1. Improving Pharmacy
Quality Using Six Sigma
Dr. John W. Watson, RPh, MBA, DBA, FASCP

2. What is quality and who
determines quality?
• Many definitions
• “meeting customers’ expectations and/or specifications”
• Quality is determined by the customer (patient).

3. Factors that contribute to quality
• Types of quality
• Performance
• Features or attributes designed into the product or service
• Example: a website
• Conformance
• How well a product or service conforms to desired goals or
specifications
• Examples: weights and measures, graduated cylinders, syringes

4. Products and Services. What is
the Difference?
• Products
• Tangible goods
• Service
• Intangible
• Bundling products and services together
• Example: pharmacies

5. Products and Services. What is
the Difference?
• Dimensions of product quality (product = tangible)
• Performance
• Features
• Reliability
• Conformance
• Durability
• Serviceability
• Esthetics
• Perceived value

6. Products and Services. What is
the Difference?
• Dimensions of service quality (service = intangible)
• Tangibles
• Reliability
• Responsiveness
• Assurance
• Empathy

7. Using Six Sigma to Improve
Quality
• What is Six Sigma?
• Definition
• Six Sigma is a method of process improvement that emphasizes
setting extremely high objectives, collecting data, and analyzing
results to systematically reduce defects in products or services.
• Sigma – a statistical term that represents standard deviation (an
indicator of the degree of variation in a process).
• Six Sigma – a statistical concept that measures a process in
terms of defects. At a six sigma level, a process is generating
only 3.4 defects per million opportunities (3.4 DPMO)
• The Six Sigma method of managing focuses on eliminating
process defects.

8. Using Six Sigma to Improve
Quality
• What Six Sigma IS NOT:
• Just about statistics
• A quality program
• Only for technical people
• Used when the solution is known
• Used for “firefighting”

9. Using Six Sigma to Improve
Quality
• Understanding Six Sigma
Normal distribution with 6 standard deviations (6σ)

10. Using Six Sigma to Improve
Quality
• Understanding Six Sigma
Current prescription dispensing process
Mean prescription dispensing
time = 15 minutes

11. Using Six Sigma to Improve
Quality
• Understanding Six Sigma
Current prescription dispensing process that is not
operating at a six sigma level
Upper Spec Limit
= 10 minutes Mean prescription dispensing
time = 15 minutes

12. Using Six Sigma to Improve
Quality
• Understanding Six Sigma
Improved prescription dispensing process
Upper Spec Limit
= 10 minutesMean prescription dispensing
time = 4.36 minutes

13. Using Six Sigma to Improve
Quality
• Understanding Six Sigma
• Levels of sigma
Sigma level DPMO Percentage yield
1 691,462 68.26%
2 308,538 95.46%
3 66,807 99.730%
4 6,210 99.9937%
5 233 99.99943%
6 3.4 99.999998%

14. Using Six Sigma to Improve
Quality
• Understanding Six Sigma
• Our world at a 4σ level:
• 4000 prescriptions filled incorrectly each year
• More than 3000 newborns accidentally falling from the hands of
nurses and doctors each year
• Two long or short landings at an American airport EACH DAY
• 400 lost letters every hour by the Post Office.

15. Using Six Sigma to Improve
Quality
• Understanding Six Sigma
• What is an acceptable sigma level for an industry or a
process?
• The acceptable sigma level depends on the nature of the
business and what customers expect.
• A 4σ level (99.99%) for the drive-thru at a fast food restaurant is
most likely very acceptable. This equates to approximately 6
incorrect orders at the drive-thru for every 1000 customers.
• A 4σ level is most likely unacceptable for maintenance workers in
the aircraft industry.

16. Using Six Sigma to Improve
Quality
• What is Six Sigma?
• History
• The term “Six Sigma” is credited to Motorola engineer Bill Smith.
• Motorola credits over $16 billion in saving from using Six Sigma.
• Six Sigma creates a cultural change within companies.
• Hundreds of companies are now using Six Sigma, including
Honeywell, IBM and General Electric.

17. Using Six Sigma to Improve
Quality
• What is Six Sigma?
• An emerging process improvement strategy
• In 1980’s, Six Sigma shifts from purely defect reduction to a
process improvement methodology.
• In 1991, Motorola certified its first Six Sigma “Black Belt”
experts.
• In 1995, GE’s Jack Welch credited Six Sigma methods with over
$750 million in cost savings for GE.
• By 2000, many firms offering Six Sigma training and
certification.

18. The Six Sigma Protocol
• DMAIC
• Define
• Measure
• Analyze
• Improve
• Control

19. DMAIC: Define
• Define
• Define who the customers are.
• What are their requirements, needs and expectations?
• External customers (end users)
• Internal customers
• Determine the Voice of the Customer (VOC).
• Example of not listening to the VOC New Coke
• Sample pharmacy problem: It takes too long to get prescriptions
filled.

20. DMAIC: Define Project Charter
Project Information
Contact
name/number
Project Title Decreasing prescription dispensing time Project leader
Pharmacy
Manager
Project Location Project mentor
Start date Process owner
Estimated end date Champion
Project details
Problem statement
Customer satisfaction is declining due to long wait times for prescriptions. As a result, prescription
volume may decrease as customers seek alternative options.
Project description
A survey was provided to customers over the most recent 6 month period by placing the survey in their
bag at the prescription checkout register. Eight hundred and fifty‐four surveys were returned. The top
concern/complaint on the survey was the long wait period for prescriptions. Thirty‐seven percent of
responders raised this complaint.
Business case
Benefits and constraints Project goals
Business benefits Increased prescription volume Success metric Metric unit
Baseline
performance
Goal
performance
Customer benefits Increased customer satisfaction
decrease in
average
dispensing time
min:sec Ave: 17.5 min Ave < 10 min
Support required
Team members Pharmacists, technicians
Limitations $250 budget for materials, supplies
*Larger image available in the handout

21. Polling Question #1
• Who determines quality?
• Managers?
• Customers?
• Investors?
• Regulatory agencies?

22. Polling Question #1
• Quality is determined by CUSTOMERS.

23. DMAIC: Define
• Define
• Tools to use
• Surveys
• Interviews
• Focus groups
• Suggestion boxes

24. DMAIC: Define
• Define
• Tools to use
• Surveys
• Advantages:
• Low cost, easy distribution
• Low error rates, data easily analyzed
• Convenient data gathering
• Little or no observer subjectivity, low sample bias
• Disadvantages
• Inflexible design
• Low response rate, lack of personal contact
• Can be annoying to customers

25. DMAIC: Define
• Define
• Tools to use
• Interviews
• Advantages:
• Customers can discuss any topic
• In person or by telephone
• Disadvantage:
• May escalate if customer starts to “vent”
• Time-consuming
• Data may be hard to quantify
• Risk of interview bias
• Focus groups
• Suggestion boxes

26. DMAIC: Define
• Define
• The payback for the problem identified for improvement must be
worth the effort. Customer satisfaction must be improved.
• Define phase deliverables:
• A well-defined project scope
• Six Sigma team formation. Includes project champion as well as
roles and responsibilities for all members.
• Risk identification and mitigation plan. The team identifies all
possible project problems and develops contingencies to address
them.

27. DMAIC: Measure
• Measure
• Characterize the process
• Flow chart or process diagram
• Baselining (determine current state)
• Quantifying the goodness (or badness!) of the current process,
before ANY improvements are made, using sample data. The key
to baselining is collecting representative sample data
• Determine the type of data that is to be collected (unbiased).

28. DMAIC: Measure
• Sample Process Flow Chart
*Larger image available in the handout

29. DMAIC: Measure
• Measure
• Pharmacy example
• Decrease prescription waiting time – time stamp data
• Beginning time – ending time = dispense time.
• Sample size – determine how many data points to collect.
• Large enough to be an accurate representation of average
dispensing time.

30. DMAIC: Measure
• Measure
• Deliverables
• Key variables are identified and agreed upon.
• A solid data collection plan is identified that includes a
description of the collection method.
• All team members are informed about the variables and the
data collection plan.

31. DMAIC: Analyze
• Analyze
• Find the top 2 or 3 causes of the problem.
• Seek team input to identify potential causes.
• Fishbone diagram (Ishikawa diagram)
• 5 Whys

32. DMAIC: Analyze
• Fishbone diagram examples
*Larger image available in the handout

33. DMAIC: Analyze
• Fishbone diagram examples: increased dispensing time
Increased Rx Dispensing Time
Environment Machines
Phone calls
Customer distractions
Slow internet
Software gliches
Hardware malfunctions
Supplies not stocked
Inventory out-of-stock Staff multi-tasking
Patient information missing
*Larger image available in the handout

34. DMAIC: Analyze
• The 5 Whys technique
• Made popular by Toyota
• Goal: get to the root cause of the problem by repeating the
question “why”.
• Example:
• Problem: The Washington Monument was disintegrating.
• Why? Answer: Use of harsh chemicals.
• Why? Answer: To clean pigeon poop.
• Why so many pigeons? Answer: They eat spiders and there are a lot of
spiders at monument.
• Why so many spiders? Answer: They eat gnats and lots of gnats at
monument.
• Why so many gnats? Answer: They are attracted to the light at dusk.
• Solution: Turn on the lights at a later time.

35. DMAIC: Analyze
• The 5 Whys technique: Pharmacy example
• Problem: Increased prescription dispensing time
• Why is the prescription not ready for pickup?
• Claim rejected by insurance.
• Why was claim rejected by insurance?
• Insurance information on file was incorrect.
• Why was insurance information on file incorrect?
• Insurance information was not verified before adjudicating?
• Why was insurance information not verified before adjudicating?
• Insurance card not available.
• Why was insurance card not available?
• Insurance card was not requested from patient at prescription drop-off.
• Why was insurance card not requested from patient at prescription drop-off?
• Requesting insurance card for verification is not part of the prescription
intake process. (root cause of the problem).

36. Polling Question #2
• Surveys are a common method used to determine
the VOC (Voice of the Customer). The advantages
of surveys include all, BUT:
• Low cost
• Low error rate
• High response rate
• Ease of analysis

37. Polling Question #2
• Surveys are a common method used to determine
the VOC (Voice of the Customer). The advantages
of surveys include all, BUT:
• High response rate

38. DMAIC: Analyze
• Summary
• Identify the gaps between the current performance of the process and the
goal performance.
• Root cause analysis
• Generate a list of possible causes (sources of variation)
• Segment and stratify the possible causes (sources of variation)
• Prioritize a list of “vital few” causes (key sources of variation)

39. DMAIC: Improve
• Identify and implement solutions
• Brainstorming
• Include people who actually perform the process
• Encourage current process rules and assumptions to be
challenged. (Look for new ways of doing things).
• Ideas should not be judged.
• No ideas are eliminated.
• Even outlandish ideas may prompt someone to think of an idea
that will work.

40. DMAIC: Improve
• Identify and implement solutions
• Select solutions to test
• Involve the people closest to the process
• Establish reasonable implementation procedures and evaluation
criteria
• Timelines
• Due dates for deliverables
• Budget requirements or restrictions
• Develop a data collection plan.
• Determine roles and responsibilities

41. DMAIC: Improve
• Identify and implement solutions
• Anticipate the effects of change
• Introduce change management techniques
• Fully communicate changes to all participants
• Ensure managements commitment to the project
• If change issues arise, they should be mitigated by the Six Sigma
team so that the project stays on track

42. DMAIC: Improve
• Identify and implement solutions
• Evaluate the results of implemented solutions (measure)
• Compare the post-improvement data to the baseline data
collected in the Measure phase.
• First attempts at improvement may not always yield
improvement. If not, repeat the process until correct process
change results in improvement.
• Pilot test

43. DMAIC: Improve
• The pharmacy example: decreasing prescription
processing time (1st attempt)
• Brainstorming
• Missing patient information
• Solution
• Develop a questionnaire or checklist for the technician at
prescription drop-off.
• Train all staff on how and when to use the new
questionnaire/checklist.
• Results
• Only a small decrease in prescription processing time.
• Did not reach target goal. Management requested further
reduction in prescription processing time.

44. DMAIC: Improve
• The pharmacy example: decreasing prescription
processing time (2nd attempt)
• Brainstorming
• Missing patient information
• Solution
• Update the telephone voice response system to request a call-
back number for patients if additional information is needed.
• Update website refill tool to require a call-back number also.
• Ask patient when desired pickup is (may not decrease time, but
may increase customer satisfaction).
• Results
• Average prescription time decreased again. The total decrease
from the two attempts reached the target goal.

45. DMAIC: Improve
• Summary
• Generate (and test) possible solutions
• Select the best solutions
• Design implementation plan
• Communicate process changes to all participants
• Include goals and timelines
• Anticipate process change problems
• Outline post-improvement measurement procedures

46. DMAIC: Control
• Goal: Maintain improvements achieved
• Standardize the improved process
• Reduces variation in the process
• Repeat the process the same way EVERY time.
• Pharmacy example
• The technician uses the questionnaire/checklist at the
drop-off counter for EVERY prescription taken in.
• The completed questionnaire/checklist is sent with the
prescription through the entire process.

47. DMAIC: Control
• Development control plan
• Control chart
• The voice of the customer (from surveys) indicates that
customers want prescriptions ready for pickup within 10
minutes.
Ave, 4.360
UCL, 10
LCL, 0.000
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Range
Sample #
*Larger image available in the handout

48. DMAIC: Control
• Develop and implement a monitoring plan
• Standardize the improved process
• Document new procedures

49. Why Companies Need Six Sigma
• Reduces dependency on “Tribal Knowledge”
• Decisions based on facts and data rather than opinion
• Attacks the high-hanging fruit (the hard stuff)
• Eliminates chronic problems (common cause variation)
• Improves customer satisfaction
• Provides a disciplined approach to problem solving
• Changes the company culture
• Creates a competitive advantage
• Improves profits!

50. Questions?