DB 310

508 Copyright © American Association of Occupational Health Nurses, Inc.

HealtH Updates

ABOUT THE AUTHOR Ms. Carter is Occupational Health, Safety and Wellness Manager, Albemarle County, Charlot- tesville, VA. The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Pam Carter, RN, COHN-S, FAAOHN, 122 Mohican Trail, Ruckers- ville, VA 22968. E-mail: [email protected]. doi:10.3928/08910162-20101124-02

Six Sigma

by Pam Carter, RN, COHN-S, FAAOHN

E xactly what is Six Sigma? Sigma, a Greek letter used in statistics, represents the

amount of variation in a process, a set of data, or anything measurable. The Six Sigma process is used to elimi- nate defects and inefficiencies in a process or service. The process has adopted the belt system used in kara- te—black belt, green belt, and yellow belt—to signify the level of training and performance an individual has completed. The Six Sigma method was introduced in the mid-1980s at the Motorola Corporation when the company began to focus on strategies to reduce product defects. As a result of those efforts, Motorola won the Malcolm Baldridge National Qual- ity Award in 1988. Today, Motorola holds the trademark for Six Sigma.

In the mid-1980s, Motorola part- nered with several other companies, including AlliedSignal, Kodak, IBM,

Texas Instruments, and ABB (Asea Brown Boveri), to found the Six Sig- ma Research Institute. General Elec- tric increased the popularity of Six Sigma when Jack Welch committed to achieving Six Sigma capabilities for the company.

One of the primary goals of the process is to eliminate anything that does not meet customers’ needs. Phrases such as “the voice of the cus- tomer” or “customer delight” are of- ten heard. Often, process owners may think they know what their customers want and expect; in reality, however, process owners and customers may not be in agreement. Therefore, one of the essential tasks of Six Sigma is to establish what is important to cus- tomers. What is critical to the qual- ity of the product or process from the customer’s standpoint? This informa- tion is referred to as CTQ (critical to quality).

The Six Sigma process uses two defined methodologies, DMAIC and DMADV. DMAIC involves five steps: define, measure, analyze, im- prove, and control. It is used to im- prove an existing process. DMADV (define, measure, analyze, design, and verify), on the other hand, is used when a new process or service is needed. This article focuses on DMAIC.

DEfinE Once a process or service has

been identified as needing improve- ment, the next step is to identify po- tential team members who are famil- iar with and knowledgeable about the elements of that process or service. Often, a master black belt discusses the project with the leadership of the organization to determine the value of the project and identify the appro- priate individual to lead the team.

Responsibilities are generally divided into four areas:

1. Team sponsor—A representa- tive from the leadership of the organi- zation who has the power to dedicate necessary resources to the project and also insight about the value of the project.

2. Team coach—This individual is often a master Six Sigma expert, having extensive training in the Six Sigma process and providing tech- nical support to the team. The team coach is often the person who sug- gests which type of tools would best support the analysis.

3. Team leader—This individual has received training in the Six Sig- ma process, but not to the degree of a master black belt. The team leader is responsible for meeting the goals of the project and providing continuous direction to keep the team moving forward.

4. Team members—These are the individuals who are most familiar with the process or service needing improvement. They execute the work of the project. A cross-functional team is important (e.g., including an individual familiar with the financial aspects of the process to add finan- cial importance to the project).

Once the team has been identi-

When I was first introduced to the Six Sigma process, I resisted it with every ounce of energy I had. I continuously fabricated reasons so that I was unable to complete the training that my company required. When it came time for my performance review, I could not hide the truth from my manager; I had not completed the required training. It was then that I began my journey into the world of Six Sigma. Once I understood that a black belt and a green belt certification had nothing to do with karate, I felt much better.

professional practice

509AAOHN JOuRNAl • VOl. 58, NO. 12, 2010

professional practice

fied, the project must be defined. To accurately focus on the correct issue, the team must understand custom- ers’ expectations and needs. Meeting with customers to clarify their needs and expectations can be beneficial. Without a clear understanding of cus- tomers’ needs and values, the team’s work may be useless. It may also be beneficial to identify measurements that would assist the team and cus- tomers in evaluating progress toward improvement.

MEASURE Next, the problem is investi-

gated in detail. Data are used to de- termine when, where, and how the problem is occurring. Accurate and appropriate data are essential be- cause all decisions are data driven. Data can have numerous sources. Customers can provide data sup- porting their complaints. Individu- als involved with executing the process or service can offer data. A request for data often leads to ad- ditional requests for data. The team may find that some of the data have already been collected. Data should be collected over a sufficient pe- riod of time to provide an accurate representation of the process being investigated. A process map may be beneficial for identifying each step in the process and the data actually needed. If data do not accurately re- flect the problem, the process begins again with the team clearly defining how to gather the desired data.

AnAlyzE Now, the team seeks to under-

stand the data that have been col- lected and make sense of the exist- ing process. In the analysis phase, the problem is clearly identified and confirmed. The team looks for trends and patterns based on the data and identifies the problem’s root cause. The team must use the data, not in- dividual opinions, to reach conclu- sions.

iMpROvE In the improvement phase, solu-

tions are identified and implemented to address the root cause of the prob-

lem. Creativity may be necessary to identify new approaches or best prac- tices with a demonstrated record of success. Some team members may wish to continue using current prac- tices; however, the team’s analysis has demonstrated that those methods are inadequate, so the team must identity new ways to operate. Once new strat- egies are identified, an implementa- tion plan is needed. Other associated processes may be impacted by this change, so these processes may also require evaluation.

COnTROl In the last phase, controls are de-

veloped to prevent the problem from reoccurring and to ensure that “fixes” are maintained over time. These con- trols may include retraining or devel-

oping and implementing a monitor- ing or auditing system to ensure that improvements continue.

CASE STUDy An example of using Six Sigma

methodologies in health care could be applied to reducing medication errors.

The first step is to obtain approv- al and support from senior leadership. Once this support has been obtained, the next step is team formation. Pos- sible team members might include nursing staff, physicians, risk man- agers, and pharmacy staff.

Once the team has formed, the project must be defined. Medication errors and opportunities for medica- tion errors would need to be defined to compute Six Sigma levels. Be-

Examples of Tools and visual Aids Used Throughout the Six Sigma process

Pareto chart—a bar graph used to identify which issues will yield the greatest improvements. Most effective when analyzing data regarding the frequency of a problem. May also be used to display the relative signifi- cance of the differences between groups of data.

Cause-and-effect diagram—often referred to as a fish bone because it re- sembles a fish skeleton. The problem is the head of the fish, and the various causes are the bones of the fish. It helps the team identify which causes need to be investigated by collecting additional data.

Scatter plot—used to determine if a relationship exists between two vari- ables. Assists in determining a hypothesis. The data used are often those collected by the cause-and-effect diagram.

Histogram—used to graphically summarize and display the distribution of a process data set. For statistically sound data, 50 to 100 data points are needed to identify reliable patterns. A histogram will identify any outliers or if the data are symmetrical.

Table

Examples of the practical Meaning of Six Sigma 99% Good (3.8 Sigma)

99.99966% Good (6 Sigma)

Incorrect surgeries per week 5,000 1.7

Incorrect medication prescriptions per year

200,000 68

Time without electricity 7 hours per month

1 hour every 34 years

lost pieces of mail per hour 20,000 7

510 Copyright © American Association of Occupational Health Nurses, Inc.

professional practice

cause errors and opportunities can be classified into three categories—pre- scription errors, dispensing errors, and administration errors—the team may choose to work on just one category or all three. The problem and customers’ expectations must be clearly understood. In this case, customers may include patients, the pharmacy, or risk managers. The ex- pectation would be to properly dis- pense the correct medication at the correct time to the correct patient.

The next step is measurement. This would be accomplished by col- lecting data such as number of medi- cation errors, categories of errors, when and where errors occurred, method of administration, ordering physicians, and administering per- sonnel.

Now, collected data are ana- lyzed. During this step, the team may find that additional data are needed. When analyzing the data, trends must be identified. Perhaps a specific physician’s orders are one common

denominator in errors, or errors may be originating from a particular nurse who has been administering medica- tions.

Next, the team identifies ways to improve or solve the problem. In this case, a policy change may be needed, with all medication orders being entered into a computerized system, thus eliminating hand writ- ten orders.

The last step is the control pro- cess. In this case, use of computer- ized medication orders may need to be monitored.

COnClUSiOn Throughout the process, numer-

ous tools and visual aids, including Pareto charts, cause-and-effect dia- grams, scatter plots, and histograms (Sidebar), are used. The types of data collected determine the tools best suited for the needed analysis. Sound project management principles are also used to achieve success.

Health care professionals use

the Six Sigma process routinely in practice. They may not refer to it by name, but they have been trained to make decisions using a scientific or evidence-based process. The ben- efits of Six Sigma methodologies are numerous (Table). Six Sigma provides structure and an objective method for identifying and address- ing business problems. Using Six Sigma ensures quality, which in turn ensures that defined customer needs are met. Customer satisfac- tion is the foundation of profitable businesses.

BiBliOGRApHy Barry, R., Murcko, A. C., & Brubaker, C. E.

(2002). The Six Sigma book for healthcare. Chicago: Health Administration Press.

Brassard, M. (1994). The Six Sigma memory jogger II. Salem, NH: GOAL/QPC.

Esimai, G. (2005, April). Lean Six Sigma re- duces medication errors. Quality Progress, 51-57.

Harry, M. J. (1994). The vision of Six Sigma. Phoenix, AZ: Sigma Publishing.

iSixSigma. (n.d.). iSixSigma.com. Retrieved from www.isixsigma.com

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.