Applying
Lean
Six
Sigma
to
your
Compliance
Program
John Kalb, JD, CHC, CCEP
Operational Excellence Executive/
Compliance Officer
Kootenai Health
April
2,
2014
1Content
•
Lean
Six
Sigma’s
goals
of
reducing
waste
and
variation
can
help
improve
organizational
compliance
•
An
overview
of
the
application
of
the
methodology
to
understand
how
it
supports
a
culture
of
compliance
•
Learn
specific
tools
that
can
be
applied
throughout
your
organization
to
increase
standardization
and
compliance
2
Lean
Six
Sigma
Leadership
Culture
•
Honor
and
Respect
People
– your
people
have
good
ideas
–
recognize
and
reward
them
for
that
– allow
them
to
contribute
through
collaboration
and
empowerment
•
Honor
The
Customer
– they
are
the
reason
we
exist
– figure
out
what
they
want
and
make
improvements
and
create
standards
around
what
they
want
•
Honor
Standards
– it
is
the
“sustain”
plan
to
keep
things
in
compliance
‐
document
what
you
do,
do
what
you
document
and
prove
it
in
practice
•
Error
proof
practices
to
ensure
minimal
regulatory
intervention
The
Lean
Six
Sigma
Difference
– Change
in
Culture
4
LSS
System
Focus
•
People
are
not
perfect
and
will
make
mistakes
•
System
factors
cause
many
negative
events/
issues
•
Reliable
outcomes
are
obtainable
with
the
right
mix
of
people
and
processes
Traditional
Individual
Focus
•
People
who
make
mistakes
are
poor
performers
•
Systems
performance
will
improve
by
removing
poor
performers
So,
What
Are
Some
Of
The
Barriers
To
Compliance?
•
Poor
Communication
•
Flawed
Teamwork
•
No
collaboration
•
Rushed
Procedures
•
Time
Pressure
•
Policies
that
are
hard
to
follow
•
Inadequate
Interfaces
•
Lack
of
error
prevention
expectations
or
accountability
The
Lean
Six
Sigma
Difference
– Change
in
Culture
5
Lean
Eliminate Waste/ Improve Flow
Reduce cycle time
Lower complexity
Analysis of physical layout
Known Solutions
3 – 5 day deployment/
implementation
Six
Sigma
Reduce defects & variability
High complexity
Unknown root causes/ solutions
Data driven control Strategy
4 – 8 month projects
Overview
of
Lean
Six
Sigma
Methodology
After
Before Work Time
(value add) Wait and ‘Other’ Time (no value) Work Time (value add) Wait and ‘Other’ Time (no value) Same value,
Less time and Resource!
Six
Sigma
+
Eliminate waste in and around Processes
Lean
Eliminate defects in Processes
= Business
Improvement Process Improvement
Benefits
of
Lean
Six
Sigma
7 1 93.32% 99.38% 99.98% 99.999% 7 61.63% 95.73% 99.97% 99.998% 10 50.08% 93.96% 99.96% 99.997% 40 25.08% 77.82% 99.00% 99.986% 100 0.10% 52.23% 97.70% 99.996% 300 0.00% 15.43% 93.26% 99.898% 700 0.00% 0.20% 84.97% 99.762% 1000 0.00% 0.00% 79.24% 99.661% 3000 0.00% 0.00% 50.15% 98.985% # of process steps 3 4 5 6 Lean – reduce
steps & waste
Six Sigma – reduce defects & variability
Lean
Processes
that
Operate
at
Six
Sigma
Repeatability
Flo
w
8
Rolled
Throughput
Yield
Patient A is treated in 3 Steps……
Rolled Throughput Yield is the Probability That the Process to
treat the Patient Will Produce Zero Defects
Patient
A
Treatment
YRT= (0.80) (0.70) (0.90) = .504 = 50.4% Triage Diagnostic TestingRolled Throughput Yield = Product of the First PassYields Diagnosis
YFP= 80% YFP= 70% YFP= 90%
How
reducing
steps
reduces
defects
It started in Japan at the Toyota Motor Company
1902:Sakichi Toyoda of the Toyota group, invented an automated
loom that stopped anytime a thread broke.
1908: Henry Ford invents the moving assembly line and raises
the daily wage to $5.00 ; continuous flow as a production
method is created.
“ The thing is to keep everything in motion and take the
work to the man and not the man to the work. This is the
real principle of our production and conveyors are only one
of many means to an end.”‐Henry Ford : Today and
Tomorrow
Several decadeslater Taiichi Ohno, a production engineer at the
Toyota Motor Company applied the same concept as he sought to
eliminate waste, or non‐value added activities, within the Toyota
organization.
In addition to stopping production at every defect (Jidoka), he
employed another key concept, JIT (just in time). Together, Jidoka
and JIT are the pillars of the Toyota Production System, supported
by a foundation of Heijunka (level loading) … the basis of Lean.
A
Brief
History
of
the
Toyota
Production
System
‐
Lean
10
Where
Does
Lean
Come
From?
• The basic philosophy of Lean is to provide the customer with… – What they want
– When they want it
– Using the absolute minimum resources
1978
1996 1943 ‐1978
Value ‐an activity that administers care or provides a service or information to meet
customer/ patient needs and requirements (usually something that the customer/
patient is willing to pay for)
Value Stream Map– A graphic map of steps that occur from a request for a product
or service to delivery of the product or service. Similar to a process map but with
greater amount of detail – such as time taken, resources consumed, inventory etc.
Value‐added– a step, activity or a process that is perceived to add valueto
the customer/ patient; it transforms the product or service
Non‐value‐added– a step, activity or process that takes time, resources
and/or space but does not contribute to adding value or satisfying
customer/patient needs
Value Enabling or Non‐Value‐Added Essential– a step, activity or process
that does not add value but must be done, usually required either because of
regulations or as a pre‐requisite to completing a value‐added step
Muda = Waste– anything that takes resources but creates no value for the customer,
usually an excessive or unwanted step, resource, or activity
TAKT Time– the rate at which a customer/ patient demands a product or service
TAKT Time is NOTCycle time
Pull– used to describe the customer/ patient generating the demand for service /
product as opposed to the producer ‘pushing’ to the customer/ patient
Kaizen / Kaizen‐event ‐a Rapid Cycle Improvement ‐3‐5 days where actual changes
are made (Action) i.e. processes are changed, equipment is moved etc.
Key
Terms
Lean
Thinking
Process
The continuous movement of products, services and information from end to end through the process Define value in from the customers
perspective and express value in terms of a specific product
Nothing is done by the upstream process until the downstream customer signals the need The complete elimination of
waste so all activities create value for the customer
2 Map the Value Stream 3 Establish Flow 4 Implement Pull 5 Work to Perfection 1 Specify Value
Map all of the steps…value added & non‐value added…that bring a product of service to the customer
The 5 steps to Lean Thinking …
Four
Rules
of
Lean
1. Work
activities
are
specified
to:
• Content
– what
is
being
done
• Sequence
– in
what
order
• Timing
– how
long
should
it
take
• Outcome
– what
are
the
expected
measurable
results
2. All
connections
must
be
simple
and
direct
3. Pathways
are
simple
and
involve
as
few
steps
and
people
as
necessary
4. Continuous
Improvement
by
those
doing
the
work
and
as
close
to
the
problem
as
possible
• Assign
corrective
action
and
improvement
• Follow
up
on
the
previous
day’s
action
items
14
TOYOTA
Just-in-T
im
e
•Single Piece Flow •Pull Production •TAKT Time Production
•Autonomation •Stopping at Abnormalities •Level Loading •Sequencing
Jidoka
Heijunka
Toyota
Production System
Toyota
Production
System:
Jidoka
Andon Boards (Call Lights) Sounds (Machine warnings)
Reasons to Stop a Process:
• Defective Material (Rapid Response Team)
• Material Shortage (Flash Sterilization)
• Equipment Breakdown
Make everything visible to everyone:
• Expose waste
• Make standards clear
• Improve efficiency
The
Lean
Toolkit
– Basic
Lean
Tools
•
Identifying
and
Eliminating
Waste
•
Value
Stream
Mapping
(VSM)
•
Root
Cause
Analysis
Using
5
Whys
•
5S
•
Spaghetti
Mapping
•
Takt
Time
•
Standard
Work
•
Level
Loading
&
Sequencing
•
Single
Piece
Flow
•
Daily
Action
Review
17
The
8
Types
of
Muda
(DOWNTIME)
Defects
Work that contains errors, rework, mistakes or lacks something necessary • Medication error • Wrong patient • Wrong procedure • Scrap • Rework • Correction Overproduction
Producing more than the customer/ patient needs
right now
• Medications given early or testing ahead of time to suit schedule • Treatments done to balance hospital staff
or equipment workload • Writing or entering the same information
many times
• Making copies of chart notes that are not used
• Producing more to avoid set-ups • Batch process resulting in extra output • Copies of reports that are sent
automatically
Waiting
Idle time created when material, information, people, or equipment is not
ready
Waiting for… • Bed assignments • Testing & Treatment, Discharge • Patient lab test results
• Waiting for parts • Waiting for inspection • Waiting for information • Waiting for others at meetings
Non-Utilized Resources
Resources that either not be used at all or not being utilized to their full potential
• Staff not be utilized at their skill level • Empty Beds due to no staff
• Excess Inventory on shelves
Transportation/ Motion
Movement of people that does not add value
• Searching for patients • Searching for meds and/or charts • Gathering tools / supplies • Handling paperwork
• Searching for equipment • Sorting through materials • Reaching for tools • Waling to fax or copier machine many
times a day
Inventory
More materials, parts, or products on hand than the
customer/ patient needs right now
• Bed assignments • Pharmacy overstock / Lab oversupplies • Specimens waiting analysis • Patients in beds past discharge time
• Raw materials • Work in process • Finished goods • Paperwork in process Missing Information / Confusion
People are not sure about the best way to perform
work tasks
• Variation in practice patterns • Unclear orders • Unclear systems for reporting/
communicating • Patients scheduled with incorrect
information
• Variation in way same activities are performed
• No knowing what the next steps are • Unclear systems for reporting/
communicating
Extra Processing/
Rework
Activities/ effort that adds no value from the patient’s/ customer’s viewpoint
• Multiple bed moves • Redundant information gathering • Excessive paperwork • Unnecessary procedures • Multiple testing / Retesting
• Multiple cleaning of parts • Paperwork • Awkward tool or part design • Regulatory paperwork • Tasks that are no longer needed
Waste
examples
that
lead
to
compliance
concerns:
•
Data
collection
– process
steps
that
do
not
add
value
for
the
patient.
For
example
when
in
clinical
trails
there
is
the
collection
of
extraneous
data
that
will
not
be
utilized
in
the
study.
This
creates
waste,
risk
and
liability.
–Can the data collection be streamlined to remove the collection and
retention of unused data?
•
When
communication
of
information
and
ideas
is
isolated
or
siloed
within
a
company
and/or
departments.
•
When
the
same
information
needs
to
be
submitted
separately
to
different
regulatory
agencies
– and
if
they
have
different
data
definitions.
•
Underutilization
of
staff
to
identify
and
help
prevent
defects
19 Reevaluate Recall Redesign Retest Retype Redo Repeat Reissue Reject Rework Remake Recheck Revise Return Remeasure Reship
Clues
to
Waste
&
Non
‐
Value
Added
Work
20
Waste
Observation
Tool
Waste Observation Tool VALUE STREAM/PROCESS NAME:
____________________________ DATE: ______________________ OBSERVER:
____________________________________________ LOCATION: __________________
NO. PROCESS NAME WASTE DESCRIPTION/OBSERVATION D O W N T I M E TIME (SEC) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
In the next 24 hours, I will remove the Waste No. _________ and communicate to the affected people.
Signature:________________________ 21
•
Explain
the
8
wastes
•
Stand
in
the
same
spot
every
day
in
the
center
of
the
workplace
(gemba)
•
Find
wastes
every
day
•
Identify
Root
Causes
•
Remove
at
least
1
waste
everyday
Ohno
Circle
Tool
22
•
Preregistration
process
call
prior
to
procedure
•
Arriving
and
waiting
for
the
nurse
to
call
for
you
•
Being
walked
to
the
exam
room
•
Taking
vital
signs
•
Waiting
for
the
doctor
•
Getting
directions
to
the
hospital
•
Finding
your
way
to
the
lab
to
get
blood
drawn
•
Filling
out
billing
information
•
Correcting
the
bill
Which
of
these
add
value
for
the
customer
23
•
Preregistration
process
call
prior
to
procedure
•
Arriving
and
waiting
for
the
nurse
to
call
for
you
•
Being
walked
to
the
exam
room
•
Taking
vital
signs
•
Waiting
for
the
doctor
•
Getting
directions
to
the
hospital
•
Finding
your
way
to
the
lab
to
get
blood
drawn
•
Filling
out
billing
information
•
Correcting
the
bill
Which
of
these
are
compliance
concerns
• Understand current situation ‐Big picture • Ratio of Non‐Value to Value Added Time • Exposes sources of waste ‐not just waste • Shows linkage between the 7 types of flow
Why
Value
Stream?
• Start at the customer and work backwards
• Walk the actual flows
•Don’t map the organization but map the flow through it
•Identify value added and non‐value added steps (muda or waste)
•Identify where to focus analysis of activities
•Don’t be too detailed this is an overview
•Use pencil not power point…quick and crude
Guidelines
for
Mapping
TOTAL VALUE STREAMINPUTS Your Hospital OUTPUTS
The
7
Flows
1. Patients 2. Communication 2. Supplies
4. Information (What and When) 5. People (Std. Work, Takt Time) 6. Equipment (Portable X‐Ray, EKG, etc) 7. Specimens
Value
Steam
Mapping
25
Example:
Cath
Lab
Value
Stream
Map
Reception Check‐in 0‐5 Pts. Discharged Admitted Recovery Cath Lab Inpatient Pre‐Cath 69 135 2338 300 10 133 38 10 122 120 96 336 431 960 78 2201 Registration
Eliminate
waste
in
and
around
processes
Value
Steam
Mapping
26
What You Think it is What it Actually is: WhatLike it You to Be Would
Current
State
VSM
is
created
from
the
patient/customer’s
perspective
(i.e.
walk
the
process).
The
process
to
develop
and
map
concepts
for
the
Future
State
provides
a
gap
analysis
between
where
you
are
and
where
you
need
to
go
and
helps
to
determine
the
improvement
strategy.
Three
Versions
of
Value
Stream
Map
Processes
Root
Cause
Analysis
(RCA)
28
Root
Cause
Analysis
(RCA)
A
process
for
identifying
the
basic
or
causal
factors
that
underlie
variation
in
performance,
including
the
occurrence
or
possible
occurrence
of
a
defect
Why
Conduct an
RCA:
•
To
identify
the
processes
and
systems
related
to
the
occurrence
as
well
as
the
proximate
cause
of
the
event
•
Leads
to
an
improvement
in
processes
or
systems
•
Decreases
the
likelihood
of
similar
events
in
the
future
29
•
A
simple
and
widely
used
tool
•
Team
asks/
considers
“why”
at
least
five
times
•
Agree
on
root
cause
•
Develop
action
plan
for
improvement
Root
Cause
Analysis
(RCA)
– 5
Whys
Tool
Department/Area: Initiator: Date:
Issue/General Information : Occurrences:
Why #1: Why #2:
Why #3: Why #4:
Why #5: Temporary Countermeasure:
1.
Final Countermeasure:
Ask WHY a final time:
Read backwards after completion. Does the analysis make sense?
Circle One: Yes No
Root
Cause
Analysis
(RCA)
– 5
Whys
Tool
31 What is 5S? Sort Simplify Shine Standardize Sustain
Arrange & Prioritize ‐Distinguish
needed and unneeded items Prevent Problems from occurring ‐
arrange and identify needed item for
ease of use
Inspect and Clean up area daily Establish Orderliness/ Standards/
clearly define tasks Discipline to maintain established
procedures – audit area
• Get everyone involved.
• Integrate 5S Principles into daily work. • Communicate need for 5S, roles of all
participants.
• Be consistent in following 5S in all areas
• Leadership involvement at all levels • Follow through ‐5S takes effort &
persistence.
• Link 5S activity with all other initiatives.
Keys to Success
5S
32
• 5 cowboys to drive 1000 cattle • Should take one look and
understand the situation • Clearly differentiate between
what is “Normal” and
“Abnormal” • Detect what is “Abnormal”
Create
Standards
…
Detect
Abnormalities
Look
Here
…
Not
Here
…
5S
5S
Classifying
Supply
Locations
By
Frequency
of
Use
Tag
based
on
Frequency
Priority Frequency
of
use
How
to
Store
Low Less than once a week Throw away !!
Store in distant place
Medium Once a week Store together or
somewhere in department
High Once a day Carry or keep at
once per takt time individual work place
34
5S
Tool
Item Score ( 0 ‐5 )
What is the team doing to improve to the next level?
Bulletin Boards Emergency Access Items on Floor Aisle‐ways Marking Aisle‐ways Maintenance Floor Cleaning Storage of Cleaning Equipment Removing unnecessary items Item # and Description Storage and Arrangement Equipment Painting
Five S Evaluation Form
All paperwork, supplies, tools, equipment, cabinets, stands etc not required for performing operations are removed from the area. Only tools and product are at work stations. All cleaning equipment is stored in a neat, orderly manner, handy and readily available when needed. All bulletin boards are arranged in a neat and orderly manner. No outdated, torn or soiled announcements are displayed. All floors are clean and free of debris, oil and dirt. Cleaning of floors is done routinely ‐daily at a minimum ‐ a posted schedule or checklist is present. Fire hoses and emergency equipment are unobstructed and stored in a prominent easy to locate area. Switches and breakers are marked or color coded for visibility. Supplies and any other materials are not left to sit directly on the floor. Large items such as boxes are placed on the floor in clearly identified and marked areas. Aisles and walkways are clearly marked and can be identified at a glance, lines are straight and at right angles with no chipped or worn paint. Aisles are always free of materials and obstructions, nothing is placed on the lines, and objects are always places at right angles to the aisles. Storage of boxes, containers and material is always neat and at right angles. When items are stacked, they are never crooked or in danger of toppling over. All machines and equipment are neatly painted, there are no places in the area less than six feet high that are unpainted. Subtotal For Page 1 Score 0 to 5 with 5 being the highest.
1 2 3 4 5 6 7 8 9 10 35
5S
Tool
Item Score ( 0 ‐5 )What is the team doing to improve to the next level?
Documents Storage Documents Control Tools and Gages Arrangement Tools and Gages Convenience Shelves Arrangement Equipment Storage Equipment Maintenance Equipment Cleanliness Item # and Description
Work area and Desk Control 5S Control and Maintenance
Five S Evaluation Form
All machines and equipment are kept clean by routine daily care. Controls of machines are properly labeled and critical points for daily maintenance checks are clearly marked. Equipment check‐sheets are neatly displayed and clean. Only documents necessary to the operation are stored at the work stations and are neat and orderly. Nothing is placed on top of machines, cabinets or equipment. Nothing leans against walls or columns. All documents are labeled clearly as to content and responsibility for control and revision. Obsolete or unused documents are routinely removed. Tools, gages and fixtures are arranged so they can be easily accessed when changeovers or setups are made. Tools, gages and fixtures are arranged neatly and stored, kept clean and free of any risk of damage. Shelves are arranged, divided and clearly labeled. It is obvious where things are stored, status and condition is recorded. Work areas and desks are kept free of objects including records and documents. Equipment is clean and placed in their proper location. There is a disciplined system of control and maintained at the highest possible level. It is the responsibility of everyone to maintain this system and environment. Subtotal For Page 2 + Subtotal Page 1 20 19 18 17 16 15 14 13 12 11
• A diagram that shows the motion of the
patient / family / care‐giver throughout
the care experience
•Obtain / draw a layout of the care area •Observe first the patient as he/she goes from
one station to another and draw on the layout •Do not lift your pencil from the paper –
continuous flow •Repeat for care‐giver & family •Measure the total distance traveled and note
Guidelines for Mapping
Spaghetti
Mapping
Not to exact scale 37Spaghetti
Mapping
Shopper Shopper Non‐shopper Non‐shopper 38Takt
Time
Takt = Rate at which the Patient/Customer PULLS from you (the heartbeat of the org). Takt = Total Available Time (in seconds)
Total Patients seen in that time frame (Demand)
Ex. If there are 60 patients that come into an ED during a given shift, Takt time can be
calculated as:
60 sec. x 60 mins. x 8 hrs.
60 patients
In order to ‘keep up’ at the rate at which a patient walks into the ED, you would need to
complete a patient treatment every 480 seconds
OR
Every 480 seconds there is a patient walking into the ED, so every 480 seconds, there
should be one being discharged – or else there will be a wait
NOTE: This does not mean it only takes 480 seconds to treat a patient! It means
that the slowest step in the process should not exceed 480 seconds, and if it does,
there will be waits and bottlenecks.
= 480 Secs.
Standard
Work
• Standardizes
the
way
everyone
does
specific
tasks
• Best
process
for
quality,
safety,
compliance
and
efficiency
• Helps
maintain
control
• Makes
it
easier
to
expose
and
solve
problems
40
“Everything
should
be
made
as
simple
as
possible,
but
not
one
bit
simpler”
‐
Albert
Einstein
Standard
Work
Sequence
Standard Work Sheet
Standard Work / Combination Sheet
Standardized
Work
Job
Instructions
(SWJI)
42
easy
to
follow
displays,
placed
where
the
Level
Loading
&
Sequencing
Process Step
Ensures
that
all
steps
in
a
Value
Stream
operate
at
or
below
Takt
43
By
redistributing
some
of
the
tasks
in
Step
D
to
A,
B,
and
C
…
.
.we
can
easily
identify
our
target
for
improvement.
If
we
reduce
the
cumulative
Cycle
Times
for
all
the
steps
by
12
seconds,
we
can
potentially
reduce
from
four
steps
to
three.
Time Step Takt Time A B C D 60” (50”) (44”) (56”) (42”) Time Step Takt Time A B D 60” (60”) (60”) (60”) (12”)CLevel
Loading
&
Sequencing
44
Catches Defects too Late • How many more do you have? • Where are they in the process? • What is the root cause?
Catches Defects Immediately • You only have one • You know where it occurred • Resolve the root cause immediately
Batch
Production
Single
Piece
Flow
From: The Toyota Production System
Single
Piece
Flow
Daily
Action
Review
• Series
of
interconnected,
brief
and
structured
daily
meetings
that:
• Compare
actual
to
expected
performance
• Assign
corrective
action
and
improvement
• Follow
up
on
the
previous
day’s
action
items
46
•
Measure
of
Quality
•
Process
For
Continuous
Improvement
What
is
Six
Sigma
47
Business Strategy An overall strategy that encompasses an organization’s quality
philosophy. It sets the vision for achieving Six Sigma levels of
quality in key processes and services.
Tools and Tactics A set of statistical tools and a disciplined methodology used by
specially trained individuals to improve processes by reducing
variation and defects.
Goal
Six Sigma refers to a
process that
produces only 3.4
defects per million
opportunities 2 308,537 3 66,807 4 6,210 5 233 6 3.4 Sigma DPMO
Statistically
Most U.S. Businesses
Understanding
of
Six
Sigma
49
Reducing
variability
is
the
essence
of
six
sigma
Every
Human
Activity
Has
Variability...
Mean
1
Target
p(defect)
Upper
Customer
Specification
Lower
Customer
Specification
Measure
of
Quality
50 Mean Customer Specification3
3
BEFORE w i d e v a r i a n c e6
AFTER slim variance Mean Customer Specification6
Patients don’t feel the averages, they feel the variation
No Defects 6.6% Defects
What
is
Sigma?
Measure
of
Quality
• 68% of data falls within 1 standard deviation of the mean
• 95% of data falls within 2 standard deviations of the mean
• 99.7% of data falls within 3 standard deviations of the mean
Six
Sigma
Quality
52
Lets look at our “average” LOS for a procedure. Looking at
the last 30 patients we had an average LOS of 5 days.
What is the problem?
5 days
Is this what our patients are feeling? Is everyone getting out
in 5 days?
Six
Sigma
Quality
53
No!
Lets look at a distribution of the actual data.
5 days
It probably looks more like this with the
average being 5 days.
8 days 2 days
Frequency
Six
Sigma
Quality
We can see that there are a significant number of patients
getting out later and earlier. Either way this can be a
source of customer dissatisfaction & regulatory inquiry
5 days
Lets say that our patients & regulators are OK if they are out
between 1 day early and 1 day late. These are our spec
limits.
8 days 2 days USL is 6 days LSL is 4 days FrequencySix
Sigma
Quality
55
Where are our defects, or, where are our dissatisfied patients?
5 days 8 days 2 days
USL is 6 days LSL is 4 days
If our standard deviation was 1day, then we would have 68% of
our patients getting out between 4 and 6 days AND 32% not.
Frequency
Six
Sigma
Quality
56
If our standard deviation was reduced to .5 day, then we
would have 95% of our patients getting out between 4 and
6 days
If we can reduce variation, we can reduce dissatisfied patients &
regulators
Six
Sigma
Quality
57 5 days 8 days 2 days USL is 6 days LSL is 4 days Frequency
Starting Point AfterProject
Patient
Wait
Times
(mins)
28 18 6 23 5 8 16 19 33 11 17 29 6 10 12 4 10 13 10 20 13 13
Average
Mean
Big Change 25% improvement What We SeeWhat Patients Feel 13 17
Variability
… No Significant Change!Six
Sigma
Quality
58
Six
Sigma
provides
a
process
based
approach
to
continuous
improvement.
It
can
be
used
to
improve
any
process…
business,
transactional
or
healthcare.
Process
for
Continuous
Improvement
59
DMAIC:
To
improve
any
existing
product
or
process
Six
Sigma
Methodologies
Define
Define 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?
Process
for
Continuous
Improvement
DMAIC
Changing to a Statistical Problem
“How good do I need to be?”
Step 5 : Define Performance Objectives
Step 6 : Identify Variation Sources “What factors make a difference?” “How good am I today?”
Step 4 : Establish Process Capability DMAIC
DMAIC
DMAIC
Developing a Statistical Solution
“What’s at the Root of the Problem?” “How can I predict the Output?”
Step 7 : Screen Potential Causes Step 8 : Discover Variable Relationships
Step 9 : Establishing Operating Tolerances “How tight does the control have to be?”
DMAIC DMAIC
DMAIC
Implementing the Practical Solution
“Can I trust the in-process data?” “Have I reached my goal?”
Step 10 : Validate X Measurement Systems Step 11 : Determine Process Capability
Step 12 : Implement Process Control “How can I sustain the improvement?”
DMAIC DMAIC
Formulating the Practical Problem
DMAIC Steps A,B,C : CTQ’s, Charter, Process Map “How do my customers look at me?”
“What do I want to Improve?”
DMAIC
“What’s the best way to measure?”
DMAIC
Step 1 : Select the CTQ characteristic Step 2 : Define Performance Standards
Step 3 : Validate the Measurement System “Can I trust the output data?”
DMAIC
Process
for
Continuous
Improvement
61
Pictures
of
Before
State:
Blocked
doorways/
clutter
Equipment in
non
‐
sterile
hallway
Case
Study
– Surgical
Services
Equipment
Availability
62
Pictures
of
Before
State:
Expensive
equipment
in
vulnerable location
Egress
blocked
by
equipment
Case
Study
– Surgical
Services
Equipment
Availability
Improvements:
• Equipment moved to storage room on first floor
– Relocated 2 pharmacy employee offices
– Removed expired equipment & supplies
– Moved vendor items to one location, initiating consignment process which
vendors had been resistant to
– Added wall boards for more efficient storage
– Taped floor for access to door and where equipment goes
– Put pictures of items on wall to indicate where it goes in room; also put picture
in old location with note indicating where it is now located
• Created equipment transport process
– Tagging process so equipment is no longer just left in elevator due to not
knowing the clean or dirty status of equipment
– Now know what equipment is going up (clean) and going down (dirty)
– Included involvement of Patent & Equipment Transport Team and Central
Sterile team, in addition to Surgical Services Staff
Case
Study
– Surgical
Services
Equipment
Availability
64
Improvements:
• Renovated Darkroom located in Surgical Services
– Was rarely used, and had become unnecessary due to new technology
– Replaced water damaged wall and flooring that had created a great
environment for growth
– Fixed water drained that leaked into Unit on floor below
– Reconfigured open space with wall mount system which allowed relocation of
supplies
• Renovated and reconfigured an exiting “work” (storage) room:
– Large 248 sq foot space with a lot of extra room that was underutilized
– Dropped par levels on supplies by over $3,000
– Removed cabinets and sinks, and expanded the doorway
– New open space allowed storing $3M of equipment that was formally stored
old hallway – expensive, easily damaged equipment now in a protected area
– Able to outline floor to ensure storage locations are maintained
Case
Study
– Surgical
Services
Equipment
Availability
65
Pictures
of
After
State:
Cleared
Egress
Hallway
cleared
of
clutter
Case
Study
– Surgical
Services
Equipment
Availability
Tenants
of
Successful
Lean
Six
Sigma
Management
•
The
basis
of
management
decisions
should
be
long
‐
term
vision
and
strategy,
even
if
that
is
at
the
expense
of
short
term
gains
•
Create
a
process
to
continuously
bring
problems
to
the
surface
•
Level
out
the
work
(The
tortoise
and
the
hare)
•
Build
a
culture
of
stopping
to
fix
problems
and
getting
things
right
the
first
time
•
Standardize
processes
and
tasks
to
get
to
and
maintain
continuous
improvement
and
front
line
empowerment
•
Implement
visual
controls
so
problems
will
not
be
concealed
67
Tenants
of
Successful
Lean
Six
Sigma
Management
•
Use
technology
that
serves
your
people
and
processes
– do
not
become
subservient
to
technology
•
Develop
leaders
who
understand
the
work,
live
the
vision,
strategy
and
values
and
teach
it
to
others
•
Develop
excellence
in
your
people
an
dteams
•
Respect
your
extended
network
of
partners
and
help
them
improve
•
Go
to
the
work
(gemba)
and
understand
the
problem
•
Make
decisions
slowly,
considering
all
your
options,
but
implement
decisions
rapidly
•
Become
a
learning
organization
68
Ending
Thoughts
•
Tracking
and
trending
data
and
issues
will
highlight
issues
that
need
to
be
brought
better
into
compliance
•
Standardized
work
and
documentation
will
improve
by
involving
the
stakeholders
•
Bringing
a
cross
functional
team
together
to
resolve
issues
ensures
a
common
approach
and
culture
throughout
the
organization
Lessons
Learned
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Successes
||||
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Self
Assessment
What
is
your
experience?
Good judgment comes from experience, and a lot
of that comes from bad judgment
– Will Rogers
70
One
Thing
Learned………..
……….One
Thing
to
Apply
Application
of
Learnings
71
It’s
easier
to
behave
ourselves
into
a
new
way
of
thinking
than
to
think
ourselves
into
a
new
way
of
behaving.
Managing on the Edge, R. Pascale
Ending
Thought
73
Questions
74
Contact
Information:
John
Kalb,
JD,
CHC,
CCEP
Operational
Excellence
Executive/
Compliance
Officer
Kootenai
Health
Phone:
208
‐
659
‐
5505