['This paper sets out to analyse the use of the Six Sigma methodology to improve quality in healthcare. It looks at how Six Sigma grew out of the concept of Total Quality Management (TQM).', 'Six Sigma is a quality improvement methodology that has been widely adopted by companies since the early 1990s and has grown exponentially in the healthcare industry during the past five years. Some of the main tenets of Six Sigma have emerged from the principles of TQM, including the notion that the entire organization must support the quality effort; that there should be a vigorous education effort; and that a quality improvement process should emphasize root cause analysis.', 'In spite of its early success, TQM "crashed and burned" for several reasons including the fact that financial benefits were difficult to assign to TQM efforts, root cause was not always determined resulting in recurring errors, there was no common metric to measure the level of quality attained, and quality efforts were sometimes aimed at processes or operations that were not critical to the customer. Six Sigma filled the vacuums created by these TQM failures in several ways. Under the Six Sigma methodology, quality improvement projects are carefully defined so that they can be successfully completed within a relatively short time frame. Financials are applied to each completed project so that management knows how much the project saves the institution.'] Does six Sigma arise from the ashes of TQM with a twist?