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Transcript of Six Sigma Process ItI mprovement Methodologyvideos.med.wisc.edu/files/Lanham.pdf · Six Sigma...
Six SigmaP I tProcess Improvement
MethodologyMethodologyPresented by Content Expert:Beth Lanham, RN, BSN, MBA
Director Six SigmaDirector, Six SigmaFroedtert Hospital, Milwaukee, WI
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
What is Six Sigma?What is Six Sigma?
• Six Sigma is a• customer focused• customer focused•project‐focused • results‐driven
…approach to Qualityapp oac to Qua ty
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Six Sigma OverviewSix Sigma Overview
• A rigorous methodology• A rigorous methodology
• Originated by Motorola (1986)– A statistically‐based method to reduce variation in– A statistically‐based method to reduce variation in electronic manufacturing processes
• Heavily inspired by • Previous quality improvement methodologies
• Quality Control Management, CQI, TQM • Based on the work of quality pioneers q y p
• Deming, Juran, Ishikawa, Taquchi and others
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Six Sigma OverviewSix Sigma Overview
• By late 1990sy– 2/3 Fortune 500 companies
• Aimed at reducing costs and improving quality
T d• Today – Utilized all over the world
• Local governments, prisons, hospitals, the armed forces, banks, g , p , p , , ,manufacturing, etc.
• In recent yearsSi Sigma often combined ith Lean Man fact ring to– Six Sigma often combined with Lean Manufacturing to yield a methodology called Lean Six Sigma.
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Why Six Sigma?Why Six Sigma?
Wh d i ’ ki ll h!• What we were doing wasn’t working well enough!– Incremental improvements “not good enough”
Need to /Desire to:– Need to /Desire to:• Focus on customer requirements
• Base decision on data, not anecdotal information
• Be Proactive vs. Reactive
• Establish a culture of ownership vs. culpability– It’s the processes, not the people
• Effect rapid and effective change
– Improvement efforts were fragmented
L id b k– Large system‐wide processes broken
– Not “holding the gains”
What does Six Sigma offer?What does Six Sigma offer?
• Augments traditional quality tools Organizational • Augments traditional quality tools
• Data driven decision‐making
gBenefits:
Competitive edge
• Focuses on customer requirements
• A focused/organized approach
Service Excellence
Empowered staff• Redefines processes for long‐term results
• Becomes ingrained in work and thought
Empowered staff
Leadership Development
processes
• Relies on evidence‐based solutions
Quality/Safety
Healthcare Costs
• Rapid/effective change
Six SigmaSix Sigma
• Methodology aimed at• Error reduction • Eliminating variation• Eliminating variation
• Goal• Design/improve processes so it is impossible to make an error
• Reliance on performance measurements and statistical analysisstatistical analysis
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
TraditionallyTraditionally…..
• Businesses have described their products or• Businesses have described their products or services in terms of averages:• Average costg• Average time to delivery• Average number infectionsA• Average usage
• Average wait time
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Are These Processes the Same?
Process 1 Process 2
20 9
5 11 Goal = less than 10
Are they performing well?
17 8
5 10 Process 1 Process 215 10
5 9 Mean 9.4 Mean 9.45 11
5 10Are all the customers happy?
5 8
12 8
ppy
Variation = Opportunities for Errorspp
Process 1 Process 2
Average 9.4 9.4
Minimum 5 8
Maximum 20 11
Median 5 9.5Median 5 9.5
Standard deviation 6.0 1.17
Customers feel the variation,
not the average!!!!!!
Variation in the ProcessVariation in the ProcessProcess 1 Process 2
100
80
Mean 9.540StDev 6.149N 1000
Histogram of Process 1Normal
80
70
60
Mean 9.412StDev 1.193N 1000
Histogram of Process 2Normal
60
40Freq
uenc
y 50
40
30
20
Freq
uenc
y
24181260-6-12
20
0
Process 124181260-6-12
10
0
Process 2
Many Defects
Fewer Defects
Process 1 is less capable of meeting our customer’sProcess 1 is less capable of meeting our customer s expectations!
Exact capability can be measured!
Six Sigma Central ConceptsSix Sigma Central Concepts
• Critical to Quality (CTQ)Critical to Quality (CTQ) – How the customer judges our products/services
• Y = The outcome measure of the process• X’s = Inputs or variables that affect the Y• Defect ‐ Failure to deliver what the customer expects• DPMO Defects per million opportunities• DPMO – Defects per million opportunities• Variation
– The enemy of predictable output and customer satisfaction
• Sigma – An expression of process yield, based on the number of
defects per million opportunities (DPMO)defects per million opportunities (DPMO)
Six Sigma
A Philosophy of
g
p y fOperational Excellence
A set of Problem SolvingA Metric Solving Tools/Tactics
A Metric
A Measure of Process Capability
Definitions of Six Sigma?Definitions of Six Sigma?
• A metricA metric– Greek letter
• A measure of process capability’– How capable is our process of meeting our customer’s
expectations?• A rigorous, structured approach to problem‐solvingg pp p g
– Includes a defined methodology with specific tools and tactics• A management philosophy
Operational excellence and continuous improvement– Operational excellence and continuous improvement
Definitions complimentary, not contradictory!p y y
Six Sigma as a MetricSix Sigma as a Metric
• A statistical concept – Represents the variation that exists in a process
l h– Relative to the customer requirements
• A process operating at a 6‐ Sigma levelS li l i i h h– So little variation, that the process outcomes are 99.9997% defect free
• Six Sigma = 6 6 Sigma or 6sSix Sigma = 6 , 6 Sigma, or 6s.
Process SigmaProcess Sigma
DPMO = Defects per Million OpportunitiesDPMO = Defects per Million Opportunities
• A more sensitive indicator than % yield or % good
Sigma Defects Yield DPMO1 69.1% 30.9% 691,462
2 30.8% 69.1% 308,538
3 6.7% 93.3% 66,807
4 0.62% 99.38% 6,210
5 0.02% 99.977% 233
6 0.0003% 99.9997% 3.4
When Compared to Best‐in‐Class (N i l D )
AntibioticBeta Blocker Use
(National Data)
1000000
Inpatient MedicationAccuracy
AntibioticOveruse
Beta Blocker UsePost MI
10000
100000
000000
illio
n
44,000 ‐ 98,000Preventable HospitalDeaths (IOM Report)
100
1000
efec
ts /
Mi
Anesthesia
1
10
1 2 3 4 5 6
D During Surgery
1 2 3 4 5 6
Sigma Domestic AirlineFatality Rate
Traditional Process Improvement
1 Sigma
Traditional Process Improvement5 & 6 Sigmag
2 Sigma
Sigma
2 Sigma
3 Sigma3 Sigma4 Sigma
4 to 5 Sigma‐ 27‐fold Performance Improvement
5 to 6 Sigma‐ Another 69‐fold Performance Improvement5 to 6 Sigma Another 69 fold Performance Improvement
Measure of Process CapabilityMeasure of Process Capability
• Focus on improving what is important to the• Focus on improving what is important to the customer– Critical to Quality (CTQs)Q y ( Q )
– This is generally referred to as the “Y” or outcome variable– Examples: wait time, response time, turn around time, % new visits, % med errors, % falls, etc.
• Measure the “Y” against the target – Target = customer expectations or specifications
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Process Capabilityp y
Lower
Specification
Upper
Specification
Li i
10
y
Limit Limit
5Freq
uenc
00
AverageAverageDefectDefect DefectDefect
A Problem Solving ApproachA Problem Solving Approach
• Highly structured methodologyHighly structured methodology• Focused on identifying the root causes • Process variables impact or influence the YProcess variables impact or influence the Y
– Root cause analysis
• Process variables are called “X’s”
Y = x1 + x2 + x3 + x4, etc.
P i t i (Y) bi tiPrimary metric (Y) = combination of a variety of variables (x’s)
What are the variables that influence the main metric?
A Management PhilosophyA Management Philosophy
• Focus is on continuous improvement by• Focus is on continuous improvement by– Understanding the customer’s needs– Analyzing business processesAnalyzing business processes
– Instituting appropriate measurement methods
• Emphasis on management of processesp g p– We don’t have faulty people, we have faulty processes!
We can’t manage what we don’t measure!We can t manage what we don t measure!
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Six Sigma Model ‐DMAICSix Sigma Model DMAIC
Define Measure Analyze Improve Control
•Establish current capability
•Select Key CTQs**
•Develop data ll i l
• Charter project
• High Level
•Optimization
•Cycle time•VariabilityC /LOS
• Determine capability of new process
•Identify key sources of variability
collection plan
•Define performance t d d
High Level Process Map
• Collect VOC
Id if
•Cost/LOS
•Validation of Improvements
p
• Implement process controls
•Define performance objectives
standards
•Validate measurement systems
• Identify Customer CTQs
• Review hi t i l d t
•Implementation• Ensure Gains are Sustained
systemshistorical data* VOC‐ Voice of Customer
**CTQ‐Critical to Quality
Tools of Six Sigma
Y = f(X x) Multi‐Vari Charts
g
Y f(X,x) Multi Vari Charts
Process Map Regression
FMEA (Failure Mode and Hypothesis Test
Effects Analysis) 95% Confidence Interval
Cause – Effect Diagram ANOVA
P t Di DOE (D i f E i t )Pareto Diagram DOE (Design of Experiments )
Gage R&R Control Plan
Process Capability Statistical Process Controlp y
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Six Sigma Key Playersg y y
•Full time • Oversee or •Full time
•Strategic Projects
•Skilled in Six Sigma T l
choose projects
• Resolve Issues
• Provide
ChampionsBlack Belts
Tools
•Teach Green Belts
• Provide Leadership
ExecutiveS
• Full Time
• Strategic j
• Part Time
•Smaller Scope
Sponsors
Master Black Belts
Projects
• Program Administration
•Smaller Scope Projects
•Help to change culture
Green Belts
• Teach Black Belts and Green Belts
culture
The Six SigmaThe Six Sigma Process…Process…
Launching a Projectg j
/• Identify a Sponsor/Champion– Energy/passion to solve the problem
• Sponsor/Champion Role• Sponsor/Champion Role– Define boundaries/scope
– Establish “stretch” goals – Provide direction and support to the team
– Remove barriers
– Recognize and celebrate successesRecognize and celebrate successes
– Accountable for completion, implementation and sustaining results from the project
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Six Sigma Model DMAICSix Sigma Model ‐DMAIC
Define Measure Analyze Improve Control
• Charter project•Problem statement ‐ How do we know we have a problem? •Goal Statement ‐ How will we know if we have made anGoal Statement How will we know if we have made an improvement?
•Project Scope and TeamHi h L l P M• High Level Process Map
• Identify Customer CTQs• Stakeholder analysis• Stakeholder analysis •Review historical data
Example Project CharterQMS Project Team Charter
Business Process Team/Svc Line: Project Team Members Review Timing
Project Name: Target Completion Date: Project Type: CAP WO PDSA Lean DMAIC
Project Champion: Start Date:Project Champion: Start Date:
Process Owner: Milestones – TBD based on methodology
Black Belt:
Finance Representative:
Project Overview
Problem Statement (*MOMS criteria):
In Scope: p
Out of Scope:
Customers and Stakeholders:
Goal (s): (**SMART criteria)
Current Performance Indicators and Levels:Current Performance Indicators and Levels: Target Performance Indicators and levels:
Expected Benefits/Business Case (target savings, target metric reduction):
Assumptions:
Constraints:Constraints:
SignaturesProject Chair(s) Signature: Champion Signature: Master Black Belt signature:
Problem and Goal StatementsProblem and Goal Statements
• Problem Statement– How do we know we have a problem?MOMS criteria– MOMS criteria
• Measureable, Observable, Manageable, Significant
• Goal Statement– How will we know if we have made an improvement?– SMART criteria
S ifi M bl Att i bl R li ti Ti l• Specific, Measureable, Attainable, Realistic, Timely
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
High Level Process Map ‐ SIPOCHigh Level Process Map SIPOC
P T hi ll di l th j tPurpose: To graphically display the process major events • Suppliers
– Who provides the inputs to your process?• Inputs
– What materials, resources and data are needed to execute process?
• Process Steps p– 5‐7 steps that use inputs to change into outputs. Use very specific start
and stop points!• Outputs p
– What is the output of the process? What did the customer receive?• Customers
– Who receives the outputs of the process?Who receives the outputs of the process?
SIPOC Example
Hand Hygiene SIPOCHand Hygiene SIPOCSuppliers-Who provides the inputs?
Inputs-Materials, resources, data
Process Steps Outputs-What did the customer receive?
Customers- Who benef its?
E t ti t•Infection Control
•H.C Prov iders(Physicians, nurses, nursing assistants, therapists,
• Policies & Procedures
• CDC guidelines
• Soap
• High quality care
• Avoidance / reduc tion of hospital
• Patients
• CMS
• Third Party PayorsWash hands
t i
Enter patient room
technicians, emergency medical staff, dental staff, pharmacists, laboratory staff, autopsy staff, students and trainees, contractual
• Alcohol hand rub
• Dispensers
• Sinks
• Paper towels
• Conscious thought
acquired infect ions
• Clean hands
• Decrease in skin irritat ion
• Other patients
• Staff
• Families
upon entering
Patient Encounter
staff not employed by the healthcare facilit y, and persons not directly involved in patient care but potentially exposed to inf ectious agents.)
•Plant
Conscious thought
• Clinical Routine
• Degree of urgent care required
• Extent of contact
MD orders
• Increased patient confidenceWash hands
upon exiting•Plant Operations
•Patient condition
• MD orders
• Call lights
• Operational routines
Leave patient room
Process Maps‐ a Tip!Process Maps a Tip!
Each process has at least 3 versionsEach process has at least 3 versions
What you think What it actually is… What you would like it yit is…
y yto be….
Voice of the Customer
Establish Voice of the Customer (VOC)
Voice of the Customer
Establish Voice of the Customer (VOC)– Identify and prioritize all customers
• Who is impacted the most by the process?• Who is the most dissatisfied with the current process?
– Solicit feedback• How does the customer view the process?How does the customer view the process?• What does the customer value from the process?• What does the customer expect from the process?
What does the customer want most of the time?
What is the limit the customer is willing to tolerate?
Stakeholder Analysis form?Stakeholder Analysis form?
St k h ld A l iStakeholder AnalysisStrongly
SupportiveModerately Supportive
Neutral (0)
Moderately Against
Strongly AgainstNames
• Who will be affected by any changes from this SupportiveSupportive(0)AgainstAgainstNameschanges from this project?
• Begin addressing issues early! y
• Not everyone needs to be strongly supportive! pp
Six Sigma Model DMAICSix Sigma Model ‐DMAIC
Define Measure Analyze Improve Control
• Select CTQ characteristics• Select CTQ characteristics• Define Performance Standards• Data Collection• Measurement System Analysis
Process X’s (Variables)
X1
Outputs or Y’s
Y1X1
X2
X3
Y1
Y2
Y3The Process
X4 Y4
CTQ characteristicsCTQ characteristics
• Select the main characteristic that the customer• Select the main characteristic that the customer uses to judge your performance– Six Sigma lingo: The big “Y”g g g
– How will I know if I have made an improvement?
• How will the “Y” be defined and/or measured?/
VOC CTQ Y
Expect to be seen Wait Time Pt. check‐in at front desk to first within 15 min of appt. contact with staff physician.
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Define Performance TargetsDefine Performance Targets
• Translate the Customer expectations into Metrics – Target:
• What does the customer want most of the time?What does the customer want most of the time? – Specification Limits:
• What are the limits the patient is willing to tolerate?
VOC CTQ Y Target Upper Limit
• Expect to be seen Wait Pt. check‐in at front 15 min 30 minwithin 15 min of appt.
•Unhappy if > 30 min
Time desk to first contact with staff physician.
Identify the Key X variablesIdentify the Key X variables
Cause and Effect Diagram
Process Env ironment Management
Manage rs no t a ccountab leClut te r obst ruct ing sinkNo tra in ing on proce ss t ime line
Cause-and-Effect Diagram
Don't have adequa te re source s
No communica t ion re : pt impact if non-compliant
Lack mot iva t ion to se t an e xample
No incent ive s/rewa rds to comply
No corre ct ive a ct ion fo r non-compliance
Spot checks no t current ly done
Divisions not a ccountable
La ck o f inst itut iona l sa fe ty clima te
Unde rsta f f ing/O ve rcrowding
Ca rrying items into pa t ient room
Need to ta ke ca re o f pa t ient and can 't
No ongo ing educa t ion on proce ss fo r
No reminde rs posted
No sink in the room
Dif f icu lty monito ring proce ss
regula rlyEqu ipment is no t w iped dow n
be fo re /a f te r conta ctPeop le a re no t awa re to w ash hands
No t ra in ing on proce ss t ime line
in teracionduring ptcompliancehy g ieneLack hand
Inadequa te org. st ructure fo r a ccountab ility
No ro le mode l fo r hand hyg iene
Lack o f inst itut iona l prio rity f o r hand hyg iene
De la ys in ge tt ing needed equipment
No a lcoho l w ipe s
Not enough hand d ispense rs
Low risk o f a cquiring in fe ct ions f rom
No lo t ion a cce ssib le
La ck immedia te feedback/outcomes
proce ssNot pa rt o f the yea rly eva lua t ion
Skept ica l about e f fe ct ivene ssInte rfe re s w /HCW re la t ionsh ip w ith pts
Disagree w /re commenda t ionsFamily/visito rs unawa re re :handw ashing in teracionNot enough hand d ispense rs
Soap/a lcoho l d ispense r empty
Broken d ispense r
O ve rf low ing ga rbage
No towe ls
Sta f f work a rea s a re d irty
Too many peop le in room, in way o f sink
Equipment in way o f sink
hgyiene on the ra te o f HAINo da ta to show the impact o f hand
Skin irr ita t ion by hand hyg iene agents
Inconvenient loca t ion o f hand san it ize r
La ck o f educa t ion ma te ria ls
F amily/visito rs don 't see be ing pa rt o f PCO the r pe rsonne l no t awa re
Pts/visito rs insu lted when a sked to w ash Pts not a t e a se a sking someone to w ash
Peop le fo rge tPeop le se t in the ir ways
Not pa rt o f the F roedte rt cu ltureNot seen a s a prio rity
Conce rned w /skin irr ita t ionDon't unde rstand need fo r handwashing
Fee l tha t no need to wash w /g love s
Sponsored by the Wisconsin Office of Rural Health and the Wisconsin Hospital Association. Copyright of the Wisconsin Office of Rural Health.
Peop le Materials Equipment
Equipment in way o f sink
Not enough sinks a va ila b le
S inks don 't work
Pa t ient room is out o f g love sDon't know prope r handwashing
O nly touch equip. , no need to w ashFee l tha t wash hands enough
Too busy/Not enough t ime
Data Collection/SamplingData Collection/Sampling
• Key considerationsKey considerations– Data must be representative of the process
– Data must be reliable
– Must capture measurements of importance
ENTRY EXITOBS # Role(s) Hand Hygiene Notes Hand Hygiene Notes
1 Sink Y / N Gloves On Sink Y / N Gloves OnHand Rub Y / N Urgent Hand Rub Y / N Removed glovesNone Y / N Full Hands? None Y / N Full Hands?
Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked AccessDirect Exit to Enter?
2 Sink Y / N Gloves On Sink Y / N Gloves OnHand Rub Y / N Urgent Hand Rub Y / N Removed glovesNone Y / N Full Hands? None Y / N Full Hands?
Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked AccessDirect Exit to Enter?
Measurement System Analysis (MSA)Measurement System Analysis (MSA)
H t i th t ?• How accurate is the measurement process?• How much variation is there in the measurement process?process?
• Attempt to minimize controllable factors that could exaggerate the amount of variation in the data
Example:I want to measure seconds. The clock only measures minutesResult:The variation of the measurement system is too large to study the current level of process variationthe current level of process variation
MSA ExamplesMSA Examples
• Fall Risk/Pressure Ulcer Risk Assessments• Fall Risk/Pressure Ulcer Risk Assessments– Performed by all RNs– Patient’s given scores, based on assessment criteria
• Door to Balloon Time– Clocks
1. Reproducibility‐ Does RN # 1 get the same score as RN # 2?
2. Repeatability‐ Does RN # 1 always get the same score when f d ith th fi di ?faced with the same findings?
Total measurement system variability should be as small as possible, but always less than 30%.
Six Sigma Model DMAICSix Sigma Model ‐DMAIC
Define Measure Analyze Improve Control
• Establish current capability• Identify key sources of variabilityD fi f bj i• Define performance objectives
How is the process performing today?p p g y
Do we need to “shift the mean” or “reduce variation”?
What are the key X’s that are driving the Y?
How do you know?
AnalyzeAnalyze
• Graphical Tools• Flow diagrams, frequency plots, Pareto charts, etc.
• Statistical Testing‐– Descriptive Statistics, Process Capability Hypothesis testing, Regression
Analysis, etc.Analysis, etc.
• Designed Experiments
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
Displaying the Data
Variable: Pt Wait Time
Descriptive Statistics
p y gBoxp lots of Pt Wa it Tim e by C LIN IC
( means are indicated by sol id cir cles)
10 35 60 85 110 135 160
A-Squared:P-Value:
MeanStDevVarianceSkewnessKurtosisN
Minimum
32.018 0.000
23.155115.3332235.1081.251964.39234
2559
0 000
Anderson-Darling Normality Test
100
150
e (in
min
)
95% Confidence Interval for Mu
20 21 22 23 24
Minimum1st QuartileMedian3rd QuartileMaximum
22.561
14.924
0.000 11.000 21.000 33.000
153.000
23.750
15.765
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
50
Pt W
ait T
ime
Overall Statistics By Patient:
95% Confidence Interval for Median 20.000 22.000
95% Confidence Interval for Median
HAC
OR
O
OR
T
0
40
Scatterplot of Hand Hygiene Events vs Time of Day
Metric Wait Time Exam Time Total TimeMean 23.16 18.94 42.10Median 21 16 40Std Deviation 15.33 11.54 19.76
30
20
10and
Hyg
iene
Eve
nts
Std Deviation 15.33 11.54 19.76Sample Size 2559 2559 2559Min 0 0 3Max 153 99 1831614121086
10
0
Time of Day
Ha
Current Process CapabilityCurrent Process Capability
How is the process performing today?
µ
p p g yDo we need to “shift the mean” or “reduce variation”?
T T1.235 1.239 1.241 1.245 1.233 1.235 1.239 1.241 1.245
USL USLLSL LSL
Hypothesis TestingG tti t th R t CGetting to the Root Causes
Which X’s had the greatest affect on the Y?
Test Details P-ValueRole DTY, EVS, Lab, LCs, PCAs, RNs, RTs 0.002
P‐Values < 0.05 are signficant factors
Which X s had the greatest affect on the Y?
RNs RNs vs. All others 0.422LCs Long Coats vs. All others 0.004DTY Dietary vs. All others 0.005EVS EVS vs. All others 0.056TSP Transport vs All others 0 020
Must use the correct statistical tests based on types of dataTSP Transport vs. All others 0.020
THP Therapists vs. All others 0.020Day of Week Mon vs. Tues vs. Wed vs. Thu vs. Fri 0.285Time of Day Observation Hours 7-16 0.039Groups Single HCW vs. Groups 0.868
types of data
p g pMethod Sink vs. Alcohol Based Hand Rub 0.000Full Hands Empty vs. Full Hands 0.000Urgency Normal vs. Urgent n/aGloves Wearing gloves vs. No gloves 0.463Timing Entry vs. Exit 0.000Access Clear access to Sink/ABHR vs. Blocked Access 0.965
Six Sigma Model DMAICSix Sigma Model ‐DMAIC
Define Measure Analyze Improve Control
/• Optimization of Y (Cycle time, Variability, Cost/LOS)• Validation of Improvements• Implementation p• Control Plan
Generate alternatives 0.9
0.8UCL=0.852
1
1
% compliance
Assess the risks
Test the alternative
S l t th b t lt ti
0.7
0.6
0.5
0.4
0.3
0.2
Indi
vidu
al V
alue
_X=0.471
Select the best alternativeWk30Wk29Wk28Wk27Wk26Wk25Wk24Wk17Wk16Wk15Wk14Wk13Wk12
0.1
0.0
C22
LCL=0.090
Evaluating solutionsEvaluating solutionsAlternatives
Pugh Matrix
on
Key Criteria Importa
nce R
ating
Tele te
ch on flo
or with
contin
uous cen
tral
monitorin
gtel
e tec
h on floor a
nd deletio
n
of cen
tral m
onitorin
g
Shift co
ordinato
r with
restru
ctured
position- n
o
patien
tsRaw
lins c
all lig
ht sys
tem
installe
d in te
le ro
om
RN accountable for patient
Generate multiple Efficient trouble shooting
Utilizes RN critical Thinking
FTE neutralGood judgement regarding whether to take patient off tele when off unit
RN knowledge of when patient leaves unit
RN knowledge of when patient returnsAssurance that patient placed back on tele when
KeyBetter Same Worse
multiple options!
Evaluate how p preturned to floor30 Second response to sustained lethal rhythms or rate alarms
Documentation of rate/rhythm changes
Consistent/accurate interpretation of rate/rhythmTimely recognition of rate/rhythm changes
Overall high standard of care maintained
= 10= 8
= 5= 3
= 1
each option meets CTQs
Continuous observation
Misc. benefits
enhance current shift coor. Responsibilities
Increased awareness of unit "big" picture
Increase resources avail. to unit RNs
Increase unit teamwork
Increase staff satisfaction
Increase coordination of care
Sum of Positives 8 10 18 1Sum of Negatives 1 2 2 0Sum of Sames 11 8 0 19
Pilot/Validate Results
Pilot PlanningPilot Planning
• Failure Mode and Effects Analysis
• Assure adequate sample size
•Validate improvements SICU confirm ed Glucose levels < 70 on insulin by m onth•Validate improvements through data and statistical analysis 70
80
90
alue
y
UCL=84.41
June-Aug 2002 02Sept
02Dec
03Jan
03Feb
03March
Baseline
30
40
50
60
Indi
vidu
al V
a
Mean=60.25
LCL=36.09
Pilots
0 10 20 30 40 50 60 70 80 90
30
Observation Number
Six Sigma Model DMAICSix Sigma Model ‐DMAIC
Define Measure Analyze Improve Control
% compliance
• Determine capability of new process• Implement process controls• Ensure Gains are Sustained
1.2
1.0
0.8
0.6
0.4Indi
vidu
al V
alue
_X=0.823
UCL=1.119
LCL=0.528
Pre Interim Pilot
• Close the projectWk30Wk29Wk28Wk27Wk26Wk25Wk24Wk17Wk16Wk15Wk14Wk13Wk12
0.2
0.0
Is the new measurement system measure what it is suppose to measure?Does the new process meet the goal?How can you sustain the gains?How can you sustain the gains?
Mistake proofing, Robust design, Process Monitoring Celebrate successes!
ControlControlDetermine new process capabilityp p y
Develop control plan– Monitor Inputs and Outputs (Y’s and Xs)
– Ensure that Gains are Sustained
Share Best Practices
Maintain the gains! 1 0 0
2 0 03 0 04 0 05 0 06 0 07 0 0
vidu
al V
alue 1
11
1
1
11
M 9 5
UC L = 2 6 3 .8
C on tro l C h art: tim e to 1 s t an tib io tic
B a s e line P ilo t P o s t P ilo t
gains!0S ub g ro up 5 0 1 0 0
-1 0 00
1 0 0
Indi
v
P i lo t P ilo t C 16
M e an= 9 5
L C L = -7 3 .7 8
4 0 05 0 0
6 0 0
Ran
ge 1 1
1
0
1 0 0
2 0 03 0 0
Mov
ing
R 11 1
R = 6 3 .4 6
UC L = 2 0 7 .3
L C L = 0
Example Six Sigma Projectsp g j
Safety/Quality
• Insulin/Diabetes
Service/Process Efficiencies
A• Falls
• Anticoagulation
• Telemetry Response
Access
Diabetes Clinic
Urology Clinic
W it ti
Patient flow• Ortho/Radiology• Ortho/OR• Pulmonary Functions Lab
• Patient Identification
• Priority Medication
• Hand Hygiene
Wait time:
Hand Center
OP Lab
OP R i i
• Pulmonary Functions Lab• Hem/Onc Lab Process• Hem/Onc Treatment Room• GI Lab
• Medication Verification Process
• Communication of Addi i l R di l
OP Registration
Delays in surgery d/t missing Instruments
• Patient Throughput• Discharge Process
Additional Radiology Findings
Lessons Learned…Lessons Learned…
• Organizational Vision• Organizational Vision • Senior Management must lead
• Be focused ‐ strategic alignment, cascading of goals, have a plan!plan!
• Hold people accountable!• Involve Medical Staff • Stay focused for a long time! y f g
• Administrative Structure • Clear roles and responsibilities
• Methodology for project selection, scoping, approval and resource allocation• Don’t take key things out of scope!y g p
• Establish ownership, reporting and tracking mechanisms
Lessons Learned• Culture Change
Lessons Learnedg
• Don’t underestimate the resistance! Expect it! Manage it!
• Stay Focused‐ Counter the “flavor of the day” • Top down visible leadership Walk the talk!• Top‐down visible leadership‐Walk the talk!• Address Change Management Strategy from the beginning!
• Economic Implications• Decide whether economics “lead or follow” as a driver• Decide whether economics lead or follow as a driver
• Organizational focus• Project focus
• Other….• There are no silver bullets!!! It’s takes plain hard work!• Leaders not inherently good sponsors!• Challenging to find time, resources, data• Difficult to find the “right” staff
• Facilitation skills, project management, healthcare knowledge, problem solving, movers/shakers
How will we know when we get there?How will we know when we get there?
The following elements will occur on a daily basis:The following elements will occur on a daily basis:
– High performing hospital processes
– Data driven decisions and problem solving
– Focus on processes not people or departments
– Recognition of widespread variation and its impacts
– Acceptance of rapid change
– Enthusiasm about finding “better ways of doing things”
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.
For More InformationFor More Information
Beth LanhamBeth Lanham Froedtert Hospital, Milwaukee, WI P: 414‐805‐8685P: 414 805 8685 E: [email protected]
Wi i Offi f R l H lth Wi i H it l A i tiWisconsin Office of Rural HealthKathryn MillerRural Hospitals & Clinics Program ManagerP: 800‐385‐0005E kmiller9@wisc edu
Wisconsin Hospital AssociationDana RichardsonVice President, Quality InitiativesP: 608‐274‐1820E drichardson@wha orgE: [email protected] E: [email protected]
This presentation is part of an on‐line series, brought to you through a collaboration between the Wisconsin Office of Rural Health and the Wisconsin Hospital Association.
Property of the Wisconsin Office of Rural Health.