Six Sigma Process ItI mprovement Methodology

Six Sigma P Process Improvement I t Methodology Presented by Content Expert: Beth Lanham, RN, BSN, MBA Director Six Sigma Director, Six Sigma Froedtert 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 app oac to Qua ty …approach to Quality


Six Sigma Overview Six Sigma Overview • A rigorous methodology A rigorous methodology • Originated by Motorola (1986) – A A statistically‐based method to reduce variation in 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 yp • Deming, Juran, Ishikawa, Taquchi and others


Six Sigma Overview Six Sigma Overview • By late 1990s y – 2/3 Fortune 500 companies • Aimed at reducing costs and improving quality

• Today T d – Utilized all over the world • Local governments, prisons, hospitals, the armed forces, banks, g ,p , p , , , manufacturing, etc.

• In recent years – Si Six Sigma often combined with Lean Manufacturing to Sigma often combined ith Lean Man fact ring to yield a methodology called Lean Six Sigma.


Why Six Sigma? Why Six Sigma? • What we were doing wasn’t working well enough! Wh d i ’ ki ll h! – 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 – Large system‐wide processes broken L id b k – Not “holding the gains”

What does Six Sigma offer? What does Six Sigma offer? • Augments traditional quality tools Augments traditional quality tools • Data driven decision‐making • Focuses on customer requirements • A focused/organized approach • Redefines processes for long‐term results • Becomes ingrained in work and thought processes • Relies on evidence‐based solutions • Rapid/effective change

Organizational g Benefits: Competitive edge Service Excellence Empowered staff Empowered staff Leadership Development Quality/Safety Healthcare Costs

Six Sigma Six 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 analysis statistical analysis


Traditionally….. Traditionally • Businesses Businesses have described their products or have described their products or services in terms of averages: • • • • •

Average cost g Average time to delivery Average number infections A Average usage Average wait time


Are These Processes the Same? Process 1 Process 2 20

9

5

11

17

8

5

10

15

10

5

9

5

11

5

10

5

8

12

8

Are they performing well? Goal = less than 10

Process 1

Process 2

Mean 9.4 Mean 9.4 Are all the customers happy? ppy

Variation = Opportunities for Errors pp Process 1 Process 2 Average 9.4 9.4 Minimum 5 8 Maximum 20 11 Median Median 5 9.5 5 9.5 Standard deviation 6.0 1.17

Customers feel the variation, not the average!!!!!!

Variation in the Process Variation in the Process Process 1

Process 2

Histogram of Process 1

Histogram of Process 2

Normal

Normal Mean StDev N

100

80

9.540 6.149 1000

70

9.412 1.193 1000

60 Frequency

80 Frequency

Mean StDev N

60 40

50 40 30 20

20 10 0

-12

-6

0

6 12 Process 1

Many Defects

18

24

0

-12

-6

0

6 Process 2

12

18

24

Fewer Defects

Process 1 is less capable of meeting our customer Process 1 is less capable of meeting our customer’ss expectations! Exact capability can be measured!

Six Sigma Central Concepts Six 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 g A Philosophy p y of f Operational Excellence

A set of Problem Solving Solving Tools/Tactics

A Metric A Metric

A Measure of Process Capability

Definitions of Six Sigma? Definitions of Six Sigma? • A metric A 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‐solving g 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 Metric • A statistical concept – Represents the variation that exists in a process – Relative to the customer requirements l h

• A process operating at a 6‐ Sigma level – SSo little variation, that the process outcomes are li l i i h h 99.9997% defect free

• Six Sigma = 6 , 6 Sigma, or 6s. Six Sigma = 6 6 Sigma or 6s

Process Sigma Process Sigma DPMO = Defects per Million Opportunities DPMO = Defects per Million Opportunities • A more sensitive indicator than % yield or % good

Sigma

Defects

Yield

DPMO

1

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 (National Data) lD ) Antibiotic Overuse

Beta Blocker Use Beta Blocker Use Post MI

Inpatient Medication Accuracy

Defects / Miillion

1000000 000000 44,000 ‐ 98,000 Preventable Hospital Deaths (IOM Report)

100000 10000 1000 100

Anesthesia During Surgery

10 1 1

2

3

4 Sigma

5

6 Domestic Airline Fatality Rate

Traditional Process Improvement Traditional Process Improvement 5 & 6 Sigma

1 Sigma g 2 Sigma 2 Sigma 3 Sigma 3 Sigma

4 Sigma

4 to 5 Sigma‐ 27‐fold Performance Improvement 5 to 6 Sigma‐ Another 69 5 to 6 Sigma Another 69‐fold fold Performance Improvement Performance Improvement

Measure of Process Capability Measure of Process Capability • Focus Focus on improving what is important to the 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


Process Capability p y Upper Specification Li i Limit

Lower Specification Limit

Frequency

10

5

0

Defect

Average

Defect

A Problem Solving Approach A Problem Solving Approach • Highly structured methodology Highly structured methodology • Focused on identifying the root causes Process variables impact or influence the Y • Process variables impact or influence the Y – Root cause analysis

• Process variables are called “X’s” Y = x1 + x2 + x3 + x4, etc. Primary P i metric t i (Y) = combination bi ti of a variety of variables (x’s) What are the variables that influence the main metric?

A Management Philosophy A Management Philosophy • Focus is on continuous improvement by Focus is on continuous improvement by – Understanding the customer’s needs – Analyzing business processes Analyzing business processes – Instituting appropriate measurement methods

• Emphasis on management of processes p g p – We don’t have faulty people, we have faulty processes!

We can’tt manage what we don We can manage what we don’tt measure! measure!


Six Sigma Model ‐DMAIC Six Sigma Model DMAIC Define

• Charter project • High Level High Level Process Map • Collect VOC • Identify Id if Customer CTQs • Review hi t i l d t historical data

Measure

Analyze

•Select Key CTQs**

•Establish current capability

•Develop data collection plan ll i l •Define performance standards t d d •Validate measurement systems

•Identify key sources of variability •Define performance objectives

Improve

Control

•Optimization •Cycle time •Variability •Cost/LOS C /LOS

• Determine capability of new process p

•Validation of Improvements

• Implement process controls

•Implementation

* VOC‐ Voice of Customer **CTQ‐Critical to Quality

• Ensure Gains are Sustained

Tools of Six Sigma g Y Y = f(X,x) f(X x)

Multi Multi‐Vari Vari Charts

Process Map

Regression

FMEA (Failure Mode and

Hypothesis Test

Effects Analysis)

95% Confidence Interval

Cause – Effect Diagram

ANOVA

Pareto Diagram P t Di

DOE (Design of Experiments ) DOE (D i fE i t )

Gage R&R

Control Plan

Process Capability p y

Statistical Process Control


Six Sigma g Key Players y y • Oversee or

•Full time •Full time •Strategic Projects •Skilled in Six Sigma T l Tools

choose projects

Black Belts

•Teach Green Belts

Champions

• Provide Provide Leadership

Executive S Sponsors • Full Time

• Part Time •Smaller Scope •Smaller Scope Projects •Help to change culture

• Resolve Issues

Green Belts

Master Black Belts

• Strategic Projects j • Program Administration • Teach Black Belts and Green Belts

The Six Sigma The Six Sigma Process…

Launching a Project g 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 successes Recognize and celebrate successes Accountable for completion, implementation and sustaining results from the project


Six Sigma Model DMAIC Six Sigma Model ‐DMAIC Define

Measure

Analyze

Improve

Control

• Charter project •Problem statement ‐ How do we know we have a problem? •Goal Goal Statement Statement ‐ How will we know if we have made an How will we know if we have made an improvement? •Project Scope and Team • High Level Process Map Hi h L l P M

• Identify Customer CTQs • Stakeholder analysis Stakeholder analysis •Review historical data

Example Project Charter QMS Project Team Charter Business Process Team/Svc Line: Project Name:

Project Team Members Target Completion Date:

Review Timing Project Type: CAP WO PDSA Lean DMAIC

Project Champion:

Start Date:

Process Owner:

Milestones – TBD based on methodology

Black Belt: Finance Representative:

Project Overview

Problem Statement (*MOMS criteria): p In Scope: Out of Scope: Customers and Stakeholders: Goal (s): (**SMART criteria) Current Performance Indicators and Levels: Target Performance Indicators and levels: Expected Benefits/Business Case (target savings, target metric reduction): Assumptions: Constraints:

Signatures Project Chair(s) Signature:

Champion Signature:

Master Black Belt signature:

Problem and Goal Statements Problem 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 • Specific, Measureable, Attainable, Realistic, Timely S ifi M bl Att i bl R li ti Ti l


High Level Process Map ‐ SIPOC High Level Process Map P Purpose: To graphically display the process major events T hi ll di l th j t

• 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 SIPOC Suppliers -Who provides the inputs?

•Infection Control •H.C Prov iders (Physicians, nurses, nursing assistants, therapists, technicians, emergency medical staff, dental staff, pharmacists, laboratory staff, autopsy staff, students and trainees, contractual staff not employed by the healthcare facilit y, and persons not directly involved in patient care but potentially exposed to inf ectious agents.)

•Plant Operations •Patient condition

InputsMaterials, res ources, data • Policies & Procedures

Process Steps

Enter E t patient ti t room

• CDC guidelines • Soap • Alcohol hand rub

Wash hands upon entering t i

• Dispensers • Sinks • Paper towels • Conscious thought

• Extent of contact

Patient Encounter Wash hands upon exiting

• MD orders • Call lights • Operational routines

What did the customer receive? • High quality care • Avoidance / reduc tion of hospital acquired infections • Clean hands

• Clinical Routine • Degree of urgent care required

Outputs-

Leave patient room

• Dec rease in skin irritation • Increased patient confidenc e

Customers - Who benefits? • Patients • CMS • Third Party Pay ors • O ther patients • Staff • Families

Process Maps‐ a Tip! Process Maps a Tip! Each process has at least 3 versions Each process has at least 3 versions What you think y it is…

What it actually is… y

What you would like it y to be….

Voice of the Customer Voice of the Customer Establish Voice of the Customer (VOC) 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? • Who will be affected by any changes from this changes from this project? • Begin addressing y issues early! • Not everyone needs to be strongly supportive! pp

St k h ld A Stakeholder Analysis l i Names

Strongly Against

Moderately Against

Neutral (0)

Moderately Supportive

Strongly Supportive


Measure

Analyze

Improve

• Select CTQ characteristics Select CTQ characteristics • Define Performance Standards • Data Collection • Measurement System Analysis Process X’s (Variables)

Outputs or Y’s

X1

Y1

X2

Y2

The Process

X3

Y3

X4

Y4

Control

CTQ characteristics CTQ characteristics • Select Select the main characteristic that the customer 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 Expect to be seen within 15 min of appt.

CTQ

Y

Wait Time Pt. check‐in at front desk to first contact with staff physician.


Define Performance Targets Define Performance Targets • Translate the Customer expectations into Metrics – Target: • What What does the customer want most of the time? does the customer want most of the time? – Specification Limits: • What are the limits the patient is willing to tolerate? VOC • Expect to be seen within 15 min of appt. •Unhappy if > 30 min

CTQ Wait Time

Y Pt. check‐in at front desk to first contact with staff physician.

Target

Upper Limit

15 min

30 min

Identify the Key X variables Identify the Key X variables Cause and Effect Diagram Cause-and-Effect P ro cess

E n v iro n men t

M an ag emen t

Clu t t e r o b st ru ct in g sin k No t ra in in g o n p ro ce ss t ime lin e

P e o p le a re n o t a w a re t o w a sh h a n d s b e f o re /a f t e r co n t a ct

M a n a g e rs n o t a cco u n t a b le

No sin k in t h e ro o m

Divisio n s n o t a cco u n t a b le S p o t ch e cks n o t cu rre n t ly d o n e

No re min d e rs p o st e d No o n g o in g e d u ca t io n o n p ro ce ss f o r

No co rre ct ive a ct io n f o r n o n -co mp lia n ce

Ne e d t o t a ke ca re o f p a t ie n t a n d ca n 't

E q u ip me n t is n o t w ip e d d o w n re g u la rly

Ca rryin g it e ms in t o p a t ie n t ro o m

Dif f icu lt y mo n it o rin g p ro ce ss

Un d e rst a f f in g /O ve rcro w d in g La ck o f in st it u t io n a l sa f e t y clima t e

No t p a rt o f t h e ye a rly e va lu a t io n p ro ce ss

Lo w risk o f a cq u irin g in f e ct io n s f ro m

No in ce n t ive s/re w a rd s t o co mp ly La ck mo t iva t io n t o se t a n e xa mp le No co mmu n ica t io n re : p t imp a ct if n o n -co mp lia n t Do n 't h a ve a d e q u a t e re so u rce s La ck o f in st it u t io n a l p rio rit y f o r h a n d h yg ie n e No ro le mo d e l f o r h a n d h yg ie n e

La ck imme d ia t e f e e d b a ck/o u t co me s

In a d e q u a t e o rg . st ru ct u re f o r a cco u n t a b ilit y S ke p t ica l a b o u t e f f e ct ive n e ss In t e rf e re s w /HCW re la t io n sh ip w it h p t s Disa g re e w /re co mme n d a t io n s F a mily/visit o rs u n a w a re re :h a n d w a sh in g F a mily/visit o rs d o n 't se e b e in g p a rt o f P C O t h e r p e rso n n e l n o t a w a re P t s/visit o rs in su lt e d w h e n a ske d t o w a sh P t s n o t a t e a se a skin g so me o n e t o w a sh P e o p le f o rg e t P e o p le se t in t h e ir w a ys No t p a rt o f t h e F ro e d t e rt cu lt u re No t se e n a s a p rio rit y Co n ce rn e d w /skin irrit a t io n Do n 't u n d e rst a n d n e e d f o r h a n d w a sh in g F e e l t h a t n o n e e d t o w a sh w /g lo ve s Do n 't kn o w p ro p e r h a n d w a sh in g O n ly t o u ch e q u ip . , n o n e e d t o w a sh F e e l t h a t w a sh h a n d s e n o u g h To o b u sy/No t e n o u g h t ime

P eo p le

De la ys in g e t t in g n e e d e d e q u ip me n t No lo t io n a cce ssib le

No a lco h o l w ip e s No t e n o u g h h a n d d isp e n se rs

No d a t a t o sh o w t h e imp a ct o f h a n d h g yie n e o n t h e ra t e o f HAI S kin irrit a t io n b y h a n d h yg ie n e a g e n t s In co n ve n ie n t lo ca t io n o f h a n d sa n it ize r

La ck o f e d u ca t io n ma t e ria ls

S o a p /a lco h o l d isp e n se r e mp t y Bro ke n d isp e n se r O ve rf lo w in g g a rb a g e No t o w e ls S t a f f w o rk a re a s a re d irt y To o ma n y p e o p le in ro o m, in w a y o f sin k E q u ip me n t in w a y o f sin k

P a t ie n t ro o m is o u t o f g lo ve s

No t e n o u g h sin ks a va ila b le S in ks d o n 't w o rk

M aterials E q u ip men t Sponsored by the Wisconsin Office of Rural Health and the Wisconsin Hospital Association. Copyright of the Wisconsin Office of Rural Health.

Lack h an d h y g ien e co mp lian ce d u rin g p t in terac io n

Data Collection/Sampling Data Collection/Sampling • Key considerations Key considerations – Data must be representative of the process – Data must be reliable – Must capture measurements of importance ENTRY OBS # 1

Group 2

Group

Role(s)

Hand Hygiene Sink Hand Rub None Did Not Observe Direct Exit to Enter? Sink Hand Rub None Did Not Observe Direct Exit to Enter?

EXIT Notes

Y Y Y Y

/ / / /

N N N N

Gloves On

Y Y Y Y

/ / / /

N N N N

Gloves On

Urgent Full Hands? Blocked Access

Urgent Full Hands? Blocked Access

Hand Hygiene

Notes

Sink Hand Rub None Did Not Observe

Y Y Y Y

/ / / /

N N N N

Gloves On

Sink Hand Rub None Did Not Observe

Y Y Y Y

/ / / /

N N N N

Gloves On

Removed gloves Full Hands? Blocked Access

Removed gloves Full Hands? Blocked Access

Measurement System Analysis (MSA) Measurement System Analysis (MSA) • H How accurate is the measurement process? t i th t ? • How much variation is there in the measurement 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 minutes Result: The variation of the measurement system is too large to study the current level of process variation the current level of process variation

MSA Examples MSA 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 faced with the same findings? fi di ? Total measurement system variability should be as small as possible, but always less than 30%.


Measure

Analyze

Improve

Control

• Establish current capability

• Identify key sources of variability • Define performance objectives D fi f bj i 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?

Analyze • Graphical Tools • Flow diagrams, frequency plots, Pareto charts, etc.

• Statistical Testing‐ – Descriptive Statistics, Process Capability Hypothesis testing, Regression Analysis, etc. Analysis, etc.

• Designed Experiments


Displaying the Data p y g Descriptive Statistics

Bo xp lots o f Pt Wa it Tim e b y C L IN IC Variable: Pt Wait Time

( means are indicated by solid cir cles)

Anderson-Darling Normality T est

10

35

60

85

110

135

160

95% Confidence Interval for Mu

32.018 0.000

Mean StDev Variance Skewness Kurtosis N

23.1551 15.3332 235.108 1.25196 4.39234 2559

Minimum 1st Quartile Median 3rd Quartile Maximum

0.000 0 000 11.000 21.000 33.000 153.000

95% Confidence Interval for Mu 22.561 20

21

22

23

24

23.750

95% Confidence Interval for Sigma 14.924

150

Pt Wait Ti me e (i n min)

A-Squared: P-Value:

100

50

15.765

95% Confidence Interval for Median

0

Scatterplot of Hand Hygiene Events vs Time of Day 40

ORT

22.000

ORO

20.000

HAC

95% Confidence Interval for Median

Ha and Hygiene Events

Overall Statistics By Patient: 30

Metric

20

10

0 6

8

10

12 Time of Day

14

16

Mean Median Std Deviation Sample Size Min Max

Wait Time

23.16 21 15.33 2559 0 153

Exam Time

18.94 16 11.54 2559 0 99

Total Time

42.10 40 19.76 2559 3 183

Current Process Capability Current Process Capability How is the process performing today? p p g y Do we need to “shift the mean” or “reduce variation”? µ

T 1.235

1.239

LSL

T

1.241

1.245

USL

1.233

1.235

1.239

LSL

1.241

1.245

USL

Hypothesis Testing G tti t th R t C Getting to the Root Causes Which X’ss had the greatest affect on the Y? Which X had the greatest affect on the Y? Test

Details

Role RNs LCs DTY EVS TSP THP Day of Week Time of Day Groups p Method Full Hands Urgency Gloves Timing Access

DTY, EVS, Lab, LCs, PCAs, RNs, RTs RNs vs. All others Long Coats vs. All others Dietary vs. All others EVS vs. All others Transport vs vs. All others Therapists vs. All others Mon vs. Tues vs. Wed vs. Thu vs. Fri Observation Hours 7-16 Single g HCW vs. Groups p Sink vs. Alcohol Based Hand Rub Empty vs. Full Hands Normal vs. Urgent Wearing gloves vs. No gloves Entry vs. Exit Clear access to Sink/ABHR vs. Blocked Access

P-Value 0.002 0.422 0.004 0.005 0.056 0 020 0.020 0.020 0.285 0.039 0.868 0.000 0.000 n/a 0.463 0.000 0.965

P‐Values < 0.05 are signficant factors Must use the correct statistical tests based on types of data types of data


Measure

Analyze

Improve

Control

• Optimization of Y (Cycle time, Variability, Cost/LOS) / • Validation of Improvements • Implementation p • Control Plan % compliance 1

Generate alternatives

Test the alternative

1

UCL=0.852

0.8 0.7 Individual Value

Assess the risks

0.9

0.6 _ X=0.471

0.5 0.4 0.3 0.2

S l t th b t lt Select the best alternative ti

0.1

LCL=0.090

0.0 Wk 12 Wk13 Wk 14 Wk 15 Wk 16 Wk 17 Wk 24 Wk25 Wk 26 Wk 27 Wk 28 Wk 29 Wk 30

C22

Evaluating solutions Evaluating solutions Pugh Matrix

Evaluate how each option meets CTQs

Utilizes RN critical Thinking FTE neutral Good judgement regarding whether to take patient off tele when off unit

te

e

ce Efficient trouble shooting

Te l

Key Criteria RN accountable for patient

Im po rt an

Generate multiple multiple options!

R

at in

g co ch nt on in uo flo m us or on c w ito en ith rin tra te le g l te ch of o n ce flo nt or ra a l m nd Sh on de re ift ito le st co rin tio ru or ct di g n ur na ed t o pa po r w tie sit ith n t ion R s aw -n o lin in s c st a al ll le lig d in ht s te y s le t e ro m om

Alternatives

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Overall high standard of care maintained

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Continuous observation

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10 2 8

18 2 0

1 0 19

RN knowledge of when patient leaves unit RN knowledge of when patient returns Assurance that p patient placed p back on tele when returned to floor 30 Second response to sustained lethal rhythms or rate alarms Documentation of rate/rhythm changes Consistent/accurate interpretation of rate/rhythm Timely recognition of rate/rhythm changes

Ç

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 Sum of Negatives Sum of Sames

8 1 11

Ç Ç

Key Better Ç Same Ù Worse È

Ç = 10 ÇÙ= 8 Ù=5 ÙÈ = 3 È=1

Pilot/Validate Results Pilot Planning Pilot Planning • Failure Mode and Effects Analysis • Assure adequate sample size • Validate improvements Validate improvements through data and statistical analysis

S ICU confirm ed Glucose levels < 70 on insulin byy m onth Sept 02

June-Aug 2002

Jan Feb 03 03

Dec 02

March 03

90

Indiv idua l Vaa lue

80

UCL=84.41

Baseline

70

Mean=60.25

60 50

Pilots 40 LCL=36.09 30 0

10

20

30

40

50

60

Observation Number

70

80

90


Measure

Analyze

Improve

Control % compliance

1.2

Interim

Pilot UCL=1.119

1.0

Individual Value

• Determine capability of new process • Implement process controls • Ensure Gains are Sustained • Close the project

Pre

_ X=0.823

0.8 0.6

LCL=0.528 0.4 0.2 0.0 W k12 W k13 W k14 Wk 15 W k16 W k17 W k24 W k25 W k26 Wk27 W k28 W k29 W k30

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!

Control Determine new process capability p p y Develop control plan – Monitor Inputs and Outputs (Y’s and Xs) – Ensure that Gains are Sustained

Share Best Practices 700 600 500 400 300 200 100 0 -1 0 0

S u b g ro u p

B a s e line 1 1

1 1

200 100 0

1 U C L = 2 6 3 .8

L C L = -7 3 .7 8 0

50 P ilo t

100 P ilo t

1

500 400

P o s t P ilo t

M e an= 9 5

600

300

P ilo t

1

1

C 16

Moving R Range

Maintain the gains!

Indivvidual Value

C o n tro l C h a rt: tim e to 1 s t a n tib io tic

1

1 1

1

1 U C L = 2 0 7 .3 R = 6 3 .4 6 LC L=0

Example Six Sigma Projects p g j Safety/Quality • Insulin/Diabetes • Falls • Anticoagulation • Telemetry Response • Patient Identification • Priority Medication • Hand Hygiene • Medication Verification Process • Communication of Addi i Additional Radiology l R di l Findings

Service/Process Efficiencies

Patient flow • Ortho/Radiology • Ortho/OR • Pulmonary Functions Lab Pulmonary Functions Lab • Hem/Onc Lab Process • Hem/Onc Treatment Room • GI Lab • Patient Throughput • Discharge Process

A Access Diabetes Clinic Urology Clinic Wait time: W it ti Hand Center OP Lab OP Registration OP R i i Delays in surgery d/t missing Instruments

Lessons Learned… Lessons Learned… • Organizational Vision Organizational Vision • Senior Management must lead • Be focused ‐ strategic alignment, cascading of goals, have a plan! • Hold people accountable! • Involve Medical Staff • Stay focused y ffor a long time! 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 Lessons Learned • Culture Change g • • • •

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 Decide whether economics “lead lead or follow or follow” as a driver 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”


For More Information For More Information Beth Lanham Beth Lanham Froedtert Hospital, Milwaukee, WI P: 414 414‐805‐8685 805 8685 E: [email protected] Wisconsin Office of Rural Health Wi i Offi f R l H lth Kathryn Miller Rural Hospitals & Clinics Program Manager P: 800‐385‐0005 E kmiller9@wisc edu E: [email protected]

Wisconsin Hospital Association Wi i H it l A i ti Dana Richardson Vice President, Quality Initiatives P: 608‐274‐1820 E drichardson@wha org E: [email protected]


Six Sigma Process ItI mprovement Methodology

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