Post on 16-Jul-2015
The shortest distance between You and Improved
Lean, Six Sigma & Emotional Intelligence
Medical Staff Presentation
April 15, 2015
The shortest distance between You and Improved
Program Overview
• Introduction to Lean & Six Sigma
• Case Study
• What we’ve learned from 16 years in supporting health systems
The shortest distance between You and Improved
We believe that healthcare leaders should have all the tools they need to excel in their mission.
Segment Leadership:• Founded 1998• ACHE, ASQ, & UM solutions• Prolific publishing activity• Average tenure per staff > 12 years• Full suite of PI technologies• Pure production in healthcare space• 3 Baldrige Award winning clients
The shortest distance between You and Improved
Insert your own horror story here
The time I was abandoned by Air China in BeijingThe time(s) Delta lost my luggage in ItalyThe time United changed my flight without telling meThe time I was stuck on the tarmac in Denver for hours…The time I was stuck on the tarmac in Phoenix for hours..The time I was stuck on the tarmac in Boston for hours….The time I was…….
The shortest distance between You and Improved
Why improve processes
when you can simply apologize nonstop?
The shortest distance between You and Improved
Why improve processes
when you can simply apologize nonstop?
Is this an option for
your Organization
?
The shortest distance between You and Improved
Better idea: “Learn to Lean”
Accelerate the speed and reduce the cost of any process by removing non-value-added activities
“Re-examine the way you think about waste, as it is often difficult to recognize.
Start by making waste obvious to everyone.”Taiichi Ohno, Founder
Toyota Production System
The shortest distance between You and Improved
Cost of Quality
© All Rights Reserved.
Up to 40%Productive
Quality
Adding
Features
• Preventing
problems
• Detecting and
correcting
problems before
the customer
sees them
• Dealing with
problems after
they occur
The shortest distance between You and Improved9
Cost of Poor Quality
• 20% to 50% = not always valued by the customer
• Up to 40% of the expense budgets in an organization are associated with COPQ (it may be even higher in health care)
• Every 4% reduction in waste increases operating margin by 1%
• - Murphy Leadership Institute
The shortest distance between You and Improved
Why is it difficult to eradicate waste?
Patient
Asks for
Information
Patient
Gets
Answer
PERCEIVED WAIT TIMEPatients over estimate their wait
time by 50% or more;
PERCEPTION IS REALITY
A B C D
ACTUAL WAIT TIMEDetermined by the process to
retrieve information
The shortest distance between You and Improved
Bottlenecks
Flow of work = process time + delay time = cycle time!
The shortest distance between You and Improved
Hand-offs
“Lessons from DMV”
The shortest distance between You and Improved
PULL
PERFECTION
Principles of Lean Thinking
© All Rights Reserved.
VALUE1.
VALUE STREAM2.
FLOW3.
4.
5.
The shortest distance between You and Improved
“The Hidden Hospital”
Rework
Hidden Hospital
NOT OK
OperationInputs First Time Yield
OK
98% Customer
Quality
Described below is any process that meets a customer need
98% Yield After Inspection or Test
65%
35%
Inspect
Exposing waste made more difficult by the way we map, and the way we measure
This classic approach
does not account for the
“Hidden Hospital”
Rework:
20-30%
The shortest distance between You and Improved
VALUE-ADDED
• Alters the work
• Meets customer
wants or needs
• Is done right the first
time
NON-VALUE ADDED
• Eliminate it
• Consolidate it
• Automate it
Protocol to Eradicate Waste
The shortest distance between You and Improved
Mastectomy Mistake: 'You Don't Have Cancer‘ Woman Told She Has Breast Cancer, but Learns After Operation Her Biopsy Slide Was Mixed Up
Darrie Eason talked to "Good Morning America" about undergoing a double mastectomy after a lab mix-up. (ABC News) Oct. 4, 2007
A state report blames Eason's mix-up on a former technician at CBLPath lab who mislabeled her biopsy results. The report said the technician "cut corners."
“The technician was batching the specimens”
They could not confirm that the other person, who did have breast cancer was ever notified.
Stakes are High in Healthcare
The shortest distance between You and Improved
Two Six Sigma “blackbelts” sitting at a bar...
The shortest distance between You and Improved
Six Sigma is Process Improvement
Process
X1
X2Y
X3
Process InputVariables
Process OutputVariable
CustomerRequirements
In-ProcessVariables
X1 X2 X3
X…n
Six Sigma focuses on the “critical X” that drives process performance more than any other variable.
The aim of Six Sigma is to fix the problem “for the last time”
The shortest distance between You and Improved
Six Sigma is Project Management
Who is the customer?What do they want? Is the data clean or dirty?
What is the baseline performance?What is the project objective?What are the various x’s?
What are the critical x’s?What solutions will control the x’s?What are the specs for the x’s?
What is the data integrity of x’s?What is the capability of the x’s?Can the improvement stand the test of time?
Y
x
Define
Measure
Analyze
Improve
Control
Describe
The customer
experience
Optimize
The customer
experience
The shortest distance between You and Improved
Six Sigma is a Metric
s s s s s s
LSL m
A six-sigma (6s) process
The distance between the mean (m) and the inflection
point is the standard deviation (s).
The shortest distance between You and Improved
A Six Sigma Project
“Home Run”
Identify and eliminate NVA activity
Identify and reduce variation
The shortest distance between You and Improved
System Performance
0
100
200
300
400
500
600
700
800
900
50.00% 60.00% 70.00% 80.00% 90.00%
(Utilization (Throughput / Max. Theoretical Throughput)
Cy
cle
Tim
e O
R W
ork
in
Pro
ce
ss
What’s Going On Here? Understanding The Role Of Variation In Process Performance
The shortest distance between You and Improved
System Performance
0
100
200
300
400
500
600
700
800
900
50.00% 60.00% 70.00% 80.00% 90.00%
(Utilization (Throughput / Max. Theoretical Throughput)
Cy
cle
Tim
e O
R W
ork
in
Pro
ce
ss
Impact
of variation
What’s Going On Here? Understanding The Role Of Variation In Process Performance
The shortest distance between You and Improved
Linking Lean and Six Sigma
• While Six Sigma will focus on the “critical few,” Lean focuses on the “trivial many”
• Lean focuses on speed, efficiency, and waste
• Six Sigma focuses, defects, variation and quality of products and processes
LEAN Six Sigma
Six SigmaLEAN
Either method provides a prescriptive approachto performance improvement
24
The shortest distance between You and Improved
USLLSL
CenterProcess
Reduce spread
USLLSL
Off-Center
USLLSL
Unpredictable
Centered
A BTarget
Remember... customers experience our variation,
not our averages
Lean/Six Sigma Improvement Strategy
The shortest distance between You and Improved
Case Study:
Lean Project in Hospital Lab
The shortest distance between You and Improved
Problem Statement: Survey data from the American College of Pathologists shows that
physicians think troponin TAT should be 45 mins or less, while laboratories strive for 60 mins or less.
Currently, the hospital is incapable of meeting its goal consistently, failing over 50% of the time.
Failure can frustrate physicians, threaten patient safety and erode the hospital’s commitment to
quality care.
Who Are The Customers? COPQ: Treatment delays, physician and patient
disatisfaction, potential impact on morbidity
ED physician and patients & mortality
What is Critical To their Satisfaction (CTS): Defect Definition: TAT > 60 minutes
Consistent and timely delivery of results (CTD)
Baseline Sigma: - 0.48
Project Scope
Test ordered Result delivered
0
10
20
30
40
50
60
70
80
OD DR RV Total
Hema
Panel
Troponin
Project Charter: Lab Cycle Time
The shortest distance between You and Improved
• Phlebotomist not available (28)
• Locating patient (26)
• Patient refusal/not available (26)
• Phone interruptions (19)
• Staff attitudes (17)
• Accuracy of labeling (16)
• Multiple draws (15)
• Poor communication (13)
• Poor workflow (10)
Only 17%
of the total
TAT is
impacted by
these obstacles…
Q. What are the obstacles to improved TAT in delivering
Lab results to ED?
What they said first, and next
The shortest distance between You and Improved
• Phlebotomist not available (28)
• Locating patient (26)
• Patient refusal/not available (26)
• Phone interruptions (19)
• Staff attitudes (17)
• Accuracy of labeling (16)
• Multiple draws (15)
• Poor communication (13)
• Poor workflow (10)
Only 17%
of the total
TAT is
impacted by
these obstacles…
…but observations
and data reinforce
the impact of these issues
Q. What are the obstacles to improved TAT in delivering
Lab results to ED?
What they said first, and next
The shortest distance between You and Improved
Measure Phase
Determining Stability of Process
Establishing Baseline Performance
Ensuring Data Integrity
Establishing Capability
Integrating Subjective Input
The shortest distance between You and Improved
Whether Lean or Six Sigma,
it all begins with Current State
The shortest distance between You and Improved
Process Flow Diagram - Troponin
ED
Lab1
Lab 2
ED
Start
Physician
Writes OrderOrder Given To
Unit Clerk
Input Sent
Order
Arrives In
Outpt. Lab
Order Has
Correct
Information?
Phl. Goes To
Outpt. Or ED
Computer For
Another Patient
Phl. Draws
Specimen
Phl. Tries
To See
Another
Patient?
Phl. Makes
Multiple
Draws?
Specimen
Arrives In Lab
Specimen
To
Hematology
Blood RolledBlood Spun
Specimen
Processed
Specimen To
Instrument
Specimen To
Instrument
Specimen
To
Chemistry
Results
Verified And
Sent To ED
Results Sent
To Chart
Physician
Reviews
Results
End
Unit Clerk
Immediately
Inputs
Order?
Draw Complete
Results
Arrive In ED
Results Reviewed
Immediately?
No
Specimen To
Instrument
Specimen Sent
For Troponin
Analysis
Yes
Pt. in
room?
Yes
Yes No
No
Phl. Tubes
Specimen
To Lab?
NoNo
Yes
Specimen
Logged In?
Yes
Input Delay
No
Yes
Specimen
Walked To Lab
Specimen
Delayed
Getting To Lab
Yes
Specimen
Movement
Delayed
No
Delay in
reviewing
results
NO
Yes
What’s wrongwith this picture?
The shortest distance between You and Improved
30 90 150 210 270 330 390
95% Confidence Interval for Mu
66 71 76 81
95% Confidence Interval for Median
TAT Troponin First Qtr 2003
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
76.037
38.863
67.000
74.078
0.000
78.7104
40.6673
1653.83
4.03449
22.2818
891
36.000
57.000
68.000
86.000
419.000
81.384
42.649
70.000
Anderson-Darling Normality Test
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
Descriptive Statistics
Turnaround Time: Troponin
The shortest distance between You and Improved
Analysis Phase
“Rounding up the usual suspects”
Hypothesis testing
Identification of Critical X’s
The shortest distance between You and Improved
In search of “X”Analysis of Troponin Process
• Ho: No significant delay due to multiple draws
• Ho: No impact from use of pneumatic tube
• Ho: No significant time loss from end of
instrument processing to delivery of results
The shortest distance between You and Improved
Does a multiple draw cause cycle time to increase or
decrease, or is it unrelated to cycle time?
60 160 260 360 460 560
95% Confidence Interval for Mu
35 36 37 38 39 40 41 42 43 44
95% Confidence Interval for Median
Variable: TAT - Phlebotomist
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
41.335
23.945
35.000
73.588
0.000
42.5212
24.7560
612.861
3.55094
26.7708
1675
10.000
27.000
36.000
51.000
334.000
43.708
25.624
38.000
M Draw: Single Draw
Anderson-Darling Normality Test
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
Descriptive Statistics
60 160 260 360 460 560
95% Confidence Interval for Mu
41 46 51
95% Confidence Interval for Median
Variable: TAT-Phlebotomist
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
45.173
29.554
41.000
50.475
0.000
47.5972
31.1758
971.933
10.4494
171.578
638
11.000
33.000
43.000
54.000
608.000
50.021
32.987
44.000
M Draw: Mult. Draw
Anderson-Darling Normality Test
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
Descriptive Statistics
The shortest distance between You and Improved
Mood Median Test: TAT for Multiple vs Single Draw
Chi-Square = 37.60 DF = 1 P = 0.000
Individual 95.0% CIs
M Draw N<= N> Median Q3-Q1 ----------+---------+---------+------
Mult. Draw 256 382 43.00 21.00 (-------+---)
Single Draw 911 764 36.00 24.00 (---+-------)
----------+---------+---------+------
37.5 40.0 42.5
Overall median = 38.00
A 95.0% CI for median(Mult. Dr) - median(Single D): (4.00,8.00)
Does a multiple draw cause cycle time to increase or decrease, or is it unrelated to cycle time?
The shortest distance between You and Improved
Does it make a difference if Phlebotomist utilizes
Tube System or drops sample direct at the Lab?
6454443424144
95% Confidence Interval for Mu
151311
95% Confidence Interval for Median
Troponin "Draw to Receive"
11.0000
8.7175
13.5792
Maximum
3rd Quartile
Median
1st Quartile
Minimum
N
Kurtosis
Skewness
Variance
StDev
Mean
P-Value:
A-Squared:
13.0000
10.0532
15.4629
66.0000
18.0000
12.0000
8.0000
0.0000
380
4.92349
1.79371
87.1895
9.3375
14.5211
0.000
11.930
95% Confidence Interval for Median
95% Confidence Interval for Sigma
95% Confidence Interval for Mu
Anderson-Darling Normality Test
Check in by Accessioning
Descriptive Statistics
6454443424144
95% Confidence Interval for Mu
11.810.89.88.87.8
95% Confidence Interval for Median
Troponin "Draw to Receive"
8.0000
7.3894
10.0289
Maximum
3rd Quartile
Median
1st Quartile
Minimum
N
Kurtosis
Skewness
Variance
StDev
Mean
P-Value:
A-Squared:
9.0000
8.4410
11.5124
50.0000
15.0000
9.0000
5.0000
0.0000
436
2.61618
1.38520
62.0944
7.8800
10.7706
0.000
11.184
95% Confidence Interval for Median
95% Confidence Interval for Sigma
95% Confidence Interval for Mu
Anderson-Darling Normality Test
Check in by Phlebotomist
Descriptive Statistics
The shortest distance between You and Improved
Does it take a significant amount
of time for the Technician to inspect and
release results?
0 40 80 120 160 200 240
95% Confidence Interval for Mu
3 4 5 6 7 8 9 10 11 12
95% Confidence Interval for Median
Perform to Verify -Positive Results Only
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
4.263
19.493
3.000
30.710
0.000
7.8732
21.7640
473.672
8.69490
86.5909
142
0.000
2.000
3.000
7.250
235.000
11.484
24.638
5.000
Anderson-Darling Normality Test
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
Descriptive Statistics
The shortest distance between You and Improved
Improve Phase
FMEA Initiation
Brainstorming solutions
Fundamentally changing the Process
The shortest distance between You and Improved
Easy Hard
Ensure draw for
Troponin 100%
of the time
Leverage
Nurse-initiated
orders for Trop
Implement
best practices
in Phlebotomy
Ensure room
or location ID
on ED orders
Eliminate
Multiple DrawsDrop off
at Lab for
Troponin Expedite attention
to instrument
4 Quadrant Analysis - A Brainstorming Tool
Effort
The shortest distance between You and Improved
Trial Summary: Overall Performance
(new draws only)
• Troponin Before
– Order to Draw
• μ = 13.1
• σ = 14
– Draw to Receive
• μ = 12.4
• σ = 9.2
– Receive to Verify
• μ = 51.4
• σ = 40
– Total TAT
• μ = 76.9
• σ = 40.7
• Troponin Trial Only
– Order to Draw
• μ = 11.0
• σ = 8.3
– Draw to Receive
• μ = 7.9
• σ = 6.7
– Receive to Verify
• μ = 40.1
• σ = 11.4
– Total TAT
• μ = 59.0
• σ = 17.6
The shortest distance between You and Improved
30 60 90 120 150 180 210
95% Confidence Interval for Mu
55 59 63
95% Confidence Interval for Median
Troponin TAT: June 1 - 20
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
58.418
19.792
54.000
15.916
0.000
60.6562
21.2614
452.048
2.49118
11.0310
349
24.000
48.000
56.000
67.500
219.000
62.895
22.968
57.000
Anderson-Darling Normality Test
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
Descriptive Statistics
Conducting the trial
enabled the organization
to anticipate impact of
expansion
The shortest distance between You and Improved
6305805304804303803302802301801308030
95% Confidence Interval for Mu
51.550.549.548.547.546.545.544.543.5
95% Confidence Interval for Median
TAT ALL TESTS - 2002
44.000
29.520
49.605
Maximum
3rd Quartile
Median
1st Quartile
Minimum
N
Kurtosis
Skewness
Variance
StDev
Mean
P-Value:
A-Squared:
45.000
30.508
51.002
656.000
60.000
44.000
33.000
8.000
7085
58.9612
5.06223
900.358
30.0060
50.3035
0.000
308.720
95% Confidence Interval for Median
95% Confidence Interval for Sigma
95% Confidence Interval for Mu
Anderson-Darling Normality Test
Descriptive Statistics
30 80 130 180 230 280 330
95% Confidence Interval for Mu
37 38 39 40 41 42 43 44 45
95% Confidence Interval for Median
TAT ALL TESTS: JUNE 1 - 20
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
42.342
25.256
37.000
91.965
0.000
43.4421
26.0115
676.600
4.81157
44.4322
2149
7.000
28.000
38.000
52.000
365.000
44.542
26.813
39.000
Anderson-Darling Normality Test
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
Descriptive Statistics
Were improvements at the expense of other tests?
Turnaround Time: All Tests Pre-Project
Turnaround Time: All Tests Post-Project
The shortest distance between You and Improved
Control Phase
Celebrating Success
Holding the Gains
Looking Ahead
The shortest distance between You and Improved
Process StepWhat's
Controlled?
Spec. Limits /
RequirementsMeasurement Method Sample Size Frequency
Who/What
Measures
Decision Rule/
Corrective ActionSOP
Order to Draw Patient Room ID In Process In Process In Process In Process In Process
I
n
P
In Process
Order to Draw Multiple DrawsNo mult draw when
one or more Trop
ordered
Compare check in time for
different samples by
Phlebotomist500-1000 Monthly Cerner* TAT > 13.0 min
Draw to ReceiveCheck in to
Chemistry
Check in to Chem
when Trop is ordered
Compare Draw ID to
Receive ID for Trop500-1000 Monthly Cerner TAT > 10 min
Draw to ReceiveCheck in to
Chemistry
Phlebotomist logs on
to PC
Compare Draw ID to
Receive ID for Trop500-1000 Monthly Cerner Compliance < 75%
Receive to Verify In ProcessI
n In Process In Process In Process In Process In Process TAT > 50
Perform to VerifyAttention to
Instrument
Use alarm to indicate
instrument completion
Monitor Peform to Verify
from instrument500-1000 Monthly Cerner TAT > 5
Troponin TAT TAT 60 mins or lessCerner stats, adjusted for
drawn before ordered500-1000 Monthly Cerner TAT > 65
*Need to identify staff person to process Cerner data Approved by:
Approved by:
Control Plan
The shortest distance between You and Improved
How we’ve evolved as an
organization, and
what we’ve learned
The shortest distance between You and Improved
Performance Improvement
Training&
Credentialing
How we’ve evolved as an organization, and what we’ve learned
The shortest distance between You and Improved
“Culture Eats Lunch”
Q x A = EBusinessResults
Quality of solution times its Acceptance = EffectivenessSee “The Missing Link to Improvement Capability,”
Becker’s Hospital Review, February 2013
The shortest distance between You and Improved
The ”burning platform” approach to
change management
© All Rights Reserved.
The shortest distance between You and Improved
• A man working on an oil platform in the North Sea awakened one night by an explosion. Amidst the chaos, he made his way to the edge of the platform. As a plume of fire billowed behind him, he decided to jump from the burning platform even though jumping is a risky option for the following reasons:o It was a 150 – foot drop to the water.o There was burning oil on the surface of the
water.o If jumping into 40°F water did not kill him, he
would die of exposure within 15 minutes.
• Luckily, the man survived the jump and was hauled aboard a rescue boat shortly thereafter. When asked why he jumped, he replied, “Better probable death than certain death.”
The ”burning platform” approach to
change management
The shortest distance between You and Improved
The shortest distance between You and Improved
The Golden Rule has Limits!
The shortest distance between You and Improved
EQ Leadership
• EQ leaders create resonance (connection) among their followers
• EQ leadership creates trust
• EQ leaders can empathize with their followers
• Ineffective leadership creates dissonance (disconnect) and mistrust among followers
The shortest distance between You and Improved
Why EQ Leadership?
The shortest distance between You and Improved
EQ Leadership
• How to recognize the behavioral styles of peers and subordinates
• How to recognize the needs of each behavioral style
• How to adapt behavior to give staff “what they need”
• How to create more harmonious and productive relationships
The shortest distance between You and Improved
Champion Training
&CandidateSelection
Performance Improvement
Training&
Credentialing
PortfolioManagement
System(“COMPASS”)
How we’ve evolved as an organization, and what we’ve learned
The shortest distance between You and Improved
• Number of CHC Clients = 10
• Number of Projects = 150
• Average Cost per Project = $45,000
• Average Return per Project = $327,058
• Median Project Return = $160,675
• Range of Returns from $60 to $3.75M
• Average ROI = 7:1
Does our approach work?
The shortest distance between You and Improved
$-
$20,000,000
$40,000,000
$60,000,000
$80,000,000
$100,000,000
$120,000,000
$140,000,000
$160,000,000
$180,000,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
CAMC Financial Impact2001 - 2013
Cumulative Total Annual Improvements
CHC Online
Training
The shortest distance between You and Improved
What Success Looks Like
A statistically significant improvement in “Corporate Culture”
Performance Improvement Scores
3.75
3.43
3.18
2.65
2.73
3.12
2.5
3.0
3.5
4.0
1998 1999 2000 2001 2002 2003 2004 2005
Year
Averag
e
The shortest distance between You and Improved
Thank you for the opportunity to be with you today!Ian R. Lazarus
irl@creative-healthcare.comwww.creative-healthcare.com