Lean six sigma for healthcare

8/10/2019 Lean six sigma for healthcare

1/57

SixSigma

rocess mprovement

PresentedbyContentExpert:BethLanham,RN,BSN,MBA

,

FroedtertHospital,Milwaukee,WI

Thispresentation

is

part

of

an

on

line

series,

brought

to

you

through

a

collaboration

between

the

WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

PropertyoftheWisconsinOfficeofRuralHealth.


2/57

SixSigma

is

a

projectfocused

resultsdriven

a roachto ualit

Thispresentation

is

part

of

an

on

line

series,

brought

to

you

through

a

collaboration

between

the




3/57

Originatedby

Motorola

(1986)

electronicmanufacturingprocesses

Heavilyinspired

by

Previousqualityimprovementmethodologies QualityControlManagement,CQI,TQM

Basedontheworkofqualitypioneers

Deming,Juran,

Ishikawa,

Taquchi

and

others

Thispresentation

is

part

of

an

on

line

series,

brought

to

you

through

a

collaboration

between

the




4/57

B late1990s

2/3Fortune

500

companies

Aimedatreducingcostsandimprovingquality

o ay Utilizedallovertheworld

Local overnments risons hos itals thearmedforces banksmanufacturing,etc.

Inrecentyears

x

w

u uyieldamethodologycalled LeanSixSigma.

Thispresentation

is

part

of

an

on

line

series,

brought

to

you

through

a

collaboration

between

the




5/57

atwewere o ngwasn twor ngwe enoug

Incrementalimprovementsnotgoodenough

:

Focusoncustomerrequirements

Basedecision

on

data,

not

anecdotal

information

BeProactivevs.Reactive

Establishacultureofownershipvs.culpability

Itstheprocesses,notthepeople

Effectrapid

and

effective

change

Improvementeffortswerefragmented

Largesystemwi eprocesses ro en

Notholding

the

gains


6/57

Or anizational

Datadrivendecisionmaking Benefits:Competitiveedge

Focusesoncustomerrequirements

Afocused/organized

approach

Service

Excellence

Redefinesprocessesforlongtermresults

Becomesingrainedinworkandthought

Leadership

Development

processes

Reliesonevidencebasedsolutions

Quality/Safety

HealthcareCosts

Rapid/effectivechange


7/57

Methodologyaimed

at

Errorreduction

Goal Design/improve

processes

so

it

is

impossible

to

make

an

error

Relianceonperformancemeasurementsand

y

Thispresentation

is

part

of

an

on

line

series,

brought

to

you

through

a

collaboration

between

the




8/57

..

servicesin

terms

of

averages:

Averagecost

Averagetimetodelivery

Averagenumber

infections

verageusage

Averagewaittime

Thispresentation

is

part

of

an

on

line

series,

brought

to

you

through

a

collaboration

between

the




9/57

Are

These

Processes

the

Same?Process1 Process2

20 9

5 11 Goal=lessthan10

Aretheyperformingwell?

17 8

5 10 Process1 Process

2

15 10

5 9 Mean9.4 Mean9.4

5 11

5 10Areallthecustomersha ?

5 8

12 8


10/57

Variation=

O ortunities

for

Errors

Process1 Process2

Average

9.4

9.4Minimum 5 8

Maximum 20 11

Standarddeviation 6.0 1.17

Customersfeelthevariation,

nottheaverage!!!!!!


11/57

Process1 Process2

100

80

Mean 9.540

StDev 6.149

N 1000

Histogram of Process 1Normal

80

70

60

Mean 9.412

StDev 1.193

N 1000

Histogram of Process 2Normal

60

40Frequency 50

40

30

20

Frequency

24181260-6-12

20

0

Process 1

24181260-6-12

10

0

Process 2

Many

Defects

Fewer

Defects

expectations!

Exact

capability

can

be

measured!


12/57

Howthe

customer

judges

our

products/services

Y=Theoutcomemeasureoftheprocess

Xs=InputsorvariablesthataffecttheY

Defect

Failure

to

deliver

what

the

customer

expects

Variation Theenemyofpredictableoutputandcustomersatisfaction

Sigma

Anexpressionofprocessyield,basedonthenumberof


13/57

SixSi ma

APhilosophy of

Operational

Excellence

AsetofProblem

Tools/Tactics

AMeasure ofProcess

Capability


14/57

Greekletter

Ameasureofprocesscapability Howcapableisourprocessofmeetingourcustomer s

expectations?

Arigorous,

structured

approach

to

problem

solving

Includesadefinedmethodologywithspecifictoolsandtactics

Amanagementphilosophy

Definitionscomplimentary,notcontradictory!


15/57

Astatisticalconcept

Representsthevariationthatexistsinaprocess

Relativetothecustomerrequirements

A

process

operating

at

a

6

Sigma

level o tt evar at on,t att eprocessoutcomesare

99.9997%defectfree

= , , .


16/57

Amoresensitiveindicatorthan%yieldor%good

Sigma Defects Yield DPMO

1 69.1% 30.9% 691,4622 30.8% 69.1% 308,538

3 6.7% 93.3% 66,807

4 0.62% 99.38% 6,210

5 0.02% 99.977% 233

6 0.0003% 99.9997% 3.4


17/57

WhenComparedtoBestinClass

Antibiotic

at ona

ata

1000000

InpatientMedication

Accuracy

Overuse

Post

MI

10000

100000

llion

44,00098,000

PreventableHospital

Deaths(IOM

Report)

100

1000

efects/M

Anesthesia

1

10D DuringSurgery

Sigma DomesticAirline

FatalityRate


18/57

1Si ma

5 &6

4Sigma

4

to5

Sigma

27

fold

Performance

Improvement

5 to 6 Si maAnother 69fold Performance Im rovement


19/57

customerCriticalto ualit CT s

ThisisgenerallyreferredtoastheYoroutcomevariable

Examples:

waittime,

response

time,

turn

around

time,

%

newvisits,%mederrors,%falls,etc.

MeasuretheYagainstthetarget

Target=

customer

expectations

or

specifications

This

presentation

is

part

of

an

on

line

series,

brought

to

you

through

a

collaboration

between

the




20/57

Process

Ca abilit

Lower

SpecificationUpper

Specification

10

y

Limit m t

5Frequenc

AverageAverageDefectDefect DefectDefect


21/57

Focusedon

identifying

the

root

causes

Rootcauseanalysis

Processvariables

are

called

Xs

Y = x1 + x2 + x3 + x4, etc.

r mary me r c = com na onof a variety of variables (xs)

Whatarethevariablesthatinfluence

themain

metric?


22/57

Understandingthe

customers

needs

Anal zin business rocesses

Institutingappropriatemeasurementmethods

Em hasison

mana ement

of

rocesses

Wedonthavefaultypeople,wehavefaultyprocesses!

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe




23/57

Define Measure Analyze Improve Control

Establish

current

capability

SelectKey

CTQs**

Developdata

Charter

project

Optimization

Cycletime

Variability

Determine

capability

ofnew

rocessIdentifykey

sourcesof

variability

co ectionp an

Define

performance

ProcessMap

CollectVOC

ost

Validationof

Improvements

Implement

process

controls

Define

performance

objectives

s an ar s

Validate

measurement

ent y

CustomerCTQs

Review

Implementation EnsureGainsare

Sustainedsys emss or ca a a

*VOCVoiceofCustomer

**CTQCritical

to

Quality


24/57

Tools

of

Six

Si ma= ,

ProcessMap Regression

FMEA(FailureModeand HypothesisTest

EffectsAnalysis) 95%ConfidenceInterval

Cause EffectDiagram ANOVA

are o agram es gno xper men s

GageR&R ControlPlan

ProcessCa abilit StatisticalProcessControl





25/57

Six

Si ma Ke

Pla ers Oversee or

StrategicProjects

SkilledinSixSigma

chooseprojects

ResolveIssuesChampionsBlack

BeltsToo s

TeachGreenBelts

Leadership

Executive

FullTime

Strategic PartTime

ponsors

Master

BlackBeltsProjects

Program

Administration

o

Projects

Helptochange

GreenBelts

TeachBlack

BeltsandGreen

Belts


26/57

Pr


27/57

Launchin

a

Pro ect

Identifya Sponsor Champion Energy/passiontosolvetheproblem

Defineboundaries/scope

Establishstretchgoals

Providedirectionandsupporttotheteam

Removebarriers

Accountablefor

completion,

implementation

and

sustaining

resultsfromtheproject


WisconsinOffice

of

Rural

Health

and

the

Wisconsin

Hospital

Association.



28/57


CharterprojectProblemstatementHowdoweknowwehaveaproblem?

improvement?

ProjectScopeandTeam

g

eve

rocess

ap IdentifyCustomerCTQs

Reviewhistoricaldata


29/57

ExampleProjectCharterQMS Project Team Charter

Business Process Team/Svc Line: Project Team Members Review Timing

Project Name: Target Completion Date: Project Type:

CAP WO PDSA Lean DMAIC

Process Owner: Milestones TBD based on methodology

Black Belt:

Finance Representative:

Project Overview

Problem Statement (*MOMS criteria):

In Sco e:

Out of Scope:

Customers and Stakeholders:

Goal (s): (**SMART criteria)

Target Performance Indicators and levels:

Expected Benefits/Business Case (target savings, target metric reduction):

Assumptions:

Signatures

Project Chair(s) Signature: Champion Signature: Master Black Belt signature:


30/57

ProblemStatement Howdoweknowwehaveaproblem?

Measureable,Observable,Manageable,Significant

GoalStatement

Howwillweknowifwehavemadeanimprovement?

SMARTcriteria pec c, easurea e, a na e, ea s c, me y


WisconsinOffice

of

Rural

Health

and

the

Wisconsin

Hospital

Association.



31/57

urpose: ograp ca y sp ay eprocessma oreven s

Suppliers Whoprovidestheinputstoyourprocess?

Inputs Whatmaterials,resourcesanddataareneededtoexecuteprocess?

ProcessSte s

57stepsthatuseinputstochangeintooutputs. Useveryspecificstartandstoppoints!

Out uts What

is

the

output

of

the

process?

What

did

the

customer

receive?

Customers Who receives the out uts of the rocess?


32/57

SIPOCExample

Suppliers-Who providesthe inputs?

Inputs-Materials,

resources,

data

Process Steps Outputs-What did thecustomer

receive?

Customers- Who benefits?

Infection Control

H.C P roviders

(Physicians, nurses,

nursing assistants,therapists,

Policies &

Procedures

CDC guidelines

So ap

High quality

care

Avoidance /

reduction ofhospital

Pat ients

CMS

Third Party

PayorsWash hands

n er pa en

room

technicians,

emergency medicalstaff, dental staff,

pharmacists,laboratory staff,

autopsy staff,students and

trainees, contractual

Alcohol hand rub

Dispensers

Sinks

Paper towels

acquired

infections

Clean hands

Decrease in

skin irritation

Other patients

S ta ff

Famil ies

upon en er ng

Patient

Encounterstaff not employed

by the healthcarefacilit y, and persons

not directly involvedin patient care but

potentially exposedto inf ect ious agents.)

Clinical Routine

Degree of urgent

care required

Extent of contact

Increased

patientconfidence

Wash hands

upon exiting

Operations

Patient con dition

or ers

Call lights

Operational

routines

Leave patient

room


33/57

What outhink Whatitactuall is What ouwouldlikeit

itis tobe.


34/57

Identifyand

prioritize

all

customers

Whoisimpactedthe mostbytheprocess?

Whoisthemostdissatisfiedwiththecurrentprocess?

Solicitfeedback

How does the customer view the rocess?

Whatdoesthecustomervaluefromtheprocess?

Whatdoesthecustomerexpectfromtheprocess?

Whatdoes

the

customer

want

most

of

the

time?

Whatisthelimitthecustomeriswillingtotolerate?


35/57

a e o er na ys s

StronglyModeratelyNeutralModeratelyStrongly

Whowill

be

affectedbyany

chan es from this

project?

Beginaddressing

issuesearl !

Noteveryone

needstobestrongly

supportive!


36/57


DefinePerformanceStandards

DataCollection

MeasurementSystemAnalysis

ProcessXs(Variables) OutputsorYs

X2

X3

Y2

Y3TheProcess

X4 Y4


37/57

usesto

judge

your

performance

SixSi malin o:Thebi Y

HowwillIknowifIhavemadeanimprovement?

Howwill

the

Y

be

defined

and/or

measured?

VOC CTQ Y

Expecttobeseen WaitTime Pt.checkinatfrontdesktofirst

within

15

min

of

appt. contact

with

staff

physician.


WisconsinOffice

of

Rural

Health

and

the

Wisconsin

Hospital

Association.



38/57

TranslatetheCustomerexpectationsintoMetricsTarget:

SpecificationLimits:

What

are

the

limits

the

patient

is

willing

to

tolerate?

VOC CTQ Y Target UpperLimit

Expecttobeseen Wait Pt.checkinatfront 15min 30min

within

15

min

of

appt.Unhappyif>30min

Time desk

to

first

contact

withstaffphysician.


39/57

Process Env ironment Management

Managers not accountableClutter o bstructing sink

i i i li

- -

Don't have adequate resources

No communication r e: pt impact if non-compliant

Lack motivation to set an example

No incentives/rewards to comply

No corrective a ction for non-compliance

Spot checks not currently done

Divisions not accountable

Lack of institutional safety climate

Understaffing/Overcrowding

Carrying items into patient room

Need to take care of patient and can't

No ongoing education on process for

No reminders posted

No sin k i n t he r oo m

Difficulty monitoring process

regularlyEquipment is not wiped down

before/after contactPeople are not aware to wash hands

i i i li

during pt

compliance

hygiene

Lack hand

Inadequate org. structure for accountability

No role model for hand hygiene

Lack of institutional priority for hand hygiene

Delays in getting needed equipment

No alcohol wipes

No t e no u h h an d dis e nse rs

Low risk of acquiring infe ctions fro m

No lotion accessible

Lack immediate feedback/outcomes

processNot part of the yearly evaluation

Skeptical abo ut e ffectivenessInterf eres w/HCW relationship with pts

Disagree w/recommendationsFamily/visitors una ware re:han dwashing

i

Soap/alcohol dispenser empty

Broken dispenser

Overflowing garbage

No towels

Staff work areas are dirty

Too many people in room, in way of sink

E ui ment in wa of sink

hgyiene on the rate of HAINo data to show the impact of hand

Skin irritation by hand hygiene agents

Inconvenient location of hand sanitizer

Lack of e ducation mate rials

Family/visitors don't see being part of PCOther personnel not aware

Pts/visitors insulted when asked t o w ashPts not at ease asking someone to wash

People forgetPeople set in their ways

Not part of the Froedtert cultureNot seen as a priority

Concerned w/skin irritationDon't understand nee d fo r handwa shing

Feel that no need to wash w/gloves

Sponsoredby

the

Wisconsin

Office

of

Rural

Health

and

the

Wisconsin

Hospital

Association.

CopyrightoftheWisconsinOfficeofRuralHealth.

People Materials Equipment

i i i

Not enough sinks available

Sinks don't wo rk

Patient room is out of gloves

Don't know proper handwashingOnly touch equip., no need to wash

Feel that wash hands enoughToo busy/Not enough time


40/57

Data Collection Sam lin

Datamust

be

representative

of

the

process

Datamustbereliable

Mustcapturemeasurementsofimportance

ENTRY EXIT

OBS # Role(s) Hand Hygiene Notes Hand Hygiene Notes

1 Sink Y / N Gloves On Sink Y / N Gloves On

Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves

None Y / N Full Hands? None Y / N Full Hands?

Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access

Direct Exit to Enter?

2 Sink Y / N Gloves On Sink Y / N Gloves On

Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves

None Y / N Full Hands? None Y / N Full Hands?

Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access

Direct Exit to Enter?


41/57

Measurement

S stem

Anal sis

MSA

owaccura e s emeasuremen process

Howmuch

variation

is

there

in

the

measurement

Attempttominimizecontrollablefactorsthatcould

exaggerate

the

amount

of

variation

in

the

dataExample:

Iwanttomeasureseconds. Theclockonly measuresminutes

Result:Thevariationofthemeasurementsystemistoolargetostudy

the current level of rocess variation


42/57

Performedby

all

RNs

Patientsgivenscores,basedonassessmentcriteria

DoortoBalloonTime Clocks

1. ReproducibilityDoesRN#1getthesamescoreasRN#2?

2. RepeatabilityDoesRN#1alwaysgetthesamescorewhen

ace w esame n ngs

Totalmeasurementsystemvariabilityshouldbeassmallas

possible,butalwayslessthan30%.


43/57


Establishcurrentcapability

Identifykeysourcesofvariability

e neper ormanceo ect ves

Howistheprocessperformingtoday?

Dowe

need

to

shift

the

mean

or

reduce

variation?

WhatarethekeyXsthataredrivingtheY?

Howdoyouknow?


44/57

Graphical

Tools Flowdiagrams,frequencyplots,Paretocharts,etc.

StatisticalTesting DescriptiveStatistics,ProcessCapabilityHypothesistesting,Regression

DesignedExperiments


WisconsinOffice

of

Rural

Health

and

the

Wisconsin

Hospital

Association.



45/57

Dis la in theData

Variable: Pt Wait Time

Descriptive StatisticsBoxplots of Pt Wait Tim e by CL INIC

( means are indicated by solid cir cles)

10 35 60 85 110 135 160

A-Squared:P-Value:

Mean

StDevVarianceSkewnessKurtosisN

i i

32.0180.000

23.1551

15.3332235.1081.251964.39234

2559

Anderson-Darli ng Normal ity T es t

100

150

(inmin)

95% Confidence Interval for Mu

20 21 22 23 24

i i1st QuartileMedian

3rd QuartileMaximum

22.561

14.924

.11.00021.000

33.000153.000

23.750

15.765

95% Confidence Interval for Mu

95% Confidence Interval for Sigma

95% Confidence Interval for Median

50

PtWaitTim

OverallStatisticsByPatient:

95% Confidence Interval for Median20.000 22.000

i l i

HAC

ORO

ORT

0

40

Scatterplot of Hand Hygiene Events vs Time of Day

Metric Wait Time Exam Time Total TimeMean 23.16 18.94 42.10

Median 21 16 40

30

20

and

Hygiene

Events

. . .

Sample Size 2559 2559 2559

Min 0 0 3

Max 153 99 18316141210860

Time of Day

H


46/57

Howisthe rocess erformin toda ?

Dowe needtoshiftthemeanorreducevariation?

T T

1.235 1.239 1.241 1.245 1.233 1.235 1.239 1.241 1.245

USL USLLSL LSL

Hypothesis Testing


47/57

HypothesisTesting

e ng

o

e

oo

auses

Test Details P-ValueRole DTY, EVS, Lab, LCs, PCAs, RNs, RTs 0.002

PValues

Documents

Lean six sigma for healthcare