Six Sigma and Total Quality Management in Healthcare

Quality improvement in health care has developed gradually as emerging ideas have been explored and implemented within various clinical and non-clinical settings.  One of the more recent methods of quality improvement which has been introduced into healthcare organizations is Six Sigma.  Six Sigma is “a rigorous set of processes and techniques to measure, improve, and control the quality of care and service based on what is important to the customer (Woodard, 2005, p. 229).”  

The goal of this approach is to bring procedures to defect-free levels by trying to eliminate variation in processes.  Defects are seen as any factors which lead to customer dissatisfaction.  Many processes in healthcare require a near-zero tolerance for error, especially in the clinical setting.  Bringing processes to a level that approaches defect-free can positively impact patient care, safety measures, heath outcomes, efficiency, and cost reduction.

 Six Sigma efforts have touched a wide range of functions in health care.  Examples of such implementations show that they can be successful in several capacities: medication error, lab turnaround time, supply chain management for supplies, claims reimbursement, nursing retention, patient condition outcomes, and others (Revere and Black, 2003).  Though the benefits of these projects are clear, the high level of specificity, analysis, and design can make them quite resource intensive.  The resource requirements involved in bringing such projects to fruition is a major challenge.  In looking at the literature surrounding this topic at least one article suggests a solution.  Revere and Black propose piggybacking Six Sigma onto existing Total Quality Management (TQM) programs.  Their underlying rationale is that similar quality efforts can be synergized to achieve better results with less disruption to organizations.  “Six Sigma is an extension of the Failure Mode and Effects Analysis that is required by JCAHO; it can be easily integrated into existing quality management efforts (Revere and Black, 2003, p. 377).”  Such an approach would involve the integration of Six Sigma into an existing program through detailed data analysis.  It would require delving into the current process examination and improvement measures on a more detailed level.

Some TQM programs may lack sufficient data collection and analysis to fully understand process variation.  Six Sigma can overcome these challenges through its emphasis on understanding process variation in tandem with implementing change.  This aspect of Six Sigma can make TQM more effective.  “The work of Six Sigma is not unlike TQM; however, its goals are more aggressive and its methods are better defined (Revere and Black, p. 379, 2003).”  Using these two approaches jointly can be valuable in creating successful programs for quality improvement in healthcare.

Though Six Sigma provides a higher level of measurement, this is not the only aspect which can make it successful in healthcare organizations.  Enhanced metrics need to be paired with skillful management in order for programs to be designed that are successful in diminishing process variation.  Programs must be designed to alter structures and processes to actually produce changes in outcome.  Furthermore, methods must be put in place to ensure compliance with these process changes.  These tasks become the responsibility of company management and program participants, and the steps involved must be administered effectively in order to be successful.  Six Sigma is guided by the DMAIC approach: define, measure, analyze, improve, and control (Riebling and Tria, 2005).

The level of detail and reporting required by Six Sigma also pose challenges to organizations: “Every component of every service needs to be reported, measured, and recorded on a regular basis (Revere and Black, 2003, p. 388).”  The specific challenges which are encountered depend on the type of organization involved, intervening processes, data sources, and data quality.  Intervening processes may be especially complex if they involve multiple entities, several layers of interaction, and numerous methods of feedback.

Using Six Sigma in healthcare organizations has clear benefits but does not come without difficulties.  In addition to the potential benefits to existing quality improvement programs, the internal benchmarking and prioritization of other projects can be improved when Six Sigma metrics are used (Revere and Black, 2003).  This can be a major advantage to company management when deciding how to allocate project resources.  Ultimately, using Six Sigma in health care can only be successful if management is committed to quality improvement and can manage the costs of such efforts.


Neri, R.A., Mason, C.E., Demko, L.A. (2008). Application of Six Sigma/CAP methodology: Controlling blood-product utilization and costs. Journal of Healthcare Management. 53:3

McLaughlin, C.P., Kaluzny, A.D., (2006). Continuous quality improvement in health care: Theory, implementations, and applications. Jones and Bartlett; Massachusetts. 3rd ed. Morgan, S.P., Cooper, C. (2004). Shoulder work intensity with six sigma. Nursing Management.

Revere, L., Black, K. (2003). Integrating six sigma with total quality management: A case example for measuring medication errors. Journal of healthcare management. 48:6.

Riebling, N., Tria, L. (2005). Six Sigma project reduces analytical errors in an automated lab. Medical Laboratory Observer.

Trusko, B.E., Pexton, C., Harrington, J.H., Gupta, P. (2008). Improving healthcare quality and cost with six sigma. Mayo Foundation for Medical Education and Research.

Weldon, J. (2005). Six Sigma for continuous improvement. The Iowa Nurse Reporter. Woodard, T.D. (2005).  Addressing variation in hospital quality: Is six sigma the answer?. Journal of Healthcare Management. 50:4.

Young, D. (2004). Six Sigma black-belt pharmacist improves patient safety. American Journal of Health-System Pharmacy.

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