Six Sigma and Healthcare – An Oxymoron?

How many healthcare processes have you measured that are 2.0 Zst or higher at the start of the project? I’ve never had one of these – most of mine have started at below 1.0 or in the negative Sigma range.

In every one of my projects, I’ve had to use lean tools to get where I needed to go. Usually, I can’t find a standard procedure (or there’s a paper procedure that no one follows). Or, there are such variances between shifts that there are 2 or 3 standard processes.

In my very first project, Inpatient Discharge, we found that none of the x’s were significant. In my second project, Emergency Department Door-to-Doc, we found that all of the x’s were significant. In addition to these clues, in both projects, everyone we interviewed had a different version of what the standard process was.

In my most recent project, Admission through the ED, there were 12 “supplier groups” in our SIPOC process map (ED Nurses, ED Techs, ED Physicians, Admitting Physicians, Case Managers,Bed Control Managers, ED Unit Clerks, Nursing Unit Clerks, Nursing Unit Nurses, Housekeepers, Maintenance, and Registration Clerks.) Each had a different time for shift change, with 8, 10, and 12 hour shifts among the various groups. The process changed each time a group’s shift changed. You won’t be surprised to find out that we started at a negative Sigma level. We moved to lean tools almost immediately. And yes, we did reach a positive Sigma outcome, although we also followed up by chartering two Standard Work Projects, one for housekeeping and one forgetting the patient ready for departure to their inpatient room.

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This makes me think that perhaps we should not start a DMAIC project with a very low Zst score – we should do a standard work project first. Is Lean – then Six Sigma – a logical approach? Or should we start with Six Sigma / DMAIC and then incorporate lean in the Improve phase? I’d love to know more about your own experiences. Thanks in advance for sharing.

Comments 3

  1. Matt Meyers

    We are in the early stages (3rd year) of implementing Lean and Six Sigma, and I think it goes without saying that evey project needs some leaning. In fact, I think that in the healthcare industry, you will get more gains out of doing lean long before you should be applying six sigma techniques. In order to get any type of statistically significant result, you need stability (or flow, to use the lingo) first and foremost, especially in transaction environments like yours.

    I might add that all of the healthcare improvements that I’ve seen that have 1) worked and 2) been sustained, have been "lean" exclusively. Virginia Mason Medical System in Seattle prides itself on appying TPS to healthcare. Cindy Jimmerson in Montana has been applying lean to numerous hospitals in that area. The Pittsburgh Regional Healthcare Initiative also applied TPS to healthcare (I think there’s PBS special or DVD about that one).

    Regardless, lean and six sigma are just toolboxes, so why get cought up in which tools to apply and what to call it? Involve the people doing the job, figure out the root cause(s), fix the problem, and keep it from happening again.

  2. Ed Blackman

    Hello Sue,

    I’ve had similar experiences since I started working in healthcare. Phase 1 (and sometimes 2) of a majority of my projects involves simply defining the current process, establishing process adherence and implementing a measurement system. Most of the MSA work does not add value initially.

  3. Robert Rainer

    Is this a rehash of the old adage garbage in, garbage out. Are you starting with something that can be controlled? In order to apply six sigma techniques, you need to be in a state of statistical process control. Very few if any health care processes can claim that state out of the box. That might be what you are seeing, and hence the degree of variability will produce your low Zst scores.

    I do agree with you that a work standardization phase that is sustainable is key to success. I found your post very interesting, and it has caused me to think a good bit about how we are tackling problems here.

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