Patty: It's unlike the process improvement emphasis previously experienced in health care. There have been methodologies introduced over the past decade such as Six Sigma, Balanced Scorecard and Rapid Redesign, but older methodologies such as Workout Sessions, Plan Do Check Act (PDCA) Methodology and Total Quality Improvement (TQM) still have an important role in the process improvement tool kit. The methodology that most health care organizations are adopting is Six Sigma. This methodology was first invented by Motorola to correct poor manufacturing quality and later adopted by General Electric among other corporations.

Leslie: With the focus on reducing medical errors and increasing patient safety, it makes sense to me that the health care industry look to the lessons of the manufacturing industry for methods of improving processes and achieving very low error rates.

Patty: Six Sigma stands apart from other process improvement methods because it focuses on reducing variability thereby reducing errors or achieving defect free products or services. It's seems like the perfect methodology to apply in reducing medical errors in our country.

Leslie: The use of Six Sigma in the manufacturing environment has resulted in significant improvements in quality from which we as consumers have benefited. As I understand it, the focus is on defect prevention as opposed to defect detection.

Patty: That's right. Six Sigma is a philosophy and perspective about quality and a way of running a business. It is not a program and it is not solely about solving problems. Six Sigma uses a number of tools and processes such as DMAIC, which is define, measure, analyze, improve and control. This is a scientific process that is systematic and based on data. Six Sigma places a heavy emphasis on data to drive decisions. But it also considers business savvy in the equation. The General Six Sigma Electric Training Manual indicates data is important because of the following:

"We don't know what we don't know meaning our knowledge is always incomplete."

"If we can't express what we know in the form of numbers, we really don't know much about it."

"If we don't know much about it, we can't control it."

"If we can't control it, we are at the mercy of chance."

Leslie: Those are good statements to help put the importance of data in context. Six Sigma is not the be-all and end-all for business improvement but I like that it is based on data where other improvement methods like re-engineering tend not to be so data focused. Oh, I was so involved in the conversation I forgot to ask, what are green belts and black belts?

Patty: They are levels of expertise in understanding of Six Sigma methods, the use of Six Sigma tools, and knowledge of statistical concepts. There are a number of formal training programs to learn Six Sigma and to earn one's green or black belt. Books and online courses are also available.

Leslie: I like the classification. You mentioned some other process improvement methods earlier in our discussion. What are they?

Patty: There are a number of process improvement methods but what you learn quickly when you study the different methods, is that they often compliment each other. You might be involved in a Six Sigma process and will implement the PDCA cycle or hold a Workout Session. Workout Sessions are a structured problem-solving approach developed by GE.

Leslie: I remember the TQM methodology became really popular in the 1980s; I am most interested to understand when it is best to use this methodology.

Patty: TQM can be considered an evolutionary process improvement method in comparison to Six Sigma and Rapid Redesign. The latter methods both are considered revolutionary. For example, TQM or continuous quality improvement (CQI) are methods that are more incremental in nature. Thus the outcomes of these methods tend to fine tune existing processes or are more evolutionary. TQM goals for example might be used to reduce coding errors by 5 percent or reduce transcription turnaround time by an additional 8 hours without adding staff.

Leslie: TQM/CQI also tends to focus on one aspect of a process at a time, which might result in ignoring other parts of the system that are not included in the process that is being studied.

Patty: That's true, and it's a common criticism of TQM/CQI. But these methods are important in health care and continue to be a useful methodology for incrementally improving processes or studying a particular part of a process. TQM for example would not work well in crafting the vision of the electronic health record (EHR) and the processes that need to support it. Nor will it be fast enough.