I read with interest the DelliFraine and colleagues1 article, "The Use of Six Sigma in Health Care Management: Are We Using It to Its Full Potential?" on the use and implementation of Six Sigma and the empirical evidence demonstrating the relationship between Six Sigma and improved quality of care in health care organizations.

I agree that many of the studies included in the DelliFraine and colleagues review did not completely report the DMAIC (Define, Measure, Analyze, Improve, Control) framework, as most failed to describe the control aspect; however, I take issue with their statement that authors and editors may find the control aspect of DMAIC less important than the other steps in the process.1

Sustaining or controlling improvements in health care quality is particularly difficult. Published estimates of change adoption suggest failure rates are as high as 70%.2 This has significant implications for the successful use of quality improvement (QI) frameworks and sustaining change in the long term. I would therefore like to propose that it is not that authors and editors find the control phase less important but it is that they in fact find this step the most challenging that leads to poor control of QI initiatives in health care.

Buchanan and colleagues3 suggest that sustainability occurs when new ways of working and improved outcomes become the norm. At this point, they suggest that it is not only the process and outcome that have changed but also the thinking and attitudes behind them that have been fundamentally altered and the systems surrounding them transformed in support.3 In support of this notion, it is said that failure of QI initiatives has a lot to do with the fact that there is often no corresponding change in organizational culture and that changes do not often sustain because they are inconsistent with prevailing values, understandings, and unspoken "rules" in organizations.4

In addition, there are many other factors that have been identified in the literature that impact on controlling QI activities in health care. These include (i) the complexity of change in health care,5 (ii) the lack of leadership and support from senior management,6 (iii) failure to include initiatives as part of ongoing performance management,7 (iv) poor continuing innovations and ongoing improvements,8 (v) limited reward and recognition,9 (vi) poor or limited stakeholder engagement and management,9 (vii) lack of clear and consistent communication, and10 (viii) failure to embed and institutionalize routines.11

Given that QI initiatives (i) often fail to address organizational cultural change and (ii) have limited resources to adequately address the multitude of factors impacting on sustainability of improvements, it is no surprise that initiatives that use the Six Sigma tool frequently fail to address or acknowledge the control phase of the framework.

With this in mind, it could be concluded that it is not that authors and editors find the control phase less important but it is, as I suggested, that they in fact find this the most challenging step that leads to failure in the control phase and limited success in sustaining benefits to patient safety and quality in the long term.

-Jacinta Baker

Melbourne Health

Parkville, Victoria, Australia

([email protected])

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