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original work!!! only no plagiarism!!! please see assignment attached and two case studies (must be referenced in final paper)
Week 5 – Final Paper
Final Paper
For the Final Paper use the U.S. Postal Service (USPS) as the main organization to critically analyze
and provide suggested improvements steps/actions based on what you have learned in this course to
help the company achieve performance excellence. Use the Xerox case study that can be found in the
textbook as a sample. Also, refer to the Healthcare’s Horizon article found through:
• http://asq.org/pub/sixsigma/past/vol2_issue2/stahl
(http://asq.org/pub/sixsigma/past/vol2_issue2/stahl )
Please create a critical analysis through answering the following:
• The Total Quality Management methodologies or practices that the organization uses or plans to
use to align performance excellence with its business objectives,
• Knowledge of Total Quality Management marketing that focuses on meeting customers’ needs
and practices to help build a customer-focused culture.
• Evaluate techniques to enhance design of work processes, process control, and process
improvement,
• Examine tools and techniques that support Six Sigma philosophy, quality in product design,
process design, and/or statistical process control (SPC) for monitoring either the company’s
service processes. Illustrate by using at least two relevant charts or figures in describing the tools
and techniques.
Writing the Final Paper
The Final Paper:
• Submit the assignment as an MS Word document.
• Must be 2,400 – 3,500 words (excluding title page and references page) in length, double-
spaced and formatted according to APA style as outlined in the Ashford Writing Center.
Contextual (Level One) headings must be used to organize your paper and your thoughts. Must
include a title page with the following:
◦ Title of paper
◦ Student’s name
◦ Course name and number
◦ Instructor’s name
◦ Date submitted
• Must address the topic of the paper with critical thought.
• Must utilize at least four scholarly and/or peer-reviewed source from the Ashford Library in
addition to the textbook.
• Must document all sources in APA style, as outlined in the Ashford Writing Center.
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• Must include a separate reference page, formatted according to APA style as outlined in the
Ashford Writing Center.
Carefully review the Grading Rubric
(https://ashford.waypointoutcomes.com/assessment/9543/preview) for the criteria that will be used to
evaluate your assignment.
Waypoint Assignment
Submission
The assignments in this course will be submitted to Waypoint. Please refer to the instructions below to
submit your assignment.
1. Click on the Assignment Submission button below. The Waypoint “Student Dashboard” will open
in a new browser window.
2. Browse for your assignment.
3. Click Upload.
4. Confirm that your assignment was successfully submitted by viewing the appropriate week’s
assignment tab in Waypoint.
For more detailed instructions, refer to the Waypoint Tutorial
(https://bridgepoint.equella.ecollege.com/curriculum/file/dc358708-3d2b-41a6-a000-
ff53b3cc3794/1/Waypoint%20Tutorial )
(https://bridgepoint.equella.ecollege.com/curriculum/file/dc358708-3d2b-41a6-a000-
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mpressive examples over the past several years illustrate the value of uti
–
lizing Six Sigma and related best practices for healthcare quality and
process improvement.
Providers, however, continue to face a daunting and escalating array of
challenges. Regulatory pressures, increased competition, cost management
issues, workforce shortages and rising consumerism all vie for attention and
remediation.
Occupying an increasingly prominent place on the healthcare execu-
tive’s radar screen are issues involving clinical quality and patient safety.
Instances of overuse, underuse and misuse of healthcare services have bee
n
costly to patients, providers and payers.
Prompted by illuminating reports from the Institute of Medicine1, 2 and
scrutiny from groups such as Leapfrog, providers are seeking effective
methods for both optimizing the care they deliver and documenting the
improvements.
It is a pivotal moment in the history of medicine—one offering great
promise through rapidly advancing technology and tremendous pressure
to deliver better care to more people for less cost.
At this juncture, then, it seems an appropriate time for reflection—both
on the progress made through Six Sigma applications and the realm of
opportunities for the future. Drawing from research and organizational
experience, we can evaluate achievements and explore the next phase in
reshaping the industry.
Applications to Healthcare
The DMAIC (define, measure, analyze, improve and control) approach
works quite well for any service line or process that can furnish measurable
response variables.
Generally, four groups of metrics or response variables in healthcare may
define a delivery system’s performance:
• Service level.
• Service cost.
• Customer satisfaction.
• Clinical excellence.
Service level metrics indicate the ability of the system’s performance to
meet the expectations of patients, referring physicians and other stake-
holders—critical to quality parameters (CTQs).
Each set of metrics has specific parameters. Service level indicators may
be generalized as access to care, wait time, service time and information
conveyance time. Service cost indicators include cost per unit of service,
labor productivity and other factors associated with the cost of providing
service. Customer satisfaction indicators may be segmented into specific
Healthcare’s Horizon
FROM INCREMENTAL
IMPROVEMENT
TO DESIGNING
THE FUTURE.
I
By Richard Stahl,
MD, Yale-New
Haven Hospital;
Bradley Schultz
and Carolyn
Pexton, GE
Medical Systems
S I X S I G M A F O R U M M A G A Z I N E I F E B R U A R Y 2 0 0 3 I 17
H E A L T H C A R E
groups such as patient and family, referring physician,
staff and payer.
Clinical excellence indicators may relate to a partic-
ular treatment pathway or department, such as com-
pliance with guidelines for prescription of aspirin to
myocardial infarction patients or reduction of rates of
infection contracted in a hospital or other healthcare
facility. Figure 1 illustrates sample metrics from an
emergency department.
Most healthcare organizations measure perform-
ance using some combination from these four groups,
but such analysis can be misleading since the metrics
often represent an average. Customers rarely experi-
ence the average performance of a system—instead,
they tend to experience the variability.
From Manufacturing to Medicine
Six Sigma came slowly to healthcare and initially was
met with some skepticism. This hesitancy stemmed in
part from disparities between processes driven by
humans vs. automated or engineered processes.
In manufacturing, it’s quite possible to eliminate
most—if not all—human variability through automa-
tion, creating precise measurement of assignable caus-
es of variation. In healthcare, however, the delivery of
patient care is largely a human process, and the caus-
es of variability are often more subtle and difficult to
quantify.
The challenge for healthcare institutions and staff
as they begin to embrace Six Sigma is to find a way to
leverage the data to drive human behavior. Where the
approach seems to have had greatest success,
providers combined a strong technical strategy (Six
Sigma) with a strong cultural strategy, such as change
acceleration process, and a sound operationalizing
mechanism, such as GE Medical Systems’ Work-Out,
Motorola’s Leadership Jump Start, lean, Pareto analy-
sis or decision trees. This is illustrated in Figure 2.
Leveraging all three aspects has led to notable
results. Most projects, however, involved optimizing
existing processes and retaining systems and struc-
tures bound by capital investment and traditional
grouping by function. A hospital’s IT system, for
example, may not fully support changing a given
process, but the facility might decide to simply opti-
mize around it until the investment is retired.
H e a l t h c a r e ’ s H o r i z o n
18 I S I X S I G M A F O R U M M A G A Z I N E I W W W . A S Q . O R G
Figure 3. Capability Analysis: Report
Turnaround
Time
Customer (physician) defined specifications: < 24 hours
Excellent mean performance, but 100,000 patient visits
per year equates to 22,000 physician disappointments.
N = 300
Mean = 14 hours
Standard deviation = 12 hours
Report turnaround time > 24 hours = 22%
Defect per million opportunities = 220,000
-40 -20 0 20 40
Defects
60 80
Source: GE Medical Systems
Figure 1. Response Variables
Service cost
Service level
Clinical excellence
Customer satisfaction
Financial analysis
Customer defined/
capability analysis
Outcomes research
Survey/focus groups
Translate customer critical to quality into process specifications
measurable specific response variables
Y11—Cost per procedure
Y12—Labor productivity
Y21—Triage
Y22—Assessment
Y23—Treatment
Y24—Disposition
Y31—Return rate
Y32—Cardiac patient time to aspirin
Y33—Cardiac patient discharged
with beta-blocker
Y41—Patient
Y42—Referring MD
Y43—Employee
Y
1
Y
2
Y
3
Y4
Source: GE Medical Systems
Figure 2. Formula for Effective Results
The effectiveness (E) of the result is equal to the quality (Q)
of the solution times the acceptance (A) of the idea.
Six Sigma
methodology
Change
acceleration
process
Work-Out
or other operationalizing mechanism
Effective
results
Q x A = E
Source: GE Medical Systems
H e a l t h c a r e ’ s H o r i z o n
Service delivery methods in healthcare have also
become entrenched and often run counter to the
notion of customer centricity. It’s common in many
facilities, for instance, to take the patient to the care
rather than bring the care to the patient. Clearly, we
need new models to create a system that genuinely
meets patient needs.
A Brief Overview of DMAIC
To implement the right solution to a problem, you
need to understand the degree to which different fac-
tors may impact the variability of the project’s
response variable (Y) before specific solutions are
designed. Projects tend to focus on response variables
from the four groups mentioned earlier.
The initial define and measure phases of a project
essentially involve translating
the voice of the customer, or
CTQs, into measurable re-
sponse variables. Customer ex-
pectations—whether patients,
referring physicians, staff or
payers—are then used to estab-
lish process specifications for
those response variables. A
measurement of the process
capability to meet CTQs is per-
formed, and the end result is
expressed as a sigma level or
defects per million opportuni-
ties (DPMO). This concept is
shown in Figure 3, using cycle
time for reporting radiology
results.
In the analyze phase, the
team identifies the causal fac-
tors (X’s) likely to have the
greatest impact on the response
variable (Y). These factors are
classified as either controllable
or uncontrollable. If a factor
(X) is controllable and con-
tributes significantly to variabil-
ity in the response variable (Y),
then an opportunity to achieve a better result presents
itself by controlling the causal factor.
On the other hand, if the primary causal factors are
uncontrollable, a new process must be built to with-
stand that variability to the degree possible. Many fac-
tors in healthcare are quite predictable, though
uncontrollable—such as arrival rate at the emergency
room. See “Common Emergency Department Critical
to Quality Factors.”
In healthcare, the improve and control phases can
be most challenging since they often involve changing
human behavior. It probably comes as no surprise to
healthcare professionals that organizational structure
can actually inhibit process thinking. Inherently, there
are multiple silos across a typical facility and few exam-
ples of big picture oversight to unify conflicting agen-
das and constituencies.
S I X S I G M A F O R U M M A G A Z I N E I F E B R U A R Y 2 0 0 3 I 19
Common Emergency Department
Critical to Quality Factors
Quality.
• Accuracy of diagnosis.
• Appropriateness of treatment.
• Timeliness of ser vice
• Wait times.
• Exam and treatment.
• Testing and report turnaround.
• Staff availability.
• Bed availability in emergency department and hospital.
• Responsiveness to squads.
Satisfaction of patient and referring doctor.
Cost of operations.
Productivity and workflow.
CUSTOMERS RARELY FEEL THE AVERAGE PERFORMANCE OF A
SYSTEM––INSTEAD, THEY TEND TO EXPERIENCE THE VARIABILITY.
H e a l t h c a r e ’ s H o r i z o n
The control phase, therefore, may require dis-
mantling root-bound bureaucracies growing around
ancient processes. To achieve long-term success, this
must be accompanied by new control measures and
process metrics to drive behavior changes.
Another challenge for healthcare is to institution-
alize the wins—in other words, to translate the
results from one area to another. For example:
• Adopt best practices to improve bed turnover
time from a given inpatient unit to all hospital
units.
• Translate ventilator weaning protocols from one
intensive care unit to another.
From Here to Futurity
Mistakes can be costly in any industry, and there
are essentially three ways to approach them. Ignore
them and hope for the best (not advisable in most
cases); find and fix them within existing processes;
or prevent them from occurring in the first place by
designing processes correctly from the ground up.
Using the DMAIC approach (the find and fix
method), many institutions have seen significant
improvement in various clinical and operational
processes. When coupled with proven change man-
agement and decision making techniques, some
have even been able to induce a beneficial transfor-
mation in the organizational culture.
But quantum leap changes in the delivery of
healthcare (and the prevention of errors through
ground floor development) will not come about
until providers begin the process of actually design-
ing for Six Sigma. In Six Sigma: The Breakthrough
Management Strategy Revolutionizing the World’s To
p
Corporations, author Mikel Harry discusses the limits
of traditional Six Sigma initiatives:
The closer companies come to achieving Six
Sigma, the more demanding the improve-
ments become. At 4.8 sigma, companies hit a
wall that requires a redesigning of processes,
known as design for Six Sigma.3
This wall is often felt at significantly lower sigma
levels in healthcare and consists of bricks retained
from old systems and structures. To get through this
wall and create quantum leap change, healthcare
will have to adopt breakthrough or revolutionary
thinking in how systems are designed and built to
optimize the interaction of people, processes and
technology.
20 I S I X S I G M A F O R U M M A G A Z I N E I W W W . A S Q . O R G
Figure 4. Design Process Map
Voice of the customer
Critical to quality
(CTQ) parameters
Service delivery system
design requirements
Subsystem/process
design requirements
Alignment of supporting
systems and structures
• Listening to the customer.
• Understanding what the customer wants.
• Segmenting customer needs or wants.
• Identifying the must haves and delighters.
• Translating customer CTQs into system
performance specifications.
• Translating performance specifications into
design considerations.
• Flowing system design requirements down to
each process step.
• Translating subsystem design requirements and
capability assessment.
• Organizational design.
• Staffing.
• Development.
• Measurement systems.
• Rewards and recognition.
• Communication.
• Information technology.
Source: GE Medical Systems
Figure 5. The Wall of Change Efforts
In
te
ns
ity
o
f c
ha
ng
e
ef
fo
rt
The wall
Stabilization Optimization
Time
Transformation
Source: GE Medical Systems
H e a l t h c a r e ’ s H o r i z o n
A Brief Overview of DFSS
The primary difference between DMAIC and design
for Six Sigma (DFSS) is that statistical tools are used to
design a new service delivery system, process or tool
rather than to improve the existing system. Customer
expectations are translated into process specifications
and then into system design requirements. These, in
turn, flow down into subsystem and process design
requirements.
Elements such as service, the care delivery model,
supporting systems and structures and facilities are
aligned with the resulting design specifications.
Similar to DMAIC, DFSS is a five-step process repre-
sented by the acronym DMADV (define, measure,
analyze, design and validate). Figure 4 is a design
process map, basically a criteria-rating matrix that
translates iteratively into system design requirements
and then into subsystem requirements—drilling down
into each level in order to design the process correct-
ly the first time.
Organizational Readiness for DFSS
It’s important to note not all organizations are ready
for DFSS. Healthcare institutions can be assessed for
readiness along a change continuum, illustrated in
Figure 5. Those at the far left have fundamentally
unstable operations and service delivery processes.
The environment is typically chaotic and repeatability
is often dependent on the performance of a few who
seem to understand the “magic” involved.
In these institutions, substantial improvement may
be achieved through developing and operationalizing
procedures that document the magic and begin mov-
ing it into the world of science.
This approach is often referred to in DMAIC as a
PM/CE/CNX/SOP approach—simply a shorthand
method of communicating the following:
• PM = process map.
• CE = cause-effect.
• CNX = controllable, not controllable, experimen-
tal variables.
• SOP = standard operating procedure.
The team first gains a common understanding
through process mapping (PM). Brainstorming then
follows to discover causes of process variability and
assess the effect (CE). Drivers of variability are classi-
fied as controllable, not controllable or experimental
(CNX).
In the analyze phase of a project, the contribution
S I X S I G M A F O R U M M A G A Z I N E I F E B R U A R Y 2 0 0 3 I 21
Table 1. Process Improvement/Solution Design Continuum
Improvement
objectives >>> Stabilization Optimization Transformation
Methods Six Sigma—DFSS
When to use
Issues or drivers of
variability are well
understood. Primary
concern is building
consensus on solutions.
Causal factors or drivers
of variability not well
understood. Not in
a position to build
consensus on solutions.
White paper improvement
initiative or development of new
and future services designed to
exceed customer expectations.
Examples
Stabilization of service
level metrics such as wait
time through role clarity
and standard operating
procedures.
• Optimization of
operating room
capacity utilization.
• Optimization of
emergency department
or radiology throughput.
• New operating room pick sheet.
• New service line.
• Renovated facility.
• New hospital.
Work-Out
Kaizen
Quality circles
Six Sigma—DMAIC
Lean thinking
Total quality managment
to variation of the experimental
variables is quantified, but the
institution may not realize imme-
diate gains by developing SOPs
targeted at controllable variables.
In the second stage, processes
are stabilized but not yet opti-
mized. The performance service
delivery may be stable and
repeatable, but still fail to meet
customer expectations or oper-
ate at lower efficiency and high-
er cost. In these cases the appli-
cation of DMAIC will provide
the mechanism for process opti-
mization. This occurs by devel-
oping a sound understanding of
the mathematical relationship
between specific response vari-
ables (Y’s) and their causal fac-
tors (X’s).
Organizations eventually reach
the previously mentioned wall
where further optimization of
existing systems and structures is
no longer feasible. The wall is
unavoidable as customer expecta-
tions increase and the retention
of legacy systems restricts
improvement. Design then becomes an important
component of the strategy for transformation.
When considering the application of DMAIC or
DFSS to a process, the following considerations
become relevant:
• To what extent does the current process meet cus-
tomer expectations?
• Does it require decreased variability alone or a
radical shift in mean?
• How committed are you to current legacy systems
that support this process?
• What new developments are on the horizon? For
example, new pick sheet of materials needed for
operating room cases; new service line or center
of excellence; renovation of facility or new facility.
An example of a process improvement or solution
design continuum is shown in Table 1 (p. 21).
DFSS may be the better approach in cases where in
which the process is simply too broken to satisfy cus-
tomer expectations or further optimization is con-
strained by legacy systems and structures. The devel-
opment of new opportunities also invites DFSS as a
mechanism to design specifically for customer CTQs
as opposed to cloning old processes that may fall
short.
The DMADV Process
The define and measure phases of a DMADV proj-
ect are similar to those of DMAIC in collecting and
using voice of the customer data to develop process
performance specifications.
The difference with DMADV is that we’re often
dealing with new products or services, so measuring
existing performance against specifications is not pos-
sible. With DMADV, the goal is to predict the per-
formance of the new product or service and facilitate
evaluation and selection of the best design alternative.
To accomplish this ambitious task of translating
voice of the customer data into actionable design cri-
teria, there is a commonly used tool known as quality
function deployment (QFD). QFD is an advanced cri-
teria rating matrix, used in DMADV to:
• Identify customer needs or CTQs (the whats).
H e a l t h c a r e ’ s H o r i z o n
22 I S I X S I G M A F O R U M M A G A Z I N E I W W W . A S Q . O R G
Table 2. Quality Function Deployment for New Emergency
And Trauma Center — Requirements
Y’s X’s
Customer expectations Importance
Parking and location signage well identified
Dedicated emergency room parking within 100 yards
of emergency department
Internal building signage clearly identifies location
Standardized triage process
No triage delays
Door to doctor time under 30 minutes
User friendly concentric wait area
Metal detectors at entrance
Staffing by arrival pattern demand
Patient communication model designed and
caregivers trained
Mechanisms to ensure staff accountability
Accurate diagnostics
Diagnostic cycle time specifications
Quality therapeutics
Decision to disposition cycle time less than 15 minutes
Coordination of aftercare by emergency department
Frequent patient contact and information exchange
Privacy of triage spaces
Privacy of treatment spaces
Availability of treatment supplies at point of care
Point of care testing
No delays to service due to parking 1
Ease of entrance identification and location 1
Ease of triage identification and location 2
Comfort and safety of wait area 3
Minimal wait time to see doctor 4
Minimal wait time to receive treatment 4
Privacy 3
To be kept informed of process status 4
Quality care 5
Positive caregiver interaction 5
Understand aftercare requirements 4
System requirements
H e a l t h c a r e ’ s H o r i z o n
• Weight customer needs by order of importance.
• Identify product and service features that meet
CTQs (the hows).
• Evaluate the ability of each feature to satisfy each
need.
For a new hospital service line, this process would be
repeated three times. The first iteration would match
customer needs with specific service line features. In
successive efforts, the hows become the whats.
The second iteration matches the features against
system level requirements. In the last iteration, system
level requirements are translated into subsystem level
requirements. A QFD for a new emergency and trau-
ma center illustrates the concept in Table 2.
Customer expectations are brainstormed and
weighted in the left-hand column. Potential system
requirements to satisfy these expectations are brain-
stormed in the right-hand column.
Each system level requirement is evaluated for its
ability to satisfy each customer requirement using a
high, medium and low scoring system, as in Figure 6.
The system requirement score in the bottom row of
the table indicates its relative importance. The custo-
mer expectation score in the table’s right-hand col-
umn indicates the extent to which this expectation is
S I X S I G M A F O R U M M A G A Z I N E I F E B R U A R Y 2 0 0 3 I 23
Figure 6. Quality Function Deployment for New Emergency and Trauma Center — Results
Source: GE Medical Systems
H e a l t h c a r e ’ s H o r i z o n
covered by the listed systems requirements and can be
compared to the weight of the associated customer
expectation.
System design requirements can then be sorted in
order of importance, as in the Pareto chart in Figure
7. The system design requirements become the expec-
tations (Y’s) for the next flow down, and the process is
repeated two more times.
On the surface, this process may seem arbitrary and
subjective. If executed correctly, however, using voice
of the customer data to drive the importance of the
whats and sound capability data to impact the hows, a
very clear picture of overall design requirements and
the trade-off between competing interests will emerge
with clarity.
It is important to note all customer needs are not
created equal in this process. Features that currently
exceed customer expectations and are considered
delighters will quickly become expected must haves
tomorrow.
This concept is illustrated using Kano’s model in
Figure 8 and must be considered carefully in assigning
importance to customer needs. The model is followed
by an illustration of the first iteration of the QFD
process that matches features with customer needs.
The define and measure phase of a DMADV project
may be summarized as a process of CTQ flow-down.
The analyze phase can be summarized as a process of
capability flow-up. This is where DMAIC and DMADV
differ significantly.
24 I S I X S I G M A F O R U M M A G A Z I N E I W W W . A S Q . O R G
Figure 7. Emergency and Trauma Center Pareto Chart
Staffing by arrival pattern demand
Accurate diagnostics
Mechanisms to ensure staff accountability
Quality therapeutics
Door to doctor time under 30 minutes
Coordination of aftercare by emergency department
Frequent patient contact and information exchange
No triage delays
Patient communication model designed and caregivers trained
Diagnostic cycle time specifications
Decision to disposition cycle time less than 15 minutes
Standardized triage process
Availability of treatment supplies at point of care
User friendly concentric wait area
Metal detectors at entrance
Privacy of triage spaces
Privacy of treatment spaces
Internal building signage clearly identifies location
Point of care testing
Parking and location signage well identified
Dedicated emergency room parking within 100 yards of emergency department
0 50 100 150 200
Source: GE Medical Systems
WHEN APPROPRIATELY IMPLEMENTED WITH LEADERSHIP SUPPORT AND
THE UTILIZATION OF CHANGE MANAGEMENT TECHNIQUES TO ADDRESS
CULTURAL BARRIERS AND BUILD ACCEPTANCE, SIX SIGMA HAS
ACHIEVED MEASURABLE SUCCESS.
H e a l t h c a r e ’ s H o r i z o n
In DMAIC, an understanding of causal factors on a
specific process outcome is quantified mathematically.
In DMADV, a specific process supporting a service line
feature and customer need may not exist. Where it
does, capability can be measured directly as illustrated
in the DMAIC section.
In cases involving new processes, systems and struc-
tures, the capability may be projected or forecast using
modeling. In healthcare, the models most relevant to
a new service line are those targeted at understanding
capacity, patient queuing, provider resource alloca-
tion and patient routing. This concept is illustrated in
Figure 9.
For a healthcare service line, the end result of the
analyze phase of a DMADV project is twofold:
1. Develop a mathematical expression of customer
needs translated to specific service line features,
service delivery system, and service subsystem
and process design specification.
2. Match needs and requirements against a mathe-
matical expression of existing or forecast pro-
posed process capabilities.
During the design phase, an optimal design is select-
ed and implemented based upon the merging of the
CTQ flow-down and the capability flow-up into an
integrated design scorecard. Capability forecasting
and analysis provides insight into how well design
requirements will be met, and the QFD translates this
into customer satisfaction. The result is a formalized,
mathematical model for understanding customer
impact associated with specific design alternatives and
trade-offs.
Finally, in the validate phase, the actual perform-
ance from a subsystem is measured against predicted
performance through the confirmation of customer
satisfaction. In a manufacturing environment this is
achieved through component, subsystem and system
level testing.
In healthcare, however, the opportunity to test seg-
ments of the service line may or may not exist. What
becomes more important in a healthcare application
of DMADV is the degree to which appropriate con-
trols are operationalized to consistently yield pre-
dictable results.
Full realization of designed service line entitle-
ments depends on translating the vision of these
entitlements to specific behaviors. This requires
appropriately targeted changes in recruitment, staff
development, measurement systems, performance
evaluation, incentives, communication and informa-
tion technology.
The validation phase of a DMADV project also
affords the opportunity to rethink many institutional
processes, systems and structures. For example, evalu-
ating design alternatives for a new imaging depart-
ment may indicate the existing patient registration
process will not meet customer expectations.
Redesign of this process should trigger rethinking of
patient registration across the institution and, at the
very least, provide a structured approach to institu-
tional transformation of service.
S I X S I G M A F O R U M M A G A Z I N E I F E B R U A R Y 2 0 0 3 I 25
Figure 8. Kano’s Model
Customer satisfaction
+
+
–
-Dysfunctional
Delighters
Must be
Features
Fully
functional
Needs not created equal
Differing impact on customer
satisfaction
Satisfaction proportional to
service and process functionality
Types of needs:
1. Basic expectations (must be)
2. Features
3. Delighters
3
2
1
Figure 9. DFSS Process
Customer
needs
Service line
features
Service system
design requirements
Subsystem and process
design requirments
Cr
iti
ca
l t
o
Qu
al
ity
fl
ow
-d
ow
n
Ca
pa
bi
lit
y
flo
w
-u
p
Source: GE Medical Systems
H e a l t h c a r e ’ s H o r i z o n
Measurable DMAIC Successes
As a methodology for process and quality improve-
ment, Six Sigma has demonstrated its ability to adapt
to virtually any process—including patient care.
Recorded achievements do not seem to be based on
the type or demographics of the organization. Six
Sigma has taken root in a wide variety of settings: with-
in individual departments, throughout small, rural
hospitals, within large teaching facilities and across
multihospital systems.
When appropriately implemented with leadership
support and the utilization of change management
techniques to address cultural barriers and build accept-
ance, Six Sigma has achieved measurable success.
The DMAIC approach has been deployed in hospi-
tals and health systems to improve service levels, cost
productivity and customer satisfaction. Conceding the
inherent distinctions between manufacturing and
medicine, however, it’s important to acknowledge the
impact of human variability on statistical process con-
trol and the importance of cultivating acceptance for
service based change initiatives.
What’s Next?
Building on the success of the DMAIC model, the
next platform for healthcare will likely follow the
DFSS approach with continued emphasis on accept-
ance. DMAIC optimizes existing processes, while
DFSS can be used to create and institute an entirely
new model for healthcare. Both promises and pitfalls
accompany current applications of Six Sigma within
healthcare, and organizations will need to carefully
assess their own unique needs and preparedness for
either targeted or systemic change.
The 21st century healthcare organization faces mul-
tiple challenges. Some are complex, longstanding
and unresolved issues, and others are emerging trends:
• Workforce shortages.
• Rising consumerism and patient expectations.
• The Health Insurance Portability and Accountability
Act of 1996 and other compliance issues.
• Quality and patient safety.
• Reimbursement issues.
• Aging of the population.
• Regulatory constraints.
• Increasing acuity of illness.
• Disaster preparedness.
Driven by a confluence of such significant factors,
the healthcare industry may soon gravitate toward an
evidence based design of new systems and structures
as a more verifiable and sustainable way to deliver
optimal patient care.
There are no easy answers and no overnight solu-
tions. It will take a considerable commitment and a
concerted effort on the part of all stakeholders to
embrace a new paradigm and build a better health-
care system by design.
REFERENCES
1. Institute of Medicine, Crossing the Quality Chasm: A New Health System for
the 21st Century, National Academy Press, 2001.
2. Institute of Medicine, To Err is Human: Building a Safer Health System,
National Academy Press, 1999.
3. Mikel Harry and Richard Schroeder. Six Sigma, The Breakthrough
Management Strategy Revolutionizing the World’s Top Corporations, Currency,
2000.
BIBLIOGRAPHY
A New Vision for Healthcare, Committee for Economic Development, 2002.
Burda, David, ed., “By the Numbers,” Modern Healthcare, Dec. 24, 2001.
Chassin, M.R., “Is Health Care Ready for Six Sigma Quality?” Milbank
Quarterly, Nov. 4, 1998.
Chowdhury, Subir, Design for Six Sigma: The Revolutionary Process for
Achieving Extraordinary Profits, Dearborn Trade Publishing, 2002.
Pande, Peter S., Robert P. Neuman and Roland R. Cavanagh. The Six Sigma
Way: How GE, Motorola and Other Top Companies are Honing Their
Performance, McGraw-Hill, 2000.
26 I S I X S I G M A F O R U M M A G A Z I N E I W W W . A S Q . O R G
WHAT DO YOU THINK OF THIS ARTICLE? Please share
your comments and thoughts with the editor by e-mailing
godfrey@asq.org.
THE CONTROL PHASE MAY REQUIRE DISMANTLING ROOT-BOUND
BUREAUCRACIES GROWING AROUND ANCIENT PROCESSES.
Quality in Practice: From Leadership Through Quality to Lean Six Sigma at Xerox
The Xerox 914, the first plain-paper copier, was introduced in 1959. Regarded by many people as the most successful business product ever introduced, it created a new industry. During the 1960s Xerox grew rapidly, selling all it could produce, and reached $1 billion in revenue in record-setting time. By the mid-1970s its return on assets was in the low 20 percent range. Its competitive advantage was due to strong patents, a growing market, and little competition. In such an environment, management was not pressed to focus on customers.
Facing a Competitive Crisis
During the 1970s, however, IBM and Kodak entered the high-volume copier business—Xerox’s principal market. Several Japanese companies introduced high-quality low-volume copiers, a market that Xerox had virtually ignored, and established a foundation for moving into the high-volume market. In addition, the Federal Trade Commission accused Xerox of illegally monopolizing the copier business. After negotiations, Xerox agreed to open approximately 1,700 patents to competitors. Xerox was soon losing market share to Japanese competitors, and by the early 1980s it faced a serious competitive threat from copy machine manufacturers in Japan; Xerox’s market share had fallen to less than 50 percent. Some people even predicted that the company would not survive. Rework, scrap, excessive inspection, lost business, and other problems were estimated to be costing Xerox more than 20 percent of revenue, which in 1983 amounted to nearly $2 billion. Both the company and its primary union, the Amalgamated Clothing and Textile Workers, were concerned. In comparing itself with its competition, Xerox discovered that it had nine times as many suppliers, twice as many employees, cycle times that were twice as long, 10 times as many rejects, and seven times as many manufacturing defects in finished products. It was clear that radical changes were required.
Leadership Through Quality
In 1983, company president David T. Kearns became convinced that Xerox needed a long-range, comprehensive quality strategy as well as a change in its traditional management culture (see
Figure 1.5
). Kearns was aware of Japanese subsidiary Fuji Xerox’s success in implementing quality management practices and was approached by several Xerox employees about instituting total quality management. He commissioned a team to outline a quality strategy for Xerox. The team’s report stated that instituting it would require changes in behaviors and attitudes throughout the company as well as operational changes in the company’s business practices. Kearns determined that Xerox would initiate a total quality management approach, that they would take the time to “design it right the first time,” and that the effort would involve all employees. Kearns and the company’s top 25 managers wrote the Xerox Quality Policy, which states:
Figure 1.5: Origin of the 1983 Xerox Quality Imperative
Xerox is a quality company. Quality is the basic business principle for Xerox. Quality means providing our external and internal customers with innovative products and services that fully satisfy their requirements. Quality improvement is the job of every Xerox employee.
This policy led to a process called Leadership Through Quality, which had three objectives:
· 1. To instill quality as the basic business principle in Xerox, and to ensure that quality improvement becomes the job of every Xerox person.
· 2. To ensure that Xerox people, individually and collectively, provide our external and internal customers with innovative products and services that fully satisfies their existing and latent requirements.
· 3. To establish, as a way of life, management and work processes that enable all Xerox people to continuously pursue quality improvement in meeting customer requirements.
In addition, Leadership Through Quality was di rected at achieving four goals in all Xerox activities:
· • Customer Goal: To become an organization with whom customers are eager to do business.
· • Employee Goal: To create an environment where everyone can take pride in the organization and feel responsible for its success.
· • Business Goal: To increase profits and presence at a rate faster than the markets in which Xerox competes.
· • Process Goal: To use Leadership Through Quality principles in all Xerox does.
Leadership Through Quality radically changed the way Xerox did business. All activities, such as product planning, distribution, and establishing unit objectives, began with a focus on customer requirements. Benchmarking—identifying and studying the companies and organizations that best perform critical business functions and then incorporating those organizations’ ideas into the firm’s operations—became an important component of Xerox’s quality efforts. Xerox benchmarked more than 200 processes with those of noncompetitive companies. For instance, ideas for improving production scheduling came from Cummins Engine Company, ideas for improving the distribution system came from L.L. Bean, and ideas for improving billing processes came from American Express.
Measuring customer satisfaction and training were important components of the program. Every month, 40,000 surveys were mailed to customers, seeking feedback on equipment performance, sales, service, and administrative support. Any reported dissatisfaction was dealt with immediately and was usually resolved in a matter of days. When the program was instituted, every Xerox employee worldwide, and at all levels of the company, received the same training in quality principles. This training began with top management and filtered down through each level of the firm. Five years, 4 million labor-hours, and more than $125 million later, all employees had received quality-related training. In 1988, about 79 percent of Xerox employees were involved in quality improvement teams.
Several other steps were taken. Xerox worked with suppliers to improve their processes, implement statistical methods and a total quality process, and to support a just-in-time inventory concept. Suppliers that joined in these efforts were involved in the earliest phases of new product designs and rewarded with long-term contracts.
Employee involvement and participation was also an important effort. Xerox had always had good relationships with its unions. In 1980, the company signed a contract with its principal union, the Amalgamated Clothing and Textile Workers, encouraging union members’ participation in quality improvement processes. It was the first program in the company that linked managers with employees in a mutual problem-solving approach and served as a model for other corporations. A subsequent contract included the provision that “every employee shall support the concept of continuous quality improvement while reducing quality costs through teamwork.”
Most important, management became the role model for the new way of doing business. Managers were required to practice quality in their daily activities and to promote Leadership Through Quality among their peers and subordinates. Reward and recognition systems were modified to focus on teamwork and quality results. Managers became coaches, involving their employees in the act of running the business on a routine basis.
From the initiation of Leadership Through Quality until the point at which Xerox’s Business Products and Systems organization won the Malcolm Baldrige National Quality Award in 1989, some of the most obvious impacts of the Leadership Through Quality program included the following:
· 1. Reject rates on the assembly line fell from 10,000 parts per million to 300 parts per million.
· 2. Ninety-five percent of supplied parts no longer needed inspection; in 1989, 30 U.S. suppliers went the entire year defect-free.
· 3. The number of suppliers was cut from 5,000 to fewer than 500.
· 4. The cost of purchased parts was reduced by 45 percent.
· 5. Despite inflation, manufacturing costs dropped 20 percent.
· 6. Product development time decreased by 60 percent.
· 7. Overall product quality improved 93 percent.
Xerox learned that customer satisfaction plus employee motivation and satisfaction resulted in increased market share and improved return on assets. In 1989, president David Kearns observed that quality is “a race without a finish line.”
Crisis and Quality Renewal
Throughout the 1990s, Xerox grew at a steady rate. However, at the turn of the century, the technology downturn, coupled with a decreased focus on quality by top corporate management, resulted in a significant stock price drop and a new crisis (see
Figure 1.6
). A top management shake-up, resulting in new corporate leadership, renewed the company’s focus on quality, beginning with “New Quality” in 2001 and leading to the current “Lean Six Sigma” initiative.
Figure 1.6: Restrengthening Quality to Address a New Crisis
The New Quality philosophy built on the quality legacy established in the 1983 Leadership Through Quality process. Soon afterward, as Six Sigma became more popular across the United States, this approach was refined around a structured, Six Sigma-based improvement process with more emphasis on behaviors and leadership to achieve performance excellence. The new thrust, established in 2003 and called “Lean Six Sigma” (see
Chapter 11
for a detailed discussion), includes a dedicated infrastructure and resource commitment to focus on key business issues: critical customer opportunities, significant training of employees and “Black Belt” improvement specialists, a value-driven project selection process, and an increased customer focus with a clear linkage to business strategy and objectives. The basic principles support the core value “We Deliver Quality and Excellence in All We Do” and are stated as:
· • Customer-focused employees, accountable for business results, are fundamental to our success.
· • Our work environment enables participation, speed, and teamwork based on trust, learning, and recognition.
· • Everyone at Xerox has business objectives aligned to the Xerox direction. A disciplined process is used to assess progress towards delivery of results.
· • Customer-focused work processes, supported by disciplined use of quality tools, enable rapid changes and yield predictable business results.
· • Everyone takes responsibility to communicate and act on benchmarks and knowledge that enable rapid change in the best interests of customers and shareholders.
The key components of Xerox’s Lean Six Sigma are as follows:
· 1. Performance excellence process
· • Supports clearer, simpler alignment of corporate direction to individual objectives
· • Emphasizes ongoing inspection/assessment of business priorities
· • Clear links to market trends, benchmarking, and Lean Six Sigma
· • Supports a simplified “Baldrige-type” business assessment model
· 2. DMAIC (define, measure, analyze, improve, control) process
· • Based on industry-proven Six Sigma approach with speed and focus
· • Four steps support improvement projects, set goals
· • Used to proactively capture opportunities or solve problems
· • Full set of lean and Six Sigma tools
· 3. Market trends and benchmarking
· • Reinforces market focus and encourages external view
· • Disciplined approach to benchmarking
· • Establishes a common four-step approach to benchmarking
· • Encourages all employees to be aware of changing markets
· • Strong linkage to performance excellence process and DMAIC
· 4. Behaviors and leadership
· • Reinforces customer focus
· • Expands interactive skills to include more team effectiveness
· • Promotes faster decision making and introduces new meeting tool
The heart of Xerox’s Lean Six Sigma is the performance excellence process, illustrated in
Figure 1.7
. It consists of three phases: setting direction, deploying direction, and delivering and inspecting results. It starts at the top of the organization—even the chair and CEO, Anne Mulcahy, has an individual performance excellence plan with objectives that are aligned with organization goals and measures and targets for assessment. This approach provides clear communication of direction and accountability for objectives. A structured approach is used to prioritize and select projects that have high benefits relative to the effort involved in accomplishing them. Statistical methods, lean work flow methods, and other process management skills are used to drive improvement from a factual, objective basis, driven by the DMAIC methodology.
Figure 1.7: Xerox Performance Excellence Process
Market trends and benchmarking help provide an external perspective required to lead the market with innovative products, services, and solutions and add value to the customer experience. This component encourages all people to share information and knowledge that enables changes in the best interest of customers and shareholders. Finally, behaviors and leadership reinforce customer-focused behaviors, based on the principle that “Quality is the responsibility of every Xerox employee.”
In 2003, Xerox trained more than 1,000 senior leaders across the company and communicated this business approach, the key differences from their quality legacy, and expectations to every employee, and is rapidly moving Lean Six Sigma concepts from manufacturing and supply chain into all business areas. They recognize that full leadership commitment is the key ingredient. As Anne Mulcahy noted, “What I worry most about is how to return Xerox to greatness … Lean Six Sigma is not the only answer, but it’s a significant part of the equation.”
Key Issues for Discussion
· 1. Contrast Leadership for Quality and Lean Six Sigma as quality initiatives for Xerox. How did their motivations differ? What differences or similarities are evident in the principles behind these initiatives and the way in which they were implemented?
· 2. What lessons might this experience—particularly in responding to the new crisis—have for other organizations?
· 3. Discuss the meaning of “Quality is a race without a finish line.” What is its significance to Xerox, or to any organization?
