Lean Sigma Healthcare

45
© SigmaMed Solutions 2011 all rights reserved Lean Sigma Healthcare A New Model for CAH and Small Hospital Quality and Performance Transformation

description

Lean Sigma Healthcare. A New Model for CAH and Small Hospital Quality and Performance Transformation. SigmaMed, the People. Jamie Martin, President & CEO Six Sigma Black Belt from GE 20 years in Healthcare IT, EMR, Surgical Sales 6 years Applying LSH to HIT Workflow in CAHs & Clinics - PowerPoint PPT Presentation

Transcript of Lean Sigma Healthcare

© SigmaMed Solutions 2011all rights reserved

Lean Sigma Healthcare

A New Model for CAH and Small Hospital Quality and Performance Transformation

© SigmaMed Solutions 2011all rights reserved

SigmaMed, the People

Jamie Martin, President & CEO Six Sigma Black Belt from GE 20 years in Healthcare IT, EMR, Surgical Sales 6 years Applying LSH to HIT Workflow in CAHs & Clinics Instructor in CEU/CME rated courses Commercial Pilot with over 1,000 hrs in Light Aircraft

Wray Paul, VP Professional Services MSEE and BSChemE, PMP Master BB, 35+ years of LSS PI Rural Hospital Director EMR/PACS implementation Consulting Design, development of PACS/EMR (5+ years on the

“Dark Side”)

Contract Healthcare Black Belts, including Nurses, PCMH and Quality Directors, and EMR Implementation Experts

© SigmaMed Solutions 2011all rights reserved

SigmaMed, the Company

Focus on Small and Rural Healthcare Facilities Generalized PI and QI in all departments EMR Deployment and Meaningful Use Process Redesign Lean PCMH and ACO - Lean Core Process Redesign

Contracted Lean Six Sigma Provider for: Colorado Rural Health Center CORHIO and CO-REC Contracted work for Wyoming PCA

Teach CE and CME rated Courses on LSH for: Colorado AHEC CU College of Nursing HIT Leadership Program HRSA Hospital and Practice Management Groups

© SigmaMed Solutions 2011all rights reserved

Key (Unconventional) Ideas

Lean Sigma Healthcare is not an additional project Rather, it’s a way to optimally complete projects you are doing

anyway, while simultaneously building internal capacity

You don’t need to master all of Lean Six Sigma to be successful… learn a few tools and get going We teach a version called Lean Sigma Healthcare, which is a

subset of LSS specific to healthcare

LSH doesn’t require huge commitment of time or money The most effective transformations begin with results LSH teaches proper project management LSH done right can be revenue positive in a very short timeframe

Change Leadership and Project Management are as important as LSH tools/technique…we teach all

© SigmaMed Solutions 2011all rights reserved

Why Lean Sigma Healthcare in Rural HC?

By Most Estimates, 40-70% of healthcare spending is 40-70% of healthcare spending is Pure Waste!Pure Waste!

External Demands External Demands for PCMH, MU, JC, and payor models are making our care provision processes making our care provision processes much much more complexmore complex

HIT Isn’t Mature Enough to Help with Complexity…HIT Isn’t Mature Enough to Help with Complexity…and in fact make it worse!and in fact make it worse!

Resource Constraints in Rural Areas Limit our Options….can’t just throw money or people at problems

If we don’t take a proactive approach to designing care processes things will only get worse as HIT is layered on… Safety-Quality-Cost-Patient & Staff Satisfaction

© SigmaMed Solutions 2011all rights reserved

The Lean Sigma Healthcare Equation

Start with a Healthcare Specific Subset of Lean Six Start with a Healthcare Specific Subset of Lean Six Sigma…Sigma… LeanLean (Toyota Production System) adapted for a

Complex service industry…eliminate waste, improve flow Six SigmaSix Sigma (Motorola and GE) adapted for a Defect-

prone service industry…focus on perfecting process

Work on the Right Project(s), Scoped Properly Work on the Right Project(s), Scoped Properly

With the Right TeamWith the Right Team

add… Change Leadershipadd… Change Leadership

plus… Process-focused Projectplus… Process-focused Project ManagementManagement

= LSH…A Simpler Methodology for= LSH…A Simpler Methodology for Healthcare

© SigmaMed Solutions 2011all rights reserved

Errors Reduced on Outpatient Services

Yuma District Hospital and Clinics, 2012

• Substantial Reduction of A/R• Eliminated 1+ FTE in Billing Department

© SigmaMed Solutions 2011all rights reserved

Cheyenne Health and Wellness Center

• Increased Patient Visits past point of Break Even in 3 months• Greatly Improved Staff and Patient Satisfaction • Developed Internal Capacity to Continue Leading LSH• Redesigned Care Delivery Processes to Meet PCMH Level 1 & 2

© SigmaMed Solutions 2011all rights reserved

CAH and FQHC Results with LSH

Decreased insurance defects at clinic admission by 100x (50% defects to 0.5% defects) - Rio Grande Hospital, Del Norte

Increased customer satisfaction on test results notification from 60% to 80%+ (red to green trending up,)

Increased patient visits 47% yr/yr in 3 months and Intake appts. 83% within 5 months at WY FQHC

Reduced rework required on outpatient procedure orders from 20% to less than 0.6%

Reduced patient waiting time for ortho surgery from 14 weeks to 31 hours (first call to surgery)—Theda Care, Wisconsin1

1 From “Lean Hospitals” Mark Graban, 2008

© SigmaMed Solutions 2011all rights reserved

So Why Doesn’t Everybody Use LSS?

Benefits Cost Satisfaction Quality Safety

Perceived Barriers Investment cost Too many other

“big changes” Not enough staff

resources What are some

others?

© SigmaMed Solutions 2011all rights reserved

Models for LSS – the Big Bang…

Big Idea Big Implementation

Hire consultants Train everyone Start lots of projects

Big bet… Leadership has too many

projects to provide needed attention

$$ makes everyone impatient

Hard to show results fast enough to justify $$

Fire consultants

Not Realistic for CAHs

© SigmaMed Solutions 2011all rights reserved

Models for LSH – Organic Growth

Big Idea Small Implementation

Start with one project Train one team Leadership support for that

one project Grow your capabilities

Small Bet… One Project = Low Risk

Something you have to do anyway

$$ often under the radar Grow excitement from

results Plan LSH growth from there

© SigmaMed Solutions 2011all rights reserved

Successful Change Begins with Results

Activity Focus Activity Focus -- many organizations cite the number of trained LSS resources, the number of projects, etc. as evidence of success of program

Results FocusResults Focus -- the only really meaningful measure of PI success is tangible resultstangible results, bottom line impact

Without tangible financial benefits, organizations lose lose patience and pull backpatience and pull back before effort has gained steam

By starting small, visibly, and meaningfullysmall, visibly, and meaningfully word of project success may permeate an organization and create the internal pull necessary to spread throughout

Change is greeted with open arms when it is proven to generate positive benefits and is notnot seen as another “flavor of the month”“flavor of the month” change program

This generates “internal pull”“internal pull” vs. shoving an unwanted program down an organization’s “throat”

This is from Schaffer & Thomson’s 1992 Classic, “Successful Change Programs Begin with Results,” in the Jan-Feb Harvard Business Review

© SigmaMed Solutions 2011all rights reserved

Keys to LSH Transformation Success

Successful LSS ImplementationsSuccessful LSS ImplementationsCommitted LeadershipUse of Top TalentSupporting Infrastructure

Formal Project Selection Process Formal Project Review Process Dedicated Resources Financial System Integration

Not So Successful LSS ImplementationNot So Successful LSS ImplementationSupportive LeadershipUse of Whoever was AvailableNo Supporting Infrastructure

No formal project selection, review process, not integratged

© SigmaMed Solutions 2011all rights reserved

SMS Virtual LSH Project Model

1. Train and Mentor Execs in Requirements for Leading a Successful LSH Transformation

2. Assist in Picking the Right Project, the Right Team, Scoping Correctly, and Keeping on Track First project can be key to a successful LSH launch

3. Just-in-Time LSH training for Teams – “Learn & Use” immediately increases retention

4. Intensive 1-on-1 Mentoring of Team Leaders in LSH methodology and Project Leadership

5. Virtual Project Facilitation by SMS BB’s to advise teams and make mid-course corrections

6. Always-available, “Asynchronous” Online LSH Training for Teams and YB Certification Program for Team Leaders

7. Ongoing mentoring in LSH roll-out to maintain momentum and assist in overcoming obstacles (that always appear!)

© SigmaMed Solutions 2011all rights reserved

LSH Thoughtware

It’s the Process that’s broken not the People…It’s the Process that’s broken not the People… design perfect processes and people perform perfectly (almost!)

The only people that can fix a process are those The only people that can fix a process are those that work in itthat work in it every day (not managers)

Data is your allyData is your ally….opinions are (nearly) always wrong (otherwise the problem would have been fixed!)

You Must Plan ChangeYou Must Plan Change in as much detail as you plan for new implementation

Follow the DMAIC frameworkDMAIC framework for all improvement projects, great and small, to stay on track

Work can (and must) be done OTIFNEWork can (and must) be done OTIFNE!

© SigmaMed Solutions 2011all rights reserved

The Change Effectiveness Formula

The Effectiveness of any change initiative is a function of the Quality of the technical solution

“times” its Acceptance by the culture.

(E) Change Effectiveness

E E ff (Q*A)(Q*A)

(Q) Technical Strategy

(A) A

cceptance Stra

tegy

Courtesy of Destra Consulting, LLC

© SigmaMed Solutions 2011all rights reserved

What do the Numbers Say?

With Effective OCM, Change Investment ROI =143%With Effective OCM, Change Investment ROI =143%That’s a gain of 43% with Effective OCMThat’s a gain of 43% with Effective OCM Characteristics of Successful OCM

Senior and Middle Managers and Frontline Employees all were involved

Reasons for the project were understood and accepted throughout the organization

Everyone’s Responsibilities were clear

With Poor OCM, Change Investment ROIWith Poor OCM, Change Investment ROI = 65%65%That’s a loss of 35% without OCMThat’s a loss of 35% without OCM Reasons for the Failures

Lack of commitment and follow through by senior executives Defective project management skills among middle managers; Lack of training and confusion among frontline employees

(Source: McKinsey & Co)

© SigmaMed Solutions 2011all rights reserved

19

Kotter’s Change Model

Kotter found that 2/3 of all Transformation efforts fail. 2/3 of all Transformation efforts fail.

However, Successful Change Follows a Pattern

• Create Shared Sense of UrgencyCreate Shared Sense of Urgency

• Remove Obstacles to the New VisionRemove Obstacles to the New Vision

• Systematically Plan and Create Short-term WinsSystematically Plan and Create Short-term Wins

• Develop a Powerful Guiding CoalitionDevelop a Powerful Guiding Coalition

• Create a VisionCreate a Vision

• Over-Communicate The Vision by a Factor of Ten – Yes 10X!Over-Communicate The Vision by a Factor of Ten – Yes 10X!

• Don’t Declare Victory Too Soon!Don’t Declare Victory Too Soon!

• Anchor the Changes in Organizational CultureAnchor the Changes in Organizational Culture

When these 8 factors are addressed, change efforts are highly likely to succeed!

© SigmaMed Solutions 2011all rights reserved

Human Elements of Change

Groundbreaking Thinking in “Switch…”, 2010, by Dan and Chip Heath When you ask people to change you are Tinkering

with Behaviors that have Become Automatic “Self control is Needed to Override Behaviors that

have Become Habits However, People’s Self-control is Finite and they

can Only Handle so much Change People Aren’t Closed to Change, Just Exhausted by

the Effort Required for Head to Over-ride Habits!

From “Switch…”, 2010, by Dan and Chip Heath

© SigmaMed Solutions 2011all rights reserved

“How to Make A ‘Switch’

Direct the Rider – Rational Follow the Bright Spots – clone what’s working Script the Critical Moves – specific behaviors Point to the Destination – vision, big picture

Motivate the Elephant – Emotional Find the Feeling – make people feel something Shrink the Change – make it manageable Grow Your People – cultivate sense of identity

Shape the Path – Process Tweak the Environment – change situation Build Habits – habits are “free” Rally the Herd – behavior is contagious, help it spread

From “Switch…”, 2010, by Dan and Chip Heath

© SigmaMed Solutions 2011all rights reserved

Essential Ideas for Change

Developing a Change Plan Change Plan is just as Important as Using Tools/Methodologies like Lean Six Sigma

An Early Win Early Win on a Visible Project is Necessary to Build the Hope and Belief Necessary for Change

Leading Change is About Engineering Hope and Working with Teams to Build a Path

Your Change Plan must Appeal to Peoples’ Heads (logic) and Hearts (emotions) for Change to Last

People are Generally Not Unwilling to Change, Rather, They are Exhausted by the Extra Effort!

© SigmaMed Solutions 2011all rights reserved

Value and the Voice of the Customer

You are in Business to Deliver Value – good care – for Patients

Steps in Your Process not Delivering Value Create Waste Your Survival Depends upon Making Customers

(Patients) Happy every chance you get View Your Processes from the Patient’s Perspective

We mistake our view of the process for the customer’s The customer doesn’t care about our process GE Concept of “Wing-on-Wing”

Projects need to have a clear connection to customer needs expressed by the customer These are called CTQ’s – Critical to Quality – or CTs An good project improves top Customer CTQ’s (as determined by

a VOC, ie patient surveys, focus groups)

© SigmaMed Solutions 2011all rights reserved

Needed - A Process View

People do a “bad job” because they are People do a “bad job” because they are working in a “bad Process”working in a “bad Process”

What is wrong with HC Processes?What is wrong with HC Processes? They were generally never “designed”, they just

happened. When they didn’t work, they got “patched” There is usually not a standard process—people just

modify (on a whim) Few indicators of Process performance get measured

We use measures broad outcomes (infections) Usually don’t measure leading indicators (adherence to

sterile process for central lines)

© SigmaMed Solutions 2011all rights reserved

What is the Result of “Bad” Process?

WastedWasted Time…Time… In end to end processes (Clinic door to door, ED door

to door, surgery appointment to discharge) 75% or more of the time is wasted.

Time = moneyTime = money and patient satisfaction Defects…Defects…

Healthcare Business processes often run at 50% defect levels

Defects (like insurance information) often have to be fixed. 25% plus of the billing department are often working on fixing Admissions Defects

Defects = moneyDefects = money, patient safety & satisfaction Net resultNet result is 40-70% of what we do is pure

waste!

© SigmaMed Solutions 2011all rights reserved

The Universal Complaint (UC)

“If [Department X] would just do their job, then we [Department Y] could do our job

better, easier, faster, cheaper…”

Sometimes (rarely) it is the people, but far more often it is the Process that is Broken

• 1% of the people in an organization should probably be in another line of work…

• But that means that the other 99% can be very effective—If we get the Process(es) right.

© SigmaMed Solutions 2011all rights reserved

Decoding the Universal Complaint (UC)

Processes usually go wrong at the interfaces and go wrong at the interfaces and handoffshandoffs. Therefore the UC is caused by: The Process actually is designed well, but Depts X

and Y don’t have a single view of how the process works so they don’t interface correctly (Rarely).

OR (more likely) The process never worked right & even if X and Y “did their jobs”, they would still be frustrated and Defects and Waste would rule the day.

Therefore if you put good people into a bad process, they will perform badly.

Bottom Line: If you are have a problem, put 99% of your effort on changing the process, 1% on changing the people.

© SigmaMed Solutions 2011all rights reserved

How Can LSH Help?

It provides tools and methods to: See where Waste is happening Find the Root Cause of Defects Redesign the Process to dramatically reduce

both It engages the staff to:

Apply their intelligence and “profound knowledge” of the Process to fix global problems

If they help design it, they have ownership of the Process

It gives the organization principles to make effective change and lead LSH expansion

© SigmaMed Solutions 2011all rights reserved

The LSH Equation

Give people the Tools to Lead Change and Lead Projects

Work on the 20% that cause 80% of your Problems! Redesign High Defect or Time Inefficient Processes

Get processes to 99.5% “good service” and high Time efficiency Data and statistics get easier

Minimize the number of LSS tools and learn to use the “vital few” Simple Process and Value Stream mapping Six Sigma DMAIC project management methods Fishbone and the 5 Whys for getting at Root Cause Fail Early and Cheaply…

© SigmaMed Solutions 2011all rights reserved

“OTIFNE” Work

Work is defect free ONLY if it is: On TimeOn Time – the next process step doesn’t have to

waitwait for it In FullIn Full – completely finishedcompletely finished so nobody

downstream in the process has to “fill in the blanks” No ErrorsNo Errors – there are no defectsdefects that somebody

downstream has to fix or the customer will see.

Simple Process Redesign Can Get You There

© SigmaMed Solutions 2011all rights reserved

LSH Defect Goals

Manufacturing aims for 6 Sigma performance, or 3.4 defects per million opportunities…

But, Healthcare isn’t Manufacturing. They are way ahead of us!

Healthcare should start with a goal of ~4.5 Sigma, or 5 defects per 1000 opportunities If we do something 1000 times1000 times, we should expect no

more than 5 OTIFNE5 OTIFNE errors (more on this later) Don’t design new processes that can’t meet that

goal. Design Safety Critical processes so they are

“failsafe” Design all others to meet this “Lean” Goal Lean Sigma Healthcare will get you There

© SigmaMed Solutions 2011all rights reserved

Defects are Just Symptoms…

BUT…You Can’t fix SymptomsCan’t fix Symptoms You Can Only Fix Root CausesRoot Causes! Example “Shortness of Breath”

Is only a symptom. To fix it, the ED Doc has to find the Root Cause

Root Causes of “SOB” (a few of 100 or so) Altitude induced pulmonary edema Pneumonia Heart disease COPD

All of those Root Causes require different treatment!

© SigmaMed Solutions 2011all rights reserved

Tools 1 -- DMAIC

DefineDefine – what do we want to do? MeasureMeasure – how can we see what we do now

and set an improvement goal AnalyzeAnalyze – see what our data tells us and

find the Root Cause Root Cause of our issues ImproveImprove – design an new process, try a pilot

of the new process, debug, improve, train & scale

ControlControl – select a few key metrics that tell us whether we have actually improved things. Use them to control the process in operation.

© SigmaMed Solutions 2011all rights reserved

DMAIC Solves Four Big Problems

Answers 4 Key Questions Before we Start Are we working on the Right StuffRight Stuff (in the Right Right

WayWay)? Do Management/Leadership &Management/Leadership & Stakeholders Stakeholders

approveapprove of what we are doing? WhoWho should be on the Team? WhenWhen will we be done?

It answers the fear-inducing question: What do we do next?What do we do next?

© SigmaMed Solutions 2011all rights reserved

Tools (2 of 4)—Process Mapping

We see too much of this…

Problems Hard to see who

does what Very hard to see

Waste Problems at

handoffs not obvious

Can’t figure out what to do next.

© SigmaMed Solutions 2011all rights reserved

Better Process Mapping - Swimlanes

Much better to do this…

Advantages Easy to see who

does what Easy to see Waste

Defects/Inspection/Rework

Overprocessing

Handoffs explicit (messages)

Easy to figure out what to do next.

© SigmaMed Solutions 2011all rights reserved

Tools (3 of 4)—Fishbone

World’s best brainstorming tool

Advantages Aims directly at

Root Cause(s) Avoids

patching symptoms

Pareto voting narrows the investigation of potential Root Causes

© SigmaMed Solutions 2011all rights reserved

Fishboning turns Symptoms into Root Cause(s) of Defects

If you’re fixing a Defect problem, at first you only have the Symptom (the Defect). “300/1000 [=30%] of our Radiology orders have Defects” If you throw “solutions” at it, they will probably won’t fix the

problem and will add Complexity to your process and Create will add Complexity to your process and Create Waste!Waste!

People who actually work on the processPeople who actually work on the process have a lot of ideas about what might Cause the Defect.

Fishbone DiagramsFishbone Diagrams are a structured brainstorming technique to get their ideas out. Once you get all of the ideas out, you can ParetoPareto the ones you

want to work on. In our work, we almost always find that the Team correctly correctly

identifies the Root Causeidentifies the Root Cause with a Fishbone Diagram.

The beauty of Root Cause is it saves you from The beauty of Root Cause is it saves you from working on the 80% of the “issues” that won’t solve working on the 80% of the “issues” that won’t solve the problemthe problem

© SigmaMed Solutions 2011all rights reserved

Deep Dive on Causes…The “5 Whys”

Why do we create Defects on the “rooming form” (1)? Because we feel rushed

Why do you feel rushed (2)? Because we only have 5 minutes Why do you only have 5 minutes (3)?

Because the Provider is Waiting and Impatient Why is the provider waiting (4)?

Because there are a lot of patients in the exam rooms

Why are there lots of patients in exam rooms (5) Root CauseRoot Cause = Because we send them back

whether we are ready for them or not….

The real Root Cause of a problem is often at the bottom of the 5 Why chain.The real Root Cause of a problem is often at the bottom of the 5 Why chain.Everything above that is a symptom, not a cause.Everything above that is a symptom, not a cause.

© SigmaMed Solutions 2011all rights reserved

Tools (4 of 4)—Graphing

Visualize your data 1

Advantages People draw

conclusions from graphs, fall asleep looking at data tables.

95% of the time, don’t need much statistical analysis.

1) Needless to say, you have to make Process measurements in the first place

© SigmaMed Solutions 2011all rights reserved

Selecting the Right Project

Good Projects Clear Objectives

Directly connected to customer needs Project is Scoped Correctly

Able to Complete within 3-4 months Fixing Problem is Relevant to the Business Fixing the Problem is Part of Team Leader’s (GB’s) job

responsibility

Makes life much easier Data is easily available Benefits are easy to calculate Have a high likelihood of Success

© SigmaMed Solutions 2011all rights reserved

Good Projects have SMART Objectives

SpecificSpecific Is it obvious what we want to do (and what’s out of

scope (bounds))? MeasureableMeasureable

Can we count defects and measure time, money, and other important variables?

AggressiveAggressive (but Achievable) Is it a little bit of a “stretch” but still possible?

RealisticRealistic Can we do it with the people, skills, time, and money

we have available? TimeboundTimebound

Have we specified when we plan to get it done?

© SigmaMed Solutions 2011all rights reserved

LSH Projects Ideas on New Initiatives

Build It Right the First Time Processes that take less time, reduce cost, ANDAND give

you the results you need

Coming Down the Pike…or already on you! PCMH/ACO/VBP ICD-10/JC EMR MU, etc… Tend to add cost, because we layer them on over

already-stressed Processes

© SigmaMed Solutions 2011all rights reserved

The path forward…what we need to do

Life is Short…Eat Dessert First Change our thinking

We can't solve problems by using the same kind of thinking we used when we created them.” Albert Einstein

Set new goals 5 defects/1000 50%+ Flow Time Efficiency

Use new Tools Lean Sigma Healthcare to eliminate Defects and

Wastes of time and human potential

© SigmaMed Solutions 2011all rights reserved

eMaster Black Belt Services (eMBB) Project Oriented Team Training, Mentoring, Facilitation

Virtual eMBB – high value, effective projects Combo Virtual and On-site – SMS resource leading on-site partly Single and Dual Project MBB – for facilities

Facility PI/QI/Data Analytics Redesign Green/Black Belt Project Mentoring

LSH Practitioner Certification Services Mentored Green or Black Belt certification in LSH Online Training

Yellow Belt Certification Course – 4o Hrs of detailed training for team Leaders

Team Training Course – 4 hrs of basic training for team members

Multi-Platform Data Reporting and Analytics Software sales, implementation, and PS

LSH Services through WY ORH