HHHoldorf SIX SIGMA IN HEALTH CARE White Belt Training All Health care workers and Students should hold a Six Sigma White Belt!! • Six Sigma White Belt training is designed to provide knowledge to all health care staff and students to help identify waste and other process improvement opportunities. • While we cannot initiate a project or process changes ourselves, the training/certification is meant to provide us with the background to identify opportunities that we should then bring to our managers as suggestions for improvements. Training Objectives & Topics • Objective: – To gain a general understanding of Six Sigma Process Improvement methodologies and the value of Process Improvement (PI). Agenda • • • • • • • • • • What is Six Sigma? Why Six Sigma? Your role as a Six Sigma White Belt Process Improvement Methodologies Benefits of Process Improvement (Financial and Operational) Project Selection Process Improvement Tools Measurement Roles and Responsibilities Certification Exam What is Six-Sigma? What is Six Sigma? • Sigma (σ) is the Greek letter that is used to define the standard deviation of a population – It measures the variability or spread of the results of a process 6 Standard Deviation • Used in statistics, shows how much variation or dispersion from the average exists. • A low SD indicates that the data points tend to be very close to the MEAN. • A high SD indicates that the data points are spread out over a large range of values. Why Six Sigma? 6 11 • Six Sigma allows us to identify and correct a problem through standardized process. Sigma Values 99% is around 3.5 Sigma Sigma Value (Also called Z) Average Hospital Today Yield % 1.5 Sigma 50% 2 Sigma 69.1463% 3 Sigma 93.3193% 4 Sigma 99.3790% 5 Sigma 99.9767% 6 Sigma 99.9997% 13 • Is 99% Ok? • That is: if you are successful 99% of the time (3.5 Sigma), are you sitting pretty? 99% defect-free examples • 12 newborns given to the wrong parents each day • 103,260 income tax returns processed incorrectly each year • 291 pacemaker operations performed incorrectly each year • Bad drinking water from your tap at home for 15 minutes each day • 20,000 incorrect drug prescriptions each year • 1 wrong medication every hour at a typical hospital 15 • 1 out of 100 patients get the wrong wrist band • 1 out 100 rooms do not get their bathroom cleaned during the cleaning process • It is ok to be 3 sigma in some processes and 6 sigma in others? • For example, in the airline industry it would be more acceptable to have a 4 sigma in lost luggage (around 6200 pieces of lost luggage per one million) but when it comes to safe landings planes are above 6 sigma. They are around 8 sigma level or 0.43 defects per million opportunities. Six Sigma Principles Six Sigma as a methodology To accomplish our BUSINESS strategy, Six Sigma says…. Focus on what the CUSTOMER values and will pay for Customer Focus The Customer Defines Quality Be excellent in these things by REDUCING VARIATION (with a side benefit of lower cost). Variability is the Enemy! This is accomplished by DATA DRIVEN DECISIONS (we know the root causes) Act on Fact! This requires Valid MEASUREMENT (which also drives Behavior) Measurement is the Key! Then Solve the problem and CONTROL the process (which utilizes TEAM brainpower) Employee Brainpower 17 – Six Sigma is a problem-solving methodology. It improves business and organizational performances. – Six Sigma performance uses statistics to help processes produce fewer than 3.4 errors per million opportunities for defects. – Six Sigma improvement is when the key outcomes of a business or work process are improved dramatically. – Six Sigma deployment is the prescriptive rollout of the Six Sigma methodology across an organization, with assigned practices, roles, and procedures according to generally accepted standards. – Six Sigma toolset is the collection of methods and tools, including statistics and analytics, that Six Sigma practitioners use to consistently achieve breakthrough levels of improvement. Your role as a Six Sigma White Belt • Six Sigma White Belt Training is designed to provide knowledge to you to help identify waste and other process improvement opportunities. • As a certified white belt, you cannot initiate a project or start a process change on your own. • The training/certification is meant to give you the background to identify opportunities that you should then bring to your manager as a suggestion for improvement. Process Improvement Methodologies Process Improvement Methodologies DMAIC PDCA Lean DFSS Define Measure Analyze Improve Control Plan, Do, Check, Act Kaizen, Design for Six Sigma Improving existing processes Used for the control and continuous improvement of processes Work Out Eliminates waste and maintain the gains Iterative method Root Cause Unknown (Repetitive or procedural method) Improve cycle times Change Management (CAP) To create business gains by designing new processes or products or services 2 1 What are the differences between Process Improvement methodologies? • -DMAIC focuses on improving existing processes. The “issue” or the reason we are having problems is unknown or not quantified. • -PDCA is used for continuous improvements. A “large scale” DMAIC project is not needed because you know the issue and how to fix it. • -Lean is mainly used to reduce cycle times and get rid of waste. • -DFSS is when you are designing a new process or service. It is used to design a high functioning process so you will not need to use DMAIC or LEAN in the future. CAP- Change Acceleration Process A methodology that helps organizations lead and sustain change efforts DMAIC The root cause of any problems are unknown • DMAIC is a structured methodology – To improve processes – Using data to make decisions • DMAIC is an acronym for the Six Sigma databased process-improvement methodology The ultimate objective is to achieve business results using a data-based improvement methodology 2 3 • DMAIC is Often the method of choice for root cause analysis. USE When the root cause is unknown • Define relates to scope. What will or will not be included in the measurements. What are the goals. • Measure involves the development of key performance indicators. • Analyze involves identifying the opportunities and gaps demonstrated by the data, “evidence-based conclusions” • Improve phase begins with a plan and should generate and test identified possible solutions • Control is not simply conclusion. Maintain the gains and keep the solution going with an outline, Standard Operating procedure, or metrics PDCA • Establish the objectives and processes necessary to achieve your results goals • Pilot to test possible effects • Create action plans on significant differences between actual and planned results. • Analyze the differences to determine their root causes. • Implement the plan • Execute the process • Collect data for charting and analysis in the following "CHECK" and "ACT" steps Plan (P) Do (D) Act (A) Check (C) • Review the actual results • Compare against the expected results (targets or goals from the "PLAN") PDCA is your everyday Process Improvement. “Just Do It” PDCA • PDCA is used for the control and continuous improvement of processes. THE ROOT CAUSE IS KNOWN • An iterative/procedural method. (basic methodology that often involves multiple tries to “get it right”) PDCA PLAN • Establish the objectives and processes necessary to deliver results in accordance with the expected output (the target or goals). By establishing output expectations, the completeness and accuracy of the specification is also a part of the targeted improvement. When possible start on a small scale to test possible effects. DO • Implement the plan, execute the process, make the product. Collect data for charting and analysis in the following "CHECK" and "ACT" steps. CHECK • Study the actual results (measured and collected in "DO" above) and compare against the expected results (targets or goals from the "PLAN") to ascertain any differences. Look for deviation in implementation from the plan and also look for the appropriateness and completeness of the plan to enable the execution, i.e., "Do". Charting data can make this much easier to see trends over several PDCA cycles and in order to convert the collected data into information. Information is what you need for the next step "ACT". ACT • Request corrective actions on significant differences between actual and planned results. Analyze the differences to determine their root causes. Determine where to apply changes that will include improvement of the process or product. When a pass through these four steps does not result in the need to improve, the scope to which PDCA is applied may be refined to plan and improve with more detail in the next iteration of the cycle, or attention needs to be placed in a different stage of the process. Lean Lean… …the relentless pursuit of the perfect process through waste elimination… Perfection vs. Continuous improvement • Lean is often used in manufacturing or industrial processes where the pursuit of complete efficiency is the goal • Lean improvement revolves around the concepts of cycle reduction and improved delivery, capacity, quality and consistency • Lean is used in the car racing industry. • How long does it take to change a tire? • How long does it take the pit crew to change a tire? It takes pit crews about 20 seconds to change all 4 Traditional definitions Value Added Activity – Any activity that transforms or shapes raw material or information to meet customer requirements Non -Value Added Activity – Those activities that take time, resources or space, but do not add value to the product itself and does not add value to the customer – Non – Value added activities can be subdivided into: – Essential – Waste (Muda) What is Muda? • Muda (無駄) is a Japanese word meaning "futility; uselessness; idleness; superfluity; waste; wastage; wastefulness“. • A Nursing Procedure = Is value added • The Registration Process = Is Non-Value essential • Waiting to be registered or the time between registration and the procedure is pure waste. • What is an example of a value added activity in their day? • What is an example of a non-value added activity in your day? Essential and Muda Value vs. Waste MINIMIZE to make improvements Value enabling i.e. required to allow steps to occur Value Necessary waste Non-value added but essential Unnecessary waste ELIMINATE to make improvements i.e. required by law or regulations Lean attacks waste! • VALUE ADDED • NON VALUE ADDED WASTE • Necessary waste is essential to a finished product • Unnecessary waste, once identified, should be the focus of improvement or correction There are 7 types of waste Waiting Inventory Defects Extra Processing Transportation Overproduction Inventory Motion Can you think of any more types of wastes? 8th type of waste-Human Potential Example • Your job does not match your skill set… • nurse filling paperwork and making phone calls • Staffed for 8 hours but only 4 hours worth of work • Give an example of common types of waste in your average work day… • An example of Overproduction waste is over ordered tests DFSS • Design for Six Sigma (DFSS) is an improvement system used to develop new processes or products at Six Sigma quality levels. Define • Define the goals of the project and that of the customers • Quantify the customer needs as well as the goals of the Measure management • Analyze the options, existing process to determine the cause of error origination and evaluate corrective measures Analyze Design • Design a new process or a corrective step to the existing one to eliminate the error origination that meets the target specification Verify • Verify, by simulation or otherwise, the performance of thus developed design and its ability to meet the target needs DFSS • New ED • Expanding units • System implementation • Process improvement for a new system as opposed to DMAIC, which focuses on modifying or improving an existing process • The go-to method for starting from scratch • Used for something brand new. • Process mapping before you have a new system • Getting it right straight off the bat Change Acceleration Process Leading Change Creating a Shared Need Shaping a Vision Mobilizing Commitment Current State Transition State Improved State Making Change Last Monitoring Progress Changing Systems & Structures 41 • Effectiveness of a project is based on the following equation: Q +A2 = Effectiveness (Quality + Acceptance and Accountability = Effectiveness) Leading Change: Having a champion who sponsors the change. • Leadership provides the time, passion and focus for the effort. Creating a Shared Need The reason to change, whether driven by threat or opportunity, is instilled within the organization and widely shared through data, demonstration, demand or diagnosis. The need for change must exceed its resistance. • • Shaping a Vision The desired outcome of change is clear, legitimate, widely understood and shared. • • Mobilizing Commitment Key stakeholders are identified, resistance is analyzed, and actions are taken to gain strong commitment from key constituents to invest in the change and make it work. • • Making Change Last Once change is started, it endures and flourishes. Learnings are transferred throughout the organization. There is consistent, visible and tangible reinforcement of the change. • • Monitoring Progress Progress is real. Benchmarks are set and realize. Indicators are established to guarantee accountability. Changing Systems & Structures • Making sure that the management practices are aligned to complement and reinforce the change (staffing, development, measures, rewards, communication, organizational design, resources, systems). Benefits of Process Improvement (Financial and Operational) • Financial – paychecks, upgraded equipment, meeting metrics for CMS and private health insurances • Operational – biomechanics, improve departmental processes to relieve employee stress PI Promotes key Values Perfect Performance Exhibiting our highest level of skill, ready to provide expert care and service. Excelling at our jobs as individuals and teams. Doing it right the first time, assuring the safest, highest quality of care. Visionary Spirit Best Self Bringing our best to work. Being positive, encouraging, professional and productive. Doing the right thing regardless of the inconvenience we face. Human Touch Treating everyone with care concern and passion. Being sensitive, always promoting a warm and welcoming environment. Embracing our diverse community. Creative and innovative. Eager to generate new ideas. Open and receptive to learning, changing and improving. Continually advancing to new frontiers of healthcare delivery. Business Best Using our resources with discipline and integrity. Assuring value and efficiency in every action that we take. Recognizing that each one of us has the power to make a difference. Types of benefits – Hard & Soft Savings Hard Savings (= cash) $$ Soft Savings (= non-cash) Financial Benefits • Revenue Enhancement • Higher prices for services • New products/ services • Cost reduction • Lower cost of products and services • Lower Cost of Non Quality • Reducing Working Capital • Capital tied up in: • Inventory • Late Receivables $$ • Opportunity Savings • Freeing up resources to work on other items • Cost Avoidance • Cost would have appeared if project not done • Soft Capacity Increase • Capital tied up in inventory, late receivables, early payments • Patient satisfaction • Improved reputation • Brand image • Employee motivation • Technology improvement • Conformance to law & regulations • Risk management & business controls • Early Payments 47 Revenue enhancement – Higher prices for products / services – Increased market share – New products / services; new market segments • Definition – Production capacity in any process is raised above its baseline level in order to meet higher supply demands – This is accomplished without large capital resources – The savings calculation is based upon production over baseline multiplied by the products’ gross margin • Example – Product A is in such a high demand, that every additional product produced, can be sold immediately – A LSS project resulted in raising the production rate to 15% above baseline period – New sales – Increased retention of profitable customers – New products Cost reduction – Lower costs to produce, sell, deliver products / services – Lower costs of non-quality • Definition – Decrease in spending from (prior year’s) baseline spending – Categories may include: unit cost of operations, unit cost of production, transaction cost, selling expenses, overhead cost, distribution costs, manpower • Example – After completion of a project regarding gas consumption in a heater, heater control optimization resulted in savings of 15% compared to previous year – Labor cost: reduced number of hand-offs – Cost of capital: decreased time of production to customer payment – Supplies: decreased volume of supplies due to process improvements – Rework: less scrap material due to improving quality at the source of the defect – Servicing cost: decreased number of quality related service calls – Occupancy: decreased storage area due to quicker shipping times – Recalls: decrease in number of quality related calls Reducing Working Capital • Reducing working capital tied up in – – – inventories late receivables early payments Project Selection 50 Project Selection Strategic Plan Customer Requirements Costs Associated with Errors and Rework Business Metrics ‘Low Hanging Fruit’ 51 • Strategic Plan • Customer Requirements – customer can be patients or physicians • Business metrics – patient satisfaction scores, door – balloon metric/cardiac cath, stroke metrics • Cost associated with errors and rework – patient identification • Low hanging fruit – easy fix projects with a high rate of return Possible Critical Strategic Initiatives Budget Drivers Strategic Drivers LOS/Capacity Management Physician Integration • Benchmarking and ongoing labor management • Competitive Compensation Program • OB Practice Acquisition • Cardiac Physician & Outpatient Center Acquisitions College Campus Operations • Start Relocation process for SED on campus Value-Based Purchasing • Reimbursement tied to quality (effective 10/1/12) Supply Reductions • Benchmarking through Thomson Reuters Capacity Management • LOS • Utilization / Intensity • Gainsharing (Medicare/Horizon) Targeted Volume Growth • Women’s Services • Pediatrics • Emergency Room (Peds & Adult) • Ambulance/MICU • Branding Ancillary Service • Generate System savings/revenue (Lab, X-ray, Ambulance, Pharmacy) Yellow Training Projects will be to impact Strategic Initiatives The goal of all SixBeltSigma 53 Key Improvement Initiatives Department Goals Patient Satisfaction Joint Commission National Patient Safety Goals (NPSG) Length of Stay (LOS) Capacity Management 54 Just Do It…”Low Hanging Fruit” 55 Process Improvement Tools Process Map • High Level Process Map or SIPOC – Suppliers (or Source) – Inputs – Process – Outputs – Customers • It is used to help set the project scope • Used to identify the Stakeholders SIPOC’s set the boundaries – the process details will be included in a detailed process map 5 7 • Used to identify the stakeholders • SIPOC provides a high level overview of the process. • Broken down into the following categories – suppliers, inputs, process, outputs, and customers – are listed directly on the SIPOC. Why use the SIPOC? • To provide a high-level understanding of the process being investigated • To identify the specific start and stop points of the process and prevent scope creep • To identify an initial high-level list of – – – – – Customers who receive an output from this process Outputs from the process Major steps of the process Inputs that are required to produce the outputs Those that supply theSIPOC’s inputs the process areto used to focus the scope of projects 5 9 • SIPOC’s help to focus the scope of projects and serve as input into project charters. • By using a SIPOC, we get clear information on the project from the start to finish. • Admit order to floor (ED MD Vs. Primary MD) • Focuses scope • Identifies stakeholders (includes both internal & external) What does a SIPOC look like? Source Inputs Process Output -Hospital -Dr.'s Office -Other Hospitals -Patient status Paper Form/ Patient Folders Patient Information Form Initial Certification Haven Hospice Haven Hospice form to Dr -Completed Statement of responsibility 2. Complete Initial Medicare Beneficiary Assesment Contact Sheet Forms Admissions Interview Progress Notes Interdisciplinary Care Plan Components Checklist Nurse Manager Schedule Paper Form/ Patient Folders Customer -Appropriate 1. Receive patient referral Hospice -Nurse Manager patient H&P Section Store for records Send to Dr. Store for records Store for records Store for records Store for records Add to Front of Chart -Nurse current schedule 3. Schedule nurse/ home -Nurse availability -Schedule of -Nurse Manager health aid -Territory Patient visits Hospice Consent Form Health Release Authorization DNR Store for records 4. Initial Patient Visit -Completed Store for records Forms Store for records/Copy in Home • • • • • SIPOC Source is internal or external Inputs are material or service Process is what do you do with the input Output is what we get as outcome from the process Customer is the end receiver of the information/service or product • When completing a SIPOC, you start with the process or middle column Process Maps A process map is a graphical illustration of a process. Process maps depict the steps of a process and who performs each step. • • • • • • Process Maps Commonly used tool May be involved in mapping a process… step by step Making coffee…. Three versions It is VERY important to know the TRUE process, through observation. (Time Commitment required to do this). Some have done a process map at work and at home. Value Stream Map Annual forecast, monthly order Monthly order Production Control Supplier Customer Weekly Shipment 100 units/month Daily shipment Daily SAP schedule Truck Shipment Mondays 500 pieces – 20 days Truck Shipment Improve quality & eliminate quality check Have supplier prepare parts Parts prep VE 11person person Implement pull with kanbans Initial assembly 100 pieces – 4 days C/T = 10 s C/O = 1 h M-F 1 shift Uptime = 80% VA 1 person Implement pull with kanbans Final assembly 100 pieces – 4 days C/T = 25 s C/O = 1 h M-F 2 shifts Uptime = 90% Leaves at 4:00pm VA 2 persons Quality check 50 pieces– 50 pieces 2 days C/T = 15 s C/O = 3 h M-F 2 shifts Uptime = 60% NVA 1 person 100 pieces – 4 days Shipping C/T = 45 s C/O = 0.5 h M-F 2 shifts Uptime = 95% Eliminate rework loop 20 pieces – 1 day 200 pieces – 8 days Rework Process NVA 4 days 10 s 4 days 25 s 2 days 15 s 4 days Wait time : 14 days 45 s Processing time : 95 s • • • • Value Stream Map Defines the values for each step of the process. Each step can be analyzed to see what is VA, NVA, essential, non essential. Patient coming in for an exam - registration is a NVA for customer but VA for business, waiting to be called in is NVA Helps to look at the current process in detail & identify waste in each step of the process. Scheduled tests entered in MiSys Telephone and fax requests Patient arrives at destination Transporter Resource Center IP Units Testing Sites Cross Functional Flow Diagram Telephone and fax requests Printout from MiSys Dispatcher enters request in PFS In PFS, assign Transporter Transporter receives page w assignment 5 mins. 10 mins 5 mins Acquire equipment 5 mins Transport Patient 15 mins Close call using IVR 40 min 67 Cross-Functional Flow Chart • This is another way to identify waste in the process based on who does what and how long it takes. • Helps determine Cycle Time based on functional areas and see how the process can be improved. • Multiple areas with multiple functions (can lead to issues) Basic Process Map 69 Basic Process Map • Defines every step of the process in detail along with their decision points. • Helps identify root cause for the issues Lean Tools Work Out Kaizen Event A process of concentrated team-based decision making an empowerment used to resolve issues and standardize processes Team: Experienced, knowledgeable people with a stake in the process who are chartered to develop LEAN solutions and action Implementation of changes: within 30-60 days 3.5 day activity to streamline the process by removing waste, standardizing work processes and developing metrics to monitor the health of the process utilizing LEAN principles Sponsored by the executive team Implementation of changes: Immediately following event Hands on…turns ideas into actions! Lean Tools • Both are hands on. People involved get together to meet and talk about the process to resolve issues and eliminate waste. • Workout involves managers/directors. Implementation is 30-60 days. Could be for a particular department. • Kaizen is more intensive running about 3 days involving executive leadership. Implementation is immediate. Could be more global throughout the organization. Measurement What really- drives change? JFK Values Behaviors Measures “People Behave based on how they are Measured” Do you agree? And how could we measure our people and processes to drive the continuous improvement? 74 • Press Ganey and HCAP (Hospital Consumer Assessment of HealthCare Providers) scores • Low score areas are the areas that we are going to concentrate on. • What are we scored on? Accreditation? Student Surveys? Measurement Persuasion by RATIONAL THOUGHT !!! 76 • Decisions must be based on data rather than opinion or hunch. Sustaining Change Establish Metrics and Goals Monitoring of Metrics Make Metrics Visible Follow up Action Plan if not meeting goals 78 • You should know your departments metrics and goals • Monitoring is important to see your progress • Post metrics for all to know where we are and allows us to make improvements based on statuses Make Metrics Visible Variability “Right the First Time” is the most cost effective way to achieve Customer Satisfaction Variability is the ENEMY ! 6 SIGMA 81 • Reducing Variability is Important in healthcare with focus on health and lives. • In a hospital environment each process should be standard for every patient because each patient deserves the same quality care. • Standardization allows the entire workforce to follow the same rules, regulations and polices. Reducing Variation A Off-center B Too much spread Two students shooting at a target • Which would you rather teach and why? Center Process Reduce Spread 83 • The Bull’s Eye Illustrates the difference between inaccuracy (mean shift) and variability. • Questions: Which is easier to correct, Accuracy or Variability? Which has more potential causes? • Which will you need to correct on your project? How can you find out? Six Sigma Roles & Responsibilities Certain roles must be fulfilled for DMAIC projects to be successful, just as orchestra members must fulfill roles to make music 85 Six Sigma Roles and Responsibilities Management Team • Identify and prioritize Six Sigma projects • Support Process Excellence Initiatives Project Champion • Own operational and functional results • Remove barriers for Black Belt • Identify and prioritize Six Sigma projects Process Owners • Implement solutions • Ensure process improvements are captured and sustained • Make project suggestions Finance Rep • Partner with Blackbelts & Champions as financial consultant • Assist w/ cost/benefit analysis (forecast & actuals) • Financial validation& reporting Black Belts • Full-time position • Lead cross-functional project teams • Apply Six Sigma strategies/methodology at functional level Green/Yellow Belts Team Members • Part-time position • Extend reach of Black Belts on Six Sigma projects • Take on mini projects of their own • Knowledgeable of the process • Can dedicate to the project Typical PI Structure Black Belt • Oversee PI Training throughout an organization • Mentors others in Process Improvement projects • Lead Cross Functional Projects • Training: Not offered Green Belt Yellow Belt White Belt • Trained in Six Sigma Methodology • 10 days of training • Complete Green Belt Project • Utilization of Process Improvement tools • Create more impactful metrics • General understanding of Process Improvement methodologies • Able to Identify Projects 87 Contact Info: Harry H. Holdorf harryhholdorf@gmail.com 88