How to Achieve Zero Retained Foreign Objects with DMAIC Part IV

In this article, we will examine the critical fourth step in the DMAIC process of the Six Sigma methodology, the Improve phase. (Read about the Define, Measure and Analyze phases.)

The Improve Phase of the Six Sigma DMAIC Model

The key to having an effective and successful Improve phase (such as identifying key process improvement ideas and conducting pilots to verify the ideas) is to first achieve clarity and scope of the Define phase, exhibit diligence in the Measure phase and narrow down the critical factors in the Analyze phase. The process improvements considered for piloting during the Improve phase should be anchored using a rational hypothesis based on mathematical and/or statistical methods. As ideas are considered for piloting, the question to ask is, "Can the new process, if successful, demonstrate the effectiveness of the solution in overcoming the problem identified in the Define phase?" If the answer is yes, then test the new process to ensure it can be successfully implemented.

Six Sigma tools common to the Improve phase include brainstorming, Failure Mode Effects Analysis (FMEA), small tests of change (PDSA, PDCA), stakeholder analysis, change management, Pareto analysis, Analysis of Variance and other statistical tools (to test if the differences due to process changes are significant or not). It is important to pilot a process improvement on a small scale by starting with one department, one doctor, one area, one shift, one week, etc. before embarking on a full roll out. The pilot enables testing of the concept and making needed changes before a full roll out. Simulation and mathematical modeling are gaining popularity to test changes in the Improve phase.

The Improve phase should not be planned and executed just by the Six Sigma project team. It is important to actively engage the staff. Engaging the members of the staff working in the process helps in getting the necessary buy-in, improves communication, elicits feedback from end users and increases the odds of a successful pilot and implementation of new ideas. As the Six Sigma project team generates ideas, a systematic approach should be used to evaluate all ideas based on the project needs and constraints, which were articulated in the Define phase. The constraints could be time, resources, and ease of implementation of ideas (effort vs. impact).

Using the Six Sigma DMAIC Approach: The Improve Phase of the Retained Foreign Objects Project at the Mayo Clinic

For the retained foreign objects project at the Mayo Clinic Rochester, the Measure and Analyze phases narrowed the critical factors. These critical factors included the need for technological solutions to keep track of the counts, improve communication among OR staff, streamline the counting protocols and guidelines, and maintain a dashboard that the staff can easily understand to keep track of the retained foreign objects. Once the process improvement areas were identified, the team brainstormed around each of these areas to develop a list of alternatives.

Examples: For the technology aid to help with the count process, the Six Sigma project team reviewed the RFID, bar-coding and other emerging technologies and decided to perform a small test of change with the most promising technology in the market. After the initial evaluation for two weeks in one operating room in two specialties, the Six Sigma project team worked with the vendor to make modifications to the software and the process to better suit the OR staff. It is important to adapt the technology to meet the needs of the user rather than forcing the user to adopt to the technology (I remember in the university I attended, when a fresh lawn was developed, the ground staff waited for a month to see the path students walked before laying the sidewalk. This ensured students stayed on the sidewalk rather than cutting through manicured lawns). The Six Sigma project team also piloted white boards and electronic white boards to help communicate (non-verbal) the status of the counts. The counting protocols were revised and simplified, and the team with input from the OR staff developed a simple decision tree that would help in following the correct path if counts during any stage of the surgery were incorrect. Several other PDSAs were conducted to make changes to the process to improve communications among the 100 plus operating rooms using simple tools such as e-mails and "Days since Last RFO" boards that were updated daily. With these process improvements in place, the sigma level has increased from 5.7 to 6.0 and the Six Sigma project team continues to improve the process further in the true spirit of continuous improvement.

The Six Sigma project team ensured that the pilot studies were evaluated for their effectiveness, economy and efficiency and implemented the most promising technology for counting in all ORs early in 2009.

Summarizing the Improve Phase of the Six Sigma DMAIC Model

To summarize, in the Improve phase the Six Sigma project team should be able to identify the critical factors that influences the project outcomes, develop pilots (either small tests of change or simulation) to verify the effectiveness of the process improvements, validate the results and verify that the process is working as intended. Once proven, the Six Sigma project team should develop plans to roll out these process improvements using project management and change management principles to ensure success scale up and roll out.

In the next article, I will discuss the Control phase and project closure.