Six Sigma: DMAIC Application on Diagnostic Imaging


Diagnostic Imaging is also called as Medical Imaging. It is the use of electromagnetic radiation to generate images of internal structures of the human body for the purpose of knowing the accurate diagnosis. Diagnostic imaging is roughly equivalent to radiology, the branch of medicine that uses radiation to diagnose and treat diseases. X-rays used since 1895, were the first type of radiation to provide images of the interior of the body. X rays pass through bodily tissues and also have the property of darkening photographic film when they strike it. As they penetrate tissues, the X rays are absorbed differentially, with denser objects such as bones absorbing more of the rays and thus preventing them from reaching the film. Soft tissues, on the other hand, absorb fewer rays; the result is that in an X-ray photograph of the interior of the body, bones show up as lighter areas and soft tissues show up as darker ones on the exposed film.

Another type of diagnostic imaging is nuclear magnetic resonance, which creates images of thin slices of the body using very-high-frequency radio waves. Ultrasound is a technique in which high-frequency sound waves are used for detecting abnormalities in internal organs. The varieties of radiation that are used in diagnostic imaging continues to expand, along with the techniques for using them. And so are the nuclear medicine, magnetic resonance imaging, PET (positron emission tomography), computed tomography and multi-slice CT scanners, Ultrasound, PACS (picture archival communication systems), RIS (radiology information systems), digital mammography, molecular imaging and speech recognition.

Use of diagnostic imaging has increased significantly within fee-for-service models of care. During the 15-year study period, enrollees underwent a total of 30.9 million imaging examinations (25.8 million person-years), reflecting 1.18 tests (95% CI, 1.17-1.19) per person per year, of which 35% were for advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MRI], nuclear medicine, and ultrasound). Use of advanced diagnostic imaging increased from 1996 to 2010; CT examinations increased from 52 per 1000 enrollees in 1996 to 149 per 1000 in 2010, 7.8% annual increase (95% CI, 5.8%-9.8%); MRI use increased from 17 to 65 per 1000 enrollees, 10% annual growth (95% CI, 3.3%-16.5%); and ultrasound rates increased from 134 to 230 per 1000 enrollees, 3.9% annual growth (95% CI, 3.0%-4.9%). Although nuclear medicine use decreased from 32 to 21 per 1000 enrollees, 3% annual decline (95% CI, 7.7% decline to 1.3% increase), PET imaging rates increased after 2004 from 0.24 to 3.6 per 1000 enrollees, 57% annual growth. Although imaging use increased within all health systems, the adoption of different modalities for anatomic area assessment varied. Increased use of CT between 1996 and 2010 resulted in increased radiation exposure for enrollees, with a doubling in the mean per capita effective dose (1.2 mSv vs 2.3 mSv) and the proportion of enrollees who received high (>20-50 mSv) exposure (1.2% vs 2.5%) and very high (>50 mSv) annual radiation exposure (0.6% vs 1.4%). By 2010, 6.8% of enrollees who underwent imaging received high annual radiation exposure (>20-50 mSv) and 3.9% received very high annual exposure (>50 mSv).

Executive Summary:

Such advancements not only just allowed disease to be detected and treated earlier but also made life-saving possibilities for patients. The treatment is also done with great accuracy. The consumer demand has grown to a very great extent and also with this growth the need to recruit and maintain qualified technologists has also grown.

The imaging technologies are providing the data with greater speed and superior image quality. However, when workflow is encumbered by inefficiencies, the benefit to the organization – and ultimately the patients – may not be fully realized. Even with the latest equipment installed, many organizations are facing delays in report-turnaround time and a backlog of patients waiting for appointments. The problems faced because of this delays are delay in diagnosis and treatment, emergency department bottlenecks, increased length of stay, patient dissatisfaction, referring physician dissatisfaction, potential loss of outpatient business, loss of revenue and so on.

The equipment must be aligned properly with people and steps must be involved in the delivery of safe and cost-effective patient care. Application of Six Sigma Strategies of DMAIC methodology can eliminate non-value-added steps that cause delays, pinpoint root causes for defects and variability, and remove inefficiencies and redundancies that can undermine any organization’s best efforts. 

The hospital or diagnostic imaging center decides that Six Sigma is the best way to achieve their goals, a project team is assembled and trained in the methodology, led by experienced consultants or process improvement experts. To maximize the benefits to the organization, it’s important for the team to examine the entire operation – including service quality, service cycle, service cost and market potential. Existing assets, resources, equipment, staff, scheduling and transport should all be considered for their potential impact on departmental productivity. 

Define and Measure Phase

Next to the team and champion involvement the main cause of project failure is not understanding the voice of customer and focusing on wrong CTQ’s. So it is very important to clearly identify critical elements and obtain voice of the customer (VOC) information through stakeholder interviews. Having clear and measurable CTQ’s are the foundations of the success of any project. Key performance indicators are gathered in a reliable way, including exam volume, exam duration and room utilization for all modalities; patient, referring physician and staff satisfaction, and staffing to identify current operational performance relative to labor expense, revenue and operational quality metrics. It expands on the business case clarifying the focus, measures of the project’s performance, and completed by a six sigma Black Belts who are the team leaders. Financial data is extracted from existing systems within the facility and cycle time data needs to be collected manually. Process mapping and sub-process mapping with assigned indicators for selected modalities helps to outline existing procedures within the department. A project team does not want to be limited by what is available, but it wants to get what it needs. During the measure phase one should define how the data is to be gathered, factors for data acquisition plan.

Analyze Phase:

During the Analyze phase, analysis is performed to check the capability of the process as compared to the present standards. Adjustments are done if the goal is not meeting the expectations. Data is partitioned in order to find the causes of the problems. Update the prediction on how improvement can be achieved in the process. Having the right data ready for analysis puts a team half way through project success. During the Analyze phase, analyzing the critical drivers that are impacting the process are examined carefully. There may be issues like slow start-up times during the mornings or there may be conflicts with physicians. The information also may indicate that a high volume of patients failing to show up for appointments is consuming capacity, or that utilization fluctuates during the day due to bottlenecks in the system or variability in patient arrival patterns. With analysis complete, the team develops action plans like how to approach, what to do and what not to do.

Improve Phase:

The role of Improve phase is to identify a solution to the problem that the project aims to address. This involves brainstorming potential solutions, selection solutions to test and evaluating the results of the implemented solutions. Often a pilot implementation is conducted prior to a full-scale rollout of improvements. The key steps involved in Improve Phase are selecting solutions to implement, implementing improvements, Evaluating improvements and wrapping up the improve phase. The Improve phase often is the most challenging one. But it is also the rewarding part of the project. As the process is changing long-standing issues will be finally addressed and better processes will be put in place – changes that will ultimately improve the overall effectiveness of the facility’s diagnostic imaging services. 

Control Phase:

Simple and Robust – if the team gets these two things right, it will have half won the control battle. The Control phase begins once process changes have been established and appear to be working. One cannot underestimate the importance of monitoring results during this phase. This plays a major role in long-term success and a differentiating element for Six Sigma. During this phase, control tools are implemented such as “dashboards” or balanced scorecards to monitor key indicators and ensure that project gains remain on track. It also is important during the Control phase to “institutionalize” the wins, celebrate success and instill ongoing change management capabilities through change management tools. 

Critical Review

Link to Strategic Imperatives high

“Effective executives know that they have to get many things done — and done effectively. Therefore, they concentrate — their own time and energy as well as that of their organization — on doing one thing at a time, and on doing first things first.”Peter Drucker, in a chapter entitled, “First Things First”, The Effective Executive (published in 1966)

The strategic imperative of this case is HIGH. The look into the future problems and solving them ahead is the key principle of an organization success. Each step the organization took for the future problems made the company to step into the success of project. Project has a very great impact on the key metrics for the organization. It is very important to maintain the grip over strategic drivers of business as it ensures that leadership remains engaged during the long run improvements. These are the team’s or organization’s critical leverage points. Strategic imperatives are vital if it is few 12 to 18 month goals, priorities, and improvement targets. If this criteria is fulfilled the team or organization runs toward it’s vision, values, and purpose.

Application of six sigma tools  

The organization didn’t use any tools except fetching the data and analyzing. They have analyzed the data which they maintained and based on this data took leaping steps to solve the issue. So I would give it low for the Application of six sigma tools

Active sponsor engagement 

I will rank it Medium because there is not much active sponsor engagement in this project to guide the project. In order to maintain the project to step into right direction to achieve major business goals Active sponsor engagement is must. We even saw the top managements completely involving in the project. They have identified the issues earlier and stepping towards solving the problem but we never saw the Sponsor engaging anywhere in the project.

Team actively engaged 

I will rank it HIGH.  Team members are proud of being part of the team and they see themselves as part of the team. The team has a clear understanding of the overall goal of the process. There has to be team participation for the successful project we can see that the team is maintaining a better understanding and each one playing their role effectively and actively.

Broad organizational awareness of the project  

The entire organization is aware of the project and they are all involved in the six sigma project. Every member of the organization is aware of the project and has a clear understanding of how it will impact their area of responsibility and plays an active role in communicating the project. I will rank it HIGH.

Project delivered anticipated results 

The project delivered the anticipated results. Everybody in the project is aware of the project changes, results and outcome. I will rank it HIGH, because the project delivered the anticipated results like increased CT capacity, better predictability, increased satisfaction, financial potential increase annually.

Project Completed on Time 

The project was completed within the stipulated time. I will rank it HIGH. Completing the project within the specified time period indicates a sign of success. If a target has to be reached successfully there should be a time period to be set. Finishing a project within the time period is a signal for the starting of success. Short project duration boosts the morale of the team members and long duration projects make team members lose focus

Successful Transition of Ownership to Process Owner

I will rank it high. A process owner has been identified and the owner has done his work effectively thus making the number of patients get their reports. There has been effective participation of Process owner.

Improvement Sustained Over Time 

This is HIGH because the improvements attained has sustained over the period of time. The results have been sustained and showed that changes have been adopted by the organization. The performance during the process is far much better as compared to the project start date .The team has embraced the changes and the manager was efficient in managing the time and team efficiently. 

Replication of results 

I will rank it HIGH. The team has developed a thorough plan to show how the improvement would be duplicated. Changed management has been put in place for successful continuation.


The organization survived and thrived in this environment, diagnostic imaging departments and facilities by adopting strategies for increasing efficiency and cost effectiveness. The organization also achieved optimal efficiency, service quality, customer satisfaction and financial success in diagnostic imaging and has reached the Sigma levels of excellence in diagnostic imaging like developing a plan, meeting customer expectations, focusing adequate attention on project selection and scoping, establishing a clear understanding of current operations and direction, determining and focusing on key metrics and success indicators.