DMAIC Improvement Approach

Basic Six Sigma Breakthrough
Improvement Process
Ph. Doaa Hussein
MBA, CPHQ,TQMD

Basic Six Sigma Breakthrough
Improvement Process
Date TOPIC
3rd August 2016 Introduction and Six Sigma Overview
10th August 2016 Define your project
17th August 2016 Measure and Analyze
24th August 2016 Improve and Control
31th August 2016 Group presentations

Content
• SIPOC
• Voice of the Customer
• Kano Analysis
BY Dr. Doaa Hussein Abdelghani MBA,
CPHQ,DTQM,HRMD,APD,CPT
3

What is Quality Management in Healthcare?
5
The Institute of Medicine defines quality as:
The degree to which health care services
for individuals and populations increase
the probability of desired health
outcomes and are consistent with
current professional knowledge of best
practice."
What is Quality

6
Appropriatene
ss
Availability/Ac
cess
Continuity
Effectiveness
Efficacy
Efficiency
Prevention/Ea
rly Detection
Respect and
Caring
Safety Timeliness Competency

Healthcare quality should be STEEEP
Institute of Medicine report Crossing the
Quality Chasm
7
 Safe,
 Timely,
 Effective,
 Efficient,
 Equitable
 Patient centered

Figure out quality dimensions to your
place
8

Measurable
Quality
Three
Aspects of
Quality
Appreciative
Quality
Perceptive
Quality
Aspects of Quality
9
THREE ASPECTS OF QUALITY “MAP”

Measurable Quality
10
 Can be defined objectively as compliance with, or
adherence to standards.
 Clinically, these standards may take the form of
practice parameters or protocols, or they may
establish acceptable expectations for patient and
organizational outcomes.
 Standards serve as guidelines for excellence.

Appreciative Quality
11
 Is the comprehension and appraisal of excellence
beyond minimal standards and criteria.
 Requires the judgments of skilled, experienced
practitioners and sensitive, caring persons.
 Peer review bodies rely on the judgments of like
professionals in determining the quality or non-
quality of specific patient-practitioner interactions.

Perceptive Quality
12
 Is the degree of excellence which is perceived by the
recipient or the observer of care rather than by the
provider of care.
 Is generally based more on the degree of caring
expressed by physicians, nurses, and other staff than
on the physical environment and technical
competence.

Quality
Planning
Quality
Measurement
Quality
Improvement
Quality
Trilogy
13
Juran trilogy

Performance Improvement Project Framework
Effective team
development
and interaction
Identify
priority area
Collecting Data
And measure
performance
Assessing
performance
Taking action
for
improvement
Assessing
improvement
Sustain
Improvement
14
Use of statistical, analytical, and consensus tools at all
steps

Six Sigma
 Six Sigma® is a business strategy,
 Focusing On Continuous Improvement:
 Understanding Customer Needs,
 Analyzing Business Processes,
 And Utilizing Appropriate Performance Measures And
Statistical Methodology.
15

Six Sigma
16
• Methodology to measure organization’s
performance, practices and systems
where you are.
• Problem solving methodology for improving
business and organizational performance.
where you could be
Quality Philosophy and the way of improving performance by
knowing

Six Sigma
 The central idea behind Six Sigma is that if you can
measure how many "defects" you have in a process.
 You can systematically figure out how to eliminate them
and get as close to "zero defects" as possible.
17

A Six Sigma organization
 Uses Methods And Tools To Improve
Performance
Continuously lower costs
Grow revenue,
Increase customer satisfaction ,
Improve capacity and capability,
Reduce complexity lower cycle time and
Minimize defects and errors
18

19
SIX SIGMA METHODOLOGY
 DMAIC
 Six Sigma Improvement Methodology
 DMADV also referred to as DFSS
 Creating new process which will perform at Six Sigma

Define specific
goals to achieve
outcomes,
consistent with
customers
demand and
business
strategy
Measure
reduction of
defects
Analyze
problems
,cause and
effects must be
considered
Improve
process on
bases of
measurements
and analysis
Control process
to minimize
defects
20
WHAT IS DMAIC?

21
WHAT IS DMAIC?
 A logical and structured
approach to problem
solving and process
improvement.
 An iterative process
(continuous improvement)
 A quality tool which focus
on change management
style.

23
BENEFITS OF SIX SIGMA
 Generates sustained success
 Sets performance goal for everyone
 Enhances value for customers
 Accelerates rate of improvement
 Promotes learning across boundaries
 Executes strategic change

To achieve Six Sigma Quality, a process must produce no more
than 3.4 defects per million opportunities.
SIGMA LEVEL DEFECT RATE YIELD
1 691,500 dpmo 30.85%
2 308,770 dpmo 69.10000%
3 66,811 dpmo 99.33000%
4 6,210 dpmo 99.38000%
5 233 dpmo 99.97700%
6 3.44 dpmo 99.99966%

25
How to Calculate
Process Sigma?

How to Calculate Process Sigma?
 Step 1:
 Identify what constitutes an "opportunity" and a
"defect."
For example, in a hospital, a single administration of a
medication is an "opportunity" and delivering the wrong
drug or the wrong dose constitutes a "defect.“
In general, opportunities and defects should be black-or-
white propositions; you either succeed or fail.
26

 Step 2 :
Quantify opportunities and defects with
precision.
27

 Step 3
Calculate your yield. Subtract the number of defects
from the total number of opportunities, then divide
by the number of opportunities and express the
result as a percentage.
28

 Step 3
For example, if a hospital administered 145,250
correct doses last month and erred in 250 of them,
then the yield is 145,500 minus 250 divided by
145,500, or 99.828 percent.
29

 Step 4
 Compare your yield to the standard threshold for
six-sigma performance. To meet six sigma levels,
the yield must be greater than or equal to
99.99966 percent.
30

31
99.9997 per cent of parts close to the average value, if the average is the same as your
print spec, it essentially means “zero defects”.

 Step 5
Find : Process sigma , Substitute the given
values in the formula,
DPMO = (Total defect / Total Opportunities)
x 1000000
33

Process sigma
= 0.8406 + √(29.37)-2.221*(log(DPMO))
34

Example
Find 60 errors for 6 critical characteristics
on 20 orders in a random sample of 400
orders . Assuming there are 6
Opportunities per order (six critical
characteristics).
35

Example
The Defects per Opportunity (DPO) is
calculated as:
 Opportunities = (400 Orders * 6 Opportunities /
Order) = 2400 Opportunities
 Defects per Opportunity (DPO) = 60 Defects /
2400 Opportunities = 0.025 Defects per
Opportunity
36

Example
 DPMO = (0.025 Defects / Opportunity) *106
Opportunities / Million Opportunities = 25,000
DPMO
 This corresponds to a Sigma Level of approximately
3.45, based on Six Sigma
37

38
Define Your Project

39
Identify
Establish
Define
Your
Project
problem statement Form a Team Verify the mission
Nominate Projects Evaluate Projects Select a Project

WHO Can Nominate A Project ?
EMPLOYEES
Process Owners knows every detail and they
front line who face the customer/client/ patient
Department Head
Impact on the department ability to meet
organizational goal and objectives
Senior Management
Impact on quality throughout the entire
organization
40

41
Source Of Information to
Nominate Projects
Customer/Client/
Patient(E/I)
Complaints
Suggestions
Questionnaires
Focus groups
Tip: Give Feedback
*Logs and Indexes
*Clinical review findings, e.g.:
-Operative/other procedure
-Medical record review
-Medication use
- Pharmacy and therapeutics function
-Mortality reports - Autopsy reports
-Functional outcome status
-Variance reports, e.g., clinical paths
-Demographics/ registration data
-Infection control reports
-Patient/client records
-Blood component use

42
Source Of Information to
Nominate Projects
Monitoring Reports
(KPIs)
OVRs & Errors Reports
Ongoing quality
control/measurement
summaries
Strategic and Business
Plan of the organization
Goal
External Data Source
--Benchmarks
--Reference
databases/performance
measure systems/
compilations

Projects of significance may require
participation of several departments
= Interdisciplinary Project
43

Evaluate Project
44
 Evaluate the nominated projects against preset
criteria :
 Retaining customer
 Attracting new customers
 Reducing the cost of poor quality
 Enhancing employee satisfaction.

45
Criteria For Selecting a Project
How chronic is the problem?
The project should correct a continuing problem not a recent specific
episode.
How significant the results will be ?
When project is completed the results should be significant and evident
and worth the effort .
Measure of potential Impact?
Retain customer . Reduce cost of poor quality, ROI, enhance customer
satisfaction , enhance employee satisfaction .

46
Urgency of the problems:
-Problems make the organization highly vulnerable to the competition
-Issues crucial to key customers
All Quality Improvement Projects should be measurable.
Size :project should be of manageable size
Project time should be to long (shouldn’t take more than 12 months)

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What Kinds of resistance might the project create ?
Change normally is face by resistance .
What is the source of resistance and how to face it ?
What are the project suspected risks ?
How uncertain is the outcome?
What is your risk management plan?
Choose A project that will be a winner specially if you are at the beginning ?

48
Identify
Establish
Define
Your
Project

Prepare a Problem Statement
WHO?
Management
Seniors.
WHY?
Written
instruction to the
team selected .
What ?
The problems to
be solved
The Goal of the
project.
49

Problem Statement:
 Problem statement should quantitatively describe the
pain in the current process
 What is the pain ?
 Where is it hurting?
 When – is it current? How long it has been?
 What is the extent of the pain?
 What a Problem Statement should not do is Assign a
Cause or Blame and Include a Solution.
50

Example
 “In the last 3 months (when), 12% of our customers are late, by over 45
days in paying their bills (what) . This represents 20%
(magnitude) of our outstanding receivables & negatively affects our
operating cash flow (consequence) .”
 (when), Our ALOS (what) for total hip replacement surgery is 7 days
which is 2 days longer (magnitude) than average in the area which
affects our reimbursements' (consequence) .
51

Goal Statement
 Defines the improvement the team is seeking to
accomplish. It starts with a verb.
 It Should not presume a cause or include a solution. It has
a deadline.
 It is actionable and sets the focus. It should be SMART
(Specific, Measurable, Attainable, Relevant and Time
Bound).
52

Goal Statement Example:
 To reduce the percentage of late payments to 15% in next 3 months, and
give tangible savings of 500KUSD/ year.
 To reduce the ALOS to 6 days in next 3 months, and increase hospital
profit by 2%.
53

Project Scope:
 Project Scope helps us to understand the start and end
point for the process .
 Gives an insight on project constraints and dimensions.
It’s an attempt to define what will be covered in the project
deliverables. Scoping sharpens the focus of the project team
& sets the expectations right.
54

Selecting Project Team
 Cross Functional team .A cross-functional team is simply a team
made up of individuals from different functions or departments
within an organization.
 Teams like this are useful when you need to bring people with
different expertise together to solve a problem, or when you want
to explore a potential solution.
55

Selecting Project Team
 For example, you might put together a team made up of people
from pharmacists ,finance, engineering , and procurement to
come up with a solution to reduce the lead-time of admixture
medications .
 Representation from various departments brings a broad working
knowledge of the process to be improved , promotes acceptance
and implementation of the remedy
56

To select a Cross Functional team
 Scope of the problem :where is the problem is observed or experienced?
 Who has special knowledge, information, or skills in uncovering the
root cause of the problem ?
 Who might be helpful when developing a remedy ?
57

To build a Cross Functional team
Set Objectives
Define Roles
and Select the
Right Team
Members
Consider
Resources
and Logistics
Establish
Ways of
Working
Adopt the
Right
Leadership
Style
Negotiate and
Communicate
58

Participatory leadership style
 The TQM Leadership/Management Style.
 The leader/manager presents a tentative decision,
"draft" of an idea, or a problem to staff/team,
receives suggestions, and then makes the decision,
based on what is deemed best for the organization.
59

Stages of Team Growth
60
 Forming
 Storming
 Norming
 Performing

Team Responsibility
61
 Accept or identify improvement projects
 Investigate the cost of poor quality
 Describe the specific problems/opportunities
 Gather and analyze data
 Identify root causes
 Develop alternative processes
 Apply alternative processes and track results
 Recommend replication
 Feedback helpful experiences (lessons learned)

Project Charter
Problem
statement
Business
case
Goal
Statement
Project
Scope
Team
Members
Project
timeline
62

Project Charter Guidance
 The listed questions are for guidance and direction purposes
(although they can be answered directly)
 The listed statements/descriptions are to be completed in full
 Keep to one page to be concise & clear and to ensure focus on
the key elements
63

Project Charter Guidance
 Expect to create numerous iterations before the final version is
approved
 Do not proceed until all key stakeholders are in agreement
with the document
 Use as a high-level communication tool
 Retain during the project life-cycle and refer often to ensure
the original purpose and direction are being maintained
64

65
Project Charter Template
Business Case Problem Statement
Who is the Client (internal and/or external)?
What is the current situation?
What is the business climate and/or environment?
What is the trend?
What are the business gaps?
What are the drivers for change?
What are the Client/Market/Regulatory requirements?
What is the level of importance and/or urgency?
How does the project connect with the overall business strategy/goals?
What are the projected benefits from the change?
What is the problem?
How do you know it is a problem?
When did the problem first occur?
Where is it occurring?
What is the frequency?
What are the defects and/or areas of waste?
What are the variations?
What is the level of complexity?
What are the impacts?
What is the cost of poor quality (soft and hard)?
Goal Statement Project Scope
Who will benefit?
What is to be achieved?
How will success be measured?
Why is it important?
When are improvements required by?
In scope activities:
Out of scope activities:
Process start point:
Process end point:
Critical to quality:
Primary metric:
Consequential metric:
High-Level Timeline Stakeholders & Key Project Members
Define – Dates from/to:
Measure – Dates from/to:
Analyse – Dates from/to:
Improve – Dates from/to:
Control – Dates from/to:
Executive sponsor:
Activity/Business Line/Product sponsor/champion:
Client/Business Partner champion(s):
Project manager:
Key project team members:

VISION OF SUCCESS
PROJECT MILESTONES & SCHEDULE
RESOURCES
• Time commitment for a 4 day Kaizen, excluding time to implement changes: Sponsor (6-10 hrs.); Team Leader
(40 hrs.); Team Members (32 hrs.); Facilitator (40-50 hrs.)
• External Resources:
• Equipment:
• Materials:
< TITLE> <date>
<sponsor>
CONTEXT / ISSUES
GOALS
SCOPE (IN BOUNDS) SCOPE (OUT OF BOUNDS)
CUSTOMERS/STAKEHOL
DERS
TEAM MEMBERS
• Team Leader:
• Team Members:
CUSTOMER REQUIREMENTS (CTQ)
Project Milestones Owner Propose
d Date
Actual
Date
1. Set project scope and goals (prepare Project
Charter, engage team, collect data)
Sponsor/Team
Leader, Facilitator
2. Understand the current situation Facilitator/ Team
3. Analyze the current situation (root causes) Facilitator/ Team
4. Define a vision of success Facilitator/ Team
5. Generate, evaluate and select improvements Team/ Sponsor
6. Implement changes and make adjustments Team Leader/ Staff
7. Measure performance Sponsor/Team Leader
8. Document standard work and lessons learned Team
9. Sustain improvement Team Leader/Process
Owner

VISION OF SUCCESS
• What outcomes or results do you want to see?
• What does success look like for our customer?
• What does success look like for other stakeholders (staff, partners)?
PROJECT MILESTONES & SCHEDULE
RESOURCES
• Time commitment for a 4 day Kaizen, excluding time to implement changes:
Sponsor (6-10 hrs.); Team Leader (40 hrs.); Team Members (32 hrs.); Facilitator
(40-50 hrs.)
• External Resources:
• Equipment:
• Materials:
< TITLE> <date>
<sponsor>
CONTEXT / ISSUES
• What is the issue and why is it important to tackle now?
• What is the purpose, the business reason for choosing this project?
• What are the anticipated benefits to customers and staff from the project?
• What performance measure needs to improve?
• Have you been to the Gemba?
• What process/program/customer data do you have regarding the problem (time,
cost, quality )? Show facts and processes visually using charts, graphs, maps, etc.
• When did the problem start?
• Where is the problem occurring?
• What is the extent or magnitude of the problem?
GOALS
• What specific, measurable , attainable, relevant, time-bound results do you want or
need to accomplish?
• Show visually how much, by when, and with what impact.
• NOTE: Be careful not to state a solution as a goal!
SCOPE (IN BOUNDS)
• What is the first step and last step in
the process?
• What is the program and geographic
area?
• NOTE: Be mindful of what you can
realistically accomplish with available
resources and time.
SCOPE (OUT OF BOUNDS)
• What is off the table due to resources?
• What are the givens or assumptions for
the project?
• Record out of scope issues in a
“Parking Lot”
CUSTOMERS/STAKEHOLD
ERS
• Who is the end-user customer?
• Who are other stakeholders who have a
role or interest in the success of the
process?
TEAM MEMBERS
• Team Leader:
• Team Members:
CUSTOMER REQUIREMENTS (CTQ)
• What do customers/stakeholders expect and require from the process? What are
their critical to quality (CTQ) requirements?
• What legal requirements (laws, rules) govern the process?
Project Milestones Owner Propose
d Date
Actual
Date
1. Set project scope and goals (prepare Project
Charter, engage team, collect data)
Sponsor/Team
Leader, Facilitator
2. Understand the current situation Facilitator/ Team
3. Analyze the current situation (root causes) Facilitator/ Team
4. Define a vision of success Facilitator/ Team
5. Generate, evaluate and select improvements Team/ Sponsor
6. Implement changes and make adjustments Team Leader/ Staff
7. Measure performance Sponsor/Team Leader
8. Document standard work and lessons learned Team
9. Sustain improvement Team Leader/Process
Owner

Verify
 Most Significant problem.
 Mission statement (problem , goals statement).
 Any aspects of the problem need clarification.
 Team members are correctly selected.
 Team members understand the mission statement and known their
roles .
68

69

SIPOC Defined
SIPOC is an acronym standing for
1. S =Supplier(s)
2. I =Input(s) & key requirements
3. P =Process
4. O =Output(s) & key requirements
5. C =Customer(s)

SIPOC Diagram Defined
• A SIPOC Diagram is a visual representation of a high-level process map;
including suppliers & inputs into the process and outputs & customers of the
process
• Visually communicates the scope of a project

How can SIPOC be used?
• SIPOC Diagrams help a team and its sponsor(s) agree on project boundaries
and scope
• A SIPOC helps teams verify that
• inputs match outputs of upstream processes
• outputs match inputs of downstream processes

Suppliers Inputs Process Outputs Customers
How a SIPOC works

Step 1: Begin with the high-level process map
74
Step 1
Step 2
Step 3
Step 4

Step 2: List all of the outputs from the process
75
Step 1
Step 2
Step 3
Step 4
Examples
Services
Products
Reports
Metrics
Raw data

Step 3: Identify the customers receiving the outputs
76
Step 1
Step 2
Step 3
Step 4
Examples
Services
Products
Reports
Metrics
Raw data
Examples
Internal
External
Vendors
End users
Management
Downstream Process

Step 4: List all of the inputs into the process
77
Examples
Internal
External
Vendors
End users
Management
Downstream Process
Step 1
Step 2
Step 3
Step 4
Examples
Services
Products
Reports
Metrics
Raw data
Examples
Data
Parts
Application
Raw
materials

Step 5: Identify the suppliers of the process inputs
78
Examples
Internal
External
Vendors
End users
Management
Downstream Process
Step 1
Step 2
Step 3
Step 4
Examples
Services
Products
Reports
Metrics
Raw data
Examples
Data
Parts
Application
Raw
materials
Examples
Internal
External
Vendors
Producers
Management
Upstream Process

Voice Of Customer
Voice of the Customer (VOC) is the name used to describe a
process of communication where there is give and take to
ensure that requirements and expectations are clearly
defined, documented, and understood by all parties
involved.
79

Voice of the Customer (VOC)
VOC is often full of emotions.
We need to restate customer
statements into fact based,
performance requirements
that we need to focus on
Of course… Customers expect
perfection
• Why don’t you guys learn how to
meet a schedule?
• Your service quality to poor
• When will you learn how to provide
service and a Customer first attitude?
• Why don’t you tell us when there is a
problem?
• I sent out e-mail after e-mail with no
response!
• Why do you try and make your
customers responsible for your
quality problems?
• Your RMA frequency is unacceptable

Listen to the voice of the customer
81
Source of
information
Complaints
Customer
Representative
Sales
Representative
Billing
Source of
information
Interviews
Focus Groups
Surveys
Observations
Internal and
External Data
Industry
Experts
Secondary
Data
Competitors

82
TargetCTQsCCR’sVOC
Critical
Customer
Requireme
nt
Critical To
Quality

Example
83
Late FilmVOC TimeCCR Right
TimeCTQs
According
to
standards
Target

Dissatisfied
Feeling
Satisfied
Feeling
Physically
Fulfilled
Condition
(Need is met)
(Need is not met)
Unstated,
Expected
Quality
“Taken
for
granted”
Kano's "3 Arrow Diagram"
Must-be Quality
These attributes are taken for granted when fulfilled but result in dissatisfaction when not fulfilled

Winter 2016ECEn 490Lecture #4 85
Dissatisfied
Feeling
Satisfied
Feeling
Physically
Fulfilled
Condition
(Need is met)
(Need is not met)
Unstated,
Expected
Quality
“Competitive”
the more the better
“Taken
for
granted”
One-dimensional Quality
These attributes result in satisfaction when fulfilled and dissatisfaction when not fulfilled.

Dissatisfied
Feeling
Satisfied
Feeling
Physically
Fulfilled
Condition
(Need is met)
(Need is not met)
Unstated,
Expected
Quality
Exciting
Quality
“Surprise &
Delighters”
“Competitive”
the more the better
“Taken
for
granted”
Attractive Quality
These attributes provide satisfaction when achieved fully, but do not cause dissatisfaction when not fulfilled

Dissatisfied
Feeling
Satisfied
Feeling
Physically
Fulfilled
Condition
(Need is met)
(Need is not met)
Unstated,
Expected
Quality
What was
exciting
yesterday
becomes
expected
tomorrow

Kano Customer Need Model
Dis-satisfiers Those needs that are EXPECTED in a product or service.
These are generally not stated by customers but are assumed
as given. If they are not present, the customer is dissatisfied.
Satisfiers Needs that customers SAY THEY WANT. Fulfilling these needs
creates satisfaction.
Exciters /
Delighters
New or Innovative features that customers do not expect. The
presence of such unexpected features leads to high
perceptions of quality.

Summary of define phase
89

90
Measure The Problem

Measure
Measurement is critical.
 Determine how the process currently performs:
Value Stream Mapping/Process Mapping
 Create a plan to collect the data:
Data Collection Plan
91

92
Process Mapping Symbols
Symbol Name Brief Definition
Operation or
process step
Decision Point
Document
Generated
Continuation
Point
Input/Output
Block
Flow lines
Depending on the level of detail being developed,
can be used to denote anything from a simple task,
major activity or a whole sub-processes.
Used to indicate the process is continued
elsewhere on the flow diagram or on another sheet.
Point at which a form or report is generated
by the process.
Point where a decision must be made before
any further action can be taken.
Optionally used to describe an input or output
from a processing block.
Use to connect all blocks to display the
sequence in which operations are performed.
Termination
point
Used to indicate the start and end of a process.

93
Flowchart
Use when:
 Identifying and describing a current process
 Questioning whether there is a process
 Questioning whether actual process meets current policy/procedure
 Analyzing problems to determine causes
 Redesigning the process as part of the action
 Designing a new process

94
Linear Flowchart Example
Yes
A
Start
Collect
inputs
Draft POD
Type rough
Submit to XO
OK ?
Retype POD
No
Type
smooth
Sign POD
Make copies
Distribute
End
AProducing
the “Plan of
the Day”

95
Levels of Flowcharts
Start
End
Draft
POD
Type
POD
Distribute
POD
Start
Get rough
draft of POD
Is it
approved
?
Type
smooth
Get
approval
End
Turn on
computer
Start word
proc. apply.
Is
rough in
word proc.
apply.
?
Type
rough POD
Edit POD
Are
there any
corrections
?
Make
corrections
Print POD
No
Yes
Yes
No
No
Yes
MACRO MINI MICRO

96
Flowchart
 Steps:
 Determine the boundaries (the start and stop points) of the process under
review.
 Brainstorm to identify all activities and decision points in the process;
 Place all activities and decision points in sequence, paying attention to seeming
repetitions, disconnection's, etc.;
Cont..

97
Flowchart
 Design the flowchart, placing:
 each activity in a box (square or rectangle)
 each decision in a diamond,
 ovals or circles for the start and stop points,
 connecting arrows indicating the flow.
 If there is more than one "output" arrow from an activity box, it probably
requires a decision diamond;
Cont...

98
Flowchart
 Analyze the flowchart, looking for process "glitches": inefficiencies,
omissions/gaps, redundancies, barriers, etc.
 Also look for the smooth parts of the process to use as models or
"best practices" for improvement;
 Decide whether to correct steps within the current process, design
a new process, or do corrections first, then redesign in the future.

99
Interpreting a Flowchart
 Step 1 - Examine each process step
Bottlenecks? Poorly defined steps? Ineffective sequence? Delays? Weak
links?
 Step 2 - Examine each decision symbol
Can this step be eliminated?
 Step 3 - Examine each rework loop
Can it be shortened or eliminated?
 Step 4 - Examine each activity symbol
Does the step add value for the end-user?

100
A
Yes No
Yes
No
Yes
No
NoYesYes
No
Yes
NoFirst drill
in set?
A
Inform the drill
leader and improvise
Props?
Search
Torpedo Room
Radios
still not
available
?
Borrow from
Quartermasters
Check with
Radiomen
Radios
available?
Props
available?
Enough
red hats?
Drill monitors
test the radios
Monitors go to Logroom to get red
hats, radios, and drill props
Complete the
Drill Brief
Drill monitors
take station
Search the
boat for
red hats
No
No
Yes
Yes
Discrepancy?
All
personnel
on station
?
Correct it
Put simulation
on the
appropriate
gages
Drill leaders walk
around to ensure
all monitors are
on station
Spot check safety
intervention points
Order initial
conditions set
Find them
and put them
on station
Fire Drill Preparation Flowchart

Data Collection Process
Dr.Doaa Hussein MBA,CPHQ,DTQM,HRM,CPT,APD
• Define data elements;
• Determine data collection plan;

Sampling
Purposes:
 To measure only a portion of a total group or
population, such as for high volume aspects of
care and service;
 To achieve accurate representation of the
entire target population, such as all
ambulatory patients; a specific procedure,
diagnosis, or DRG; or all cardiologists;
 To generalize the results to the larger
population based on sample findings.

Non-probability Sampling
 An intentionally-biased way to sample, involving
qualitative judgment about an issue that is suspected to be
common or widespread.
 Examination of relatively few cases is assumed to be
enough to reveal the nature of any problem and its
probable causes.
 This methodology does not include techniques to estimate
the probability that each case will be included,
 The results cannot be generalized to the entire population
without further study.

Types of non-probability sampling
 Convenience:
 Using data most readily available, e.g., all patients seen
in the ED in a given week.
 Quota:
 Portions or percentages of persons/cases in a stratified
population (subset), e.g., 10% of male patients with
diabetes and heart disease over age 55.
 Purposive:
 Persons/cases/issues selected because they
demonstrate a desired characteristic and can be
measured against specific, predetermined criteria, e.g.,
all patients over age 60 with total hip replacements
Dr.Doaa Hussein
MBA,CPHQ,DTQM,HRM,CPT,APD

Probability sampling:
Introducing statistical techniques into the selection process,
thus permitting the reviewer to draw inferences about a
population. It assures that each case in the population has an
equal and independent (random) chance of being selected and
is, therefore, truly "representative" of the entire population
being sampled.

Types of Probability Sampling
 Simple random:
Using a Table of Random Digits (available in all statistical
software) to select the persons/cases from a list of every
case in the defined population.
 Stratified random:
Creating 2 or more homogeneous categories or
dimensions of a population and selecting an
appropriate number of persons/cases that are
representative of the whole. Patients with IVs in home
care might be sampled by diagnosis,type of solution, or
with and without complications.

Types of Probability Sampling
 Systematic random:
 Randomly selecting the first case and then selecting
every nth case thereafter based on standard/fixed
intervals, e.g., every 5th referral to a specialist by a
primary care physician in an HMO after random
selection of the first case.
 Multistage random
 In large studies, sampling could be done in stages, a
sample is drawn from each stage randomly.

Sampling
 Sample Size & Effect Size
 Sampling error
 Consequences

Joint Commission general guidelines for sampling:
These sample sizes for these populations (total cases meeting
criteria) are considered statistically significant and can be
applied to measurement activities for the specified time period,
e.g., monthly, quarterly:
Population Size Sample Size

Sampling strategy
 The characteristics of the population that the sample must
represent;
 The location and time period from which the sample must be
drawn;
 The type of sampling technique that will assure that the sample
accurately represents the population;
 The selection of a sample that will not introduce a bias

DATA COLLECTION TOOLS
Keep the tool as short and simple as possible;
 Include all data elements necessary to monitor the
specified issue/indicator;
 Consider computerizing whenever feasible;
 Provide appropriate definition of terms
 key for using the tool.

Types of Data Collection Tools
 Data Sheet or Work Sheet: Form for recording data; requires
subsequent processing for analysis and interpretation;

Check sheet: Form for recording data; designed to facilitate interpretation
directly from form;

 Interview or Focus Group: Questionnaire
format; can be open-ended discussion to obtain
input from people;

 Download: Automated retrieval from a computerized data source.

Surveys
Surveys are methods by which we can measure customer satisfaction, get
feedback on written materials and oral presentations.

How to Develop a Survey
 Know your audience
 Remember who will be answering your survey and imagine how
they might interpret the questions you are asking.
 KISS (Keep It Short and Simple), People tend not to answer
lengthy surveys.
 Be direct. Ask exactly what you want to know.
 Make your statements or questions neutral. If you state your
question in a negative manner, you may be swaying the
respondent.

Measuring Effectiveness Of The Tool
Checklist for adequacy of the tool:
 Does the tool really measure the process or aspect of care
and its indicator?
 Will you get the information you really need?
 Will you get more than you need?
 Will the data you get be interpretable? Will it help to
gather other data to facilitate interpretation, e.g., age,
weight, secondary diagnosis, etc.?
 Too much time? Can it be cut down?

119
Analyze Phase

Analyze phase
 Having completed the Measure phase, the project team should have
already established a clear problem statement which specifies what the
problem is and under what circumstances it occurs.
 They should have already gathered and analyzed data to establish the
baseline performance of the process, relative to the Critical To Quality
measures (CTQs) established based on customer input.
120

Analyze phase seeks
The question that the Analyze phase seeks to answer is
“Why is this problem occurring?“
Another way to ask it is,
“What is the cause of the problem?“
It is not possible to make improvements to the process until the causal
factors are identified.
121

ANALZE PHASE
 1- Data Analysis : Analyzing data relative to a particular project.
 2-Root Cause Analysis: The other is that the goal of Analyze is to
determine root causes, which requires digging deeper than what is
apparent on the surface.
122

Steps in DATA Analyze
1. Define your performance objectives.
2. Identify independent variables (X’s).
3. Analyzing Sources of Variation : The goal of this step is
to use visual and statistical tools to better understand the
relationships between dependent and independent variables
(X’s and Y’s).

Process variation
 Process variation can be classified as Variation for a period of Time and
Variation Over Time.
 Variation for a period of time can be defined for discrete and continuous
data types as below :
Discrete Data: Bar Diagram, Pie Chart, Pareto Chart
Continuous Data: Histogram, Box Plot, Run Chart, Control
Chart.
124

Tools for Analyzing Sources of Variation
Scatter Diagram
• To correlate variables
A bar diagram is a graphical representation of attribute data.
It is constructed by placing the attribute values on the
horizontal axis of a graph and the counts on the vertical axis.
Pie Chart
• Illustrate numerical proportion
125

Tools for Analyzing Sources of Variation:
Histogram
A histogram is a graphical representation of numerical data. It is
constructed by placing the class intervals on the horizontal axis of a graph
and the frequencies on the vertical axis.
126

Cause and Effect Diagram / Fish Bone Diagram /
Ishikawa Diagram:
 This is a visual tool used to brainstorm the probable causes for a
particular effect to occur. Effect or the problem is analogously captured
as the head of the fish and thus the name. The causes for this effect or
problem is generated through team brainstorming and are captured
along the bones of the fish. The causes generated in the brainstorming
exercises by the team will depend on how closely the team is related to
the problem.
127

Potential Root Causes
1-Cause and Effect Diagram / Fish Bone Diagram / Ishikawa Diagram.
2- Pareto Charts
128

Cause and Effect Diagram / Fish Bone Diagram /
Ishikawa Diagram:
129

The potential causes could be due to any of the 6(M's) , 8
(P's), & 4 (S's)
 6M's - Machines, method, material, maintenance, man & mother nature
 8P's - Price, promotion, people, process, place, policy, procedure,
product
 4S's -Surrounding, suppliers, systems, skills
130

HIGH TAT
131

Pareto Chart:
A data display tool for numerical data that breaks down discrete
observations into separate categories for the purpose of identifying the
"vital few".
132

Wrapping Up the Analyze Phase
At the end of the Analyze phase, the project team should have at
least one confirmed hypothesis regarding the root causes of the
problem the project aims to resolve. Once the root cause is known,
action can be taken in the Improve phase to counter it.
133

134
IMPROVE

Objectives of Improve Phase
The goal of the DMAIC Improve phase is to identify a solution to the
problem that the project aims to address. This involves brainstorming
potential solutions, selection solutions to test and evaluating the results
of the implemented solutions. Often a pilot implementation is conducted
prior to a full-scale rollout of improvements.
135

Identifying Potential Solutions
 In the first stage of Improve it is important to include the
people who are involved in performing the process. Their input
regarding potential improvements is critical, and this step
should not be completed by the project team alone.
 A variety of techniques are used to brainstorm potential
solutions to counter the root cause(s) identified in Analyze.
136

Identifying Potential Solutions
Brainstorming
• Create as
many ideas
as possible
in as short a
time as
possible
Lotus
Diagrams
• A tool to
expand
thinking
around a
single topic
Affinity
Diagram
• organize
large
volumes of
ideas or
issues into
major
categories.
137

Organizing Ideas
Lotus Diagram Affinity Diagram
138

Selection between alternatives
139
 The goal of this step is to determine the appropriate solutions to
implement using objective means, rather than making a decision based
on assumptions or preferences.
 This is a common theme throughout the Six Sigma methodology.
Prioritization Matrix Selection Grids can be used to help in decision making.

Selection between alternatives
Prioritization Matrix Selection Grids
140
 A Prioritization matrix
is a tool used to select
one option from a group
of alternatives, be they
problems or solutions.
 It promotes objective
decision making.

141
Prioritization Matrix
 Steps:
 Limit the list of options (of problems or solutions) to no more
than eight (8);
 Select the criteria against which each option will be rated, stated
in either positive or negative terms, but not both;
 Determine the weight (relative value) of each criterion; perhaps
some are more important to meet than others;
 Determine the desired score, what number of criteria must be
met, etc. for the option to remain under consideration;
 the matrix with options down the left side and criteria/total score
column across the top.

Implementing Improvements
 Planning the implementation is largely a matter of basic project
management. The team needs to plan the budget and time line of the
implementation, determine roles and responsibilities, and assign and
track tasks.
 Tools for planning include gantt charts, action plans and flowcharts. A
deployment flowchart can be created for the implementation process
itself, as well as for the new process that will be followed as a result of
the improvements being implemented.
142

143
Action Planning
 Once the team selects a solution, an action plan need to be
developed.
 Action plans at a minimum identifies:
 what to be done? (deliverables)
 How a certain task will be done?(Implementation Strategies)
 who will do it?( Responsible person)
 Time Frame (due date)
 A mean of verification that a certain task has been done (target , KPI).
what to be done?
(deliverables)
Implementation
Strategies
Responsible
person
Due Date Evaluation

GANTT CHART
 Definition: A Gantt chart is a project-planning tool for developing
schedules; a graphic display—a type of bar chart—of the individual parts of a
quality improvement process as bars on a horizontal time scale.
 The Gantt chart includes a list of tasks (process steps) and estimates of time
and people resources required to complete the quality improvement effort.
 Most project-planning software includes Gantt charts.
144

145
Gantt Chart
1 2 3 4 5 6 7 8 9 10
1-
2-
3-
Responsibility Resources
Month or
WeeksList of Tasks
Goal:………………………………….

Pilot The selected solution
The most common piloting options include either making changes only in
one group or department or making changes for a limited time period.
The benefit of a pilot test is that the project team can ensure the changes
result in the desired improvements before a full roll out. In addition, the
team can gain insights to allow a more effective implementation during
the full roll out.
146

Improve: Implement and Check
 Verify effectiveness by checking current performance against original
baselines;
 Apply statistical comparative methods if necessary.
Before Pareto Chart After Pareto Chart

Wrapping Up the Improve Phase
 By the end of the Improve phase, the project team has demonstrated
that the solutions implemented do in fact counter the identified root
causes and thus result in substantial improvement in the CTQ metrics.
 The new process is in place and the team is ready to create a plan to
maintain the gains and close out the project.
148

149
Control Achieved Improvement

© Max Zornada (2005)Slide 150
Control
 Standardise the solution by making it part of the standard procedure for
the process;
 Update the performance measurement scorecard for the process;
 Implement control charts;
 Document the project.
 Share and celebrate your success.
 Ensure the process is being managed and monitored properly.
 Continuously improve the process.
 Apply new knowledge to other processes in your organization.

Wrapping Up the Control Phase
 By the end of the Control phase, the project team has
successfully
 Standardized and documented the new process,
 Created training and reference materials and established a plan
for ongoing process monitoring.
 The improvements are fully established and a plan exists for
updating the process in response to changes in the environment.
 The team is now ready to close out their six sigma dmaic project
and hand the process off to the process owner.
151

Closing Out the Project
 The five phases of DMAIC have been completed. The Six Sigma project
team has:
 Established the customer requirement (CTQ)
 Measured the process against that requirement
 Clarified the problem that had to be addressed
 Confirmed one or more root causes of that problem
 Identified one or more solutions to counter the root causes
 Demonstrated that the solutions implemented result in substantial
improvement in the CTQ metrics
 Rolled out the new process
152

153

© Max Zornada (2005)Slide 154
Future Plans
 Review the previous non-pareto causes to see which ones have
upgraded themselves and assess whether these are worth going after;
 Review any obvious opportunities to apply the solution in other areas;
 Communicate the solution to other parts of the organisation where it
may also apply;
 Review and document lessons learnt and institutionalise the learning.

156

DMAIC Improvement Approach

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