Six Sigma Process ItI mprovement Methodology...Six Sigma Process ItImprovement Methodology Presented by Content Expert: Beth Lanham, RN, BSN, MBA Director, Six Sigma Froedtert Hospital,

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



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



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.



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



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



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



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!



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



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



Six Sigma Model DMAICSix Sigma Model ‐DMAIC


• 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



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



• 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.



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%.



• 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



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



/• 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



% 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”



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]



Documents

Six Sigma Process ItI mprovement Methodology...Six Sigma Process ItImprovement Methodology Presented by Content Expert: Beth Lanham, RN, BSN, MBA Director, Six Sigma Froedtert Hospital,