Addressing Variation in Hospital Quality: Is Six Sigma the Answer?

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Addressing Variation in Hospital Quality: Is Six Sigma the Answer?

  1. 1. H I L L - R O M U N D E R G R A D U A T E Addressing Variation in Hospital Quality: Is Six Sigma the Answer? Tanisha D. Woodard, James Madison University, Harrisonburg, Virginia ................................................................................................ E X E C U T I V E S U M M A R Y [First Pa Quality of care has become a focal point in healthcare. Hospitals and health sys- [226], ( tems continue to produce care that varies in quality. This leads to customer dis- satisfaction as well as inefficient processes and output. As a result, administrators face a challenge to improve the quality of care in their organizations. One way to Lines: 0 address quality improvement is to use various quality management models. ——— Six Sigma is an innovative program that uses data analysis to achieve defect- * 193.3 free processes and to decrease variation. The program can provide management ——— with a viable solution to quality improvement. This article presents an analysis Long Pa of existing quality management tools, encourages consideration of Six Sigma, * PgEnds: and outlines the potential benefits of Six Sigma. Finally, the article discusses an organization’s capacity to implement a Six Sigma program as well as the possibility [226], ( for an organization to incorporate Six Sigma into its existing quality management program. For more information on the concepts in this article, please contact Ms. Woodard at tanisha. woodard@gmail.com. Ms. Woodard is the first-place winner of the undergraduate division of the 2004 Hill-Rom Management Essay Competition in Healthcare Administration. Sponsored by the Hill-Rom Company, Inc., the industry leader in hospital beds and patient care systems located in Batesville, Indiana, the competition is intended to stimulate student thinking and writing about important issues and developments in the field of healthcare management. For more information on this competition, please contact Reed Morton, Ph.D., FACHE, at (312) 424–2800. Photocopying and distribution of this PDF is prohibited without 226 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  2. 2. Hil l -Rom Under g r aduate A s a result of continued variation in quality across hospitals and healthcare systems, quality of care concepts: quality assurance and quality management (Table 1). Quality assurance (QA) was one of the first in the United States has received attempts to deal with the variation in increased attention from the public quality among different hospitals. The and governments. According to the creation of the Joint Commission on Institute of Medicine (IOM), quality is Accreditation of Hospitals (now the “the degree to which health services for Joint Commission on Accreditation of individuals and populations increase Healthcare Organizations) aided in the the likelihood of desired health care development of QA efforts, as did the outcomes and are consistent with requirements under Medicare (Luke, current professional knowledge” Krueger, and Modrow 1983). The goal [227], (2) (Rowell 2004, 178). Therefore, quality of QA is to develop a formal system efforts by hospitals and healthcare that allows hospitals to consistently Lines: 30 to systems aim to ensure that healthcare produce high clinical quality care and ——— consumers receive care that is service. QA identifies outliers (errors) 0.0pt PgV appropriate, provided correctly, and and then examines ways to eliminate ——— effective. These efforts include the these outliers from the organization’s Long Page use of total quality management or output. * PgEnds: Ejec continuous quality improvement, Quality management (QM) reengineering, and the relatively new is a more recent philosophy that [227], (2) Six Sigma. Although these efforts have uses managerial concepts centered worked to increase quality, serious on quality improvement and the quality issues remain in the current satisfaction of customers. The present healthcare system (IOM 2001). Thus, understanding of healthcare quality identifying strategies to better the and quality management methods quality of care should be a continuing can be attributed to the work of priority for hospital administrators. industrial quality experts W. Edwards While various methods do exist Deming and Joseph M. Juran and the to improve quality, their approaches work of the distinguished health and effectiveness are uncertain. This system researcher and professor article discusses the current quality Avedis Donabedian, who pioneered management models, argues for quality assessment. Two key elements consideration of Six Sigma in hospitals, of QM are technical quality and and lists barriers to the implementation customer satisfaction. Technical of Six Sigma. Finally, the author quality focuses on the competency suggests a pilot of Six Sigma and of providers as well as on the examines the capability of a hospital to accurate and proper procedures and implement such a program. care. This particular type of quality determines requirements for clinical Q U A L I T Y I N H E A LT H C A R E : care. Customer satisfaction, on the AN OVERVIEW other hand, is based not only on the The evolution of quality improvement technical quality provided but also on efforts in hospitals reflects two broad attributes such as empathy, reliability, Photocopying and distribution of this PDF is prohibited without 227 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  3. 3. J o u rna l o f H e a lt hca re Ma na ge m e n t 5 0 :4 Jul y/Augus t 2 0 0 5 ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• TA B L E 1 Evolution of Quality Improvement Efforts in Hospitals Time of Initiation Quality Effort Strategy 1950s Quality assurance Identify outliers in clinical care to eliminate these outliers from within the organization. 1980s Quality improvement Decrease variation to reduce error as well as improve clinical and nonclinical processes. 1990s Quality management Use managerial concepts centered on quality [228], ( improvement to achieve technical quality and customer satisfaction. Late 1990s Six Sigma Achieve defect-free processes and reduce variance Lines: 5 through Six Sigma improvement projects. ——— 0.0pt ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ——— Normal responsiveness, communication, and organizational processes and activities * PgEnds: caring to define a patient’s perceptions (Chong, Unklesbay, and Dowdy 2000). of quality and satisfaction (Bowers, CQI/TQM seeks to better the [228], ( Swan, and Koehler 1994). These two quality of care and services by first elements are the foundation of the looking at the output quality of the QM theory and are reflected in specific hospital. Output quality determines if models that have been developed. healthcare organizations are providing The specific elements of each quality products and services that meet improvement strategy are discussed in customer needs (Longest, Rakich, Table 2. and Darr 2000). Outputs that satisfy the desires of customers confirm that Continuous Quality Improvement/Total organizations are indeed producing Quality Management quality goods and services. Another Continuous quality improvement aspect of CQI/TQM examines how in healthcare can be referred to as a hospital can advance its processes total quality management (TQM), to make them more efficient and continuous quality improvement effective. Consequently, process (CQI), or a combination of both improvement must address both (CQI/TQM). The ultimate goal of clinical and nonclinical areas. A CQI/TQM is to control variation and process is defined as a series of eliminate poor quality. CQI/TQM operations that are linked together focuses on how to satisfy customer to provide a result that has increased needs and expectations while value, which may not be possible striving to constantly improve all if each operation were performed Photocopying and distribution of this PDF is prohibited without 228 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  4. 4. Hil l -Rom Under g r aduate ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• TA B L E 2 Key Elements of Quality Improvement Models in Hospitals Continuous Quality Improvement/Total Quality Management Reengineering Six Sigma Purpose Control variation Recreate task relation- Analyze rigorous set of through analysis ships to achieve more processes and techniques and improvement efficient and effective to measure, improve, and of output and relationships among control the quality of process quality. tasks in a defined process care and service based on [229], (4) (i.e., to improve quality). what is important to the customer. Lines: 95 to Focus Organizationwide Suborganization Organizationwide framework framework or suborganization ——— framework 0.0pt PgV ——— Tools and Identifies priorities Uses multistep process Develops improvement Normal Pag Techniques for process that critically analyzes projects to achieve defect- PgEnds: TEX and outcome internal work processes, free processes and reduce improvement. and plans ways to variation. Only uses tools [229], (4) Understands redesign these processes. necessary to complete processes to reduce Outward focus is on the projects. variation. Utilizes customer. as many tools as possible when engaging in the process. Training Educate and train Senior management Participants in the and Prepa- staff on CQI/TQM provides direction and process must be trained ration objectives and education to process experts and become activities. Use teams. certified in Six Sigma committees and techniques (e.g., task forces. Green and Black Belt Certifications). ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• individually (Chong, Unklesbay, and improved as well (Longest, Rakich, and Dowdy 2000). Therefore, process im- Darr 2000). Process quality includes provement is based on the logic that to technical quality (providing technically improve output quality, the processes appropriate care) as well as activities that produce the outputs must be that meet the needs of the healthcare Photocopying and distribution of this PDF is prohibited without 229 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  5. 5. J o u rna l o f H e a lt hca re Ma na ge m e n t 5 0 :4 Jul y/Augus t 2 0 0 5 consumer such as timely care, respect, Healthcare System in Savannah, and providing knowledge about the Georgia, was able to decrease patient medical condition. Given that engaging waiting time by 76 percent, save in activities to satisfy customer needs is $200,831 on clerical usage, and save essential to process quality, employees $117,000 by changing the formulary are an integral part of process for antibiotics based on effectiveness improvement; they must not only and efficiency (Dowd and Tilson understand systematic processes but 1996). Similarly, North Valley Hospital also take advantage of ways to improve (NVH) in Whitefish, Montana, used their own work and actions when the CQI/TQM principles in its selection opportunity arises. Through the anal- process of an information system. ysis of outcome and process quality, Through use of the model, NVH [230], ( CQI/TQM encourages an organization was able to meet management’s to perfect its processes and outputs expectations regarding the duration, Lines: 1 to the point that they are completed cost, and result of its selection process ——— correctly the first time, every time. (McConnell and Ciotti 1995). As 0.0pt As a quality management model, demonstrated in the examples above, ——— CQI/TQM can provide many benefits CQI/TQM has proved to be valuable Long Pa to a hospital, including better output and beneficial to some organizations. PgEnds: quality, productivity improvement, Nonetheless, CQI/TQM does have and an enhanced competitive position its drawbacks, falling victim to two [230], ( (Longest, Rakich, and Darr 2000). common problems in healthcare: An improvement in output quality determining what quality is and creates a positive reputation for how to define it. Additionally, the a hospital, showing healthcare process of implementing CQI/TQM is consumers that the organization is extremely time consuming. It cannot aware of and committed to satisfying be mastered quickly, and its process customer needs. For these reasons, needs constant attention (Chong, the competitive position of the Unklesbay, and Dowdy 2000). It organization is strengthened as well. also relies on gradual negotiation Productivity is constantly a concern and implementation (Locock 2003). for hospitals because they must rely The necessity of gradualism and on a limited supply of resources. The constant attention make the CQI/TQM fact that CQI/TQM can address this process an unappealing approach concern presents an additional strength to hospitals, which need quick yet of the model. CQI also increases the effective solutions. Time is of the dignity of staff because it recognizes essence for hospitals, because even a them as a part of a team and as mere minute of poor quality could leaders in improving a process; this become a matter of life or death. results in increased employee morale The literature suggests that CQI/ (McLaughlin and Kaluzny 1994). TQM has not been as successful as Organizations that have adopted hoped. Evidence on this model in the CQI/TQM model can attest to its healthcare shows that improvements benefits. Within a single year, Candler in quality after use have occurred Photocopying and distribution of this PDF is prohibited without 230 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  6. 6. Hil l -Rom Under g r aduate gradually and have been fairly small their own processes (Luck and Peabody scale. CQI/TQM techniques can have 2000). One of the main characteristics some success within individual teams of reengineering is that it is an outward or departments, but the resulting process, focusing on external forces changes tend to be limited in scale and such as what must be done to achieve impact (Locock 2003). Furthermore, customer needs and how to maintain not much evidence supports the claim a competitive advantage. Reengineering that CQI/TQM programs can act as is radical and requires organizations a means to achieve organizationwide to disregard existing structures and change (Locock 2003). The model fails procedures and develop new ones that to take into account the complexity work. It involves long and laborious of healthcare and the nature of implementation of processes that are [231], (6) professional knowledge of clinicians developed internally to better serve and other staff. The language and healthcare consumers (Longest, Rakich, Lines: 160 to values used in CQI/TQM are often and Darr 2000). Reengineering is ——— foreign to healthcare and, as a result, commended for its ability to seek 0.0pt PgV cause resistance as it is thought breakthrough concepts rather than ——— to be a management fad (Locock build off of existing processes—a Long Page 2003). Clearly, CQI/TQM lacks the key difference from CQI/TQM. By PgEnds: TEX capacity to successfully improve focusing on healthcare consumers, healthcare quality without redesign the reengineering model presents an [231], (6) or the incorporation of other quality additional strength: “ . . . reengineering improvement programs. pushes the CQI philosophy and mindset upstream to the customer and Reengineering a more macro level—to more quality Another approach to quality improve- consciousness that is external to the ment is reengineering. Reengineering HSO/HS” (Longest, Rakich, and Darr is similar to CQI/TQM in that both 2000, 436). models focus on processes and are The strengths of reengineering dedicated to improvement. However, are evidenced by organizations that while CQI/TQM starts with output have used this strategy successfully. For quality, reengineering begins with the example, the endoscopy unit of a 176- customer (Longest, Rakich, and Darr bed teaching medical center in central 2000). Walston and Bogue (1999, New Jersey undertook reengineering 456) define reengineering as “the efforts to increase its efficiency and re-creation of task interdependencies maintain or reduce costs. Benefits to to achieve more effective, efficient the unit as a result of reengineering relationships among tasks.” This include a reduction in total hours redesign of tasks occurs through a worked per procedure, from 4.52 hours multistep process in which hospitals to 3.60 hours; a 23.26 percent decrease critically examine their internal work in the total salary cost per procedure; processes, compare them to those of and a decrease in the amount of paid known healthcare industry leaders, hours per procedure, from 4.86 hours and plan ways to radically redesign to 3.90 hours (Cole 1999). Despite Photocopying and distribution of this PDF is prohibited without 231 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  7. 7. J o u rna l o f H e a lt hca re Ma na ge m e n t 5 0 :4 Jul y/Augus t 2 0 0 5 these strengths, reengineering, just as produce the level of detail required to CQI/TQM, comes with weaknesses understand process variation” (Revere that prevent it from being the most and Black 2003, 378–79). This leads favorable solution to improving quality to a complicated analysis that hinders of care and services. the ability to create satisfactory quality Reengineering was developed in improvement programs. With the response to the failures of CQI/TQM’s failure of CQI/TQM in mind, how can incrementalism and to achieve organ- true quality improvement actually be izationwide change; however, research achieved in an organization that desires suggests that reengineering results to provide better care? have not been as great as anticipated. Six Sigma is an innovative and Locock (2003, 56) states that with comprehensive management tool that [232], ( reengineering “ . . . a particular problem has been in use for many years in has been its aggressive rhetoric and its manufacturing. Its success has led to Lines: 1 failure to engage the staff on whom its selective adoption by hospitals and ——— the organization relies.” Because of health systems. Six Sigma, as a quality 0.0pt the belief that reengineering is a improvement plan, uses data analysis ——— brutal and inappropriate technique, and other problem-solving techniques Normal clinical resistance has developed, to evaluate the ability of a process to PgEnds: creating a major obstacle to its perform defect free, where a defect implementation and success (Locock is anything that results in customer [232], ( 2003). Additionally, reengineering dissatisfaction (Revere and Black 2003). requires top management to be Thus, the primary goal of Six Sigma personally committed to the effort; is to curb and eventually eliminate lack of this commitment prevents the number of defects that occur in a reengineering from being successful. given process. To achieve defect-free Thus, reengineering fails to effectively processes and reduce variation, Six better the quality of an organization Sigma creates a number of Six Sigma in the same way that CQI/TQM is also improvement projects. These projects unsuccessful. are created through the use of the Six Sigma methodology, DMAIC (define, A NEW PERSPECTIVE: measure, analyze, improve, control). SIX SIGMA DMAIC is an analytical process that Six Sigma has recently advanced requires organizations to pursue the to address continued variation in following steps (Samuels and Adomitis hospital quality. Revere and Black 2003): (2003) find that the reason many of the initiatives that seek to reduce • Define the purpose of a project and error are unsuccessful may be the its scope, especially the critical-to- focus on CQI/TQM programs (Revere quality factors. and Black 2003). “Although TQM • Measure through the creation of a encourages data collection and analysis, performance baseline to which data it is often not implemented so as to that show errors can be compared, Photocopying and distribution of this PDF is prohibited without 232 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  8. 8. Hil l -Rom Under g r aduate leading to a more precise definition and variation reduction, Six Sigma has of the problem. produced benefits, such as improved • Analyze the root causes of problems customer satisfaction and stronger as evidenced by actual data. financial status, that exceed those that CQI/TQM and reengineering models • Improve performance through currently offer (Samuels and Adomitis implementation of procedures that 2003). will eliminate the root causes of Regardless of the benefits Six Sigma error. has to offer, the program faces a sig- • Control the process by evaluating nificant hurdle to being implemented, performance before and after or even considered, in hospitals. This improvement attempts; initiate a barrier stems from hospital adminis- [233], (8) monitoring system to reduce trators’ reluctance to stray from their future errors. CQI/TQM efforts, in which they have Lines: 187 to invested considerable time and money. DMAIC requires a continual effort ——— However, this is an unacceptable reason to optimize processes that affect an 0.0pt PgV to dismiss the Six Sigma program. Six ——— organization’s critical-to-quality factors Sigma’s creation differs from CQI/TQM Normal Pag and differs from CQI/TQM programs, and reengineering: “Unlike TQM, Six PgEnds: TEX which are generally aimed at fixing Sigma was not developed by techies problems periodically (Samuels and who only dabbled in management [233], (8) Adomitis 2003). Although CQI/TQM and therefore produced only broad claims to be an ongoing process, it guidelines for management to follow” does not address issues continuously. (Pyzdek 2001, 1). Six Sigma is from Furthermore, the systemic process of the minds of talented executives who DMAIC ultimately leads to a precise understand the complexity and impor- identification of the problem, defined tance of management when making methods to appropriately measure and adjustments to the organization (i.e., analyze the problem, and concrete improving quality) (Pyzdek 2001). performance improvement as well as The internal organizational control of the process. infrastructure that Six Sigma presents Six Sigma also uses a detailed also sets it apart from CQI/TQM and statistical analysis in which defects reengineering. Six Sigma creates new are assigned a sigma value. These positions in the organization where sigma values are then compared to employees become change agents: a “world class” quality defect rate of 3.4 per million opportunities to These people [employees] represent determine the quality performance organizational slack dedicated not of a service (Johnstone et al. 2003). to producing routine work, but to producing change. Their performance is This analysis provides tangible data for judged by their innovation, which takes use in the development of Six Sigma the form of tangible improvements improvement projects that address that benefit customers, shareholders or defects. Through perfection of processes employees (Pyzdek 2001). Photocopying and distribution of this PDF is prohibited without 233 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  9. 9. J o u rna l o f H e a lt hca re Ma na ge m e n t 5 0 :4 Jul y/Augus t 2 0 0 5 Additional differences between Six “When an event is performed Sigma, total quality management, and hundreds or thousands of times, even reengineering are listed in Table 2. a small percentage of variance can represent a large absolute number of WHY IS SIX SIGMA A GOOD errors” (Johnstone et al. 2003, 53). APPROACH? The previous statement strikes on a Six Sigma has the potential to achieve subject that is critical to the survival of phenomenal quality improvement, hospitals. Healthcare is an industry that as it reduces variation in systems is about the lives of human beings. processes (Revere and Black 2003). The Thus, in healthcare a seemingly small program allows for recognition of error variance could result in a much more and forces hospital administrators to harmful effect such as the death of a [234], ( develop solutions to address this error: baby, malpractices charges on a physi- cian, or a misdiagnosis of a patient. Lines: 2 Six Sigma thus discredits the all- The benefits of Six Sigma are begin- ——— too-common excuse of plausible ning to be seen in hospitals and health deniability. By focusing on the 0.0pt systems. Mount Carmel Health in ——— causes of errors, financial hospital Columbus, Ohio, was one of the first Normal administrators can begin to implement healthcare organizations to implement PgEnds: changes early in a process at minimal cost, thereby preventing those errors Six Sigma through its entire organiza- from becoming much more costly tion (Revere and Black 2003). One of [234], ( problems later (Samuels and Adomitis its first Six Sigma projects sought to 2003). achieve timely and accurate Medicare + Choice claims reimbursement by The accountability aspect of Six Sigma, looking at where claim reimbursement as well as its timely ability to identify was substandard. For Mount Carmel and solve error, presents an asset to Health, “Process improvements at- hospital administrators. This benefit tained through Six Sigma resulted in an can indeed be useful to a hospital and $857,000 gain in net income” (Revere to its current CQI/TQM effort. and Black 2003, 380). Consequently, Six Sigma follows formal quality Mount Carmel Health, through Six analysis and process improvement Sigma, improved its financial stability. to provide hospital administrators Similarly, Virtua Health, a health- with concrete information that allows care system that provides services in them to specifically understand what is New Jersey and Philadelphia, used Six contributing to error. This information Sigma to improve clinical care, patient is discovered through an approach that satisfaction, and financial performance. measures process variance according to A congestive heart failure team at the Six Sigma scale. The Six Sigma scale Virtua Health found that outcomes, reveals the degree to which a process lengths of stay, and treatment pathways achieves its objectives, and it measures were highly variable (Revere and Black variance based on the unit defects per 2003). The team employed Six Sigma million opportunities. to define the causes of variation, allow- Photocopying and distribution of this PDF is prohibited without 234 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  10. 10. Hil l -Rom Under g r aduate ing the team to develop solutions that As Revere and Black (2003, 379) involved both patients and families state, “Six Sigma is a relatively new in the delivery of care. As a result, quality approach that complements, the team was able to streamline the embellishes, and expands TQM. The process of delivery of care, decreasing work of Six Sigma is not unlike TQM; the length of stay from 6.2 days to 4.6 however, its goals are more aggressive days (Revere and Black 2003). and its methods are better defined.” These successes by various Therefore, Six Sigma deserves the healthcare organizations not only opportunity to be considered and demonstrate Six Sigma’s ability to analyzed by hospital administrators in enhance quality improvement but also their determination of a quality model justify consideration of the Six Sigma that will solve the modern quality [235], (10) program by healthcare management. issues they face. Once hospital administrators are able After taking into account the points Lines: 247 to to see how well the Six Sigma program outlined in this article, administrators ——— works, they can be encouraged by these should consider engaging in a pilot 0.0pt PgV successes and become optimistic about effort of Six Sigma to see how well ——— its success in their own organizations. it fits within their organization Normal Pag and how it can contribute to their PgEnds: TEX CONCLUSIONS AND current quality management efforts. I M P L I C AT I O N S Administrators must also determine [235], (10) Organizations have chosen a variety of their organizations’ capacity to methods to address the issue of quality implement the Six Sigma program. improvement. This article describes “Applying Six Sigma in health care the major methods that have been is in some ways more difficult than traditionally employed and introduces it is in other industries, because the benefits that the more recent Six of the complexity of healthcare Sigma model offers. Six Sigma has the processes” (Samuels and Adomitis capability to successfully reduce error 2003). Nonetheless, Six Sigma, and achieve efficiency in healthcare when implemented with vigor organizations. Thus, the future of Six and dedication, can be used to Sigma is promising. effectively eliminate variation of The fear of healthcare organizations quality in healthcare. Success of Six to completely overhaul their improve- Sigma is dependent on access to ment programs often hinders the expert knowledge about Six Sigma, implementation or even consideration commitment from senior management, of the Six Sigma program. However, an environment conducive to change, as a quality management tool, Six and thorough knowledge of the areas Sigma does not require a complete being evaluated by the Six Sigma transformation and can instead be program (Samuels and Adomitis 2003). integrated into an organization’s Six Sigma may require some initial current CQI/TQM program, providing effort, but it is sure to provide rewards numerous benefits to the organization. in the future. Healthcare demands a Photocopying and distribution of this PDF is prohibited without 235 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.
  11. 11. J o u rna l o f H e a lt hca re Ma na ge m e n t 5 0 :4 Jul y/Augus t 2 0 0 5 better solution to quality improvement, Luck, J., and J. W. Peabody. 2000. “Improving and the time to embrace new methods the Public Sector: Can Reengineering Identify How to Boost Efficiency and such as Six Sigma is now. Effectiveness at a VA Medical Center?” Health Care Management Review 25 (2): References 34. Bowers, M. R., J. E. Swan, and W. F. Koehler. Luke, R. D., J. C. Krueger, and R. E. Modrow. 1994. “What Attributes Determine Qual- 1983. Organization and Change in Health ity and Satisfaction with Health Care Care Quality Assurance. Rockville, MD: Delivery?” Health Care Management Review Aspen Systems Corporation. 19 (4): 49–55. McConnell, P., and V. G. Ciotti. 1995. “Apply- Chong, Y., N. Unklesbay, and R. Dowdy. ing TQM/CQI Principles to Information 2000. “Clinical Nutrition and Foodservice Systems Selection.” Healthcare Financial [Last Pa Personnel in Teaching Hospitals Have Management 49 (5): 48–52. McLaughlin, C. P., and A. D. Kaluzny. 1994. [236], ( Different Perceptions of Total Quality Management Performance.” Journal of Continuous Quality Improvement in Health American Dietetic Association 100 (9): Care. Gaithersburg, MD: Aspen Systems 1044. Corporation. Lines: 2 Cole, D. A. 1999. “Creating Outcomes with Pyzdek, T. 2001. “Six Sigma and Beyond.” Quality Digest. [Online article; retrieved ——— Redesign Efforts.” AORN Journal 70 (3): 11/29/04.] http://www.qualitydigest.com 110.39 406. ——— Dowd, S. B., and E. Tilson. 1996. “The Bene- /feb01/html/sixsigma.html. Revere, L., and K. Black. 2003. “Integrating Six Normal fits of Using CQI/TQM Data (Continuous Quality Improvement/Total Quality Man- Sigma with Total Quality Management: A PgEnds: agement).” Radiologic Technology 67 (6): Case Example for Measuring Medication 533–37. Errors.” Journal of Healthcare Management Johnstone, P. A. S., J. A. W. Hendrickson, 48 (6): 377–91. [236], ( A. J. Dernbach, A. R. Secord, J. C. Parker, Rowell, P. 2004. “Appropriateness of Care: The M. A. Favata, and M. L. Puckett. 2003. Case for Changing the Focus of ‘Quality’ “Ancillary Services in Health Care Indus- Measurement.” Quality Management in try: Is Six Sigma Reasonable?” Quality Health Care 13 (3): 178–82. Management in Health Care 12 (1): 53– Samuels, D. I., and F. L. Adomitis. 2003. “Six 63. Sigma Can Meet Your Revenue-Cycle Institute of Medicine. 2001. Crossing the Qual- Needs: Six Sigma Is Far from Being the ity Chasm: A New Health System for the Latest Quality Improvement Fad; It Is a 21st Century. Washington, DC: National Proven Technique Grounded in Principles Academies Press. that will Endure As Long As There Are Locock, L. 2003. “Healthcare Redesign: Mean- Processes that Require Improvement.” ing, Origins and Application.” Quality and Healthcare Financial Management 57 (11): Safety in Health Care 12 (1): 53–57. 70–75. Longest, B. B, J. S. Rakich, and K. Darr (eds.). Walston, S. L., and R. J. Bogue. 1999. “The 2000. Managing Health Services Organiza- Effects of Reengineering: Fad or Com- tions and Systems, 4th Edition. Baltimore, petitive Factor?” Journal of Healthcare MD: Health Professions Press. Management 44 (6): 456. Photocopying and distribution of this PDF is prohibited without 236 the permission of Health Administration Press. For permission, please fax your request to 312.424.0014.

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