NHS Improvement

An Overview of Six Sigma

October 2011
What is ‘Six Sigma’?
‘Six Sigma’ is a continuous improvement philosophy, methodology and toolkit that has a proven
commercial pedigree that can be traced back to the quality revolution of the 1940’s.

• As a business strategy it focuses on the requirements of the customer and of improving

processes, products and reducing costs. It enables organisations to improve performance
by eliminating unnecessary processes and delays.

• As a methodology it provides a robust multistage framework with which to control

improvement efforts. This framework typically has the following stages; Define, Measure,
Analyse, Improve and Control. This is often referred to by its acronym ‘D.M.A.I.C’.

• Six Sigma projects emphasise the importance of fully understanding customer needs and
of the identification of ‘problem’ root causes (rather than reacting to problem symptoms).
Six Sigma projects concentrate on facts rather than management anecdote or opinion
and most importantly ensure that improvement is underpinned and sustained by rigorous
statistical measurement and analysis.

• Six Sigma seeks to improve process performance, decrease variation and maintain
consistent quality of the output of the process. It provides a disciplined data driven
approach to quality and a method for eliminating defects.

• As a statistical concept, Sigma represents the amount of variation present in a process

relative to customer requirements or specifications. When a process operates at the six-
sigma level the variation is so small that the resulting products and services are
99.9997% defect free. (Equivalent to 3.4 defects per million opportunities).

• Typically the ideas, concepts and the methodology that are Six Sigma are formally
incorporated into the business and operational strategies of an organisation. This
requires a substantial investment in training at all levels within the business.

Once trained, different improvement methodologies are available which can be aimed at either
improving existing processes (D.M.A.I.C) or in the design of brand new processes (Define,
Research, Analyse, Define, Validate – D.R.A.D.V).

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NHS Improvement, 3 Floor, St Johns House, East Street, Leicester, LE1 6NB October 2011
The D.M.A.I.C. methodology

The 5 step D.M.A.I.C approach

The five steps of the DMAIC method are as follows;

1) Define the project

Define the project’s purpose and scope.

Collect background information on the process and your customer’s needs and
requirements.

2) Measure the current situation

Gather information on the current situation in order to provide a clearer focus for the
improvement effort.

3) Analyse to identify causes

Identify the root causes of problems.

Confirm them with data.

4) Improve

Develop, improve and implement solutions that address root causes.

Use data to evaluate results for the solutions and the plans to carry them out.

5) Control

Maintain the gains by standardising work methods or processes.

Anticipate future improvements and make plans to capture the lessons learned from the
improvement effort.

The table below illustrates each stage of the process together with the types of activities the
project teams will carry out. Note that the tools and techniques listing is by way of example and
is not exhaustive.

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Step Purpose Main Activities Tools & Techniques

Define Defines the problem, develops • Identify improvement • Charter

a clear mandate based on a opportunity • Milestone plan
real problem • Develop Charter • Project plan
• Listen to Voice of the • Customer surveys
Customer • Process maps
• Define critical customer • Affinity diagrams
requirements
• Map processes

Measure To understand the baseline and • Identify measures • Detailed process

current levels of performance • Develop operational mapping
definitions • Measurement plan
• Develop & implement (existing versus new
measurement plan data)
• Collect other baseline
information

Analyse To establish problem root • Identify root causes • Statistical process

causes and understand their • Validate root causes control
effect on the process Process capability
• Determine true sources of •
variation calculations
• Process control and • Defects per million
capability calculations
• Analysis of detailed • Fish bone diagrams
process maps for • X & Y analysis
improvement opportunities • Cause & effect
• Plot and analyse data matrix
• Determine the amount of • 5 whys
variation within processes • Pareto analysis
• Determine sigma score • Hot spot matrix,
value/non value
added analysis
• Histograms

Improve To develop, select and • Generate solution ideas • Process mapping

implement the best solutions • Evaluate & select solutions • Brain storming
• Develop process map for • Chain letter/ideas
solution box
• Initiate measure and • Affinity diagrams
evaluate pilot • Force field analysis
• Communicate solutions to • Solution screening
stakeholders and evaluate • PDSA/pilot studies
plan

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Control To ensure the solutions are • Verify reduction in variation • Control
embedded, that the process and sigma score plan/dashboard
has robust controls • Develop standard practices • Procedures and
• Monitor performance standards
• Integrate lessons learned • Process control
• Recommend future plans systems
• Identify next steps and • Statistical process
remaining opportunities control
• On going training &
education

Relevance to the NHS and 18 weeks

A study jointly conducted by the CHD Collaborative and the NHS Modernisation Agency over a
two year period (and some 20 projects) identified that the strength of Six Sigma lay in the five
stage DMAIC process which guides the improvement process, together with rigorous statistical
measurement, analysis and control that exists at the core of the methodology. It was also
recognised that the comprehensive nature of Six Sigma training provides an opportunity for
improvement practitioners (and project team members) to gain new skills and also to enhance
and consolidate existing skills. These benefits provide the platform for the delivery of quantifiable
service improvement based on hard data (customer requirements, process performance, root
cause analysis and so on) rather than ‘soft’ management anecdote.

A recent Six Sigma project conducted at Sherwood Forest NHS Trust with regard to outpatient
department and diagnostic improvements has demonstrated the methodology’s applicability to
the 18 week outcomes. Set up correctly, Six Sigma projects will balance the process or output
requirements of all customers (patients, clinicians, diagnostic technicians and so on) with the
resources available to deliver that process or output both efficiently and effectively.

What makes for successful NHS Six Sigma projects?

The study identified a number of areas in the application of the methodology that required
refocusing together with a number of recommendations as to the required skill sets of the Six
Sigma practitioners.

1) Skill sets

In addition to full Six Sigma training practitioners must be competent in project planning, project
leadership and team facilitation. Without these complementary skills, projects will fail as they are
needed to support the DMAIC methodology. The tool kit is only a means to an end and not an
end in itself. Of fundamental importance is the ability of the practitioner to use discretion in the
application of the methodology and tools; most NHS problems will not need advanced statistical
analysis or hypothesis testing to gain significant improvement.

2) Application of the methodology

Commercial Six Sigma projects are typically run within Six Sigma organisations whose business
strategy has been created to support this methodology. This means that organisations will have

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a Six Sigma trained workforce together with a board level mandate to pursue improvement in
order to gain competitive advantage. In short, Six Sigma will be part of the culture of the
organisation.

The NHS environment does not have this type of platform to conduct improvement from. There is
little in the way of coherent improvement strategies and it suffers from competing priorities and
limited resources.

With this in mind, it is imperative that projects are set up ‘for success’ and that time is taken prior
to the ‘define’ stage to ensure that all parties/stakeholders connected with the initiative are clear
as to the extent of the commitment and risks involved with the proposed undertaking. It is vitally
important that these issues are surfaced as early as possible as they may determine the timing
of the project, (i.e. not during waiting list initiatives) or indeed whether the project will run at all
(conflicting priorities, no clear change imperative – lack of buy in).

See Top Tips Section on Successful Projects ‘Work before the work’

The table below details the type of activities that help set the project up for success;

Step Purpose Main activities Tools & Techniques

Preplanning To set and communicate the • Team selection, • Strategic option

purpose and content obtaining commitment & appraisal
requirements\expectations of the buy-in • Stakeholder attitude
project within the context of the • Assess the position of analysis
organisation. all stakeholders • Stakeholder
regarding commitment influence strategy
and reaction to project. • Project risk
(joint expectations) assessment plan
• Assess the most • Communication plan
appropriate (or • Pre charter
required) approach to • Draft charter
service improvement • Draft milestone plan
(i.e full or partial • Train champion
application of
methodology – low
hanging V high fault)
• Assess organisation
requirements – high
level identification of
quick win versus low-
level detailed projects
(optional appraisal)
• Develop
communication plan
• Develop project risk
assessment plan
• Identify & appoint
project champion
(recommend medical
director)

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Hints and tips

The charter forms the contract for improvement and as such is the single most important
document in the project set up;

– Business case and opportunity.

– Team requirements and backfill.
– Risk assessments.

The charter will go through a number of iterations during the life of the project as the problem
is refined.

Be prepared to cancel the project if the basic support criteria aren't evident.

Initial projects should be small and simple.

People get hung up on the Sigma score and ‘defect’ – its less important than achieving
improvement.

Clinicians like the statistical element of Six Sigma. However, be aware of the potential for
evidence to emerge that will challenge the way individuals and departments work. This
will make for some interesting team meetings.

Use only the tools that are needed for the job, you don’t need a statistical sledge hammer
to crack a nut!

Clinical problems always require consultant buy in.

Ensure that a degree of ‘redundancy’ is built into the project team as it is highly likely that
key individuals will be ‘lost to the service’ during the life of the project. Ensure team
members have deputy or ‘buddy’ arrangements in place to ensure project continuity.

Data collection and analysis can be time consuming especially where manual data trawls
are required and/or they impact on clinical areas; plan accordingly. This also applies to
‘Voice of the Customer’ questionnaires (which are likely to require Research and Ethics
Committee approval prior to being issued). Staff involved in any manual data collection
process will need training to ensure that data is collected in line with the measurement
plan, is consistent and follows the data operational definition. Staff may need training in
the measurement device which may need calibrating.

Improvement project solutions that require new or different ways of working need careful
planning and the total commitment of operational staff if they are to be successful
(especially in clinical and public areas).The testing stage may actually increase the
workload as the ‘bugs’ are being ironed out of the processes (particularly where the test
is being run in parallel with existing processes). Ensure that plans are robust and have
been accurately risk assessed. Completion of a ‘Failure Mode and Effects’ analysis on
the revised processes will ensure that risks are appropriately mitigated. Ensure that
measurement plans together with arrangements to collect review data are in place and
that any measurement devices are correctly set up and synchronised .This may require
the collection staff to be trained.

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NHS Improvement, 3 Floor, St Johns House, East Street, Leicester, LE1 6NB October 2011
Links to further resources

Isixsigma – contains articles, frequently asked questions, and explains how to use the tools &
techniques. Also contains a healthcare section with examples at: www.isixsigma.co.uk

For further information regarding Six Sigma in healthcare, contact:

garry.white@improvement.nhs.uk

Further information on all service improvement tools and techniques are also available at:
www.institute.nhs.uk

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NHS Improvement, 3 Floor, St Johns House, East Street, Leicester, LE1 6NB October 2011
NHS Improvement
3rd Floor St Johns House
East Street
Leicester LE1 6NB

Telephone 0116 222 5253

Email: Support@improvement.nhs.uk