Define, Measure, Analyze, Improve, and Control (DMAIC) (Monday, 2022)

DMAIC, the traditional project method for Six Sigma, is a well-established methodology for process and quality improvement that aims to create innovative, targeted solutions and influence change.

• Define the project objective, scope, and time frame.

  • Develop an aims statement, describing the desired outcomes in a measurable way.
  • Perform a stakeholder analysis.
  • Complete value stream mapping (current state, ideal state, and future state map).
  • Create a process map.
  • Conduct customer-focused research.
• Measure data to evaluate the current process and set a baseline for comparison.
  • Establish a data collection plan.
  • Verify data accuracy.
  • Utilize statistical tools such as descriptive statistics, run charts, and Pareto charts.
• Analyze the data and identify ways to achieve goals.
  • Verify the causes of error, deviation, waste, or delay.
  • Review all data collected using charts and graphs (pareto diagrams, histograms, Ishikawa diagrams, or 5-whys analysis).
• Improve standardization of the process.
  • Conduct a best practice review; identify benchmarks.
  • Brainstorm and communicate solutions.
  • Optimize the process flow based on analysis.
  • Implement changes to remove the issues leading to errors, variability, and waste.
  • Provide education and revise policies.
  • Explain the concept of Kaizen (which means “change for the better”), a philosophy that improvement is a continuous and methodical process.
• Control
  • Track process performance.
  • Implement control charts to monitor variation in processes.
  • Utilize visual process control which improve efficiency and effectiveness of process by making the steps more visible (e.g., color coding, floor signage).
  • Repeat DMAIC or Plan-Do-Study-Act cycle (see below).

Quality Improvement Tools

Many tools are available to assist in the quality improvement process.

Model for Improvement/Plan-Do-Study-Act (PDSA) (Harkness & Pullen, 2019)
PDSA is a systematic approach to reassess processes and improve outcomes. Three main questions form the improvement plan.

• What are we trying to accomplish? This sets the vision for the program.
• How will we know that a change is an improvement? This outlines the steps to achieve the desired outcome.
• What changes can be made that will result in improvement? This generates ideas for testing.
• Pilot the PDSA program on a small scale, analyze the data, refine the program, and repeat until the desired outcome is achieved.

 
Lean Process Improvement (Monday, 2022)
Lean is a systematic method to improve efficiency and deliver the best product by eliminating waste. It answers the question: “What changes can we make that will result in improvement?” Key definitions include:

• Value: what the customer is willing to pay for
• Nonvalue added: a process that does not add value but must be done
• Waste: what the customer is not willing to pay for

 
Root Cause Analysis (RCA) (SixSigma, 2024)
RCA is a retrospective, systematic approach to pinpoint the causes of an adverse event and identify system weaknesses that can be improved to prevent the error from occurring again. The RCA process involves:

• Defining the problem and identifying its impact
• Gathering information and data, creating a timeline of events, and documenting contributing factors.
• Identifying causal factors and determining the relationship between the factors
• Pinpointing the root cause(s)
• Implementing preventative solutions, developing a corrective action plan, allocating resources, and assigning responsibilities
• Writing a summary and sharing it with administration, staff and all involved in the event

 
Frontline Dyad (Harkness & Pullen, 2019)
Frontline dyad is a bottom-up approach which utilizes a small team of two frontline staff members to identify both clinical and nonclinical issues in daily work. It involves a timeline, design benefits, specific actions, and design/test strategies. The team or dyad is responsible for the work and must show significant improvement in 30 days or less.
 
Failure Mode and Effects Analysis (FMEA) (Harkness & Pullen, 2019)
FMEA is used to assess possible failures and prevent them as opposed to reacting to adverse events after mistakes have been made. The analysis prompts teams to review, evaluate, and record steps in the process:

• Failure mode - What could go wrong?
• Failure causes - Why would the failure happen?
• Failure effects - What would be the consequences of each failure?

FMEA analysis includes the following (SixSigma, 2024):

• Identify the potential failures (risks).
• Identify the effect of each failure.
• Identify the root cause.
• Prioritize the failures according to the risks.
• Take action.
• Eliminate/reduce the risk.

Nurses at every level of practice should participate in QI initiatives, be aware of key elements in the QI process, promote a culture of QI, and serve on QI teams (Harkness & Pullen, 2019).