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Adrienne ElberfeldSix Sigma Master Black Belt
Virtua HealthMarlton, NJ
Six Sigma...Getting Real about
Results in Healthcare
Virtua Facilities
Virtua Locations
Virtua Health
Four hospital system in Southern New Jersey Two Long Term Care Facilities Two Home Health Agencies Two Free Standing Surgical Centers Ambulatory Care - Camden Fitness Center 7000 employees + 1700 physicians 7,000 deliveries $600 million in revenues STAR Culture
Dramatically improve patient satisfaction scores. Advance Virtua’s POE development. Continue implementation of medical staff development
plan. Continue to improve and sustain global clinical quality
and patient safety metrics. Continue rigor in cost expense management, revenue
enhancement and reduced length of stay. Recognize and continuously develop best people and
monitor employee satisfaction. Begin facilities planning and development of ambulatory
sites and regional medical centers.
Virtua Imperatives 2005
The “STAR”…PERFORMANCEEXCELLENCE
Clinical Quality & Safety
Caring Culture
Best People
Excellent Service
Resource Stewardship
Outstanding Patient
Experience
Achieve Vision and Receive Recognition
MISSION ANDVALUES
STRATEGICINITIATIVES
The STAR InitiativeAn organization wide cultural transformation initiative that will assure that Virtua fulfills its
covenant with the community, achieves its vision, and is highly successful over the
long-term.Three Objectives:1) Focus the work on creating an outstanding experience for patients
2) Become a high performing organization
3) Be recognized for our excellenceWe Know Where We Want to Go, How
Are We Going to Get There?
Current State: STAR
Commitment
Desired State: STAR
Performance
It’s Great to Have a Philosophy
. . . But We Need a Strategy !!
Six Sigma is our strategy on our journey through the mazeSix Sigma is our strategy on our journey through the maze
The Tool Chest
Paths to Change•Strategic Decision
•Operational issue Requiring a Decision
•“Wisdom of the Group” Problem
•Analytical Problem
Change Acceleration
WorkOut
Six Sigma
VIRTUA’S QUALITY JOURNEYVIRTUA’S QUALITY JOURNEY
WJ: Quality Circles: early - late 1980sMH: Morbidity and Mortality Reviews, Quality Audits
WJ: Quality Assurance: mid 1980’s
MH: Quality Assurance: mid 1970’s to mid 1980’s
WJ: Quality Assessment: late 1980’sMH: Quality Assessment mid to late 80’s (Leadership explores Total Quality Management Concepts with VHA 1988 - 1990)
WJ: Total Quality Management: early 1990s
MH: Total Quality Management 1990 - 1995
WJ: Re-engineering / Patient Centered Care: mid 1990’sMH: Metric Focused Quality Improvement (AQP) / Patient Focused Care: mid 1990’s
Virtua Health: Quality Management, Six Sigma, Workout: 2000 and beyond
April 2001
What is Six Sigma?…
Methodology for achieving goals and objectives
Quantitative technique for problem solving
Comprehensive improvement process
Tools For Driving Sustainable Change
Solid tools but….
Quality toolVague goalsNo standard metricsOpen-ended, unstructuredDepartment-basedFocus on product quality
Real results that matter to customers….
Business toolClear goals/deliverablesClear, consistent metricsRigorous timelineBusiness-basedFocus on customer
Six Sigma builds on Lessons Learned from prior approaches
TQM Six Sigma
What Makes Six Sigma Different?Adapted with permission from Hamadi Said, US Mint Philadelphia, PA
The Nature of Variation
. . . So how does this principletranslate into the real world?
Mean is Centered ( it is On Target), but
there is Large Variation (Big Sigma!)
Mean is Centered ( it is On Target), but
there is Large Variation (Big Sigma!)
Accurate but not Precise
Mean is not Centered ( it is Off Target);
the Variation is Small
Mean is not Centered ( it is Off Target);
the Variation is Small
Precise but not Accurate
Six Sigma is… A Quantitative Methodology
Sigma = Standard Deviation
Goal: Eliminate Defects
“Move the Mean…Reduce Variability”
1
2
3
TargetCustomer
Spec
36.6% Defects
Today
1
36
Target
No Defects!
Desired State
6
2 308,537
3 66,807
4 6,210
5 233
6 3.4
DPMO
Y= f(X1+X2+X3+…..Xn)
Why Six Sigma as a Tool?…
A Health System The Size of Virtua Fills ~400,000 New In-Patient Medication Orders Per Year…
Six Sigma Can Make a Difference in Healthcare
Error Rates atError Rates at2to 6 2 123,415 69.1%
3 26,723 93.3%
4 2,484 99.4%
5 93 99.98%
6 1.4 99.99966%
Script Errors / Yr % Correct
…Six Sigma Means 1-2 Incorrect Orders Per Year
Overall Approach
Practical ProblemPractical Problem Statistical ProblemStatistical Problem
Statistical SolutionStatistical SolutionPractical SolutionPractical Solution
y f x x x k ( , , . . . , )1 2
What is Six Sigma?
DMAIC: To improve any existing product or process
Six Sigma Methodologies
DefineDefine MeasureMeasure AnalyzeAnalyze ImproveImprove ControlControl
Who are the customers and what are their priorities?
How is the process performing and how is it measured?
What are the most important causes of the defects?
How do we remove the causes of the defects?
How can we maintain the improvements?
What is Six Sigma?
What measurements will the process owner use to confirm sustained
improvements? What system and structure changes support sustained
gains?
Define
Project Scoping
Operations Plan
Strategic Plan
Control
ImproveAnalyze
Measure
What is the right operational area for a project?
What is the right process result to address? What does the customer
expect?How is the current process
performing?
What are the most important factors driving the process results? What changes will deliver the desired process
result?
How well did the changes improve the process?
Project Conclusion
The DMAIC Process
DEFINE PHASE: Focus on the Y Y = f (x)“How do my customers look at me?”
Define
Define Phase: Focus on the Y Y = f (x)
Measure Phase: Focus on the Y
“What do I want to improve?”“What’s the best way to measure?”“Can I trust the output data?”
Measure
X1 X2 X3 X4
X5 X6 X7 X8 X9 X10
X11 X12 X13 X14 Define Phase: Focus on the Y
X1 X2 X3 X4 X5 X6
X7 X8 X9 X10 X11
X12 X13
X14
Y = f
Measure Phase: Focus on the Y
Analyze Phase: List & prioritize X’s
“How good am I today?”“How good do I need to be?”“What factors make a difference?”
Analyze
Define Phase: Focus on the Y
Measure Phase: Focus on the Y
Analyze Phase: Identify vital X’s
Y = f +
X1 X2 X3 X4 X5 X6
X7 X8 X9 X10 X11
X12 X13
X14
X2 X 7
“How good am I today?”“How good do I need to be?”“What factors make a difference?”
Analyze
Define Phase: Focus on the Y
Measure Phase: Focus on the Y
Analyze Phase: Identify vital X’s
Improve Phase: Focus on vital X’s
+X2 X 7X2 + X7Y = f“What’s at the root of the problem?”
“How can I predict the output?”
Improve
24
10
5
0
6
5
4
3
2
1
0
Y
X7
Define Phase: Focus on the Y
Measure Phase: Focus on the Y
Improve Phase: Focus on vital X’s
Control Phase: Sustain improvements
Analyze Phase: Identify vital X’s
“Have I reached my goal?”“How can I sustain the improvement?”
Control
DMAIC Training & Project Management Plan
Define Project
Measure
TRAINING
REVIEWS
R0R0
The Fundamentals
Define & CAP
Application
R1R1 ApplicationAnalyze
ImproveR2R2 Application
R3R3 ApplicationControl & CAP
R4R4
4 weeks
4 weeks
6 weeks
6 weeks
6 weeks
Project Management
Master Black Belt role Driven by the “R” document cycleTracking software
– Formal Project Management software - (November 2004 implementation of e-project)
– “Good Enough for Now” software
The Work-OutTM Process - An Enabling Technology
A 1-2 day session that involves employees to fix the problem
Concentrated, empowered decision making Leadership responds with
immediate decision or alternative direction
Follow up ensures completion of action plans
Work-OutWork-OutTMTM Is… Is… Key OutcomesKey Outcomes
Tool That Drives Decisions and Actions for Employees
Process to drive improvement
Opportunity to engage and empower people
Results-based:DecisionsAccountabilityFollow up
What’s a Work-Out?
Addresses an important process Facilitated by a STAR coach (130 trained) Gives immediate feedback to staff Examples:
Create a new process for Root Cause AnalysisCreate a process to deliver patient satisfaction data
to leaders and managersFix night call schedule for residentsFix transport process for LTC patients
Total: 161 so far
The Change Acceleration Process
Leading Change
Changing Systems and Structures
CurrentState
TransitionState
ImprovedState
Creating A Shared NeedCreating A Shared Need
Shaping A VisionShaping A Vision
Mobilizing CommitmentMobilizing Commitment
Making Change LastMaking Change Last
Monitoring ProgressMonitoring Progress
Simple, Yet Powerful Model to Assure that Change Happens
Summary: Six Sigma Methodologies
Six Sigma Six Sigma Six Sigma Six Sigma Change Change Acceleration Acceleration
ProcessProcess
Change Change Acceleration Acceleration
ProcessProcess
Effective Effective ResultsResults
Effective Effective ResultsResults
Work-OutWork-Out™™Work-OutWork-Out™™
Q x A = E
The Effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea.
A Proven Formula For Results
How they work together:
Six Sigma
project
Decisions
Implementation
Implementation
Development
WorkOut
Detailed
Analysis
Six Sigma
project
What’s Different About Six Sigma?
Quantitative: Where is the bang for your buck?
Accelerates and sustains change
Applicable to all parts of the system
Reduce defects----Increase dollars
More Than Just Another Flavor of the Month
Six Sigma Personnel Master Black Belt: Full time; advanced training in Six Sigma;
leads initiative, consults, teaches, and leads projects. Black Belt: Full time; trained in Six Sigma; leads projects and
assists green belts. Six Sigma Analyst: Full time; trained in Six Sigma and
reports directly to campus COO Green Belt: Part time; trained in Six Sigma; undertakes one
project every nine months. STAR Coach: Part time; trained in CAP and Work-Out; leads
two projects a year.
Accepted Nomenclature Adapted to Virtua
Virtua Health: The Initial Investment
Commitment of leadership: CEO and Board Executive sponsor Project manager Training from GE Six full time blackbelts 60 STAR coaches Leadership Coalition Resources for internal communications
$1.4 Million!
Six Sigma: Why partner with GE? Need for tools to improve performance and
to initiate and sustain change
Proven track record at GE
Tell you what you need to hear, not what you want to hear
Clear commitment to our success and independence
Complete package
The Right Company and Capabilities
What Makes a Good Target for a Six Sigma Project?
Addresses an important business objective Data driven Process Map and Measurable Output Foundation team (key staff) is the driver of the
project Black Belt leads the team as a consultant Average time to completion ~6 months
Large and Complex Undertaking
Driving the Project …..
Black Belt and
Project Team
Process Owner
and Project Team
Define Measure Analyze Improve Control
Evolution of Six Sigma at Virtua
2001 Present Central Control Deployed to Operations
Physician Six Sigma Champion Six Blackbelts Two MBB, Six BB, Forty GB
Just another thing to do Method to hit the metrics
Just do it MBB are consultants
World hunger type projects Well scoped projects
Emphasis on Work-Out Emphasis on CAP
Commitment and Flexibility
Cardiac Meds: A PRO/CMS Quality Indicators Project
What the Cardiac Meds Team Did … Why They Did It …
Project started in 7/02. All PRO indicators were achieved for Q4 ‘02. Project closed out in July ’03; continued success sustained!
• Gaged current data collection system
Project requested by physician leadership
Documentation was more of a problem than the actual delivery of care
Major progress in achieving physician support for process improvement (including physicians firmly addressing physician outliers!)
• Improve quality and consistency of data
• Created a cardiac discharge instruction sheet
• “Contained” defects immediately while implementing more sustainable systems and structures to support improvements
• To obtain immediate results to achieve aggressive system targets
• Increase compliance from docs and support accurate data collection
>90%CHF ACE at DC
ResultsIndicator
>95%AMI Beta Blocker at DC
>95%AMI Beta Blocker < 24 hrs
>95%AMI ASA at Discharge
>95%AMA ASA < 24 hrs
Project Results …
Home Care HHRG Case Weight Mix and Coding
What the Team Did … Why They Did It …
Total Project Benefit Estimate $1,200,000
Medicare Length of Stay
• Established standards in completion of initial OASIS form
• Enhanced Care Manager role in team
• Implementation of standard operating procedures for both agencies, two bargaining units through use of WorkOuts
• Weekly review of lock days for concurrent review by manager
• Substantial ROI to purchase new computerized system
• On-going sustainable changes in place during training and implementation of new system
• Increase in initial HHRG case weight mix & broader knowledge base of MO questions
Overall Case Weight Mix Average = 1.34
Agency OASIS Lock Within 7 Days = 92%
Percentage of Agency LUPA’s = 15%
• Decreased percentage of LUPA’s to 15%
• Surpassed the Medicare threshold for OASIS lock within 7 days
• Decrease in adjustments (refunds) to government
• Decrease in technical denials and increase in cash flow
Project Results …
Advantages to Virtua Health
Results measured in dollars, quality and service Common language Breaks down silos Physicians like it Faster decisions and implementation A method to accelerate and sustain change Creates clarity and objective measures of
success
All in all, a Great Return on Investment
Key Success Factors
Six Sigma should be undertaken with a clear vision of where you want to be
Introduce Six Sigma as a tool, not a philosophy CEO must own it Make Six Sigma a system wide effort….Focus on $$$,
productivity and patient issues Measure, measure measure…Deal with information issues Hold people accountable for using Six Sigma to achieve
outcomes that are important to the organization Invest in resources and make a long term commitment Change the systems and structures to support the effort
It Has to Become the Way You Do Your Work
Lessons Learned Clear objectives, measurable outcomes and ‘doable’
projects are a must----scope the projects It is about the process There is plenty of ‘fat’ in healthcare Hold people accountable to use the tools to get
results----Resistance to change and accountability is high and in high places
Teach management how to use the tools Hit the areas that are ready and fertile--Finance! Over communicate by a factor of 1000
Q X A = E!
Lessons Learned
Be flexible and patient Deal with the problem of bad data Use CAP Sponsor Education is critical-teach them how to ask good
questions-implementation of Yellow Belt training It is all about the customer It is a process that shines the light, there is nowhere to hide Can help identify future leaders Massive staff empowerment Common language This is constantly evolving…there is always something to
improve
Six Sigma: Leadership Development
Emerging leadersTime limited position“Rotating Internship”Developing business rigor and results
orientation“Infecting” the organization with
excellence and competence
Leadership Developmentsome success stories
Director Patient Billing Services Black Belt AVP Home Care VP Operations
Director Quality Master Black Belt VP Quality Nurse Manager Med Surg Black Belt Quality
Director Home Care Home Care Director of Nursing HR IS Black Belt Cardiology Product Line at
Marlton Nurse Manager Emergency Department Master
Black Belt Virtua Enterprise Manager AVP Community Services Black Belt VP Nursing
Services AVP Operations Black Belt Director of Finance
Director Patient Billing Services Black Belt AVP Home Care VP Operations
Director Quality Master Black Belt VP Quality Nurse Manager Med Surg Black Belt Quality
Director Home Care Home Care Director of Nursing HR IS Black Belt Cardiology Product Line at
Marlton Nurse Manager Emergency Department Master
Black Belt Virtua Enterprise Manager AVP Community Services Black Belt VP Nursing
Services AVP Operations Black Belt Director of Finance
Should You Use Six Sigma?
Purpose?– Vision– Motivation
Commitment?– CEO– At least 3 years– Investment
Capacity?– Culture– Accountability– Skills of the managers
Are You Willing to Destroy the Good to Get Better?