Quality at Its Best

No doubt you have heard of either Total Quality Management (TQM) or Continuous Quality Improvement (CQI). But have you heard of Six Sigma? If you’ve read anything by or about Jack Welch, the former CEO of General Electric, who used the method to improve GE’s business model, then you probably have.

Six Sigma is a process-enhancement program that uses facts and data to develop better solutions. It is a quality improvement program that changes how organizations operate. Six Sigma shares some of the fundamental principles and tools of TQM and CQI, such as the study of processes and statistics, but the similarities stop there. Six Sigma is a smarter way to manage a business because it brings both the customer and the employee into the process, stimulating breakthrough results in every area of an organization. While TQM and CQI focus on detecting and correcting problems (also known as defects), Six Sigma provides specific methods to recreate a process itself, so that defects in it are never produced in the first place. Six Sigma focuses primarily on improving customer satisfaction, reducing waste, decreasing the time it takes to complete a task (cycle time), and producing significant cost savings by utilizing valuable employee input.

What is Six Sigma?

Originated by Motorola in the late 1980s after working with Japanese business models, Six Sigma’s use and popularity were turbocharged in 1996 when Jack Welch implemented it at GE with phenomenal results.

What exactly is Six Sigma? The word “Sigma” is a statistical term that measures how far a given process deviates from perfection. The main idea behind Six Sigma is: If you can measure how many “defects” you have in a process, you can systematically figure out how to eliminate them and get as close to zero defects as possible.

To achieve Six Sigma quality, a process must produce no more than 3.4 defects per million opportunities. An opportunity is defined as a chance to not meet expectations or a required specification. A One Sigma equals 690,000 defects per million opportunities. Obviously, achieving Six Sigma quality means you’ve created a nearly perfect process. It is certainly a difficult goal, but it’s one that is transforming organizations throughout the business world.

Six Sigma has produced significant results in companies such as GE, Motorola, American Express, 3M and Johnson & Johnson. These companies have saved billions of dollars, improved customer satisfaction and raised employee morale.

A Practical Example

An emergency department in a New York hospital was fast becoming the main source of medical care for many people. As a result, it struggled with the increased volumes of patients, excessive wait times and rising healthcare costs. By collecting, measuring and analyzing data, an in-house Six Sigma project team found that the average cycle time for treat-and-release walk-in ED patients was more than three hours. The team went to work breaking down the patient visit process from arrival to discharge. They studied the triage component, as well as registration and time spent with the physician. The team discovered major delays in treating patients were due to wide deviations in the manner in which the registration staff processed charts. The physician on duty was also a source of variation in the process. The team then utilized Six Sigma tools and improved the patient flow process, resulting in a decrease in wait time by 37% from 187 minutes to 118 minutes.

At the beginning of the project everyone involved said the ED was understaffed. The team also believed the ED was understaffed, but knew they had to trust the Six Sigma program and not react from gut instinct. Much to the team’s surprise, the data revealed the problem was not a staffing issue, but a process issue. Once the appropriate changes were made to the process, employees were not only attending to more patients, but were enjoying their work more. Staff members claimed that the tension was removed from the work environment. Employee absenteeism also decreased. Patients had shorter, more pleasant visits while in the ED. This was all accomplished without adding any more personnel.

How Does Six Sigma Work?

Six Sigma teams are generally led by a “Black Belt” or a “Green Belt” in the method. No, it has nothing to do with the martial arts. A Black Belt in Six Sigma terminology is a person who has graduated from a Black Belt Six Sigma program (usually four weeks spread over 3–4 months) and is dedicated to tackling critical change opportunities and driving a team to achieve results. As the expert in applying Six Sigma tools to assess problems and fix or redesign processes, the Black Belt leads, inspires, manages, delegates and coaches colleagues to improve the quality of their systems. In large corporations, a Black Belt tends to be a full-time position. A Green Belt is someone who has received less training than a Black Belt (approximately 40 hours), but is still able to lead Six Sigma teams, especially in smaller organizations. Green Belts remain in their current positions while overseeing Six Sigma teams.

A Six Sigma team is made up of employees who work in or with the process that is being evaluated. The concept here is to engage the brains of the people who actually do the work and allow them to contribute to process improvements. After all, who knows the process better than the people who work with it every day?

DMAIC: “Duh-MAY-ick”

Once the team is assembled, they are taught the “Six Sigma Problem-Solving Model,” called DMAIC (pronounced duh-MAY-ick). DMAIC stands for Define, Measure, Analyze, Improve and Control; it is a road map that all team members will follow to achieve their goals. By following this five-step process, the team works from a statement of the problem to implementation of a solution, creating improvements and initiating them along the way.

Define the Problem

This first step sets the stage for the proj­ect, leading to an array of questions: What are we working on? Why are we working on this? Who is the customer? What are the customer’s requirements? How is the work currently being done? What results are we seeking? What are the benefits of improving this process? When will each phase (D, M, A, I and C) be completed?

These questions drive new and original ways of thinking about business problems and opportunities that in the past were overlooked. The answers to these questions are documented in a charter that serves as a foundation for the rest of the project, especially for the next step.

Measure the Process

Measuring is a logical follow-up to defining and is a bridge to the next step, analyzing. In the measure phase, the team gathers data to validate and quantify the problem or opportunity. They take a process view of the business and use that view to set priorities and to make good decisions about what measures are needed. They determine how they are going to collect their data, how many to count (sampling) and how often to count.

Once the team gathers its information, it begins testing out facts and numbers that offer clues about the causes of the problem. This leads the team into the Analyze phase.

Analyze the Data

In this step, the Six Sigma team dives into the details, enhances its understanding of the process and problem, and identifies the culprit behind the problem. The team utilizes the Analyze step to find the “root cause.” Sometimes the root causes of the problem are evident. When they are, the team moves through this step fairly quickly. However, the root causes are often buried under tons of paperwork and old processes, and sometimes the documentation doesn’t exist at all. When this happens, the team might spend weeks utilizing various Six Sigma tools and testing proposed ideas before moving to the Improve phase.

Improve the Process

This is the step for planning and achieving results. Solutions and actions need to be developed, tested, refined and implemented. Sometimes “best practices” are borrowed from other organizations and tested in the newly proposed process. Small-scale pilot programs are often used to help identify what could go wrong and help prevent or manage difficulties. Data are gathered to track and verify the impact and possible unintended consequences of the solutions. Once the solutions and new processes are validated and proven to be successful, the team moves into the Control phase.

Control the Solutions

During this final step, the team puts controls in place to prevent future bugs. In other words, they take steps to “mistake-proof” the new process. Mechanisms are also established to monitor the new process and identify variations that would lead to less- desirable results. Sometimes a response plan is created for dealing with problems that may arise.

Sound like a lot of work? It can be at the outset. But Six Sigma teams have found that it’s also a thrill to see their efforts pay off, as defects are reduced, problems are solved, costs are diminished and customers are better served.

Six Sigma and EMS

Six Sigma can be applied to any area of a system from financial to marketing, from supplies to collections to clinical operations. The EMS industry is no different than other businesses—all suffer from quality problems, chronic waste and recurring customer complaints. Research has shown that the cost of poor quality in service operations exceeds 30% of gross revenue. Whether you work for a public or private EMS?agency, you are in a service operation. Six Sigma, if implemented correctly, will produce the same positive results in EMS organizations as it has in many other businesses.

My organization, for example, adopted Six Sigma as our company-wide quality improvement program. Our first project focused on customer complaints. Up till then, whenever a customer called with a concern or complaint, the details of their call were documented on a “communication report.” These communication reports filtered through the appropriate managers and field staff until the customer’s concern or complaint was resolved. This was a great tool for us in ensuring that we addressed the customer’s issue; however, it failed to identify patterns of complaints, so we could take measures to prevent the activities or behaviors that led to the complaints in the first place. This is where Six Sigma made the difference.

We assembled our Six Sigma team with field personnel and supervisors. As we went through the Define phase, we asked questions such as: What exactly are we working on, and who is the customer? The answers were in our communication reports. We discovered that 51% of all complaints revolved around lost or misplaced patient belongings, such as glasses, shoes and dentures.

We decided to focus on studying the process in which patient belongings were handled. We knew that if we could improve this process, our customers would benefit. The customers associated with this process included the patients anguishing over their lost items, the supervisors spending time searching for lost items, and the field crew who must account for these lost items days or even weeks after a call.

The team moved into the Measure phase and gathered data from both the communication reports and our electronic prehospital care reports. The type of data we collected included the range between the date the complaint was initiated to the date the complaint was resolved, the type of incident (trauma or medical), the type of item, where the item was lost, and where it was found.

All this information was closely evaluated in the Analyze phase, utilizing a variety of Six Sigma tools. Two components of how patient belongings were processed that required attention were communications on scene and documentation regarding the disposition of each patient’s personal items.

The improvements we made included raising the awareness of the field crews that the problem existed, educating them to effectively communicate with the patient and/or family members about what’s going to happen, and implementing documentation of their handling and disposition of the patient’s items.

These solutions were tested over a period of 90 days. The results? A 75% reduction in calls regarding lost or misplaced belongings. And when items were lost, the supervisor was able to resolve the incident prior to completion of the call because the information was documented in the prehospital care report.

To control this new successful process, a required data field was incorporated into our prehospital care report to help make it mistake-proof. Our field crews are now unable to close out their charts unless they complete this section that asks about the patient’s personal items.

As a result of this project, our external customers are happier, the supervisors can utilize their time more productively, and our field staff feels more empowered regarding their contribution to superior customer satisfaction. Finally, the company realized a cost savings of $7,500 per year as a result of not having to search for lost items.

Our company has incorporated Six Sigma tools and methodologies throughout the entire organization and we are reaping the benefits. We have reduced employee turnover by 14%, improved morale by 36%, decreased overtime expenses by more than 50% and produced a cost savings in excess of $350,000.

Conclusion

Six Sigma is an all-encompassing quality and performance improvement program that is changing the way companies do business. As EMS professionals, we share a passion for clinical quality and superior performance, because lives depend on it. Six Sigma provides us with the ability to apply that passion to the rest of the components that make up our EMS organizations and systems. It creates an atmosphere—or culture—of asking “what-if” questions that get to the heart of the matter. Six Sigma cuts through complexity and discerns underlying patterns. It gives us insight into our agencies and businesses and shows us how to dig deep to the core issues and eliminate problems that rarely get solved. Six Sigma shows us how to use processes to constantly raise the bar and improve upon everything we do. It benefits customers, employees and the financial health of any organization.

Next month, Larry Boxman continues his discussion of Six Sigma by talking about organizational culture and how his EMS agency changed theirs from “one of inertia to one of power.”