potential solutions.

Visual displays are usually used to help relate information about quality measures (Protzman et al., 2011). A visual display could include a clinical dashboard that reports a specific clinical quality measure, such as average wait time in an emergency room. By making information on wait times readily available, trends can be examined and real-time solutions can be provided when quality standards are not met. For example, if wait times in the emergency room are routinely monitored and become excessively long, additional staff could be called in to assist with patient care. Some hospitals are adding admit-discharge nurses to help manage patients and make sure when a beds opens up that maintenance staff immediately prepare it for the next patient. Once the additional staff have helped manage the surplus of patients and wait times have decreased, staffing ratios could return to prior levels. If wait times consistently increase during certain times, such as flu season, then adjustments in staffing ratios can be made for those specific times.

Visual controls are used to relay information about decisions related to efficiency or safety (Protzman et al., 2011). An example of a visual control includes signs indicating the proper location and use of medical equipment, such as a code chart used to help revive a patient with a cardiac arrhythmia. In an emergency situation, it would be critical that all staff know where the code chart is located so they can retrieve it and know where to place the shock pads to administer life saving shocks and revive the patient as quickly as possible. Another example would be posted signs to remind staff about the importance of hand washing to help decrease the rate of hospital associated infections.

Five Ss The five Ss describe the importance of a neat, clean, and organized work environment. The goal of the five Ss is to increase efficiency by making sure items are readily accessible and fin81226_07_c07_177-222.indd 212 10/30/14 7:27 PM Section 7.7 Overview of Lean Concepts and Methods available. Definitions and examples of the five Ss are provided in Table 7.9. Some organiza - tions have added safety as a sixth S.

Table 7.9: Five Ss in lean theory S Japanese translation Meaning Example Seiri Proper arrangement; clean up Separate and consoli - date items necessary for proper functioning of the work area Remove items that are unnecessary Seiton Arrange; put in order Arrange items so they can be found immediately Label spaces and create an appropriate place for items Seiso Neat, tidy, clean Make sure everything is neatly in its proper place Sweep floors, remove clutter Seiketsu Cleanliness, standard - ized, spotless Find ways to keep the environment clean and organized Remove documents once they are no longer in use Shitsuke Discipline, sustain, training Maintain the area once it has been organized and cleaned Everyone takes respon - sibility for the environ - ment and continues to examine the workplace Source: Protzman, C., Mayzell, G., & Kerpchar, J. (2011). Transforming your enterprise into a high quality patient care delivery system. New York, NY: Taylor & Francis Group. The five Ss should be included in all improvement projects. For example, a clinic with long wait times and low patient satisfaction may focus on several areas in need of improvement, including increasing staffing ratios and nursing work flow. However, to achieve these goals, the work environment must also be considered. Having an organized clinic space increases the efficiency of staff. Clean waiting areas and physician visit rooms also impact patient satis - faction. Therefore, this improvement project may also include elements of the five Ss.

Standard Work Standard work refers to a common process in creating a product or delivering a service (Tous - saint & Berry, 2013). It is emphasized in lean to decrease variation, which can lead to error or fluctuation in quality, and it ensures consistency in the quality of a product or service.

Standard work also serves as a checkpoint to ensure specific steps are not missed. For exam - ple, pharmacists could be required to follow several identical steps each time a new medica - tion is ordered. Standard work in this case could include sequential steps, such as a reviewing a patient’s medication allergy list to make sure the patient is not allergic to the new medica - tion, cross referencing the new medication with the patient’s existing medications to rule out any known interactions, and confirming that the amount ordered is consistent with known dosing guidelines to avoid over-dosing. Organizations with an electronic health record will fin81226_07_c07_177-222.indd 213 10/30/14 7:27 PM Section 7.8 Lean Theory in Healthcare Questions to Consider 1. Why is it important to have companywide engagement in improvement? What are the advantages and disadvantages, as compared to the use of “specialists” who are dedi - cated to full-time quality improvement activities? 2. Standard work helps to decrease variation and increase efficiency. Are there any poten - tial downsides to having standardized approaches to the delivery of healthcare? set those checks within that system. If pharmacists conducted these steps the same way for each new medication order, they would be more likely to prevent medication errors.

A3 A3 refers to a single sheet of paper used for lean project proposals (Protzman et al., 2011). An A3 usually includes a description of the problem, the current or existing state, the goal for improvement, a root cause analysis or list of causes contributing to the problem, a plan for improvement, follow-up on actions taken, and summary of the results.

The name is derived from the paper size used to generate this form (A3 = 11x17 inch). It is purposely limited to a single page so that it can be easily incorporated into day-to-day operations (i.e., it can be completed in a short period of time to promote quality improve - ment activities, as opposed to a detailed report, which would take time to write and may slow improvement activities). It is not unusual to have 15 drafts of the A3 because these are used to organize and communicate findings as a process is examined and re-examined (Toussaint & Berry, 2013).

7.8 Lean Theory in Healthcare Over the past 15 years, healthcare leaders have been drawn to the impressive results of lean implementation across other industries. The healthcare lean movement began with a few select hospitals adopting this methodology and is now spreading to more and more organizations.

As of 2009, 53% of hospitals reported some level of lean implementation, ranging from minor to full (Targeted News Service, 2009). In 2012, the Institute of Medicine also published a report highlighting the successes of organizations that have adopted lean principles (Insti - tute of Medicine, 2012b). Some of the first and most well-known examples of lean implemen - tation in healthcare organizations include Virginia Mason Medical Center, ThedaCare, and Denver Health. fin81226_07_c07_177-222.indd 214 10/30/14 7:27 PM Section 7.8 Lean Theory in Healthcare Virginia Mason Medical Center Virginia Mason is a non-profit hospital that was originally founded in 1920. It has a 336-bed inpatient hospital with 450 staff physicians and integrated outpatient primary care and spe - cialty clinics. In the midst of a financial and quality crisis in early 2000, the hospital leader - ship was looking for a way to change the existing culture. They chose to adapt TPS philoso - phies and practices for their use because they felt that the healthcare industry lacked effective management methods to help the hospital reach its goals: “to always put the patient first; to provide the highest quality, safest care; to foster and maintain patient and staff satisfaction; and to achieve financial success” (Kennedy, 2011).

Lean was adopted in 2002 and is embedded in every aspect of operations and care delivery throughout the institution (Kennedy, 2011). Virginia Mason now operates the Virginia Mason Institute, which oversees all lean-related activities that are formally referred to as the Virginia Mason Production System (VMPS). All hospital leaders are trained by the VMPS and respon - sible for leading improvement projects annually.

The following items are highlights that came from Virginia Mason’s implementation of lean (Institute of Medicine, 2012b; Kennedy, 2011): • Highlights in Quality Improvement • Over 1,250 continuous-improvement activities involving staff and patients • In 2009, 92% of patients rated their overall satisfaction with care at the top of survey scales • Recognition as a top quality hospital by the Leapfrog Group four consecutive years in a row (finishing in the top 1% on a combination of quality and cost in 2009) • Patients spend more value-added time with providers and experience fewer errors • Better patient safety, less delay in seeing physicians for care, and more timely results and treatments • Highlights in Cost Savings • Positive margins of 4–5% per year since implementing lean • 2008: $28 million gain, 2009: $47 million gain • $11 million saved in capital investment over 8 years by more efficient use of space One problem that leadership at Virginia Mason was interested in addressing was the over - use of magnetic resonance imaging (MRIs) (Institute of Medicine, 2012b; Kennedy, 2011).

They had noted that MRIs were often ordered for common conditions, such as low back pain and headaches, that usually resolve on their own, and for which the use of an MRI is not supported in the medical literature. To address this issue, the hospital implemented health- system-wide, evidence-based decision pathways that physicians could use as guidelines to help them decide when it was appropriate to order an MRI (i.e., visual controls). This MRI decision support system helped to decrease unnecessary MRIs by 23.2% for headaches and 23.4% for low back pain (Institute of Medicine, 2012b). The project also resulted in better care, with reduced delays for patients who need imaging studies and reduced unnecessary tests, with the risk from radiation exposure, for those not needing them. fin81226_07_c07_177-222.indd 215 10/30/14 7:27 PM Section 7.8 Lean Theory in Healthcare Another example of a lean project at Virginia Mason included the reorganization of patient supplies and shift assignments to increase inpatient nursing efficiency and workflow. For years, nurses had spent most of their time outside of patient rooms to complete tasks such as charting or gathering supplies and medications. Nurses were also assigned to patients all over the ward, which meant that they spent a great deal of time walking between far ends of the unit.

Several simple and inexpensive changes led to major improvements in efficiency and work - flow. The first was the relocation of the most commonly used patient supplies inside the patient’s room. The second was the use of “nursing cells” or shift assignments with proxi - mally located patients. These changes led to a 30% increase in the time nurses spent in direct contact with their patients and an 85% decrease in the number of steps nurses walk per shift (from 5,818 to 846 steps per shift) (Kennedy, 2011).

ThedaCare ThedaCare is an integrated network of 3 hospitals and 27 clinics serving 150,000 patients annually. The network has personalized lean-related activities, formally referred to as the ThedaCare Improvement System (TIS), and has created a separate institute to oversee all lean activities called the ThedaCare Center for Healthcare Value. (For more information, see ht tp://w w w.slideshare.net/Vijay_Bijaj/thedacare -improvement-system .) Like Virginia Mason, ThedaCare also had much success from implementing lean practices (Barnas, 2011; Institute of Medicine, 2012b; Toussaint, Gerard, & Adams, 2011): • Highlights in Quality Improvement • Between 2004 and 2009, 6 to 10 rapid improvement events per week • 88% of safety and quality indicators improved • 85% of patient satisfaction indicators improved • Highlights in Cost Savings • $3.3 million saved in 2004 (first year after lean adoption) • Increase in cash flow margin from 10.5% to 12.5% One example of specific projects under TIS was the creation of collaborative care units to deliver higher quality care for hospitalized patients (AHRQ, 2005a; Barnas, 2011; Toussaint et al., 2011). The emphasis of this project was to add value and eliminate waste in the inpa - tient experience. Patients admitted to the inpatient wards were usually visited several times during the day and night by different members of the medical team who provided informa - tion about specific pieces of the medical plan. Patients were often frustrated by the high fre - quency of scattered visits and piece-by-piece nature with which they received information.

For example, the nurse would provide information about medication changes but often could not answer patients’ questions about upcoming medical tests, which were typically discussed and ordered by physicians. If patients had a question about an upcoming test, the nurse would page the physician who would come to the bedside at a later time. When physicians were at the bedside they might be asked about a medication the patient was waiting to receive but they would have to refer to nurses or pharmacists. fin81226_07_c07_177-222.indd 216 10/30/14 7:27 PM Section 7.8 Lean Theory in Healthcare ThedaCare realized that there was great room for improvement in patient communication as well as among the medical team. They instituted collaborative care units, which used mul - tidisciplinary team rounds for all hospitalized patients. At least once per day, the medical team would visit the patient together. This resulted in a decrease in average length of stay for patients by 17%, a 25% reduction in costs of inpatient care, and an increase in patient satis - faction from 68% to 95% (Toussaint et al., 2011).

Denver Health Denver Health was founded in 1860 and is a large integrated system including a 525-bed inpa - tient hospital, 8 family health centers, 12 school-based clinics, 100-bed detoxification center, a correctional care facility, and a call center for regional poison control. Denver Health serves approximately 150,000 patients, 70% of which are ethnic minorities and 42% of which are uninsured (Barnas, 2011). In 2005, Denver Health became a unique example of a large safety net institution that successfully adopted lean. The overall mission is “Getting it Right: Perfect - ing the Patient Experience,” and they have created a Lean Academy to promote lean activities.

Denver Health’s successes with lean include (Institute of Medicine, 2012b): • Highlights in Quality Improvement • Achieved lowest rates of hospital mortality • Highlights in Cost Savings • $158 million in financial benefit despite a 60% increase in uncompensated care since 2006 An example of a lean project is the creation of patient registries to reduce variations in care (Institute of Medicine, 2012b). Specific issues that Denver Health wanted to address included poor overall blood pressure control in their patient population and low rates of use of pre - ventative care services, such as colon cancer screening. To improve quality in these areas, Denver Health created real-time reporting of these quality measures. They began actively tracking the number of patients that needed to meet certain quality measures using visual displays available in real time. In doing so, they identified and improved quality measures among providers or clinics that had higher percentages of noncompliance with known qual - ity measurements. These changes resulted in improved blood pressure control from 68% to 72% of patients and doubling of colon cancer screening rates. Questions to Consider 1. Why is it important to consider issues surrounding quality and cost when approaching an improvement project in healthcare? 2. Are there common attributes of healthcare organizations that have successfully imple - mented lean? What are some important issues that a healthcare organization looking to implement lean should keep in mind? fin81226_07_c07_177-222.indd 217 10/30/14 7:27 PM Summary & Resources Summary & Resources Chapter Summary There are growing challenges in healthcare for which sustainable and effective solutions are desperately needed. Six Sigma is an improvement methodology that aims to center a process on a specified target and reduce process variation as much as possible. The technical defini - tion of Six Sigma is to aim for less than 3.4 defects per million opportunities in any process, product, or service. Six Sigma projects have five defined process steps, collectively referred to as DMAIC, which stands for Define, Measure, Analyze, Improve, and Control.

Emphasis is placed on measurable customer-oriented, or center-to-quality metrics, as well as financial metrics. Six Sigma advocates the use of dedicated specialists within the organi - zation to help lead Six Sigma activities. Leadership support and engagement is also critical to Six Sigma success. Many healthcare organizations have used Six Sigma to improve their processes and outcomes.

Lean is another type of process improvement methodology that originates from automobile manufacturing and has been successfully adopted in other industries. The lean movement in healthcare began with only a few organizations on a quest for patient prioritization, qual - ity improvement, and cost savings. Experts have argued that lean “represents a valuable approach to addressing critical challenges we face in healthcare, including medical errors, escalating costs, and staffing shortages” (Institute of Medicine, 2012b). Based on the suc - cesses of organizations like the Virginia Mason Medical Center, ThedaCare, and Denver Health, basic lean principles are gaining momentum in healthcare.

At-a-Glance: Six Sigma and lean theory Six Sigma Lean theory Introduced in 1987 by the Motorola Company as a new way to decrease the number of defects in manufacturing Originates from the Toyota Motor Corporation and has been successfully adopted in other industries Adopted by many healthcare organizations over the last 20 years Advocated for by many healthcare experts and lead - ing organizations, including the Institute for Health - care Improvement Strives for fewer than 3.4 defects per million oppor - tunities (DPMO) in any process, product, or service Applies the concept of jidoka, or rapid identification and correction of mistakes in a process to prevent defects; the aim is to have zero defects, with sys - tems to support poka-yoke, or error proofing Projects have five defined steps collectively referred to as DMAIC: Define, Measure, Analyze, Improve, and Control Lean implementation includes five basic steps:

specify value from the standpoint of the customer, map the value stream, create flow, establish pull, and strive for perfection through continuous improvement Emphasis is placed on measurable customer- oriented, or center-to-quality metrics, as well as financial metrics Core concepts of the Toyota Production System include rigorous problem solving, teamwork, stan - dard work, zero defects, and elimination of waste fin81226_07_c07_177-222.indd 218 10/30/14 7:27 PM Summary & Resources At-a-Glance: Six Sigma and lean theory Six Sigma Lean theory Advocates the use of dedicated specialists to lead Six Sigma activities Advocates companywide engagement in improve - ment from all individuals, regardless of their level within the organization Leadership support and engagement is critical to success Leadership support is integral to success, with lead - ers emphasizing the importance of quality improve - ment and customer satisfaction as priorities Mini Case Study Mrs. Jackson is an 81-year-old patient who was admitted to the hospital after her blood count showed evidence of an infection. The infection left her feeling weak, but a nursing assessment did not identify her as a patient who might be at risk of falling. When her call light to summons a nurse was left out of reach, Mrs. Jackson got out of bed by herself and tried to make her way to the bathroom. Unfortunately, she was unsteady on her feet, tripped on a chair that was in the pathway to the bathroom, and fell. Luckily, Mrs. Jackson did not break any bones, but the fall left her with major bruises.

The facts show that Mrs. Jackson was not alone in taking a fall during her hospital stay. Up to 50% of hospitalized patients are at risk for falls, and almost half of those who fall suffer an injury (American Nurse Today, 2011). While falls impact patients, they also can be costly to healthcare organizations. Patients who experience a fall spend more time in the hospital.

The average hospital stay for patients who fall is 12.3 days longer, and injuries lead to a 61% increase in costs.

Mrs. Jackson was treated for her bruises and after an extended stay in the hospital was able to return to her daughter’s home, where she has been living for several years. She was very lucky. Many fall victims spend up to a year in recovery and some are never able to return to their homes. With the number of older Americans increasing, the problem of fall-related injuries is likely to rise over the next few decades.

Discussion Questions 1. Were there factors that may have been preventable that led to Mrs. Jackson’s fall? 2. Describe some of the steps that hospitals can take to prevent patient falls. Key Terms A3 A single sheet outline that summarizes a lean improvement project.

analytic tools Used to help identify and organize the plan of action in process improvement.

analyze Third of five process steps in Six Sigma; in this step, the root causes of defects or problems are examined. Black Belts Dedicated Six Sigma specialists. control Last of five process steps in Six Sigma; in this step, actions are taken to sus - tain improvements over time.

creating flow The process of ensuring that each step involved in creating a product or service is as efficient as possible. fin81226_07_c07_177-222.indd 219 10/30/14 7:27 PM Summary & Resources critical-to-quality (CTQ) characteris - tics Key measurable characteristics of a process or product that are essential for cus - tomer satisfaction; also known as customer- oriented metrics . customer-oriented metrics Key measur - able characteristics of a process or product that are essential for customer satisfac - tion; also known as critical-to-quality (CTQ) characteristics . define First of five process steps in Six Sigma; in this step, the problem or defect that needs improvement is identified.

DMAIC Acronym referring to the five pro - cess steps in Six Sigma ( Define, Measure, Analyze, Improve, and Control). DMAICR Acronym referring to an updated version of Six Sigma process steps, which includes an additional sixth step known as Reporting.

financial metrics Measurements of finan - cial impact.

five Ss Term that conveys the impor - tance of a neat, clean, and organized work environment.

gemba Direct observation of work where it actually occurs.

improve Fourth of five process steps in Six Sigma; in this step, modifications are made for improvement to occur.

jidoka Rapid identification and correction of mistakes in a manufacturing process to prevent defects.

just-in-time Describes the concept of mak - ing “only what is needed, when it is needed, and in the amount needed.” Kaizen To improve. Kaizen event Assembly of a small team of individuals to work together on a project to improve a process or service.

lean theory One type of process improve - ment methodology that was derived from Toyota manufacturing; also referred to as simply lean.

measure Second of five process steps in Six Sigma; in this step, data is collected on the existing process and outcomes of interest.

metric Measureable factors that provide useful information about the performance of a process.

Pareto analysis A type of analytic tool using lines and graphs to visually demon - strate the relative frequency of root causes for a defect or problem.

poka-yoke Error proofing. process flow diagram A type of analytic that maps the general flow of a process.

process improvement methodolo - gies A systematic approach to process improvement.

project hoppers Senior management involved in Six Sigma project selection.

pull Allowing the customer’s need for the final product or service to guide how much of that product or service will be generated or offered.

reporting The sixth step in DMAICR; in this step, communication and internal reporting about improvements take place.

Six Sigma A type of process improvement methodology. fin81226_07_c07_177-222.indd 220 10/30/14 7:27 PM Summary & Resources Critical Thinking Questions 1. What are some of the most common quality concerns in healthcare today? How would Six Sigma and lean theory be applied in these cases? 2. What are the main strengths and limitations of Six Sigma applications in healthcare?

How can any existing limitations be overcome? 3. What are the main advantages that lean theory provides? What are the biggest chal - lenges an organization might face in implementing lean? 4. What are some areas of overlap between Lean and Six Sigma? In what ways do these two processes improvement methodologies differ? Suggested Websites • Institute for Healthcare Improvement (IHI):

ht tp://w w w.ihi.org/search/pages/results.aspx?k=six%20sigma This website includes some general information along with detailed examples of Six Sigma projects. • Agency for Healthcare Research and Quality (AHRQ):

http://search.ahrq.gov/search?q=six+sigma&spell=1&entqr=0&output=xml_no _dtd&proxyst ylesheet=AHRQ _GOV&client=AHRQ _GOV&site=default _collection& x =0&y=0&ulang=en&ip=172.250.10.171&access=p&sort=date:D:L:d1&entqrm=0&o e = U T F- 8 & ud=1 This website lists some general information and detailed examples of Six Sigma projects. • Society of Hospital Medicine (SHM):

ht tp://w w w.hospitalmedicine.org/Content/NavigationMenu/Qualit yImprovement /PrioritizingQualit y/Qualit yImprovementMethodologies/Qualit y_Improvement.htm This website provides some basic information on quality improvement methodolo - gies, case examples of Six Sigma applications, and a review of analytic tools in the section titled, “Tools for Process Improvement.” standard work Common process in creat - ing a product or delivering a service and uniform way of approaching a task.

statistical process control charts A type of analytic tool used to visually track quality over time.

Toyota Production System (TPS) For - mal description of core concepts that were integral to the way Toyota conducted daily activities.

value Quality from the customer’s perspec - tive; what the customer is willing to pay for. value stream Detailed map of all the steps or activities that are required to create a product or service.

visual controls A way to relay informa - tion about decisions related to efficiency or safety.

visual displays Usually used to help communicate information about quality measures.

waste Anything that does not add value from the customer’s perspective. fin81226_07_c07_177-222.indd 221 10/30/14 7:27 PM Summary & Resources • North Carolina State University:

http://www.tx.ncsu.edu/sixsigma/faq.cfm This university website covers some basic information on lean Six Sigma and links to courses. • Toyota Global:

ht tp://w w w.toyota-global.com/company/vision_philosophy/toyota_production _system / This website reviews the Toyota philosophy and production system. • Lean Enterprise Institute:

ht tp://w w w.lean.org This website includes a review of the lean concepts. fin81226_07_c07_177-222.indd 222 10/30/14 7:27 PM