Six Sigma is perceived as a smarter way to manage a business, or a veterinary practice, which IS supposed to be a business. It is defined as:

1.  A statistical measure of the performance of a process or a product.

2.  A goal that reaches near perfection for performance improvement.

3.  A system of management to achieve lasting business leadership and world class performance.

Six Sigma actually puts the client first and uses facts and data to drive better solutions. Six Sigma efforts target three main areas:

 Improving client satisfaction.

 Reducing cycle time.

 Reducing defects.

Improvements in these three areas usually represent: an increase in net income, a dramatic cost savings, higher client retention, the capture of new markets, and builds a reputation for top-performing services. Yes, like CQI, it is improvement-focused, yet it offers three key characteristics that some intuitively knew, and practiced, but seldom measured:

1.  Six Sigma is client focused. It is almost an obsession to keep external client needs in plain sight, driving the improvement effort.

2.  Six Sigma projects produce major returns on investment. At General Electric, where it became a cornerstone, CEO Jack Walsh wrote in the annual report
We did not invent Six Sigma - we learned it. The cumulative impact on the company's numbers is not anecdotal, nor a product of fancy charts. It is the product of 276,000 people executing and delivering the results of Six Sigma to our bottom line: in 1998, cost savings of $400 million and returns of more than $1 billion.

3.  Six Sigma changes how management operates. It is much more than improvement projects. Practice owners and medical directors, as well as staff leaders throughout the healthcare organization, are learning the tools and statistical assessment concepts of Six Sigma: new approaches to thinking, planning, and executing to achieve results. In a lot of ways, Six Sigma is putting into practice the notions of working smarter, not harder.

Six Sigma is a statistical measure, where the lower case Greek letter sigma (σ) stands for standard deviation .Standard deviation is a statistical way to describe how much variation exists in a set of data, a group of items, or a process. The assessment process looks at outcome standards and change impact, rather than just internal processes. In reference to the above example, even if it would take a long time for your practice to do a million appointments, don't worry. This scale is just a projection of the number that would happen if you did!

The first step in calculating sigma, or in understanding its significance, is to grasp what your clients expect. Exceeding client expectations is what differentiates any practice in the modern competitive marketplace of veterinary medicine alternatives. "Exceptional service" occurs when clients' perceptions perceive their expectations have been exceeded, as in this formula: ECS = CP - CE.

In the language of Six Sigma, client requirements and expectations are called CTQs (critical to quality).

Even if you are on the right track you'll get run over if you just sit there! - Will Rogers, humorist

Figure 17: Six Sigma Illustrated

Six Sigma is data driven. When a practice violates important client expectations, it is generating defects, complaints, and cost. Healthcare research tells us that a client who received "exceptional service" will tell five or six others, and we also know we only hear from one out of eleven unhappy clients. The challenge is that every unhappy client tells a dozen more people, and each of those tells five more. When data is derived from events in the form of measurements, it becomes actionable information.

What level of data does your practice view data?

 We only use experience as perceived by the doctor(s), not data.

 We collect data but never look at it as a team.

 We collect data, but just look at the average client transaction (ACT).

 We collect data, look at the numbers, but talk only about gross sales

 We group data by doctor, so we can compete and compare internally

 We use our data to form charts and graphs, but talk about ACT and gross.

 We use sample data and generate trend assessments for discussions

 Our sample data is used to generate descriptive statistics.

 We use sample data and generate inferential statistics.

You don't fatten the cow by weighing it more often! - Six Sigma Factoid

Six Sigma is a philosophy and a culture, client-centered, and in veterinary medicine, with high levels of patient advocacy. Traditionally, it has been a "goal post mentality", with lower specifications limits (LSLs), as well as upper specification limits (USLs), and we still expect the best of the best to miss sometimes. Six Sigma is a Taguchi philosophy, where any deviation from the target causes loss to the community, and, therefore, variation is evil.

Six Sigma embraces proven project management systems, with the same basic five components, and a lot of internal nomenclature we already know:

Keeping clients happy is good, and it is profitable. A five percent increase in client retention has been shown to increase profits more than twenty-five percent in the multi-visit per year companion animal hospitals.

It is estimated that most veterinary practices lose fifteen to twenty percent of their revenues each year, due to ineffective, inefficient processes. Although some practices' neglect of client-centered patient advocacy suggests that is even higher.

Six Sigma provides a goal that applies to both product and service activities, and that sets attainable, short-term goals, while striving for long-range business objectives. In the future, statistical assessments will likely drive your practice programs. But right now, to get a team-based buy-in, don't wait, and don't just take my word for it, test it on two programs starting today:

 Nutrition: Currently, only about seven percent of the patients nationally stay on their prescription diets. Every prescription diet patient is immediately assigned to a nursing staff member to follow and bring back at least once a month for a courtesy weigh-in or recheck nursing appointment.

 Post-natal care: Currently, only about fifty-six percent of the patients nationally stay on initial vaccination schedule. Every puppy or kitten patient is immediately assigned to a nursing staff member to follow and bring back on the prescribed schedule. This person calls a day in advance to remind the client of the appointment. Any failure to appear as expected gets a phone call from the nurse, saying something like, "The doctor and I missed you and Powderpuff today. Is everything okay at your house?"

These two programs have traditionally been assigned by the doctor to the client to self-monitor, and as such, lower compliance has been seen. Remember the examples we used in human healthcare, when something was critical (CTQ)?. It was assigned to an individual staff member to ensure completion. Doctors are very hard to train in wellness medicine principles and procedures, but most all veterinary staff want to be patient advocates, so allow them that privilege.

Six Sigma is also a management system. A significant difference between Six Sigma and seemingly similar programs of the past years is the degree to which the practice's leadership plays a key role in regularly monitoring and recognizing public program results and accomplishments.

When Jack Welch introduced the Six Sigma program at General Electric, he told senior executives that forty percent of their annual bonus would be based on their involvement and success in implementing the Six Sigma programs at GE. hat turbo-charged the focus of most all the executives immediately, training was given a major boost, and thousands of teams became trained in very short order.

But training alone is not Six Sigma Six Sigma is a management system, which answers the following questions:

 Who are the Champions and Sponsors?

 Who will be the team members that want accountability/responsibility?

 What are the top level goals and strategy of the practice?

 Who are the significant practice clients we are targeting?

 What are the core competencies/processes of the practice?

 What are the key macro-processes?

 What are the enabling processes?

The practice leadership system involves accountability for results and ongoing reviews to ensure results. This places the doctors, managers, and coordinators into a guiding position for the practice's business goals.

Starwood Hotels, which owns and operates Westin, Sheraton, and several luxury resort hotels, launched the first Six Sigma program in the hospitality industry, and their managers at all levels were being held accountable for a variety of measures, including:

 Customer satisfaction.

 Key process performance.

 Scorecard metrics on how the business is running.

 Profit-and-loss statements.

 Employee attitude.

Figure 18: Six Sigma Intensified and Illustrated

A Six Sigma healthcare system has been working in a $300 million annual revenue triple-hospital complex in Kentucky. The complex includes a four hundred thirty-bed, acute care hospital in Bowling Green, a one hundred five-bed long-term care facility in Scottsville, and a primary/secondary day-surgery practice complex in Franklin. This complex provides open heart surgery, cancer treatment, neonatal intensive care, psychiatric services, home health, EMS, managed care, primary care walk-in clinics, OP rehabilitation center, twelve-physician practice affiliation, and even a free clinic. They have evolved into three primary healthcare quality initiatives, emphasizing:

 Customer service/satisfaction

 Reduced wait times.

 Consistent service.

 Enhanced reputation in community.

 Delivered quality care

 Reduced medical errors.

 Increased patient safety.

 Use of appropriate technology.

 At lower cost

 Increased productivity.

 Decreased cost through reduced variation.

 Reduced waste of limited resources.

After adopting the Six Sigma system and watching the changes, this healthcare complex had revised their vision to state: "By the year 2004, be proudly recognized by our employees, patients, clients, community, physicians, and payers as the unquestionable leader in healthcare and service, providing flawless quality never before achieved in the healthcare industry".

Concurrently, their strategic focus changed to three key factors, and three new assessment systems:

 Customer satisfaction (Press Ganey scores).

 Quality: timeliness of service (rolled "Z score" of core processes).

 Efficiency (cost per unit).

This healthcare complex understood from the very beginning that sixty-two percent of all quality initiatives fail from lack of attention to the culture and people side of change. They said:

The effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea

As a management system, Six Sigma is NOT owned by the senior leadership, although their role is critical, nor is it driven by middle management, although their participation is key to success. The ideas, solutions, process discoveries, and improvements that arise from the Six Sigma systems take place in the front lines of the organization:

 The more responsibility put into the hands of the consultation room doctor, the better the diagnostics and medical records.

 The more responsibility put into the hands of the client relations team, the better the client bonding and return rates.

 The more responsibility put into the hands of the OPNT team, the better the client education and subsequent acceptance of "needed" care.

 The more responsibility put into the hands of the IPNT team, the better and more timely the quality patient care.

 The more responsibility put into the hands of the animal caretaker team, the better the patient surveillance, as well as cleanliness and facility maintenance.

As a practice strives to put more responsibility and accountability for outcomes in the hands of the staff, who work directly with clients and patients, the changes start becoming client-centered instead of the traditional provider-centered perspectives. A Six Sigma system combines strong leadership with grassroots energy and involvement. As such, the benefits are not just financial. People at all levels find a better understanding of clients, clearer processes, meaningful measures, and powerful improvement tools that make their work more effective, less chaotic, and usually, more rewarding.

Six Sigma is process improvement. In the text Building The Successful Veterinary Practice: Leadership Tools we introduced fourteen leadership skills that can be taught, and with repetitive reinforcement, can be learned and incorporated in the practice culture. This is not an easy task and should not be taken lightly, nor even tried as a "test". Either you want to change the practice culture, or you do not. Do not start this with a promise that your staff and methods can return to the past. It is a commitment of major magnitude. Consider the process as a new mathematical formula: