Six Sigma - Introduction

SixSigma
P I t ProcessImprovement
Methodology Methodology
PresentedbyContentExpert:
BethLanham,RN,BSN,MBA
Director Six Sigma Director,SixSigma
FroedtertHospital,Milwaukee,WI
Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
What is Six Sigma? WhatisSixSigma?
SixSigmaisa
customer focused customerfocused
projectfocused
resultsdriven
approachtoQuality app oac to Qua ty
Six Sigma Overview SixSigmaOverview
A rigorous methodology Arigorousmethodology
OriginatedbyMotorola(1986)
A statisticallybased method to reduce variation in Astatisticallybasedmethodtoreducevariationin
electronicmanufacturingprocesses
Heavilyinspiredby
Previousqualityimprovementmethodologies
QualityControlManagement,CQI,TQM
Basedontheworkofqualitypioneers q y p
Deming,Juran,Ishikawa,Taquchiandothers
Six Sigma Overview SixSigmaOverview
Bylate1990s y
2/3Fortune500companies
Aimedatreducingcostsandimprovingquality
T d Today
Utilizedallovertheworld
Localgovernments,prisons,hospitals,thearmedforces,banks, g , p , p , , ,
manufacturing,etc.
Inrecentyears
Si Sigma often combined ith Lean Man fact ring to SixSigmaoftencombinedwithLeanManufacturingto
yieldamethodologycalledLeanSixSigma.
Why Six Sigma? WhySixSigma?
Wh d i ki ll h! Whatweweredoingwasntworkingwellenough!
Incrementalimprovementsnotgoodenough
Need to /Desire to: Needto/Desireto:
Focusoncustomerrequirements
Basedecisionondata,notanecdotalinformation
BeProactivevs.Reactive
Establishacultureofownershipvs.culpability
Itstheprocesses,notthepeople
Effectrapidandeffectivechange
Improvementeffortswerefragmented
L id b k Largesystemwideprocessesbroken
Notholdingthegains
What does Six Sigma offer? WhatdoesSixSigmaoffer?
Augments traditional quality tools
Organizational
Augmentstraditionalqualitytools
Datadrivendecisionmaking
g
Benefits:
Competitiveedge
Focusesoncustomerrequirements
Afocused/organizedapproach
Service
Excellence
Empowered staff
Redefinesprocessesforlongtermresults
Becomesingrainedinworkandthought
Empoweredstaff
Leadership
Development
processes
Reliesonevidencebasedsolutions
Quality/Safety
HealthcareCosts
Rapid/effectivechange
Six Sigma SixSigma
Methodologyaimedat
Errorreduction
Eliminating variation Eliminatingvariation
Goal
Design/improveprocessessoitisimpossibletomakean
error
Relianceonperformancemeasurementsand
statistical analysis statisticalanalysis
Traditionally Traditionally..
Businesses have described their products or Businesseshavedescribedtheirproductsor
servicesintermsofaverages:
Averagecost g
Averagetimetodelivery
Averagenumberinfections
A Averageusage
Averagewaittime
AreTheseProcessestheSame?
Process1 Process2
20 9
5 11
Goal=lessthan10
Aretheyperformingwell?
17 8
5 10
Process1 Process2
15 10
5 9
Mean9.4Mean9.4
5 11
5 10
Areallthecustomershappy?
5 8
12 8
ppy
Variation=OpportunitiesforErrors pp
Process1 Process2
Average9.49.4
Minimum58
Maximum2011
Median 5 9.5 Median59.5
Standarddeviation6.01.17
Customersfeelthevariation,
nottheaverage!!!!!!
Variation in the Process VariationintheProcess
Process1 Process2
100
80
Mean 9.540
StDev 6.149
N 1000
Histogram of Process 1
Normal
80
70
60
Mean 9.412
StDev 1.193
N 1000
Histogram of Process 2
Normal
60
40
F
r
e
q
u
e
n
c
y50
40
30
20
F
r
e
q
u
e
n
c
y
24 18 12 6 0 -6 -12
20
0
Process 1
24 18 12 6 0 -6 -12
10
0
Process 2
Many
Defects
Fewer
Defects
Process 1 is less capable of meeting our customers Process1islesscapableofmeetingourcustomer s
expectations!
Exactcapabilitycanbemeasured!
Six Sigma Central Concepts SixSigmaCentralConcepts
Critical to Quality (CTQ) CriticaltoQuality(CTQ)
Howthecustomerjudgesourproducts/services
Y=Theoutcomemeasureoftheprocess
Xs=InputsorvariablesthataffecttheY
Defect Failuretodeliverwhatthecustomerexpects
DPMO Defects per million opportunities DPMO Defectspermillionopportunities
Variation
Theenemyofpredictableoutputandcustomersatisfaction
Sigma
Anexpressionofprocessyield,basedonthenumberof
defects per million opportunities (DPMO) defectspermillionopportunities(DPMO)
SixSigma
APhilosophy of
g
p y f
OperationalExcellence
AsetofProblem
Solving
A Metric
Solving
Tools/Tactics
AMetric
AMeasure ofProcess
Capability
Definitions of Six Sigma? DefinitionsofSixSigma?
A metric Ametric
Greekletter
Ameasureofprocesscapability
Howcapableisourprocessofmeetingourcustomers
expectations?
Arigorous,structuredapproachtoproblemsolving g pp p g
Includesadefinedmethodologywithspecifictoolsandtactics
Amanagementphilosophy
Operational excellence and continuous improvement Operationalexcellenceandcontinuousimprovement
Definitionscomplimentary,notcontradictory! p y y
Six Sigma as a Metric Six Sigma as a Metric
Astatisticalconcept
Representsthevariationthatexistsinaprocess
l h Relativetothecustomerrequirements
Aprocessoperatingata6 Sigmalevel
S li l i i h h Solittlevariation,thattheprocessoutcomesare
99.9997%defectfree
Six Sigma = 6 6 Sigma or 6s SixSigma=6,6Sigma,or6s.
Process Sigma ProcessSigma
DPMO = Defects per Million Opportunities DPMO=DefectsperMillionOpportunities
Amoresensitiveindicatorthan%yieldor%good
Sigma Defects Yield DPMO
1 69.1% 30.9% 691,462
2 30.8% 69.1% 308,538
3 6.7% 93.3% 66,807
4 0.62% 99.38% 6,210
5 0.02% 99.977% 233
6 0.0003% 99.9997% 3.4
WhenComparedtoBestinClass
(N i l D )
Antibiotic
Beta Blocker Use
(NationalData)
1000000
InpatientMedication
Accuracy
Antibiotic
Overuse
BetaBlockerUse
PostMI
10000
100000
000000
i
l
l
i
o
n
44,000 98,000
PreventableHospital
Deaths(IOMReport)
100
1000
e
f
e
c
t
s

/

M
i
Anesthesia
1
10
1 2 3 4 5 6
D
DuringSurgery
1 2 3 4 5 6
Sigma
DomesticAirline
FatalityRate
Traditional Process Improvement
1Sigma
TraditionalProcessImprovement
5&6
Sigma
g
2 Sigma
Sigma
2Sigma
3 Sigma 3Sigma
4Sigma
4to5Sigma 27foldPerformanceImprovement
5 to 6 Sigma Another 69fold Performance Improvement 5to6Sigma Another69 foldPerformanceImprovement
Measure of Process Capability MeasureofProcessCapability
Focus on improving what is important to the Focusonimprovingwhatisimportanttothe
customer
CriticaltoQuality(CTQs) Q y ( Q )
ThisisgenerallyreferredtoastheYoroutcomevariable
Examples:waittime,responsetime,turnaroundtime,%
newvisits,%mederrors,%falls,etc.
MeasuretheYagainstthetarget
Target=customerexpectationsorspecifications
ProcessCapability p y
Lower
Specification
Upper
Specification
Li i
10
y
Limit
Limit
5
F
r
e
q
u
e
n
c
00
Average Average
Defect Defect Defect Defect
A Problem Solving Approach AProblemSolvingApproach
Highly structured methodology Highlystructuredmethodology
Focusedonidentifyingtherootcauses
Process variables impact or influence the Y ProcessvariablesimpactorinfluencetheY
Rootcauseanalysis
ProcessvariablesarecalledXs
Y = x
1
+ x
2
+ x
3
+ x
4
, etc.
P i t i (Y) bi ti Primary metric (Y) = combination
of a variety of variables (xs)
Whatarethevariablesthatinfluence
themainmetric?
A Management Philosophy AManagementPhilosophy
Focus is on continuous improvement by Focusisoncontinuousimprovementby
Understandingthecustomersneeds
Analyzing business processes Analyzingbusinessprocesses
Institutingappropriatemeasurementmethods
Emphasisonmanagementofprocesses p g p
Wedonthavefaultypeople,wehavefaultyprocesses!
We cant manage what we dont measure! Wecan tmanagewhatwedon tmeasure!
Six Sigma Model DMAIC SixSigmaModel DMAIC
Define Measure Analyze Improve Control
Establish
current
capability
SelectKey
CTQs**
Developdata
ll i l
Charter
project
High Level
Optimization
Cycletime
Variability
C /LOS
Determine
capability
ofnew
process
Identifykey
sourcesof
variability
collectionplan
Define
performance
t d d
HighLevel
ProcessMap
CollectVOC
Id if
Cost/LOS
Validationof
Improvements
p
Implement
process
controls
Define
performance
objectives
standards
Validate
measurement
systems
Identify
CustomerCTQs
Review
hi t i l d t
Implementation
Ensure
Gainsare
Sustained
systems
historicaldata
*VOC VoiceofCustomer
**CTQCriticaltoQuality
ToolsofSixSigma
Y = f(X x) MultiVari Charts
g
Y f(X,x) Multi Vari Charts
ProcessMap Regression
FMEA(FailureModeand HypothesisTest
EffectsAnalysis) 95%ConfidenceInterval
Cause EffectDiagram ANOVA
P t Di DOE (D i f E i t ) ParetoDiagram DOE(DesignofExperiments)
GageR&R ControlPlan
ProcessCapability StatisticalProcessControl p y
SixSigma KeyPlayers g y y
Full time
Overseeor
Fulltime
StrategicProjects
SkilledinSixSigma
T l
chooseprojects
ResolveIssues
Provide
Champions
Black
Belts
Tools
TeachGreenBelts
Provide
Leadership
Executive
S
FullTime
Strategic
j
PartTime
Smaller Scope
Sponsors
Master
BlackBelts
Projects
Program
Administration
SmallerScope
Projects
Helptochange
culture
Green
Belts
TeachBlack
BeltsandGreen
Belts
culture
The Six Sigma TheSixSigma
Process Process
LaunchingaProject g j
/ IdentifyaSponsor/Champion
Energy/passiontosolvetheproblem
Sponsor/Champion Role Sponsor/ChampionRole
Defineboundaries/scope
Establishstretchgoals
Providedirectionandsupporttotheteam
Removebarriers
Recognize and celebrate successes Recognizeandcelebratesuccesses
Accountableforcompletion,implementationandsustaining
resultsfromtheproject
Six Sigma Model DMAIC SixSigmaModelDMAIC
Charterproject
Problemstatement Howdoweknowwehaveaproblem?
Goal Statement How will we know if we have made an GoalStatement Howwillweknowifwehavemadean
improvement?
ProjectScopeandTeam
Hi h L l P M HighLevelProcessMap
IdentifyCustomerCTQs
Stakeholder analysis Stakeholderanalysis
Reviewhistoricaldata
ExampleProjectCharter
QMS 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:
Signatures
Project Chair(s) Signature: Champion Signature: Master Black Belt signature:
Problem and Goal Statements ProblemandGoalStatements
ProblemStatement
Howdoweknowwehaveaproblem?
MOMS criteria MOMScriteria
Measureable,Observable,Manageable,Significant
GoalStatement
Howwillweknowifwehavemadeanimprovement?
SMARTcriteria
S ifi M bl Att i bl R li ti Ti l Specific,Measureable,Attainable,Realistic,Timely
High Level Process Map SIPOC HighLevelProcessMap SIPOC
P T hi ll di l th j t Purpose:Tographicallydisplaytheprocessmajorevents
Suppliers
Whoprovidestheinputstoyourprocess?
Inputs
Whatmaterials,resourcesanddataareneededtoexecuteprocess?
ProcessSteps p
57stepsthatuseinputstochangeintooutputs.Useveryspecificstart
andstoppoints!
Outputs p
Whatistheoutputoftheprocess?Whatdidthecustomerreceive?
Customers
Who receives the outputs of the process? Whoreceivestheoutputsoftheprocess?
SIPOCExample
Hand Hygiene SIPOC Hand Hygiene SIPOC
Suppliers
-Who provides
the inputs?
Inputs-
Materials,
resources,
data
Process Steps
Outputs-
What did the
customer
receive?
Customers
- Who benefits?
E t ti t
Infection Control
H.C Providers
(Physicians, nurses,
nursing assistants,
therapists,
Policies &
Procedures
CDC guidelines
Soap
High quality
care
Avoidance /
reduction of
hospital
Patients
CMS
Third Party
Payors
Wash 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
infections
Clean hands
Decrease in
skin irritation
Other patients
Staff
Families
upon entering
Patient
Encounter
staff not employed
by thehealthcare
facility, andpersons
not directly involved
in patient care but
potentially exposed
to infectious agents.)
Plant
Conscious thought
Clinical Routine
Degree of urgent
care required
Extent of contact
MDorders
Increased
patient
confidence
Wash hands
upon exiting
Plant
Operations
Patient condition
MD orders
Call lights
Operational
routines
Leave patient
room
Process Maps a Tip! ProcessMaps aTip!
Each process has at least 3 versions Eachprocesshasatleast3versions
Whatyouthink Whatitactuallyis Whatyouwouldlikeit y
itis
y y
tobe.
Voice of the Customer
Establish Voice of the Customer (VOC)
VoiceoftheCustomer
EstablishVoiceoftheCustomer(VOC)
Identifyandprioritizeallcustomers
Whoisimpactedthemostbytheprocess?
Whoisthemostdissatisfiedwiththecurrentprocess?
Solicitfeedback
How does the customer view the process? Howdoesthecustomerviewtheprocess?
Whatdoesthecustomervaluefromtheprocess?
Whatdoesthecustomerexpectfromtheprocess?
Whatdoesthecustomerwantmostofthetime?
Whatisthelimitthecustomeriswillingtotolerate?
Stakeholder Analysis form? StakeholderAnalysisform?
St k h ld A l i Stakeholder Analysis
Strongly
Supportive
Moderately
Supportive
Neutral
(0)
Moderately
Against
Strongly
Against
Names
Whowillbe
affectedbyany
changes from this
Supportive Supportive (0) Against Against
Names
changesfromthis
project?
Beginaddressing
issuesearly! y
Noteveryone
needstobestrongly
supportive! pp
Select CTQ characteristics SelectCTQcharacteristics
DefinePerformanceStandards
DataCollection
MeasurementSystemAnalysis
ProcessXs(Variables)
X1
OutputsorYs
Y1 X1
X2
X3
Y1
Y2
Y3
TheProcess
X4 Y4
CTQ characteristics CTQcharacteristics
Select the main characteristic that the customer Selectthemaincharacteristicthatthecustomer
usestojudgeyourperformance
SixSigmalingo:ThebigY g g g
HowwillIknowifIhavemadeanimprovement?
HowwilltheYbedefinedand/ormeasured? /
VOC CTQ Y
Expecttobeseen WaitTime Pt.checkinatfrontdesktofirst
within15minofappt. contactwithstaffphysician.
Define Performance Targets DefinePerformanceTargets
TranslatetheCustomerexpectationsintoMetrics
Target:
What does the customer want most of the time? Whatdoesthecustomerwantmostofthetime?
SpecificationLimits:
Whatarethelimitsthepatientiswillingtotolerate?
VOC CTQ Y Target UpperLimit
Expecttobeseen Wait Pt.checkinatfront 15min 30min
within15minofappt.
Unhappyif>30min
Time desktofirstcontact
withstaffphysician.
Identify the Key X variables IdentifytheKeyXvariables
Cause and Effect Diagram
Process Environment Management
Managers not accountable Clutter obstructing sink
No training on process timeline
Cause-and-Effect Diagram
Don't have adequate resources
No communication re: pt impact if non-compliant
Lack motivation to set an example
No incentives/ rewards to comply
No corrective action for non-compliance
Spot checks not currently done
Divisions not accountable
Lack of institutional safety climate
Understaffing/ Overcrowding
Carrying items into patient room
Need to take care of patient and can't
No ongoing education on process for
No reminders posted
No sink in the room
Difficulty monitoring process
regularly
Equipment is not wiped down
before/ after contact
People are not aware to wash hands
No training on process timeline
interacion
during pt
compliance
hygiene
Lack hand
I nadequate org. structure for accountability
No role model for hand hygiene
Lack of institutional priority for hand hygiene
Delays in getting needed equipment
No alcohol wipes
Not enough hand dispensers
Low risk of acquiring infections from
No lotion accessible
Lack immediate feedback/ outcomes
process
Not part of the yearly evaluation
Skeptical about effectiveness
I nterferes w/ HCW relationship with pts
Disagree w/ recommendations
Family/ visitors unaware re: handwashing
interacion
Not enough hand dispensers
Soap/ alcohol dispenser empty
Broken dispenser
Overflowing garbage
No towels
Staff work areas are dirty
Too many people in room, in way of sink
Equipment in way of sink
hgyiene on the rate of HAI
No data to show the impact of hand
Skin irritation by hand hygiene agents
I nconvenient location of hand sanitizer
Lack of education materials
Family/ visitors don't see being part of PC
Other personnel not aware
Pts/ visitors insulted when asked to wash
Pts not at ease asking someone to wash
People forget
People set in their ways
Not part of the Froedtert culture
Not seen as a priority
Concerned w/ skin irritation
Don't understand need for handwashing
Feel that no need to wash w/ gloves
SponsoredbytheWisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
CopyrightoftheWisconsinOfficeofRuralHealth.
People Materials Equipment
Equipment in way of sink
Not enough sinks available
Sinks don't work
Patient room is out of gloves
Don't know proper handwashing
Only touch equip. , no need to wash
Feel that wash hands enough
Too busy/ Not enough time
Data Collection/Sampling DataCollection/Sampling
Key considerations Keyconsiderations
Datamustberepresentativeoftheprocess
Datamustbereliable
Mustcapturemeasurementsofimportance
ENTRY EXIT
OBS # Role(s) Hand Hygiene Notes Hand Hygiene Notes
1
Sink Y / N Gloves On Sink Y / N Gloves On
Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves
None Y / N Full Hands? None Y / N Full Hands?
Group
Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access
Direct Exit to Enter?
2
Sink Y / N Gloves On Sink Y / N Gloves On
Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves
None Y / N Full Hands? None Y / N Full Hands?
Group
Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access
Direct Exit to Enter?
MeasurementSystemAnalysis(MSA) Measurement System Analysis (MSA)
H t i th t ? Howaccurateisthemeasurementprocess?
Howmuchvariationisthereinthemeasurement
process? process?
Attempttominimizecontrollablefactorsthatcould
exaggeratetheamountofvariationinthedata
Example:
Iwanttomeasureseconds.Theclockonlymeasuresminutes
Result:
Thevariationofthemeasurementsystemistoolargetostudy
the current level of process variation thecurrentlevelofprocessvariation
MSA Examples MSAExamples
Fall Risk/Pressure Ulcer Risk Assessments FallRisk/PressureUlcerRiskAssessments
PerformedbyallRNs
Patientsgivenscores,basedonassessmentcriteria
DoortoBalloonTime
Clocks
1. Reproducibility DoesRN#1getthesamescoreasRN#2?
2. Repeatability DoesRN#1alwaysgetthesamescorewhen
f d ith th fi di ? facedwiththesamefindings?
Totalmeasurementsystemvariabilityshouldbeassmallas
possible,butalwayslessthan30%.
Establishcurrentcapability
Identifykeysourcesofvariability
D fi f bj i Defineperformanceobjectives
Howistheprocessperformingtoday? p p g y
Doweneedtoshiftthemeanorreducevariation?
WhatarethekeyXsthataredrivingtheY?
Howdoyouknow?
Analyze Analyze
GraphicalTools
Flowdiagrams,frequencyplots,Paretocharts,etc.
StatisticalTesting
DescriptiveStatistics,ProcessCapabilityHypothesistesting,Regression
Analysis, etc. Analysis,etc.
DesignedExperiments
DisplayingtheData
Variable: Pt Wait Time
Descriptive Statistics
p y g
Boxplots of Pt Wait Time by CLINIC
(means are indicated by solid circles)
10 35 60 85 110 135 160
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
32.018
0.000
23.1551
15.3332
235.108
1.25196
4.39234
2559
0 000
Anderson-Darling NormalityTest
100
150
e

(
i
n

m
i
n
)
95% Confidence Interval for Mu
20 21 22 23 24
Minimum
1st Quartile
Median
3rd Quartile
Maximum
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
P
t

W
a
i
t

T
i
m
e
OverallStatisticsByPatient:
95% Confidence Interval for Median
20.000 22.000
95% Confidence Interval for Median
H
A
C
O
R
O
O
R
T
0
40
Scatterplot of Hand Hygiene Events vs Time of Day
Metric Wait Time Exam Time Total Time
Mean 23.16 18.94 42.10
Median 21 16 40
Std Deviation 15.33 11.54 19.76
30
20
10
a
n
d

H
y
g
i
e
n
e

E
v
e
n
t
s
Std Deviation 15.33 11.54 19.76
Sample Size 2559 2559 2559
Min 0 0 3
Max 153 99 183
16 14 12 10 8 6
10
0
Time of Day
H
a
Current Process Capability CurrentProcessCapability
Howistheprocessperformingtoday?
p p g y
Doweneedtoshiftthemeanorreducevariation?
T
T
1.235 1.239 1.241 1.245 1.233 1.235 1.239 1.241 1.245
USL USL LSL
LSL
HypothesisTesting
G tti t th R t C GettingtotheRootCauses
Which Xs had the greatest affect on the Y?
Test Details P-Value
Role DTY, EVS, Lab, LCs, PCAs, RNs, RTs 0.002
PValues<0.05are
signficantfactors
WhichX shadthegreatestaffectontheY?
RNs RNs vs. All others 0.422
LCs Long Coats vs. All others 0.004
DTY Dietary vs. All others 0.005
EVS EVS vs. All others 0.056
TSP Transport vs All others 0 020
Mustusethe
correctstatistical
testsbasedon
types of data TSP Transport vs. All others 0.020
THP Therapists vs. All others 0.020
Day of Week Mon vs. Tues vs. Wed vs. Thu vs. Fri 0.285
Time of Day Observation Hours 7-16 0.039
Groups Single HCW vs. Groups 0.868
typesofdata
p g p
Method Sink vs. Alcohol Based Hand Rub 0.000
Full Hands Empty vs. Full Hands 0.000
Urgency Normal vs. Urgent n/a
Gloves Wearing gloves vs. No gloves 0.463
Timing Entry vs. Exit 0.000
Access Clear access to Sink/ABHR vs. Blocked Access 0.965
/ OptimizationofY(Cycletime,Variability,Cost/LOS)
ValidationofImprovements
Implementation p
ControlPlan
Generatealternatives
0.9
0.8
UCL=0.852
1
1
% compliance
Assesstherisks
Testthealternative
S l t th b t lt ti
0.7
0.6
0.5
0.4
0.3
0.2
I
n
d
i
v
i
d
u
a
l

V
a
l
u
e
_
X=0.471
Selectthebestalternative
Wk30 Wk29 Wk28 Wk27 Wk26 Wk25 Wk24 Wk17 Wk16 Wk15 Wk14 Wk13 Wk12
0.1
0.0
C22
LCL=0.090
Evaluating solutions Evaluatingsolutions
Alternatives
Pugh Matrix
o
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Key Criteria I
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l
e

r
o
o
m
RN accountable for patient
Generate
multiple
Efficient trouble shooting
Utilizes RN critical Thinking
FTE neutral
Good judgement regarding whether to take patient
off tele when off unit
RN knowledge of when patient leaves unit
RN knowledge of when patient returns
Assurance that patient placed back on tele when
Key
Better
Same
Worse
multiple
options!
Evaluatehow
p p
returned to floor
30 Second response to sustained lethal rhythms or
rate alarms
Documentation of rate/rhythm changes
Consistent/accurate interpretation of rate/rhythm
Timely recognition of rate/rhythm changes
Overall high standard of care maintained
=10
=8
=5
=3
=1
eachoption
meetsCTQs
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 1
Sum of Negatives 1 2 2 0
Sum of Sames 11 8 0 19
Pilot/Validate Results
Pilot Planning PilotPlanning
FailureModeandEffectsAnalysis
Assureadequatesamplesize
Validate improvements
SICU confirmed Glucose levels <70 on insulin by month
Validateimprovements
throughdataandstatistical
analysis
70
80
90
a
l
u
e
y
UCL=84.41
J une-Aug 2002
02
Sept
02
Dec
03
J an
03
Feb
03
March
Baseline
30
40
50
60
I
n
d
i
v
i
d
u
a
l

V
a
Mean=60.25
LCL=36.09
Pilots
0 10 20 30 40 50 60 70 80 90
30
Observation Number
% compliance
Determinecapabilityofnewprocess
Implementprocesscontrols
EnsureGainsareSustained
1.2
1.0
0.8
0.6
0.4
I
n
d
i
v
i
d
u
a
l

V
a
l
u
e
_
X=0.823
UCL=1.119
LCL=0.528
Pre Interim Pilot
Closetheproject
Wk30 Wk29 Wk28 Wk27 Wk26 Wk25 Wk24 Wk17 Wk16 Wk15 Wk14 Wk13 Wk12
0.2
0.0
Isthenewmeasurementsystemmeasurewhatitissupposetomeasure?
Doesthenewprocessmeetthegoal?
How can you sustain the gains? Howcanyousustainthegains?
Mistakeproofing,Robustdesign,ProcessMonitoring
Celebratesuccesses!
Control Control
Determinenewprocesscapability p p y
Developcontrolplan
MonitorInputsandOutputs(YsandXs)
EnsurethatGainsareSustained
ShareBestPractices
Maintainthe
gains! 100
200
300
400
500
600
700
v
i
d
u
a
l

V
a
l
u
e
1
1
1
1
1
1
1
M 95
UC L =263.8
C ontrol C hart: time to 1st antibiotic
Baseline P ilot
P ost P ilot
gains!
0 S ubgroup 50 100
-100
0
100
I
n
d
i
v
P ilot P ilot C16
Mean=95
L C L =-73.78
400
500
600
R
a
n
g
e
1 1
1
0
100
200
300
M
o
v
i
n
g

R1
1
1
R =63.46
UC L =207.3
L C L =0
ExampleSixSigmaProjects p g j
Safety/Quality
Insulin/Diabetes
Service/ProcessEfficiencies
A
Falls
Anticoagulation
TelemetryResponse
Access
DiabetesClinic
UrologyClinic
W it ti
Patientflow
Ortho/Radiology
Ortho/OR
Pulmonary Functions Lab
PatientIdentification
PriorityMedication
HandHygiene
Waittime:
HandCenter
OPLab
OP R i i
PulmonaryFunctionsLab
Hem/OncLabProcess
Hem/OncTreatmentRoom
GILab
Medication
VerificationProcess
Communicationof
Addi i l R di l
OPRegistration
Delaysinsurgeryd/t
missingInstruments
PatientThroughput
DischargeProcess
AdditionalRadiology
Findings
Lessons Learned LessonsLearned
Organizational Vision OrganizationalVision
SeniorManagementmust lead
Befocused strategicalignment,cascadingofgoals,havea
plan! plan!
Holdpeopleaccountable!
InvolveMedicalStaff
Stayfocused foralongtime! y f g
AdministrativeStructure
Clearrolesandresponsibilities
Methodologyforprojectselection,scoping,approvaland
resourceallocation
Donttakekeythingsoutofscope! y g p
Establishownership,reportingandtrackingmechanisms
Lessons Learned
CultureChange
LessonsLearned
g
Dontunderestimatetheresistance!Expectit!Manageit!
StayFocused Countertheflavoroftheday
Top down visible leadership Walk the talk! Topdownvisibleleadership Walkthetalk!
Address ChangeManagementStrategy fromthebeginning!
EconomicImplications
Decide whether economics lead or follow as a driver Decidewhethereconomics leadorfollow asadriver
Organizationalfocus
Projectfocus
Other.
Therearenosilverbullets!!!Itstakesplainhardwork!
Leadersnotinherentlygoodsponsors!
Challengingtofindtime,resources,data
Difficulttofindtherightstaff
Facilitationskills,projectmanagement,healthcareknowledge,problem
solving,movers/shakers
How will we know when we get there? Howwillweknowwhenwegetthere?
The following elements will occur on a daily basis: Thefollowingelementswilloccuronadailybasis:
Highperforminghospitalprocesses
Datadrivendecisionsandproblemsolving
Focusonprocessesnotpeopleordepartments
Recognitionofwidespreadvariationanditsimpacts
Acceptanceofrapidchange
Enthusiasmaboutfindingbetterwaysofdoingthings
For More Information ForMoreInformation
Beth Lanham BethLanham
Froedtert Hospital,Milwaukee,WI
P: 4148058685 P: 414 805 8685
E: blanham@fmlh.edu
Wi i Offi f R l H lth Wi i H it l A i ti WisconsinOfficeofRuralHealth
KathrynMiller
RuralHospitals&ClinicsProgramManager
P:8003850005
E kmiller9@wisc edu
WisconsinHospitalAssociation
DanaRichardson
VicePresident,QualityInitiatives
P:6082741820
E drichardson@wha org E:kmiller9@wisc.edu E:drichardson@wha.org

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