Engaging the Leadership Triad in AcceleratingChange Using Lean Six Sigma
Stephen Mayfield, Dr. H.A., MBA, MBBSenior Vice President
American Hospital [email protected]
Several Themes from High Performing Organizations
Seeing differently – especially using variation and error as welcome feedback.
Engaging two levels of leadership for collaboration which means:
embracing system thinking which cultivates process excellence in which the human factors tendencies within the system are attended.
Use of tools that facilitate the dialogue between levels of leadership.
Establishing the value proposition, or the Business Case for Quality
Using Lean / Six Sigma as methods to Reduce Waste and Eliminate Defects
It All Starts With:
Create awareness for transformative change that focuses on the Patient’s Experience
Grow capacity for Robust Performance Improvement
Executive Leadership owns Common Cause Variation
Aspects of the Situation
• Humans are fallible • Healthcare is a high-risk environment • Faulty communication and hierarchal
barriers are common root causes of medical error
• Healthcare providers do not receive adequate training in communication, teamwork, and assertiveness skills
• Errors can be reduced through a definable set of teamwork concepts and skills
From Check Six Training
Observations from High Performing Organizations
Learning to SEE differently – it’s not about more data, it’s how you look at existing information.
DeKalb, IllinoisDeKalb, Georgia
How Did Healthcare Become So Unsafe?
Number Of Deaths
Years
Disease
Treatment
From P. Gluck
“Medicine used to be simple, ineffective and relatively safe.
Now it is complex, effective and potentially dangerous.”
Cyril ChantlerLancet, 1999
Lessons from Other Fields
It’s About Leadership
Executive Leaders – Administrators, Trustees & Physician Leaders
Patient Care Leaders – those close to the delivery of care to the patient
Executives have to “own” common cause” variation !
PI Hospitals in Pursuit of Excellence
PI Hospitals in Pursuit of Excellence
Core Principles
Focus on the Patient’s Experience - Care must be respectful of, and responsive to, individual preferences, needs and values
Create a Culture of Reliability - Culture defines the values and behaviors of organizations. Highly reliable cultures are known to be the safest organizations in the world
Manage Organizational Variability - Achieve consistency wherever possible in what you do and how you do it
Core Principles
Remove Inefficiency and Waste - Removing waste, including in the form of unnecessary steps, has a direct, positive impact on clinical and financial performance
Eliminate Harm and Defects - Finding and resolving problem points will result in greater efficiency and better health outcomes
Reduce Process Variation - Using quality tools and frameworks can increase consistency in processes of care and administration, thus reducing the risk of errors
PI Hospitals in Pursuit of Excellence
More Important than ever: The New Realities
Moody’s has a negative outlook for the US not-for-profit hospital sector, as virtually all rated healthcare credits are facing some degree of credit stress due to a combination of impaired access to the capital markets, soaring credit spreads, counterparty downgrades, and a slowdown in the global economy.
Moody’s Investors Service
Dec. 2008
The New Realities
= Margin
Non payment adverse events
Medicare pressures
Non payment readmissions
Waste & Inefficiency
“20% to 50% of all health care efforts are attributable to waste and inefficiency.”
Rework, work arounds, defects, errors, unnecessary
harm, delays, misuse, overuse, underuse.
- COSTSREVENUES
A Physician CEO Sees Differently
Seeing Differently 1847
See
Patients Deaths Percent
4,010 459 11.4
Dr. Ignaz Semmelweiz
General Hospital of Vienna
Patients Deaths Percent
3,754 105 2.7
First WardSecond Ward
Outward Visible Signals of Culture
Outward Visible Signals of Culture
Jump From 1847 to 2009
Number One National Patient Safety Goal of the Joint Commission for reducing Healthcare Associated Infection:
Seeing Differently 1986
Challenger Disaster resulted from decisions made in 1972
Individual competence in a poorly designed system
Seeing Differently 2003
•Successful transplant surgery (twice)•No verification system for “matching blood type”
Jesica Santillan
Individual competence in a poorly designed system
Optimizing the System – Context and Content
Premise:
All patient care is a system, every system has processes and every process has waste and variability.
Corollary:
Separating all the processes and optimizing each one and then combining them DOES NOT optimize system performance
Four Major Components of Care Delivery
Patient Information
Clinical Decisions
Care Processes
Patient Flow
Systems of Care and Simple MetricsAt the Operational Level
Information -> Clinical Decisions -> Care Processes -> Patient Flow
Clinical Information SystemFinancial System
Patient Patient Patient Patient
Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….
CD CD CD
Evidenced Based
Medicine
Clinical Best
Practices
Outcome
Indicators
(LOS, Mortality, Infection, Readmits)
Patient Flow
Process Measures(Waste, SMR,
Cycle Time Variances, etc.)
Charges
On a Cruise who has the most impact on your safety?
What is Human Factors Science?
“…..Concerned primarily with the performance of one or more persons in a task-oriented environment interacting with equipment, other people, or both.”
National Academy of Sciences
The Study of factors that contribute to errors including:
• Human Vulnerabilities related to memory
• Situational or environmental aspects
• Cognitive Lapses
Perception and Communication
An Example
Perception and CommunicationHow Many Squares Do You Count?
Silently count, and write down your total
Image One
Say the Color of the word
Say the Color of the word
Mistake Proofing
Perception and Communication
An Example of How Technologies Impact System Performance
In Short – Performance is affected by Human Tendencies related to cognitive processing attributes and limitations and the effects of system variability and interactions, ESPECIALLY those associated with decisions and communication.
PI Hospitals in Pursuit of Excellence
Core Principles
Focus on the Patient’s Experience - Care must be respectful of, and responsive to, individual preferences, needs and values
If it starts with the Patient’s Experience, what does the system deliver?
ConsumerismBook:
New Book I’m Working On:
“If a Hospital Ran Your McDonald’s”
Are we getting the message?“American industry has become very
accustomed to running their businesses by watching each other. In fact many of them are still focusing on the competition, only this time it is Japan. In a few years it will be Korea, then China, then some other country. If you just try to meet the competition, you will not survive in this new economic age. You must try to meet the customer, not just the competition.
And it is you who must change, not the competition.”
-- William Scherkenbach, 1986, excerpted from a presentation to General Motors
Engage Leaders
-Systemness
-Culture
-Structure
-Strategy
-Process Field
-Process Excellence
-Competencies
-Team
-Training
-Process Improvement
Healthcare Excellence Requires Collaborative LeadershipSystem Thinking that Supports Process
Excellence Context Leaders
(executive, trustee, physician leaders)
Content Leaders(clinical and non-
clinical)
Culture
StrategyS
truc
ture P
rocess
Leadership Creates the Framework for a System that Supports Process Excellence
Mayfield/1995
UCL
UCL
Standardize
Ho
urs
.5
1.0
1.5
2.0
Standardize
Weeks
Stabilize
Innovation
Stabilize
ContinuousImprovement
ContinuousImprovement
LCL
LCL
Standardize....Stabilize....Improve....Innovate
Process Excellence
Performance Improvement is a function of standardizing the methods, stabilizing the performance, reducing variation until the next innovation moves performance
to a new level
Mayfield/1995
UCL
UCL
Standardize
Ho
urs
.5
1.0
1.5
2.0
Standardize
Weeks
Stabilize
Innovation
Stabilize
ContinuousImprovement
ContinuousImprovement
LCL
LCL
Standardize....Stabilize....Improve....Innovate
Iceberg of Ignorance: What % of the Organization’s Problems are known to….
4 %
9 %
74 %
100%
Top Management
Middle Managers
Supervisors
Front-line
Employees
Problems hidden from management
Adopted from Sydney Toshida
Five Important Questions for Trustees:
What are we trying to accomplish with respect to our performance?
What level of quality and safety are we pursuing?
How do we measure it?How is our performance
changing?Is what we’re doing making a
difference?
Trustees have a Right and a Responsibility to ask:
How do we know if care in our hospital is –
Safe?Timely?Efficient?Effective?Equitable?Patient-Centered
(The Six Institute of Medicine Aims: STEEP )
Five Important Questions for Physicians:
How do we know if our care processes are reliable?
How do we embrace and promote evidence-based practices?
Are we eliminating preventable harm?
Am I managing the care of my patients and their flow through the system, or have I assigned that to others?
Are we actively engaged in peer review learning?
Seven Important Questions for Executive Leaders:
Are we developing Systems of Care?Are we providing efficient
processes?What indicators of quality and
safety are we bringing to our Board and Physicians?
How are we engaging our Physicians?
What are our Costs of Poor Quality?How is the CFO involved?How are we continually reducing
variation?
Hierarchy of Activities for High Performers:
Engage the Triad
Has the organization clearly established what is important?
Has the organization determined expected performance levels for: (a) Clinical outcomes(b) Operational performance(c) Safety(d) Satisfaction?
Has the organization developed a Balanced Measurement System?
Has the existing performance been assessed?
Hierarchy of Activities for High Performers
Has the Business Case for Quality been established clearly?
Are departments/functional areas aligned with the organization’s performance expectations?
Are priorities for process improvement identified?
Are appropriate tools and methods used to bring about successful change and improved performance?
Outpatient Surgery
Process Oriented – Results Driven
“The Toyota mind develops brilliant processes in which average employees may excel.” (Taiichi Ohno)
Process Oriented – Results Driven
“The Toyota mind develops brilliant processes in which average employees may excel.” (Taiichi Ohno)
Healthcare Analogue - “Healthcare systems have
discontinuous processes in which brilliant staff struggle to produce average results.”
Six Sigma Example:High Level Phlebotomy Flow
MQC
Retrieve Order
Print Label
Travel to Patient
Collect Specimen
Deliver Specimen
Detailed Phlebotomy FlowMQC
Over 40 specific defects identified in 5 classes:
Label defects (unlabeled, misplaced, wrong patient labels, misaligned, etc.)
Patient ID band defects ( improper matching, no label, wrong label, etc.)
Unsuccessful draw (not first stick, second phlebotomist required)
Unacceptable specimen/recollect (wrong tube, clotted, hemolyzed, insufficient quantity, contaminated, overfilled, etc.)
Order entry defects (time, test, patient)
Surrounded by Defects !
The System will get you if you Choose
Sub-Optimal Solutions !
Cost of Poor Quality and DefectsFor Error that can lead
to harm - What is the:Possibility?Availability?Probability?Liability?Opportunity Cost?
It’s About Leadership
Executive Leaders – Administrators, Trustees & Physician Leaders
Patient Care Leaders – those close to the delivery of care to the patient
PI Hospitals in Pursuit of Excellence
Leaders must ask:
How do we know if care in our hospital is –
Safe?Timely?Efficient?Effective?Equitable?Patient-Centered
(The Six Institute of Medicine Aims: STEEP )
Several Themes from High Performing Organizations
Seeing differently – especially using variation and error as welcome feedback.
Engaging two levels of leadership for collaboration:
embracing system thinking which cultivates process excellence in which the human factors tendencies within the system are attended.
Use of tools that facilitate the dialogue between levels of leadership.
Establishing the value proposition, or the Business Case for Quality
Becoming a Learning Organization
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