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October 1, 2011

Six Sigma for EMS

EMS has become more sophisticated over the past 20 years, but the sophistication of how we manage quality and improve processes hasn't kept pace.

For many EMS organizations, quality management efforts are primarily focused on addressing complaints along with reviewing charts in search of inconsistencies or errors in care.

Today's most successful methods for improving quality stem from the work of such quality pioneers as Walter Shewhart, Joseph Juran, and W. Edwards Deming.

Deming's work was featured in a 1980 NBC special in 1980 entitled "If Japan Can, Why Can't We," which highlighted Japan's then-growing lead in product quality over the US.

The program discussed Dr. Deming's decades of teaching quality methods in Japan and how those methods were largely ignored in the US. The program sparked a renewed focus in the US on continuous improvement, and his teachings provided the methods needed to deliver such quality.

While Dr. Deming's teachings were rapidly accepted and implemented in manufacturing environments, they were slow to gain interest in the health care arena. That is no longer the case.

One of the leading figures in applying these industrial quality models to healthcare was Don Berwick, MD, author of the landmark book Curing Healthcare. He subsequently established the Institute for Healthcare Improvement (

In the late 1980's the manufacturing world was introduced to a new quality program called Six Sigma. It has since been adopted by manufacturing, service, and healthcare organizations with tremendous success.

In many ways, Six Sigma is the result of working process improvement techniques on process improvement methods. It provides a framework for managing an organization's overall process for improvement projects, as well as a robust framework for conducting individual projects.

This framework is called DMAIC — an acronym for the high level steps in the life cycle of a process improvement project:

  • Define — Clearly define what it is that you hope to improve and ensures that it links to the mission, values, and strategic plan of the organization
  • Measure — Establish a baseline for the structure and performance of the process to be improved
  • Analyze — Identify the factors with the most influence on process improvement so that the focus remains on those factors
  • Improve — Tests improvement ideas using the scientific method to make a valid determination of their effectiveness; this may require testing several different ideas
  • Control — Establishes ways to monitor process performance over time and pre-plans interventions should performance backslide

Perhaps the most important aspect of Six Sigma is the philosophy it brings to managing quality. Six Sigma uses many of the same tools as Total Quality Management and Continuous Quality Improvement, but places a strong emphasis on delivering ‘bottom-line' results that are important to the mission, vision, and values of the organization. These could be annual cost savings, customer satisfaction rates, or lives saved. This makes Six Sigma valuable to all parts of an EMS organization — clinical, operations, and administration.

The Six Sigma Body of Knowledge is rather large, but most process improvement projects can be handled with mastery of only a small subset of these techniques.

Mikel Harry, the "godfather" of Six Sigma, was a martial artist enthusiast and he developed his education system using the martial arts philosophy of "belts." Like in the martial arts, the higher the level of mastery of core concepts the higher the degree of belt.

Within Six Sigma there are four or five primary belt designations. These include:

  • White Belts — Usually an hour or two of instruction meant to provide the participant with a basic introduction to the terminology of Six Sigma
  • Yellow Belts — Participants learn how to interpret data and use the basic DMAIC framework. This allows them to participate as active team members and content experts in Six Sigma project teams
  • Green Belts — Participants learn how to use the DMAIC framework to facilitate project teams. In addition, they learn how to use computer software to perform many of the data analysis techniques commonly required in Six Sigma projects
  • Black Belts — Participants master even more data analysis techniques and formally participate in a project that requires a comprehensive understanding of these methods
  • Master Belts — This designation is reserved for individuals who have gone on to do additional work in several of the Six Sigma Bodies of Knowledge and have mastered the educational practices needed to teach Six Sigma skills to other individuals

So, how can Six Sigma help EMS organizations?

EMS organizations can use these techniques to make a wide array of processes more effective and efficient. From improving response times and improving protocol compliance, to increasing the service life of an ambulance fleet, Six Sigma can help managers reduce waste, cut costs, and most important, improve safety.


About the Author

Mic Gunderson has been involved in EMS for more than 30 years in managerial and clinical roles with third service, fire, private and military EMS systems, research teams, EMS medical direction groups, and as an educator/consultant. He has served on the boards of directors for several national EMS organizations and the editorial boards for several academic EMS journals, including Prehospital & Disaster Medicine, Prehospital Emergency Care, Journal of Emergency Dispatch, Emergencias Medicas and others. He has also served as an editor for several NAEMSP texts and is the editor/moderator of the NAEMSP Dialog listserv.

Mic now serves as the President of Integral Performance Solutions (IPS), specializing performance improvement, system/process design, and EMS system assessments. Mic is an adjunct faculty member for the University of Maryland. Among his previous positions, Mic was the National Director for Quality, Education and Research with Rural/Metro and served for many years as the Director of Research and Education with the Office of the Medical Director in the Pinellas County, Florida EMS system.

Before taking on the role of CEO at IPS, Todd Hatley was the Chief Operating Officer of HealthAnalytics. Prior to that, he was an Adjunct Assistant Professor in the Department of Emergency Medicine at the University of North Carolina. Todd's formal education includes an Associate degree in EMS, Bachelors degree in Business Administration and dual Masters Degrees in Business Administration and Healthcare Administration.

Todd has been involved in numerous national EMS projects and organizations including service as the past-president of the National EMS Management Association; service on the National EMS Information Systems Taskforce; and as a faculty member for NHTSA. Todd is also involved in many non-EMS groups including the Society for Industrial and Organizational Psychology, the North Carolina Industrial and Organizational Psychologists, the American Society for Quality.

Contact Mic at

Contact Todd at