DMAIC Improvement Approach

Basic Six Sigma Breakthrough

Improvement ProcessPh. Doaa Hussein MBA, CPHQ,TQMD

Basic Six Sigma Breakthrough Improvement ProcessDate TOPIC

3rd August 2016 Introduction and Six Sigma Overview

10th August 2016 Define your project

17th August 2016 Measure and Analyze

24th August 2016 Improve and Control

31th August 2016 Group presentations

Content • SIPOC• Voice of the Customer • Kano Analysis

BY Dr. Doaa Hussein Abdelghani MBA, CPHQ,DTQM,HRMD,APD,CPT 3

What is Quality Management in Healthcare?

The Institute of Medicine defines quality as: The degree to which health care services for individuals and populations increase the probability of desired health outcomes and are consistent with current professional knowledge of best practice."

What is Quality

Appropriateness

Availability/Access

Continuity

Effectiveness

Efficacy

Efficiency

Prevention/Early

Detection

Respect and Caring

Safety

Timeliness

Competency

Healthcare quality should be STEEEPInstitute of Medicine report Crossing the Quality Chasm

Safe, Timely, Effective, Efficient, Equitable Patient centered

Figure out quality dimensions to your place

BY Dr. Doaa Hussein Abdelghani MBA, CPHQ,DTQM,HRMD,APD,CPT

Measurable Quality

Three Aspects of

Quality

Appreciative Quality

Perceptive Quality

Aspects of Quality9

THREE ASPECTS OF QUALITY “MAP”

Measurable Quality

Can be defined objectively as compliance with, or adherence to standards.

Clinically, these standards may take the form of practice parameters or protocols, or they may establish acceptable expectations for patient and organizational outcomes.

Standards serve as guidelines for excellence.

Appreciative Quality

Is the comprehension and appraisal of excellence beyond minimal standards and criteria.

Requires the judgments of skilled, experienced practitioners and sensitive, caring persons.

Peer review bodies rely on the judgments of like professionals in determining the quality or non-quality of specific patient-practitioner interactions.

Perceptive Quality

Is the degree of excellence which is perceived by the recipient or the observer of care rather than by the provider of care.

Is generally based more on the degree of caring expressed by physicians, nurses, and other staff than on the physical environment and technical competence.

Quality Planning

Quality Measurement

Quality Improvement

Quality Trilogy

Juran trilogy

Performance Improvement Project Framework Effective team development

and interaction

Identify priority area

Collecting Data And measure performance

Assessing performance

Taking action for

improvementBY Dr. Doaa Hussein Abdelghani MBA,

CPHQ,DTQM,HRMD,APD,CPT 14

Use of statistical, analytical, and consensus tools at all steps

Six Sigma Six Sigma® is a business strategy,

Focusing On Continuous Improvement: Understanding Customer Needs, Analyzing Business Processes, And Utilizing Appropriate Performance Measures

And Statistical Methodology.

Six Sigma

where you are.

•Methodology to measure organization’s performance, practices and systems

where you could be

•Problem solving methodology for improving business and organizational performance.

Quality Philosophy and the way of improving performance by knowing

Six Sigma The central idea behind Six Sigma is that if you

can measure how many "defects" you have in a process.

You can systematically figure out how to eliminate them and get as close to "zero defects" as possible.

A Six Sigma organization Uses Methods And Tools To Improve Performance

Continuously lower costs Grow revenue, Increase customer satisfaction ,Improve capacity and capability, Reduce complexity lower cycle time and Minimize defects and errors

SIX SIGMA METHODOLOGY

DMAIC Six Sigma Improvement Methodology

DMADV also referred to as DFSS Creating new process which will perform at

Six Sigma

Define specific goals to achieve

outcomes, consistent with

customers demand and

business strategy

Measure reduction of

defects

Analyze problems ,ca

use and effects must

be considered

Improve process on

bases of measurements and analysis

Control process to minimize defects

WHAT IS DMAIC?

A logical and structured approach to problem solving and process improvement.

An iterative process (continuous improvement)

A quality tool which focus on change management style.

WHAT IS DMADV?

BENEFITS OF SIX SIGMA

Generates sustained successSets performance goal for everyoneEnhances value for customersAccelerates rate of improvementPromotes learning across boundariesExecutes strategic change

To achieve Six Sigma Quality, a process must produce no more than 3.4 defects per million opportunities.

SIGMA LEVEL DEFECT RATE YIELD1 691,500 dpmo 30.85%

2 308,770 dpmo 69.10000%

3 66,811 dpmo 99.33000%

4 6,210 dpmo 99.38000%

5 233 dpmo 99.97700%

6 3.44 dpmo 99.99966%

How to Calculate

Process Sigma?

How to Calculate Process Sigma?Step 1:

Identify what constitutes an "opportunity" and a "defect."

For example, in a hospital, a single administration of a medication is an "opportunity" and delivering the wrong drug or the wrong dose constitutes a "defect.“ In general, opportunities and defects should be black-or-white propositions; you either succeed or fail.

How to Calculate Process Sigma?Step 2 : Quantify opportunities and defects with precision.

How to Calculate Process Sigma?Step 3 Calculate your yield. Subtract the number of defects from the total number of opportunities, then divide by the number of opportunities and express the result as a percentage.

How to Calculate Process Sigma?Step 3 For example, if a hospital administered 145,250 correct doses last month and erred in 250 of them, then the yield is 145,500 minus 250 divided by 145,500, or 99.828 percent.

How to Calculate Process Sigma?Step 4

Compare your yield to the standard threshold for six-sigma performance. To meet six sigma levels, the yield must be greater than or equal to 99.99966 percent.

99.9997 per cent of parts close to the average value, if the average is the same as your print spec, it essentially means “zero defects”.

To achieve Six Sigma Quality, a process must produce no more than 3.4 defects per million opportunities.

SIGMA LEVEL DEFECT RATE YIELD1 691,500 dpmo 30.85%

2 308,770 dpmo 69.10000%

3 66,811 dpmo 99.33000%

4 6,210 dpmo 99.38000%

5 233 dpmo 99.97700%

6 3.44 dpmo 99.99966%

How to Calculate Process Sigma?Step 5 Find : Process sigma , Substitute the given values in the formula, DPMO = (Total defect / Total Opportunities) x 1000000

How to Calculate Process Sigma?

Process sigma = 0.8406 + √(29.37)-2.221*(log(DPMO))

Example

Find 60 errors for 6 critical characteristics on 20 orders in a random sample of 400 orders . Assuming there are 6 Opportunities per order (six critical characteristics).

Example

The Defects per Opportunity (DPO) is calculated as:

Opportunities = (400 Orders * 6 Opportunities / Order) = 2400 Opportunities

Defects per Opportunity (DPO) = 60 Defects / 2400 Opportunities = 0.025 Defects per Opportunity

ExampleDPMO = (0.025 Defects / Opportunity) *106 Opportunities / Million Opportunities = 25,000 DPMO

This corresponds to a Sigma Level of approximately 3.45, based on Six Sigma

Define Your Project

Identify

Establish

Define

Your Project

problem statement

Form a Team

Verify the mission

Nominate Projects

Evaluate Projects

Select a Project

WHO Can Nominate A Project ?EMPLOYEES

Process Owners knows every detail and they front line who face the customer/client/ patient

Department Head

Impact on the department ability to meet organizational goal and objectives

Senior Management

Impact on quality throughout the entire organization 40

Source Of Information to Nominate Projects

Customer/Client/Patient(E/I) ComplaintsSuggestions

QuestionnairesFocus groups

Tip: Give Feedback

Source Of Information to Nominate Projects

Monitoring Reports (KPIs)

OVRs & Errors Reports

Ongoing quality control/measuremen

t summaries

Strategic and Business Plan of the

organization Goal

External Data Source

--Benchmarks--Reference

databases/performance measure systems/

compilations

Projects of significance may require participation of several

departments= Interdisciplinary Project

Evaluate Project

Evaluate the nominated projects against preset criteria : Retaining customer Attracting new customers Reducing the cost of poor quality Enhancing employee satisfaction.

Criteria For Selecting a Project

How chronic is the problem?The project should correct a continuing problem not a recent specific episode.

How significant the results will be ?When project is completed the results should be

significant and evident and worth the effort .

Measure of potential Impact?Retain customer . Reduce cost of poor quality, ROI, enhance customer satisfaction , enhance employee

satisfaction .

Urgency of the problems:-Problems make the organization highly vulnerable to

the competition-Issues crucial to key customers

All Quality Improvement Projects should be measurable.

Size :project should be of manageable size Project time should be to long (shouldn’t

take more than 12 months)

What Kinds of resistance might the project create ?Change normally is face by resistance .

What is the source of resistance and how to face it ?

What are the project suspected risks ?How uncertain is the outcome?

What is your risk management plan?

Choose A project that will be a winner specially if you are at the beginning ?

Identify

Establish

Define

Your Project

problem statement Form a Team Verify the

mission

problem statement Form a Team Verify the

mission

Prepare a Problem Statement

ManagementSeniors.

Written instruction to the team selected .

What ?

The problems to be solved The Goal of the project.

Problem Statement:Problem statement should quantitatively describe the

pain in the current process What is the pain ? Where is it hurting? When – is it current? How long it has been? What is the extent of the pain?

What a Problem Statement should not do is Assign a Cause or Blame and Include a Solution.

Example “In the last 3 months (when), 12% of our customers are late,

by over 45 days in paying their bills (what) . This represents 20% (magnitude) of our outstanding receivables & negatively affects our operating cash flow (consequence) .”

(when), Our ALOS (what) for total hip replacement surgery is 7 days which is 2 days longer (magnitude) than average in the area which affects our reimbursements' (consequence) .

Goal Statement Defines the improvement the team is seeking to

accomplish. It starts with a verb.

It Should not presume a cause or include a solution. It has a deadline.

It is actionable and sets the focus. It should be SMART (Specific, Measurable, Attainable, Relevant and Time Bound).

Goal Statement Example: To reduce the percentage of late payments to 15% in next 3

months, and give tangible savings of 500KUSD/ year.

To reduce the ALOS to 6 days in next 3 months, and increase hospital profit by 2%.

Project Scope: Project Scope helps us to understand the start and

end point for the process .

Gives an insight on project constraints and dimensions.

It’s an attempt to define what will be covered in the project deliverables. Scoping sharpens the focus of the project team & sets the expectations right.

Selecting Project Team Cross Functional team .A cross-functional team is simply

a team made up of individuals from different functions or departments within an organization.

Teams like this are useful when you need to bring people with different expertise together to solve a problem, or when you want to explore a potential solution.

Selecting Project Team For example, you might put together a team made up of

people from pharmacists ,finance, engineering , and procurement to come up with a solution to reduce the lead-time of admixture medications .

Representation from various departments brings a broad working knowledge of the process to be improved , promotes acceptance and implementation of the remedy

To select a Cross Functional team Scope of the problem :where is the problem is observed or

experienced?

Who has special knowledge, information, or skills in

uncovering the root cause of the problem ?

Who might be helpful when developing a remedy ?

To build a Cross Functional team

Set Objectives

Define Roles and Select the Right Team Members

Consider Resources

and Logistics

Establish Ways of Working

Adopt the Right Leadership

StyleBY Dr. Doaa Hussein Abdelghani MBA, CPHQ,DTQM,HRMD,APD,CPT

Participatory leadership style The TQM Leadership/Management Style.

The leader/manager presents a tentative decision, "draft" of an idea, or a problem to staff/team, receives suggestions, and then makes the decision, based on what is deemed best for the organization.

Stages of Team Growth

Forming Storming Norming Performing

Team Responsibility

Accept or identify improvement projects Investigate the cost of poor quality Describe the specific problems/opportunities Gather and analyze data Identify root causes Develop alternative processes Apply alternative processes and track results Recommend replication Feedback helpful experiences (lessons

learned)

Project Charter

Problem statement

Business case

Goal Statement

Project Scope

Team Members BY Dr. Doaa Hussein Abdelghani MBA,

CPHQ,DTQM,HRMD,APD,CPT 62

Project Charter Guidance The listed questions are for guidance and direction purposes

(although they can be answered directly)

The listed statements/descriptions are to be completed in full

Keep to one page to be concise & clear and to ensure focus on the key elements

Project Charter Guidance Expect to create numerous iterations before the final version is

approved

Do not proceed until all key stakeholders are in agreement with the document

Use as a high-level communication tool

Retain during the project life-cycle and refer often to ensure the original purpose and direction are being maintained

Project Charter TemplateBusiness Case Problem StatementWho is the Client (internal and/or external)?What is the current situation?What is the business climate and/or environment?What is the trend?What are the business gaps?What are the drivers for change?What are the Client/Market/Regulatory requirements?What is the level of importance and/or urgency?How does the project connect with the overall business strategy/goals?What are the projected benefits from the change?

What is the problem?How do you know it is a problem?When did the problem first occur?Where is it occurring?What is the frequency?What are the defects and/or areas of waste?What are the variations?What is the level of complexity?What are the impacts?What is the cost of poor quality (soft and hard)?

Goal Statement Project ScopeWho will benefit?What is to be achieved?How will success be measured?Why is it important?When are improvements required by?

In scope activities:Out of scope activities:Process start point:Process end point:Critical to quality:Primary metric:Consequential metric:

High-Level Timeline Stakeholders & Key Project MembersDefine – Dates from/to:Measure – Dates from/to:Analyse – Dates from/to:Improve – Dates from/to:Control – Dates from/to:

Executive sponsor:Activity/Business Line/Product sponsor/champion:Client/Business Partner champion(s):Project manager:Key project team members:

VISION OF SUCCESS

PROJECT MILESTONES & SCHEDULE

RESOURCES• Time commitment for a 4 day Kaizen, excluding time to implement changes: Sponsor (6-10 hrs.);

Team Leader (40 hrs.); Team Members (32 hrs.); Facilitator (40-50 hrs.)• External Resources: • Equipment:• Materials:

< TITLE> <date><sponsor>

CONTEXT / ISSUES

SCOPE (IN BOUNDS) SCOPE (OUT OF BOUNDS)

CUSTOMERS/STAKEHOLDERS

TEAM MEMBERS• Team Leader: • Team Members:

CUSTOMER REQUIREMENTS (CTQ)

Project Milestones Owner Proposed Date

Actual Date

1. Set project scope and goals (prepare Project Charter, engage team, collect data)

Sponsor/Team Leader, Facilitator

2. Understand the current situation Facilitator/ Team

3. Analyze the current situation (root causes)

Facilitator/ Team

4. Define a vision of success Facilitator/ Team

5. Generate, evaluate and select improvements

Team/ Sponsor

6. Implement changes and make adjustments

Team Leader/ Staff

7. Measure performance Sponsor/Team Leader

8. Document standard work and lessons learned

9. Sustain improvement Team Leader/Process Owner

VISION OF SUCCESS • What outcomes or results do you want to see?• What does success look like for our customer? • What does success look like for other stakeholders (staff, partners)?

PROJECT MILESTONES & SCHEDULE

RESOURCES• Time commitment for a 4 day Kaizen, excluding time to implement

changes: Sponsor (6-10 hrs.); Team Leader (40 hrs.); Team Members (32 hrs.); Facilitator (40-50 hrs.)

• External Resources: • Equipment:• Materials:

< TITLE> <date><sponsor>

CONTEXT / ISSUES• What is the issue and why is it important to tackle now? • What is the purpose, the business reason for choosing this project? • What are the anticipated benefits to customers and staff from the

project?• What performance measure needs to improve? • Have you been to the Gemba?• What process/program/customer data do you have regarding the

problem (time, cost, quality )? Show facts and processes visually using charts, graphs, maps, etc.

• When did the problem start?• Where is the problem occurring?• What is the extent or magnitude of the problem?

GOALS • What specific, measurable , attainable, relevant, time-bound results do

you want or need to accomplish?• Show visually how much, by when, and with what impact.• NOTE: Be careful not to state a solution as a goal!

SCOPE (IN BOUNDS)• What is the first step and last step

in the process?• What is the program and

geographic area?• NOTE: Be mindful of what you

can realistically accomplish with available resources and time.

SCOPE (OUT OF BOUNDS)• What is off the table due to

resources? • What are the givens or

assumptions for the project?• Record out of scope issues in a

“Parking Lot”

CUSTOMERS/STAKEHOLDERS• Who is the end-user customer?• Who are other stakeholders who

have a role or interest in the success of the process?

TEAM MEMBERS• Team Leader: • Team Members:

CUSTOMER REQUIREMENTS (CTQ) • What do customers/stakeholders expect and require from the process?

What are their critical to quality (CTQ) requirements?• What legal requirements (laws, rules) govern the process?

Project Milestones Owner Proposed Date

Actual Date

1. Set project scope and goals (prepare Project Charter, engage team, collect data)

Sponsor/Team Leader, Facilitator

2. Understand the current situation Facilitator/ Team

3. Analyze the current situation (root causes)

Facilitator/ Team

4. Define a vision of success Facilitator/ Team

5. Generate, evaluate and select improvements

Team/ Sponsor

6. Implement changes and make adjustments

Team Leader/ Staff

7. Measure performance Sponsor/Team Leader

8. Document standard work and lessons learned

9. Sustain improvement Team Leader/Process Owner

VerifyMost Significant problem. Mission statement (problem , goals statement).Any aspects of the problem need clarification.Team members are correctly selected.Team members understand the mission statement and known

their roles .

SIPOC DefinedSIPOC is an acronym standing for

1. S =Supplier(s)2. I =Input(s) & key requirements3. P =Process4. O =Output(s) & key requirements5. C =Customer(s)

SIPOC Diagram Defined• A SIPOC Diagram is a visual representation of a high-level process map;

including suppliers & inputs into the process and outputs & customers of the process

• Visually communicates the scope of a project

How can SIPOC be used?• SIPOC Diagrams help a team and its sponsor(s) agree on project boundaries

and scope• A SIPOC helps teams verify that

• inputs match outputs of upstream processes• outputs match inputs of downstream processes

Suppliers Inputs Process Outputs Customers

How a SIPOC works

Step 1: Begin with the high-level process map

Step 1

Step 2

Step 3

Step 4

Step 2: List all of the outputs from the process

Step 1

Step 2

Step 3

Step 4

Examples

Services

Products

Reports

Metrics

Raw data

Step 3: Identify the customers receiving the outputs

Step 1

Step 2

Step 3

Step 4

Examples

Services

Products

Reports

Metrics

Raw data

Examples

Internal

External

Vendors

End users

Management

Downstream Process

Step 4: List all of the inputs into the process

Examples

Internal

External

Vendors

End users

Management

Downstream Process

Step 1

Step 2

Step 3

Step 4

Examples

Services

Products

Reports

Metrics

Raw data

Examples

Application

Raw materials

Step 5: Identify the suppliers of the process inputs

Examples

Internal

External

Vendors

End users

Management

Downstream Process

Step 1

Step 2

Step 3

Step 4

Examples

Services

Products

Reports

Metrics

Raw data

Examples

Application

Raw materials

Examples

Internal

External

Vendors

Producers

Management

Upstream Process

Voice Of Customer

Voice of the Customer (VOC) is the name used to describe a process of communication where there is give and take to ensure that requirements and expectations are clearly defined, documented, and understood by all parties involved.

Voice of the Customer (VOC)

VOC is often full of emotions. We need to restate customer statements into fact based, performance requirements that we need to focus on

Of course… Customers expect perfection

• Why don’t you guys learn how to meet a schedule?

• Your service quality to poor• When will you learn how to provide

service and a Customer first attitude?• Why don’t you tell us when there is a

problem?• I sent out e-mail after e-mail with no

response!• Why do you try and make your

customers responsible for your quality problems?

• Your RMA frequency is unacceptable

Listen to the voice of the customer

Source of information

Complaints

Customer Representative

Sales Representative

Billing

Target CTQsCCR’sVOC

Critical Customer Requirement

Critical To Quality

Example

• Late FilmVOC • Time CCR• Right

TimeCTQs• According

to standards

Target

Dissatisfied Feeling

Satisfied Feeling

Physically Fulfilled Condition

(Need is met)(Need is not met)

Unstated, Expected

Quality“Taken

for granted”

Kano's "3 Arrow Diagram"

Must-be Quality These attributes are taken for granted when fulfilled but result in dissatisfaction when not fulfilled

Winter 2016ECEn 490Lecture #4 85

Satisfied Feeling

"One-Dimensional" Q

uality

Unstated, Expected

Quality

“Competitive”the more the better

“Taken for

granted”

One-dimensional Quality These attributes result in satisfaction when fulfilled and dissatisfaction when not fulfilled.

Satisfied Feeling

"One-Dimensional" Q

uality

Unstated, Expected

Quality

Exciting Quality

“Surprise & Delighters”

“Competitive”the more the better

“Taken for

granted”

Attractive Quality These attributes provide satisfaction when achieved fully, but do not cause dissatisfaction when not fulfilled.

DissatisfiedFeeling

SatisfiedFeeling

PhysicallyFulfilled Condition

Unstated, Expected

Quality

What was exciting yesterday becomes expected tomorrow

Kano Customer Need Model

Dis-satisfiers Those needs that are EXPECTED in a product or service. These are generally not stated by customers but are assumed as given. If they are not present, the customer is dissatisfied.

Satisfiers Needs that customers SAY THEY WANT. Fulfilling these needs creates satisfaction.

Exciters /Delighters

New or Innovative features that customers do not expect. The presence of such unexpected features leads to high perceptions of quality.

Summary of define phase

Measure The Problem

MeasureMeasurement is critical.

Determine how the process currently performs:Value Stream Mapping/Process Mapping

Create a plan to collect the data:Data Collection Plan

Process Mapping SymbolsSymbol Name Brief Definition

Operation orprocess step

Decision Point

DocumentGenerated

ContinuationPoint

Input/OutputBlockFlow lines

Depending on the level of detail being developed, can be used to denote anything from a simple task, major activity or a whole sub-processes.

Used to indicate the process is continued elsewhere on the flow diagram or on another sheet.

Point at which a form or report is generated by the process.

Point where a decision must be made before any further action can be taken.

Optionally used to describe an input or output from a processing block.Use to connect all blocks to display the sequence in which operations are performed.

Termination point

Used to indicate the start and end of a process.

Flowchart

Use when: Identifying and describing a current process Questioning whether there is a process Questioning whether actual process meets current policy/procedure Analyzing problems to determine causes Redesigning the process as part of the action Designing a new process

Linear Flowchart Example

Collectinputs

Draft POD

Type rough

Submit to XO

Retype POD

Typesmooth

Sign POD

Make copies

Distribute

AProducingthe “Plan of the Day”

Levels of Flowcharts

DraftPOD

TypePOD

DistributePOD

Get roughdraft of POD

Is itapproved

Typesmooth

Getapproval

Turn oncomputer

Start word proc. apply.

Isrough in

word proc.apply.

Typerough POD

Edit POD

Arethere any

corrections?

Makecorrections

Print POD

MACRO MINI MICRO

Flowchart Steps:

Determine the boundaries (the start and stop points) of the process under review.

Brainstorm to identify all activities and decision points in the process;

Place all activities and decision points in sequence, paying attention to seeming repetitions, disconnection's, etc.;

Cont..

Flowchart Design the flowchart, placing:

each activity in a box (square or rectangle) each decision in a diamond, ovals or circles for the start and stop points, connecting arrows indicating the flow. If there is more than one "output" arrow from an activity box, it

probably requires a decision diamond; Cont...

Flowchart Analyze the flowchart, looking for process "glitches":

inefficiencies, omissions/gaps, redundancies, barriers, etc.

Also look for the smooth parts of the process to use as models or "best practices" for improvement;

Decide whether to correct steps within the current process, design a new process, or do corrections first, then redesign in the future.

Interpreting a Flowchart

Step 1 - Examine each process stepBottlenecks? Poorly defined steps? Ineffective sequence? Delays? Weak links?

Step 2 - Examine each decision symbolCan this step be eliminated?

Step 3 - Examine each rework loopCan it be shortened or eliminated?

Step 4 - Examine each activity symbolDoes the step add value for the end-user?

Yes No

NoYesYes

NoFirst drillin set?

Inform the drillleader and improvise

Props?Search

Torpedo Room

Radiosstill not

available?

Borrow fromQuartermasters

Check withRadiomen

Radiosavailable?

Propsavailable?

Enoughred hats?

Drill monitorstest the radios

Monitors go to Logroom to get redhats, radios, and drill props

Complete theDrill Brief

Drill monitorstake station

Search theboat forred hats

YesDiscrepancy?

Allpersonnelon station

Correct it

Put simulation on the

appropriate gages

Drill leaders walk around to ensure all monitors are

on station

Spot check safetyintervention points

Order initialconditions set

Find themand put them

on station

Fire Drill Preparation Flowchart

Data Collection Process

Dr.Doaa Hussein MBA,CPHQ,DTQM,HRM,CPT,APD

• Define data elements;

• Determine data collection plan;

Sampling

Purposes: To measure only a portion of a total group

or population, such as for high volume aspects of care and service;

To achieve accurate representation of the entire target population, such as all ambulatory patients; a specific procedure, diagnosis, or DRG; or all cardiologists;

To generalize the results to the larger population based on sample findings.

Non-probability Sampling

An intentionally-biased way to sample, involving qualitative judgment about an issue that is suspected to be common or widespread.

Examination of relatively few cases is assumed to be enough to reveal the nature of any problem and its probable causes.

This methodology does not include techniques to estimate the probability that each case will be included,

The results cannot be generalized to the entire population without further study.

Types of non-probability sampling Convenience:

Using data most readily available, e.g., all patients seen in the ED in a given week.

Quota: Portions or percentages of persons/cases in a

stratified population (subset), e.g., 10% of male patients with diabetes and heart disease over age 55.

Purposive: Persons/cases/issues selected because they

demonstrate a desired characteristic and can be measured against specific, predetermined criteria, e.g., all patients over age 60 with total hip replacements

Dr.Doaa Hussein MBA,CPHQ,DTQM,HRM,CPT,A

Probability sampling:

Introducing statistical techniques into the selection process, thus permitting the reviewer to draw inferences about a population. It assures that each case in the population has an equal and independent (random) chance of being selected and is, therefore, truly "representative" of the entire population being sampled.

Types of Probability Sampling Simple random:

Using a Table of Random Digits (available in all statistical software) to select the persons/cases from a list of every case in the defined population.

Stratified random: Creating 2 or more homogeneous categories or

dimensions of a population and selecting an appropriate number of persons/cases that are representative of the whole. Patients with IVs in home care might be sampled by diagnosis,type of solution, or with and without complications.

Types of Probability Sampling Systematic random:

Randomly selecting the first case and then selecting every nth case thereafter based on standard/fixed intervals, e.g., every 5th referral to a specialist by a primary care physician in an HMO after random selection of the first case.

Multistage random In large studies, sampling could be done in

stages, a sample is drawn from each stage randomly.

Sampling

Sample Size & Effect Size Sampling error Consequences

Joint Commission general guidelines for sampling:

These sample sizes for these populations (total cases meeting criteria) are considered statistically significant and can be applied to measurement activities for the specified time period, e.g., monthly, quarterly:

Population Size Sample Size

Sampling strategy

The characteristics of the population that the sample must represent;

The location and time period from which the sample must be drawn;

The type of sampling technique that will assure that the sample accurately represents the population;

The selection of a sample that will not introduce a bias

DATA COLLECTION TOOLS

Keep the tool as short and simple as possible; Include all data elements necessary to monitor

the specified issue/indicator; Consider computerizing whenever feasible; Provide appropriate definition of terms key for using the tool.

Types of Data Collection Tools Data Sheet or Work Sheet: Form for recording data; requires

subsequent processing for analysis and interpretation;

Types of Data Collection Tools Check sheet: Form for recording data; designed to facilitate interpretation directly from form;

Types of Data Collection Tools Interview or Focus Group: Questionnaire

format; can be open-ended discussion to obtain input from people;

Types of Data Collection Tools Download: Automated retrieval from a computerized data

source.

Surveys

Surveys are methods by which we can measure customer satisfaction, get feedback on written materials and oral presentations.

How to Develop a Survey

Know your audience Remember who will be answering your survey and

imagine how they might interpret the questions you are asking.

KISS (Keep It Short and Simple), People tend not to answer lengthy surveys.

Be direct. Ask exactly what you want to know. Make your statements or questions neutral. If you state

your question in a negative manner, you may be swaying the respondent.

Measuring Effectiveness Of The Tool

Checklist for adequacy of the tool: Does the tool really measure the process or

aspect of care and its indicator? Will you get the information you really need? Will you get more than you need? Will the data you get be interpretable? Will it

help to gather other data to facilitate interpretation, e.g., age, weight, secondary diagnosis, etc.?

Too much time? Can it be cut down?

Analyze Phase

Analyze phase Having completed the Measure phase, the project team

should have already established a clear problem statement which specifies what the problem is and under what circumstances it occurs.

They should have already gathered and analyzed data to establish the baseline performance of the process, relative to the Critical To Quality measures (CTQs) established based on customer input.

Analyze phase seeks The question that the Analyze phase seeks to answer is

“Why is this problem occurring?“Another way to ask it is,

“What is the cause of the problem?“

It is not possible to make improvements to the process until the causal factors are identified.

ANALZE PHASE 1- Data Analysis : Analyzing data relative to a particular

project.

2-Root Cause Analysis: The other is that the goal of Analyze is to determine root causes, which requires digging deeper than what is apparent on the surface.

Steps in DATA Analyze

1. Define your performance objectives.

2. Identify independent variables (X’s).3. Analyzing Sources of Variation : The goal of this

step is to use visual and statistical tools to better understand the relationships between dependent and independent variables (X’s and Y’s).

Process variation Process variation can be classified as Variation for a period of

Time and Variation Over Time.

Variation for a period of time can be defined for discrete and continuous data types as below :

Discrete Data: Bar Diagram, Pie Chart, Pareto ChartContinuous Data: Histogram, Box Plot, Run Chart,

Control Chart.

Tools for Analyzing Sources of VariationScatter Diagram• To correlate variables

A bar diagram is a graphical representation of attribute data. It is constructed by placing the attribute values on the horizontal axis of a graph and the counts on the vertical axis.

Pie Chart• Illustrate numerical proportion

Tools for Analyzing Sources of Variation: HistogramA histogram is a graphical representation of numerical data. It is constructed by placing the class intervals on the horizontal axis of a graph and the frequencies on the vertical axis.

Cause and Effect Diagram / Fish Bone Diagram / Ishikawa Diagram: This is a visual tool used to brainstorm the probable causes

for a particular effect to occur. Effect or the problem is analogously captured as the head of the fish and thus the name. The causes for this effect or problem is generated through team brainstorming and are captured along the bones of the fish. The causes generated in the brainstorming exercises by the team will depend on how closely the team is related to the problem.

Potential Root Causes 1-Cause and Effect Diagram / Fish Bone Diagram / Ishikawa Diagram.

2- Pareto Charts

Cause and Effect Diagram / Fish Bone Diagram / Ishikawa Diagram:

The potential causes could be due to any of the 6(M's) , 8 (P's), & 4 (S's) 6M's - Machines, method, material, maintenance, man &

mother nature 8P's - Price, promotion, people, process, place, policy,

procedure, product 4S's -Surrounding, suppliers, systems, skills

HIGH TAT

Pareto Chart:A data display tool for numerical data that breaks down discrete observations into separate categories for the purpose of identifying the "vital few".

Wrapping Up the Analyze Phase

At the end of the Analyze phase, the project team should

have at least one confirmed hypothesis regarding the root

causes of the problem the project aims to resolve. Once

the root cause is known, action can be taken in the

Improve phase to counter it.

IMPROVE

Objectives of Improve Phase

The goal of the DMAIC Improve phase is to identify a solution

to the problem that the project aims to address. This involves

brainstorming potential solutions, selection solutions to test

and evaluating the results of the implemented solutions. Often

a pilot implementation is conducted prior to a full-scale rollout

of improvements.

Identifying Potential Solutions In the first stage of Improve it is important to include

the people who are involved in performing the process. Their input regarding potential improvements is critical, and this step should not be completed by the project team alone.

A variety of techniques are used to brainstorm potential solutions to counter the root cause(s) identified in Analyze.

Identifying Potential Solutions

Brainstorming

• Create as many ideas as possible in as short a time as possible

Lotus Diagrams

• A tool to expand thinking around a single topic

Affinity Diagram

• organize large volumes of ideas or issues into major categories.

Organizing Ideas

Lotus Diagram Affinity Diagram

Selection between alternatives

The goal of this step is to determine the appropriate solutions to implement using objective means, rather than making a decision based on assumptions or preferences.

This is a common theme throughout the Six Sigma methodology. Prioritization Matrix Selection Grids can be used to help in decision making.

Selection between alternativesPrioritization Matrix Selection Grids

A Prioritization matrix is a tool used to select one option from a group of alternatives, be they problems or solutions.

It promotes objective decision making.

Prioritization Matrix Steps:

Limit the list of options (of problems or solutions) to no more than eight (8);

Select the criteria against which each option will be rated, stated in either positive or negative terms, but not both;

Determine the weight (relative value) of each criterion; perhaps some are more important to meet than others;

Determine the desired score, what number of criteria must be met, etc. for the option to remain under consideration;

the matrix with options down the left side and criteria/total score column across the top.

Implementing Improvements Planning the implementation is largely a matter of basic

project management. The team needs to plan the budget and time line of the implementation, determine roles and responsibilities, and assign and track tasks.

Tools for planning include gantt charts, action plans and flowcharts. A deployment flowchart can be created for the implementation process itself, as well as for the new process that will be followed as a result of the improvements being implemented.

Action Planning Once the team selects a solution, an action plan need to

be developed.

Action plans at a minimum identifies: what to be done? (deliverables) How a certain task will be done?(Implementation Strategies) who will do it?( Responsible person) Time Frame (due date) A mean of verification that a certain task has been done (target ,

KPI).what to be done? (deliverables)

Implementation Strategies

Responsible person

Due Date Evaluation

GANTT CHART Definition: A Gantt chart is a project-planning tool for

developing schedules; a graphic display—a type of bar chart—of the individual parts of a quality improvement process as bars on a horizontal time scale.

The Gantt chart includes a list of tasks (process steps) and estimates of time and people resources required to complete the quality improvement effort.

Most project-planning software includes Gantt charts.

Gantt Chart

1 2 3 4 5 6 7 8 9 10

Responsibility ResourcesMonth or

WeeksList of Tasks

Goal:………………………………….

Pilot The selected solution

The most common piloting options include either making changes only in one group or department or making changes for a limited time period. The benefit of a pilot test is that the project team can ensure the changes result in the desired improvements before a full roll out. In addition, the team can gain insights to allow a more effective implementation during the full roll out.

Improve: Implement and Check Verify effectiveness by checking current performance against

original baselines; Apply statistical comparative methods if necessary.

Before Pareto Chart After Pareto Chart

Wrapping Up the Improve Phase By the end of the Improve phase, the project team has

demonstrated that the solutions implemented do in fact counter the identified root causes and thus result in substantial improvement in the CTQ metrics.

The new process is in place and the team is ready to create a plan to maintain the gains and close out the project.

Control Achieved Improvement

Control Standardise the solution by making it part of the standard

procedure for the process; Update the performance measurement scorecard for the

process; Implement control charts; Document the project. Share and celebrate your success. Ensure the process is being managed and monitored properly. Continuously improve the process. Apply new knowledge to other processes in your organization.

Wrapping Up the Control Phase By the end of the Control phase, the project team

has successfully Standardized and documented the new process, Created training and reference materials and

established a plan for ongoing process monitoring. The improvements are fully established and a plan

exists for updating the process in response to changes in the environment.

The team is now ready to close out their six sigma dmaic project and hand the process off to the process owner.

Closing Out the Project The five phases of DMAIC have been completed. The

Six Sigma project team has: Established the customer requirement (CTQ) Measured the process against that requirement Clarified the problem that had to be addressed Confirmed one or more root causes of that problem Identified one or more solutions to counter the root causes Demonstrated that the solutions implemented result in

substantial improvement in the CTQ metrics Rolled out the new process

Future Plans Review the previous non-pareto causes to see which ones

have upgraded themselves and assess whether these are worth going after;

Review any obvious opportunities to apply the solution in other areas;

Communicate the solution to other parts of the organisation where it may also apply;

Review and document lessons learnt and institutionalise the learning.

DMAIC Improvement Approach

Healthcare

Transcript of DMAIC Improvement Approach

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