International Journal of Health Care Quality Assurance

Application of Six Sigma methodology to a diagnostic imaging process

Mehmet Tolga Taner, Bulent Sezen, Kamal M. Atwat,
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IJHCQA
25,4 Application of Six Sigma
methodology to a diagnostic
imaging process
274
Mehmet Tolga Taner
Department of Health Care Management, Uskudar University, Istanbul, Turkey
Received 11 January 2011
Revised 22 March 2011 Bulent Sezen
Accepted 7 June 2011
Department of Business Administration, Gebze Institute of Technology,
Kocaeli, Turkey, and
Kamal M. Atwat
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Department of Health Policy, Management and Evaluation,

University of Toronto, Ontario, Canada

Abstract
Purpose – This paper aims to apply the Six Sigma methodology to improve workflow by eliminating
the causes of failure in the medical imaging department of a private Turkish hospital.
Design/methodology/approach – Implementation of the design, measure, analyse, improve and
control (DMAIC) improvement cycle, workflow chart, fishbone diagrams and Pareto charts were
employed, together with rigorous data collection in the department. The identification of root causes of
repeat sessions and delays was followed by failure, mode and effect analysis, hazard analysis and
decision tree analysis.
Findings – The most frequent causes of failure were malfunction of the RIS/PACS system and
improper positioning of patients. Subsequent to extensive training of professionals, the sigma level
was increased from 3.5 to 4.2.
Research limitations/implications – The data were collected over only four months.
Practical implications – Six Sigma’s data measurement and process improvement methodology is
the impetus for health care organisations to rethink their workflow and reduce malpractice. It involves
measuring, recording and reporting data on a regular basis. This enables the administration to
monitor workflow continuously.
Social implications – The improvements in the workflow under study, made by determining the
failures and potential risks associated with radiologic care, will have a positive impact on society in
terms of patient safety. Having eliminated repeat examinations, the risk of being exposed to more
radiation was also minimised.
Originality/value – This paper supports the need to apply Six Sigma and present an evaluation of
the process in an imaging department.
Keywords Six Sigma, Radiology, Image, Repeats, Cost, Health services, Quality improvement, Turkey,
Medical diagnosis, Image scanners
Paper type Research paper

International Journal of Health Care Introduction

Quality Assurance Imaging systems, using different types of radiation and supported by modern
Vol. 25 No. 4, 2012
pp. 274-290 microelectronics produce images of the living organisms, are today a permanent
q Emerald Group Publishing Limited feature of medical diagnostics. Different forms of medico-technical systems have been
0952-6862
DOI 10.1108/09526861211221482 developed to meet the needs of different diagnostic techniques (Krestel, 1990).
 With the advent of a number of new procedures in the last few decades, X-ray Diagnostic
diagnostics as originally developed by Wilhelm Conrad Röntgen in the year 1895 has imaging process
undergone major changes. Today’s total image format has been possible since the
advent of the Anger camera in 1958. The first total image unit for ultrasound diagnoses
appeared in 1966 and in 1972 followed the development of computed tomography (CT)
by G.N. Hounsfield. In 1973, P.C. Lauterbuhr introduced magnetic resonance
tomography, which was followed by the introduction of such systems to the market in 275
early 1980s. The decades to follow produced a steadily increasing stream of innovation
including the advent of positron emission tomography (PET), picture archival
communication systems (PACS), radiology information systems (RIS), digital
mammography, molecular imaging, speech recognition, ultrasound, CT and
magnetic resonance imaging (MRI) (Krestel, 1990).
The rapid developments in microelectronics of the last few decades have
contributed significantly to improvements in medico-technical systems. These include
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improved image quality, made possible by the introduction of microchips, greatly

simplified system operation, a considerable extension of the range of applications, and
a substantial reduction in size and weight (Krestel, 1990). Such advancements opened
up life-saving possibilities for patients, allowing diseases to be detected and treated
earlier and with more success. With the availability of faster technologies, however,
came a sharp rise in consumer demand, a growing need to recruit and retain qualified
technologists between advancing technologies and traditional workflow. It seemed
that although the industry had continued to evolve from a technological standpoint, the
processes surrounding diagnostic imaging services had not kept pace with the science
delivering better equipment and information systems.
Today’s workflow is full of inefficiencies. The losses to the organisation and
ultimately the patients are not fully realised. The examination repeats are one of those
efficiencies. Even with the latest equipment installed, many radiology units still face
human errors resulting from the misinterpretations of the images by radiologists.
Errors and variability can obviously undermine the delivery of safe and effective
patient care (Buck, 2001; Kohn et al., 2000). Hospitals can combine process
management with information technology to redesign patient flow for optimal
efficiency and clinical outcomes (Mahaffey, 2004).
The etiology of radiological error is multi-factorial. They fall into recurrent patterns
and may arise from poor technique, failures of perception, lack of knowledge,
misjudgements, system failure, bad quality of image, anatomy of patient and improper
calibration. The work of diagnostic radiology consists of the complete detection of all
abnormalities in an imaging examination and their accurate diagnosis. Every
radiologist, technician and physician should understand the sources of error in
diagnostic radiology as well as the elements of negligence that form the basis of
malpractice litigation (Pinto and Brunese, 2010).
An accurate diagnosis in radiology is pre-requisite to effective patient care.
However, diagnostic errors are often caused by both imaging equipment and
radiologists. Technology changes human tasks and shift workloads, and tends to
reduce or eliminate human decision making. Radiologists are the easiest targets for
blame in the wake of a major system failure, although the real problem often lies in
poor system design. On the other hand, there is always the risk of variation since the
reading may change from observer to observer.
 IJHCQA The domain of errors by medical practitioners has received considerable attention in
25,4 recent years. The number of repeated procedures, costs and deaths caused by such errors
is alarming (Revere and Black, 2003). According to the Institute of Medicine (IOM) report,
somewhere between 44,000 and 98,000 people die in different American hospitals every
year because of errors committed by medical professionals (Bion and Heffner, 2004).
Many new imaging technologies are introduced to the healthcare market each year.
276 These modalities deliver increased image quality and provide diagnostic confidence to
physicians to more accurately treat patients. However, this is generally achieved only
at considerable additional expense. To optimise the performance of the workflow,
design and diagnosis, technology must not only be the leading edge, but it should also
be appropriately aligned with the medical professionals and process steps that are
involved in the delivery of safe and cost-effective patient care.
The radiology unit of a recently founded private hospital has been suffering from
the cost of repeated sessions and delays although the equipment implanted was of the
most recent technology. If these errors in the radiology process are not immediately
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found and the patient receives inappropriate treatment or no treatment, those errors
can lead to a number of types of adverse events.
In this study, technical strategies offered by the Six Sigma methodology are
implemented in a radiology unit to eliminate the repeated procedures.
Although the process improvement in radiology departments using Six Sigma
methodology has been studied by many researchers in the literature (Benedetto, 2003;
Cavagna et al., 2003; Chan et al., 2005; Chen et al., 2005; Corn, 2009; Elsberry, 2000;
Gorman et al., 2007; Kang et al., 2005), this study is the first attempt to apply Six Sigma
in a medical imaging department in Turkey.

Six Sigma methodology

Sigma methodology is one of the most powerful performance improvement tools that
are changing the face of modern healthcare delivery today. It is embraced by many
organisations and industries involved in manufacturing and services as a cost-effective
way to improve quality and productivity. As a method to eliminate variation and
defects, Six Sigma makes use of a structured approach named DMAIC to find the root
causes behind problems and to drive processes toward near-perfection (Cherry and
Seshadri, 2000).
The define, measure, analyse, improve and control (DMAIC) is a five-step
improvement cycle with the aim to continuously reduce errors:
(1) Define the problems, clarify scope and define goals.
(2) Measure the current performance, gather and compare data, refine
problems/goals.
(3) Analyse by identifying sources, gaps and root causes of errors and analyse best
practices.
(4) Improve by conducting trials to eliminate root causes, testing various solutions,
measuring results, standardising solutions and, implementing the improved
processes by designing creative solutions to fix and prevent problems.
(5) Control the performance of the new process by institutionalising improvements
and putting a mechanism for ongoing monitoring in place (Park and Antony,
2008).
 DMAIC for diagnostic imaging Diagnostic
Applied to diagnostic imaging, Six Sigma approach focuses on optimising time, human imaging process
and equipment resources; improving service delivery (to patients by technologists,
radiologists, referring physicians); and reducing costs while enhancing revenue. Using
the DMAIC methodology can eliminate non-value-added steps that cause delays and
bottlenecks, pinpoint root causes for errors, repeats and variability, and remove
inefficiencies and redundancies that can undermine a department’s best efforts. 277
In manufacturing, it is quite possible to reduce or even eliminate (in some cases)
most of human variability through automation (Riebling, 2005). In the healthcare
industry, however, the delivery of patient care is largely a human process, and hence
the causes of variability are often difficult to identify and quantify (Sehwail and
DeYong, 2003). This difficulty can be overcome by Six Sigma methodology.

Define phase
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The hospital administration considered the application of Six Sigma from the
perspective of improving the quality and capability of current processes as well as
the ability of processes to deliver patient care and safety. Thus, having taken the
administrative support of the hospital, the radiology unit decided that Six Sigma
was the best way to achieve their goals and a project team was assembled and
trained in the methodology, led by an experienced consultant. Having gone through
Six Sigma training, black-belts and green-belts formed a multidisciplinary and
comprehensive team in the hospital. The project lasted for one year and examined
the data of the initial four months in the radiology department. First, main errors in
the workflow were defined. The entire operation was examined including the
equipment’s calibration times, capacity (number of patients per week), time
constraints related to bringing the patient to the equipment room and delivering the
film to the patient, the amount of annual maintenance to equipment, the
radiologists’ years of experience, age of the equipment and training given for
properly calibrating the equipment were all considered for their potential impact on
the performance of the radiologists (Figure 1).
A suppliers, inputs, process, outputs, customers (SIPOC) diagram is generated
(Table I). Critical to quality (CTQ) factors are established by examining the voice of the
staff. Bias and accuracy are considered as proximal antecedents as they are the strong
direct predictors of efficiency. Distal variables are the correlates of factors affecting in
the work place determined by conducting an employee satisfaction survey among the
technologists, radiologists and physicians (Tables II and III). The critical-to-quality
(CTQ) characteristics for distal independent variables are the proximal independent
variables and for proximal independent variables, CTQ is the efficiency.
Departmental workflow was drawn (Figure 2). Current workflows pertaining to
different equipment were examined separately. For example, CT involves the following
multi-step process:
.
the patient arrives;
.
the patient receives any necessary preparation by the technologist;
.
the examination is performed by the technologist;
.
the films are printed;
.
the radiologist interprets the images, edits and signs a report;
 IJHCQA
25,4

278
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Figure 1.
Overview of the Six Sigma
implementation in this
study

Suppliers Inputs Process Outputs Customers

Medical schools Facilities Calibration of the High diagnostic Patients

equipment accuracy (sensitivity
and specificity)
Medical instrument Cost of the Calibration of the High efficiency
manufacturers equipment scanner
Technical schools Education of the Examining the Low bias
radiologist/ patient
technologist
Experience of the Printing the film Low repeats of
radiologist/ examination
technologist
Training of the Reading the film High patient safety
radiologist/ Interpreting the
Table I. technologist images
SIPOC table Editing the report

.
the film and report are sent to the physician and to the patient’s chart; and
.
the physician writes an overall report.

It is firstly decided that all communication barriers should be eliminated in the

department. A good teamwork between the radiologist, technologist and physician is a
must in radiology to improve the workflow as it solely depends on correctly identifying
 the duties and doing them right. Next, bottlenecks, redundancies and inefficiencies in Diagnostic
the overall workflow were identified and realised. imaging process
Measure phase
The hospital makes use of a RIS/PACS system that handles images from the medical
imaging instruments in the department such as CT, ultrasound, nuclear medicine,
PET, and MRI. It is an advanced storage system, providing rapid retrieval of images, 279
access to images acquired with multiple modalities, and simultaneous access at
multiple sites. It is particularly important as the diagnosis reports are created based on
the images retrieved for presenting from PACS server by physician/radiologist and
then saved to RIS system. When the system stops or is blocked due to a problem from
the main computer while examining patient, there is no means to continue acquiring an
image from the patient. This was one of the causes of the repeats.
Another major problem related to the RIS/PACS system, was due to its use by
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incompetent physicians. In most cases, the physicians had chosen to write the orders for
examination on a piece of paper. This incompetency often resulted in radiologist’s having

From technologists’ From radiologists’ From physicians’

Factors perspective perspective perspective

Transportation £ £
High patient volume £ £ £
Malfunction of RIS/PACS system £ £ Table II.
High workload £ £ £ Factors affecting the
Lack of teamwork £ radiologist, technologist
Lack of respect £ and physicians in the
Lack of continuous education £ £ work place

From From From

technologists’ radiologists’ physicians’
Factors perspective perspective perspective

Malfunction of RIS/PACS systems £ £

Improper positioning of patient £ £ £
Anatomy of patient (e.g. body size) £ £ £
Unnecessary movement of patient while
imaging/scanning £ £ £
Language barrier (patient-examiner) £
Presence of light in the environment £
Improper equipment maintenance and calibration £
Inexperience £ £ £
Lack of training £
Technological advancement of equipment £ £ £
Age of equipment £ Table III.
Quality of body image £ Factors affecting the
Film reading £ £ radiologist and
Working environment and conditions £ £ £ technologist while
Time constraints £ £ examining a patient
 IJHCQA
25,4

280
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Figure 2.
Work flowchart and
failure modes

no electronic information of the appointment in order to examine the patient. This had
actually been the main cause of waiting time and delayed diagnosis in the department.
Therefore, physicians should provide adequate and timely information to radiologists.
The team determined the factors affecting the radiologist, technologist and
physicians in the work place (Table II) and while examining a patient (Table III).
The fishbone diagrams for CT (Figure 3), PET (Figure 4), MRI (Figure 5) and
ultrasound (Figure 6) indicating the equipment parameters were drawn. Although
 Diagnostic
imaging process

281
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Figure 3.
Fishbone diagram (CT)

Figure 4.
Fishbone diagram (PET)
 IJHCQA
25,4

282
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Figure 5.
Fishbone diagram (MRI)

Figure 6.
Fishbone diagram
(ultrasound)
 interior design of different equipment involves different parameters, the type of errors Diagnostic
involved and root causes of repeated examinations are similar. This was followed by imaging process
the collection of data to measure the current sigma level. Data were collected on a daily
basis. Comparisons between data were made both in daily and weekly basis.
Frequency of repeated examinations, patient volume, root causes of the delays and
repeats, calibration times and delivery time of films were recorded.
283
Analyse phase
Failure trends over a four-month period were monitored and recorded. The team
utilised the failure mode and effect analysis (FMEA) to break down the process into
individual steps: potential failure modes, effects, likelihood, causes, frequency of
occurrence, control, and detection, so that the team members could look at key drivers
in the process based on the past experience. Failure data in each step together with
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their consequences were recorded (Table IV).

By means of the fishbone diagrams, the team take advantage of engineering
knowledge and collect information to understand and reduce the current and possible
future failures. Visual displays of data such as the fishbone diagrams (Figures 3-6) and
Pareto diagram (Figure 7) were utilised. Graphical analysis using the Pareto chart (see
Figure 7) indicated 44 per cent of the defects can be attributed to patients, whereas 56
per cent are attributed to the equipment.
A total of six radiology failure modes were identified causing the repeat sessions. In
these cases repeat were necessary as any resulting misinterpretation of the images
would cause misdiagnoses. All these causes were prioritised according to how serious
their consequences were (severity score), how frequently they occurred (probability
score) and how easily they could be detected. Hazard analysis was employed in order to
identify failure modes and their causes and effects. The team determined the severity
and probability of each failure and assigned scores for them. The severity and
probability of an event were scored from 1 to 4 (Table V). The hazard matrix was
derived by multiplying both scores. The severity and probability of each cause was
estimated and its hazard score was calculated. The decision tree analysis is employed.
Subsequently, Pareto chart was incorporated to determine the “vital few” causes that
had been responsible for the majority of errors causing the repeat examinations. It
appeared that the most frequently faced drivers of repeats that might impact the
workflow under examination were the malfunction of RIS/PACS system and improper
positioning of the patient. Then, the team developed a corrective action plan for each
cause (see Table VI) in the improve phase.
The malfunctioning of the RIS/PACS system was determined to be related to:
(1) Downtime of RIS.
(2) Downtime of PACS.
(3) Downtime of the hospital network.
(4) Downtime of the power.
(5) Downtime of single modality.
(6) Downtime of workstation.
(7) Software bugs.
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25,4

284

repeats
Table IV.
IJHCQA

Patient volume and

Number of Repeats Number of Number of Repeats Number of
examinations in examinations Repeats in examinations in examinations Repeats in
Capacity (August) August (September) September (October) October (November) November

Ultrasound 720 677 18 684 12 699 7 718 2

MRI 360 340 8 344 6 352 3 359 1
PET 240 197 7 205 4 214 3 227 2
CT 1,440 1,312 30 1,346 21 1,380 10 1,432 5
Total 2,760 2,526 63 2,579 43 2,645 23 2,736 10
 Diagnostic
imaging process

285
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Figure 7.
Pareto diagram

Standards of acceptable image quality were established. By utilising the fishbone

diagrams, acceptability limits for parameters that categorise each modality’s image
quality are standardised by the radiologists. The rejected images were judged and
analysed according to the cause of reject.
In addition, the analysis of the survey also revealed issues related to delays such as
slow or late start-up times in the mornings that were one causes of bottlenecks. In
addition, the collected information indicated that a high volume of patients failing to
show up for appointments taken by telephone calls had been consuming capacity, and
that utilisation had fluctuated during the day causing the other cause of bottlenecks in
patient arrival and exit patterns.
Baseline capability was measured. Sigma level and yield of the current workflow
were found to be 3.5 and 97.57 per cent, respectively. This measurement was the sigma
quality level with which the core imaging processes were currently operating in the
department. This process level provided a baseline performance for improvement
activities.

Improve phase
Functionality of RIS/PACS system was improved by training the physicians on how to
use the electronic system effectively. Training was also conducted on radiologists and

4 3 2 1

Severity of failure Permanent causes Temporary causes Bias No harm

of wrong of wrong
Table V.
diagnosis diagnosis
Criteria for severity and
Probability of failure Frequent Occasional Uncommon Remote probability of failures
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25,4

286

Table VI.
IJHCQA

Potential causes of

decision tree analysis

failure, hazard analysis,
Hazard analysis Decision tree
Severity Probability Hazard analysis
Potential cause of failure score score score Critical? Detectable? Action

Malfunction of RIS/PACS system 3 4 12 Yes Yes Conduct training to physicians, radiologists and technicians
Employ a full-time IT engineer
Improper positioning of patient 3 3 9 Yes Yes Conduct training to radiologists on safe techniques for
proper positioning of patient’s body, head, forehead, chin
etc.
Unnecessary movement of patient 2 2 4 Yes Yes Remove clothing from the injured part and place clothing
first on the injured side
Bad image quality 2 2 4 Yes Yes Reduce the variations of performance in the equipment by
taking quality control and assurance actions
Infrequent calibration 1 2 2 Yes Yes Properly calibrate equipment prior to and during usage to
ensure proper calibration levels
Anatomy of patient 1 1 1 Yes Yes Conduct training on 3-D anatomy to technologists
 technologists on the equipment (e.g. calibration), patient care and positioning the Diagnostic
patient, and film reading. As this training program was implemented, recent concerns
were finally addressed and a better workflow was put in place. In addition, a full-time
imaging process
IT engineer who had knowledge in the networking infrastructure, IT, departmental
workflow and data management, was employed.
One frequent cause of repeats was identified to be the unnecessary movement of the
patient during the examination because of pain. This problem was often faced with the 287
elderly and children. Technologists made sure to instruct them to remove their clothing
from the injured part and place clothing first on the injured side.
All equipment were properly calibrated prior to and during usage to ensure proper
calibration levels and scheduled for regular maintenance.
Technologists often face with unusual anatomy of patient such as morbid obesity or
a physical deformity. Therefore, they were given training on 3-D anatomy so that they
can perform necessary imaging procedures involving placement of needles, catheters,
etc., into proper anatomy of patient.
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Calculations. A six sigma process is a process that produces 3.4 defective parts per
million opportunities (DPMO). Normal distribution underlies the statistical
assumptions of the Six Sigma model. An empirically-based 1.5 sigma shift is
introduced into the calculation. In order to calculate the DPMO (see Table VII), three
distinct pieces of information are required:
(1) Number of films produced.
(2) Number of repeat opportunities per film.
(3) Number of repeats.
The formula to obtain DPMO is as follows:
DPMO ¼ðNumber of repeats £ 1; 000; 000Þ=ðNumber of repeat opportunities=FilmÞ
£ Number of films produced

Changes ultimately improved the overall uptime and productivity of the unit’s
diagnostic imaging services. After the improvements, the sigma level was recalculated
and found to be 4.2. The higher level of sigma indicates a lower rate of errors and more
accurate/efficient process. Rolled throughput yield was calculated by multiplying the
monthly yields and found to be 94.8 per cent between August 2009 and November
2009.

Control phase
This phase was begun once the improvements in the workflow had been established
and appeared to be working. The importance of monitoring the results during this
phase had become a departmental policy. This phase had been the most critical key to

August September October November

DPMO 24290.62 16673.13 8695.65 3654.97 Table VII.

Sigma level 3.5 3.6 3.9 4.2 Defects per one million
Monthly yield (%) 97.57 98.36 99.14 99.64 opportunities (DPMO)
 IJHCQA long-term continuation of improvement and a differentiating element for the employed
25,4 Six Sigma strategies. During this phase, balanced scorecards were implemented. The
benefits of the improved system and the new departmental safety culture were
institutionalised.

288 Conclusions and discussion

Process improvement and workflow adjustments using Six Sigma can have a
measurable impact on cost and quality of services. Addressing additional areas
such as providing specialised training for technologists also helps the diagnostic
imaging department gain advantages by minimising cost and loss, and accelerates
their return on investment for equipment such as the ultrasound, CT scanners, PET
and MRI.
Diagnostic imaging departments must recognise and respond to new market
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realities. In the US, the business of radiology in all its various forms is growing at a rate
of 10 per cent each year, driven by an aging population and increasing demand for
services. This growth is continuing to strain the ability of healthcare organisations to
maintain adequate services. Thus, diagnostic imaging departments and facilities must
recruit experienced radiologists for increasing diagnostic accuracy and cost
effectiveness.
Training of the staff resulted in an increase in patient volume and decrease in
repeated examinations by 9.5 and 84.12 per cent, respectively. It also resulted in
reductions in patient’s turnaround times. Patients’ waiting time, which had averaged
22 minutes from when they had arrived until they began being processed, was reduced
to 7 minutes on average. Repeated examinations due to positioning of the patient or
movement of the patient was eliminated. Competency on the RIS/PACS system was
improved. The decrease in repeated examinations resulted in the fall of scrap film
costs. Quality and interpretation of the images was improved. Distribution of the
survey resulted in the reorganisation and improvement in staff scheduling.
Departmental efficiency is improved.
The hospital management understood that achieving optimal efficiency, service
quality, customer satisfaction and financial success in diagnostic imaging required
more than the installation of superior equipment and RIS/PACS system. It also entails
adopting a performance-improvement approach that incorporates both a technical and
cultural strategy to realise significant, and long-term results. Therefore, additional
recommendations for the imaging department to avoid radiologic malpractice can be
listed as follows:
(1) Establish a clear understanding of current operations.
(2) Focus on key metrics and success factors such as the calibration of the
equipment.
(3) Do not underestimate the importance of the control phase. Always monitor the
process.

To conclude, the adoption of Six Sigma helped the hospital management and the
imaging department to evaluate several processes, determine the risks involved and
correct the errors before adverse events took place.
 Glossary Diagnostic
.
Bias. Deviation of results or inferences from the truth, or processes leading to imaging process
such systematic deviation.
.
Bottleneck. Equipment working continually with work to be processed still
waiting.
.
Failure modes. Different ways in which the process or sub-process can fail to 289
achieve its purpose.
.
Rolled throughput yield. A measure of yield throughout an entire process.
.
Sensitivity. The proportion of persons with the disease who are correctly
identified by defined criteria.
.
Specificity. The proportion of persons without a disease who are correctly
identified by defined criteria.
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References
Benedetto, A.R. (2003), “Adapting manufacturing-based six sigma methodology to the service
environment of a radiology film library”, Journal of Health Care Management, Vol. 48
No. 4, pp. 263-80.
Bion, J.F. and Heffner, B.J. (2004), “Challenges in the care of acutely”, The Lancet, Vol. 363
No. 9413, pp. 970-7.
Buck, C. (2001), “Application of Six Sigma to reduce medical errors”, Annual Quality Congress
Proceedings, Vol. 55, pp. 739-42.
Cavagna, E., Berletti, R., Schiavon, F., Scarsi, B. and Barbato, G. (2003), “Optimized delivery
radiological reports: applying Six Sigma methodology to a radiology department”,
La Radiologica Medica, Vol. 105 No. 3, pp. 205-14.
Chan, W.P., Chiu, W.T., Chen, W.M., Lin, M.F. and Chu, B. (2005), “Applying Six Sigma
methodology to maximise magnetic resonance imaging capacity in a hospital”,
International Journal of Healthcare Technology and Management, Vol. 6 No. 3, pp. 321-30.
Chen, Y.K., Lin, J. and Chang, C.C. (2005), “Taiwan: improving radiography through Application
of Six Sigma techniques”, Journal for Healthcare Quality, Vol. 27 No. 3, pp. 44-52.
Cherry, J. and Seshadri, S. (2000), “Six Sigma: using statistics to reduce process variability and
costs in radiology”, Radiology Management, November-December, pp. 42-5.
Corn, J.B. (2009), “Six sigma in health care”, Radiologic Technology, Vol. 81 No. 1, pp. 92-5.
Elsberry, R.B. (2000), “Six Sigma: applying a corporate model to radiology”, Decisions in Imaging
Economics, Vol. 13 No. 7, pp. 56-66.
Gorman, A., Donnell, L., Hepp, H. and Mack, T. (2007), “Improving communication and
documentation concerning preliminary and final radiology reports”, Journal for Healthcare
Quality, Vol. 29 No. 2, pp. 13-21.
Kang, J.O., Kim, M.H., Hong, S.E., Jung, J.H. and Song, M.J. (2005), “The application of the Six
Sigma program for the quality management of the PACS”, American Journal of
Roentgenology, Vol. 185 No. 1, pp. 1361-5.
Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. (2000), To Err Is Human: Building a Safer Health
System, Institute of Medicine, National Academy Press, Washington, DC.
Krestel, E. (1990), Imaging Systems for Medical Diagnostics, Siemens Aktiengesellschaft, Berlin.
Mahaffey, S. (2004), “Optimizing the patient flow in the enterprise”, Health Management
Technology, Vol. 25 No. 8, pp. 34-6.
 IJHCQA Park, S.H. and Antony, J. (2008), Robust Design for Quality Engineering and Six Sigma, World
Scientific Publishing, Hackensack, NJ.
25,4 Pinto, A. and Brunese, L. (2010), “Spectrum of diagnostic errors in radiology”, World Journal of
Radiology, Vol. 2 No. 10, pp. 377-83.
Revere, L. and Black, K. (2003), “Integrating Six Sigma with total quality management: a case
example for measuring medication errors”, Journal of Healthcare Management, Vol. 48
290 No. 6, pp. 377-90.
Riebling, N. (2005), “Six Sigma project reduces analytical errors in an automated lab”, Clinical
Issues, June, pp. 20-3.
Sehwail, L. and DeYong, C. (2003), “Six Sigma in health care”, International Journal of Health
Care Quality Assurance incorporating Leadership in Health Services, Vol. 16 No. 4, pp. 1-5.

Further reading
Abujudeh, H.H. and Kaewlai, R. (2009), “Radiology failure mode analysis: what is it?”, Radiology,
Downloaded by Universidad Icesi At 23:33 14 March 2018 (PT)

Vol. 252, pp. 544-50.

Erturk, S.E. and Ondategui-Parra, S. (2005), “Quality management in radiology: historical
aspects and basic definitions”, Quality Management in Radiology, Vol. 2 No. 12, pp. 985-91.
Taner, M.T., Sezen, B. and Antony, J. (2007), “An overview of Six Sigma applications in
healthcare industry”, International Journal of Health Care Quality Assurance, Vol. 20 No. 4,
pp. 329-40.

About the authors

Mehmet Tolga Taner is a Post-Doctoral Fellow. He received his PhD from Gebze Institute of
Technology, his BSc and MSc from Bosphorus University, and his MBA from Yeditepe
University. His research interests include medical decision-making, SERVQUAL, Taguchi
methods and Six Sigma. Mehmet Tolga Taner is the corresponding author and can be contacted
at: mtaner@gyte.edu.tr
Bulent Sezen is a Professor of Operations Management at Gebze Institute of Technology. He
obtained his PhD in Operations Management from Gebze Institute of Technology in 2001. His
research interests focus on lean production, logistics, inventory management and supply chain
management. His research studies have been published in several international journals
including Journal of Business Research, Industrial Marketing Management, Production Planning
and Control, Total Quality Management, Journal of Business & Industrial Marketing, Expert
Systems with Application, Supply Chain Management, and in numerous Turkish-language
scholarly journals.
Kamal M. Atwat holds a Bachelor of Science (BSc) degree in Biology from the American
University of Beirut, a Master of Science (BSc) degreed in Biomedical Engineering from Bogazici
University, and a professional Master of Health Science (MHSc) degree in Health Administration
from the University of Toronto. His current fields of research and interest include medical
imaging equipment, process improvement in healthcare and project management methodologies.

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