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8/12/2019 Quality Management - Focus on Six Sigma
1/45
Chapter 8. Quality Management: Focus
on Six Sigma
An Integrated Approach to
Improving Quality and Efficiency
Daniel B. McLaughlin
Julie M. Hays
Healthcare Operations
Management
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Copyright 2008 Health Administration Press. All rights reserved. 8-2
Chapter 8. Quality Management:
Focus on Six Sigma Defining Quality Cost of Quality
Quality Programs
Six Sigma- DMAIC Process
- Seven Basic Quality Tools
- Statistical Process Control (SPC)
Benchmarking
Quality Function Deployment (QFD)
Taguchi Methods
Mistake Proofing (Poka-Yoke)
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Copyright 2008 Health Administration Press. All rights reserved. 8-3
Defining Quality
Organizations perspective- Performance (design) quality
- Conformance (design) quality
Customer perspective- Garvins eight dimensions
- Parasuraman, Zeithaml, and Berrys five
dimensions- Institute of Medicine
- Quality assurance program
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Copyright 2008 Health Administration Press. All rights reserved. 8-4
Cost of (Poor) Quality
External failurecosts associated with failureafter the customer receives the product or service
Internal failurecosts associated with failure
before the customer receives the product orservice
Appraisalcosts associated with inspecting andevaluating the quality of supplies and/or final
product/service Preventioncosts incurred to eliminate or
minimize appraisal and failure costs
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Copyright 2008 Health Administration Press. All rights reserved. 8-5
Quality Programs
Total Quality Management (TQM) orContinuous Quality Improvement (CQI)
ISO 9000
Baldrige Criteria
Six Sigma
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Copyright 2008 Health Administration Press. All rights reserved. 8-6
Total Quality Management (TQM)
Focus on the customer
Top-management leadership and support
Employee involvement
Systems thinking
Continuous improvement
Data-based decision making
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ISO 9000
International standards concerned withensuring that organizations maintainconsistently high levels of quality
Five sections:- Quality management system
- Management responsibility
- Resource management- Measurement, analysis, and improvement
- Product realization
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8/45Copyright 2008 Health Administration Press. All rights reserved. 8-8
Baldrige Criteria
Award established to recognize organizations fortheir achievements in quality and to raiseawareness about the importance of quality
Seven categories:- Leadership- Strategic planning
- Customer and market
focus
- Measurement, analysis,and knowledgemanagement
- Human resource focus
- Process management
- Results
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Six Sigma
Philosophy- Eliminate defects through prevention and process
improvement
Methodology
- Team-based approach to process improvement usingthe DMAIC cycle
Set of tools
- Quantitative and qualitative statistically based tools Goal
- 3.4 defects per million opportunities (DPMO)
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Successful Six Sigma
Top-management support
Extensive training
DMAIC approach
Use of quantitative measures
Team-based projects
Impact on organizations financials
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Six SigmaCulture
Leadership Training
- Green belt
- Black belt
- Master black belt
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DMAIC Process
Define Measure
Analyze
Improve
Control
Define
Improve
Control
Measure
Analyze
Plan
Check
Act
Do
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Copyright 2008 Health Administration Press. All rights reserved. 8-14
DMAIC ProcessMeasure
CUSTOMERS
Key
Process
Input
Variables
(KPIV)
Key
Process
Output
Variables
(KPOV)
Crit ical
to
Qual i ty
(CTQ)
INPUT OUTPUTPROCESS
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Copyright 2008 Health Administration Press. All rights reserved. 8-15
DMAIC Process
Analyze- Analyze collected data to determine the root
causes
Improve- Identify, evaluate, and implement the
improvement solutions
Control- Put controls in place to ensure process
improvement gains are maintained
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Copyright 2008 Health Administration Press. All rights reserved. 8-16
Seven Basic Quality Tools
Run Chart
Scatter
Diagram
Histogram
FishboneDiagram
Check Sheet
Pareto Chart
Flow Chart
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Copyright 2008 Health Administration Press. All rights reserved. 8-17
Statistical Process Control (SPC)
SPC is a statistics-based methodology fordetermining when a process is moving out of
control.
All processes have variation in output. Some of the variation is inherent in the process
(common).
Some of the variation is due to assignable
(special) causes.
SPC is aimed at discovering variation due toassignable causes and correcting those causes.
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Copyright 2008 Health Administration Press. All rights reserved. 8-18
Statistical Process Control (SPC)
20
25
30
35
40
0 5 10 15 20 25 30
Day
MeanWaitTime(minutes)
+/- 1 +/- 2 +/- 3
Out ofControl
Sample
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Copyright 2008 Health Administration Press. All rights reserved. 8-19
SPCOut-of-Control Situations
Observation
_X=0
UCL=3
LCL=-3
8 or More Samples Above (or Below) Mean
Observation
_X=0
LCL=-3
UCL=3
6 or More Samples Increasing (or Decreasing)
Observation
_X=0
UCL=3
LCL=-3
One Sample More Than +/- 3 Standard Errors fromMean
Observation
_X=0
UCL=3
LCL=-3
14 or More Samples OscillatingOne Sample More Than +/- 3 Standard
Errors from Mean
14 or More Samples Oscillating
8 or More Samples Above (or Below)
Mean
6 or More Samples Increasing (or
Decreasing)
Observation
_X=0
UCL=3
LCL=-3
8 or More Samples Above (or Below) Mean
Observation
_X=0
LCL=-3
UCL=3
6 or More Samples Increasing (or Decreasing)
Observation
_X=0
UCL=3
LCL=-3
One Sample More Than +/- 3 Standard Errors fromMean
Observation
_X=0
UCL=3
LCL=-3
14 or More Samples OscillatingOne Sample More Than +/- 3 Standard
Errors from Mean
14 or More Samples Oscillating
8 or More Samples Above (or Below)
Mean
6 or More Samples Increasing (or
Decreasing)
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Copyright 2008 Health Administration Press. All rights reserved. 8-20
Statistical Process Control (SPC)
Current Wait Time
15 20 25 30 35 40 45
Wait Time (m inutes)
Wait Time Goal
15 20 25 30 35 40 45
Wait Time (minutes)
50% of
patients
wait
morethan 30
minutes
10% of
patients
waitmore
than 30
minutes
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Copyright 2008 Health Administration Press. All rights reserved. 8-21
Process Capability
A measure of how well the process canproduce output that meets desiredstandards or specifications
Compares process specifications(set bythe customer or management) to controllimits(the natural or common variability in
the process)
P C bilit
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Copyright 2008 Health Administration Press. All rights reserved. 8-22
Process CapabilityCp and Cpk
sxUSLor
sLSLxC
xUSLor
LSLxC
s
LSLUSL
C
LSLUSLC
pk
pk
p
p
33min
byestimatedisand33
min
6
byestimatedisand6
P C bilit
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Copyright 2008 Health Administration Press. All rights reserved. 8-23
Process CapabilityCp and Cpk
sxUSLor
sLSLxC
xUSLor
LSLxC
s
LSLUSL
C
LSLUSLC
pk
pk
p
p
33min
byestimatedisand33
min
6
byestimatedisand6
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Copyright 2008 Health Administration Press. All rights reserved. 8-25
Rolled Throughput Yield
Step 2
95/100error-free
products
Step 3
95/100error-free
products
Step 4
95/100error-free
products
Step 1
95/100error-free
products
Proportions
Step 2
95 in90 error-freeproducts
out
Step 3
90 in86 error-freeproducts
out
Step 4
86 in81 error-freeproducts
out
Step 1
100 in95 error-freeproducts
out
Actual
Q lit F ti D l t (QFD)
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Copyright 2008 Health Administration Press. All rights reserved. 8-26
Quality Function Deployment (QFD)House of Quality
Correlation
matrix
Design
requirements
Customer
requirementsCompetitive
assessment
Relationship
matrix
Specifications
or
target values
Importance
Importance weight
Importance
Importance weight
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Copyright 2008 Health Administration Press. All rights reserved. 8-27
Customer
needs
Knowledge that it is time for an office visit
Knowledge of why follow-up is needed
Convenient to schedule
Known appointment length
Appointment on time
Goal: Develop a system to
ensure that diabetes patients
receive preventive exams
QFD Example
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Copyright 2008 Health Administration Press. All rights reserved. 8-28
Technical
responses
On-time
appo
intmen
t
Appo
intmen
t
lengt
hrange
Time
to
sc
hedu
le
Inform
ationon
need
Su
bs
equen
t
no
tifi
ca
tion
Initial
no
tifi
ca
tion
Time knowledge
Why knowledge
ConvenientAppointment length
Appointment time
QFD Example
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Copyright 2008 Health Administration Press. All rights reserved. 8-29
Importance:
Patient desire
Cost
Compet i t ive
advantage
Time knowledge 5
Why knowledge 3
Convenient 4
Appointment length 3
Appointment time 4
QFD Example
On-t
im
e
appoin
tmen
t
Appoin
tmen
t
leng
th
range
Timeto
sc
hedu
le
Informa
tion
onnee
d
Su
bsequen
t
no
tifica
tion
Initial
no
tifica
tion
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Copyright 2008 Health Administration Press. All rights reserved. 8-30
Time knowledge 5 Why knowledge 3 Convenient 4 Appointment length 3 Appointment time 4
QFD Example
On-t
ime
appo
intmen
t
Appo
intmen
t
leng
thrange
Time
to
sc
he
du
le
Infor
ma
tion
onnee
d
Subs
equen
t
no
tif
ica
tion
Initia
l
no
tif
ica
tion
Relationships: Strong = 5 Medium = 3 Weak = 1
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Copyright 2008 Health Administration Press. All rights reserved. 8-31
Time knowledge 5 5 3
Why knowledge 3 5
Convenient 4 3Appointment length 3 5 3
Appointment time 4 3 5
QFD Example
On-t
ime
appo
intmen
t
Appo
intmen
t
leng
thrange
Time
to
sc
he
du
le
Infor
ma
tion
onn
ee
d
Subsequen
t
no
tif
ica
tion
Initia
l
no
tif
ica
tion
Replace icons with numbers
Relationships:
Strong = 5 Medium = 3
Weak = 1
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Copyright 2008 Health Administration Press. All rights reserved. 8-32
Time knowledge 5 5 3
Why knowledge 3 5
Convenient 4 5Appointment length 3 5 3
Appointment time 4 3 5
25 15 15 20 27 29
QFD Example
On-t
ime
app
ointmen
t
App
ointmen
t
leng
thrange
Tim
eto
sch
edu
le
Info
rma
tion
onnee
d
Sub
sequen
t
not
ifica
tion
Initial
not
ifica
tion
Mult ip ly b y impor tance and sum
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Time knowledge 5 5 3
Why knowledge 3 5
Convenient 4 5
Appointment length 3 5 3
Appointment time 4 3 5
25 15 15 20 27 29
QFD Example
On-t
ime
appo
intmen
t
Appoin
tmen
t
leng
thrange
Time
to
sc
he
du
le
Informa
tion
onnee
d
Su
bseq
uen
t
no
tifica
tion
Initial
no
tifica
tion
TechnicalcorrelationsRelationships:+= Strong positive = Strong negative
+ +
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Copyright 2008 Health Administration Press. All rights reserved. 8-34
Time knowledge 5 5 3
Why knowledge 3 5
Convenient 4 5
Appointment length 3 5 3
Appointment time 4 3 5
25 15 15 20 27 29
QFD Example
On-t
ime
appo
intmen
t
Appoin
tmen
t
leng
thrange
Time
to
sc
he
du
le
Informa
tion
onnee
d
Su
bseq
uen
t
no
tifica
tion
Initial
no
tifica
tion
Target:
100diabetics/month;85% compliance
QFD Example
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Copyright 2008 Health Administration Press. All rights reserved. 8-35
QFD ExampleOutcome
To: Dan McLaughlin
From: Southview Clinic
Dear Dan,
You had an appointment with Dr. Adams about six months ago, and it
is now time for another visit. We need to check your blood pressure,do some blood tests, and adjust your prescriptions if needed. We
would like to review these preventive procedures in advance, so
please see www.southview.com/prev22.
We have two openings available next week, on Tuesday at 8:30 am
and Thursday at 2:30, to see Dr. Adams. Click on one of these days to
make the appointment, or e-mail us with dates and times that workfor you.
We appreciate you continuing your care with us, and Dr. Adams looks
forward to seeing you.
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Taguchi Methods
Taguchi loss function- A quality product is a
product that causes aminimal loss
(expressed in $) tosociety during its entirelife.
Design of Experiments
(DOE) Design for Six Sigma
(DFSS)
Taguchi Loss Function
Y ($)
LSL Target USL
Loss
222 $whereLoss
kTYk
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Design of Experiments (DOE)
A structured approach to the investigation ofa system or process that determines thelevel of each input variable for each trial and
does not require all possible levels of everyinput variable
Requires fewer trials because it eliminates
the need to change one variable at a time Can find effects of combinations of input
variables
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Benchmarking
Process of identifying, understanding, andadapting outstanding practices andprocesses to improve organizational
performance Steps in benchmarking:
- Determine what to benchmark
- Determine how to measure it- Gather information and data
- Implement the best practice within theorganization
Best
Worst
Rangeof
values
Yourorganization
Best
Worst
Rangeof
values
Rangeof
values
Yourorganization
Yourorganization
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Mistake Proofing (Poka-Yoke)
A mechanism that either:- Prevents a mistake from being made
- Makes the mistake immediately obvious
Eliminates errors
Riverview Generic Drug Project
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Riverview Generic Drug Project
Riverview Drug Prescription Process
Patient
needs
drug
Clinician
prescribes
drug
Informationon drugs
Type of
drug
Drug
efficacyEnd
Drug
efficacyEnd
GenericDrug
works
Non-Generic
Drug
works
Drug
doesnt
work
Drug doesnt work
Ri i G i D P j t
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Copyright 2008 Health Administration Press. All rights reserved. 8-41
Riverview Generic Drug ProjectDrug Type and Availability
65% 35%
15%
20%
Generic
Non-Generic,GenericAvailable
Non-Generic,Generic NotAvailable
Microsoft Excel screen shots reprinted with permission from Microsoft Corporation.
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Riverview Generic Drug Project
Microsoft Excel screen shots reprinted with permission from Microsoft Corporation.
Clinician Prescriptions
0
5
10
15
20
Davis Jones Smith Swanson AndersonClinician
Non-genericprescriptions
whereagenericis
available/month
Non-Generic Prescriptions Where There Is a Generic Available
0
5
10
15
20
O W J V B H M A C I G D K L T U N P Q R
Drug
Prescriptions/month
DMAIC Process
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DMAIC Process
Seven Quality Control Tools
Tools and TechniquesDe
fine
Mea
sure
Analyze
Improv
e
Control
Cause-and-Effect Diagram xRun Chart x x
Check Sheet
Histogram x x
Pareto Chart x x x
Scatter Diagram x xFlowchart x x
DMAIC Process
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DMAIC Process
Other Tools
Tools and Techniques
Bar Graph x
Line Graph x
Pie Chart x5 Whys/ Root Cause x
FMEA x x
Hypothesis Testing x
Regression Analysis x
DOE x
Control Chart x x x
Process Capability x x x
Simulation x
DMAIC Process
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DMAIC Process
Other Tools
Tools and Techniques
Quality Function Deployment x x x
Poka-Yoke x
Brainstorming
x
x
xBenchmarking x x x x
Project Planning x x x
Charters x
Gantt Chart x
Tree Diagram xForce Field Analysis x x
Activity-Based Costing
Balanced Scorecard
Cost and Benefit Analysis x