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Introduction
As healthcare spending rises, so do concerns about healthcare quality. A major impetus toward recognizing the need to improve healthcare quality and patient safety occurred when the Institute of Medicine released a report in November 1999 in which the authors estimated that around 98,000 patients die following medical errors in hospitals each year ([72] IoM, 2000). Through process and quality-improvement efforts, healthcare quality for millions of Americans has improved but varying performance continues to leave many people receiving substandard care. The IoM report and ongoing interest in improving operational cost and quality led authors to recommend applying Six Sigma to US healthcare and elsewhere ([61] Guinane and Davis, 2004; [132] Woodard, 2005). [17] Carrigan and Kujawa (2006) state that Six Sigma is an effective strategy for establishing and sustaining competitive advantage and achieving long-term goals. Six Sigma offers time and cost savings, and revenue enhancement; metrics to indicate current process, outcome or service quality and a focus on improving 'critical to quality' (CtQ) characteristics vital to internal and external customers ([11] Black and Revere, 2006, p. 264). Physician participation in Six Sigma projects is critical; [45] Ettinger and Van Kooy (2003) discuss strategies to support their engagement. However, Six Sigma's value in improving healthcare is not well-established. [83] Landek (2006) argues that Six Sigma is a useful tool, which may not be effective in hospitals because cash and resources are required. [95] Neff (2003) states that Six Sigma's scope can be overwhelming if not broken down into manageable pieces that require significant time investment.
The author's purpose, therefore, is to comprehensively review and assess the extant Six Sigma healthcare literature, focusing on: application; process changes; outcomes, including process-metrics; cost; and revenue improvements. Those areas that have seen the most successful application are identified and suggestions for other applications and Six Sigma's improved usage are discussed.
Six Sigma and Lean Six Sigma
Six Sigma projects are undertaken to identify and remove a defect's cause or errors and reduce variability to improve processes, focusing on CtQ. The goal is to achieve a 3.4 part per million error rate, although significant improvements towards this goal would be deemed a success. A structured approach is used to uncover a problem's root cause using the DMAIC method: Define the...