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2

Ricardo Leaño, MD, MBA, CSSBB

s Physician. Board Certified Anesthesiologists Master of Business Administration. Specialization

in Health Administration and Policy. University Of Miami.

s Leading Teams and Organizations, Effective Leadership, Executive Leadership Strategies. University of Notre Dame. Mendoza College of Business

s American Society for Quality (ASQ) Certified Six Sigma Black Belt.

s Co-Chair Educational Committee ASQ-HCDs American College of Healthcare Executives-ACHE

3

Ricardo Leaño, MD, MBA, CSSBB

s Clinicals Managerials Leaderships Quality

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“It is not the strongest that survive,

nor the most intelligent,but the one

most responsive to change”

Charles Darwin (1809-82)

5

Why you are here

"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe]

is right.“Jane Goodall

InformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009

6

HEALTHCARE

ORGANIZATIONS

SIX SIGMA

EMPOWERMENT.

H.O.R.S.E. LEANRicardo Leaño, MD, MBA, CSSBB

7

s Healthcares ORganizationss Six sigmas Empowerment

H.O.R.S.E. Lean

horse [v. to haul or hoist energetically]

Webster’s II New Riverside University Dictionary

8

H.O.R.S.E. Concept

The H.O.R.S.E. principles greatly emphasize leadership and

strategic management together with Lean Six Sigma

methodologies so as to hoist energetically our healthcare

system in the right direction.

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H.O.R.S.E. Concept

s Every internal organization must understand how and why other individuals/organizations work, how and why they make decisions and unite them to keep the mission, vision and goals of their institution as part of their own missions, visions and goals.

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Lean Six Sigma

Leadership

H.O.R.S.E.

Principles

Strategic Managemen

t

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Positive Financial Impact

Process

Improve

ment

Increased Productivity

Waste

Reduction

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Lean, Six Sigma and Lean Six Sigma

Jing, G.G. “A Lean Six Sigma Breakthrough”

Quality Progress. May 2009

Lean:Improvement approach

aimed at improving efficiency by removing

wastes

Six Sigma:Improvement approach

aimed at improving process capability by

reducing variation

Lean Six Sigma:Improvement approach aimed at

combining both Lean and Six Sigma to improve efficiency and capability primarily by removing wastes and

variation

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primum non attero [first do no waste]

primum non nocereFirst do no harm

secundus non atteroSecond do no waste

14

ISO 26000 Defines Social Responsibility

“responsibility of an organization for the impacts of its decisions and activities on society and the environment, through transparent and ethical

behavior that contributes to sustainable development, health and the welfare of society;

takes into account the expectations of stakeholders; is in compliance with applicable law and consistent with international norms of

behavior; and is integrated throughout the organization and practiced in its relationships”

Vincent, C. “Back in Circulation”

Quality Progress. May 2009

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…in healthcare…

wasted

16

Margin

Revenue = Outputs x Prices Expenses = Inputs x Costs

Profitability = Productivity x Price Recovery

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Margin

Margin Compression ↑ Revenue = Outputs x Prices Expenses = Inputs x Costs ↑ ↑

Margin Looseness ↑ ↑ ↔ ↑ Revenue = Outputs x Prices Expenses = Inputs x Costs ↓ ↓ ↓

Profitability = Productivity x Price Recovery ↑ ↑ ↑

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Budget

Profit is determined by revenue and expenditures

Financial position is determined by profit and capital expenditure

These are determined by Market share Price Customer satisfaction Quality Worker satisfaction

Griffith J, White K “The Well-Managed Healthcare Organization”. 6th Edition

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DRA (Deficit Reduction Act of 2005)

Beginning October 1, 2008, Medicare will no longer pay the higher MS-DRG for these HACs (Hospital Acquired Conditions)

s pressure ulcer stages III and IV; s falls and trauma; s surgical site infection after bariatric surgery for

obesity, certain orthopedic procedures, and bypass surgery

s vascular-catheter associated infection; s catheter-associated urinary tract infection; s administration of incompatible blood; s air embolism; and s foreign object unintentionally retained after surgery.

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To err is human

“medical errors do not result from … a ‘bad apple’ problem. More

commonly, errors are caused by faulty systems, processes, and

conditions that lead people to make mistakes or fail to prevent them. “

I N S T I T U T E OF M E D I C I N E November 1999

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Institute of Medicine

Six Aims for Improvement1. Safety – Avoiding injuries2. Effectiveness – Services based on scientific

knowledge3. Efficiency – Avoiding waste4. Patient-centered care – Care that is respectful of

and responsive to individual patient preferences, needs and values

5. Timeliness – Reducing waits and harmful delays6. Equitable care – Equal care to all regardless of

gender, ethnicity, location and socioeconomic status Institute of Medicine

Crossing the Quality Chasm:

A New Health System for the 21st Century

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Healthy People 2010 goals…

“…safe, effective, patient-centered, timely, efficient, and equitable care

that extends the quality [and length] of life and reduce health disparities”

Griffith, J.R., White, K.R.

“The Well-Managed Healthcare Organization”

6th ed. Health Administration Press

23

Concepts

s Sigma (). Standard deviation. Provides an estimate of the variation in a set of measured data

s Sigma level. Describe the performance of a process relative to the specification limits.

s Process: Sequence of activities that transform inputs into Outputs

s Quality: “Is a predictable degree of uniformity and dependability, at low cost and suited to the market”

Deming, W.E.

s Defect: Failure to meet customer requirements

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Sigma

Narrow VariationNarrow Variation Wide VariationWide Variation

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Sigma Level

Performance of a process relative to the specification limits Yield Defects per

million opportunities

Sigma Level

69.1500% 308,500 2.0

84.1300% 158,700 2.5

93.3200% 66,800 3.0

97.7300% 22,700 3.5

99.3800% 6,200 4.0

99.8700% 1,300 4.5

99.9770% 230 5.0

99.9970% 30 5.5

99.9997% 3.4 6.0

International Survey Supported by the Commonwealth Fund 2007

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s One in three of U.S. respondents reported experiencing medical mistakes, medical errors, inaccurate or delayed lab results.

s Highest rate of any of the six countries in the survey.s U.S. 32%s Canada 28%s Australia 26%s New Zealand 22%s Germany 16%s U.K. 24%

s Most patients (61% - 83%) in each country said health care providers did not tell them about the errors.

(Schoen, et. al. Health Affairs, Web Exclusive; W5-509-W5-525)

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Process. Y = f(x)

Everything is a Process

“A systematic series of actions directed to the achievement of a goal” J.M. Juran

Method(x)

Man(x)

Material(x)

Machine(x)

PROCESSING(f)

Environment

(x)

Output(Y)

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Lean Six Sigma

Blame the processnot the individual

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To err is human

“medical errors do not result from … a ‘bad apple’ problem. More

commonly, errors are caused by faulty systems, processes, and

conditions that lead people to make mistakes or fail to prevent them. “

I N S T I T U T E OF M E D I C I N E November 1999

30

Quality Definitions

s “…a predictable degree of uniformity and dependability, at a low cost and suited to the market” W.E. Deming

s “…any characteristic that improves the product or service in the eyes of the buyer.” J. Griffith, K. White

s Hard to define, but you recognize it when you see it ACHE Congress 2008

s “The least cost to Society” Genichi Taguchi

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Lean Six Sigma Definitions

s “A comprehensive and flexible system for achieving, sustaining and maximizing business success”

MoreSteam University

s “…relentless and rigorous pursuit of the reduction of variation in all critical process … that impact the bottom line … and increase customer satisfaction”

H. Gitlow. University of Miami

s “a disciplined, data-driven approach and methodology for eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process”

iSixSigma.com

s An objective journey toward process improvement

Ricardo Leaño

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Lean Six Sigma

s Structured methodologies for sustained process improvement

s Both are complementary processes, not competitive approaches

s Both represent a cautious compilation of previously developed quality tools and a framework for action with the particular and common objective of improving quality by performing relative to customer requirements and eliminating waste.

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How they work

s Identify and eliminate non value-added activities

s Identify and reduce variations Understand and optimize

processes by focusing on inputs

34

DMAIC

s Defines Measures Analyzes Improves Control

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Define (DMAIC)

s Dashboard - Scorecards Project charter (Business Plan)s SMART project (specific, measurable, achievable,

relevant, time bound)

s SIPOC analysiss Process Flow Charts Voice of the Customer (VoC) analysis

Affinity Diagram Operational Definitions

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Mission: To provide safe anesthesia in a pleasant enviroment and create a cost-effective Operating Room

             Anesthesiologist   OR Management

Key Objectives Key Indicators   Key Oblectives Key Indicators   Tasks or Projects

             Provide Safe Anesthesia having updated equipment, bringing patients in the most optimized condition and having detailed information about patient's condition

Number of patients arriving to pre-op area not optimized per day

Have patients in the best of her medical condition prior to surgery

Number of patients in pre-op area not optimized due to delay in executing MD orders

Develop, with ward nurses, a system to prioritize patients going to OR and more effective communication with PMD

  Number of patients in pre-op area not optimized due to lack of PMD evaluation

Develop with PMDs a set of minimum parameters in terms of lab results before taking the patient to an elective surgery

  Number of patients without a complete cardiac clearance per day

Medical clearance should include complete and objective information useful to the anesthesiologist

Number of incomplete cardiac evaluations per day

Develop, with cardiologists, a format to fill up the information required prior to an elective surgery

  Age of anesthesia monitors and machines per room

Anesthesia equipment and monitors must be updated

Age of anesthesia monitors and machines per room

Install modern equipment that is compatible in all the perioperative areas

             Create a Cost-effective OR with less sub-utilized OR time

Number of cases that are not properly booked in terms of length of surgery and start time

Booking process must be revised and improved to eliminate unused Ors

Number of cases that are not properly booked in terms of length of surgery

Surgical time per especific surgery has to be determined by surgeon's historical data and as an average for new surgeons

  Number of cases that are not properly booked for other reasons

Develop a detailed flowchart and analisys to improve process through PDSA cycle.

  Time in minutes of unused OR rooms per day Eliminate time of non-used OR during the 7-3 shift

  Time in minutes of delay per case Delays should be eliminated Number of delays due to late patient arrival per day

Improve patient's understanding the importance of on-time arrival and help solving difficulties they may have

  Number of delays due to hospital reasons (anesthesia, nursing) per day

Identify and improve processes shown to create delays

  Number of delays due to surgeons, per day Identify and improve processes shown to create delays

  Average time between cases per day Decrease turnover time Average turnover time at AM, at lunch time and PM

Improve processes to decrease turnover time

  Average tardiness time in minunes per surgeon per day

Arrival time should be controlled Record arrival time of surgeons if first case in AM vs. later case

Develop and implement polices to encourage surgeons to be on-time

  Number of cancellations per day Cancellations should be avoided Number of cancellations by surgeon by surgery type per day

Find and correct the reasons that lead to cancellations

  Surgeon satisfaction survey by quarter Estimulate surgeons to have this OR as his/her most important one

Survey surgeons the degree of importance of each of the hospitals they go

Estimulate loyal and managed surgeons. Avoid policy breakers. Create a pool of "good customers"

             Pleasant enviroment Average working hours of personnel per day Improve employee satisfaction. Avoid work

overloadAverage working hours per position per day Avoid work overload. Hire personnel for several shifts if

necessary.

  Number of cases performed after hours that are not true emergencies

Avoid work overload. Avoid elective cases after hours

  Employee satisfaction survey per quarter Improve employee satisfaction. Maintain morale Number of resignations per quarter Empower certain employees Create and implement policies regarding any form of abuse

  Employee survey regarding verbal or other form of abuse

  Improve employee satisfaction. Maintain respect Survey patient satisfaction periodically   Create and implement policies regarding any form of abuse. Specialized trainning to satisfy surgeon's demands

Suppliers Inputs (Xs) Process (Xs)

Outputs (CTQ) Customer

Surgeon/ResidentAnesthesiologistOR staffRR/ICU nurseRN/Scrub techPt/familyHolding RN

Closure. Next pt readyPt emergenceTransfer pt/clean roomAccepts ptOpen next caseSign consentsNext pt ready

Pt will leave the OR and the next pt will be in the OR safely and in compliance with the regulatory agencies

Patient and relativesNursing Staff (OR)Scrub tech/OR staffPhysiciansSurgeons AnesthesiologistsManagementRegulatory agenciesPayers

Pt emergence Pt out of OR Clean room Case open Next pt ready Next pt to OR

Anesthesiologist decides pt is ready to safely leave the OR

Pt is safely transferred via stretcher with all necessary monitors. Room available in PACU/ICU

Instruments are removed and the room is cleaned according to protocol

New instruments and necessary equipment is ready available in the room

Holding nurse has the next pt ready. Consents are signed. Surgical site marked.

Pre-op meds including antibiotics are given and anesthesiologist and nurse transfer the pt to the OR

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Yes

MSAs clean the

room

Charge RN sends for next patient (Surgery)

Pt leaves the OR

OR tech removes

instruments

MSA leaves OR to pick up the

patient (Surgery)

OR RN goes to Holding to verify if

next pt is ready

Bring new instruments to the room

X-Ray tech

needed

Pgt arrives to holding area (Floor

or Same day Surgery)

Holding RN verify check list (Green

Check List)

Anesthesiologist OKs patient (Consent)

Surgeon sign consents and

mark site

Get X-Ray tech

Patient in to the OR

Voice of the Customer – Affinity Test

MSAs (10) Anesthesia (4) Surgeons (12)

Radiology (6) Instruments (8) Nurses (8)

CTQ TAT (Door to Door)

Lack of paper work readiness/Site not Marked.

Lack of adherence to original schedule.

Lack of communication among OR RNs with floor RNs and Residents

Shortage of RNs

Lack of Pre-op evaluation on time

Supply not stocked properly

Insufficient C-arms

Delay in the tech availability

Washer machine broken frequently

They are responsible for two different task (cleaning room and transportation) Short staff (3 MSA for 6 ORs)

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Measure (DMAIC)

“If you can’t measure it, you can’t improve it”

“Not everything that can be counted counts and not everything that counts

can be counted”Albert Einstein

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Measurement System Analysis

s Identify what to measures Determine how to measures Develop sampling plan and reaction

plans Validate measurement system (Gage R

& R)s Add to overall control plan

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SPC charts

9181716151413121111

300

200

100

0

Observation

Indiv

idual V

alu

e

_X=84.4

UCL=205.9

LCL=-37.1

9181716151413121111

300

200

100

0

Observation

Movin

g R

ange

__MR=45.7

UCL=149.2

LCL=0

1

1

1

11

1

1

1

1

11

1

TAT - June and July

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Analyze (DMAIC)

Identify and understand causal relationshipss Characterize the process (current state)

s Fishbone, Box plots, Regression Analysis,s Validate the suspects and compare treatments

(which action is more effective)s Hypothesis testing. Z-test, t-test, ANOVA, chi

squareds Model the process (understand relationships,

how X impact Y)s DOE (Design Of Experiments)

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Pareto Chart

C2 50 30 12 3 2 1 1 1Percent 50.0 30.0 12.0 3.0 2.0 1.0 1.0 1.0Cum % 50.0 80.0 92.0 95.0 97.0 98.0 99.0 100.0

C1 OtherORT/ReconENTTR/MSORT/FORT/HTCUORT/T

100

80

60

40

20

0

100

80

60

40

20

0

C2

Perc

ent

Pareto Chart of C1

Turn Around Time (TAT) Process. Direct Observation (minutes)

OR 825 13 12

26

OR 824 15 52

70

OR 84 2 11 24

29

OR 854 24 18

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Instruments Out Mean: 3.2 min

Room is Clean Mean: 18 min

OR 86 26 14

36 Next Case Set-Up Mean: 24 min

Goal for TAT is less than 45 min Total TAT Mean: 41.8 min

11 12 Best times !24

3.2 18 24

Time average41.8

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Improve (DMAIC)

s Benchmarkings Brainstormings FMEA (Failure, Mode, Effect, Analysis)s Poka-yoke (Error-Proofing)s Continuous flows Quick changeoverss Theory of constrainss Pull scheduling/JIT (Just In Time)s Correction action matrixs Pilot a solution

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48

Improve - Benchmarking

Process of developing higher performance standards for your process based on a comparison to other processes, internal within your organization or external from competitors with better performance (most common)

s Industry publications & trade journalss Industry related meetingss Public financial reportss Third party studiess Company publications/ facility visits

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Improve - Brainstorming

s Brainstorming is a technique used to elicit a large number of ideas from a team using its collective thinking power”

Gitlow, HS “Six Sigma for Green Belts and Champions”

s The foundation of brainstorming is an atmosphere of suspended judgment (no criticism) so that a large number of ideas freely flow from the participants.

s Brainstorming is intended to encourage fresh thinking and ‘crazy’ ideas

Moresteam.com/university

50

Improve - FMEA

s Failure Mode Effect Analysis is a tool used to prioritize potential defects based on their severity, expected frequency, and likelihood of detection

s Scores are assigned to each potential defect mode of a process in 3 categories: Severity, Occurrence, Detection

s Scores will lead to a Risk Priority Number (RPN)

s The highest RPN would be the highest priority for improvement

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Improve – F.M.E.A.Causes Sev

erity

Occurrence

Detection

RPN

Action Plan Owners

Tardiness 8 7 5 280 (3)

Collect data. Analyze. Present to upper management

Lou, Carlos

Lack of anesthesiology protocol

9 10 5 450 (1)

Create perioperative protocol

John, Raul

Redundant paperwork

7 10 3 210 (4)

Create consolidated perioperative forms

Kevin, Juan

No enforced “Bumping protocol”

10 4 5 200 (5)

Readdress existing policy to surgeons

Alexander, Sandy

Shortage of anesthesia tech

9 8 5 360 (2)

Develop a process to tech to follow

Lou, Jose

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Improve – Poka-yoke

s Error-proofing or mistake proofing refers to the implementation of fail-safe mechanisms to prevent a process from producing defects

s The philosophy: It is not acceptable to make even a very small number of defects, and the only way to achieve this goal is to prevent them from happening in the first place

s FMEA, fishbone and brainstorming are used to organize efforts

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Improve – Quick Changeovers (SMORE)

s Single Minute Operating Room Exchange. From Shigeo Shingo’s SMED (Single Minute Exchange of Die)

s The foundation is the distinction between Internal Setup (work that occurs when the system is idle) and External Setup (work that occurs while the system is running)

moresteam.com/university

54

Improve – Quick Changeovers (SMORE)

s Staged equipment (preference cards)s Operations conducted in parallel (emergence–bags

out)s Standardization (same tools, stretchers, 5S)s Quick attachments (laparoscopic equipment)s No-Adjust equipment and tooling s Duplicate equipment and tooling (double

instruments)s Assisted tool movement (for cleaning, equipment,

patient, etc)moresteam.com/university

55

Improve – Continuous Flow

s In many ways, the term Continuous Flow defines Lean Methods by improving the movement of material or information through a process

s It means a service progresses through a series of value-added steps without delays (inventory), rework (defects) or non-value added operations

s Reducing cycle time requires achieving a more continuous flow to match the pace of demand with the pace of production

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Flow in a Healthcare Environment

s Flow of patientss Flow of clinicianss Flow of

medications Flow of supplies

s Flow of informations Flow of equipments Flow of process

engineerings [Flow of housekeeping]

Black, J with Miller D

The Toyota Way to Healthcare Excellence

ACHE Management Series. 2008

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Control (DMAIC)

s The goals of the Control phase ares 1. Sustain the improvement

s SPCs 5S [Sort, Set in order, Shine, Standardize,

Sustain]s Total Productive Maintenance (TPM). Goal: Drive

waste to zeros 2. Sharing the knowledge

s Best practices & Lessons learned s Project Close-Outs Maintain LEAN education and LEAN ambiance

58

Waste (Muda) - Taiichi Ohno

s Overproductions Defectss Inventorys Motion primum non attero

s Overprocessings Transports Waitings [Underuse of talent]

Black, J with Miller D

The Toyota Way to Healthcare Excellence

ACHE Management Series. 2008

59

primum non attero [first do no waste]

primum non nocereFirst do no harm

secundus non atteroSecond do no waste

60

5 S

s Sort (seiri): Sort out necessary from unnecessary items

s Set in Order (seiton): Necessary items should be easily accessible

s Shine (seiso): Dispose of unnecessary items Standardize (seiketsu)s Sustain (shitsuke)

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The most essential tool

The least common of the senses..

the Common Sense

62

63

Barriers to Lean 6

s Lack of knowledges Fearfulness of statisticss Lack of unification of information .

ASQs Stubborns Fear of physicians desertion

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Change

s Three types of Knowledges Awareness knowledge. Information that innovation exist s How-to knowledge. Information to use it properlys Principles knowledge. Information dealing with the

principles underlying how the innovation workss Equilibrium

s Stable equilibrium. Status Quos Dynamic Equilibrium. The rate of change occurs at a

rate that is equal with the system’s ability to cope with it

s Disequilibrium. The rate of change is too rapid to permit the system to adjust

Rogers, E. M. Diffusion of Innovations. 5th Edition

65

To Remember

s Everything is a processs If you can’t measure it, you can’t

improve its Use data instead of ‘paper, scissors, rock’s Software will help with statistics

s Maintain Lean ambience and educations primum non attero - First do no Wastes Be Socially Responsibles Start a dialogue

66

Why you are here

"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe]

is right.“Jane Goodall

InformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009

67

Be clear

s TEACHER: Maria, go to the map and find America MARIA: Here it is. TEACHER: Correct. Class, who discovered America?

CLASS: Maria. &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

s TEACHER: What is the chemical formula for water? DONALD:     H I J K L M N O. TEACHER:  What are you talking about? DONALD:     Yesterday you said it's H to O.

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ralmdmba@yahoo.com

Thank You!

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