Karen Young – Chapter Thirteen

Karen Young

DMAIC: A Common Sense Approach to Healthcare


Newly trained Lean Six Sigma practitioners, middle managers and project team members in the healthcare industry will benefit from this simple explanation of the Lean Six Sigma DMAIC approach to solving quality problems. Unlike some tools in the Lean Six Sigma tool box, DMAIC is a universally applicable tool that can carry over into any industry. Healthcare is different than manufacturing, high tech or other service industries, as healthcare quality issues are unique: failure to identify, fix and control issues can mean the difference between life and death. If the proper procedures and processes are not in place, and if we don’t follow the process carefully, the costs are much higher than an analysis of the financials.

In this chapter, we will look at a common sense approach to applying the five phases of DMAIC to healthcare improvement initiatives. Some of the essential tools and tollgates will be discussed in a way that hopefully removes the “scary mask” that frightens many people about Lean Six Sigma and its emphasis on statistics.

This chapter will help you to:

  • Learn how to select the right tools to improve healthcare.
  • Follow specific healthcare examples demonstrating the correct use of the essential tools, common to most projects.
  • See the logic behind some of the “not so intuitive” concepts.

Common Sense is a Universal Tool

A 45-year-old-man was brought into the emergency department in an ambulance. He had been in a serious car accident that rendered him unconscious with possible extensive internal injuries. The trauma team was faced with two decisions. First, they needed to assess the current condition in order to stabilize the patient; second, determine the correct course of action to repair any injuries. Both decisions needed to be made quickly and correctly under extreme pressure. Clinicians have several diagnostic tools available to aid them in making a diagnosis. Some tools quantify the problem, some provide images of the problem, some provide pathways to identify the causes of the problem and others prescribe solutions to the problem. The key is to know the purpose and functionality of each tool so the user can choose the right tools for the job. These choices are not made arbitrarily. There is a common sense approach to this process. Clinicians follow a structured set of guidelines, algorithms, and visual clues to help make decisions that lead to improving patient outcomes.

Within the healthcare industry, there are numerous inefficient or ineffective processes that lead to waste and mistakes. Identifying them requires the efforts of specialized teams using specialized guidelines and tools to improve outcomes. Lean Six Sigma provides that structured approach using process information to solve many of the quality problems faced by clinicians. It is coordinated around a five phase process – Define, Measure, Analyze, Improve, and Control (DMAIC). Each phase involves specific objectives and tollgates designed to guide teams to improve overall effectiveness and capability, strengthen competitiveness and improve key metrics for the organization. This
philosophy focuses on the delivery of continually improving value to its customers and stakeholders. Philosophy? Yes, philosophy: a shared
belief in attaining excellence through the elimination of waste and the reduction of process variation. But getting there requires a culture
transformation with buy-in from every level within the organization.

The Define phase is the discovery period where we identify the problem from the customer’s perspective. Critical to Quality characteristics (CTQ’s) are determined and validated against customer requirements. Initial performance standards are then set as a basis for measurement.

In the Measure phase, we study the voice of the process and the voice of the customer. Current state process capability is assessed and performance objectives are finalized. It is important to validate the measurement system at the beginning of this phase and again at the end of the Analyze phase. This criterion is often overlooked, resulting in bad data that leads to bad decisions.

The Analyze phase is where we encounter the “scary mask” of statistics. Here we have the opportunity to identify and understand the sources of variation in the problem process. Potential causes identified in the measure phase are analyzed in an effort to get to the root of the problem. From that, hypothesis tests are performed to determine if the data support the organization’s claims about current performance. The outcomes provide insight on potential solutions that feed into the Improve phase.

The Improve phase gives us a look into the relationships between process variables. Here we test, confirm and validate the solutions slated for implementation. Finally, in the Control phase, process capabilities are redefine based on the new current state and a process control plan is implemented to monitor sustainability.

DEFINE – Get the Picture

Tollgates provide an excellent opportunity for the project champion to review work done to date and to give guidance. Tollgates represent a minimum set of tangible deliverables that must be present before the team can move forward. Key tollgates in this phase are the project charter, SIPOC, and tools that evaluate the voice of the customer. The project charter is essential in making our case for selecting a project. However, many teams work without one to the detriment of the project. There are key elements that must be included in every good charter. (See Chapter 19 for a simple sample charter). It must have a compelling business case, a specific problem statement, a succinct project scope, clearly defined goals and objectives, realistic milestones, constraints and assumptions, and clearly defined roles and responsibilities for the team. As you finish each section, go back and ask yourself, “Is it in there?”

Support for the project starts with the business case. Here you are trying to connect the project, the problem process and the customer requirements to the organization’s goals and strategic objectives. Explain the issues you are addressing and why this project is important. What are the consequences if a project is not initiated now to fix this problem? Be brief, specific and create a sense of urgency.

Problems result in customers or stakeholders not getting what they need from your organization. A well-written problem statement paints the finer picture. It must be quantifiable and measurable, identify the specifics of what is causing the problem and describe any gaps in performance. In other words, where are we compared to what is desired? Most importantly, the problem statement must identify the pain or the severity of the impact that this problem is having on either the organization or its customers. Be sure to use facts and not assumptions when writing the problem statement.

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