Six Sigma in Health Literature, What Matters?

The Feasibility of AgileNudge+ Software to Facilitate Positive Behavioral Change: Mixed Methods Design

BACKGROUND

In today's digital age, web-based apps have become integral to daily life, driving transformative shifts in human behavior. "AgileNudge+" (Indiana University Center for Health Innovation and Implementation Science) is a web-based solution to simplify the process of positive behavior change using nudging as an intervention. By integrating knowledge from behavioral economics with technology, AgileNudge+ organizes multiple steps, simplifies complex tasks, minimizes errors by enhancing user engagement, and provides resources for creating and testing nudge interventions.

OBJECTIVE

This paper aimed to outline the design process, methodologies, and usefulness of "AgileNudge+" for the development of evidence-based nudges. It used a mixed methods approach to evaluate the software's interface usability and usefulness for creating and testing nudge interventions.

METHODS

AgileNudge+ was developed through iterative processes integrating principles from behavioral economics and user-centered design. The content of AgileNudge+ operationalizes an Agile science-based process to efficiently design, embed, and disseminate evidence-based nudges that encourage positive behavior change without limiting choice. Using a mixed methods approach, we tested AgileNudge+ software's ability to organize and simplify the nudge intervention process, allowing a diverse range of scholars with limited knowledge of Agile science to use nudges. Usability testing assessed the tool's usefulness and interface with a sample of 18 health care professionals, each asked to interact with the software and create a nudge intervention to solve a problem within their professional project's sphere.

RESULTS

The study was funded in August 2022, with data collection occurring from June 2023 to July 2024. As of July 2024, we have enrolled 18 participants. Quantitative results found a mean usefulness rating of AgileNudge+ of 3.83 (95% CI 3.00-4.66). Qualitative results highlighted ways to modify the language used in AgileNudge+ to be more comprehensible to a diverse user base and promoted modifications to the software that facilitate real-time assistance and prioritize time efficiency in user interactions. Feedback further supported the positive impact of gamification on participant motivation when using the software.

CONCLUSIONS

AgileNudge+ is an effective assistive tool for simplifying the positive behavior change process using nudge interventions, with tailored content and interactions to meet users' needs and demands. Building onto the current design, future iterations of AgileNudge+ will use artificial intelligence to process large volumes of data while reducing the time and mental energy required to scan for existing cognitive biases and nudge prototypes. The software is also being upgraded to build on current gamification efforts, encouraging more sustained motivation by increasing the temporal resolution of the digital interface. These modifications stay true to the agility and user-centered aspects of AgileNudge+, emphasizing the novelty of the constantly evolving software design process.

Six Sigma can significantly reduce costs of poor quality of the surgical instruments sterilization process and improve surgeon and operating room personnel satisfaction

Operating room (OR) management is a complex multidimensional activity combining clinical and managerial aspects. This longitudinal observational study aimed to assess the impact of Six-Sigma methodology to optimize surgical instrument sterilization processes. The project was conducted at the operating theatre of our tertiary regional hospital during the period from July 2021 to December 2022. The project was based on the surgical instrument supply chain analysis. We applied the Six Sigma lean methodology by conducting workshops and practical exercises and by improving the surgical instrument process chain, as well as checking stakeholders' satisfaction. The primary outcome was the analysis of Sigma improvement. Through this supply chain passed 314,552 instruments in 2022 and 22 OR processes were regularly assessed. The initial Sigma value was 4.79 ± 1.02σ, and the final one was 5.04 ± 0.85σ (SMD 0.60, 95%CI 0.16-1.04, p = 0.010). The observed improvement was estimated in approximately $19,729 of cost savings. Regarding personnel satisfaction, 150 questionnaires were answered, and the overall score improved from 6.6 ± 2.2 pts to 7.0 ± 1.9 pts (p = 0.013). In our experience the application of the Lean Six Sigma methodology to the process of handling the surgical instruments from/to the OR was cost-effective, significantly decreased the costs of poor quality and increased internal stakeholder satisfaction.

The Influence of Sample Size on Long-Term Performance of a 6σ Process

There are many criticisms for the association between the Six Sigma concept and the two statistical metrics associated to 6σ processes: 1.5σ shift for maximum deviation and 3.4 PPM non-conformities for the long-term performance. As a result, the paper aims to carry out an analysis of this problem, and the first result obtained is that a stable process can reach a maximum drift, but its value depends on the volume of the sample. It is also highlighted that, using only the criterion “values outside the control limits” for monitoring stability through the Xbar chart, a minimum value can be calculated for the long-term performance of a process depending on the sample size. The main conclusion resulting from the calculations is that, in the case of a 6σ process, the long-term performance is much better than the established value of 3400 PPB: For small volume samples of two pieces it is below 700 PPB, for three pieces it is below 200 PPB, and for samples with a volume greater than or equal to four pieces the performance already reaches values below 100 PPB! So, the long-term performance of 6σ processes is certainly even better than the known value of 3.4 PPM.

Lean and Six Sigma as continuous quality improvement frameworks in the clinical diagnostic laboratory

Processes to enhance customer-related services in healthcare organizations are complex and it can be difficult to achieve efficient patient-focused services. Laboratories make an integral part of the healthcare service industry where healthcare providers deal with critical patient results. Errors in these processes may cost a human life, create a negative impact on an organization's reputation, cause revenue loss, and open doors for expensive lawsuits. To overcome these complexities, healthcare organizations must implement an approach that helps healthcare service providers to reduce waste, variation, and work imbalance in the service processes. Lean and Six Sigma are used as continuous process improvement frameworks in laboratory medicine. Six Sigma uses an approach that involves problem-solving, continuous improvement and quantitative statistical process control. Six Sigma is a technique based on the DMAIC process (Define, Measure, Analyze, Improve, and Control) to improve quality performance. Application of DMAIC in a healthcare organization provides guidance on how to handle quality that is directed toward patient satisfaction in a healthcare service industry. The Lean process is a technique for process management in which waste reduction is the primary purpose; this is accomplished by implementing waste mitigation practices and methodologies for quality improvement. Overall, this article outlines the frameworks for continuous quality and process improvement in healthcare organizations, with a focus on the impacts of Lean and Six Sigma on the performance and quality service delivery system in clinical laboratories. It also examines the role of utilization management and challenges that impact the implementation of Lean and Six Sigma in clinical laboratories.

Transformational Performance Improvement: Why Is Progress so Slow?

In this chapter, we identify three distinct transformational performance improvement (TPI) approaches commonly used to redesign work processes in health care organizations. We describe the unique components or tools that each approach uses to improve the delivery of health services. We also summarize what is empirically known about the effectiveness of each TPI approach according to systematic reviews and recent studies published in the peer-reviewed literature. Based on examination of this research, we discuss what knowledge is still needed to strengthen the evidence for whole system transformation. This involves the use of conceptual frameworks to assess and guide implementation efforts, and facilitators and barriers to change as revealed in a recent evaluation of one major initiative, the Lean Enterprise Transformation (LET) at the Veterans Health Administration. The analysis suggests ways in which TPI facilitators can be developed and barriers reduced to improve the effectiveness and sustainability of quality initiatives. Finally, we discuss appropriate study designs to evaluate TPI interventions that may strengthen the evidence for their effectiveness in real world practice settings.

Analysis of Effect of Six Sigma Method Combined with CI Strategy on Improving of Nursing Quality in Outpatient Infusion Rooms

Objective. The infusion room is the last part of an outpatient visit, with high patient density, large staff mobility, and a wide variety of conditions. In addition, most patients are accompanied by their families during infusion, and nursing staff in infusion rooms have to face more trivial and miscellaneous tasks than nursing staff in other treatment departments, which are more complex. The purpose of this research is to explore the impact of the Six Sigma method and CI strategy on the quality of nursing management in infusion rooms, so as to provide reference for clinical research. Methods. A total of 2142 patients treated in our outpatient infusion rooms from June 2019 to June 2020 was included into this retrospective analysis. Of these, 1105 patients admitted before 2020 received routine care management services and were considered as the control group. Another 1037 patients were admitted after 2020 and received the Six Sigma method combined with CI strategic care management and were considered as the research group. The incidence of adverse events during treatment was counted in both groups, and patients’ compliance behavior and psychology were investigated. After treatment, patients’ evaluation of the quality of nursing and their satisfaction with the nursing were investigated. Results. The incidence of adverse events during infusion in the research group was dramatically lower than that in the control group, while the compliance behavior scores were higher ( $P<0.05$ ). In addition, SAS and SDS in the research group were lower than those in the control group, while the quality of nursing were higher ( $P<0.05$ ). It was also clear that the research group had 93.39% satisfaction with nursing, which was also higher than the control group ( $P<0.05$ ). Conclusion. Implementation of infusion room nursing management according to the Six Sigma method with CI strategic plan can avoid adverse events and improve infusion nursing satisfaction. It also helps reduce the incidence of dispute events.