Six Sigma Rept

8/18/2019 Six Sigma Rept

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A

PROJECT REPORT

ON:

REDUCING AND OPTIMIZING THE CYCLE TIME OFPATIENTS DISCHARGE PROCESS IN A HOSPITAL USING SIX

SIGMA DMAIC APPROACH

Submitted to Prof Abhijit Ananta NagBy Ajay More

Zeba Khan

CONTENTS

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• Introduction

• Methodoogy

• !MAIC Mode

• Anay"i" of data

• !i"cu""ion of finding"

• Concu"ion

• #imitation

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Ab"tract$

A lengthy and in-efficient process of discharging in-patients from the Hospital is an essential component that needs to be addressed in order to improve the quality of Health care facility.

Even though, several quality methodologies are adopted to improve such services in hospitals,the implementation of Six Sigma DA!" methodology to improve the hospital discharge processis much limited in the literature. #hus, the ob$ective of this research is to reduce the cycle time of the patients discharge process using Six Sigma DA!" odel in a multidisciplinary hospital

setting in !ndia. #his study had been conducted through the five phases of the Six Sigma DA!" odel using different %uality tools and techniques. #his study suggested various improvement

strategies to reduce the cycle time of patients discharge process and after its implementation&there is a '() reduction in the cycle time of the *atients discharge process. Also, a control planchec+ sheet has been developed to sustain the !mprovements obtained. #his Study ould be aneye opener for the Health "are anagers to reduce and optimie the cycle time of *atientsdischarge process in Hospitals using Six Sigma DA!" odel.

Introduction$

%o"&ita i" the mo"t im&ortant "er'ice indu"try( Today) e'erybody i" concerned about the *uaity

of %eath Care faciitie" and the term “*uaity” become" an e""entia eement to combatcom&etition in the %eath care En'ironment( In the &roce"" of attaining *uaity) each and e'ery

&roce"" in the %o"&ita need" to be o&timi+ed to the fue"t "ati"faction of the &atient"( One "uch &roce"" that dri'e" direct attention from the &atient" i" the &re&aration and the timey a'aiabiityof di"charge "ummary at the time ,hen they are ea'ing the ho"&ita( The "ucce"" of anyorgani+ation de&end" on it" re"ource utii+ation and by en"uring the &ro&er di"charge &roce""- ,ecan a""ure &atient "ati"faction and a"o utii+ing re"ource" for more &atient care(

A engthy) inefficient &roce"" for di"charging in.&atient" i" a common concern for the ho"&ita" inIndia( It not ony cau"e" fru"tration to the &atient" and famiy member") but a"o ead" to deay"for incoming &atient" from admitting ( %eath care manager" ha'e been ado&ting "e'era"trategie" to addre"" thi" i""ue and one "uch "trategy i" Si/ Sigma( Six-sigma i" a bu"ine""

im&ro'ement "trategy u"ed to im&ro'e bu"ine"" &rofitabiity to dri'e out ,a"te) to reduce co"t" of &oor 0uaity and to im&ro'e the effecti'ene"" and efficiency of a o&eration" "o a" to meet or

e'en e/ceed cu"tomer ’" need" and e/&ectation"(Si/ Sigma i" an organi+ed and "y"tematic methodfor Strategic &roce"" im&ro'ement" and ne, &roduct and "er'ice de'eo&ment that rey on"tati"tica and the "cientific method to ma1e dramatic reduction" in cu"tomer defined defect rate"(The name Si/ Sigma come" from the fact that it i" manageria a&&roach de"igned to create

&roce""e" that re"ut" in no more than 2(3 defect" &er miion(

DMAIC 4 Define, Measure, Analyze, Improve and Control 5 in Si/ Sigma i" de"cribed a" ana&&roach for &robem "o'ing( !MAIC i" a&&icabe to em&irica "tudie" ranging from ,e."tructured to "emi "tructured) but not to i."tructured &robem" or &urai"tic me""e" of "ubjecti'e

&robem"( The ad'antage of "uch method i" that they are 'ery 'er"atie( Ma"t and #o11erbo ha'e

highighted the characteri"tic" of the !MAIC a&&roach and it" imitation) "&ecificay from &robem "o'ing &er"&ecti'e"(

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6or the t,o decade") many manufacturing com&anie" ha'e im&emented "i/."igma to im&ro'etheir &roce""e"( But it" im&ementation in "er'ice indu"trie" i1e heath care i" much imited "ince"i/."igma i" a journey to reach the target by changing cuture of the organi+ation ,hich i" a ongterm &roce""( On re'ie,ing the iterature) fe, "tudie" demon"trated the utiity of Si/ SigmaMode" in %eath care Indu"trie" ,ith "&ecific focu" on "urgery turnaround time) cinica&&ointment acce"" ) hand hygiene com&iance) antibiotic &ro&hya/i" in "urgery ) "cheduing

radioogy &rocedure" ) catheter.reated bood"tream infection") meeting "tandard" for cardiacmedication admini"tration) no"ocomia urinary tract infection") and o&erating room 4O75through&ut( More recenty) 7o"aie Sager and Eric #ing conducted a "tudy by im&ementing the"i/ "igma methodoogy to im&ro'e the ho"&ita bed a'aiabiity and em&ha"i+ed that the#eader"hi& "u&&ort and acti'e &artici&ation from em&oyee" ,ere 1ey factor" in "ucce""fuim&ementation of Si/ Sigma Methodoogy in ho"&ita"( Simiary) %eath 7u"hing and CaroynPe/ton conducted a "tudy u"ing Si/ Sigma Mode and reduced the admitting deay" byim&ro'ing Bed Management(

The &re"ent "tudy ,a" conducted ,ith t,o fod objecti'e" u"ing Si/ Sigma !MAICMethodoogy 'i+$ 4i5 To reduce the time inter'a bet,een ,hen a di"charge order ,ritten by thePhy"ician and ,hen the di"charge "ummary i" ready to be handed o'er to the &atient- 4ii5 To findout ,hich a"&ect of the current &roce"" ,oud be in and out of "co&e to achie'e the timey hando'er of di"charge "ummary to the &atient"( A"o) thi" "tudy addre""ed the non.'aue addedacti'itie" increa"ing the cyce time of di"charge "ummary &re&aration &roce""(

Methd!"#

St$d# Sett%n"&:

Thi" "tudy ,a" conducted at K8 %o"&ita) India during the &roce"" of attaining %o"&ita

accreditation in the year 9:;:.9:;;( A" a mea"ure to im&ro'e the *uaity of Ser'ice") onecritica i""ue con"i"t" of deay in hando'er of di"charge "ummary to the Patient" ,a"

identified and a cro"" functiona *uaity management team ,a" formed to addre"" the

underying i""ue" that might be cau"ing the deay" in di"charging the &atient"( Accordingy)

the team member" e/&ored 'ariou" *uaity a&&roache" and finay) decided to u"e !MAIC

Mode ,ith an objecti'e to o&timi+e the cyce time of Patient" di"charge &roce""( The "tudy

,a" conducted for the duration of 2 month" and nece""ary &roce"" rede"ign ,a" carried

during thi" &eriod for obtaining o&tima re"ut"(

DMAIC Mde! 'De(%ne, Mea&$)e,

Ana!#*e, I+)-e and Cnt)! Mde!.

The methodoogica frame,or1 ado&ted in thi" "tudy i" ba"ed on !MAIC Mode( The *uaitytoo" and techni0ue" and the "trategie" ado&ted in each &ha"e of !MAIC to o&timi+e the Patient"di"charge &roce"" i" de"cribed beo,$

De(%n%n" the P)/!e+

6ir"ty) the e/act critica i""ue to be in'e"tigated ,a" ceary defined in thi" &ha"e by the Chief

E/ecuti'e Officer 4CEO5 of the %o"&ita( The "eection of that critica i""ue i" ba"ed on the three

1ey &arameter" 'i+( 4i5 Patient centered %o"&ita Mi""ion- 4ii5 Pa"t com&aint" recei'ed from the

Patient" and- 4iii5 %i"torica Patient "ati"faction Sur'ey re"ut"( By anay+ing the abo'e three 1ey &arameter" ,ith &articuar attention to the 'oice of cu"tomer 4Patient feedbac1 form5) it ,a"

inferred that there i" need to reduce &atient di"charging time) ,hich had been identified a" one of

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the critica factor contributing to di""ati"faction among in.&atient"( In order to e/ecute thi" "tudy

on a &iot ba"i") one "&ecific de&artment caed) 8enera Medica and Surgica !e&artment ,a"

"eected( The anti0ue data 4for &re'iou" 2 month"5 in the %o"&ita &ro'ide" the "ummary of the

tota turnaround time ta1en for di"charging the &atient" in the 8enera Medica and) Surgica

de&artment"( %o,e'er) after due con"utation ,ith the &roce"" o,ner" of the Patient" di"charge

&roce"" and the concerned %O! of the de&artment") the 5( So a" toaccom&i"h thi" &roject) a Si/ Sigma team con"i"ted of a Team eader 4u"uay a %eath care

&rofe""iona ,ith a Si/ Sigma Bac1 Bet Certification5) Medica Su&erintendent) Nur"ingSu&erintendent) Nur"ing Manager of the Medica ? Surgica ,ard") One IT "&eciai"t 4mo"ty a"enior manager from the E!P de&artment5 and a technica "taff from the biing de&artment ,ereformed by the CEO of the %o"&ita(

The &rimary objecti'e of the team i" to im&ro'e and o&timi+e the &atient di"charging &roce"" andthe initia target ,a" fi/ed to hand o'er the di"charge "ummary to the &atient" ,ithin t,o hour"and ;= minute" hour" 4i(e( ;2= minute"5 of the di"charge deci"ion ,a" ta1en by the attendingPhy"ician or Surgeon( The Key &roce"" out&ut 'ariabe ,a" the a'erage time ta1en for Patient"di"charging the Patient in that

&articuar de&artment(

Mea&$)e the C$))ent P)0e&&

The mea"ure &ha"e in'o'e" documentation and e'auation of the e/i"ting Patient" ‟ di"charge

"y"tem before im&ementation of the Im&ro'ement "trategy that the team might "ugge"t( A" an

initia "te&) the &roce"" "igma e'e of the Patient di"charging &roce"" of the "eected "&eciatyde&artment ,a" cacuated ba"ed on the anti0ue data and it i" "ho,n in the tabe ;(

The abo'e cacuation of the current Sigma #e'e of error or defect" in the di"charging &roce"" ,a"done ,ith the goa of finding out ho, co"e the di"charge &roce"" i" to the target of "i/ "igma

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"tandard de'iation bet,een the mean 923(2= minute" and the target ;2= minute"( The re"ut""ho,ed that in the ;9: "am&e" data obtained there ,ere @= di"charge" that fe abo'e the target of ;2= minute") ,hich i" :(>= or ; "tandard de'iation from the mean of 923(2= minute"( The idea"igma e'e a,ay from the mean of 923(2= minute" ,oud be "tandard de'iation"( Therefore) thecurrent di"charge &roce"" at the %o"&ita i" = "tandard de'iation" a,ay from the target( Thi" may be

becau"e the e/i"ting di"charge &roce"" contain" many 'ariabe" or "&ecia ca"e" "&read out

throughout the &roce""( A" a further e/&oration) the team de'eo&ed 6o, diagram to ma& a 'i"uare&re"entation of a the major "te&" in the Patient" di"charge &roce"" a" "ho,n in 6igure.;( Thi""te& ,i he& in under"tanding ho, the entity 4di"charge re&ort5 fo," through the &roce"" and,hat i" the roe of each "ta1ehoder in the &roce""(

The ma&&ing of the Patient" di"charge &roce"" ,a" carried out u"ing Proce"" fo, chart to anay+ea the "te&" "tarting from the &re&aration of the di"charge "ummary by the &hy"ician and continued,ith "e0uentia acti'itie" unti it i" handed o'er to the &atient(

The &roce"" com&ri"ing of a "e0uentia "te&" "tarting from the di"charge deci"ion ta1en by thePhy"ician and end" ,ith the timey hando'er of di"charge "ummary to the &atient( It ,a" bro1en

do,n into fi'e ogica "ub &roce""e" 'i+$

;5 Pre&aration of di"charge note" by the attending Phy"ician or Surgeon

95 Proce""ing of di"charge note" by the ,ard "ecretary by a&&ending the nece""ary aboratory re&ort"(

25 Proce""ing and ty&e"etting of the di"charge "ummary by the Editor

35 Com&etion of fina di"charge "ummary by the Editor after &roof read by the Phy"ician or Surgeon

=5 !i"charge "ummary ready to be handed o'er to the Patient after "igned by the Phy"ician or Surgeon(

A time "tudy ,a" u"ed to mea"ure each "te& in the &roce"" to determine the time con"umed by eachof the fi'e "ub &roce""e" to,ard" the &re&aration of the di"charge "ummary( Time "tudy i" a directand continuou" ob"er'ation of a ta"1) u"ing a time1ee&ing de'ice 4e(g() decima minute "to&,atch)com&uter.a""i"ted eectronic "to&,atch) and 'ideota&e camera5 to record the time ta1en to

accom&i"h a ta"1( The ob"er'ed mean time for each of the "ub &roce""e" of the Patient" di"charge &roce""

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6rom the &roce""ma&&ingand thetime "tudy of

each "ub &roce""e") it i" found that "i/ area" ,ere identified a" critica area" that may deay thetimey hando'er of di"charge "ummary to the Patient"( 6ir"ty) a deay might occur at the Phy"ician

or Surgeon’" end in the rough &re&aration of di"charge note"( Secondy) a deay might occur at the &roce""ing of the di"charge note" by the ,ard "ecretary due to interru&tion" in getting thein'e"tigation re&ort"( Thirdy) due to interru&tion in getting the com&eted di"charge note" by the,ard "ecretarie") there i" a &otentia "ource of deay in "ending the rough draft of di"charge note" to

the editor( The ne/t "ource of deay may occur at the editor ‟" de"1 due to the centrai+ed di"charge"ummary &re&aration &roce""( E'en after the rough draft of di"charge "ummary &re&ared by the

editor) there might be a chance that the di"charge re&ort may hod u& at the doctor" ‟ de"1 for getting hi" fina a&&ro'a and "ignature( 6inay) e'en ,hen the di"charge "ummary i" ready to behanded o'er to the &atient") there might be a chance for deay in the &roce"" of getting cearancefrom the In"urance or biing de&artment(

Ana!#&%& ( the Data:

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In the anay+e Pha"e) a i"t of Key &roce"" In&ut 'ariabe" 4KPI"5 ,ere anay+ed(

Key &roce"" in&ut 'ariabe" incude„Time factor" ‟ that are controing the O&&ortunitie" of the

Patient" !i"charge &roce""( The time con"umed for each of the "i/ &roce"" "te&" of the Patient"

di"charge &roce"" i" "ho,n in the tabe 9( Ba"ed on the homogeneity of acti'itie" reated to &re&aration of di"charge "ummary) it i" found that four critica area" con"umed more time ,ith

re"&ect to the u&&er "&ecification imit 4i(e( ;2= minute"5 fi/ed by the &roce"" o,ner" 'i+$

;5 Pre&aration of rough di"charge note by the Phy"ician-

95 6urther &roce""ing and i""uance of di"charge note by the ard "ecretary-25 Proce""ing time for ty&e"etting the di"charge "ummary by the Editor 4combine" the &roce"" "te&" III)

I ? 5-

35 Proce""ing time to hando'er the di"charge "ummary to the &atient after getting cearance from the biing and the In"urance de&artment(

In order to ocate the rea"on" for the deay in each of the "ub &roce""e" of the Patient" di"charge &roce"") a root cau"e anay"i" 46i'e hy"5 ,a" carried out and it i" de&icted in the tabe 2( It i" a"y"tematic techni0ue of a"1ing fi'e 0ue"tion" "ucce""i'ey in order to &robe the cau"e" of aProbem to get to heart of the &robem( It i" a 'ery effecti'e too and can be u"ed to identify theroot cau"e" of a &robem(

The tabe 2 de&ict" four critica i""ue" that might be cau"ing deay" in timey hando'er of thedi"charge "ummary to the &atient" at the time ,hen are ea'ing the %o"&ita( A the i""ue"identified ,ere further e/&ored and "ubjected to the root cau"e anay"i" u"ing brain "tormingtechni0ue"( The fir"t i""ue e/&ored ,a" to the find out the rea"on" for the deay in the

&re&aration of di"charge note by the Phy"ician( After di"cu""ion ,ith each of the Phy"ician incharge of &re&aring the di"charge note) it ,a" found that the &hy"ician ha'e to &re&are thedi"charge note manuay by 'erifying a the ree'ant record" of the Patient"( Such acti'ity

con"ume" a itte ong time and thi" ha&&ened becau"e the Information technoogy ,a" notedfuy utii+ed to generate and 'erify the re0uired &atient record" needed for &re&aration of thedi"charge note(

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The "econd i""ue e/&ored ,a" to find out the rea"on for the deay in further &roce""ing ?i""uance of di"charge note by the ,ard "ecretarie" and it ,a" "ubjected to the root cau"e anay"i"(

The anay"i" yied" four &o""ibe "e0uence of e'ent" that ead" to the occurrence of thi" &robema" &ercei'ed by the ard Secretarie" 'i+( 4i5 more time con"umed for carifying certain criticai""ue" "uch a" drug" and it" do"age) foo,.u& detai" etc( ,hich are generay incor&orated in the

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di"charge note- 4ii5 The hand ,ritten di"charge note by the Phy"ician i" difficut to under"tandthat re0uire" further carification- 4iii5 !ifferent ,ard "ecretarie" ,ere u"ed to &roce"" the "amedi"charge note due to change in their "hift timing"( The e'entua "oution to o'ercome thi""&ecific critica i""ue i" to u"e "ame and trained ,ard "ecretarie" to &roce"" the di"charge note "othat they can be famiiar ,ith the Phy"ician" hand,riting" and the ,hoe &roce"" ,i be fini"hed,ithin o&tima time(

6urther the root cau"e for the deay in ty&e"etting the rough di"charge "ummary by the editor ,a"e/&ored( T,o "&ecific rea"on" ,ere traced from the feedbac1 of the &roce"" o,ner"( The fir"tone i" the Centrai+ed di"charge "ummary &re&aration &roce"" ado&ted by the %o"&itaadmini"tration( A" re"ut of thi") a the di"charge "ummarie" ,ere &re&ared at a centrai+ed unitand there ,a" a ong 0ueue that ead" to a ong ,aiting time to com&ete the &roce""( Thi" coud

be a'oided by ma1ing the di"charge "ummary &re&aration &roce"" decentrai+ed to eachde&artment e'e( The "econd i""ue ,a" reated to the &roce"" ,here the deay ,a" occurring dueto the non.a'aiabiity of Phy"ician" to &roof read and correct the rough di"charge "ummary

&re&ared by the editor"( Thi" coud be attributed to the fact that the attending &hy"ician might bein'o'ed in ard round" or attending "urgerie"( The a&&ro&riate "oution ,oud be to in'o'e or

em&o,er A""i"tant Surgeon or Phy"ician to &roof read the rough di"charge "ummary and to ma1enece""ary change" if re0uired(

#a"ty) the root cau"e for the deay in hando'er of the di"charge "ummary to the &atient after it,a" "igned by the corre"&onding Phy"ician or Surgeon ,a" e/&ored( One "&ecific rea"on ,a"

&ointed out by the &roce"" o,ner" in'o'ed in that acti'ity( There ,a" a &otentia deay in gettingthe Patient" bi" to be ceared either from the In"urance com&anie" or from the Patient" it"ef(hie e/&oring the rea"on" for thi" deay) it ,a" found that it too1 ong time to get the bi"cearance manuay u"ing &en and &a&er ba"ed a&&roach( A"o) there ,a" no Enter&ri"e 7e"ourcePanning 4E7P5 "oft,are or Intranet faciity to connect a the de&artment" for confirming the

bi" cearance of the &atient") ,hen the need ari"e( The "uitabe "oution ,oud be to in"ta ana&&ro&riate E7P &ac1age to in1 a the com&uter" 'ia intranet "o that thi" &robem coud be

re"o'ed in "hort run(

I+)-e Pha&e

In thi" Pha"e) the re"ut" of the anay+e &ha"e ,ere carefuy im&emented to ma1e a&&ro&riatechange in the de"ign of Patient" di"charge &roce"" by remo'ing the non.'aue added acti'itie"contributing to the deay in di"charging the &atient" and foo,ing recommendation" ,ereim&emented 'i+$

;5 8enerate u&.to.date information about the drug" and thera&ie" utii+ed by the &atient" before and

during the "tay in the ho"&ita u"ing Information technoogy "y"tem( En"ure a the informationabout the &atient" i" a'aiabe in a com&uter generated &rinted form and be in"erted in to themedica record of the &atient on the day &rior to the e/&ected di"charge( Thi" form &ro'ide" ano&&ortunity for the Phy"ician to re'ie, the medication" ta1en by the &atient" &rior to admi""ion andan o&&ortunity to indicate or modify the medication" and dietary "chedue to be con"umed by thePatient" after di"charge( a"o the drug" and thera&ie" &re"cribed during the ho"&ita "tay( Chec1

bo/e" are gi'en that he& the Phy"ician ,ith(

95 Effort" ha'e been ta1en to train and utii+e "ame ard "ecretaryDtechnica "taff at each de&artment "othat the deay in &roce""ing of di"charge "ummary coud be reduced( The ta"1 of carrying out the

&re&aration of di"charge "ummary ,a" a""igned to "&ecific "taff at each de&artment "o that the ta"1

,oud be com&eted at a&&ro&riate time( Moreo'er) a Proce"" !e"ign Program Chart 4P!PC5 ,a" &re&ared de&icting the &atient di"charging &roce"" cu"tomi+ed to each de&artment and made readiya'aiabe to faciitate the &roce""( A"o) the Patient" di"charge &roce"" fo, ha'e been de'eo&ed

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and di"&ayed in the in&atient room "o that the di"charge e/&ectation" are communicated to the &atient" during their ho"&ita "tay 4Ajami and Ketabi 9::5(

25 !ecentrai+e the %o"&ita di"charge &roce"" ,here the &re&aration of di"charge "ummary i" done ateach indi'idua de&artment it"ef( Ade0uate faciitie" and man &o,er ,ere de'eo&ed at eachde&artment to &re&are di"charge "ummary( Thi" ,i reduce the deay in the ty&e"etting thedi"charge "ummary by the Editor at a Centrai+ed di"charge


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D%&0$&&%n ( (%nd%n"&$

Thi" "tudy i" the documentation of the effecti'ene"" of im&ementing Si/ Sigma !MAIC method"to reduce and o&timi+e the Patient" di"charging &roce"" at K8 %o"&ita) Coimbatore) India( In order to e/ecute thi" "tudy on a &iot ba"i") one "&ecific de&artment namey 8enera Medica and Surgica

de&artment ,a" "eected ba"ed on the homogeneity of "er'ice" offered and the com&e/ity of the &atient" handed in the de&artment(

!uring the define &ha"e) the &robem ,a" defined ba"ed on the in&ut" ca&tured through the Patientfeedbac1 form"( Accordingy) a Project charter ,a" &re&ared and roe" and re"&on"ibiitie" of theteam ,ere fi/ed( A"o) the team fi/ed the


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"uch a" #ab re&ort" and Bi cearance had been done through manua method" in"tead of u"ingInformation technoogy 4i(e( chec1ing 'ia intranet5- 4ii5 6aiure to utii+e "ame ? trained ,ard"ecretarie" to &roce"" the di"charge re&ort( The a&&icabiity of Gob rotation techni0ue e/&o"e"different ,ard "ecretarie" to &roce"" the di"charge "ummary and it im&ede" the em&oyee" to be"&eciai+ed in that Gob- 4iii5 #ac1 of decentrai+ed di"charge "ummary &re&aration &roce""( There"&on"ibiity for &re&aring the di"charge "ummarie" had been underta1en by a centrai+ed


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decrea"e) but it i" higher than the u&&er "&ecification imit 4;2= Minute"5 a" fi/ed by the Proce""o,ner"( %o,e'er) the re"ut" demon"trated a &o"iti'e im&act on reducing the &atient di"chargetime due to the a&&ication of "ugge"ted recommendation" for the &eriod of t,o month"( A" re"utof thi" brea1through im&ro'ement) more &atient" ,i be managed in the &articuar de&artment,hich indirecty increa"e the number of admi""ion") turno'er of the room") increa"e ho"&ita

&rofitabiity and ,i a"o enhance Patient "ati"faction( Thi" "tudy a"o demon"trated the

contribution of the mutidi"ci&inary team member" of the ho"&ita in reducing Patient" di"chargetime(

L%+%tat%n&

The Co'erage of thi" "tudy and im&ro'ement" obtained ,a" imited to ony to the 8eneraMedica and Surgica !e&artment of Study Setting( So) an a&&ro&riate &recaution need" to beta1en ,hie generai+ing the re"ut"( Thi" "tudy ,i he& the %o"&ita admini"trator" and &oicy

&anner" in e/&editing deci"ion about the im&ementation of "i/ "igma Method" to im&ro'e the*uaity of care in %o"&ita"(

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Six Sigma Rept

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