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

DMAIC is a well-established methodology for process and quality improvement that aims to create innovative, targeted solutions and influence change (Christopher et. al 2014, Kurnik, n.d.).

• Define
  • Clarify the purpose and scope of the project while conveying a deep understanding of the problem.
  • Develop the team and assign responsibilities based on individual strengths.
  • Identify key stakeholders to ensure ownership and accountability throughout the project.
  • Develop a team charter to clearly define goals.
• Measure
  • Develop a detailed process map.
  • Develop an audit tool or identify a metric that is representative of the process performance.
• Analyze
  • Audit current processes (retrospectively and prospectively).
  • Review all data collected and consider chart/graph for ease of understanding.
  • Brainstorm solutions.
  • Focus on actual problems to solve.
• Improve and Control
  • Conduct a best practice review.
  • Develop a pilot.
  • Assign resources to improvement tasks along with a timeline for task completion. Consider assigning projects to individuals outside the team to identify the best person to execute the task (i.e., has authority to effect change).
  • Consider using a metric control chart to track actions, assignees, target completion dates, actual completion dates, and task status on a weekly basis and address obstacles.
  • Create a system to ensure that critical tasks continue without the team’s ongoing support so that process improvement initiatives are not lost.

Quality Improvement Tools (Harkness & Pullen, 2019)

Many tools have been developed and utilized to assist in the quality improvement process. 

Model for Improvement/Plan-Do-Study-Act (PDSA)
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
Lean is a systematic method to identify and eliminate waste by implementing value-added processes based on customers’ perceptions of satisfaction. 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

Six Sigma
Six Sigma is a process to decrease variation and is similar to the DMAIC process described above. Steps include the following:

• Define: set goals that are consistent with customer demands and the organization’s strategy.
• Measure: evaluate the current process and set a baseline for comparison. Utilize statistical tools such as descriptive statistics, run charts, and Pareto charts.
• Analyze: verify cause and effect and identify ways to achieve goals.
• Improve: optimize the process based on analysis. Implement and evaluate the plan and transition it into the standard processes.
• Control: ensure the variances are corrected before they result in defects. Identify and communicate processes through ongoing data collection and evaluation.

Root Cause Analysis (RCA)
RCA is a retrospective, systematic approach to discern 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:

• Identifying what occurred
• Reviewing what could have or should have happened
• Determining the causes
• Developing causal statements
• Generating recommended actions to prevent recurrence
• Writing a summary and sharing it with administration, staff and all involved in the event 

Frontline Dyad
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)
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?

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).