There is no limit to where we can and should implement objective quality improvement measures.


If you are impressed by all the beeping electronic marvels and the brushed chrome lobbies in a modern hospital, you may naturally think of health care as a cutting edge industry. But these glitzy exteriors hide an embarrassing truth: healthcare professionals have been living in the dark ages. Clinging to ill-defined, quaint notions such as "trust" and "professionalism," the hoary leaders of hospitals and medical practices have often failed to adopt scientific principles of management--the same principles that have led to astonishing advances in other industries.

Fortunately, the health care industry is finally coming to its senses. Many physicians, hospital administrators, and medical societies, including the American Medical Association, now em-brace the scientific study of quality improvement or "QI." In fact, completing a "QI project" has become not just a mark of honor for a physician, but in some cases a requirement for maintain-ing medical certification.

The science of quality improvement began in the late 1800s, with Frederick Taylor's now-canonical Principles of Scientific Management. Since then, Taylorism has spawned an endless stream of textbooks, trademarks, seminars, and certifications. The central tenet remains the same: there is "one best way" to accomplish a task, and deviations from this approach represent defects.

Yet the science of quality improvement remains an enigma to many of the nearly one million physicians, three million nurses, and seven million other healthcare workers in the US. How can we ensure that the members of such groups gain adequate experience with quality im-provement principles? Given that lives are at stake, we don't want them trying out such tech-niques for the first time when patient's lives are on the line. How can we enable healthcare per-sonnel to gain such experience in a safe, non-threatening environment?

We believe that quality improvement should begin at home, and specifically, in bed. Why? To begin with, many people who inspect this domain see substantial room for improvement. Second, sex is an utterly necessary activity, in which the very perpetuation of the species is at stake. Finally, the enormous economic impact of sex is both immediate and undeniable. Indeed, in view of how much time people spend on sex, it is amazing that it has so rarely been subjected to systematic quality improvement techniques.

As rather experienced hands in this domain, we are tempted to lay out in detail the key elements of a new and highly effective sexual quality improvement programs. In the interests of fostering individual creativity, however, we have resisted this impulse. In what follows, we outline only the broad parameters of such a program, leaving the more delicate features to the reader's imagination.

The first step is to choose a quality improvement methodology. For this purpose, we have selected one of the most widely touted methodologies of the past few decades: Six Sigma. First developed at Motorola in the 1980s, Six Sigma represents a form of statistical process control. It turns out that this technique that was originally developed for the manufacture of electronic devices is now one of the most popular quality improvement approaches used by hospitals.

Because we have chosen sex as our quality improvement exemplar, we have tentatively dubbed our process Sex Sigma™. Its goal is to achieve measurable and reproducible improvements in sexual performance. Like industrial processes such as etching a microchip or riveting an airplane, sex exhibits features that can be measured, analyzed, improved, and controlled.

For our purposes, one of the most tantalizing features of Six Sigma is its rigid hierarchy. Participants work at various levels of authority, including "champions" responsible for enterprise-wide implementation, "black belts" who provide in-house coaching, "green belts" who do the grunt work on the ground, and novice "white belts" who merely observe. Everyone at all levels must commit to the process, particularly those functioning in leadership capacities. If those on top are not fully committed or fail to buy in, failure is inevitable.

At the heart of Six Sigma is the Plan-Do-Check-Act cycle. This concept has been refined and developed into the DMAIC ("duh-may-ick") methodology, an acronym that should be repeated through the process as a kind of mantra. By attending appropriately to each of DMAIC's elements in the proper order, the cost-effective design and implementation of a Sex Sigma project are virtually guaranteed, providing the greatest bang for the organization's buck. The components of DMAIC are as follows:

Design. First, give voice to the consumer's perspective. Who is your buyer? What is he or she expecting? What would be required to fulfill his or her desires? Goals must be specified as precisely as possible. What does satisfaction really amount to, and how can we measure it more accurately? If we do not clearly know what the customer wants, we are unlikely to provide it.

Measure. An old management adage states, "If you can't measure it, you can't manage it." Ask yourself: What are the key pieces of equipment? What are their physical dimensions? At what rate do they function? What length of time is needed to complete the task? At the very least, you are likely to need such basic tools as a tape measure and stopwatch, although more refined instruments such as audio and video recording devices with playback and stop-motion features may prove revealing.

Analyze. Once you amass your data, you can massage it using a variety of questions. Are you achieving just-in-time production? Do supplies come too early or too late? What are the root causes of these inefficiencies? Is there a sticking point? Take your best guess and don't worry--the process may need to be repeated dozens or even hundreds of times before conclusions can be conceived.

Improve. Armed with a tight grasp of cause-and-effect relationships, you are now ready to design enhancement initiatives. Defective process features can be weeded out and successful ones enhanced and expanded. The Japanese coined the term poka-yoke ("mistake-proofing") for this process. You should point out misdirected efforts in real time and take corrective action immediately. Of note, poka-yoke was originally known as baka-yoke, or "idiot-proofing." But please, resist the temptation to use terms such as idiot or klutz in this domain.

Control. Once the process has been completely rationalized, all deviations from the winning formula should be ruthlessly suppressed. You should strive to codify your findings, both for your own reference and for the sake of future generations. Imagine a process-behavior chart on the wall providing up-to-the-minute visual feedback as to whether current performance is within no more than a standard deviation of optimal. Now imagine how delightful this can be.

That's all there is to it. Large corporations have achieved massive cost savings through the application of Six Sigma to their business processes. General Electric reported savings of more than $1 billion, and many hospitals have reported substantial reductions in per-patient costs. You can expect similar savings from Sex Sigma, for which preliminary results show boosted throughput with minimal outlay.

There is one important caveat in the adoption of Sex Sigma. Thanks to the huge returns on investment it affords, the field is likely to be flooded with opportunistic consultants and other itinerant change agents hawking their own quality improvement techniques. Unless you are dealing with a small cadre of authenticated experts, foremost among them the intrepid authors of this article, the traditional motto of the marketplace, "Caveat emptor" or "Buyer beware," should prevail.

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It is equally important to resist the impertinences of naysayers and skeptics who point out supposedly negative effects or purported deficiencies in evidence. Others claim that "silver bullet" quality improvement techniques are at best ineffective and at worst counterproductive. This is pure malarkey. As experts in the field know, doing something is always preferable to doing nothing, and merely taking action almost always gets results. This quality improvement approach provides its own validation.

Although we have presented only a cursory overview, we hope that this peep into Sex Sigma has provided you the know-how to initiate your fledgling in-house quality improvement program. With one or two such domestic projects under your belt, you will be well adapted to the corporate management structures of modern health care. You, too, will have the wherewithal to throttle health spending while increasing patient satisfaction scores. The trick to quality improvement is to have confidence. This may be precisely what some observers have in mind when they refer to Six Sigma and its newest namesake as confidence tricks.