Like a true consulting fog-factor, we have added to the alphabet soup of your life, using the contemporary Six Sigma jargon

 LSL: Lower Specification Limit.

 USL: Upper Specification Limit.

 CTS: Critical To Satisfaction.

 CTQ: Critical To Quality

 CTC: Critical To Cost.

 CTD: Critical To Delivery.

 C-R-A-M goals: Challenging, Realistic, Attainable, and Measurable.

 S-M-A-R-T objectives: Specific, Measurable, Attainable, Realistic, and Time- managed.

Plus a host of new terms: "Champions", "Sponsors", "Green Belts", "Black Belts", "Master Black Belts", and "Change Agents". Some will "turn off" because of the new nomenclature, but like new metrics, if you do not change the jargon when you change the metrics, you will find slipping back to the old system a very comfortable regression process.

So let's add another set of letters to your vocabulary. The most important string of letters you will need to ever learn is probably DMAIC (pronounced duh-MAY-ick). DMAIC is a Six Sigma process: Define, Measure, Analyze, Improve, and Control. We showed these graphically back on Page 440. It is a flexible, but powerful, five-step process to make improvements happen and stick. Improvement, problem-solving, and process-design teams will be the most visible and active components of the initial Six Sigma effort, and they will all use DMAIC. When the boundary-less team is brought together, their inherent diversity needs to accept common process, or model, so all can share. That is DMAIC.

Several broad Phases apply to the life cycle of almost all teams, and although some of the Phases may be modified, or the sequences may be adjusted, it also applies to the zone teams, Six Sigma teams, and DMAIC teams (see the VCI® Signature Series Monograph Zoned Systems & Schedules):

Phase 1: Identifying and selecting the project.

Clear definitions and direction are critical, as are predetermining priorities and success measurements for the expected outcome. Some planners define a good project by the "two Ms": meaningful and manageable. The CRAM or SMART criteria can also be used to add clarity to the project. Remember, "realistic" pertains to the environmental limitations and latitudes, while "attainable" applies to the individual's skill and knowledge to assume accountability for achieving the desired outcome.

Phase 2: Forming the team.

Concurrent with problem identification comes identifying the team and team leader as Black Belt or Green Belt. In larger veterinary practices, the Black Belts will likely come from the administrative team, while in virtually all practices, the Green Belts are coordinators from within the specific or affected zone(s). This is NOT the place to put an idle slacker .When someone is selected for one of the teams, it means they are viewed as someone with the "smarts" and the "energy" to be a real contributor, with "boat-rocking" potentials.

Phase 3: Developing the charter.

This is a written guide to address the problem or project, typically drafted by the Champion, Sponsor, or Change Agent. It is added to and refined by the project team. In fact, most "learning teams" modify the charter over time, as the team member skills and strengths are brought to bear on the project/problem. It is no different for a DMAIC team.

Phase 4: Training the team.

In most veterinary practices, training is pointing in a direction, and then handing someone a job description, or a thick SOP (Standard Operating Procedures), or a protocol binder. In Six Sigma, training is a high priority, and learning is a check-and-balance mandate, with the application Phase showing competency. The focus is on the skill set, and on a DMAIC team, it is the analytical process and measurements that increase effectiveness. This training can require one to four weeks, depending on the statistical methods selected for assessment and analysis. For best effect, adult training is done in sequential, yet short, Phases, so it is "learn and apply" in a series of experiential learning opportunities. Most DMAIC teams plan a two to five-week teaching/learning period, then apply it on the job, after the first week of statistical training.

Phase 5: Implementing solutions and revising.

Nearly all teams are accountable for their own implementation process, with the coach on the sideline. On a DMAIC team, the Green Belt, or possibly a Black Belt, is a player coach. Seldom does a team hand off their program to someone else. Teams develop project plans, training, pilots, and procedures for the solutions, and are responsible for both putting them in place AND ensuring they work as expected, by measuring and monitoring for a meaningful period of time.

Phase 6: Sharing the solution.

Eventually, every team disbands, and in some cases, new players join the team and the direction changes. On a DMAIC process, there is a formal point in time where the DMAIC team hands off the solution to the official owner , the practice zone. The zone team then accepts accountability for CQI to sustain the gains and improve the processes further. The DMAIC team will then disband, and take their new skill set and experiences back to their own sphere of influence, to continue CQI within their own zone.

"What," you may ask, "makes DMAIC different from or better than the other problem-solving techniques?". The first point to remember is that Six Sigma is an old wine in a new bottle. It may be the same model you are using.

The second point to realize is that if you are asking this question, you are already practicing one of the key skills of Six Sigma management: asking good questions before you seek change.

If you see DMAIC as just a set of letters, or steps, it is not better. What needs to be realized is that it is an integrated step in a much larger process, and it gains importance by developing the people who work through the six Phases listed above the biggest differences or advantages of DMAIC probably boil down to seven basic core competencies. There are more with each attempt, but they will vary:

1.  Measuring the problem: No assumptions. You must validate the facts.

2.  Focusing on the client, not doctors: Without clients, no practice can survive.

3.  Verifying root cause: Team agreement is inadequate. Prove cause with facts.

4.  Breaking old habits: No minor adjustments. Real change requires creativity.

5.  Managing risks: "Bugs" will occur. Testing and perfecting, with common sense.

6.  Measuring results: No gut feelings. Verify real impact with real facts/data.

7.  Sustaining change: No reversion. Nurturing and support by entire team.

The traditional production model has always been published and discussed as a three factor process:

Since we already know that in veterinary healthcare delivery, we must address client satisfaction (the front door must swing). We know there is a step past the output of a cured animal.

The outcomes which must be addressed include:

 Satisfied/happy client.

 Satisfied/proud staff.

 Net income from procedure(s).

So, if we apply the Six Sigma logic to the original appointment problem we proposed, and you ask, "What would be a good measurement method for the on-time appointment problem?", we can show you the actual Sigma determination process. See the box on the following page.

Calculating Sigma Figuring the sigma for most processes is pretty easy. A calculator or computer is helpful, but no advanced math is really needed. What is needed is basic data and definitions for the following:  The "unit" or item being delivered to the client.  The "requirements" that make the unit good or bad for the client.  The number of requirements, or defect opportunities, for each unit. For example, with on-time appointments, our unit is a point in time, the appointment. The four main ingredients are: doctor on time, schedule on time, rooms available, and outpatient nurses available. We collect data from one doctor for one month. That is four hundred appointments. We find that the doctor was late forty-one times, the schedule was wrong three times, rooms were filled seven times, and the OPNT was missing thirteen times. To calculate sigma, we take the total number of defects counted, divide by the total number of units, and multiply by the number of defect opportunities: This gives us sixty-five divided by sixteen hundred, or 0.040625.This is called "defects per opportunity" (DPO). As you recall, we usually consider one million opportunities, so that would be forty thousand six hundred twenty-five defects per million opportunities (DPMO).Now look up that DPMO number in the table in Appendix T of this text to find out what sigma it represents. In this case, the appointment process is performing at 3.25 sigma, which means on time about ninety-six percent of the time.

In most companion animal practices, an appointment schedule that is "on time" ninety-six percent of the time is good enough, unless you consider the sixty-five unhappy clients, who each will tell eleven more, which equals seven hundred fifteen people, who each will then tell five more. Now you're up to three thousand five hundred seventy-five "unhappy" clients. If these were potentially available clients, and only fifty-five percent have animals, this is about a one-doctor workload loss, which equals four thousand population per one FTE doctor. Unless they are all stewards of companion animals, then you have lost a two-doctor staffing opportunity from just one month of ninety-six percent on-time appointments.