Six Sigma and the Healthcare Industry

I am currently taking a Six Sigma Green Belt course put on by the Orange County, CA chapter of ASQ. Sometimes before the class formally starts, those of us who get to the class early have an opportunity to ask the instructor questions, and for the past two weeks these questions have led to interesting discussions.

The first question was directed to Milt Krivokuca, our instructor for the portions of the material dealing with statistics. The health care industry has been focusing on quality improvement, especially since some of this has been mandated by the Affordable Care Act passed on March 23rd 2010.  The question to the instructor was: is the health care industry at the point where they can start implementing Six Sigma methods to improve quality?

The answer was “it’s on the verge, but it’s not there yet.” The instructor went on to explain why, and his explanation I thought was very illuminating on what you need to have Six Sigma be effective.

In order to implement Six Sigma, you have to a process that is first “in control.” What does this mean, “in control”?  It means you have to have an operational baseline against which variances can be meaningfully measured. To use an analogy, if you can’t differentiate between the signal and the noise, you cannot make the signal clearer. If you can’t establish this operational baseline, then you don’t know if the measurements you take are variances to a single process or from multiple processes. In other words, you may have too many variables on your hands.

Here’s an example taken from one of the slides in the instructor’s presentation.

Let’s say that you are in a clinic that treats diabetes and you notice that many patients have not had their quarterly HbA1c test which shows what their average level of glucose has been over the past three months.

1) The doctor could have made the mistake by not giving the requisition for the test at the last quarterly visit. If the requisition was given by the doctor, go to 2).

2) The patient could have made a mistake by not getting the test done as ordered in the requisition. If the patient did get the test done, go to 3).

3) The lab could have made a mistake by spoiling the test and forgetting to tell the patient to come back for another test.

The first and the third paragraphs are fairly straightforward, but in the second paragraph, if it is the patient who is at fault, then here are the possible reasons that the patient did not get the test done.

2a) The patient forgot

2b) The patient remembered, but thought it was not important

2c) The patient remembered, but thought lab hours were inconvenient

2d) The patient remembered, but chose not to have it done because of depression

2e) The patient remembered, but chose not to have it done because of other reasons.

If you think of the fact that that people are complicated and have complex motivations for the things that they do, you might see that it is possible that it would be hard to narrow down the cause to one particular choice among the ones listed.

This is an example where you might get data and not be able to tell which of the causes listed are truly the most prevalent (with Pareto analysis). So in the context of what the instructor said, the hospital or clinic conducting this study may not have a clear enough picture of where the problem is in order to be able to solve it.

And for this reason, Six Sigma may not be appropriate at this stage in the evolution of quality management in the healthcare field. However, mapping processes, and analyzing where potential errors, waste, etc., are made, is something from which health care can certainly benefit. So there are some quality improvement tools that can be used, but Six Sigma requires that the process be already in control in order to be able to improve it.

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