Six Sigma for
Performance Improvement
Duke University Hospital
THEF
November 29, 2007
Why Six Sigma?
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Six Sigma is a disciplined, datadriven approach to process
improvement aimed at the nearelimination of defects from every
product, process, and transaction.
The purpose of Six Sigma is to
gain breakthrough knowledge on
how to improve processes to do
things BETTER, FASTER, and at
LOWER COST. Six Sigma can be
used for any activity that is
concerned with cost, timeliness,
and quality of results.
Years
2
What is the Six Sigma Methodology?
• Six Sigma is based on . . .
– Statistical process control techniques
– Data analysis methods
– Systematic training of all personnel involved in the
activity or process targeted by the program
• The Six Sigma goal is to . . .
– Eliminate defects, waste and/or quality problems
– Improve bottom-line results, and customer satisfaction
• Six Sigma can be applied to . . .
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Manufacturing
Sales and customer service
Management
Any process
3
Six Sigma Focal Points
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Focus on the customer
Focus on teamwork
Focus on reducing variation
Focus on results
4
Focus on Customers
CTQ’s
(Critical To Quality)
5
Focus on Teamwork
• Leads Team
• Partners with
Process Owner
• Part Time
• Works Projects
Black
Belt
• Breaks Down Barriers
• Owns Project Cluster
Project
Champion
Process
Owners
• Manages Day to Day
Operations
• Controls Resources
Green
Belt
Team
Members
• 3-5 Process/Product Experts
6
Focus on Reducing Variation
• Highly variable processes result in a high number of
defects
• If an ADE is a defect and DUH administers 5 meds to
each patient per day on average, at:
– 2 Sigma – 1,001 ADE’s would occur each day (69.2% good)
– 3 Sigma – 217 ADE’s would occur each day (93.3%)
– 4 Sigma – 20 ADE’s would occur each day (99.4%)
– 5 Sigma – 3 ADE’s would occur every 4 days (99.98%)
– 6 Sigma – 1 ADE would occur every 3 months (99.9997%)
7
Hand Tools
• Brainstorming
• Cause-and-effect Diagrams
• Graphs and Charts
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Box Plot
Dot Plot
Histogram
Pareto Chart
Run Chart
Scatter Plot
• Process Flow Diagrams
• Statistical Process Control
• Stratification
8
Power Tools
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Value Stream Analysis
Analysis of Variance (ANOVA)
Correlation & Regression
Design Of Experiments
– Full Factorial Designs
– Fractional Factorial Designs
– 2k Designs
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FMEA
Hypothesis Testing
Measurement System Analysis
Process Capability Studies
Response Surface Methods
9
Focus on Results
Y = f(X)
10
Focus on Results
Patient Safety
Cost Avoidance
Cost Savings
Revenue Generation
Quality Care
Public Confidence
Include hidden cost
11
Technical Definition of a Six Sigma Process
Off-Target
A Six Sigma Process
LSL
USL
6σ
Too Much Variation
6σ
Process is centered around
the target with 6 standard
deviations between the
mean and upper and lower
specification limits.
12
What does a Six Sigma
Program look like?
Structure
• Leadership
• Direction
• Resources
Strategic
Alignment
Tools
• Business
Objectives
• Customer
Requirements
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•
•
•
DMAIC
FMEA
Workout
LEAN
13
The Tools of Six Sigma
• Analysis Tools
– The Scientific Method
(DMAIC)
– LEAN
• Improvement Tools
– Mistake-Proofing
– Design of Experiments
– FMEA
• Process Monitoring
Tools
– Audits
– Control Charts
• Facilitation and
Project Management
Tools
– Workout and Kaizen
– Brainstorming
14
DMAIC – Scientific Method
Define
Project goals and boundaries are set, and issues
are identified that must be addressed to achieve
an improved quality level (i.e., defect rate).
Measure
Information about the current situation is
gathered in order to obtain baseline data on
current process performance and identify
problem areas.
Analyze
Root causes of quality problems are identified
and confirmed with appropriate data analysis
tools.
Improve
Solutions are implemented to address the root
causes of problems identified during the analyze
phase.
Control
Improvements are evaluated and monitored.
15
What does a Six Sigma
Program look like?
Structure
• Leadership
• Direction
• Resources
Strategic
Alignment
Tools
• Business
Objectives
• Customer
Requirements
•
•
•
•
DMAIC
FMEA
Workout
LEAN
16
Sources for Nominating Projects
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Balanced Scorecards
Patient complaints, responses to surveys
Regulatory Issues
Benchmarking shortfalls
Critical items in financial reports
Strategic business plans
17
Alignment
DUH Priority
Be a top performing hospital for publicly reported data
CSU Measure
CMS Evidence-Based Care Score
Improvement
Opportunity
Adherence to AMI Process Measures
Research supports
that measure
adherence drives
outcome.
Six Sigma
Project
Improve Time to PCI
Outcome
1. Improve median PCI time to 54 min
2. Leadership of State-Wide RACE Project
3. Research Studies
4. Process Recommendations to ACC
18
What does a Six Sigma
Program look like?
Structure
• Leadership
• Direction
• Resources
Strategic
Alignment
Tools
• Business
Objectives
• Customer
Requirements
•
•
•
•
DMAIC
FMEA
Workout
LEAN
19
The Structure of a Six Sigma Program
• Executive/Owner Involvement
– Top-level support is the most important factor leading
to success
– Organizational leaders must
• Set the vision for success
• Create an environment demanding of improvement
• Review all projects and expect results
• Resource Allocation
– Utilize your best employees
– Make time for them to do the work
20
The Structure of a Six Sigma Program
• Structured project review process
– Review projects regularly
– Develop clear guidelines for success and completion
• Training
– Ensure all involved employees understand their roles
in the improvement process
– Invest in advanced training for project leaders
21
Resource Model
• 45 trained black belts; 123 trained green belts
• Centrally placed
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Organize and execute the deployment plan
Lead organizational projects
Support operationally placed black belts
Located in Performance Services
• Operationally placed
– Aligned with Clinical Service Units (CSU) and targeted
Departments
– Primary reporting relationship with the departmental / CSU
leadership
22
Six Sigma Oversight Committee
• Accountable to DUH Executive Committee
• Oversight of projects and organizational project
selection
• Structured review format
– Approval of projects
– Tollgate reviews
• Oversight members
– COO, CFO, CNO, Director of HR, Director of
Accreditation/Clinical Quality/PSO, Senior AOO
23
Six Sigma Black Belt Council
• Coordinate and collaborate as a collection of key
subject matter experts to review analysis and
provide input for other black belt projects
• Provide input to Six Sigma Oversight Committee
regarding potential black belt projects
• Review and recommend improvements to the
Six Sigma training programs
24
Project Example
Orthopedic Patient Satisfaction
CTQs
What is “Critical to Quality” (CTQ)?
– Patient Outcome
– Patient Safety
– Positive Experience
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Appropriate Response to Concerns
Inclusion in Decisions about Treatment
Address Emotional Needs
Sensitive to Inconvenience
Attention to Personal Needs
Information and Communication
26
Problem and Mission
Statements
Problem Statement
The FY05 average overall patient satisfaction mean
score for Duke University Hospital Orthopedics
Specialty was a .6 deviation from the target.
Orthopedics Specialty ranks in the 65th percentile
compared to COTH hospitals.
Mission Statement
Improve overall mean satisfaction score to 84.1,
increasing the specialty ranking to approximately the
74th percentile compared to COTH and orthopedic
specialty hospitals, for discharges starting April 2006.
Rank based on Jul 04 – March 05
27
Initial Performance
Overall Mean Score
90
89
88
87
86
85
84
83
82
81
80
79
78
77
76
75
85.3
84.9
83.1
83.5
82.8
82.5
81.4
80.8
81
78.9
78.7
76.5
2005-07 2005-08 2005-09 2005-10 2005-11 2005-12 2006-01 2006-02 2006-03 2006-04 2006-05 2006-06
Actual
Target
Linear (Actual)
28
Measure/Control
Hospital Level
IP Overall Mean Score
SAS Scorecard
CSU Level
SAS Scorecard
Unit Level
6100 Overall Mean Score
6100 Overall Mean Score
Nursing BSC
Unit Level
6100 Mean Score by Unit and Question
Press Ganey Report
Detail
Patient Surveys and Comments
Press Ganey
29
Potential Factors
Y=f (x1)+f(x2)+f(x3)+f(x4)+f(Xu)
X1 = Age
X2 = Gender
X3 = Procedure
X4 = Race
X5 = Timeframe
X6 = Discharge Disposition
X7 = Procedure
X8 = PG Question
Process
Inpatient
Mean Score
X8a = Task
X9 = Pre-op Education
X10 = Staffing
X11 = Turnover
30
Productivity Correlation
87.5
Summary of Fit
85
RSquare
RSquare Adj
Root Mean Square Error
Mean of Response
Observations (or Sum Wgts)
sat
82.5
80
0.227417
0.150159
2.413577
82.32117
12
Analysis of Variance
Source
Model
Error
C. Total
77.5
75
75
80
85
90
DF Sum of Squares Mean Square
1
17.147515
17.1475
10
58.253522
5.8254
11
75.401037
95
F Ratio
2.9436
Prob > F
0.1170
prod
 Satisfaction Increases as Efficiency Increases
 No correlation between Census and Satisfaction
31
Work-OutTM February 23, 2006
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Response to concerns and complaints
Include in decisions re: treatment
Staff addresses emotional needs
Staff sensitivity to inconvenience
Nurses kept you informed
Attention to special/personal needs
A
B
Staff Chose Option A:
More concrete concept, staff able to control, easier
to create processes to improve
32
Implementation of Action Items
• Communicate with Patient About their Care
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Develop process for shift goal ID during assessment (Vanita)
Develop call light process (Lisa H & Lisa W)
Develop scripting messages (Lisa H)
Develop & implement training for basic rehab skills (Jennie &
Kathy)
– Display mobility on white boards (Kathy)
• Communication Between Staff
– Communicating assignment in report process (Vanita)
– Implement process for posting PRM & PT assignments
(Joyce & Kathy)
– Identify patients that will be seen early by PT/OT (Kathy)
– Develop infrastructure for complaint resolution (Carey)
– Communicate recommendations from team related to report
process (Vanita)
33
Implementation of Action Items
• Expectation Setting for the Inpatient Experience
– Create “Welcome to 6100” document (Shane)
– Communicate with MDs about classes (Carey & Jennie)
– Implement incentive for class (Jennie)
• Training/Behaviors for Staff
– Communicate performance expectations as outlined in PPS
(Linda)
– Develop schedule and plan for training (Joyce, Alene, Linda &
Shane)
• Culture of the Unit
– Develop structure and avenue to implement peer feedback
(Monica)
– Posting Press Ganey Scores and Comments (Carey)
– Ensure peer support for breaks (Monica)
– Develop award system for staff (Alicia)
34
Control Process
• Measure Reviews by Nurse
Manager/Clinical Operations Director
– Overall Score monthly
– Question review monthly
– Good/Very Good review monthly
• Reaction Point
– 2 points below target requires follow-up at
Musculoskeletal CSU Executive Meeting
• Rounding/Leadership Follow-Up
• Staff awareness through storyboards
• Pay and performance Link at Management
and Staff Level
35
Performance Summary
Overall Mean
90
89
87.9
88
87
86
Implementation of Action
Items
85.4
86
85.3 84.9
85
Project Start
83.5
85.6
85.2
84.8
Work-Out
83.1
84
83.3
83
82.8 82.7
82.5
82
83.1
81.4
81
80.8
81
81
83.4
82.8 82.7
81.3
80
79
78.9
78.7
78
77
76.5
76
75
Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-07 Feb-07
Actual
Target
Linear (Actual)
36
Performance Summary
Percentile Ranking
37
Questions?