I was recently perusing Time magazines “Top 100” list for 2008, and came across this entry for Peter Pronovost. I had never heard of Pronovost. Here’s part of what profiler Kathleen Kingsbury had to say about him:

“A critical-care researcher at Johns Hopkins University, Pronovost may have saved more lives than any laboratory scientist in the past decade by relying on a wonderfully simple tool…”

I know what you’re are thinking, but no, Six Sigma is not the tool. Before I tell you what it is, consider that after implementing it in hospital ICUs in Michigan, hospital-acquired infections dropped from 2.7 per 1,000 patients to zero. That means more than 1,500 lives were saved in the first 18 months.

So what is this ingenious invention? What critical breakthrough occurred? What fancy bit of science and statistics produced these stupendous results? Which process improvement methodology was put to work?

A checklist.

That’s right, Pronovost provided physicians with a list of steps as a reminding them how to complete routine procedures. 1500 lives were saved over 18 months in one state by writing down the steps for procedures, photocopying them, and handing them out. Pronovost estimates he could roll his system out across the entire US for three million dollars. Which, I think it’s worth noting, might be comparable to the annual budget for a corporate Six Sigma deployment in bigger companies.

One of the reasons I was so captivated by this story is that more and more, I find myself returning to the basics and fundamentals of process improvement methodology. I read the primary literature and wonder at the complexity of current process improvement methodology. I wonder where the power of elegance of simplicity has gone.

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For example, one of my favorite books is Kaoru Ishikawa’s Guide to Quality Control. It’s long out of print, but you can still pick up used copies online and elsewhere. You might not know Ishikawa by name, but if you’ve ever done a fishbone diagram, you know his work. He introduced his now-eponymous diagram along with six other quality tools in the Guide. Each was elegant and simple. Things like check sheets, Pareto charts, scatter plots, basic control charts – simple tools explained concisely. It’s a slim volume, but everything is there. Every time I read it, I wonder to myself how on earth we’ve allowed the continuous improvement world to become so complex and unapproachable. I’m at a loss to explain what value Six Sigma and similar methodologies add to Ishikawa’s approach. Sure, they provide the sizzle that sells programs to organizations, but it’s quite possible that that’s all they do. Which is worrisome.

Ishikawa and Pronovost have proven that very clear and simple approaches can yield stunning results. Much as Deming and others did before them. Modern Six Sigma is anything but simple. Most Black Belts take four week to train. But I can get through Ishikawa on a flight from Chicago to Denver, and I’m guessing Pronovost can train his folks in about five minutes.

Have we taken a wrong turn?

Comments 6

  1. michael cardus

    I appreciate the post on simplicity. This “system” of a checklist seems so basic – yet companies often chase these large implementations strategies. I often tell groups that I consult if you cannot explain what you are implementing to your wife and children and they fully understand – you need to reorganize what the Process Improvement is.

    6 Sigma is at its heart a way to lesson deviations – we often geek out with the math and crazy terms – created what I call the 6 Sigma Bubble. When we speak to the people on the floor – who have never heard of DMAIC or VOC’s and to them Fish Bones are just that bones on fish! etc..

    They often never ask because the Higher Ups are explaining these foreign language that they feel makes sense. 6 Sigma also employs Keep It Simple philosophy – like understandable SOP’S (standard operating procedures) and checklists should be a part of that.

  2. Marek Kozlowski

    I agree with the need for simplicity but this would kill the consulting business. I was part of LEAN SIX Sigma programs run by reputable global consultants and the output was : 20 pages of color slides. Stage IC was not actually implementing anything but dreaming of how the implementation would loook like.

    Remove waste : YES
    Eliminate process variation: YES

    Feed parasitic consultants : NO NO NO

  3. Russell Clark

    If people that are using Lean and Six Sigma methodologies keep in mind that the goal is to improve a process or product then the ’simplicity’ will be present. I am a consultant (although I have never been termed by any client as parasitic) and one thing I work hard with the trainees is to avoid ’over Six Sigma-ing’ any project. Sorry that Marek got stuck with a ’training consultant’ and not a project oriented consultant, the difference is easy to identify as project oriented group will have IC stages fully involved in the trainees workload.

    If it can be improved upon in the early phases of the project then do it – don’t wait. Quite often improvements and solutions can be determined during the development of the fishbone, basic process flow map or in early data collection and be seen graphically in a pareto or time series plot.

    Improvements such as the one that Pronovost made is a great example
    a) identifying the defect (high infection rate due to ???)
    b) identifying what process step was missing (no check system) which could be seen in a fishbone or PFM or FMEA
    c) developing the improvement item (checklist)
    d) perform trials, implement across all areas
    d) ensure a audit / control system is in place

    and then celebrate the success.

    Using other statistical tools are often necessary – especially in manufacturing operations. However this project has a LEAN solution that was effective – just ask the people who did not require secondary medical treatment!

  4. Andrew Downard

    Hi Russell,

    I agree with what you said. However, I do think most of the more modern continuous improvement methodologies (especially Six Sigma) are guilty of over-complicating projects at times. This is especially true during training, when projects may be considered failures if they don’t make use of all the stages or tools. While we both agree that this shouldn’t be the case, I expect anyone who has been in the field a while could describe multiple examples where it has happened. And when it does happen, it is often dramatic and becomes a story for detractors to pounce upon. In my opinion, this is a significant problem for methodologies that rely on roadmaps.

    To paraphrase Aristotle (via Goldilocks), too little or too much of anything can be harmful, but there is often virtue in the mean. Bravery is a virtue, but to be too brave is to be foolhardy, and to be not brave enough is to be a coward. I think the same concept applies to structure (lists, roadmaps, etc) in continuous improvement. Too little and you have chaos. Too much and you have non-value added work and un-necessary complexity. This trick is to have just enough structure to produce the results you need – no less, anc certainly no more. Like I said above, I think Six Sigma is often guilty on the "too much structure" side.


  5. Sue Kozlowski

    When I teach lean to healthcare workers, I teach the value of simple checklists – and often get responses like "we all know how to do our jobs" and "we don’t need to be treated as if we can’t remember what we need to do." Then I ask them – have they ever been up in an airplane? There’s this little thing called a pre-flight checklist – and how many of you would like the pilot to say, "Well Charlie, we’ve done this many times before, and we know what we’re doing, so let’s just skip the pre-flight checklist today, what do you think?" And if Charlie says, "OK!" how safe will you feel on that flight?

    It’s the same with healthcare procedures and checklists – I’d rather have a surgeon that goes down a checklist to make sure everything is ready – than to have a surgeon (usually running late, who has skipped lunch, and is worried about other patients) start off by assuming everything is ok for the procedure.

    So put me on the side of keeping it simple – and safe – with the use of checklists. Thanks Andrew for your post!

  6. Laura

    It is amazing how simple tools can prove to be so effective. I believe in the simplicity principle but most companies are not comfortable adopting this principle.

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