Title of Paper Your name HCA375– Continuous Quality Monitoring and Accreditation Type Instructor Name Here Type Date HCA375 - WEEK 4 ASSIGNMENT PART 1 – DETAIL OF THE ADVERSE EVENT CHOSEN Refer to the instructions in the Week 4 Assignment of your online course to understand what is expected in each row. This completed template should be between eight to ten pages in length. Include APA citations within the description row where appropriate. List your references in APA format according to the Ashford Writing Center guidelines on the last page of this template. CONTENT DESCRIPTION ADVERSE EVENT HISTORICAL BACKGROUND LEGAL & ACCREDITING AGENCY REQUIREMENTS CQI TEAM COMMUNICATION OPERATIONAL OR SAFETY PROCESSES IMPACT OF THIS EVENT WEEK 4 ASSIGNMENT PART 2 - GRAPH THE DATA You are tasked with graphing the data in Excel for your chosen event. The data is located in the classroom under the Week 4 Assignment Directions. Make sure to use only the data for your chosen event. The directions identify which columns of information to use depending on the chosen adverse event. Once you complete the graph in Excel, copy/paste your graph below. Include an analysis of the data in paragraph format. Discuss the frequency of the adverse event as compared to the increase or decrease of patient discharges. What is the data telling you? What possible factors in your opinion could be attributed to the change? WEEK 4 ASSIGNMENT PART 3 – CQI TOOL · Choose one of the CQI Tools listed below to illustrate the use of the tool with your chosen Adverse Event. · You will be responsible for creating the CQI Tool, completing the tool, taking a screenshot, and copying/pasting the screenshot into the space below. If you are unfamiliar with these tools, please refer to the recommended readings, specifically the article from Week 2, which is listed below. You can locate the article in the Ashford Library. · In addition, as a learning resource, the CQI tools listed below are hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates examples of each type of tool. Siriwardena, A. (2009). Using quality improvement methods for evaluating health care. Quality in Primary Care, 17(3), 155-159. ISSN: 1479-1072 PMID: 19622265 · Choose a CQI Tool that best suits your chosen Adverse Event from the following list. · Fishbone (Cause and Effect) Diagram · Flowchart · Pareto Diagram WEEK 4 ASSIGNMENT PART 4 - FUTURE PREVENTION APPLYING PDSA - Worksheet PHASE PHASE ACTIVITIES EXPLANATION PLAN Problem Objective Team members Communication Data collected Pilot phase DO Three possible solutions One solution to implement Result of pilot (create own scenario) Methods of communication STUDY Summarize data Observations and problems Comparison of pilot plan to pilot results Revisions needed to meet objective ACT Revised improvement plan How to Implement the plan hospital wide Plan for monitoring the improvemen ...

1. Title of Paper
Your name
HCA375– Continuous Quality Monitoring and Accreditation
Type Instructor Name Here
Type Date
HCA375 - WEEK 4 ASSIGNMENT
PART 1 – DETAIL OF THE ADVERSE EVENT CHOSEN
Refer to the instructions in the Week 4 Assignment of your
online course to understand what is expected in each row. This
completed template should be between eight to ten pages in
length. Include APA citations within the description row where
appropriate. List your references in APA format according to
the Ashford Writing Center guidelines on the last page of this
template.
CONTENT
DESCRIPTION
ADVERSE EVENT
HISTORICAL BACKGROUND
LEGAL & ACCREDITING AGENCY REQUIREMENTS
CQI TEAM COMMUNICATION
OPERATIONAL OR SAFETY PROCESSES

2. IMPACT OF THIS EVENT
WEEK 4 ASSIGNMENT
PART 2 - GRAPH THE DATA
You are tasked with graphing the data in Excel for your chosen
event. The data is located in the classroom under the Week 4
Assignment Directions. Make sure to use only the data for your
chosen event. The directions identify which columns of
information to use depending on the chosen adverse event.
Once you complete the graph in Excel, copy/paste your graph
below.
Include an analysis of the data in paragraph format.
Discuss the frequency of the adverse event as compared to the
increase or decrease of patient discharges.
What is the data telling you?
What possible factors in your opinion could be attributed to the
change?
WEEK 4 ASSIGNMENT
PART 3 – CQI TOOL
· Choose one of the CQI Tools listed below to illustrate the use
of the tool with your chosen Adverse Event.
· You will be responsible for creating the CQI Tool, completing
the tool, taking a screenshot, and copying/pasting the screenshot
into the space below. If you are unfamiliar with these tools,
please refer to the recommended readings, specifically the
article from Week 2, which is listed below. You can locate the
article in the Ashford Library.

3. · In addition, as a learning resource, the CQI tools listed below
are hyperlinked to the Institute for Health Care Improvement
website, which discusses and illustrates examples of each type
of tool.
Siriwardena, A. (2009). Using quality improvement methods for
evaluating health care. Quality in Primary Care, 17(3), 155-159.
ISSN: 1479-1072 PMID: 19622265
· Choose a CQI Tool that best suits your chosen Adverse Event
from the following list.
· Fishbone (Cause and Effect) Diagram
· Flowchart
· Pareto Diagram
WEEK 4 ASSIGNMENT
PART 4 - FUTURE PREVENTION
APPLYING PDSA - Worksheet
PHASE
PHASE ACTIVITIES
EXPLANATION
PLAN
Problem
Objective
Team members
Communication
Data collected
Pilot phase
DO

4. Three possible solutions
One solution to implement
Result of pilot (create own scenario)
Methods of communication
STUDY
Summarize data
Observations and problems
Comparison of pilot plan to pilot results
Revisions needed to meet objective
ACT
Revised improvement plan
How to Implement the plan hospital wide
Plan for monitoring the improvement plan
Checks and balance
References
Excluding your textbook or course readings include at least four
scholarly sources in addition to the course text. The sources
should be peer-reviewed sources; that were published within the
past five years. All references must be cited within the rows
where the referenced material was used to support your ideas.
The citations and references must be in APA format per the 6th
edition guidelines, which can be found at the Ashford Writing
Center.
These examples are correctly-formatted references. Note that
they are in alphabetical order. You may NOT use these
examples as your sources.

5. 223
What is Special Education? 1
iStockphoto/Thinkstock
Pre-Test
1. You can use the terms disability and handicap
interchangeably. T/F
2. The history of special education began in Europe. T/F
3. The first American legislation that protected students with
disabilities was passed in the 1950s. T/F
4. All students with disabilities should be educated in special
education classrooms. T/F
5. Special education law is constantly reinterpreted. T/F
Answers can be found at the end of the chapter.
8Real-World Aspects
of Quality Improvement
iStock/Thinkstock
Learning Objectives
After reading this chapter, you should be able to do the
following:
• Summarize the impacts—economic, sociological, safety, and
ethical—that a quality improvement
project can have on an organization.
• Relate the importance of communication and teamwork to a
quality improvement project.

6. • Examine the ways that organizations can help their employees
adapt to change and why this is
critical in quality improvement.
• Contrast how continuous PDSA is used in quality
improvement with other methods described in
the book.
• Evaluate the principles of continuous quality improvement
(CQI) and its importance in healthcare.
• Describe the role that social media can play in quality
improvement.
fin81226_08_c08_223-246.indd 223 10/30/14 7:30 PM
Section 8.1 Decision-Making Considerations
Introduction
Quality improvement is a science that involves close
examination of practical concepts that
can be widely applied. Much like building a house, quality
improvement requires pre- and
post-project stages. Every quality improvement project,
regardless of scope, will require some
investment of time and resources. Just as a contractor would do,
a quality improvement team
must consider whether available resources are sufficient to
complete the proposed project
scope and timeline. If the scope is too expansive or the timeline
is insufficient, the project
may be doomed to fail before it starts. It is also important to
consider the sociologic impacts

7. and safety issues ahead of time, much like a contractor would
do. Thus, a great deal of pre-
planning must occur to ensure quality improvement project
success.
In the post-project stage, quality improvement efforts must be
ongoing to ensure long-term
sustainability of gains achieved. This is part of an
organization’s continuous quality improve-
ment program. When building a house, a contractor cannot walk
away as soon the home is
constructed. There are tests and several rounds of walk-throughs
with code inspectors to
ensure everything is in working order and up to city standards.
The same principle can be
applied to quality improvement. There should be continuous
monitoring of progress and fine-
tuning of quality even after desired improvements are put in
place.
Lastly, even after a home is sold and occupied it is possible that
additional issues (i.e., plumb-
ing, electrical) may arise over the long term, prompting the
need for additional attention.
These types of issues are bound to occur over the lifetime of
any home and a contractor would
need to revisit the situation and help resolve it. The same is true
of quality improvement
efforts in healthcare organizations. The task of quality
improvement never really ends and
remains a continuous process over the lifetime of the
organization as its members strive for
effective, efficient, safe, patient-centered care. This chapter
will review some of the pre- and
post-planning efforts that must be part of every quality
improvement effort.

8. 8.1 Decision-Making Considerations
Quality improvement efforts are intended to lead to change and
significantly impact the day-
to-day operations and interactions in a healthcare setting. This
includes the obvious and
intended effects of improving a current process or service, but it
is also important to con-
sider the spillover effects, which are less obvious and possibly
unintended impacts from a
sociologic, economic, or safety viewpoint. Prior to embarking
on a new quality improvement
initiative, it is important for the team to closely consider the
risks and benefits of proposed
changes, which are unique to each project.
There are a number of decision-making models that healthcare
organizations can use. One is
a 10-step process that includes the following steps (Hammond,
Keeney, & Raifa, 1999):
1. Identify problems. Collect and analyze facts of what, where,
when, how, who, and
why (i.e., 6Ws). Describe the impact of a do-nothing approach.
Quantify priority and
impact of the problem using decision support information.
fin81226_08_c08_223-246.indd 224 10/30/14 7:30 PM
Section 8.1 Decision-Making Considerations
Stockbyte/Thinkstock
Cost effective means demonstrating that a

9. substantial improvement can be achieved relative
to the associated cost or with little costs, such as
using trained nurses, instead of pharmacists, who
will call to remind patients about the importance of
medication compliance.
2. Define objectives. Prioritize potential for improvement in
qualitative and quantitative
terms. Determine 6Ws. Make them realistic, understandable,
measurable, behav-
ioral, and achievable (RUMBA).
3. Identify alternatives. Be creative and exhaustive. Define the
6Ws and the contribu-
tions to the objectives. Consider benchmarking or comparison to
another business
entity. Consider economic and legal implications. Define costs
and feasibility of each
alternative, using decision support information.
4. Understand consequences. Clearly understand the pros and
cons of each alterna-
tive identified. Decision support systems may help with micro
simulation and mock
scenario outcomes. Establish potential implementation and
problem solving time
frames.
5. Assess tradeoffs. Determine the give and take of decision
making. Identify the win-
ners and losers in a decision process.
6. Clarify uncertainty. Identify the possibilities of changes in
the basis of which a deci-
sion was made. Decision support systems to identify “what if ”
scenarios may help.

10. 7. Identify risk tolerance. Determine the amount of, or
willingness to take, risks. Avoid
common pitfalls of decision making. Try to share risk or seek
risk-reducing decision
support information.
8. Consider linked decisions. Consider how one decision may
affect other decisions or
require other decisions to be made. Look at the problem history
or healthcare trends
that may affect the process.
9. Evaluate and choose an alternative. Based on steps 2 through
8, it must remedy the
problem and remain consistent with mission statements,
philosophy, and organiza-
tional policies.
10. Implement the decision. Follow up on the results and degree
of goal achievement.
Reorganize, reverse, replace, or revise any lack of problem
solution. Hold your gains.
Economic Impacts
Economic impacts of quality improve-
ment projects are important to appre-
ciate in current times. Rising medical
costs remain a national concern and
many healthcare organizations are
struggling to decrease medical costs
of care (Porter & Lee, 2013). Thus, the
quest to improve quality in healthcare
must go hand-in-hand with consider-
ation of all associated costs.

11. For feasibility and sustainability over
the long term, a quality improvement
project must either be cost saving
or cost effective. Cost saving means
demonstrating that money can be
saved over the long term. Cost effec-
tive means demonstrating that a sub-
stantial improvement can be achieved
relative to the associated cost or with
fin81226_08_c08_223-246.indd 225 10/30/14 7:30 PM
Section 8.1 Decision-Making Considerations
little costs. For example, one way to determine whether a
quality improvement initiative is
cost effective is to weigh the expected gain against the
associated cost. For example, one way
for a nursing home to help prevent resident falls is to install a
new lighting system for all
bathrooms that automatically turns on when the door is opened.
Purchasing the lighting sys-
tem will cost money, but will make the facility safer for
residents. On the other hand, hiring
a round-the-clock monitor for each patient at risk for falls is
expensive and not sustainable
over the long-term. Consider an example in an outpatient
medical clinic where the goal is
to improve blood pressure control among patients with high
blood pressure or hyperten-
sion. It’s estimated that 67 million Americans have high blood
pressure and only half of them
have their condition under control (CDC, 2014a). Yet high
blood pressure contributes to over

12. 360,000 deaths each year in the United States. The National
Committee for Quality Assurance
(NCQA) developed Healthcare Effectiveness Data and
Information Set (HEDIS) to measure the
performance in care and service of health insurance plans and
included a measure to deter-
mine whether blood pressure is controlled in patients ages 18 to
65 with a diagnosis of hyper-
tension. According to a February 2014 report, only 64% of adult
patients with diagnosed high
blood pressure who are enrolled in HEDIS-reporting health
plans had documentation that
their blood pressure was controlled (CDC, 2014b). It is no
wonder that healthcare organiza-
tions are working to improve. An outpatient medical clinic’s
quality improvement team may
consider a variety of initiatives but may not have the resources
to implement more than one
initiative per year. Choosing the measure that would have the
most impact on patient health
and at the same time be the most cost effective initiative would
be one way to decide among
the list of possible interventions.
One intervention that has shown promise is involving nurses or
pharmacists to follow up
with patients on their treatment plans. For example, pharmacists
at the medical clinic may
call patients to remind them of the importance of taking their
high blood pressure medica-
tion. This may prompt more patients to take their medication as
prescribed, but it comes with
added costs of hiring and maintaining pharmacists in the clinic.
Pharmacists typically com-
mand high salaries. Therefore, the clinic may consider less
costly options: training individu-

13. als with a different medical degree and with enough medical
background to review medica-
tions, such as nurses, or automating the process by using
recorded messages or sending text
messages.
Nurses, for example, could make the same type of reminder
phone call, but at a lower wage
than pharmacists, which would be more cost effective.
Therefore, if both options were thought
to improve blood pressure control and medication compliance to
a similar degree, it would be
most logical to choose the more cost-effective method.
In summary, some key questions regarding economic issues
include:
• What is the cost of proposed change(s)?
• Does the cost change over time?
• Is there a way to lower cost while achieving the same
outcome?
• Is this change cost effective or cost saving while achieving the
same outcome?
In order to answer these questions, it is important to have a
budget and detailed overview of
project finances as a team is making decisions. Examples of
items that must be included in a
budget are costs for salaries, training, IT/computer systems, and
supplies/materials needed
fin81226_08_c08_223-246.indd 226 10/30/14 7:30 PM
Section 8.1 Decision-Making Considerations

14. to support proposed quality improvement changes. As noted in
Chapter 7, many quality
improvement teams in large healthcare organizations include
financial analysts to help with
these types of decisions.
Sociologic Impacts
In addition to economic impacts, it is also important to consider
the sociologic impact of qual-
ity improvement initiatives. Examples of sociologic effects
include how proposed changes
might affect the culture of the organization, the well-being and
satisfaction of staff, and the
interaction among staff members. A particular solution,
although improving a process or ser-
vice, can have a negative impact on staff satisfaction or well-
being.
Consider an example in an outpatient medical clinic where the
goal is to improve patient wait
times. A proposed change could include increasing the work
hours of the clinic physicians
by adding mandatory weekend shifts. Clinic staff may prefer the
traditional Monday through
Friday hours and resent being forced to work on weekends,
leading to unanticipated negative
impacts, such as poor morale. This may result in increased
conflict in the work setting (i.e.,
if there is disagreement on coverage of holiday shifts) or
increased staff turnover. Ironically,
this could also negatively impact patient wait times if the clinic
were to become short-staffed
because of turnover. Thus, it is important to consider the social
impact of proposed changes
over the short and long term.

15. Another example of sociologic impact may involve the need to
eliminate employee jobs while
making a process more efficient. If a process is automated, then
the number of employees
required to complete the work may be reduced. This reduction
may lead to cost savings and
increased efficiency but can significantly impact the social
system, or group of employees,
within the organization. Will other employees fear for their
jobs? Will they resent managers
for laying off their colleagues? Will they feel the hospital
administration cares only about
money and not its workers?
Safety and Ethical Issues
In addition to economic and sociologic impacts, it is critical
that quality improvement teams
closely consider safety and ethical issues prior to initiating
proposed changes. This is particu-
larly true in healthcare systems where patients’ lives are at risk.
Consider the previous exam-
ple in which physician work hours are increased to reduce
patient wait times. If physician
work hours are increased so much that they become more
fatigued and work continuously
without intermittent days off, the likelihood of medical errors
may increase. Thus, it would be
important to consider how physician hours can be increased
within reason, or alternatively, if
new physicians can be hired to cover the additional after-hours
or weekend shifts.
Additional examples of safety issues could include:
• Safe deployment of new systems: a new automated medication

16. order entry system
would need additional checks in place before it can go live
through a health system.
• Data security issues: ensuring patient privacy is of utmost
concern and will have
legal implications if data is not properly stored and transmitted.
fin81226_08_c08_223-246.indd 227 10/30/14 7:30 PM
Section 8.1 Decision-Making Considerations
The consideration of ethical issues is also important to keep in
mind when conducting quality
improvement work. Ethical issues focus on moral behavior and
concepts of right and wrong.
For example, ethical concerns can arise when quality
improvement efforts result in any of the
following: 1) harm to patients, staff, or resources; 2) unfair or
inequitable care (i.e., a certain
group or type of patients receiving benefit over others); or 3) an
increase in the self-interest
of the healthcare provider or organization (as opposed to the
interest of the patients) (Nelson
& Gardent, 2008). Most large healthcare organizations have an
institutional review board
(IRB) or an ethics committee that can resolve any potential
ethical issues or concerns that
may arise (Nelson & Gardent, 2008).
Quality improvement does not occur in a vacuum. It is
important that both anticipated and
unanticipated ramifications of proposed changes are considered.
The risks versus the ben-

17. efits of each potential initiative must be weighed carefully so
that quality improvement teams
can identify the most appropriate initiative.
The Patient Voice
An emphasis on patient-centered care, or care that is focused on
the needs of the patient,
and a decision-making process that involves patients and
families, is also important (Barry &
Edgman-Levitan, 2012).
In almost all instances, having the patient voice included in the
decision-making process
helps ensure that proposed initiatives are appropriate. Patients
bring a unique and critical
perspective to the decision-making process because they
ultimately have the most at stake
when healthcare organizations consider change. In many
hospitals, patient advisory boards
are used to guide quality improvement work. Patient volunteers
can also be part of a quality
improvement project team.
Consider, for example, a pediatric unit that provides care to
very ill children. There is a great
deal of anxiety that parents feel when their child is admitted to
a hospital. Physicians and
nurses are aware of this, but parents who have had ill children
have lived through the experi-
ence and may be in the best position to suggest areas for needed
improvement. The input of
parents can guide hospital staff as they think through issues
such as facilitating the admis-
sion process and decreasing the anxiety parents experience. The
overall goal of ensuring
higher quality care is one of the main areas of emphasis in

18. patient-centered care.
Patient-centered healthcare organizations are adopting various
practices to respond to the
needs and preferences expressed by patients and their families.
The idea of a patient-centered
culture is to try to satisfy what patients are looking for in their
healthcare experience.
One component is the environment of care itself. Patients often
enter the doors of a healthcare
facility with heightened feelings of stress, anxiety, and
vulnerability. What they find inside can
help allay or exacerbate those emotions. Is there a desk manned
by a friendly person who can
direct them to the laboratory or mammography center? Is the
facility clean and safe? Does the
physical arrangement help guard patient privacy?
Take, for instance, the fact that many patient-centered hospitals
have rid themselves of clut-
tered corridors. They’ve created solutions (storage areas at the
end of hallways or little used
closets) to remove clutter and improve patient safety. It’s not
only aesthetics at work here.
fin81226_08_c08_223-246.indd 228 10/30/14 7:30 PM
Section 8.2 The Importance of Communication and Teamwork
One of the most frequently cited standards in Joint Commission
surveys is a life safety code
standard that requires hospitals to maintain the integrity of the
means of exit. The fear is that

19. medical equipment will block corridors in a fire or emergency,
making it difficult to evacuate
patients in beds and wheelchairs and putting lives in danger.
Questions to Consider
1. You are leading a quality improvement initiative to decrease
emergency room wait
times. A detailed analysis of the current state and extensive
discussion with the emer-
gency room staff has led to two proposed initiatives, but
hospital leadership has asked
you to choose the best option. What are some things to consider
in making this type of
decision?
2. The team ultimately decides one of the key solutions to
reducing wait times in the emer-
gency department is to accelerate the receipt of laboratory
results. If physicians don’t
have to wait as long for lab results, they can diagnose patients
and either send them
home or admit them into the hospital. This will free up beds for
other patients waiting
to be seen in the emergency department. What are some of the
economic, sociologic,
and safety issues surrounding the decision to ensure staff
members receive lab results
in a more timely manner?
8.2 The Importance of Communication and Teamwork
The overwhelming majority of quality improvement work is
conducted by groups of people
who come together to work on a specific project. These are
often referred to as interdisci-
plinary teams. Multiple healthcare professionals, administrative

20. personnel, and people inter-
ested in an issue who volunteer are often represented on these
teams. Anytime collaboration
occurs, there are two elements that can significantly impact the
success of the group project.
These elements involve how information is exchanged among
group members (communica-
tion) and the cohesiveness of the group as a whole (teamwork).
When teams come together, they typically go through a number
of stages, which are some-
times referred to as form, storm, norm, and perform. In the
initial stage, forming happens
when people first come together. This is the typical
“honeymoon” period, where people are
initially polite, finding out about one another and the work they
will focus on. It’s important
to introduce people to each other and ensure people who are
naturally quiet are included.
The next phase, storm, can occur as the initial politeness wears
off, people get more into the
work of the team, and start to argue. There may be more than
one person who wants to lead
the group and asserts dominance. It’s important to resolve
differences that can splinter the
team. A third phase is the group norm. Roles and personal
conflicts are sorted out and people
focus on the task at hand. Feeling they are a team, people help
one another more. The last
phase is perform, in which the team reaches an optimal level of
performance.
fin81226_08_c08_223-246.indd 229 10/30/14 7:30 PM

21. Section 8.2 The Importance of Communication and Teamwork
Communication
Communication is the way in which individuals exchange
information. Communicating effec-
tively with patients and families is critical in providing quality
healthcare. It’s considered a
cornerstone of the patient-centered care discussed earlier.
Patients need to understand their
health problems and treatment options, know what medications
they are being prescribed,
and understand any follow-up instructions. Patients should feel
free to ask questions about
their care and feel that they have a firm grasp of what’s going
on with their health.
In medicine, ineffective or inaccu-
rate information exchange about a
patient’s medical case may result in
serious injury or even death. During
an average four-day hospital stay, a
patient may see as many as 50 differ-
ent healthcare staff members, includ-
ing physicians, nurses, and technicians
(O’Daniel & Rosenstein, 2008). It is
important for staff to communicate
information to patients about their
condition, lab results, and tests.
It is important to appreciate that com-
munication extends beyond words or
verbal exchanges. People can use a
combination of words, sounds, signs,
or nonverbal behaviors to communi-
cate with others. In fact, the majority of

22. information exchange depends heavily on nonverbal cues, tone,
and body language (O’Daniel
& Rosenstein, 2008). This is true between staff and patients.
Does a physician give a patient
her full attention or is she distracted? Does a nurse make eye
contact and seem receptive to
questions from a patient?
Communication is also a key to effective multidisciplinary
quality improvement teams. Team
members must be able to agree on goals and tackle the tasks at
hand. After developing initial
trust, team members must be comfortable expressing their
differing opinions and challeng-
ing others when they don’t agree. It’s important, however, that
team members aren’t unpleas-
ant and unprofessional. Team members must be able to resolve
their differences and allow
everyone on the team to participate in the decision-making
process. It’s important everyone
feels they can express their opinions and views.
Teamwork
Teamwork is also a critical component of both medical care and
quality improvement activi-
ties. All improvement methodologies require that a group of
individuals come together to
work on a quality improvement project. For example, if an
organization uses the Six Sigma
method (described in Chapter 7), the team may consist of one or
more Six Sigma Black Belts
iStock/Thinkstock
It is critical that effective communication take place
between the patient and all of the health providers

23. she interacts with.
fin81226_08_c08_223-246.indd 230 10/30/14 7:30 PM
Section 8.2 The Importance of Communication and Teamwork
or experts and one or more Six Sigma Green Belts working
closely with a group of provid-
ers at the front line (i.e., physicians, nurses, technicians, etc.).
Applying lean methodology
(described in Chapter 7), the team may consist of a group of
front line providers who have
come together for a Kaizen event, where the team will
collaborate on an improvement project.
Or a healthcare organization may not use one of these particular
methodologies. It may
decide that it wants to pull together a quality improvement team
to address a specific prob-
lem and includes a variety of people who can help come up with
solutions. Members of the
team depend on the issue at hand.
For instance, a hospital decides it wants to integrate traditional
social work functions with
the case management department so it can improve discharge
planning for patients ready to
leave the hospital. As with most changes, initiating such a
merger comes with challenges. The
hospital forms a broad-based committee that includes
supervisors, as well as case managers,
who are typically registered nurses, and social workers. It also
includes “transitions of care”
staff who help patients plan for discharge from the hospital and

24. representatives from outside
agencies from the community who collaborate with the hospital
to ensure patients have the
services they need when they get home. It includes the medical
director and hospital leaders,
including the chief medical officer.
In each of these quality improvement scenarios, communication
and teamwork are key pre-
dictors of ultimate success.
If group members do not communicate effectively about data
regarding the current situation,
it could lead to an inability to identify the true problem(s), the
associated root causes, and
the ultimate solution. For example, in the case of combining
social work and case manage-
ment into one department, the team should look at the facility’s
average daily patient census,
payer mix, demographics, and emergency department use. What
is the right mix in terms of
the number of social workers and case managers that are needed
in the facility? A hospital
with a high number of low-income patients may need more
social workers. A facility with
many elderly patients on Medicare may need an equal number of
case managers to deal with
medically complex cases and social workers to provide frail
elderly patients with community
resources when they are discharged from the hospital.
Additionally, if the group members are unable to work
cohesively, as a team, toward a com-
mon solution for the problem at hand, it is unlikely that the
project will be completed success-
fully (O’Daniel & Rosenstein, 2008). For instance, the last

25. thing a hospital trying to merge two
departments wants to do is create a battleground between its
social workers and case manag-
ers. It’s important to bring all parties together to fairly
determine the new roles of both social
workers and case managers. Ultimately, many staff members
will see their responsibilities
change, and they must integrate new team members and allow
them to take on new duties.
The importance of teamwork is heavily emphasized in quality
improvement methodologies
for these reasons.
A list of components of successful teamwork for quality
improvement activities include
(O’Daniel & Rosenstein, 2008):
• Open and effective communication;
• Non-punitive environment/avoidance of the blame game;
fin81226_08_c08_223-246.indd 231 10/30/14 7:30 PM
Section 8.2 The Importance of Communication and Teamwork
• Clear and known roles and tasks for group members;
• Appropriate balance of member participation for the task at
hand;
• Respectful atmosphere;
• A common goal or direction;
• Acknowledgment and processing of conflict;
• Clear and known decision-making procedures; and
• Regular and routine communication and information sharing.
Different quality improvement projects will require various

26. team members and range from
smaller groups of 1–2 individuals to very large groups of 10 or
more members. It’s worth-
while to mention that larger teams may not always lead to
speedier project completion. This
is highlighted by the Mythical Man Month analogy, which states
that certain tasks can’t be
divided (i.e., they must occur sequentially) so bringing on
additional team members does not
always add speed (Kim, 2013). In fact, team dynamics may be
more complicated as the size
and personalities of team members increase.
In this and prior chapters, the importance of communication has
been emphasized in great
detail. In Chapter 7, the importance of a non-punitive
organizational culture and avoidance
of the traditional “blame-game,” or tendency to identify and
punish one individual for a par-
ticular error, was also discussed. Clear roles/tasks and balanced
participation are also high-
lighted by Six Sigma (e.g., Black Belt levels) and lean (e.g.,
identification of team leaders and
clear assignment of medical staff to a Kaizen event for one
week as opposed to routine clini-
cal duties). A respectful atmosphere and unifying goal are also
key components of quality
improvement activities, and explicitly discussed as part of lean
methodology in Chapter 7.
The acknowledgment and attempted resolution of any conflict,
clear procedures for making
decisions, and routine communication are also just as critical to
the success of any quality
improvement project. Effective group meetings should include
all three of these additional

27. components of teamwork. In order to have an effective quality
improvement team meeting,
it is important to set an agenda for the session; designate
member roles, such as who will
take minutes; agree on how decisions will be reached; document
action items or to-dos; and
assure that all members are heard and can play a role in overall
project progress (Langley et
al., 2009). In other words, effective meetings are those in which
decision making follows a
delineated process and includes several previously agreed upon
steps, providing an avenue
for identification and resolution of conflict.
Communication and teamwork are critical to any and all quality
improvement projects. As
such, quality improvement methods emphasize the importance
of both as integral to the suc-
cess of all quality improvement efforts.
fin81226_08_c08_223-246.indd 232 10/30/14 7:30 PM
Section 8.3 Adapting to Change
8.3 Adapting to Change
Innate to the study and improvement of processes is the need to
make change. Understanding
and appreciating the human side of change is critical in quality
improvement. According to
experts, the human side of change helps us understand the
motivations of people, how they
interact with one another, and how they will react to a specific
change in order to gain com-
mitment (Langley et al., 2009). Change usually elicits some

28. kind of reaction, ranging from total
agreement to animosity (Langley et al., 2009). In many
situations, change can feel uncomfort-
able and may be unwelcomed despite the promise that it will
lead to improvements in quality.
Consider the case of a hospital pharmacy responsible for
processing all inpatient medication
orders. A quality improvement project focused on increasing the
efficiency by which pre-
scriptions are filled may lead to changes in the day-to-day
pharmacy operations, such as the
order and nature of tasks handled by the pharmacists. Steps the
pharmacists routinely fol-
lowed may be removed or a series of new steps may be added.
The new flow in pharmacy
operations will feel foreign to the pharmacy staff and possibly
even uncomfortable. Although
the pharmacists might appreciate the need to improve
efficiency, they are also bound to have
a range of reactions to the changes taking place. Thus,
preparing the pharmacists for upcom-
ing change will be critical to the success of this quality
improvement project.
The acceptance and commitment to change is critical to the
ultimate success of any given
quality improvement project. If employees on the front lines do
not embrace the proposed
change(s), the quality improvement initiative is unlikely to
impact day-to-day operations and
lead to improvement.
Committing to Change
To help employees commit to change more readily,
organizations should: 1) inform employees

29. why change is needed, 2) include them in the way change is
created, and 3) notify them of the
progress being made after the change (Langley et al., 2009).
The first concept involves letting
employees know why change is needed so they can understand
why a quality improvement
project is going to take place. It is important to do this as soon
as possible—even before the
Questions to Consider
1. In communicating with patients and their family members,
it’s important to establish a
connection. Providers can fail to do that when they do not truly
listen to a patient before
responding, don’t introduce themselves to a patient, or don’t
acknowledge the patient
by name. Can you think of other ways that providers fail to
establish communication?
Can you establish some guidelines to assist caregivers in
establishing effective commu-
nication?
2. When a team collaborates on a quality improvement, it is
conceivable that conflicts
may arise among group members. Consider a scenario where
two team members have
identified two potential solutions for the problem at hand. What
are some components
of effective teamwork in resolving this type of conflict in the
context of ongoing quality
improvement activities?
fin81226_08_c08_223-246.indd 233 10/30/14 7:30 PM

30. Section 8.3 Adapting to Change
quality improvement project team is fully assembled. This way,
employees will appreciate why
a change is taking place and have as much time as possible to
get used to the idea of change.
In the case of the hospital merging its social work and case
management departments, staff
members should know why this change is critical to the
organization. It may help to explain
that while many hospitals have traditionally separated the two
functions, there is a strong
movement in the case management field toward a collaborative
model that recognizes the
partnership of social work and nursing. The change will allow
the hospital to use resources
more effectively and meet its goals and objectives, such as
improving length of stay numbers,
reducing readmissions, and increasing patient flow by
increasing patient capacity.
Including employees in the way change is created can range
from asking for their input about
a particular step in a process to asking for their participation as
a full member of the quality
improvement project team. The importance of engaging all
employees within the organiza-
tion in quality improvement activities was discussed in the
context of both Six Sigma and lean
methodologies.
Gathering input from those who will be most affected by
change, such as the pharmacists
in the previous example, is critical for several reasons. First,

31. the pharmacists have the best
understanding of the pharmacy workflow. Their input would
therefore provide the most
relevant opportunities for making improvements and identifying
what problems they expe-
rience with existing processes. A project team that does not
have a solid understanding of
the existing pharmacy system may create a solution that is
difficult to implement, possibly
leading to further inefficiencies in day-to-day operations.
However, by getting input from the
pharmacists, or even including them on the project team, it is
more likely that the proposed
solution(s) will be feasible on the front lines and lead to
improvements in efficiency.
Once change is being tested and is in place, it is important to
inform employees of the ongoing
progress. This serves several purposes. The first is a constant
reminder of the common goal
that everyone is working together to achieve. This helps to
decrease any continued resistance
and unify the front line staff affected by change. The second is
the avoidance of reverting back
to the old way of doing things. If everyone is aware progress is
being made, there is motivation
to continue with change. Lastly, updates on ongoing progress
serve as a check that the team
is headed in the right direction. If the changes were not leading
to the anticipated results, this
would be a signal to re-evaluate the new process and consider
further adaptations until the
desired success is achieved.
For example, it is important that hospital leaders support the
transition of social workers and

32. case managers into one department. It is well and good to plan
for a change, but actual imple-
mentation may not go as anticipated. Leaders should expect the
case management depart-
ment will run into obstacles when it actually starts doing the
work with combined teams of
case management and social workers. It’s important to be
flexible and to change processes
as needed if issues arise. Quality improvement teams should not
be firmly committed to an
idea if it does not work. For example, the discharge planning
process may work differently on
some hospital units. Social workers may provide more services
on some units that affect their
caseload. So, the quality improvement team may not have
foreseen every obstacle or may find
that what they expected to happen didn’t work in reality. It’s
important that quality teams are
prepared to revise their process down the road.
fin81226_08_c08_223-246.indd 234 10/30/14 7:30 PM
Section 8.3 Adapting to Change
The cooperation of front line employees is essential to make
effective change (Langley et al.,
2009). Front line employees will naturally be concerned about
how the change will affect
their responsibilities, tasks, and roles within the organization.
In our pharmacy example,
pharmacists may be asked to give up control of a step in the
medication processing flow. It
is important for the team to recognize and deal with these
concerns (Langley et al., 2009).

33. The quality improvement team should listen to these concerns
and come up with solutions if
possible to ensure the pharmacists are not negatively impacted
by the proposed changes. Per-
haps they can agree to modify pharmacy staff work hours and
improve satisfaction. Or in the
case of merging social workers and case managers into one
department, the hospital should
be prepared to help staff transition into their new roles.
In the 1960s, Everett Rogers, professor of communication
studies, first described his Diffu-
sion of Innovation theory, which includes four main elements
(Rogers, 2003):
• Innovation: the change or the new idea/practice/object
• Communication channels: how information about the
innovation is spread
• Time: the rate of adoption or the speed with which adoption of
an innovation occurs
• Social system: the group or related units that are involved in
communication, adop-
tion, and diffusion
In this model, adoption refers to what happens at an individual
level, such as when one
employee decides to accept a new process (Rogers, 2003).
Diffusion, on the other hand, is
the spread of change across a group of people, or the collective
decision among a group of
employees to adopt a change (Rogers, 2003).
Within a social system, there are different categories of
adopters of change, which vary based
on their degree of innovativeness and speed of adoption. There

34. are the first individuals to
adopt change, or innovators, followed by the second group of
early adopters, followed by the
early majority, late majority, and finally the laggards (Rogers,
2003). The laggards are the
slowest to adopt change and need the most convincing. It is
important that organizations
understand the varying degrees with which their employees may
be committed to the idea of
change and willing to adopt new ideas or practices. In doing so,
they can outline strategies to
help staff adopt change and spread its use more seamlessly
across organizations.
It’s also important for organizations to be aware of people’s
subconscious resistance to
change. The subconscious mind wants to keep a person safe and
is very resistant to change.
So, even if the possibility of change consciously seems exciting
and new, the subconscious
works against that, doing its utmost to keep people firmly
rooted where they currently are
because it is safe and familiar. People feel the benefit of staying
where they are now, even if
consciously they want to move forward and change.
Consequently, successful change agents or leaders must always
create and communicate to
people what’s been referred to as WIIFMs (What’s In It For Me)
in order to sustain behavioral
changes in employees. Employees who believe they will
personally benefit from a change are
more likely to accept a new way of doing things.
fin81226_08_c08_223-246.indd 235 10/30/14 7:30 PM

35. Physiological Needs
Breathing, food, water, shelter, clothing, sleep
Safety and Security
Health, employment, property, family, and social stability
Love and Belonging
Friendship, family, intimacy, sense of connection
Self-Esteem
Confidence, achievement, respect of
others, the need to be a unique individual
Self-
Actualization
Morality, creativity,
spontaneity, acceptance,
experience, purpose,
meaning, and inner potential
Section 8.3 Adapting to Change
Motivating Behavior
When it comes to motivating behavior, including change,
another well-established theory that
deserves mention is American psychologist Abraham Maslow’s
hierarchy of needs (Maslow,
1943). Maslow (1943) describes a hierarchy of needs that begins
with the most fundamental
needs, such as food and water, and moves up toward less
tangible needs, such as esteem and

36. self-confidence. This hierarchy is shown in Figure 8.1.
What motivates behavior? According to Maslow, actions are
motivated in order to achieve
certain needs. Fundamental needs must be met first before a
person can transition to higher
level needs. This is another framework for consideration when
creating and spreading change
within an organization. It is important to ensure that change
does not hinder basic needs for
employees and can promote the attainment of these whenever
possible. Changes that threaten
employees’ basic needs, such as work breaks and wages, or
safety needs, such as job security,
seniority, or pensions, will be met with resistance.
Figure 8.1: Maslow’s hierarchy of needs
Higher order needs can only be achieved once the lower order
needs have been met.
Source: Maslow, Abraham H., Frager, Robert D., & Fadiman,
James. Motivation and Personality, 3rd Edition, © 1987. Printed
and
electronically reproduced by permission of Pearson Education,
Inc., Upper Saddle River, New Jersey.
Physiological Needs
Breathing, food, water, shelter, clothing, sleep
Safety and Security
Health, employment, property, family, and social stability
Love and Belonging
Friendship, family, intimacy, sense of connection

37. Self-Esteem
Confidence, achievement, respect of
others, the need to be a unique individual
Self-
Actualization
Morality, creativity,
spontaneity, acceptance,
experience, purpose,
meaning, and inner potential
fin81226_08_c08_223-246.indd 236 10/30/14 7:30 PM
Section 8.4 Continuous Use of PDSA
8.4 Continuous Use of PDSA
Plan-Do-Study-Act (PDSA) provides a framework and sequence
with which quality improve-
ment can take place. The four PDSA steps were discussed in
detail in Chapter 6. (Just as a
reminder, you may sometimes see this described as Plan-Do-
Check-Act [PDCA]. However, as
this quality improvement model evolved it has been changed to
PDSA to encourage organiza-
tions to study or analyze the information from its improvement
project and determine the
success or failure of the interventions undertaken.)
With PDSA, it is unlikely that the desired improvement may be
achieved in just one cycle
(Jain, 2005). It is generally the case that several back-to-back

38. cycles of PDSA will occur before
a project is completed. In the rare instances where the desired
changes are achieved in just
one cycle, it is possible that new goals or areas for further
improvement will arise, requiring
additional cycles (Jain, 2005).
Social needs can include a sense of belonging in one’s
relationships with others, and can be
met with participation in work groups, teamwork, and
encouraging participation in the orga-
nization. Based on Maslow’s theory, once those needs are met,
people can pursue the needs of
self-esteem. A worker appreciates recognition for a job well
done and recognition will moti-
vate them to continue working hard for an organization.
Organizations should recognize qual-
ity work in many ways, from praise in the presence of peers to
promotions. Self-actualization
is the highest level in the hierarchy of needs. People are seeking
personal growth and are
interested in fulfilling their potential. Organizations can do that
by providing challenges and
encouraging creativity, including problem-solving and quality
improvement activities.
While a change may be ultimately good for healthcare
organizations and their patients, mak-
ing a change isn’t always easy for people. Healthcare
organizations implementing quality
improvement projects need to make it clear why they are
making changes and make efforts
to get everyone on board.
Questions to Consider

39. 1. Consider a scenario in an outpatient clinic where an increase
in patient dissatisfaction
has led to the initiation of a quality improvement project aimed
at identifying the exist-
ing problems, associated root causes, and potential solutions.
What are some key things
to consider when discussing the proposed project with the clinic
staff ? What should be
emphasized to those most affected by the project?
2. In the example provided in Question 1, how would you a)
inform the staff why change is
needed, b) include the clinic staff in the way change is created,
and c) potentially notify
the clinic staff of progress being made after change?
fin81226_08_c08_223-246.indd 237 10/30/14 7:30 PM
Section 8.4 Continuous Use of PDSA
With each additional PDSA cycle, it is expected that knowledge
about a particular process
will increase. Therefore, PDSA cycles are meant to occur in a
repeating manner, which is also
referred to as iterative—that is, building on the knowledge
gained from the previous cycle. In
fact, the “A” in PDSA, which usually stands for “Act,” is
sometimes also referred to as “Adjust”
in order to illustrate the need for additional cycles. Questions to
ask in the “A” step of PDSA
include:
• What have we learned from this test?
• Have we achieved the desired effect (ideal state)?

40. • Is there room for further improvement?
• What other changes could lead to further improvement?
• How can we spread the improvement to other areas?
Once a PDSA cycle is complete, it is important to assess what
was learned and whether the
desired goals have been met. If the goals have not been met,
which is usually the case after
one or two cycles, the project team will need to conduct further
cycles. With each PDSA cycle,
the team should be planning and testing additional changes to
move closer and closer to the
ideal desired state. When the desired goals are met, additional
cycles may still be required to
spread the change. Spreading the change may entail more
widespread implementation of the
initial test conducted.
Recall the pharmacy example from the previous section to help
illustrate this further. Suppose
the project team plans an intervention to increase the time it
takes to process medication
orders, replacing the traditional handwritten orders in the
patient’s chart with a new com-
puter order entry system. Since computer programs are prone to
glitches and pharmacists
need to learn how to use the new system, a small test
incorporating simulated patients is an
ideal first step. If glitches in the computer order entry system
are not caught and resolved
prior to widespread implementation across the entire hospital,
the results could be disastrous.
If the desired effects are achieved with the small test, the next
PDSA cycle could involve real
patients but only those in a small section of the hospital. An

41. ideal choice for the test would be
a unit or floor with patients requiring less acute care. In that
case, medication changes are not
likely to occur as frequently or be as urgent. Again, if the
desired effects are achieved, then
testing can be expanded to an even larger section of the hospital
until widespread implemen-
tation is achieved.
Once desired effects are achieved on a hospital-wide basis,
additional PDSA cycles may also
be used to continually monitor progress in order to sustain
quality improvement efforts. In
many instances, there is a lot of excitement, enthusiasm, and
attention focused on a newly
initiated project that can eventually fade over time. In order to
keep momentum and ensure
the implemented changes result in the desired effects over both
the short and long term,
additional cycles are necessary.
fin81226_08_c08_223-246.indd 238 10/30/14 7:30 PM
Section 8.5 Continuous Quality Improvement (CQI)
Questions to Consider
1. Suppose you are about to lead a quality improvement project
and plan to use PDSA
cycles to improve emergency room wait times. How will you
describe the PDSA process
to your team members? What should they expect when working
on a PDSA project?

42. 2. Suppose your project in Question 1 is completed after 12
PDSA cycles. Emergency room
wait times are now down to an all-time low of one hour per
patient. Everyone in the
emergency room has been enthusiastic about the changes made.
What will you tell your
team now? What should they expect would happen moving
forward? What are some
ways to sustain the improvements implemented?
8.5 Continuous Quality Improvement (CQI)
Continuous quality improvement (CQI) is defined as a
comprehensive management philoso-
phy that applies scientific methods to increase knowledge,
reduce variation, and sustain con-
tinuous improvement (Tindill & Stewart, 1993). In other words,
CQI philosophy states that
quality improvement never rests and should be ongoing. Thus,
as soon as problems have been
identified and improved, a new cycle should begin. The new
cycle incorporates the use of
analytical decision-making tools, such as Pareto charts or
process control charts (described
in Chapter 7), to monitor the improved process.
CQI Steps
CQI involves several steps that can be
adapted to any of the process improve-
ment methods discussed in prior chap-
ters, including Six Sigma or lean the-
ory. As a general summary, the steps in
CQI can include the following (Kahan
& Goodstadt, 1999):
Step 1: Identify the problem.

43. Step 2: Define the current situ-
ation—identify major problem
areas in existing processes or day-
to-day operations.
Step 3: Analyze the problem—
identify the root causes of the
problem using charts and dia-
grams as needed.
Step 4: Develop an action plan—
outline ways to correct the root
causes of the problem and the next
specific actions needed to resolve
the problem.
Shironosov/Thinkstock
Step five of Continuous Quality Improvement (CQI)
is to examine the results—confirm that the problem
and its root causes have decreased, identify whether
the target has been met, and display results in
graphic format before and after the change.
fin81226_08_c08_223-246.indd 239 10/30/14 7:30 PM
Section 8.5 Continuous Quality Improvement (CQI)
Step 5: Examine the results—confirm the problem and its root
causes have decreased,
identify whether the target has been met, and display results in
graphic format before and
after the change.

44. Step 6: Start the cycle again—go back to the first step and use
the same process to move
closer to the ideal state or address another problem.
A key feature of CQI is the detection of variation, which is the
fluctuation in an existing pro-
cess or the tendency to revert back to the old system (see
Chapter 7). If variation is detected,
then additional processes may be tested and put into place to
sustain improvements over the
long term. Dr. Walter Shewart is credited with developing the
concept of control in respect
to variation while he was working to improve quality in the Bell
Telephone factories in the
1920s (Statit Software, 2007). Dr. W. Edwards Deming built on
the work of Shewart and later
took these concepts to Japan, including PDSA, where he was
also extremely influential (Statit
Software, 2007).
Guiding CQI Efforts
Several key questions can be continually asked to guide CQI
activities. The first involves an
assessment of the current state: “How is this process/service
doing?” By using analytic meth-
ods, it is possible to gather detailed information on how things
are going. Once an assess-
ment of the current state is conducted, it is possible to ask
several other follow-up questions,
including:
• Can this be more effective?
• Can this be faster?
• Can this be done with less cost?
• Can this be better?

45. Consider the pharmacy example discussed earlier, and assume
that initial tests and subse-
quent larger trials were conducted, leading to hospital-wide
implementation of the new com-
puterized medication order entry system. The first step in CQI
would be continued monitor-
ing once the new system is in place. For example, it would be
important to know the average
turnaround time for a medication order in the new system. By
tracking the average time from
when a physician entered an order in the system to the delivery
of the medication, the quality
improvement team would have a measure of process efficiency
that could be used as a bench-
mark moving forward.
By charting the times in a statistical process control chart, the
quality improvement team
would have a visual representation of this information and allow
for rapid identification of
any variations in the process. Does the chart show times have
decreased since the new system
was put in place? The turnaround time for all medications
ordered could be averaged and
plotted on a daily basis. Significant trends in turnaround times
would be easy to detect. The
team could also continually ask if there are additional ways to
improve the process once the
desired state has been achieved.
fin81226_08_c08_223-246.indd 240 10/30/14 7:30 PM
1

46. LCL = 18.410
15
20
25
30
35
40
45
Average days, positive mammogram to definitive biopsy,
control chart
Week
Avg Delay
1
34
2
30
3
35
4
32
5
28

47. 6
26
7
29
8
28
9
35
10
26
11
34
12
31
13
28
14
40
15
26
16
32
17
31

48. 18
30
19
33
20
35
21
26
22
19
23
21
24
23
25
25
26
17
27
21
28
22
29
21

49. 30
17
31
23
32
22
33
24
34
19
35
20
36
21
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31 32 33 34 35 36
UCL = 43.890
Benchmark
Mean = 31.190
LCL = 12.980
UCL = 29.650
Note the Improvements

50. Mean =
21.313
Section 8.5 Continuous Quality Improvement (CQI)
An example of a statistical process control chart, showing the
turnaround from the time a
suspicious spot was found on a woman’s mammogram test to a
follow-up biopsy to determine
whether she has breast cancer, is provided in Figure 8.2. Here,
the quality improvement effort
was aimed at decreasing the average delay in time to biopsy
after a mammogram showed a
concern for possible breast cancer. The average turnaround time
was plotted in weekly incre-
ments for patients who received mammograms. Significant
decreases in turnaround times
are detected after week 20, when the quality improvement
initiative had begun. This bench-
mark is continually assessed to ensure the gains from the
quality improvement initiative are
sustained.
It is important to note that CQI data analysis and feedback is
meant to occur in real time.
As illustrated by the examples provided, it would not make
much sense to implement a new
system and then wait one or two years before understanding
whether this has led to improve-
ments. In the pharmacy example, it would be important for
hospital leadership and front
line providers to know as soon as possible whether the new
order entry system is improving
efficiency. If it is not working as anticipated, then further

51. refinements must be made. Waiting
extended periods of time or retrospectively collecting data
would delay the ability to achieve
the desired state within a reasonable time frame.
Figure 8.2: Sample statistical process control chart
Process control charts allow desired benchmarks (in this case,
time from abnormal mammogram to
biopsy) to be continually assessed to ensure the gains from the
quality improvement initiative are
sustained.
Source: From “Improving Healthcare with Control Charts” by
Raymond G. Carey, PhD. Reprinted by permission
1
LCL = 18.410
15
20
25
30
35
40
45
Average days, positive mammogram to definitive biopsy,
control chart

52. Week
Avg Delay
1
34
2
30
3
35
4
32
5
28
6
26
7
29
8
28
9
35
10
26
11
34

53. 12
31
13
28
14
40
15
26
16
32
17
31
18
30
19
33
20
35
21
26
22
19
23
21

54. 24
23
25
25
26
17
27
21
28
22
29
21
30
17
31
23
32
22
33
24
34
19
35
20

55. 36
21
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31 32 33 34 35 36
UCL = 43.890
Benchmark
Mean = 31.190
LCL = 12.980
UCL = 29.650
Note the Improvements
Mean =
21.313
fin81226_08_c08_223-246.indd 241 10/30/14 7:30 PM
Section 8.6 An Online Presence and Social Media
CQI can be adapted to a variety of quality improvement
methodologies. In fact, the concepts
of continual improvement and use of analytic methods are
embedded in PDSA, Six Sigma, and
lean methodologies. Thus, CQI is easily added and in many
ways already incorporated in the
core concepts of existing quality improvement methodologies.

56. Questions to Consider
1. You recently led a quality improvement initiative to decrease
wait times in the emer-
gency room. With the input of emergency room providers, your
team tested and ulti-
mately implemented a new patient triage system that fast tracks
urgent or emergent
cases (such as possible heart attacks or strokes) to physicians
while common, everyday
conditions (such as flu-like symptoms or minor cuts/wounds)
are seen by newly hired
physician assistants. What type of information should be
collected to understand if the
new system is working?
2. What are some additional questions your team might want to
consider in the first few
months after the new triage system is in place?
8.6 An Online Presence and Social Media
Online media allows the spread of information about healthcare
organizations—both good
and bad. You’ve heard the expression “blow your own horn”;
when it comes to their quality
improvement efforts, some healthcare organizations are doing
just that. With people across
the globe increasingly using the Internet and social media
websites, including blogs and social
networking sites such as Facebook, Twitter, and YouTube, for
business and personal commu-
nications, more and more healthcare organizations are jumping
on the bandwagon.
After all, if healthcare organizations are using quality
improvement for steps such as reducing

57. resident falls, avoiding medication errors, or reducing surgical
site infections, why hide the
good news under a barrel? Healthcare organizations are sharing
their successes with patients
and potential future customers. Social media is a way for users
to participate in communica-
tion forums that reach many people. In fact, hundreds of U.S.
hospitals are now using social
networking tools, with numbers increasing dramatically.
Hospitals have their own websites
and are finding social media is too difficult to ignore.
Healthcare organizations can use social media to reach out to
patients with information about
their programs and also to educate patients about healthcare
issues. Social media also pro-
vides a way for consumers to bring a great deal of attention to
healthcare issues, both pro and
con. They may have good things to say about their care at a
healthcare organization. On the
flip side, they can also bring attention to poor quality, which
can adversely affect an organiza-
tion’s reputation.
fin81226_08_c08_223-246.indd 242 10/30/14 7:30 PM
Summary & Resources
One caveat for all healthcare organizations is that they must
keep medical information of
patients confidential, which is a requirement of the Health
Insurance Portability and Account-
ability Act (HIPAA) regulations. Healthcare organizations must
ensure that patients’ health

58. information and pictures are not posted on the Internet without
permission. They need to
caution staff members about the dangers of blogging about a
patient they have cared for if
that information allows the patient to be identified.
But despite those concerns, healthcare organizations are using
social media for marketing,
including connecting with patients about the quality
improvement taking place within their
walls. The Mayo Clinic, which has been a leader in the use of
social media, has established a
Center for Social Media, which helps other healthcare
organizations adopt and explore social
media tools.
Questions to Consider
1. How might you use social media to spread the word about a
quality improvement proj-
ect you have just led?
2. What type of information should you share on social media?
Is there information you
should not publicize?
Summary & Resources
Chapter Summary
This chapter reviewed the pre- and post-project efforts that must
be part of all quality
improvement activities. In the pre-project phase, it is important
to consider the economic,
sociologic, and safety impacts a project may have. The risks
versus benefits of each project
and associated solutions must be weighed carefully. The project

59. scope and timeline must
align with available resources. Effective communication and
teamwork are also necessary to
move the project forward smoothly. It is important to keep the
lines of communication open
among the team members and between the team and the rest of
the organization. Preparing
the organization for upcoming change is critical to help
everyone adapt and move forward in
unison. Once a project achieves the desired state, continuous
monitoring is needed to ensure
these gains can be sustained. Quality improvement never really
ends and should be consid-
ered a continuous process. Social media is a new way for
organizations to share the progress
made in improving patient care through their quality
improvement efforts.
Mini Case Study
If it takes a village to raise a child, it takes more than
physicians and nurses to make a hos-
pital. A hospital must ensure the quality and delivery of a range
of services that include feed-
ing patients and employees; managing the facility; transporting
patients; maintaining clini-
cal equipment; safeguarding the facility; and providing a clean,
comfortable environment.
fin81226_08_c08_223-246.indd 243 10/30/14 7:30 PM
Summary & Resources
Consider the role that a hospital’s safety officer and facility
management play in ensuring

60. patient satisfaction. Facility department staff undertake all
kinds of jobs, from changing light
bulbs to unclogging toilets and cleaning rooms—all tasks
needed to maintain a safe and
comfortable environment. But just what role does facility
management play in improving
the quality of patient care?
When the hospital where he worked as the safety officer
launched an initiative to improve
hand hygiene, Joe Thomas didn’t see how his department would
be involved. However,
the facility department staff played a role. Caregivers need to
wash their hands every time
before they touch a patient or they increase the risk for
hospital-associated infections.
However, if the sink in the room is broken, caregivers might
skip washing their hands or
instead go into the next room to wash their hands, which can
increase the risk of cross-
contamination if germs from one patient are spread to another.
Therefore, Joe and the main-
tenance staff committed to fixing sinks throughout the facility
within 24 hours of receiving a
work order for a repair. The facility management department
has tracked performance and
found that 97% of sinks are fixed within 24 hours of a report.
Discussion Questions
1. What are some ways non-clinical staff can contribute to
improving patient care?
What are some of the most important contributions various
departments make to
patient care? What role can those departments play in improving
quality?

61. 2. What other ways can the facility maintenance department
help improve quality?
Key Terms
adoption Accepting change at an individual
level, such as when one employee decides to
adopt a new process.
communication channels How informa-
tion about the innovation is spread.
continuous PDSA Several back-to-back
PDSA cycles to move from the present situa-
tion to the ideal future situation.
cost effective Demonstrating that a sub-
stantial improvement can be achieved rela-
tive to the associated cost or with little cost.
cost saving Demonstrating that money can
be saved over the long term.
diffusion The spread of change across a
group of people, or the collective decision
among a group of employees to adopt a
change.
innovation The change; the new idea/
practice/object.
social system The group or related units
that are involved in communication, adop-
tion, and diffusion.

62. time The rate of adoption or the speed with
which adoption of an innovation occurs.
variation Fluctuation in an existing process
or the tendency to revert back to the old
system.
fin81226_08_c08_223-246.indd 244 10/30/14 7:30 PM
Summary & Resources
Critical Thinking Questions
1. You have been assigned to lead a quality improvement effort
on the inpatient oncol-
ogy ward. One of the main goals is to improve the efficiency
with which the medical
team evaluates and manages ongoing medical issues. Ideally,
this effort should help
decrease patient length of hospital stay, which may also result
in cost savings for the
hospital. What are some social and ethical considerations that
might be relevant to
this case?
2. What are the benefits of conducting quality improvement
activities in a continuous
fashion? What are the downsides, if any?
3. In what ways do the concepts discussed in this chapter, such
as PDSA and CQI, over-
lap with methodologies, such as lean or Six Sigma, covered in a
prior chapter? Are
there notable differences?

63. Suggested Websites
• U.S. Department of Health and Human Services (HHS):
https://www.childwelfare.gov/management/reform/soc/communi
cate/initiative
/soctoolkits/cqi.cfm#phase=pre-planning
This website provides a review of Continuous Quality
Improvement.
• Agency for Healthcare Research and Quality (AHRQ):
http://www.ahrq.gov/
This website provides information on evidence to make
healthcare safer, higher
quality, more accessible, equitable, and affordable.
• National Center for Biotechnology Information (NCBI):
http://www.ncbi.nlm.nih.gov/books/NBK2651/
This website includes a 51-chapter book on quality
improvement in the healthcare
setting [Hughes, R. G. (Ed.). (2008, March). Patient safety and
quality: An evidence-
based handbook for nurses (Prepared with support from the
Robert Wood Johnson
Foundation; AHRQ Publication No. 08-0043). Rockville, MD:
Agency for Healthcare
Research and Quality.].
• Robert Wood Johnson Foundation:
http://www.rwjf.org/en/research-publications/research-
features/evaluating-CQI.html
This website describes the Robert Wood Johnson Foundation,
which has worked to
improve the health and healthcare of all Americans, including
information on the
Science of Continuous Quality Improvement.

64. • Communication Theory:
http://communicationtheory.org/shannon-and-weaver-model-of-
communication/
This website reviews the Shannon and Weaver Model of
Communication.
• Business Communication Answers:
http://www.answers.com/Q/Shannon_weaver_model_of_commu
nication
This website includes information on the Shannon and Weaver
Model of
Communication.
fin81226_08_c08_223-246.indd 245 10/30/14 7:30 PM
https://www.childwelfare.gov/management/reform/soc/communi
cate/initiative/soctoolkits/cqi.cfm#phase=pre-planning
https://www.childwelfare.gov/management/reform/soc/communi
cate/initiative/soctoolkits/cqi.cfm#phase=pre-planning
http://www.ahrq.gov/
http://www.ncbi.nlm.nih.gov/books/NBK2651/
http://www.rwjf.org/en/research-publications/research-
features/evaluating-CQI.html
http://communicationtheory.org/shannon-and-weaver-model-of-
communication/
http://www.answers.com/Q/Shannon_weaver_model_of_commu
nication
fin81226_08_c08_223-246.indd 246 10/30/14 7:30 PM
177

65. What is Special Education? 1
iStockphoto/Thinkstock
Pre-Test
1. You can use the terms disability and handicap
interchangeably. T/F
2. The history of special education began in Europe. T/F
3. The first American legislation that protected students with
disabilities was passed in the 1950s. T/F
4. All students with disabilities should be educated in special
education classrooms. T/F
5. Special education law is constantly reinterpreted. T/F
Answers can be found at the end of the chapter.
7Two Methods of Quality Improvement: Six Sigma
and Lean Theory
KEENE/BSIP/SuperStock
Learning Objectives
After reading this chapter, you should be able to do the
following:
• Evaluate Six Sigma and its role in quality improvement.
• Describe the Six Sigma Belts and metrics used.
• Analyze the five steps that define Six Sigma.
• Compare and contrast the successes and limitations of Six
Sigma.

66. • Describe the origin and evolution of lean theory from the
manufacturing industry.
• Summarize core principles of lean theory implementation.
• Explain fundamental concepts and methods used in lean
methodology.
• Discuss examples of lean projects in healthcare.
fin81226_07_c07_177-222.indd 177 10/30/14 7:26 PM
Introduction
Introduction
Compared to other developed countries, such as the United
Kingdom, France, or Canada, the
United States spends more money on healthcare but has poorer
healthcare outcomes (Col-
laborators, U.S. Burden of Disease, 2013; Squires, 2011). In
2012, healthcare spending in the
United States was $8,895 per capita, the third highest in the
world (only Norway and Swit-
zerland had a higher per capita rate, at $9,055 and $8,980
respectively; see Table 7.1) (World
Bank, 2012).
Table 7.1: The top 15 countries for healthcare expenditure per
capita
Country Expenditure per capita
Norway $9,055

67. Switzerland $8,980
United States $8,895
Luxembourg $7,452
Monaco $6,708
Denmark $6,304
Australia $6,140
Canada $5,741
Netherlands $5,737
Austria $5,407
Sweden $5,319
Japan $4,752
Belgium $4,711
France $4,690
Germany $4,683
Source: World Bank. (2012). Health expenditure per capita
(current US$). Retrieved from
http://data.worldbank.org/indicator
/SH.XPD.PCAP/countries
Despite this higher investment, the United States struggles with
lower quality healthcare, fin-
ishing far worse than many of its counterparts on various health

68. outcomes. These outcomes
include higher infant mortality rates, higher rates of hospital
admissions for most chronic
diseases, and the highest rate of foot amputations for patients
with diabetes (see Table 7.2)
(Squires, 2011).
fin81226_07_c07_177-222.indd 178 10/30/14 7:26 PM
http://data.worldbank.org/indicator/SH.XPD.PCAP/countries
http://data.worldbank.org/indicator/SH.XPD.PCAP/countries
Introduction
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fin81226_07_c07_177-222.indd 179 10/30/14 7:26 PM
Section 7.1 Definition and History of Six Sigma
A 2013 report published in the Journal of the American Medical
Association confirmed that
overall mortality rates in the United States still lag behind many
countries, including sev-
eral with much lower gross domestic product and healthcare
spending, such as Chile, South
Korea, and Slovenia (Collaborators, U.S. Burden of Disease,
2013).
Improving healthcare quality and efficiency, while
simultaneously curbing rising medical
costs, is a major goal for U.S. healthcare organizations
(Toussaint & Berry, 2013). To achieve a
higher level of quality, healthcare organizations must use a
systematic approach to improve-
ment. First, they need to recognize healthcare problems within
their organization. Next, they
must determine their goals for improvements in quality, as well

96. as the changes required to
achieve them. Finally, they need to measure the impact and
monitor to ensure that enhance-
ments in quality are appreciable and sustained.
Many of the widely accepted methods to improve quality
originated in the manufacturing
world and are now increasingly being applied to healthcare. In
this chapter, we will examine
two popular methods of quality improvement—Six Sigma and
lean theory—and how they
can be used to improve healthcare operations.
Methods of quality improvement have some basics in common.
Process improvement meth-
odologies provide an established and systematic approach to
improving processes. Usually
these methodologies include a step-by-step guide to help
organizations identify problems,
implement interventions, measure the impact of changes, and
monitor processes so that
improvements in care are sustained.
The overarching goal for any quality improvement method is to
reduce the number of defects
in a product or process as much as possible. Defects are
deficiencies in the process being eval-
uated—in other words, a result that is outside of the established
parameters or benchmarks.
Some of the common healthcare organizational processes that
might be the target for quality
improvement include improving waiting room times, surgery
scheduling, and patient satis-
faction. A secondary goal is to reduce costs or save the
organization money. The added goal of
sustaining improvements is also critical to quality improvement

97. methods. This is emphasized
because organizations need to avoid the natural tendency to
revert back to old processes,
which can lead to variability in quality over time. Let’s take a
look at the details of two process
improvement methodologies: Six Sigma and lean theory.
7.1 Definition and History of Six Sigma
Six Sigma is one of the most well-known process improvement
methodologies, and it has
been adopted by many healthcare organizations over the last 20
years. It has been described
as a disciplined and quantitative approach to process
improvement methodology (Hahn, Hill,
Hoerl, & Zinkgraf, 1999; Markarian, 2004). Central features of
Six Sigma include (Antony,
2004; Schroeder, Linderman, Liedtke, & Choo, 2008):
1. A clear focus on measurable financial results;
2. Emphasis on data collection and analyses;
3. A defined structure with specified steps and tools;
4. Use of dedicated Six Sigma specialists within the
organization; and
5. Emphasis on leadership support and engagement.
fin81226_07_c07_177-222.indd 180 10/30/14 7:26 PM
Section 7.1 Definition and History of Six Sigma
Six Sigma History
In 1987, Motorola Company formally
introduced Six Sigma as a new way
to decrease the number of defects
in manufacturing (Schroeder et al.,

98. 2008). Soon after, the methodology
was adopted by some of the country’s
leading companies, including Honey-
well (which was acquired by AlliedSig-
nal) in 1994 and GE in 1995.
In the early 1990s, the healthcare
industry began to embrace process
improvement methodology and qual-
ity management approaches. In 1993,
one study showed that 44% of 1,083
U.S. hospitals surveyed applied some
form of quality management approach
(Choufournier & St. Andre, 1993).
Beginning in 2000, reports were published on the successful
implementation of Six Sigma
at hospitals across the United States, signifying a new chapter
in Six Sigma history. One of
the most cited examples came from Heidi L. Frankel, MD, and
colleagues who used Six Sigma
methodology to reduce catheter-related bloodstream infections
at Yale New Haven Hospital
(Frankel et al., 2005). Other applications of Six Sigma in
healthcare include Stanford Medical
Center in California and the Red Cross Hospitals in the
Netherlands (Koning, Verver, Heuvel,
Bisgaard, & Does, 2006).
While healthcare organizations are adopting Six Sigma
techniques, it is not clear if they
are using the process correctly. In 2013, a comprehensive
literature review found over 300
articles published on the use of Six Sigma in healthcare
management (Dellifraine, Wang,
McCaughey, Langabeer, & Erwin, 2013). Among these, 55

99. articles were peer reviewed, but
only 16 reported correct use of Six Sigma. Based on these
findings, the authors concluded
that the evidence that Six Sigma is being used correctly in
healthcare remains “weak” (Delli-
fraine et al., 2013). This review also reported the increasing
number of hybrid models, which
include combined elements of Six Sigma and lean quality
improvement methodologies (lean
will be discussed later in this chapter). Together these are
referred to as lean Six Sigma; they
can be used as complementary tools for quality improvement.
A brief timeline of major events in the history of Six Sigma is
included in Table 7.3.
AP Photo/LM Otero
Motorola Company formally introduced the concept
of Six Sigma as a new way to decrease the number of
defects in manufacturing in 1987.
fin81226_07_c07_177-222.indd 181 10/30/14 7:26 PM
Section 7.1 Definition and History of Six Sigma
Table 7.3: Historical timeline of major events in Six Sigma
history
Year Milestone
1985 Motorola needs to make major changes to deal with
growing competition from Japan and
begins to create Six Sigma.

100. 1987 Six Sigma concept formally introduced by Motorola.
1988 Motorola wins the Malcolm Baldrige Award for Quality
and reports $940 million in savings
from Six Sigma.
1994 Honeywell (acquired by AlliedSignal) adopts Six Sigma.
1995 GE adopts Six Sigma.
1997 Honeywell reports successful implementation of Six
Sigma, resulting in less than 3.4 defects
per million products manufactured.
1999 GE reports net income from Six Sigma exceeding $2
billion.
2003 Reports of successful implementation of Six Sigma in
several healthcare organizations, includ-
ing Good Samaritan Health System in Kearney, Nebraska; the
Charleston Area Medical Center
(CAMC) in West Virginia; and Mount Carmel Health System in
Columbus, Ohio.
2013 A total of over 300 articles (to date) published on the use
of Six Sigma in healthcare.
Sources: Antony, J. (2004). Some pros and cons of Six Sigma:
An academic perspective. The TQM Magazine, 16(4), 303–306;
Schroeder, R. G., Linderman, K., Liedtke, C., & Choo, A. S.
(2008). Six Sigma: Definition and underlying theory. Journal of
Operations
Management, 26(4), 536–554.
While rooted in manufacturing, Six Sigma is helping healthcare

101. organizations to improve
their processes and patient care.
Six Sigma Explained
The technical definition of Six Sigma is to strive for less than
3.4 defects per million opportu-
nities (DPMO), in any process, product, or service (Hahn et al.,
1999; Linderman, Schroeder,
Zaheer, Choo, & Carlson, 2003). Sigma refers to the Greek
letter (represented by the Σ in
lower case Greek) that is used in statistics to measure how far
something deviates from per-
fection. The “six” refers to a statistical calculation worked out
by the creators of Six Sigma,
which aims for a very high percentage of defect-free products.
At Motorola, William Smith, John Mitchell, and Robert Galvin
are credited as the masterminds
behind the Six Sigma concept (Hahn et al., 1999). They
combined two rules to derive the now
infamous 3.4 DPMO value. The first is the well-known
empirical rule in statistics, which states
that nearly all values (or 99.7%, to be exact) lie within three
standard deviations of the mean.
The second rule was an assumption based on the creators’
experiences in the manufacturing
world (Hahn et al., 1999; Kumar, Nowicki, Ramírez-Márquez, &
Verma, 2008). Their assump-
tion was that even the most controlled manufacturing processes
eventually vary, or drift away
from perfection (specifically 1.5 standard deviations) over time.
In the case of a hospital seeking to improve hand hygiene
among staff members to reduce
the number of infections and therefore achieve healthier
outcomes for patients and reduced

102. recovery times, the organization can expect compliance to be
high after the initial launch
of its initiative. As part of the roll-out, staff members will
receive training on hand hygiene
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Section 7.2 Six Sigma Quality Improvement
Questions to Consider
1. What are two specific examples of ways to improve quality of
care in a clinic, hospital,
pharmacy, or outpatient laboratory setting?
2. What are some important points to consider when applying
quality improvement pro-
cesses in healthcare?
protocols during meetings on each hospital floor. They will be
reminded about the hand
hygiene policy at regular staff meetings. Supervisors will
monitor to see if staff members are
following the protocols.
However, after six months, there may be less emphasis on hand
hygiene. Supervisors may be
focused on other priorities. Some staff members may become
less vigilant about following the
protocols and slip into old habits. While infection rates may
have dropped because of hand
hygiene, the hospital may now see a gradual increase in these
numbers. Therefore, over the long
term, it may become increasingly difficult to maintain the same

103. level of quality. This variation in
process over the long term is what the originators of Six Sigma
tried to capture mathematically.
How do you calculate the now-infamous 3.4 DPMO, which is
one of the key measurements of
a Six Sigma quality system? A process is said to be operating at
Six Sigma if the DPMO is 3.4
or less. If a defect means, for instance, a patient acquiring an
infection, then for every mil-
lion patients, fewer than four would acquire a healthcare-
associated infection. Of course, in
healthcare, even one patient with an infection is one too many.
As they did with manufacturing, the Six Sigma concept can
improve healthcare quality,
enhance patient satisfaction, and allow an organization to
compete with others in a competi-
tive market.
7.2 Six Sigma Quality Improvement
Just as some of the largest and most successful U.S. companies
have adopted Six Sigma, the
healthcare industry provides numerous examples of successful
Six Sigma implementation.
Numerous studies have tried to dissect the inner workings of the
most notable Six Sigma
organizations to reveal the secrets of their success (Hahn et al.,
1999; Schroeder et al., 2008;
Senapati, 2004). These studies have shown that many
manufacturing companies employ the
use of parallel-meso structures to support Six Sigma activities
(Schroeder et al., 2008). Paral-
lel structures operate outside of and do not directly interfere
with daily operations. Thus, to

104. ensure success, Six Sigma activities are usually supported in
ways that do not alter “normal”
operations of an organization.
An example of parallel support for Six Sigma activities include
dedicated Six Sigma specialists
within the organization. These individuals are specifically
trained in Six Sigma methodology
and work with existing personnel and processes to improve
quality. The significant time com-
mitment to manage and move quality improvement projects
forward lies on the shoulders of
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Section 7.2 Six Sigma Quality Improvement
these specialists so that daily processes and routines are
minimally disrupted. In a healthcare
setting, the Six Sigma specialists, who might be physicians,
nurses, and others in the organiza-
tion, would oversee quality improvement projects, while other
personnel remain focused on
their daily responsibilities. Healthcare organizations can
implement Six Sigma by bringing in
experts in this improvement process from outside the
organization and teaching them about
how healthcare works or by sending their own personnel to
learn the Six Sigma methods. For
instance, an organization can send physicians, nurses, and other
leaders to seminars to train
in Six Sigma and bring their knowledge back to the facility.
Additionally, meso theory describes the integration of data at

105. multiple levels, ranging from
micro- to macro-level (Schroeder et al., 2008). Micro level data
is very detailed and can include
information about individual steps in a process (e.g., the amount
of time it takes to register a
patient). Macro level data is less detailed and can include
information about the process as a
whole (e.g., the average length of stay for patients admitted to
the hospital).
Six Sigma projects require the connection of multiple pieces of
information within one orga-
nization. This can occur in several ways. Examples include the
engagement of participants
from various levels within the organization (i.e., from front line
workers to leadership) to col-
laborate on one project and the integration of various pieces of
data from different steps
within the process to improve one final product or service
(Schroeder et al., 2008).
Six Sigma Belts
The use of full-time Six Sigma specialists within
organizations is a unique attribute of this method-
ology. It is not unusual to have dedicated Six Sigma
specialists who spend 50% to 100% of their time
on Six Sigma-related activities (Hahn et al., 1999;
Schroeder et al., 2008). Different companies use var-
ious names to describe the individuals working on
Six Sigma projects, but the most widely known are
the Black Belts, who typically run these improve-
ment projects. While others with less training in Six
Sigma may be involved in projects and collect data,
the structure, reports, and number analysis is typi-
cally done by Black Belts. In the Six Sigma methods,
white, yellow, and green belt describe individuals

106. with less intense training.
Black Belts are typically selected to attend at least four
weeks of intense Six Sigma training, which provides
review as well as hands-on application of quantita-
tive methods (including statistical programs) (Hoerl,
2001). Qualitative skills in the areas of team leader-
ship and communication are also usually covered, but
are emphasized less (Hahn et al., 1999; Hoerl, 2001).
The number of Six Sigma belts will vary depending on the
available resources, size of the com-
pany or organization, and scope of projects. As a general
guideline, most companies aim to have
AndreyPopov/iStock/Thinkstock
“Black Belts,” the most widely used
name to describe individuals working
on Six Sigma projects, are typically
selected to attend at least four weeks
of intense Six Sigma training.
fin81226_07_c07_177-222.indd 184 10/30/14 7:26 PM
Section 7.2 Six Sigma Quality Improvement
1% of their workforce trained at the Black Belt level (North
Carolina State University Lean Six
Sigma, n.d.). Most Six Sigma projects take an average of four to
six months to complete. Black
Belts should be able to support three to four large-scale projects
annually. Thus, it is estimated
that two to three full-time Black Belts are needed to support

107. quality improvement activities in
a typical acute care hospital with 150 to 300 beds (Caldwell
Butler & Associates, n.d.).
When Six Sigma is adopted within an organization, individuals
are usually first trained by
external experts. Trainees typically have the opportunity to
progress through belt levels.
It is important to note that the Six Sigma certification and
training processes are not stan-
dardized across organizations. Currently, there is no single
society or council that provides
Six Sigma certification. A survey of businesses found that
companies with fewer than 500
employees were reporting an average of $10,000 or less in total
costs of Six Sigma implemen-
tation each year (Dusharme, 2004). Additionally, companies
that have adopted Six Sigma over
many years eventually provide internal training and certification
programs that are tailored
to the company as needed. Thus, studies have demonstrated that
the skills and expertise
developed by Black Belts are inconsistent among companies
(Antony, 2004).
Executive leadership plays a key role in all Six Sigma
activities. Leadership must first provide
adequate support for these activities in the form of funding. It is
impossible to implement
Six Sigma methods without spending money to certify
employees and paying the salaries to
retain experienced Black Belts and higher level Master Black
Belts. Leadership may also need
to provide additional resources for a particular project. As an
example, the use of informa-

108. tion technology (IT) support services to assist with data
collection, monitoring, and analysis
would require leadership approval.
Additionally, leadership must align Six Sigma activities with
company priorities and values.
Leadership must encourage participation and enthusiasm around
Six Sigma activities at all
levels. Leadership should also promote a culture that empowers
employees to seek oppor-
tunities to improve quality, rather than being content with the
status quo. Senior executives’
continuous support and engagement is necessary to successfully
carry out Six Sigma projects
(Schroeder et al., 2008). Thus, involvement of executive
leadership is critical to the success of
Six Sigma in any organization.
Six Sigma Metrics
Metrics are specialized measures that play a central role in all
Six Sigma improvement proj-
ects. They are measureable factors that provide useful
information about the performance of
a process. A variety of metrics can be employed in Six Sigma
projects; they will generally fall
under one of two categories: 1) customer-oriented metrics and
2) financial metrics.
Customer-Oriented Metrics
Customer-oriented metrics are measurements of performance
from the customer’s perspec-
tive. Also referred to as critical-to-quality (CTQ)
characteristics, these metrics are defined
as key measurable characteristics of a process or product that
are essential for customer sat-
isfaction (Antony, 2004). Healthcare organizations may

109. consider medication errors or emer-
gency room throughput as examples of customer-oriented
metrics. It is easy to imagine the
impact on patient satisfaction, not to mention patient well-
being, if medication doses were
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Section 7.2 Six Sigma Quality Improvement
erroneously mixed up or emergency room wait times were too
long. Examples of metrics are
included in Table 7.4.
Table 7.4: Examples of two CTQ projects
Project Example Example
CTQ Metric Wait times to obtain new obstetrical visits Patient
time spent in obstetrical clinic
Benefits Reduced from 38 to 8 days 52% reduction
Sources: Kwak, Y. H., & Anbari, F. T. (2006). Benefits,
obstacles, and future of Six Sigma approach. Technovation,
26(5–6), 708–715;
Bush, S. H., Lao, M. R., Simmons, K. L., Goode, J. H.,
Cunningham, S. A., & Calhoun, B. C. (2007). Patient access and
clinical efficiency
improvement in a resident hospital-based women’s medicine
center clinic. American Journal of Managed Care, 13(12), 686–
690.
Customer-oriented metrics can provide a picture of how well a

110. healthcare organization is
performing in the eyes of its patients.
Financial Metrics
Six Sigma projects are usually selected based on their potential
to improve specified met-
rics and have a financial impact. Financial metrics are
measurements of monetary impact.
Examples include the amount of money saved when processes
are made more efficient or the
additional amount of money generated. For instance, a
healthcare organization can bring in
increased revenues by performing more surgeries with high
reimbursement levels or attract-
ing more patients. While businesses may select improvement
projects that will generate high
levels of annual savings or benefits, it may not be realistic for
many healthcare organizations
to expect such high levels of return. Many large organizations
routinely monitor and report
their financial results; therefore, the incorporation of a financial
analyst on their Six Sigma
teams is common (Schroeder et al., 2008).
Financial analysts collect data in real time as projects unfold,
but also track outcomes beyond
just one project cycle (this can vary depending on the project
but typically could include
tracking results several months to one year pre-project and one
year post-project). Examples
of reported financial metrics are provided in Table 7.5.
Table 7.5: Examples of financial metrics from Six Sigma
healthcare
organizations

111. Healthcare organization Savings
Women and Children’s Hospital (Charleston
Area Medical Center)
Gross obstetrics and gynecology clinic revenue increase of
73% in the first 6 months of 2006 (Bush et al., 2007)
Radiology Department in a Hospital (Taiwan) Savings of
$36,000 from reduced hospital lengths of stay
(Chan, Chiu, Chen, Lin, & Chu, 2005)
Mount Sinai Medical Center (New York) Savings of $75,000 by
switching from IV to oral antibiotics
(DuPree et al., 2009)
Froedtert Hospital (Milwaukee, WI) Increase in revenue of $1.2
million by improving commu-
nication and documentation of radiology reports (Gor-
man, Donnell, Hepp, & Mack, 2007)
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Section 7.2 Six Sigma Quality Improvement
In healthcare, where organizations are always trying to save
money while at the same time
improving patient care, managers who can show a potential
savings from implementing a
new project are more likely to receive approval from top
leaders. However, healthcare orga-
nizations are not only focused on quality improvements that can
save them money. Their rev-
enues, or earnings, may be directly tied to quality