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8/2/2019 Six Sigma Project Work
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Six Sigma inHealthcare:
A prescription forchange?
DR. BINITA SINGH
PRADEEP JAINDR. SWATI NALWADE
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Objectives
2
Articulate the case for organizationaltransformation in healthcare
Acquire high-level understanding of Six Sigma
and related change management methods
Learn from case study examples
Know the keys to a successful deployment
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The Need for
Change inHealthcare
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A Perfect Storm
Patient safety and qualityconcerns
Demographic changes
Rapidly changingtechnologies and treatment
Digital transition
Workforce issues
Financial constraintsRising consumerism
Un and Under-insured
Leadership challenges
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Time cover story - May 1,2006
Q: What ScaresDoctors?
A: Being thePatient
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Hospitals must alsoredesign processes andaddress the human side ofchange.
Simply overlaying 21st
century technologies on topof 20th century workflow willnot yield the necessarycost, quality and efficiencybenefits.
hnology alone isnt the answer
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Overcoming the barriers
Culture
Alignment and accountability
Control
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Getting there from here
Transformation inhealthcare wont happenwithout transparency.
Transparency cant happenwithout culture change.
Culture change wont happen
without a bold vision, a commontoolset and unwaveringcommitment.
http://images.google.com/imgres?imgurl=http://www1.istockphoto.com/file_thumbview_approve/855441/2/istockphoto_855441_winding_road_isolated.jpg&imgrefurl=http://www.istockphoto.com/file_closeup/%3Fid%3D855441%26refnum%3D375718&h=285&w=380&sz=29&hl=en&start=2&tbnid=xWbtdKQ-p-0q0M:&tbnh=92&tbnw=123&prev=/images%3Fq%3Dwinding%2Broad%26gbv%3D2%26svnum%3D10%26hl%3Denhttp://images.google.com/imgres?imgurl=http://www1.istockphoto.com/file_thumbview_approve/855441/2/istockphoto_855441_winding_road_isolated.jpg&imgrefurl=http://www.istockphoto.com/file_closeup/%3Fid%3D855441%26refnum%3D375718&h=285&w=380&sz=29&hl=en&start=2&tbnid=xWbtdKQ-p-0q0M:&tbnh=92&tbnw=123&prev=/images%3Fq%3Dwinding%2Broad%26gbv%3D2%26svnum%3D10%26hl%3Den8/2/2019 Six Sigma Project Work
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Six Sigma
Background andBasics
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Where did Six Sigma ComeFrom?
During the first five years, even supplierswere required to participate in the process
Six Sigma was adopted by Allied Signaland GE and further developed into a true
management system
Success led to global deployment across avariety of companies and industries
including healthcare!
Initially developed at Motorola
in the 1980s to improveprocesses, meet customerexpectations and maintainmarket leadership
http://images.google.com/imgres?imgurl=http://img75.imageshack.us/img75/2216/chickxc4.gif&imgrefurl=http://mytribeblog.com/category/work/&h=274&w=320&sz=22&hl=en&start=22&um=1&tbnid=_o3PGoSH1vNg4M:&tbnh=101&tbnw=118&prev=/images%3Fq%3Dchicken%2Begg%26start%3D20%26ndsp%3D20%26svnum%3D10%26um%3D1%26hl%3Den%26sa%3DN8/2/2019 Six Sigma Project Work
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What does Six Sigma mean?
The term Sigma is a measurement
of how far a given process deviatesfrom perfection a measure of thenumber of defects. Six Sigmacorrelates to just 3.4 defects per millionopportunities.
A qualityimprovement methodologythat applies statistics to measure andreduce variation in processes.
A management systemthat iscomprehensive and flexible forachieving, sustaining, and maximizingsuccess.
2
3
4
5
6
308,537
66,807
6,210
233
3.4
BB DPMODPMO
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Key Concepts
Critical to Quality (CTQ)Critical to Quality (CTQ):: Attributes most
important to the customer
DefectDefect:: Failing to deliver what the customer
wants
Process CapabilityProcess Capability:: What your process can
deliver
Stable OperationsStable Operations:: Ensuring consistent,
predictable processes to improve what the
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How does the customer view myprocess?
What does the customer look at tomeasure performance?
Time to
Park Car
Registration
Walk to
ProcedureArea
Procedur
e Time
Time to
drive tofacility
Hospitals Viewof Registration
Patients View
ofRegistration
An Enabler for CulturalChange
Lobby
Time
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20,000 lost articles of mail per hour
The Classical View of Quality
99% Good (Z = 3.8)
Seven lost articles of mail per hour
The Six Sigma View of Quality
99.99966% Good (Z = 6)
One hour without electricity every
34 years
68 wrong drug prescriptionseach year
No electricity for almost
7 hours each month
200,000 wrong drug prescriptionseach year
One short or long landing at most
major airports every five years
2 short or long landings at most
major airports daily
5,000 incorrect surgical operationsper week 1.7 incorrect surgical operationsper week
One minute of unsafe drinking water
every seven months
Unsafe drinking water almost
15 minutes each day
How good do we need to be?
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Define
CTQs
StatisticalProblem
PracticalProblem
Statistical
Solution
PracticalSolution
DMAIC METHOD:
...measure your target metricand know your measure is good...
look for root causes andgenerate a prioritized listing of them.
... determine and confirm the
optimal solution ...
be sure the problem doesntcome back sustain it
and relate it to the customer..,... define the problem, clarify
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Translating Goals intoResultsThe Big Ys
Clinical excellence
Patient safety
Financial results
Patient satisfaction
Physician/staff
satisfaction
Community service
ALL DRIVEN BY
PROCESSES
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In simple terms
Listen to the customer
Define their expectations
Measure how many times we get it wrong
Fix it
Prove the fix is real and meaningful
Make it stick !!!!!
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Large scaleimprovementsrequire precise
coordination anda commoncadence
to advancesmoothly
62% of
initiatives fail
due to lack ofleadership
commitment
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Healthcare Case StudyExamples
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Improving process/safety for medication administration
Reduction in Blood Stream Infections in ICU
Reducing ventilator acquired pneumonia
Emergency Department Patient Wait Time
Improved Patient Throughput in Radiology
Reduction in Lost Films
MR Exam Scheduling Improvement
Staff Recruitment and RetentionOperating Room Case Cart Accuracy
Physician (Professional Fee) Billing Accuracy
Appointment Backlog for Hospital-Based Orthopedic Clinic
Quality of Care and Satisfaction of Families in Newborn ICU
Healthcare Project
Examples
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Project Description :PS - Moving Treat-to-Street patients through the EDtakes too long. PD - One-third of our patients waitlonger than 60 minutes to be seen by a physician.
Project Description :PS - Moving Treat-to-Street patients through the EDtakes too long. PD - One-third of our patients waitlonger than 60 minutes to be seen by a physician.
Project Scope:In Scope - Treat to Street pts, Staffing patterns (ED MDs &
RNs), Equipt, FTEs, Registration, Lab, X-R.
Out of Scope - ED Admits, ED Hold Hours, Bed Control,Housekeeping, Transport to Floor, MR, US, CT, Pharm.
Project Scope:In Scope - Treat to Street pts, Staffing patterns (ED MDs &
RNs), Equipt, FTEs, Registration, Lab, X-R.Out of Scope - ED Admits, ED Hold Hours, Bed Control,Housekeeping, Transport to Floor, MR, US, CT, Pharm.
Potential Benefits:
Decrease LWBS Increase patient satisfaction (Press Ganey #s) Reduce ED LOS (Soft Dollars)
Potential Benefits:
Decrease LWBS Increase patient satisfaction (Press Ganey #s) Reduce ED LOS (Soft Dollars)
Alignment with Strategic Plan: Customer Service Growth Efficiency
Alignment with Strategic Plan:
Customer Service Growth Efficiency
Project Title: ED ThroughputProject Title: ED Throughput
Customer(s):Patients, Physicians
Customer(s):Patients, Physicians
Case Study: Improving ED
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What is the Right Y (CTQ) to Measure? How will it be measured? Y = Door to Doc Time. From the time a patient enters through the door until the physicianenters the exam room to assess the patient, measured in minutes.
What is the Right Y (CTQ) to Measure? How will it be measured?
Y = Door to Doc Time. From the time a patient enters through the door until the physicianenters the exam room to assess the patient, measured in minutes.
What is our goal?
We will improve the average ED Throughput Time for Treat and Street Patients by 40%.This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes.
We will improve our throughput yield of patients seeing a physician within 60 minutes(USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over7,500 customers.
What is our goal?
We will improve the average ED Throughput Time for Treat and Street Patients by 40%.This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes.
We will improve our throughput yield of patients seeing a physician within 60 minutes(USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over7,500 customers.
Measure
What are the specification limits? (LSL, USL) What is the Target? Based upon our VOC data, we have set a USL of 60 minutes and a Target Mean of 40minutes.
What are the specification limits? (LSL, USL) What is the Target? Based upon our VOC data, we have set a USL of 60 minutes and a Target Mean of 40minutes.
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Value Stream Map Opportunities for Performance Improvements:Value Stream Map Opportunities for Performance Improvements:
Analyze
Door-to-Doc Subcycle
Other
Flow
(blood,
etc.)Patient WaitTime
PhoneCall
ED
Waiting
Room
Triage
EKG, Draw
Blood, UA,
Order X-Ray,
administer Pain
med
2- RNs
1 Tech
Front
Desk / QR
Treatment
X-Ray
In ED
Lab
Team Area
Tube/blood
MD
Portable
Faxwrittenreport/
ED
Call criticalvalues
Arr QR QR Triage Triage Bed Bed MD
6.3 min 11.6 min 23.5 min 22.9 min
Current Average Cycle Times
PatientFlowPeople
Flow (RN,
MD, etc.)E-Info
Flow
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Analyze
Statistical AnalysisStatistical Analysis
Door-to-Doc
Environment
Measurements
Methods
Materials
Machines
People
Associate Attributes
Physicians
Nurses
Registration
Patient Attributes
Office Equipt
Pyxis
EKG
Computers (screens)
Dynamap
Supplies
Software
Chart
Triage Sheets
Ancillary Svcs
Transportation
Advanced Triage
Financial Metrics
LWBS
Satisfaction
Time
Triage Level
Staffing
Seasonality
Acuity
GenderAge
Registrar
QuickReg
ChargeTriage
Speed
ExperienceSkill
CopierFax
Hyperion (Finance)Invision
EDTracking
XRayLab
Months
WeeksDays
Shifts
Minutes
Physician
Associate
Patient
ROICost
Revenue
TimeofDay
DayofWeek
Holidays
Quarterly
Monthly
Levels
Patterns
Door-to-Doc Causes (Xs )Hypothetical
Driver (X)
Statistically
Proven (X)
Nurses
X-Ray
DayofW
eek
Shift
Bed Available
Census
Lab
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Analyze
What Xs (inputs) are causing most of our variation?
Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open`
What Xs (inputs) are causing most of our variation?
Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open`
Estimated Effects and Coefficients for D2D (coded units)
Term Effect Coef SE Coef T P
Constant 87.34 2.547 34.30 0.000
Express Care 35.56 17.78 2.547 6.98 0.000
X-Ray 36.06 18.03 2.547 7.08 0.000
Bed Open -37.81 -18.91 2.547 -7.42 0.000Express Care*X-Ray 33.69 16.84 2.547 6.61 0.000
Express Care*Bed Open 32.56 16.28 2.547 6.39 0.000
X-Ray*Bed Open 14.06 7.03 2.547 2.76 0.025
Express Care*X-Ray*Bed Open 5.19 2.59 2.547 1.02 0.338
S = 10.1865 R-Sq = 96.87% R-Sq(adj) = 94.12%
Analysis of Variance for D2D (coded units)
Source DF Seq SS Adj SSAdj MS F P
Main Effects 3 15979.9 15979.9 5326.6 51.33 0.000
2-Way Interactions 3 9571.7 9571.7 3190.6 30.75 0.000
3-Way Interactions 1 107.6 107.6 107.6 1.04 0.338
Residual Error 8 830.1 830.1 103.8
Pure Error 8 830.1 830.1 103.8
Total 15 26489.4
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What Xs (inputs) have we chosen to improve?
1. Bed Availability
The Measure Phase data demonstrated that Door-to-Doctor time increased by two tothree times when there is no bed open for the patient.
1. Ancillary Services The data further showed that the time it takes to perform an X-Ray or Lab testing isstatistically significant in relation to Door-to-Doctor time.
3. Express Care
Lower acuity patients (i.e. Level 3 / Express Care) wait longer to see a physician thando higher acuity patients (i.e. Level 1).
What Xs (inputs) have we chosen to improve?
1. Bed Availability
The Measure Phase data demonstrated that Door-to-Doctor time increased by two tothree times when there is no bed open for the patient.
1. Ancillary Services
The data further showed that the time it takes to perform an X-Ray or Lab testing isstatistically significant in relation to Door-to-Doctor time.
3. Express Care
Lower acuity patients (i.e. Level 3 / Express Care) wait longer to see a physician thando higher acuity patients (i.e. Level 1).
What do we want to know?Screen Potential Causes?
Discover Variable Relationships?
Establish Operating Tolerances?
What do we want to know?Screen Potential Causes?
Discover Variable Relationships?
Establish Operating Tolerances?
Improve
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Value Stream Map Key Points / Opportunities for Improvement:Value Stream Map Key Points / Opportunities for Improvement:
Improve
Registration
If rooms ful
may reg ptwhile
waiting.
ED
Waiting
Room
Triage
EKG, Draw
Blood, UA,
Order X-Ray,
administer Pain
med2- RNs
1 Tech
Front
Desk / QR
Bedside Registration
Patient
Flow
People
Flow (RN,
MD, etc.)E-InfoFlow
Patient WaitTime
Impacts:1 Inc. Patient Satisfaction2 Red. time by 8.7 minutes3 Red. variability in process
Non-value added
step removed
Non-value addedstep removed
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What is the mean and median of our process? What is the standard
deviation?
Measure Phase Control Phase + % Mean score 64.3 minutes 39.8 minutes 38.1%
Median 38.5 minutes 34.0 minutes 11.7% Standard Deviation 44.7 minutes 27.7 minutes 38.0% HI/LO 241 / 11 minutes 129 / 4 minutes 46.5% (HI; outliers) Range 230 minutes 125 minutes 45.7%
What is the mean and median of our process? What is the standard
deviation?
Measure Phase Control Phase + % Mean score 64.3 minutes 39.8 minutes 38.1% Median 38.5 minutes 34.0 minutes 11.7% Standard Deviation 44.7 minutes 27.7 minutes 38.0% HI/LO 241 / 11 minutes 129 / 4 minutes 46.5% (HI; outliers) Range 230 minutes 125 minutes 45.7%
What is our process capability (Z score, DPMO, Yield %)? Z Short-Term Score = 1.91 2.35 0.44 DPMO = 333,333 175,000 Yield % = 66.7% 82.5% 15.8%
What is our process capability (Z score, DPMO, Yield %)? Z Short-Term Score = 1.91 2.35 0.44
DPMO = 333,333 175,000 Yield % = 66.7% 82.5% 15.8%
Improve
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What are our financial results? How were they calculated?
Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and thecorresponding admissions as well as a conservative (5%) recognition as a result ofthroughput improvement.
What are our financial results? How were they calculated?
Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and thecorresponding admissions as well as a conservative (5%) recognition as a result ofthroughput improvement.
Control
What is the plan for monitoring/ auditing the process? What is the ControlPlan?
What is the plan for monitoring/ auditing the process? What is the ControlPlan?
M e t r i c
T a r g e t
V a lu e s M e a su re m e n t De fin itio n
M e a s u r e m e
M e t h o d
U p p e r / L o w e
S p e c L i m i ts
C o n t r o l
M e th o d F re q u e nc y
R e s p o n s i b i l i t
(W h o w il l m e a s A le rt F la g s
D o o r t o D o c t o r T im e
< 6 0 m i n u t
Y i e l d = 8 0
T i m e b e g i n s w h e n a p a t i e n
c r o s s e s t h e r e a c h e s Q u i c
Reg is t r a t ion . Th is t im e is
c o m p l e te d w h e n a p h y s i c i
g r ee t s t h e p at ie n t a t th e b M a n u a l - C D R W e bU S L = 6 0 m i n u t e s
D a s h b o a r d
Xb ar-R C h W e ek ly M . K e lly -N ic ho ls
Two ou t o f t h ree week s
8 0 % o f p a t i e n t s a r e n o t
b y a p h y s i c i a n w i t h in 6
m i n u t e s .
L W B S % < 1 . 0%
P a t i e n t le a ve s t h e E D a ft e
l e a s t c o m p l e t in g t h e Q u i c
p r o c e s s b u t b e fo r e p h y s i c i
p e r fo r m s e x a m i n a t io n .
A u t o m a t e d -
E D T r a c k i n g
U S L = 1 . 0 % o f
E D v is i t s
D a s h b o a r d
Xb ar-R C h W e ek ly M . K e lly -N ic ho ls
Two ou t o f t h ree week s
L W B S % e x c ee ds 1 .0
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Summary and Keys
to Success
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Better patientsafety with 91%improvement in
post-surgeryantibiotic use,delivering annualsavings over $1million at hospital inSoutheast
Achieving 35%higher take homebaby rate with
increase insuccessfulimplantation athospital inNortheast
The Big Why
Shorter ED waittimes allow 28more patients
per day to beseen, withpotentialfinancial impactover $13 millionannually at
hospital inSouthern
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Think about it.Are the mission, vision and values ofyour health system merely bullet points
on a web site, or are they clearlyunderstood and activated across theorganization?
Are people empowered to drive changeand accountable for results?
Culture Change
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Gain leadership support
Identify opportunities
Ensure strategic alignment
Develop a business case
Establish measurements and evaluate
performance Manage change
Monitor results and sustain improvement
Keys to implementing Six Sigma in
Healthcare
and network with others who have
embarked on similar initiatives!
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ZERO ERROR SIX SIGMA ?
CAN WE ACHIEVE IT IN INDIAN
HEALTHCARE SECTOR ?
THANK YOU !