The Six Sigma Book for Healthcare: Improving Outcomes By Reducing Errors, by Robert Barry, Amy C. Murcko, and Clifford E. Brubaker. Milwaukee, WI. Health Administration Press, ACHE Management Series. American Society for Quality, Quality Press, 2002. 226 pages, softcover, $65.00.
This slim volume was designed to help the health care executive cope with the tasks entailed in implementing a Six Sigma program in his or her organization. The material is organized into two principal parts. Part I consists of five chapters covering the background of Six Sigma, error prevention, problem solving, problem detection, and the management of change. Part II is a collection of 20 case studies addressing problems that might be handled with the Six Sigma approach, plus several problems in managing workflow on which the reader can test himself. The case studies include instructions, supported by a Web site, for applying Six Sigma methodology in resolving the observed problems.
The appendix contains the formulae for five of the major distributions, including the Poisson and Student's t distributions, as well as an excellent discussion of ways to estimate the standard deviation in the presence of very small sample size. The book contains an annotated bibliography and a helpful glossary.
The writers' breezy style makes the book easy to read. Their simple graphics and use of plenty of clarifying examples make even the most highly technical information easy to navigate. As they point out, a Six Sigma trainee does not need to have extensive training in statistics to learn the fundamentals of the method and achieve green belt status, the first level of competence in the system. It would be helpful, though, to have at least a basic acquaintance with sampling theory, the characteristics of the normal distribution, and the general principles of statistical process control.
The authors get off to a good start with a brief history of the icons of the efficiency-productivity-quality movement in corporate America from the turn of the last century to the present. They trace the development and spread of Motorola Corporation's Six Sigma program aimed at reducing performance error rates. In the second chapter they introduce the concept of poka-yoke [po/ka-yo/kay], or mistake-proofing. In showing the reader how to implement the poka-yoke guidelines (make doing the task right easier than doing it wrong; make errors immediately obvious; and make on-the-spot corrections possible) the authors provide environmental, administrative, clinical, and workflow examples that are relevant to health care settings, rather than to the factory floor.
In Chapter 3, "Problem Solving," the authors address and categorize some common types of health care setting problems and present some diagrammatic tools for analyzing and resolving them. They provide excellent descriptions of failure modes and effects analysis, the Ishikawa or "fishbone" approach, and root cause analysis. In the fourth chapter, on problem detection, they offer a clear roadmap for using the Six Sigma analytical steps to identify a problem-prone process, analyze it, and institute and evaluate remedial measures. In the fifth chapter, on the management of change, the authors provide detailed discussions and practical examples of using the Six Sigma methodology to bring about reduction in error rates.
The piece de resistance may be the Web site. This powerful teaching device has been set up as a companion to the book, for use in working on the cases. On the Web site are the lists of data that must be used in handling the cases and sample Excel spreadsheets showing the application of the statistical functions used in the book. The data need not be keyed in by the user-they're already entered. The Web site presents (1) data for all of the cases in Excel format; (2) complete solutions for indicative cases; (3) PowerPoint templates for case reports; (4) complete analysis of examples not carried to completion in Part II; and (5) a Microsoft Excel "ice breaker." Your reviewer tried it out, and can report that it works. This teaching tool is invaluable.
The first 10 cases in Part II are suitable for a Six Sigma trainer to use in training Green Belt candidates. The authors suggest that a trainer of potential Black Belts might assign the trainees the first 6 cases plus Cases 11 through 20. On completion of the case studies-practicum, the trainee is expected to give a PowerPoint presentation based on his or her Six Sigma project. The authors' instructions to the Green Belt or Black Belt candidate for developing and presenting his or her PowerPoint presentation are a classic, augmented with a few choice insights that should be memorized by any upwardly mobile first line or middle manager. This book would be extremely helpful to any health care executive or manager who wants to be prepared to plan or to carry out a Six Sigma outcomes improvement effort.
For another look at an application of Six Sigma to health care, the reader is referred to a report published in the January-March 2003 issue of Quality Management in Health Care. A team at the Naval Medical Center, San Diego, California, led by Peter A. S. Johnstone, MD, Director of Ancillary Services, studied Six Sigma applications to radiation oncology, clinical laboratory, blood bank, and pharmacy services (Peter A. S. Johnstone, M.D. et al. "Ancillary Services in the Health Care Industry: Is Six Sigma Reasonable?" Q Manage Health Care. 2003;12(1):53-63).