Operational Excellence at Lifespan

Sharon Tripp RN, MS, CPHQ

Director of Clinical Excellence
Objectives
• Discuss Lifespan’s approach to establishing a system-based
quality structure

• Describe the organization’s approach to applying six-sigma

methodologies
 Lifespan as a System
 Founded in 1994 as RI’s first integrated health
system

 Present partners: Rhode Island Hospital/Hasbro

Children's Hospital, The Miriam Hospital, Bradley
Hospital (Providence, RI), Newport Hospital
(Newport, RI), Gateway Healthcare

 Mission: Delivering health with care.

 Multiple outpatient clinics, surgery, diagnostic and

treatment centers in the state of Rhode Island
Lifespan Mission
“Delivering health with care.”
4Ps
 Patients
 We put patients at the center of everything we do.
 Providers
 We will ensure that our caregivers have the resources to
maximize professional satisfaction, collaboration, efficiency and
patient outcomes.
 People
 All Lifespan employees are members of the care delivery team—
each with a different contribution to make.
 Purpose
 We must be financially strong to meet our academic mission and
fulfill our promise of Delivering health with care.
 Organizational Infrastructure -
System
• System quality, safety and patient experience
strategy co-led by executive RN-MD dyad
• Executive VP, Nursing Affairs
• Executive VP, Physician Affairs
• Affiliate CNO-CMO dyad as site executive leads
for quality, safety and patient experience

• Nearly all staff dedicated to quality functions

serving under system quality
• Staff organized by core quality function led by a
system Director
Aligning Quality Across the
System
• Staff and department structures and core
quality functions centralized to system in
October 2014
• Committee structures remain affiliate-based
with some system structures to coordinate and
align activity
• Transparent dashboards with system and
affiliate performance available to all via
Lifespan intranet
Operational Excellence
Operational Excellence (OpX) is Lifespan's applied philosophy
towards continuous improvement, data-driven decision-
making and the use of Six Sigma and Lean tools to drive
efficiency, meet and exceed customer needs, and achieve
optimal clinical and performance outcomes. It is the umbrella
under which all key core quality functions and
performance/process improvement functions support the
organization.

The division is divided into distinct departments focusing on

Clinical Excellence, Patient Safety, Accreditation & Regulatory
Readiness, Service Excellence, OpX Programming &
Informatics, as well as a team of OpX Analysts, Senior OpX
Analysts and Performance Improvement Consultants.
Operational Excellence (OpX)
• Utilizes OpX tools to address complex problems from identification to
resolution/sustainability of improvement

• Supports key process owners in the use of the OpX tools to drive
improvement

• Leads and facilitates process improvement projects using data driven

and results-oriented methodologies (DMAIC, DMADV)

• Provides support for major lean workouts, Kaizen events, OpX Walk
activities

• Enhances training programs for certification in Lean/Six Sigma and

other core performance/process improvement tools
 Operational Excellence (OpX)
Staffing:
Administrative Director, Operational Excellence (OpX)
Senior OpX Analysts
OpX Analysts
Administrative Assistant

Core Competency Expectations:

Experienced Master Black Belt
Experienced Black Belts/Green Belts (Senior OpX Analysts)
Black Belt or Green Belt within 18 months (OpX Analysts)
Certification in TapRooT®, FMEA
 Clinical Excellence
• Oversees quality measure abstraction and reporting-
CMS, TJC, multiple registries
• Identifies improvement opportunities and leads
improvement project teams
• Provides PPE Support
• Manages the compliment and complaint process
Clinical Excellence
Staffing:
Director of Clinical Excellence
Manager of Clinical Excellence
Clinical Quality Improvement Specialists
Clinical Abstraction Specialists
Clinical Excellence Assistants
Supervisor of Patient Liaison Services
Patient Liaison Advocates
Administrative Assistant

Core Competency Expectations:

Certification as Lean/Six Sigma Green Belt or Black Belt within 18
months
Certification in TapRooT®
CPHQ preferred
Service Excellence
• Executes system strategy for Service Excellence and training
aligned with Lifespan brand mission, incorporating the best of
the best practices from each affiliate’s current Service
Excellence programs
• Supports Patient Experience data mining, analytics and action
• Supports service recovery efforts
• Supports new manager orientation and training needs for
process improvement work
Service Excellence
Staffing:
Director, Service Excellence
Manager, Service Excellence
OpX Training Specialists
Administrative Assistant (shared)

Core Competency Expectations:

Certification as Lean/Six Sigma Green Belt or Black Belt
within 18 months
 Patient Safety
• Manages event reporting system systemwide
• Triages/screens all reported events
• Assigns appropriate event follow-up
TapRoot®, ACA, FMEA, Peer Review, Manager review
• Promotes culture of safety
• Facilitates improvements to reduce hospital acquired
conditions
• Facilitates improvements to promote patient safety
 Patient Safety
Staffing:
Director of Patient Safety
Manager, Patient Safety
Patient Safety Specialists
Administrative Assistant

Core Competency Expectations:

Certification as Lean/Six Sigma Green Belt or Black Belt
within 18 months
Certification in TapRooT®, FMEA
CPHQ preferred
 OpX Programming and Informatics

• Develops system-wide and affiliate scorecards, dashboards,

quality reporting, analytics with common branding and data
standards
• Coordinates technological aspects of internal/external
reporting
• Defines and implements data and reporting standards
• Ensures access to clinical information necessary to perform
quality functions/address real-time opportunities
• Manages and controls release of quality data
OpX Programming and Informatics
Staffing:
Director, OpX Programming and Informatics
OpX Programmers
OpX Informatics Specialists
Administrative Assistant (shared)

Core Competency Expectations:

Consistent with our UHC peers in similar departments
Computer systems analysis
Application development
Accreditation & Regulatory
Readiness
• Coordinates continuous survey readiness TJC, CMS,
others
• Centralizes mechanisms to ensure standards compliance
• Manages Command Center activity and onsite survey
management processes
• Formalizes mechanisms to identify potential vulnerabilities
and disseminates across system
• Incorporates required maintenance/readiness systems into
daily work
Accreditation & Regulatory
Readiness
Staffing:
Director of Accreditation and Regulatory Readiness
Accreditation & Regulatory Readiness Specialists
Administrative Assistant (shared)

Core Competency Expectations:

Certification as Lean/Six Sigma Green Belt or Black Belt
within 18 months
CPHQ preferred
Core Competencies
 For most – certified Six Sigma green belt within 18 months of
entry to position
 Ability to lead and facilitate meetings and project teams independently
 Knowledge of process improvement methods and standards
 Knowledge of practice methods and tools related to measuring and
driving performance improvement
 TapRooT® / Apparent Cause Analysis Training
 Strong verbal and written communication skills
 Proficiency with data analysis and use of Microsoft and other
applications
 Word, Excel, PowerPoint, Visio
 MiniTab
Characteristics of a Six Sigma
Organization
• Customer Focused (What customers expect)
• Process Focused (Our capability to deliver)
• Causal Thinking (What makes this happen)
• Accountability Driven (Ownership)
• Fact-Based Statistical Thinking (Data Driven)
• Stretch Goals (More than continuous improvement)
• Standardized Approach to Improvement
• Partnership (Employees working together)
• Open Communications
 Six Sigma Defined
The “Six Sigma” term refers to a Management Philosophy

• Executive Leadership Driven

• Strategic Alignment with Operations and People
• Impact of the Voice of the Customer
• Established Customer/Supplier Partnerships
• Focused and Dedicated Resources
• Staff Accountability
• Competitive Business Results
• Open Communications
Six Sigma Defined

The “Six Sigma” term refers to Methodology (DMAIC)

D - Define in numerical terms problems or opportunities

M - Measure the current levels of performance
A - Analyze and determine the root cause of the problem
I - Improve the situation
C - Control the new process to ensure continued better
performance
Lifespan Rapid Cycle Methodology

D M A I C
Define Measure Analyze Improve Control

30 Day 60 Day 90 Day Project Closure

Rapid Cycle Testing
Using Lean Concepts Hardwiring using Control Plans
 OpX/Quality - Organizational
Commitment
Optimizing internal competency for robust process improvement:
 Currently, under the OpX/Quality umbrella:

 1 Master Black Belt

 5 Black Belts
 2 Black Belts in training
 14 Green Belts
 9 Green Belts in training
 11 Green Belts to be trained (staff in roles with GB expectations)
 Across System outside the OpX/Quality Department
 19 Green Belts and 1 Black Belt
 1 BB in training
Six Sigma Roles

• Executive /Senior Team

• Sponsor/Champion
• Master Black Belt
• Black Belt/Green Belt
• Team Member
• Process Owner
Commonly Used Tools

 Charter  Run charts

 SIPOC  Affinity Diagrams
 Flowcharting  Multi-voting
 Brainstorming  Scatter Diagrams
 Fishbone Diagram  Control Charts
 C&E Matrix  Pareto Charts
 FMEA  Process Capability
 Stakeholder Analysis  Descriptive Statistics
Project Requests

Any Lifespan employee may submit a project

request for consideration

Requests can be submitted verbally, via e-mail,

or via the Lifespan Intranet
 OpX Steering Committee

This executive leadership committee guides and provides

general oversight for OpX programming, activities and
projects with the goal of driving improved outcomes and
performance across key clinical and service processes. The
committee aligns OpX support with the pursuit of Lifespan’s
annual goals, and strategic objectives.

The committee reviews all project requests, utilizes a decision

matrix for project prioritization and selection, and charters and
supports selected projects
OpX Check-Ins

Open to executive leadership, board members, and

all Lifespan employees

Held quarterly-teleconferenced to all affiliates

Projects shared by Belts and Process Owners

New projects
Project Updates
TapRooT 
What is TapRooT?

TapRooT  is a root cause analysis system and

training program that helps solve problems both
reactively and proactively.

Identifies root causes without finger pointing and

blame.

Used internationally in many industries

JC Sentinel Event Division has been trained in the
TapRooT  methodology
TapRooT Basic Steps
1. SnapCharT  the Event Chronologically
2. Identify Failure modes
3. Identify the Causal Factors (contributing factors)
4. Obtain Audits/Observations (Data) and Evidence
5. Determine the Root Causes
6. Design Corrective Actions
7. Implement Corrective Actions
8. Monitor Redesigned Process
TapRooT Roles & Responsibilities

• Executive Sponsor

• Facilitator

• Process Owner

• Team Members
Team Member Role / Responsibilities

• Participates in the development of the content of the

SnapChart .

• May be asked to complete an assignment between

meetings.

• Can assist to brainstorm improvements for the corrective

action plan.

• Makes every effort to complete the investigation within

30 days of the TapRooT  request.
SnapCharT Diagram

• Visual tool to explain what happened

• Display in chronological order (for retroactive
analyses)
• Show all process steps and conditions
• Identifies points of failure/possible failure
• Audited and validated prior to completion of
analysis by team
Corrective Action Planning

All root causes must be addressed in a corrective action

plan. Elements of the action plan must include:
 Action
 Responsible Party
 Date for Completion
 MOS
Contact Information

Nidia Williams, PhD, CCC-SLP, CPHQ

Administrative Director, Operational Excellence
Master Black Belt
(401) 444-3510
nwilliams4@lifespan.org

Sharon Tripp, RN, MS, CPHQ

Director of Clinical Excellence
Black Belt
(401) 444-8353
stripp@lifespan.org
Questions?