ES382 Assignment Table of Contents Intro. 1 What is Six Sigma?. 2 Quality in a hospital 3 General Tools and techniques that can be implemented in DMAIC. 4 Technique to improve hospitals: Lean Six Sigma (LSS).
4 Tool: Quality Circle. 5 Recommended DMAIC Process Specific Tools. 6 Define.
6 Measure. 7 Analyse. 7 Improve and Control 8 Conclusions. 9 Bibliography.
10 Number of words: 3956IntroSix Sigma is a quality technique thatfocuses primarily on the reduction of defects (per million opportunities) henceimproving the reliability of a process. It has clear applications havingprimarily been used for manufacturing processes, however, the service sector(which includes hospitals) can also benefit from the tools and techniques thatare used in aiming for Six Sigma quality – with techniques such as Lean Six Sigmabeing employed in service organisations and Design for Six Sigma also commonlypracticed in manufacturing applications (NPD Solutions 2016). The tools employed in attaining Six Sigmaquality will be applied to the service of hospitals which often perform poorlyand could benefit from this implementation. Six Sigma applied to a hospitalshould offer an increase in quality which will deliver improvements to customerservices (for the patients) and financial performances (for the hospitalitself) which would further benefit from tools applied within their DMAIC cycleranging from process flowcharts to statistical process controls to reduce thedefects per million opportunities (DPMO) and thus increase the quality of theseprocesses. What is Six Sigma? Figure 1 – Depiction of the hidden factory being intrinsic to normal processes (Lean Strategies International LLC 2016) Six Sigma is a statistical definition highlightinghow far a process deviates from its ideal output (Knowles, Six Sigma 2011). Hence a comparisoncan be made with the hidden factory approach (see figure 1) – whereby it takesthe same resources to offer bad products or services as it does to offer goodones thus it is a way to quantify the size of the ‘hidden factory’ in a process (iSixSigma 2018),this linking to the idea of the Cost of Poor quality. A Six Sigma quality is achieved when thereare a maximum of 3.
4 defects per million opportunities (Knowles, Process Improvement and LSS 2016) – hence a 0.0034 %of the output has a defect. Whilst this seemingly is a minor number of defects,with a population of 65.64 million in Britain (Office for National Statistics 2017)that is approximately 2230 defects.
Hence, with relative scale factored in Six Sigmaquality really is essential in providing a product or service in a reliable way. Figure 2 – Highlights the structure of Six Sigma implementers (Google Images 2017) Six Sigma is also a philosophy that is often attemptedto be engrained into a company’s culture with continuous improvement (Kaizen)often cited as a mindset to employ – with this being a main feature of Lean SixSigma. In addition to the use of Kaizen, Six Sigma uses certain terminologiesto denote members of an organisation whose sole purpose is to achieve this(figure 2), such as black belts – who are experts working on critical problemsfacing the current process and from an understanding of a project at a processlevel, provides improvements – and Green Belts who implement these ideas (Knowles, Six Sigma 2011).
Figure 3 – Less costs incurred in design phase compared to later in the process (ACCA 2017) Furthermore, Six Sigma can be approached indifferent ways; with Design for Six Sigma (DFSS) and Lean Six Sigma (LSS), bothusing acronyms1 – DMAICfor Six Sigma (standing for Define, Measure, Analyse, Improve and Control) tofocus the efforts of a manufacturer or service into reducing defects. Commonly,DFSS is used in the manufacturing industry to improve the quality of an existingproduct by redesigning with the aim to reduce defects when created and the probabilityof future reworks – thus investing the time in the design phase to get theproduct correct the first time, whereby less costs are incurred (ACCA 2017) as highlighted infigure 3. Alternatively, Lean Six Sigma (LSS) uses the Lean managementtechniques which aims to reduces Muda (waste or wastefulness) and combines itwith the reduction of defects expected from Six Sigma to make processes more efficientand faster with this approach working its way into the service sectors ratherthan solely manufacturers.Quality in a hospitalIt is important to define quality andunderstand the problems incurred with the cost of poor quality applied to a servicesector such as a hospital; however, quality is often defined by the recipienthence it is subjective.
Further to this, the service sector inherently includesa human element, hence human errors are intrinsic to the operation (Knowles, Quality by Design 2017). If applying quality techniques to ahospital process, reduced variation in a process will be an improvement, thusreducing the necessity for future check-ups and further decrease the maintenancecosts. This highlights that a measurement of quality for the service of ahospital is counter intuitive to the standard service – thus when defining thecustomer satisfaction, it should be considered that a satisfied patient will beone that does not have to return to the hospital hence getting the processright first time will be essential. Improvements in financial performance will typicallybe attained through breakthroughs in efficiency – see Figure 4 (GoLeanSixSigma 2016).
Furthermore, Financial improvement may not be solely measured on the profit orloss, but can also be measured in time – as time is often remunerated in money (Knowles, Quality by Design 2017) hence if a processis made more efficient a member of staff at the hospital may have to work lesshours resulting in less wages paid, or alternatively, will have more time towork on other issues and will have time to further improve and reflect on aprocess. Figure 4 – Highlighting how efficiency can increase the number of patients visits (GoLeanSixSigma 2016) With two major beneficiaries of quality ina hospital, customer satisfaction and financial improvement, achieving a Six Sigmaquality will result in these standards to increase with the tangible benefit ofa reduction in waste. The reduction of waste (LSS) increases the efficiency ofa hospital process and the use of Six Sigma means that a reliable process iscreated in achieving the desired defects per million opportunities (Knowles, Process Improvement and LSS 2016). This combinationwill reduce the time wasted (an example of quality in a process) and further downstreamof management in a hospital, reduces the time wasted by hospital employees.
Helpingpatients get out of hospital faster results in pleased patients and lessstressed doctors. This having a multiplier effect as less stressed doctors willperform better and more reliably hence the quality of the service ought toincrease. Thus, quality is interconnected and engrained into the all processesover a service organisation.
General Tools and techniques thatcan be implemented in DMAICTechnique to improve hospitals:Lean Six Sigma (LSS) Figure 5 – Explaining how Lean and Six Sigma work together to improve quality (GoLeanSixSigma 2016) One major way of a hospital to aim for Six Sigmaservice is the focus on the reduction of waste – this being a part of Lean Six Sigma.Waste can be defined by Toyota’s 7 wastes which include waiting and defects (Knowles, Process Improvement and LSS 2016). Figure 6 – Floorplan of hospital depicting size of waiting areas (small but specialised) (USMD Hospital at Fort Worth 2017) Using hospital waiting rooms as an example; not onlyis it evident of letting patients wait (this being a negative factor regardingthe customer and one of Toyota’s 7 wastes) but it is also a great space that islost and could be put to better use hence having a financial impact – forexample a waiting room could be of a minimal size (see figure 5) thereforeincreasing the amount of rooms for doctors to work in or additional beds forovernight stays) thereby making use of potentially wasted space. However due tovarying capacity at hospitals and the likelihood of special cause variationoccurring at hospitals this may not be wise due to the expectations of havingmultiple patients for every doctor.
Lean Six Sigma is a workplace culture,which when applied to a hospital could reap benefits. With efficiency endorsed(without rushing), engraining a reduction in waiting times into hospital practicesand further educating patients in other tools put in place by the health servicessuch as online GP services (such as GP at hand), waste can be controlled andreduced (GoLeanSixSigma 2016). Therefore, the use oftools such as current state mapping (Six Sigma Material 2018) can help organisethe health services and coordinate their response (hence delegating demand toGPs and services such as NHS 111) resulting in a more predictable demand for hospitals– this linking to Statistical Process Control (SPC)2.The mechanism of a more predictable andcontrolled demand may reduce waiting times due to hospital staff balancing workloadsfrom the result of planning made from LSS and current state mapping3.This can lead to other positive impacts such as the potential to reduce stressand the likelihood of a stress related accident further reducing DPMOs. However,Special cause variation is still likely to cause problems, to counter this adedicated accident and emergency hospital or ward could be used, thus the useof specialisation to negate these effects.
Overall, the use of the technique LeanSix Sigma and planning tools associated with it can be used as a basis forhospitals to at least reduce their wasteful processes, and ascertain wherequality may be lacking, this will provide an understanding of what needs to bedone to achieve Six Sigma quality.Tool: Quality CircleA tool that can aid the definition stage ofDMAIC but also fits in throughout the process is the use of quality circles.Quality circles can help reduce waste as it uses the employees that sharecommon work to meet up and talk through problems that impede the effectivenessof their work (Knowles, Quality Management 2011). Despite thisoccurring during hospital time on a weekly basis – thus costing the hospital inthe short run– it would reduce the need for expensive research groups hence acost reduction improvement can be made in this regard. In addition to this, theemployees will have the greatest understanding of how to define their processand impedances hence improvements can be made faster. To apply this in ahospital may provide a positive step to achieving Six Sigma as it could be integratedinto a schedule to ensure that doctors have a rest period and a chance toreflect upon their own practices – and may also lead to doctors learning fromother practices thus aiming for Six Sigma quality. A further positive impact that this may bring aboutis the opportunity to have a dialogue upstream of the organisation which couldfeed into the blackbelts further helping the improvement (as highlighted infigure 7 with employees feeding upstream).
This would also provide a place ofsupport which will help reaffirm the culture of quality improvement. Hence,this tool does not solely help define problems faced by members of staff, but aclear improvement is the promotion of Kaizen in employees with continuous reflectionsof their own work practices. Figure 7 – Structure of a quality circle (Slideshare 2012) Hence, not only are there financial performancebenefits expected with this tool, but the use of feedback and effectivecommunication in hospitals should improve customer satisfaction as resolutionsto issues can be found easier through exchanging thoughts with hospitalemployees, furthering improving practices – hence kaizen is a mechanism for anincrease in quality. This may increase the chances of a patient beingdischarged faster (as the process that the patient goes through is refined) henceas already identified, this is a way of achieving higher customer satisfaction.To support this tool, good planning of a doctor’sday is necessary to provide the free time to meet in a quality circle – withtime not being readily available in a hospital! – and the culture of self-improvementwould have to develop, with a possible elimination of targets (The Deming Institute 2018) to remove relianceon quantitative evaluation of processes and giving a chance to break down the orderof operations.Recommended DMAIC Process SpecificTools There many tools that can be used to develop a Six Sigmaapproach within the DMAIC process (figure 8), often these can be used atdifferent points in this process.
The following have been chosen in theirrespective categories to be best applicable to a hospital.Define Figure 8 – Six Sigma DMAIC cycle (Knowles, Six Sigma 2011) Within the Define stage there are many toolsemployed to ascertain a strong understanding of what the hospital faces toimprove its quality. This is one of the major steps in the DMAIC process as byunderstanding the problems and the customer requirements will allow a morefocused approach to attaining six sigma. Figure 9 – Basic Process flowchart example applied to a hospital (Quality Assurance 2017) Process flowcharts (such as current and future statemaps (Davis 2016)are often analysed to gain a full understanding of what is occurring – theseare usually created with right to left thinking hence starting at the customerand going in reverse through all the processes (see figure 9). From here thehospital can understand which parts of the process are dependent on one another– for instance a hip replacement operation requires an artificial hip to besourced before the operation is undertaken (this being a logical thought processbut there are many operations that occur between these two occurring) – thus it important to have anoverview of the process established during this stage as it enablesimprovements and wastes to be identified whilst highlighting theinterdependence of tasks in a process. With this technique, an improvement wouldnot be expected instantaneously however, it is used to facilitate the changerequired to achieve Six Sigma. Further to this the use of Critical toQuality (iSixSigma 2018) definitions can provide an aim for the process.
In this case by starting with the patient (the customer) an understanding ofwhat is desired to achieve patient satisfaction can be ascertained. From this,surveys or other information gathering techniques can be used to quantifydefects. In the case of a hospital offering a hipreplacement, applying this to the Define stage of DMAIC, there is the objectiveto increase the patient care quality whilst reducing the length of the stay andthe likelihood of returning due to errors in the operation – this being a case in the USA wherebydefective hip joints had to be fixed hence quality can be attained from thesupply chain too and using process flowcharts can help identify these issues (Indian Journal of Orthopaedics 2015). The process flowmap of the customers journey through the hospital can be applied to find wherethe quality established is in the supply chain or actual hospital itself, andcan be further compared to the CTQs. This can feed into Lean Six Sigma wherebywastes can be easily identified and analysis can be completed of it.MeasureBenchmarking is a tool that allows themeasurements and comparison to a competitor- in this case a poorly performing hospitalcan be compared to a higher performing one (iSixSigma 2018). Alternatively, (once again using akaizen mechanism) internal benchmarking between departments can be done. Thiscan provide quantitative and qualitative data to be compared.
Despite hospitalshaving a vast range of operations, this tool can be used to give an indicatoras to how a department may be succeeding or failing in an operation – forinstance measuring patient turnover to understand the average time a patientspends in hospital.AnalyseThe analyse stage identifies the rootcauses of poor quality and will eventually feed into the improve and controlstage. A clear application of the analyse stage to hospitals is asking why patientsare staying for longer than necessary as this has evident customer satisfactionand financial implication.
A tool such as the five whys can be employed todrive this analysis.By asking why about a hospital process acausal pathway is developed (NHS 2003), and despite it beingcalled the five whys, why should be asked as many times until a satisfactorycause has be attributed.An expected improvement with this will bethe likelihood of understanding where problems arise in the process.
This usesthe information from the define and measure stage and works out where the qualityis suffering. Figure 10 – Example of five whys in NHS (NHS 2003). Figure 10 is an example of how the five whys can beused in a hospital. The example is an extreme case of a poor process, wherebythe quality has suffered due to poor planning. This gives an indicator as tohow to improve the process to ensure that the same mistake does not happenagain – in this case a supporting factor to improve the quality will beadditional training (as they have never been asked to do the planning for theamputation before).By getting to the root cause, hospitals canintegrate quality from the beginning of a process, hence if quality isengrained from the offset, by the time patients are being treated (henceupstream in the operation), the process should meet the spoken requirements ofthe customer. Improve and ControlAt this point, quality solutions should beimplemented using the information attained in the previous stage.
This is thepoint whereby defects are eliminated using techniques such as the House ofQuality (in the improve stage) or Statistical Process Control (control ormeasure). Figure 11 – Shows how limits are placed in SPC using a range of Six Sigma (3 Standard deviations from the centre line) (Quality Digest 2018) Statistical Process Control is represented in theform of a graph in which limits have been set and is a method of ensuringimprovement (Flexstudy 2018). Being outside of those limits iscalled Special Cause Variation – and indicates special measures being required– and being within the limits are Common Cause – whereby fluctuations from thecentreline still occur however they are within limits as highlighted in figure11. Despite Statistical Process Control commonly applied to the manufacturing,there could be some application within a hospital, especially in regardsincrease customer satisfaction. SPC is often used to measure and controlpatient vital signs such as heart rates and oxygen (Quality Digest 2018).
Despite this not being the standard approach to SPC, the use of it is essentialin understanding the condition of a patient – hence minimum patientsatisfaction will be ensured by monitoring whether a patient is alive! This is commonto most hospitals around the world, and other instances of SPC applicationsinclude machinery such as X-rays which may require maintenance or and canemploy SPC to ensure it is in working order – hence financial implications ofmaking sure equipment lasts the longevity of life.Furthermore, the best example to apply SPCto is to highlight staffing averages. This can be used to understand whetherstaff are being overworked (which can lead to poor quality of processes) or whetherthey are being underutilised. This can be compared to the demand of certainhospitals procedures and can feed into the root cause analysis – such as askingwhy there was special cause variation on a certain day, and furthering this bychecking whether it was due to understaffing or special cause variation.As a result, the improvements in financialperformances are expected by understanding when peak demand occurs for ahospital and the use of planning to control any shortfalls. This results inunderstanding the hours worked by the employees to ensure they are notoverworked; further increasing customer satisfaction by having enough doctorsor nurses to cover the influx of patients throughout the day thereforeincreasing the likelihood of being seen and treated earlier.
Kaizen once again is an important mechanismand supporting factor as SPC will be necessary to feed back into earlier stagesto improve the process. Furthermore, SPC can be used in the measure stage forcomparison hence it has multiple applications within a DMAIC analysis. ConclusionsSix Sigma is a vital aim in improving thequality of a process by improving the reliability; with those involved in theprocess benefiting from the reduction of defects. Despite its wide use inmanufacturing, services such as hospitals benefit from tools and techniquesassociated with it.
It is evident that within a system such as a hospital thereare many interconnected risks and rewards that can be affected by Six Sigmatools being implemented. Quality for the patient is also counter intuitive tothe rest of a service industry whereby not having to return to the hospital isa sign of good quality. Alongside this, patient satisfaction can improvefinancial performance – as highlighted by the fact that patients spending lesstime in the hospital will being less of a financial burden compared to thosestaying longer.
Techniques such as Lean Six Sigma would bea strong way of improving a hospital as it adjusts the culture to strive forefficiency with Kaizen (continuous improvement) being one of the most vitalmechanisms in developing quality in the service. Further to this, theelimination of a great deal of waste and links to process flow maps are integralto creating a service of a high quality as it highlights the importance ofplanning and process understanding. Thisfeeds into the other stages of DMAIC with other tools such as Statistical ProcessControl allowing processes to be controlled, measured and fed back into thecycle. This highlighting the importance of continuous development in strivingfor quality as reaching a 3.4 defects per million opportunities target isincredibly difficult in a service sector which is catering for special causevariation. Overall, this service sector requires numerous tools and techniquesworking in conjunction with mechanisms for support to ensure quality isprovided across an interconnected process.