TRIZ Helps Your Next Quality Improvement Project


By:  DMKashmer, MD MBA MBB


TRIZ Helps Generate Creative Ideas In A Focused Manner


An important factor in quality improvement projects, surprisingly, is creativity.  How do we generate and select interventions for a system?  How do we create entire new systems that have high levels of quality designed in?  The TRIZ tool (pronounced as “trees”) helps us design creative interventions in a focused, effective manner.


A Criticism Of Six Sigma & Lean Is That They Don’t Allow For Creativity


It’s a typical criticism:  Lean and the Six Sigma DMAIC pathway do not allow for creativity.  Clearly, to anyone who has participated in a DMAIC project, there is quite a bit of room for creativity.  Specifically, Six Sigma does not prescribe the specific interventions to make a system better.  It does, however, give certain philosophies like poka-yoke.


Poka-yoke Directs Us To Look For Creative Interventions


As we begin to explore TRIZ methodology, let’s take a moment to review one of the design philosophies routinely used by Six Sigma:  poka-yoke (pronounced “poke ah yoke”).  After all, the philosophic underpinnings of Six Sigma are what lead us to use TRIZ methodology in the hunt for creative, effective interventions.  Poka-yoke is an idea that guides us to make it easier to do the right thing.  That is, if we want physicians to record some piece of data on patients, we should make it very easy to input that data.  If we want someone to be somewhere on time, we should build a system that makes it as easy as possible to get to that place on time.  Poka-yoke says we should make it as easy as possible for a system / person to achieve the outcome we want.


This is challenging, often, for us in healthcare; we typically don’t see systems designed to make it easier to obtain a certain outcome.  We do get plenty of feedback telling us how important something is to do or how we MUST do something.  Yet we often have systems that conspire to make it difficult to achieve whichever item is being pushed.  However, let me share that processes which make it easier for us in healthcare do exist, and when we help create them it makes for a much more high-performing system.


In fact, poka-yoke design philosophy extends to many interventions.  For example, one trauma program with which I have participated needed to make sure trauma surgeons arrived to the trauma bay within 15 minutes of patient arrival to the trauma bay.  The team needed to make sure this happened more frequently than was typically occurring.  The poka-yoke design philosophy allowed the team to focus on specific interventions that made a higher probability the surgeon would be there on time.  This included NOT simply focusing on telling the surgeon ‘You need to do a better job’. Interventions included focusing on early identification and triage of trauma patients and positioning the call room physically closer to the trauma bay.  This type of poka-yoke design philosophy and associated interventions made it easier to do the right thing and achieve a timely arrival.


Now that we see how poka-yoke directs us to look for solutions to make it easier to do the right thing, where do we go to create them?  Typical tools that teams use to generate solutions include brainstorming, mind-mapping, and many other standard, creative tools.  Here, let’s add another tool to your toolbox that allows brainstorming along certain high-yield directions.  TRIZ methodology takes brainstorming sessions and focuses them in directions that are apt to be high-yield.  Here’s how.


TRIZ Tool Explained And Link To Where To Find It


The acronym TRIZ comes from the Russian wording equivalent of ‘Theory of inventive problem solving.‘   GS Altshuller and colleagues, between 1946 and 1985, reviewed world wide patent applications so as to determine themes and manners in which certain problems were solved.


Over time, the team identified fundamental conflicts that were at the heart of the many issues which the patents / designs attempted to resolve.  For example, some patents embodied a design used to make something stronger yet lighter.  These conflicts (and their solutions) were then codified into a TRIZ matrix.  TRIZ gives direction to resolve these conflicts by looking to how they have been resolved previously.  In other words, TRIZ is the process of codified creativity.  An oxymoron?  Maybe–yet TRIZ methodology has proven highly effective to accelerate our creative processes in the past.  You can use the TRIZ matrix here.


Consider this example of TRIZ applied to Six Sigma:  one of the challenges in designing a new system involved the trade off between strength of a product and weight of a product.  The TRIZ gave us focused ideas on how this problem has been solved across many, many, patents and designs throughout the world.  TRIZ focused meetings and sessions allowed us to be creative along certain highly productive lines. In fact, TRIZ methodology assisted us in many of our design projects and even in our DMAIC projects where brainstorming for intervention was more challenging.  TRIZ allows us to resolve the fundamental contradictions inherent in a problem in a codified, effective way.


In conclusion, TRIZ methodology gives us a focused tool that is often superior to the perhaps more routine brainstorming.  Once data have been reviewed and it is time to design an intervention, TRIZ methodology has been very handy for us.  There are multiple, online TRIZ resources including here, here and here. Remember, for your next quality improvement project, if you want to solve an issue with the forest in a creative fashion, look towards the TRIZ.


Questions, comments, or thoughts on TRIZ methodology in your quality improvement project?  Have you previously seen TRIZ methodology be successful for your project?  Let us know beneath.

Use The Project Charter For Your Quality Project


By:  DMKashmer, MD MBA MBB



The Project Charter Is The Most Frequently Used Tool

In earlier entries we talked about the DMAIC pathway and some of the different tollgates that make up DMAIC.  In any quality improvement project that you perform for your health care system, startup, or established business, one of the most useful tools that the Lean Six Sigma Black Belts use is the project charter.  There are many tools from which the black belt can select when they run a project.  One of the tools most frequently employed by black belts for each project is the project charter.  Whether you are a black belt or trying to run an ad hoc quality improvement project for your healthcare system, or working in a formal Six Sigma deployment, the project charter is a very useful tool.  Let’s take a moment and explore the project charter.


The Three Most Important Parts of The Project Charter

First, the project charter lays out the nature of your project.  The title clearly establishes what you are working on.  However, to my mind, the three most important elements of the project charter are 1: the stakeholders, 2: the project scope, and 3: the cost of poor quality.  We have previously discussed some of these elements.  For more information on the cost of poor quality you can look here.  The COPQ gives a bottom line expected return on the quality improvement project.  This is something that management and other administrators can rally around to get a sense of the impact your project will have on the bottom line.  Again, in healthcare, the cost of poor quality can be challenging to establish and is composed of the four buckets described here.


Scope Creep Is A Common Reason Projects Fail

Next, consider the stakeholders.  Although Lean and Six Sigma do have a substantial focus on math and statistics, it is important to realize that lean and six sigma are team sports.  Making it very clear up front who the involved parties are is key to overall improvement.  In the absence of a strong team, no improvement can be made.  One of the elements of the project charter that we have not described previously is the scope.  The scope is the defined interval to which the project applies.  By this I mean that we need to be very clear about the start and stop for a project.  If the project concerns admitting patients to the hospital we need to be clear that we intend to focus the project on the interval between when the patient arrives at the emergency department until the time at which the patient physically leaves the emergency department.  This is how we clearly scope the project.  The scope is very key to a projects success because one of the most common issues associated with project failure is called ‘scope creep’.  ‘Scope creep’ occurs when the project becomes too large with too many elements.  Therefore, defining the scope clearly and adequately at this point in the project is important.  There will be later opportunities to clarify this scope during the formation of a data collection plan.


Project Charter Is One Of the Most Important Elements In A Successful Project

In the end, the project charter is one of the most important elements of a successful quality improvement project.  It focuses us on the team members involve, the scope of the project, and the projects expected return.  For a sample project charter please click here:  charter for blog.  Questions, comments, or thoughts on the project charter?  Please let us know beneath.

Why Don’t We Develop Talent In Surgery?


By:  The Generation Y Surgeon (@GenYSurgeon)

What We Should Do Versus What Happens Now

When it comes to raw talent, Medicine has plenty.  However, we do a poor job of cultivating the skills of the individuals who make up this profession.  Innovation is about looking from an alternative viewpoint.  It’s about finding the answer to questions others don’t realize exist, and often involves finding what no one else sees.  Innovation, after all, is evolution and we must evolve or die.  Why then don’t we make better use of the talent we already have to grow our profession and innovate our way out of our current issues?  We should encourage these doctors to lead and innovate…but Medicine does the opposite.

They Come In Diverse And They Go Out Looking The Same

Medical schools covet diversity.  Medstudents enter with varied degrees ranging from history to engineering, and bring life experiences from business, education, farming, and teaching.  Each individual has unique motivations.  Throughout the early years of training, however, they are molded into a singular species and then neatly divided into groups: surgery, medicine, subspecialty, research.  Somehow we have developed a culture that encourages students to strive for “resume builders” instead of encouraging creative paths and ideas.  Medical students all look much the same when they finally apply to residency programs.  Is that what we want?

Take research for example.  Many (maybe most) medical students do research during their schooling.  Why?  Mostly because it’s what you need to do to get a residency.  But why not encourage the engineers to build a device?  Patents are just as impressive as papers.  Students with understandings of statistics or interest in management or business could be performing quality improvement projects.  Isn’t that the ultimate research?  Yet instead of pursuing creative ventures, most students devote their nearly nonexistent free time to a research project that they care very little about because it will help them get a good residency.

Fresh Eyes Don’t Last Long And Should Be Used While They Can

I’m not saying that research isn’t good for students.  Quite the opposite for a student who is truly interested in academics and finds genuine fulfillment in the process.  For them, research is fantastic.  It’s the students who don’t love research that I’m talking about.  Some of these are the fresh voices and creative minds that we should be looking to for innovative ideas!  Medical students are special because they are still naive to the culture of medicine and they see it for what it is.  Fresh eyes don’t last long and should be leveraged for what they bring.  It doesn’t take long for the system to gobble you up and change how you see the world, so let’s make the most of their viewpoints!  We should think carefully about how we train medical students.  Let’s mold them into the kinds of physicians we ourselves want to be–creative, independent and forward thinking.

Next Time You Hear Something Unusual From A Medstudent, Entertain The Idea

Doctors find it uncomfortable to think outside the box sometimes, and our experiences can train us to be rigid in our thinking.  But next time a student or colleague offers an idea that seems a little wild, entertain it and encourage them.  Some of those ideas may become the way of the future…

To Stay Or Go: Paramedicine As A Career


By:  The Musing Medic (@TheMusingMedic)


The Grass Is Always Greener

Most everyone is aware of the old adage “the grass isn’t always greener on the other side”.  And this rings true when considering a career in EMS versus moving up the medical hierarchy to another profession within the field.  I have made it no secret that my end game is becoming a physician but I certainly have considered other avenues.  But why should a paramedic consider a change of scenery?  I have identified the two reasons that make the most sense to me.


One Important Reason To Consider Is Finance

Probably the most obvious choice is financial considerations.  Paramedics and other pre-hospital workers earn a paltry wage that forces us to work two or three jobs with different services.  Around the Pittsburgh region, it is safe to say the average hourly wage is $15.00, give or take a dollar or two.  If a paramedic was to earn their RN certification, this would boost their hourly wage to around $22.00 to $25.00 as a brand new nurse.  Considering the average number of hours worked per year is a bit north of 2,000, that adds up to an additional $20,000 per year.  And that is just working one full-time job.  If they add on a part-time or per diem job, that number rapidly increases.  So less jobs held and increased wages is a solid reason to move from the paramedic to RN.


Obesity Epidemic Impacts Decision

Another consideration is the physical strain working as a paramedic puts on the body.  Climbing in and out of the truck, working in confined spaces, pushing, pulling, and lifting patients in awkward positions.  And let’s just put all the cards on the table here and mention that there is an obesity epidemic in the United States.  With a direct correlation between obesity and medical issues, it is no wonder that a significant number of scene runs involve a patient who is classified as overweight or obese.  Regardless of the technology available to pre-hospital crews, there is still a significant amount of lifting and the body can only take so much before it starts to break down.  Lower backs, knees, and shoulders seem to be the most common.  For a happy retirement it may be best to walk away from the pre-hospital environment before you are forced to limp away.


So What Are The Options Beyond Paramedic?

So what options are out there?  Well the quickest and most readily available path out of the pre-hospital world is nursing. Training is less than two years for a diploma or associates degree. There is a lot of versatility in the RN degree and the pay is certainly attractive.  But I think it could be difficult from moving from a very autonomous position as a paramedic to a position where autonomy is diminished and orders carried out.


PA Is An Option

Another option is Physician Assistant.  These mid-level providers are trained in the medical model and working in collaboration with an attending physician.  They diagnose, order tests, prescribe, and more. Physician Assistant programs are typically masters level so a bachelors degree is required first.  I think this is a solid forward move for seasoned paramedics.  The pay is fantastic at around $90k a year on average. Autonomy exists in spades typically but there is always a physician to bounce ideas off and consult with.  It seems like a logical extension of paramedic training.


Some Additional Options

What I left out were two other options; Nurse Practitioner and Physician.  I left these out because NP is an extension of nursing and being an RN is prerequisite for advanced practice nursing.  And I left out medical school because the duration of training and costs associated, both financial and non-financial.  After a certain age, the cost benefit declines sharply.


None of these options are the magic ticket to happiness but I think they are viable options for advancement and personal satisfaction.  So while the grass may not be any greener, maybe there is just more grass.


I’d be okay with that.


Till next time


The Musing Medic

Peeling Back The Curtains On A Startup: Team Formation


Click beneath for the podcast version:



By:  David Kashmer MD MBA (@DavidKashmer)


60% Of Startups Fail Owing To Team Factors

When colleagues and I become involved in a startup, there are certain things for which we look.  One of these elements for which we search is a unique vantage point that generates a sustainable revenue stream. That is, there has to be an idea which is somehow unique.


Next, that uniqueness must translate into profit.  It is preferable to have an idea that is challenging to imitate for one reason or another.


…but, just as important as those factors is the startup team dynamics and skill set.  Did you know it has been estimated that over 60% of startup failure are actually owing to team factors?  Some teams can take poor ideas and via strength of execution create a very solid business. Other teams can be given the best idea in the world and yet it falters.  Execution is equally important, then, with the initial idea in our opinion.  For that reason, the team factors are key for a startup.


The Provider Lifestyle Experts Team

In this series of entries we have been discussing a startup called Provider Lifestyle Experts.  In case you haven’t heard, Provider Lifestyle Experts focuses on the provision of administrative resources to improve lifestyle for people in healthcare. Healthcare has a large administrative burden which often is challenging for healthcare providers.  It can even lead to burnout.  Imagine working all those hours AND being buried under paperwork or unable to get simple life maintenance things done owing to workload issues.  Some even attempt to keep up with the burden of paperwork and other issues themselves.  This is a real pain point for people who practice in healthcare, and Provider Lifestyle Experts focuses on relieving that pain.


As mentioned in an earlier blog entry, I had an idea to have a business of virtual person assistants who functioned particularly in the healthcare space.  Healthcare paperwork and issues require special knowledge which is difficult to imitate.  Healthcare-related tasks typically befuddle current virtual assistant groups.  For that reason I worked on the creation of a business model around this idea.


However, owing to time constraints and other challenges I had the realization that I would not be the one to execute this idea, and I passed the idea off.  I can’t stress enough the importance of knowing ourselves well enough to decide whether we can (and should) execute on a particular idea.  So, as mentioned, I passed off the idea.


Team Members Need A Complimentary Skill Set

The team that was interested in executing the idea had some unique skills.  First, there was experience. This team is composed of three members who each have complimentary experience and who can work well together. Noam Wasserman, in The Founder’s Dilemmas, describes how important it is to have a team that can be collegial and yet can discuss the elephants in the room.  (That’s just one of the reasons why Noam recommends we don’t start businesses with family, as it can be challenging to discuss those elephants.)


When a team of complimentary individuals comes together it can be a truly powerful sight.  In the case of Provider Lifestyle Experts, the team is composed of a talented, entrepreneurial virtual personal assistant who has been in the business providing these services for years. Additionally there are two healthcare providers who maintain very different careers in healthcare.  These two staffers have business experience and are able to give guidance to the virtual personal assistant team member regarding specific healthcare issues. Interestingly, the virtual personal assistant on the team has functioned previously as a virtual personal assistant for a physician and has gained a great deal of experience with this.


The team has asked me to continue to intermittently advise them as they go along their startup journey.  I can’t say often enough how important it is that the team have complimentary skills rather than all sharing the same strength.  There are many components to a startup beyond simply design. We will explore some of these in the next blog entries.  For now, it suffices to say that sales, customer development, financial acumen, and conscientious follow up are all key at the beginning of a startup.


It’s Key For Each Team Member To Thoroughly Check Out The Others

For these reasons, the team members vetted of each other over a period of weeks to months to learn whether they can and would be able to function effectively in the new endeavor. It was important for everyone to go into the new venture with their eyes open and having a sense of whether they can and would perform.  In the case of PLE, the team took 3 months (as it decided to use Lean Startup methodology) to learn how it worked together and whether things would seem to work well.


So, to this day, Provider Lifestyle Experts is growing its client base, and already has passed its break-even point with customers. The excellent team dynamics have translated into a flexible adaptable team that executes well and has really capitalised on different opportunities. In our next blog entry we will follow these team dynamics and start to focus on exactly what the team did in terms of steps they used to create their unique business model and begin acquiring customers.

Future Attendings? Yeah Right.

By:  The Generation Y Surgeon (@GenYSurgeon)

I Hear This On A Daily Basis


I hear it nearly everyday now:

“They’re just not ready…”

“When I was a resident we would do ___, nowadays residents don’t even know what ___ is.”

“This patient is VIP so I will do most of the case…”

“We need the real attending before we can start the case.”

“They seem too young…”

And on and on.  As a graduating resident I find myself bombarded with demotivating, confidence destroying comments and feedback. Even as I interviewed for fellowship, I was encouraged to take the longer training option…from people who had never met me let alone see me in a clinical setting!  In almost every aspect of my training I feel the wrong kind of pressure:  it’s the kind of critical, demoralizing pressure that kills confidence and raises unproductive concerns instead of the feedback and constructive criticism that will help my colleagues and I grow into junior attendings.

Not What We Signed Up For

I signed on to surgery with an understanding that I would be trained and groomed by surgeons until I was a surgeon myself.  It was supposed to be that, during my five (or more!) years of training, the wise men and women would cultivate me into their likeness.  My naiveté would be replaced with the knowledge of the mentors who footsteps I followed, and that by the end of my residency I would be a surgeon-product that my predecessors would be proud to let fly and with which they would be proud to be associated.  Instead of graduating with cautious confidence and the immature skill set of a surgeon set to succeed on his/her own, I’m leaving my residency with a ticket to fellowship…and a head full of crippling, often useless, and often derogatory feedback.

Maybe I assumed wrong, or maybe I’ve too idealistic (unlikely), but I thought being a surgeon was about being a leader…a leader in the trauma bay, in the OR, and in the ICU.  So if I’m supposed to be  a confident, skilled leader then shouldn’t confidence and leadership be part of my training?

One Bad Idea On How To Fix A Broken System:  Make It Take Longer

General Surgery News just published an article about a surgeon’s proposal for a fellowship requirement after Surgery (read it here:

This surgeon stressed that his personal views are not those of the ABS; however, these are the personal views of a real thought leader in our field.

This article does an excellent job of outlining the barriers we face in improving resident education, including the 80-hour workweek and reduced autonomy in our current hospital systems; however, I don’t think you can blame the 5-year system for any shortcoming.  Before another year (or two) is added to the training schedule, aren’t we are obligated to fix what happens within the 5 years?

Can’t We Innovate Some Better Way Than Tacking On More Years To A Broken System?

For example improving the curriculum (SCORE has been a good first step), increasing dry-lab training and building in some meaningful training in leadership.  Furthermore, there’s much room for improvement when it comes to building confidence and loosening the “leash” as residents approach the end of their training.  Instead of being treated like a junior resident, chiefs should be treated like the attendings they are supposed to become in upcoming months.  It’s not just being able to start a case, it’s being able to run a team and assume the duties of an attending (as well as shedding some of the menial duties of being a resident).  This confidence should come not only from the attendings but from how juniors treat the chiefs as well.  Somewhere along the way, we’ve lost that hierarchy that used to exist within residency and along with it some of the inherent leadership that came with the roles.

I wonder if a mandatory fellowship would solve any of the problems identified in this article, by attendings or residents, regarding the quality of the final products of residency training (graduating chiefs).  Is adding time to our training really the answer?  I doubt it.  We need to change the content and culture of our training to find a better way to use the time we have.

Residents & Students:  Don’t Accept More Years Until We’ve Tried To Fix What We Have

I urge you to read the article, especially junior residents and medical students!  A mandatory fellowship turns 5 years into 6 or 7 years, maybe more.  That’s a long time to be a resident/fellow and that time requirement may influence your decision to pursue General Surgery.  If you’re spending that much time in training, then why not go into integrated plastics or vascular?  Or a different field altogether like cardiology or interventional radiology?  And for physicians who plan on working in rural and underserved areas as general surgeons, this is just another barrier….but that’s a whole other blog entry.

We face physician shortages in all fields these days, and especially in Surgery.  It’s important that we find a way to produce confident and effective surgeons and learn to do it in a timely fashion…or soon we will be graduating geriatric surgeons who need crutches both in and out of the operating room!

Utilizing Paramedics in the Hospital: A New Perspective


By:  The Musing Medic (@TheMusingMedic)


Here’s The Current Situation

Let me be blunt:  paramedics are woefully underutilized in the hospital setting.  Typically, paramedics employed by a healthcare system can be found in the ED or on hospital-based response units. This is our comfort zone–our arena. But, in the ED, our training tends to go by the wayside.  Our abilities and knowledge are neglected.  We are relegated to starting IVs, performing ECGs, and transporting patients.  In some places we are able to administer medications, but this usually is the upper limit of what we are allowed to do.  So how do we advance the role of the paramedic in the hospital?


Is It Necessary Or Useful For Paramedics To Do More?

As always, the first thing to do is determine need.  Physicians in the ED are constantly bombarded with patients at all hours of the day.  Some of these patients require more intensive care and procedures.  These procedures take time and delay treatment of other patients.  This causes a substantial logjam in the ED.  I think physicians could collaborate with paramedics to develop a training program that instructs paramedics on performing common procedures such as laceration repair, I&D, and central lines.


I am not insinuating that these procedures are a walk in the park, but I will argue that procedures (for all intents and purposes) can be taught to most people.  With enough practice they can be successfully completed.  Think about it:  send the paramedic in to start a femoral line on a patient requiring pressors, antibiotics, etc.  We complete this while you are assessing and discharging the dental pain down the hall.  By the time you get back, the procedure is completed.


What About During Codes?

The same can be applied to resuscitations. The physician should act as a leader during these codes and be focusing on the big picture as well as the details.  But many times, the physician is tasked with intubations, line insertions, etc.  This can be distracting (I have first hand knowledge of this when I’ve run codes in the field) and be a disservice to the patient.  Why not charge the paramedic with the intubation (which we do in the field often) or other procedures?


Yes, NPs & PAs Are There Too

I could cover more examples but for the sake of brevity, I will leave it with the two above. I realize that midlevels (PA and NP) are present in many facilities but they too can be taxed with a number of patients.  In the days of customer satisfaction and questionable metrics, the best model is proper and innovative utilization of resources.  That is where paramedics could come in to use.


A Few Potential Issues & Other Barriers

Potential issues could be resistance from state agencies, hospital administration, and the nursing lobby. If a proper program was developed and the proper channels traversed, there is potential for a new hybrid paramedic to be developed.

Perhaps this is all wishful thinking but new ideas are the foundation of positive change.



Till next time,

The Musing Medic

Have You Heard Of DMAIC? (Blogging A Book Part 2)


By:  DMKashmer, MD MBA MBB


Origin Of The Name


Now let’s talk about the pathways for Six Sigma.  First, let me share with you the origin of the name “Six Sigma”.  The idea behind the name of Six Sigma is that we want to be able to fit six standard deviations of data between the lower limit we would accept for the data and the upper limit we would accept for the data.  In other words, we take a process that usually functions with 0 or 1 standard deviations between the lowest and highest value (most systems) and attempt to make the process much more likely to deliver a good result by creating a situation where six standard deviations of data fit between the upper and lower specification limit. This will become much more clear as we go on.  For now just know that the term Six Sigma refers to the level of quality we are trying to achieve.


Six Sigma Uses Statistical Tools You May Already Know Arranged In A Certain Way


Next, take a minute and realize that Six Sigma takes existing statistical tools and puts these together in a meaningful way to achieve this outcome.  Six Sigma is nothing magical or revolutionary in terms of methodology.  It simply takes known tools that we could use by themselves and puts these together in a much more meaningful way.  So, to my healthcare colleagues:  don’t worry, Six Sigma is just the same old statistics you’ve seen elsewhere coupled with a methodology to apply these to what we do.  The system also sets up the pre-condition for us to all be on the same page with these useful tools and it allows to draw similar conclusions from similar data.


Six Sigma Evolved From Western Management Gurus Who Went East


It should be at least mentioned here that Six Sigma evolved in a unique environment.  We won’t go into the history too much in this text but you probably know post World War II Japan went through a rebuilding stage. American quality gurus went to Japan and were able to use the latest in management methods to help rebuild the organizational culture.  The focus on quantitative tools for management with a data driven culture really resonated with the local environment and over time this set of tools emerged as a slick, packaged system called Six Sigma.  Motorola is one of the most well known progenitors of Six Sigma and clarified the process greatly.


DMAIC, DMADV, & Tollgates


What are the processes of six sigma?  There are two.  The first is DMAIC, the next is DMADV. Each of these is usually pronounced as word “dah-may-ick” and “dah-mad-vee”.  This is a portion of the many acronyms and specialized language of Lean and Six Sigma that we’ll see as we walk through these processes.  In this section, we’ll focus on DMAIC.


DMAIC is the system utilized to improve processes.  The acronym standards for Define, Measure, Analyze, Improve, and Control.  Each represents an important step in the pathway to improving a process, and each step has certain checkpoints which we call tollgates that must be satisfied before progressing to the next step.  Let’s discuss each.


As we work our way through each tollgate and step, keep in mind that we haven’t discussed how to choose a project or pathway to improve.  There are many tools and criteria you can use to select which system you want to improve, and DMAIC are those steps to use once you’ve identified the target system.


Each Step In DMAIC With Tollgates


The D in DMAIC, as mentioned, stands for Define.  The Define phase has many important tollgates as shown beneath, and the first of these is the project charter.  The project charter is a tool that defines the scope of the project involved, the stakeholders (team members for the project from throughout organization) who have a role in its completion, the timeline for completion, and the expected cost savings in terms of the Cost of Poor Quality (COPQ)  that will be recouped.  For more information on the COPQ, look here.


From Villanova University's Lean & Six Sigma Black Belt Course (Fall 2011)
From Villanova University’s Lean & Six Sigma Black Belt Course (Fall 2011)



The next tollgate in the Define phase focuses the team on customer needs and requirements.  As usual in healthcare, we are faced with determining who exactly the customer is.  Is it the patient receiving the care?  Is it the third party payor who reimburses the health system?  Both?


The Voice of the Customer (VOC)


It is at this point in the Define phase that the customer(s) of the process being quantified is identified, and the customer’s voice is made visible as the Voice of the Customer (VOC).  As mentioned previously this can be very challenging but is central to the Six Sigma system.  The VOC is often used to determine the limits into which the system must fit.  In other words, if customers won’t accept, for some reason, waiting times more than 30 minutes then 30 minutes is the VOC and represents the upper limit for wait times.  Anything greater than that is a defect.


Sometimes, of course, the VOC can come from state regulatory bodies, JCAHO, or another accrediting body.  If an accrediting body was going to review a trauma center and published “trauma surgeons must be present within 15 minutes of patient arrival in the trauma bay” then that can be taken as a VOC and any arrival times greater than 15 minutes may be treated as defects.  Yes, they may be reasons which are perfectly valid for arrival time greater than 15 minutes, and the magic of Six Sigma is that it makes us look at how things lined up to get the situation where the surgeon arrives beyond 15 minutes…and it does it without pointing fingers or naming names.


The SIPOC Diagram


The next toll gate in the defined phase is the process map.  The process map, sometimes called a SIPOC diagram, helps us formalize what each step of the process is and eventually how we will obtain data.  This high-level map includes information regarding Suppliers, Inputs, Processes, Outputs, & Customers and from there we create the acronym SIPOC.  We use the process map to help select what data can and should be measured to characterize the system in the next step of the DMAIC process.


Next, in the measure phase, we formulate a data collection plan.  This crystallizes how many data points we will need to detect certain size changes in the system and sets up a statistically valid study.  We decide how and where we will get data, and we focus on a certain number of data elements for each portion of the SIPOC diagram.  Next we measure the process and establish a base line sigma level or CPK value.  This very clearly tells everyone involved how the system is currently performing.  For more information on the CPK visit here.


Data Driven Analysis


Next is the Analyze phase of the DMAIC pathway and so we focus the team on data analysis.  Data analysis uses the statistical tools of Six Sigma and, like the rest of the process, these take special training.  What is very useful about Six Sigma is that the participants involved will come to similar valid conclusions given similar data because they share a common body of statistics knowledge and those trained in Lean and Six Sigma know how to use the statistical tests to make valid conclusions.


The Ishikawa Diagram


Another tollgate closely follows.  A process analysis is performed whereby the process is analyzed for potential manners in which it can be revised in light of data, and a root cause analysis is performed with an Ishikawa diagram to determine what the roots are underlying the current state.  At times, a Black Belt or Master Black Belt may utilize a root cause analysis, coupled with a multiple regression, earlier in the process.


Six Sigma Statistics Have Ability To Change Our Minds


One of the tendencies typically seen in the DMAIC pathway is that staff and team members will jump to the Improve phase prior to the Measure and Analyze phase.  It is very normal, especially in the West, to think that we know what is wrong with the process because we live with it everyday. How can we ever know anything better than living in the system every day?  It’s powerful, intuitive, experiential, and (unfortunately) incorrect in terms of how a system needs improvement.  Healthcare colleagues, I’ve been there:  we work in a system everyday, are sure we know what’s wrong, and when the Six Sigma project data shows us something unexpected, well, it can’t be right.  Then changes are made based on the data and (huh) things improve greatly.  Amazing…guess it was right!


To climb up on the soapbox for a minute:  the power of these Six Sigma processes are that they place a cross-disciplinary team on the same page, they make the current state of performance VERY clear to everyone, they are not pejorative, AND they show a business case for why change is worthwhile.  The steps of Six Sigma, in many ways, satisfy all 8 of Kotter’s classic steps for culture change.  The DMAIC process even shows us where our every day experience of a system doesn’t line up with data.  Isn’t that the power of statistics?  To disabuse us when we think we are doing well but we aren’t and to change our minds about the way forward?


We have opinions and these are often strong and highly personalized.  In healthcare especially, we see opinions focused on people and the personally assignable portion of issues.  This is only one factor in meaningful quality improvement.  Therefore, I will take this moment to describe that it is important that the team wait until the data is in before jumping to analyse or suggesting solutions. That ensures this process is data driven.  Often, very often in fact, we find that the data have the ability to change our mind about what we thought was wrong, and when we listen to the data to make changes we see meaningful lasting improvement.   (Ok, stepping down off the soapbox.)


Rigorous Testing After Improvements Made


Next we pass into the Improve phase.  The Improve phase has several toll gates including stakeholder generated solutions.  The stakeholders generate different solutions based on the now visible and shared data.  Again, generating solutions based on the data that are present makes an important difference for not just project outcome but overall quality in the system.  Then, solutions are selected from among candidate solutions based on criteria like how easily they maybe implemented, resource expenditure and impact in the system.  Solutions are implemented and follow-up data is collected to ensure a significant improvement as demonstrated by statistical testing.


Things Are Improved, But Let’s Not Forget Maintenance


Next, importantly, is the control phase of the DMAIC pathway.  Once a system has been improved, it is important to have ongoing review of the system and oversight with control.  That way, if the system relapses into a poor state of quality, we are aware and can make changes.  Tools like individual moving range charts (ImR charts) and similar techniques are useful as we focus on keeping the improved system under control.  Finally, a response plan is generated so that when the system does give us the signal that it is having quality issues there is a planned response.


If You Don’t Have DMAIC, You Probably Just Have An Opinion


Above, we have described the DMAIC pathway for Six Sigma.  Remember, the point of this pathway is to promote Six Sigma’s stated goal of achieving six standard deviations of data between the upper and lower spec limit.  That may not have much meaning to you now, but it states that Six Sigma seeks to make great improvements in things like defect rates.  The DMAIC pathway is the overall scheme by which this is performed.  You have seen that this is very different than how we typically function in healthcare in that it is highly data-driven and that personally assignable, opinion-based changes are highly discouraged.  The saying, in Six Sigma, is that “if you don’t have data you just have an opinion.” The DMAIC pathway has certain tollgates which the team progresses through.  These tollgates are steps by which meaningful improvement is achieved and sustained before the final control phase.


Clearly the DMAIC pathway is very different than our typical approach to quality control in healthcare, and, as we close this section, let me share with you that it is much more effective.