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Linking Six Sigma to simulation: a new roadmap to improve the quality of patient care
Giovanni Celano, Antonio Costa and Sergio Fichera
Dipartimento di Ingegneria Industriale e Meccanica, University of Catania, Catania, Italy, and

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Received 9 September 2010 Revised 15 December 2010 Accepted 27 December 2010

Giuseppe Tringali
Azienda Ospedaliero Universitaria Policlinico Vittorio Emanuele, Catania, Italy
Abstract
Purpose Improving the quality of patient care is a challenge that calls for a multidisciplinary approach, embedding a broad spectrum of knowledge and involving healthcare professionals from diverse backgrounds. The purpose of this paper is to present an innovative approach that implements discrete-event simulation (DES) as a decision-supporting tool in the management of Six Sigma quality improvement projects. Design/methodology/approach A roadmap is designed to assist quality practitioners and health care professionals in the design and successful implementation of simulation models within the dene-measure-analyse-design-verify (DMADV) or dene-measure-analyse-improve-control (DMAIC) Six Sigma procedures. Findings A case regarding the reorganisation of the ow of emergency patients affected by vertigo symptoms was developed in a large town hospital as a preliminary test of the roadmap. The positive feedback from professionals carrying out the project looks promising and encourages further roadmap testing in other clinical settings. Practical implications The roadmap is a structured procedure that people involved in quality improvement can implement to manage projects based on the analysis and comparison of alternative scenarios. Originality/value The role of Six Sigma philosophy in improvement of the quality of healthcare services is recognised both by researchers and by quality practitioners; discrete-event simulation models are commonly used to improve the key performance measures of patient care delivery. The two approaches are seldom referenced and implemented together; however, they could be successfully integrated to carry out quality improvement programs. This paper proposes an innovative approach to bridge the gap and enrich the Six Sigma toolbox of quality improvement procedures with DES. Keywords Quality improvement, Six sigma, Modelling, Discrete event simulation, Simulation, Health services Paper type Research paper

International Journal of Health Care Quality Assurance Vol. 25 No. 4, 2012 pp. 254-273 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/09526861211221473

The authors wish to thank the anonymous referees for valuable suggestions which allowed improvement of the quality of the nal paper. Furthermore, the authors are grateful to Dr G. Brown, PhD (Department of Psychology, Royal Holloway, University of London), and Dr F Messineo, PhD (Kent School of Law, University of Kent), who gave valuable support during the editing process of this paper.

Introduction Continuous quality improvement of patients care is recognised as essential for achieving excellence in the healthcare service delivery. In the last 20 years, Six Sigma (6s) has received a lot of attention among the several quality management philosophies. Six Sigma is a rigorous, focused and highly effective implementation of proven quality principles and techniques, which aims at virtually error free business performance (Pyzdek, 2003). In the 1980s, Six Sigma was initially implemented in the industrial setting by Motorola; it subsequently attracted much attention among people working in the service sector, including healthcare professionals. In 1998, Kentuckys Commonwealth Health Corporation was the rst healthcare organisation which fully embraced the Six Sigma philosophy the US; successively, Six Sigma was implemented within several US organisations (Sehwail and DeYong, 2003). A survey of Six Sigma programs in 56 US healthcare organisations conducted by means of questionnaires is presented by (Feng and Manuel, 2008). Six Sigma improvement programmes and personnel training have also been employed in European healthcare organisations. Some case studies presenting Six Sigma implementation in the nursing department at the Red Cross Hospital of Beverwijk (The Netherlands) are discussed in Van den Heuvel et al. (2004); the annual savings obtained in the same hospital by means of the implementation of quality improvement projects are presented in Van Den Heuvel et al. (2005). A review about the Six Sigma methodology application to healthcare organisations is proposed in Taner et al. (2007). More recently, Taner and Sezen (2009) have proposed the implementation of the Six Sigma toolbox to study the turnover problem of doctors in medical emergency services and paramedic backup. However, all of these case studies show that a strong nancial and organisational effort is needed to carry out a successful Six Sigma project in the healthcare eld. This is a barrier to its deployment within organisations with a limited budget capacity or which are already implementing another quality management philosophy like, for example, the ISO 9000 family of standards. The question arises if there are ways to introduce the Six Sigma techniques within budget-conscious healthcare organisation while retaining an effective outcome. Based on several years of experience about the implementation of Six Sigma programmes, Magnusson et al. (2003) claim that there are three main approaches to deploy Six Sigma within a company. The rst approach assumes that Six Sigma can be initiated as a company-wide strategy at the highest level and deployed throughout the entire organisation under the full senior management commitment. This approach requires a strong company effort to achieve breakthrough quality-improvement objectives which should be supported by a well dened organisational structure, (Glickman et al., 2007). Alternatively, the second approach assumes that Six Sigma can be implemented as an improvement programme by one or more organisational units and, if successful, extended to the other areas of the company. Finally, accordingly to the third approach Six Sigma can be adopted as a toolbox into specic projects for improvement with a particular focus to problem solving: this third approach does not require the commitment from senior management or a large company involvement. This third vision and approach to Six Sigma will be adopted in this paper; it ts with the denition of Six Sigma given in (Linderman et al., 2003), who consider Six Sigma as an organised and systematic problem-solving method for strategic system improvement and new product and service development based on statistical methods.

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Hundreds of papers and several research journals show the implementation of operations research (OR) tools in the eld of healthcare service. Operations Research is applied to problems that concern how to conduct and coordinate the operations (i.e. the activities) within an organisation. Among the OR tools, discrete-event simulation (DES) allows for the complexity of stochastic systems to be modelled which cannot be caught by a pure mathematical model (Hillier and Lieberman, 2005). Healthcare settings, like those investigated in the case study discussed in this paper, are often complex stochastic systems. These are characterised by random variables describing the times to complete activities; complex ow of patients to be managed throughout the departments, random patient interarrival times; shared resources availability among several departments. Thus, describing all these aspects by means of a pure mathematical model is often a prohibitive task; otherwise, they can be efciently (and quite easily) modelled through DES. A comprehensive review of discrete-event simulation models applied to healthcare problems is reported in Jun et al. (1999): this paper surveys the application of discrete-event simulation modelling to healthcare clinics and systems of clinics, i.e. hospitals, outpatient clinics, emergency departments, and pharmacies. A second more recent review (Fletcher and Worthington, 2009) is focused on the simulation of emergency patient ows and provides for exhaustive references to papers related to the study of accident and emergency (A&E) departments, bed management, surgery, critical care and diagnostics and other specic environments. Often the key performance measures (KPM) optimised by means of a discrete-event simulation model can coincide with the critical to quality (CTQ) parameters selected to achieve quality-improvement within a Six Sigma programme. Thus, trying to get a synergy between Six Sigma and DES techniques seems to be appropriate and deserves attention from the researchers and quality practitioners. In light of this, a recent paper (Tang et al., 2007) suggests as a major strengthening for Six Sigma to expand its toolbox through the integration of the OR techniques in the training courses for Six Sigma Black Belts. In this paper, a theoretical framework based on a roadmap facilitating the process of embedding discrete-event simulation as a decision tool within a Six Sigma quality-improvement project is discussed. The roadmap is built as a structured and hierarchical procedure to achieve quality improvement in a general setting. A case study showing the rst in-hospital implementation of the roadmap is presented to the readers. In the next section, the proposed roadmap is discussed in detail. Then, the development of a DES based quality-improvement Six Sigma programme is presented to show the implementation of the roadmap in practice. This was a programme aimed at reorganising the ow of emergency patients affected by vertigo symptoms. Successively, the lessons learned from the case study and the potential benets from the proposed approach are discussed. Finally, conclusions and future research opportunities complete the paper. Linking Six Sigma to simulation: denition of a roadmap Six Sigma quality practitioners select, develop and validate a quality-improvement project by selecting and implementing a dene-measure-analyse-improve-control (DMAIC) or, alternatively, a dene-measure-analyse-design-verify (DMADV) ve step

procedure. Whenever process improvement should be investigated by comparing an existing conguration to alternative scenarios, the DMAIC methodology is adopted. When new processes, products or services should be designed, the DMADV methodology is adopted instead; for further details, readers can refer to (Pyzdek, 2003). Often, the comparison among different scenarios or testing new product or process congurations can only be performed by means of simulation because of the complex management issues and associated costs required in the performance of real trial runs. The design of a simulation model is a structured ve-step procedure working as follows. First, the process requires mapping and a clear denition of its boundaries: a review and application of several visual techniques to map processes in the healthcare eld can be found in (Guglielmino et al., 2009). Then, the stochastic process data are collected to dene the base of knowledge needed to design the model. The third step consists of analysing these data to get a good statistical t of their variability. Then, the simulation model logic can be designed and developed. Finally, the model is validated through a set of trial runs. After the simulation model has been validated, it can be used to compare the current conguration, if it exists, against hypothesised new scenarios in order to nd the optimum with respect to one or more pre-selected key performance measures. This ve-step procedure has been adapted in Seppanen et al. (2005) to t it with the DMAIC procedure. A roadmap extending this approach is proposed here as a theoretical framework to manage Six Sigma projects aimed at improving the quality of a service: it merges both the DMADV and DMAIC methodologies to achieve a hierarchical procedure able to manage an ongoing Six Sigma quality-improvement project of an existing service based on a discrete-event simulation model. We denote it as the DMAIC-DMADV roadmap. Similarly, if the Six Sigma improvement project is focused on new service congurations to be investigated, the double DMADV2 roadmap should be considered. Figure 1 shows the ow chart of the DMAIC-DMADV roadmap. The roadmap description intentionally refers to a generic process, thus assuring a high degree of generality and a wide applicability of the framework either to a service or a manufacturing environment. In the proposed hierarchical approach, the DMAIC methodology denes the ve steps for the quality-improvement project and contains the DMADV methodology related to the DES model design and development. Thus, in Figure 1, the upper (lower) case notation and plain (dashed) line boxes denote a phase and the activities belonging to the outer DMAIC (inner DMADV) methodology, respectively. Of course, given the parental relationship between the two methodologies, each activity belonging to the inner DMADV methodology is also part of the outer DMAIC methodology. In the next Sub-sections a brief description of each phase of the roadmap is presented. Dene The rst phase of the outer DMAIC methodology consists of the sequence of steps aimed at deciding if a quality-improvement project is suitable to be carried out by following the proposed roadmap. First, the quality-improvement project should be selected: the expected quality improvement of patient care and, possibly, cost savings are drivers to the selection; then, the work team should be formed by involving, if needed, external consultants and people from the quality assurance and the other departments affected by the project. To implement the proposed approach, the

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Figure 1. The roadmap linking 6s and the discrete-event simulation model development

prerequisites are: the need to test one specic process scenario or comparing different process (service) congurations; the need to implement the simulation tool to model the process because of the massive presence of random variables and uncertainty, multiple ows of information and activities, several interactions between resources and the

difculty of performing trial runs. Once the presence of these prerequisites has been conrmed, the project continues by starting the inner dene phase aimed at modelling the process. The clear understanding about which department is involved and, for each department, what the resources and the areas to be modelled are allows for the boundaries of the process to be dened. This represents the starting milestone to dene the cross-functional process maps and the value added stream of activities. Software allowing the visualisation and analysis of complex information, systems and processes and common spreadsheets are useful during this phase. For each activity dened within a cross-functional process map the following information should be recorded: upstream and downstream activities, required resources, time to completion and associated costs. The outcomes of this phase are one or more detailed process owcharts and a partially complete database of records each containing an activity to be performed and its related information. Some empty elds of these records, like time and costs to perform the activities, cannot be lled at this step of the roadmap. Thus, the measurement of the available historical data or the on-line collection of new data is required: to accomplish this information, the measure phase should be started. Measure Assuming that a measurement system is already present and active, during this phase the project development proceeds with the model building. Data retrieved from the organisations databases and/or hardcopy registries should be checked and ltered to remove errors. The data should also be formatted for the subsequent roadmap phases. Sometimes, it is not possible to retrieve information about some categories of data. In those cases, the only ways to gather knowledge about them are direct sampling or reliable estimates based on interviews with those directly involved in the service delivery. Usually, the data to be collected to simulate a healthcare service include standard costs and time schedules related to the involved resources, i.e. nurses, technicians and physicians; costs and times needed to perform exams and/or surgical interventions; transportation times between departments, and so on. Basic information about patients includes volumes, arrival rates at each time of day (TOD), type and severity of illness, length of stay. The outcomes of this phase are spreadsheets collecting the data to be analysed. Analyse Once collected and pre-processed, the data should be classied and analysed. Standard costs can be retrieved from the organisations accounting system: usually, they have a deterministic value. Conversely, a statistical distribution tting is required for all the random data: for example, times to perform a consultation, to complete an exam, or to perform a surgical intervention are stochastic and should be statistically modelled. Usually lognormal, normal or triangular distributions are adopted. The patients arrival times are modelled as a non-stationary Poisson process with exponential interarrival times. The nal step of this phase assigns costs and times to a specic activity area of the process coinciding with each department included within the model. The outcome of this phase is a set of deterministic data and statistical distributions completing the information contained within the database of the activities. Then, the project can proceed with the DES model building.

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Improve This phase of the project coincides with the formalisation of different process congurations to be compared. In the proposed roadmap, Improve is the core phase because it involves the DES model design and validation: that is, it includes the design and verify phases belonging to the inner DMADV procedure, see Figure 1. For each scenario, the model logic is built within a specic simulation software environment by referring to the cross-functional process maps drawn during the dene phase. Each block of the simulation model is dened by loading the quantitative data modelled during the Analyse phase. Finally, the critical to quality parameters, which were dened so as to compare the different process congurations, are embedded within the DES model as variables or expressions to be triggered during the simulation. This step ends the design phase for the DES model. Then, during the verify phase the DES model logic is tested and validated through a set of pilot simulation runs to demonstrate its consistency with real process data. Once the DES model has been validated, an experimental plan can be designed by setting at different levels the factors inuencing the quality of service delivery: usually, these factors may include process congurations, amount of available resources capacity and costs. For each experimental run, the CTQs are the response variables to be optimised. Each run of the DES model performed with a specic combination of factors represents a replication of the experimental study. A statistical analysis allows the best process conguration to be selected. The outcomes of this phase are the simulation models of the different process congurations and a report presenting the results of the statistical analysis. Then, the last phase of the quality-improvement project can be initiated. Control Once the best scenario is selected, all the cost and time savings are computed and documented for each activity area. Finally, the quality-improvement project requires the documentation and dissemination of the results throughout the involved areas of the organisation and, if required, outside the organisation. Brainstorming meetings should be scheduled to share opinions about the results and to organise the implementation the best process conguration. An in-hospital implementation of the roadmap A rst in-hospital test of the roadmap has been performed in the emergency department of a large town public hospital in southern Italy to compare two different procedures designed to manage the ow of emergency patients affected by vertigo symptoms illness (later denoted as VSI patients). This quality-improvement project development has been carried out by academic staff from the University of Catania and by staff from the emergency department and the other departments involved in the vertigo patients ow reorganisation. The hospital has an ISO 9000 standard certication, and it has never implemented a Six Sigma project in the past. The Six Sigma approach was not adopted to carry out quality improvement programs within the hospital organisation for two main reasons. First, a cultural issue arising from the approach to quality based on the ISO 9000 standard. This puts more emphasis on correct management of documentation, procedures description and bookkeeping, rather than to promote efforts reducing variability and improving processes by means of sharply focused projects. Second, an operational issue: the lack of internal resources

having a strong background on the Six Sigma techniques rendered their implementation difcult. Getting a diagnosis for a walk-in emergency patient affected by vertigo symptoms requires the execution of several exams and consultations from different departments. Thus, the time to diagnosis can be extremely long and high rates of light symptoms patients leave the service. The objective of the quality-improvement project implementation in the ED has been to eliminate unnecessary exams and to reduce the time and cost needed to get the VSI patients diagnosis leading to ward admission or their discharge. To achieve the Six Sigma improvement project goals, a new procedure (scenario B) for the management of VSI patients in the emergency department has been designed and compared to the current procedure, denoted here as scenario A. Both procedures are described below and graphically detailed in Figures 2 and 3. The combined DMAIC-DMADV roadmap served as the framework problem solving tool. In Table I, each step of the roadmap is presented with reference to the project. The dene phase started by deciding to compare the time to diagnosis and the associated costs by means of two DES models describing the currently adopted procedure (scenario A) and the alternative procedure (scenario B). Implementing DES models allowed to cope with the VSI patient ow complexity and to avoid the raising of project costs associated to real trial runs. Historical data about VSI patients were available from the emergency department registries. At the beginning of the inner dene phase the process boundaries have been dened: the team developing the project decided that all but the ED activities required for VSI patients should be included within the models. This strong simplication avoids to simulate all the ED activities, i.e. an overwhelming task far from the project objectives. As a consequence, the results from the simulation runs have been considered as the lower bound values corresponding to a limiting condition where all resources are unlimited, i.e. not shared with other emergency patients. After a cycle of meetings and interviews with the chairs from the departments involved in the project, two cross-functional process maps related to scenario A (current procedure) and scenario B (alternative procedure) have been generated, see Figures 2 and 3, respectively. In the two gures, a rectangular box corresponds to a value-added activity to be considered in the value stream analysis as well as in the database recording information about resources needed to perform each activity. The term value-added activity means an operation (a physician consultation or an exam specically performed for that patient) which adds information to the patient diagnosis prole. The set of value-added activities for the VSI patients has been dened by means of interviews with people from the departments involved in the project. Both scenarios start with the triage nursing assessment and colour code assignment to a patient, which ranges through the following three levels: white, yellow and green colour from the less to the most severe assessment. The two scenarios signicantly differ in the route whereby yellow and green patients are examined across the hospital departments. Accordingly to the current procedure (scenario A), see Figure 2, only white code patients (those having apparently light symptoms) immediately undergo an otoneurologic examination, whose outcome decides for their admission or discharge. Yellow and green code patients immediately receive a complete medical assessment and undergo a full blood count. If no internal pathologies are diagnosed, then the

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Figure 2. Cross-functional process map of the current VSI patient path (scenario A)

patient path continues with a cardiological EGC examination and the study of blood cardiac markers. If abnormal cardiac conditions are diagnosed, the patient is admitted to the cardiology ward, otherwise further exams are started to diagnose suspect neurologic pathologies: a computer assisted tomography (CAT) exam is performed. The presence of a pathological condition immediately calls for the ward admission to a stroke unit or a neurologic/neurosurgery department If the CAT exam does not reveal any pathology, then the patient is sent to the audiology department to undergo an

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Figure 3. Cross-functional process map of the alternative VSI patient path (scenario B)

otoneurologic exam. The outcome of this exam decides for his/her admission or discharge. The new procedure (scenario B), see Figure 3, maintains the same patient ow for the white code patients as scenario A. However, yellow and green patients immediately receive a clinical assessment with questionnaires to detect an abnormal brain diffuse

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DMAIC Select the quality-improvement project Should one or more scenarios be considered? Brainstorming meetings Brainstorming meetings Brainstorming, meetings Brainstorming meetings Brainstorming meetings

Dene

Measure

Analyse

Table I. The proposed roadmap for the VSI patient ow quality-improvement project Step Tool Outcome Is the area of improvement a complex process? Check availability of existing historical data or possibility of estimation Dene the process boundaries Observe, document and map process steps and ow Dene the value stream Collect historical process data Pre-process historical process data Gather unbiased estimates of further data Stratication of the available data Brainstorming interviews Microsoft Visio Brainstorming Microsoft Excel Managing the ow of emergency patients affected by vertigo symptoms illness (VSI patients) Two scenarios: the current and one alternative procedure managing VSI patients Yes. Involvement of several departments. Complex patient pathway Yes. Existence of patients records and unitary costs Study restricted to the ow of patients affected by VSI between ED entrance and admission/discharge Cross-functional process maps for the two scenarios Database of activities for each involved Department to be completed Data mining techniques Microsoft Excel Raw Databases of historical data Data mining techniques Microsoft Excel Cleaned Databases of historical data Interviews sampling Microsoft Excel Estimates and condence intervals of further data Distribution tting of the grouped samples of data Classication of the value added operations into activity areas Data mining techniques Microsoft Excel For the VSI Patients: interarrival times per day and month Rates of patients leaving the service Probability for each colour code assigned at the triage VSI Patients Illness diagnosis occurrencies Statistical inference minitab Triangular distributions tting times to perform each activity Resource allocation tools Complete database of activities for each involved Department (continued )

DMADV

***

***

***

***

Dene

Dene

Dene

Measure Measure Measure

Analyse

Analyse

Analyse

DMAIC

DMADV

Step

Tool

Outcome

Improve

Design

Design

Design

Dene the DES model logic from the Rockwell ARENA process map Add the information about the available Rockwell ARENA data to the DES model Dene the proper CTQ parameters in the Brainstorming Rockwell ARENA DES model Check the DES Model Logic Validate the DES model

Verify Verify

Logic denition for the simulation models of the two scenarios Characterisation of each object model for the simulation of the two scenarios CTQs: Expected overall cost per year Expected Departmental costs per year Flow times for each category of VSI patient Testing procedures Rockwell ARENA Correct model logic for each scenario Testing procedures interviews Rockwell DES models for the two scenarios ARENA validated and ready to be run for comparison purposes

Improve Design the experimental plan

***

*** ***

***

Minitab/design expert Rockwell ARENA CTQs assumed as response variables Factors possibly affecting each scenario conguration Design of the experiment Run the DES model replications Rockwell ARENA Values of the CTQs for each run Perform a statistical analysis on CTQs to Minitab/design expert Rockwell ARENA Empirical distributions and parameters compare the scenarios for the CTQs Select the best performing scenario Brainstorming Rockwell ARENA Best scenario and optimal values for the CTQs

Control

***

***

Estimate cost/time savings and resource Rockwell ARENA utilisation Document, communicate and visualise Meetings results

Reports about cost and time data and resource utilisation Presentation and dissemination of the results

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Table I.

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perfusion: if a perfusion is suspected, then cardiological exams are immediately started. The outcome of these exams supports decisions about the ward admission destination of a patient. If the abnormal brain diffuse perfusion is not suspected for a yellow/green patient, then the otoneurologic examination is immediately conducted. The patient ow continues with the admission within the audiology ward or the request of a neurologic visit including a CAT exam. When the suspicion of neurological pathologies is excluded, a complete medical assessment with blood count is started to detect the presence of internal organ pathologies. Scenario B signicantly increases the audiology department workload because the otoneurologic examination is scheduled at the beginning of the patient ow, whatever the patient colour code. It calls for a 24 hours presence or availability of a specialised physician. However, at the moment of designing scenario B professionals involved in the project believed this would reduce the overall number of exams required to get a diagnosis for a patient and consequently the associated times and costs. The VSI patients completing the path to diagnosis and needing to be hospitalised have been categorised into one of the following four groups, depending on the department wherein the ward admission is decided: audiology (AD), cardiology (CD), medicine (MD), neurology/neurosurgery/stroke unit (ND). Based on the information in the cross-functional process maps, the development of a spreadsheet containing the database of activities completed the dene phase. During the measure phase, historical data was collected from the emergency department. Information about every VSI patient arriving at the ED in 2007 was retrieved and coded into spreadsheets. When a service characterised by multiple ows of patients is to be modelled, the transportation time estimation and the relative resources availability should be carefully investigated by practitioners because different hospital congurations can lead to sensibly different patient ow times. Thus, further information has been gathered by means of time study and interviews with ED nurses and professionals about the times required to perform exams and to direct patients from one department to another. With the exception of the audiology department, all the other departments and wards involved in the case study are located at different oors in the same building. This location of the departments signicantly reduces the transportation times to a few walking minutes. Finally, unit costs of resources and exams have been retrieved from the hospital IT system. During the analyse phase, a statistical distribution has been tted to each family of sampled data by means of the Minitabw commercial software: patients inter-arrival times have been modelled through exponential distributions; the times to complete medical exams and to transport patients between departments have been modelled through triangular and normal distributions. The explicit values of times and costs for each exam and patient transfer are not reported here for the sake of brevity. Table II presents the stratied historical data about the VSI patients. The improve phase of the roadmap has been started by designing the DES models corresponding to the two scenarios within the Rockwell ARENAw simulation environment: the cross functional process maps presented in Figures 2 and 3 helped consultants in designing the models. Several activity areas each coinciding with a department have been introduced in the two models to get explicit cost estimation for each involved department, (Kelton et al., 2007). Model logic was animated by means of

Interarrival rates of VSI patients showing at the ED (exponential distrib.) 2.25 patients/day

8 a.m.-3 p.m. 3 p.m.-8 p.m. 8 p.m.-8 a.m. 9.4 10.3 80.3 68 31 33 15 43 9

0.966 patients/day 0.495 patients/day 0.788 patients/day

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Incidence of colour codes for VSI patients White (%) Yellow (%) Green (%) VSI patients completing the path to diagnosis (%) VSI patients needing admission (%) Incidence of each in-patient group Audiology (%) Cardiology (%) Medicine (%) Neurol./neurosurg./stroke unit (%)

Table II. Historical data observed for the VSI patients during year 2007

suitable pictures to facilitate comprehension during the results dissemination. Then, the CTQs to be collected by the DES models have been selected. According to the project objectives, a set of departmental yearly costs have been identied to quantify the service effectiveness for each scenario. Similarly, the service efciency for each scenario has been quantied through the computation of the mean ow time for each category of VSI patient, from the emergency department entrance to the ward admission or discharge. Overall, ten response variables have been considered (see Table III). Model logic checking and validation was achieved through several trial runs. A direct comparison with the available historical data did not show any anomaly. The two scenarios have been assumed as potential factors affecting the service CTQs. For each scenario model, 1,000 replications have been run. Table IV shows the replication statistics of the CTQs for both scenarios. An empirical distribution tting of the yearly costs based on the Anderson Darling test led to model them as Gamma distributed random variables. Thus, in Table IV, for each cost the expected value, the scale parameter u and the shape parameter k of the tting Gamma distribution are reported.
CTQs CTOT [e/year] CED [e/year] CAD [e/year] CLD [e/year] CRD [e/year] FTAD [h ] FTCD [h ] FTMD [h ] FTND [h ] FTDP [h ] Total cost to deliver the service to VSI patients Cost at the emergency department Cost at the audiology department Cost at the laboratory test department Cost at the radiology department Mean ow time of the patients admitted within the audiology department ward Mean ow time of the patients admitted within the cardiology department ward Mean ow time of the patients admitted within the medicine department ward Mean ow time of the pat. adm. within the neurology/neurosurg./stroke unit dept. ward Mean ow time of the discharged patients

Table III. The critical to quality parameters (CTQs) selected for the case study

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Scen. 8507 16368 3216 5990 2.645 2.732 20279 7533 2.692 138.4 2 94.9 2 53.8 2 81.8 2 62.6 835 324.5 2.574 1834 672 2.729 1.50 (0.56) 1.71 (0.51) 10092 3790 2.663 3.25 (0.87) 4.57 (0.66)

Table IV. Comparison of scenario B vs scenario A. Results from the simulation runs
CAD [e/year] White Y/G CLD [e/year] CRD [e/year] FTAD [h ] FTCD [h ] 1.73 (0.07) FTMD [h ] 1.14 (0.02) FTND [h ] 2.22 (0.15) FTDP [h ] 2.51 (0.14) 1.29 (0.02) 1.29 (0.01) 2.23 (0.62) 1.67 (0.3) 2 25.4 13.2 0.4 2 33.5

CTOT [e/year]

CED [e/year]

A u k

98285 63318 36014 23178 2.729 2.732

B u k

65209 24136 2.702

42261 15634 2.703

DC% DT%

2 33.7

2 33.3

The control phase of the project started with the evaluation of the cost and ow time savings obtained by simulating the B scenario. Cost comparisons presented in Table IV immediately show that the effectiveness of scenario B clearly overcomes that of scenario A: . The yearly expected cost saving to deliver the service to VSI patients equals 33.7 per cent. . The yearly expected cost saving in the emergency department equals 33.3 per cent. . As expected by the project development team, the number of seized exams in the audiology department is signicantly increased: thus, the yearly expected cost increases of 138.4 per cent. . The largest cost savings are achieved in the laboratory test department, (DC per cent 2 94.7 per cent), and the radiology department, (DC per cent 2 81.8 per cent); this means that the currently adopted procedure calls for a signicantly larger number of blood and CAT exams than required. Finally, the availability of empirical distributions for each of the investigated costs allows decision makers to take decisions about provisional budgets for the service delivery based on reliable data estimation. Table IV also presents within parentheses the mean and the standard deviation of the ow times for each category of patients and the ow time percentage reduction DT per cent obtained by implementing scenario B as opposed to scenario A. The performance of scenario B in terms of efciency is better than that of scenario A. In particular, it has been found that: . The expected ow times for patients who need to be admitted in the audiology department ward reduce of more than 50 per cent whereas those admitted in the cardiology department reduce their ow time of more than 25 per cent. . The expected ow time increases for those to be admitted in the medicine department ( 13.2 per cent), and remains quite unchanged for patients having a pathological condition to be treated within the neurology/neurosurgery/stroke unit departments. Thus, the project demonstrates that scenario B looks promising both in terms of service efciency and in terms of efcacy and that it is worth choosing it for further investigation and the implementation of real trial runs. Dissemination of results to professionals working in the hospital and a cycle of informative meetings with people from other hospitals completed the project. Lessons learned and benets from the proposed approach The implementation of the roadmap to the in-hospital case study allowed some strength points of the proposed theoretical framework to be experienced. First, getting a precise denition of the cross-functional process maps and the value-added stream analysis at the early steps of the project i.e. during the design phase was demonstrated to be a key factor in stating the problem correctly and successfully developing the project. During the brainstorming meetings, doctors, nurses and technicians were stimulated to re-think every step of the service in

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which they operate as resources; a shared view about the way service is delivered and the awareness about eliminating unnecessary activities can be progressively achieved through this problem solving approach. Some bugs have been detected in the hospitals information system during the measure and analyse phase aimed at collecting and tting the historical data: these have been progressively corrected or eliminated. The improve phase required the design and validation of the two simulation models. The trial tests on the models were performed at the presence of the chairs of the involved departments: the graphical representation of the patient ows during the simulation runs helped professionals from the hospital to visualise the entire ows and detect the presence of bottlenecks increasing ow times; statistical distribution tting for the expected costs allowed budgeting forecasts to be prepared; the evaluation of percentage costs savings and ow times reduction provided with a quantitative basis of knowledge to promote further investigation of scenario B. Finally, dissemination of the results inside and outside the hospital during meetings and seminars received a positive feedback from operators, especially in terms of interest to the roadmap implementation to other healthcare settings. In particular, during seminars the interest was originated by the opportunity that such a procedure gives to people in achieving self-awareness about the activities they are requested to do in their organisation. In those seminars where developing part of the design procedure was proposed as a classroom exercise for small groups, great emphasis was put by the attendees in the process of visualising the procedures they usually follow in their organisations through process maps. The common feeling was that getting precise process maps allowed for a re-thinking and questioning of apparently well-structured practices and nding useless activities. Sharing different points of view further enriched this process. Showing the graphical interface of the DES models during the simulation running increased interest in the classroom. Costs and time estimates based on simulated data gave people more condence to gure out workload and budgeting for each involved department. It is worth noting that by linking the Six Sigma quality perspective to the operational research toolbox, the proposed roadmap can serve as an operational framework to create opportunities for starting innovative Lean Six Sigma experiences in the healthcare organisation (George, 2003; De Koning et al., 2006): its intrinsic structure allows both activities control and the identication and elimination of waste and non-value added activities, i.e. the muda, as commonly known by the lean thinking practitioners. Further investigation is suggested in this direction. Lastly, it is also important to speak about some shortfalls of the proposed framework. First, there are many situations where some prerequisites required to start the synergy are not respected. Second, as stated in ( Jackson, 2003), problem contexts within an organisation can be different depending on the combination of the following two dimensions: the nature of the investigated system/organisation, i.e. simple or complex, and the attitude of participants: unitary or pluralist or coercive. Quality management in the service sector, and in particular healthcare organisations, can cover all of these problem contexts depending on the level of the organisation it impacts. Given this perspective, the proposed roadmap supporting sharply-focused quality-improvement projects is particularly suited to support system thinking and

problem solving when a simple unitary combination is present. This is the eld of application of what is called hard system thinking. Conclusions This paper has presented a theoretical framework based on a roadmap dening an approach integrating Six Sigma and discrete-event simulation during the development of a quality-improvement project. The roadmap merges DMAIC/DMADV or DMADV/DMADV Six Sigma procedures in a hierarchical approach aimed at developing the Six Sigma project and the simulation model. The roadmap has been tested to carry out a project focused on the re-organisation of the ow of emergency patients affected by vertigo symptoms. The implementation of the proposed roadmap allowed the following potential benets to be identied: . The design of a DES model aimed at simulating and comparing different scenarios is signicantly enhanced by the adoption of the roadmap, which simplies the formalisation and execution of the successive steps to get a correct model. . Conversely, the Six Sigma quality improvement project cost can be signicantly reduced if DES simulation can be adopted: in fact, real trial runs are not needed to get results about different process congurations. . Discussion and dissemination of results inside and outside an organisation is facilitated by the roadmap because it can serve as a structured approach to be followed during presentations. Visualisation of the different scenarios through DES models stimulates the interest of people and makes the comprehension and motivation of results easier. The positive outcome from the practice has demonstrated the effectiveness of the proposed roadmap in the healthcare eld and calls for further investigation in other clinical settings. Thus, research will be continued in this direction to enhance the proposed framework and to create potential opportunities for Lean Six Sigma implementation in healthcare.
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About the authors Giovanni Celano received his PhD in 2003 from the University of Palermo defending a thesis on the sequencing of mixed model assembly lines. He is currently Assistant Professor at the University of Catania (Italy). His research is focused on statistical quality control, production scheduling and operations management applied to both industrial and service sector. He is currently a member of the European Network of Business and Industry Statistics (ENBIS), and the International Institute for Innovation, Industrial Engineering and Entrepreneurship (I4e2). He has authored/co-authored about 85 papers in international journals and in the proceedings of national and international conferences. Dr Celano is Associate Editor of Quality Technology and Quantitative Management. Giovanni Celano is the corresponding author and can be contacted at: gcelano@diim.unict.it

Antonio Costa holds a PhD in Structural Mechanics from the University of Catania. He is currently Assistant Professor in Technology and Manufacturing Systems at the University of Catania (Italy) and a Senior Member of the Associazione Italiana di Tecnologia Meccanica (AITeM). His research involves supply chain network management, mixed model assembly line sequencing and heuristic optimisation applied to manufacturing systems. He is a co-author of about 45 papers published in international journals and in the proceedings of national and international conferences. Sergio Fichera is an Associate Professor in Technology and Manufacturing System at the Dipartimento di Ingegneria Industriale e Meccanica of the University of Catania, (Italy). He holds a MS degree from the University of Catania and MBA degree from the Schools of Management at the University of Turin. His research interests are in production scheduling, statistical quality control, optimisation of machining processes. He is a member of the Associazione Italiana di Tecnologia Meccanica (AITeM). He has co-authored about 80 papers in international journals and in the proceedings of national and international conferences. Giuseppe Tringali is the head of the Audio-Vestibolo-Fonologia Unit at the Vittorio Emanuele hospital, Catania (Italy). He frequently collaborates with the University of Catania to develop quality improvement and service re-engineering projects in the healthcare eld.

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