How bad is it really - Mercy Medical Center

Copyright 2008 Business Excellence Group, Inc and the Nebraska Hospital Association. All rights reserved

How bad is it really?

How to measure and analyze your process problems

Video #3

1

Personal Introductions• This is the 3rd of 6 videos produced by the Nebraska Hospital Association for the support

of Quality initiatives in any health care environment in Nebraska. The content was developed by the Business Excellence Group, Inc. an organization with over 15 years of experience supporting medical care clients in deploying Quality programs.

• The Business Excellence Group, Inc focuses on implementing service quality programs that drive validated benefits – customer related and financially auditable. They work with clients at their level of organizational maturity to evolve quality into everyone‘s DNA.

• This presentation is given by Annette Stanton, Director, Health Care and Human Services Quality Practice. Annette is a Master Black Belt in Six Sigma methodology with 20+ years of experience in finance and quality functions for Fortune 500 companies and in hospital and health care settings, integrating the financial benefits of quality in each of her organizations.

Patricia Tyre, PresidentBusiness Excellence Group, [email protected]

Annette StantonPractice DirectorBusiness Excellence Group. IncAStanton @businessexcelllencegp.com

2

So what have we learned so far:

• In video #2, you understood what the patients (or internal customers) were complaining about

• You selected some projects to work on that maybe some of your patients, doctors or nursing staff were passionate about correcting

• You listened to the Voice of the Customer – all the customers - and what was critical to them (CTQ’s)

• You understood what possible errors occurred and how the customer felt about the errors

So how bad is it, really?

3

Introduction to Video #3 – How bad is it really?

• In this video we are going to:Introduce you to some tools on how to assess how bad your process problems are ReallyGive your team some ideas for making easy changes to the process for improvementOr, if you have the time, to drill down to the real root cause of the problem in order to fix it - permanently

4

It’s time to get the numbers – let’s measure !!

Use your computer and CalculateProcess Sigma – its worth the effort

602601600599598

USLLSL

Process Capability Analysis for Supp1

PPM TotalPPM > USLPPM < LSL



PpkPPLPPUPp

Cpm

CpkCPLCPUCp

StDev (Overall)

StDev (Within)Sample NMeanLSLTargetUSL

6367.35 39.19

6328.16

4940.04 21.66

4918.39

10000.00 0.00

10000.00

0.830.831.321.07

*

0.860.861.361.11

0.620865

0.599648100

599.548598.000

*602.000

Exp. "Overall" PerformanceExp. "Within" PerformanceObserved PerformanceOverall Capability

Potential (Within) Capability

Process Data

Within

Overall

Don’t just stand there! Develop a DataCollection Plan and start collecting

Validate MeasurementSystem

Collect Data &Endure Consistency

Establish Operational Definitions

Problem1 2 3 Total

A II II I 5B II I II 5C IIII II IIII 10

Total 8 5 7 20

MonthChecksheet

Graph your Baseline Performance& Display your Variation

VOP — Control Charts

#

Measurement

#

Measurement

Histogram *

Box Plot

5

First - Select the project outcome (Y), the CTQ, that makes the biggest impact.

Select a process that gives you an outcomeC

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ng

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ntity

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ive

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75

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40%

65%

80%90%

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ber o

f Com

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nts

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shed

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ng

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ntity

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ive

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605550454035302520151050 0

25

50

75

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80%90%

Num

ber o

f Com

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nts

PARETO of CTQ Defects

CTQ’sVoice of Business

Mgmt.

Project Y Metric

For anyone in a Quality Role – pick the problem that has the biggest impact – but is doable

There are two groups to consider:1.The patient2.Hospital management

6

Data collection - act on fact, not assumptions!

• Why is the data being collected?• What kind of data is needed?• Is the data already available?• How will the data help to meet customer

needs or improve operations?• What does the data tell us?• How much data is needed?• What procedures are needed to collect data?

Don’t assume!

For some processes, data may have never been collected; for others, the wrong data has been collected, and using it will not solve the problem. You need to ask yourself:

7

Benefits of data...

• It separates what we think is happening from what is really happening.

• Confirms or disproves preconceived.• Establishes a baseline of performance.• You see the history of the problem over time.• Measure the impact of changes on a process.• Identify and understand relationships that help explain

variation.• Control a process (monitor process performance).• Avoids “solutions” that don’t solve the real problem.

8

Your SIPOC can tell you where to measure

S I P O C

Input Measures

Process Measures

Output Measures

Re-examine SIPOC and create more detailed processplan to identify areas for measurements.

9

4-Step data collection process

• Clarify purpose of data collection.

• Identify what data to collect.

• Understands operational definitions.

• Create data collection forms.

• Create data collection procedures.

• Establish sampling plan.

• Test and validate measurement systems.

• Train data collectors.

• Pilot process and make adjustments.

• Collect data.• Monitor data

accuracy and consistency.

Data collection is the first step to understandthe variation the customer feels

Ensure data consistencyand stability

Collect dataand monitor consistency

Develop operational definitions and procedures

Establish data collection goals





10

Step 1: Establish data collection goals

• In order to establish your data collection goals you must:– State the purpose of the data collection– Identify what data is required– Identify steps in the process where defects occur in order to focus data

collection efforts.• Asking these questions will help you clarify your goals:

– What do I need to know about my process?– What data do I need? – What is the plan for analysis once the data is collected?– What data is already available?– What potential unique attributes exist in my data? – Do I have natural segmentation in my data?








11

When establishing data collection goals

Strive to make the data characteristics meaningful ask yourself:• How would this data change if the process was improved? • If this data showed improvement, does this imply significant

improvement in the performance of the process?• What other factors are influencing the data? • Will the data that we collect be sufficient to understand the

process? • Will it be relevant?• Will it be representative of the larger population?• Will it be contextual?

12

Step 2a: Develop operational definitions

Clear operational definitions of each metric and process stepswill lead to consistency in data collection

• What is Operational Definition?– A precise description of what you will measure and how to get a value for that measure.

• Purpose:– To remove Ambiguity

• Everyone has the same understanding.– To provide a clear way to measure the characteristic

• Identifies what to measure• Identifies how to measure it• Makes sure that no matter who does the measuring, the results are essentially the same.





13

Operational definition features

• What: What steps should data collectors use?• How: How should they take the measurement?

Tip: Check if the operational definitions follow the “Outside In” concept.

Test Operational Definitions:• Use the people on the project team first.• Does each person get the same results when

measuring the same things?– If not, you must refine measurement descriptions.

14

Step 2b: Data collection procedures

• Data collection procedures need to be documented for quick reference and understanding. Specify the details of the data collection process:

– How you will collect the data?– How you will record the data?– Determine the period of time for data collection.– The sampling plan to be followed.

• Consider concepts in your procedures such as:• Sampling of Population• Time frame to collect data• Cost to sample.

• Know how you will use the data before launching a large collection. Do a pilot on data collection.

– Ask yourself: Have we tested out, through simulation or a quick pilot, how we will gather and use the data?





15

Step 2c: Choose the level of measurement

Scale of scrutiny:• Measure one scale or level smaller than what your

patient, doctor, or management measures.For example:• If your patients measures cycle time in days,

your scale of scrutiny would be hours.• If your patient measures cycle time in hours,

your scale of scrutiny would be in minutes.• Scale of scrutiny may expose larger true variation.

16

Step 2d: Understand the type of data

Continuous Anything that results from being measured on a continuum or scale.

Example:Continuous measure (Cycle time of a process)

Anything that can be categorized or designated as either/or.

Examples:• Male/female• Off/on• Defect/no defect• Day of week (Mo/Tu/We/Th/Fr)• Accept/Reject• Yes/No• Democrat/Republican

Discrete

17

Definition

Step 2 e. Consider data collection tools

• A description of what data is being collected.• Places to put the data.• Room for comments.• Room to keep track of stratification factors.

• Keep the form simple to use and understand.• Include only information you intend to use.• Pilot the data collection form.

Elements

Things to Remember

• Forms that help you collect data.• If more than one person is collecting data, checksheets

help to standardize both the data that is collected and the data collection process.

18

Checksheet Example: Patient delay for Orthopedic group

Potential Orthopedic Group waiting time causesName of Medical Staff: Date/Time:P.S.K 19 Sept 2002; 14.00 – 16.00

Reason

Not enough personnel

No referral given

Computer down

Not previously scheduled

Language issues

Patient completed wrong form

Specialist Needed- not available

No patient identification

Frequency Comments

Location: Middle City, IA

19

Frequency plot checksheets

A frequency plot checksheet creates a picture that shows how often the data values occur

Use a frequency plot checksheet with data that has a sequence, such as:• Weight• Time• Temperature

Do not use a frequency plot checksheet with data that is divided into categories, such as:• Type of problem• Location• Day of week

Definition

When To Use

When Not To Use

20

Frequency plot check - sheets (cont.)XXXX

X XX X X X

X X X X X X16.0 16.1 16.2 16.3 16.4 16.5 16.6 16.7 16.8

Package Weight

Weight In OuncesW

eigh

t In

Oun

ces

16.816.716.616.516.416.316.216.116.0

X

XXXXXXXXXXXXXX

X

HorizontalFrequency Plot

VerticalFrequency Plot

21

Disadvantages

Definition

Concentration diagramA concentration diagram is a specific type of data collection form where you write directly on a picture of the object — the most important aspect of a concentration diagram is that it lets you quickly see where problems occur and how they cluster.

Concentration diagram shows you:• A graphic representation of the product or form• Where problems occur• Types of problems that occur.

• Doesn’t need a lot of words• Easy to fill out• Lets you see how problems cluster.

• Requires a physical product or form• Can become cluttered.

What They Show

Advantages

22

Concentration diagram (cont.)Insurance Report

Name Week EndingPatients A through Z July 2 19 94

Date Dependent Code

Referral Approval

Dr. Name Diagnosis Misc. Total Comments

EEEE

Totals

EEEE

RR RR RRRRR

EEEEE MMTMT

R RRR EA

EEE E AEAE EAEEAE

EEEEEAEEA

E: Entry Missing

R: Illegible entry

M: “Misc.” Not Explained

T: Wrong entry

A: Arithmetic Error

Errors Made Calculating Column And Row Totals

23

Step 3: Ensure data consistency and stability

Key elements to test and validate your measurement system:• What is the variation in your measurement system?

– Operator error– System error

• What impact will the measurement system error have on your results?• What can you do before data collection to eliminate or mitigate the

measurement system error?

Can all project team members collect the same results from the same source using your operational definitions?





24

Step 4: Monitor for consistency

Check data consistency and stability to expose problems that could lead to incorrect conclusions.

• Validate that the measurements are stable? If you measure the same item 10X and you get the same answer, the measurement system is stable.

• Are the standards for measuring degrading over time? Then the measurement is not consistent.

• Do your frequency plots show any strange patterns? Do the data point stop at a barrier, this may indicate that points over an illusionary barrier are not being recorded.

Continue improving measurement consistency. Monitor collected results, verify data and check for any signs of bad data.





25

Create a data collection planData Collection Plan Project ________________________

What questions do you want to answer?

Data Operational Definition and ProceduresWhat Measure

type/ Datatype

Howmeasured1

Relatedconditions to

record2

Samplingnotes

How/whererecorded (attach

form)

Being clear about your question will help you make sure you collect the right data.

Record what data to collect as a reminder of what needs to be accomplished. The

type of data determines how the

data should be analyzed.

An operational definition defines exactly how to go about collecting and recording the data.

26

Type Type HowMeasure Measure Data What How (Attach Data Form) What Where When Many

Clarify Data Develop Operational Definitions Collection Goals and Procedures

Operational Other Conditions Collecting/ SamplingDefinition To Record Recording

Billing Accuracy

Output Discrete Inaccurate — Bill with any of 5 fields not matching customer order form

Reconcileinvoice

with customer order for 5 fields

Invoice/Bill Accts. Receivable dept. —invoices prior to be mailed

Systematic— every nth bill where n is selected at random between 1 and 30.

One

Date_____ Region_____

DefectProduct

Total

1 2 31 II2 IIII IIII IIII3 III4 III III

Data Collection Plan — completed

Data collection plan example

27

Ok, we have some numbers, now what do they say?


602601600599598

USLLSL





PpkPPLPPUPp

Cpm

CpkCPLCPUCp

StDev (Overall)


6367.35 39.19

6328.16

4940.04 21.66

4918.39

10000.00 0.00

10000.00

0.830.831.321.07

*

0.860.861.361.11

0.620865

0.599648100

599.548598.000

*602.000



Process Data

Within

Overall

Graph your Baseline Performance& Display your Variation

VOP — Control Charts

#

Measurement

#

Measurement

Histogram *

Box Plot

Use Charts and Graphs to develop a picture of how bad the problem

really is?

28

Why care about variation?

Customers don't judge us on averages, they feel the variation in the service we provide. We need to recognize that variation can produce defects — failing to deliver what the customers want.

Customers value consistent, predictable care that delivers world-class levels of quality.

There will always be some variation present. We can tolerate this variation if:

•The process is on target•The variation is small compared to the process specifications•The process is stable over time. Head in the

freezer, feet in the fire; on

average you are OK!

29

Measurement

Time

Variation — voice of the process

• All repetitive activities of a process contain some fluctuation.

• Fluctuation can be present in Input, Process, and Output measures.

• This fluctuation is called variation.

Variation is the “Voice of the process.”

30

Common cause

Special cause

Generally, noise in the process

Usually the results of many small variations

Harder to remove

Can arise out of specific circumstances

Easier to detect

Easier to remove

Always present at some level

Expected

Normal

Random

Not always present

Unexpected

Not normal

Not random

Type Definition Characteristics

If you listen to the Voice of the Process, you can determine the types of variation present in the process.

Two types of variation

31

Reasons for displaying variation• It is difficult to look at large sets of data and observe any existing

variation or pattern.• Graphically displayed data provides a basic description of the underlying

patterns in the measures.• Enables you to focus team’s efforts on the key measures and problems.

From raw data… …to graphical display

Score A Score B Score CTest 1 96 90 77Test 2 89 81 73Test 3 94 79 90Test 4 94 91 80Test 5 90 80 71Test 6 91 82 79

70

75

80

85

90

95

100

Test 1 Test 2 Test 3 Test 4 Test 5 Test 6

Score A Score B Score C

32

200150100

20

10

0

Score

Freq

uenc

y

Histogram of Score

Why use it?To show the shape, or distribution of the data by displaying how often (or the frequency of) different values occur.

When to use it? When you have Continuous Data

Histogram

33

What to look for in a histogram

• Location of the distribution — Is it centered?• Spread or variation of the distribution — Wide or narrow

dispersion?• Shape of the distribution — Symmetrical, skewed, cliff-like

shape, twin peaks, flat• Evidence of extreme or outlying points — “irregularities”• Disadvantages of Histograms:

– Do not show the shifts or changes over time– Generally requires larger sets of data.

34

Pareto chart

What does it do?• Helps a team to focus on those causes that will have the

greatest impact if solved.• Based on the proven Pareto principle: 20% of the sources

cause 80% of the problem.• Displays the relative importance of problems in a simple,

quickly interpreted, visual format by showing their relative frequency or size in a descending bar graph.

Vilfredo Pareto, 1848-1923 born July 15, 1848, in Paris, France —died August 19, 1923 in Lausanne, Switzerland) made several important contributions to economics, sociology and moral philosophy, especially in the study of income distribution and in the analysis of individuals' choices. He introduced the concept of Pareto efficiency and helped develop the field of microeconomics.

35

The Pareto chart: 80/20 ruleThe Pareto principle is often described by the “80/20 rule” - or roughly 80% of the problems are caused by only 20% of the contributors.

The Pareto principle implies that we can frequently solve a problem by identifying and attacking its “vital few”sources. The 20% of the problems !

36

Example of a Control Chart

Average

Time

Observed Value

Control charts – most important display of allWhat do they do?• Monitors the performance of a process over time to detect trends, shifts, or

cycles.• A process is in a state of statistical control when the outcome of a process can

be predicted with some degree of certainty. • Variation in the process is measured historically over time.

37

Average

.... Data points

Time

Observed Value

Looking at control chart• Control Charts have 2 basic purposes:

– To analyze past data to determine past and current performance– To measure control of the process against standards

38

Shift Same Value

Trend/Drift Cycle/ Seasonal

Look for pattern that indicates Special cause.

8 or more consecutive points on the same side of the centerline.

7 or more consecutive points increasing or decreasing.

7 or more consecutive points have the same value.

14 or more consecutive points up and down.

Analyzing a control chart

39

Control charts -

• A process in which only common causes are present is said to be in a state of statistical control –the process is stable and future output can be predicted.

• If special causes are present, the process is said to be out of control, which means the process is unpredictable and unstable.

Its not a good idea to be “out of control”

Its not a good idea to be “out of control”

40

And what statistical tools can we use?


602601600599598

USLLSL





PpkPPLPPUPp

Cpm

CpkCPLCPUCp

StDev (Overall)


6367.35 39.19

6328.16

4940.04 21.66

4918.39

10000.00 0.00

10000.00

0.830.831.321.07

*

0.860.861.361.11

0.620865

0.599648100

599.548598.000

*602.000



Process Data

Within

Overall

It’s fun to perform either basic mathematical formulas or some

complex analysis on your numbers.

41

Some basic statistical terms

• Minimum (Min)• Maximum (Max)• Range• Median• Mean• Standard Deviation

42

Min, Max, Range, and Median

• Min is the smallest value data point in a set.• Max is the largest value data point in a set.• Range is the difference between the Max

and the Min; Range = Max - Min• Median is the data point that would be in the center if you

arrange your data in ascending or descending order.

For example, if you had 5 data points in order then the 3rd datapoint would be the median. If you had 6 data points then the median would be the average value of the sum of the 3rd and 4th data points.

43

• Mean is the arithmetic average of a set of data.• The mean or average is the sum of all the data points

divided by the number of data points• You can take the mean of a whole population (parent) or a

sample population (child) and they will tend to match • However, you can not average a series of averages. An

average represents one group of data only

The mean or the average

44

What is standard deviation?

μ Point of Inflection

1σ

X 3σ+ � σ

p(d)

Mean of the distribution (μ)Standard Deviation of the distribution (σ)

3σ

The distance between the point of inflection and the mean constitutes the size of a standard deviation. If three such deviations can be fit between the target value and the specification limit, we would say the process has “three sigma capability.”

− σ

45

Understanding the terms

2

1

3

5

4

0

1

2

3

4

5

6

7

i 1 2 3 4 5i

VAR =

σ =

Given 5 data points: 2, 1, 3, 5, 4

( ) ( ) ( )X Xi − = − = - =2 2 21 3 2 4 (X )

N - 1

i2

i =1

N

−∑ X

(X )

N -1

i2

i=1

N

−∑ X

46

Calculating process sigma — key terms

Why?To calculate the capability of the process to meet customer requirements.

Key Terms:• Unit: The item produced or processed.• Defect: Any event that does not meet the specification of a

CTQ. A unit may have multiple defects.• Defect opportunity must be important to the customer and

opportunity per unit must stay constant before and after improvement.

• Number of opportunities per unit can be used to compare processes and outputs of different complexities.

47

1. Number Of Units Processed N = __________2. Total Number Of Defects Made

D = __________3. Number Of Defect Opportunities

Per Unit (DPMO) O = __________4. Solve For Defects Per Million

Opportunities DPMO = 1,000,000 *

=1,000,000 •

= __________5. Look Up Process Sigma In

Sigma Conversion Table Sigma(ST)= __________

( )

( ) ( )

DN*O

Worksheet — calculating process sigma

48

DPMO — Defects per Million Opportunities

Where:D = Number of defectsN = Number of units O = Opportunities Per Unit

DN*OFormula: X 1,000,000

Take DPMO value and look correspondingSigma Level in sigma conversion table

Then…

Calculating process sigma

49

σ

93.0% 66,807.0 3.098.0% 22,750.0 3.599.0% 6,210.0 4.099.87% 1,350.0 4.599.9997% 3.4 6.0

DPMO*Yield

Six Sigma scale

* Defects per million opportunities

Increase in process sigma requires exponential defect reduction.

50

A few tricks with Excel software

To calculate the following:1.Minimum: = Min(select your cells)2.Maximum: = Max(select your cells)3.Mean or average: = Average(select your cells)4.Mode: = Mode(select your cells)5.Median: = Median(select your cells)6.Standard deviation: = STDEV(select your cells)

51

Detailed Process Mapping

Identify Possible Causes

PROBLEM

METHOD

MATERIAL

MACHINE

MEASURE MOTHERNATURE

MAN

Cause & Effect diagram

C & E Matrix

Do we know the root cause of the problem?

There are 3 possible tools you can use to dig deep into your process to find the real root cause – a Detailed

Process Map, a Cause and Effect Diagram and a Cause and Effect Matrix.

52

Why build a process map?

I still don’t understand how this process

flows…I know things go in and come out, but I don’t know

how.

Process maps provide a common level of knowledge abouta process among many diverse individuals.

I think this is what we do

next. So when is my product ready for

the customer?

53

What a good process map tells you

• What “really happens” in the process• Process Boundaries• Major Activities• Key Process Inputs• Communication Loops• Key Process Outputs• Value added and non-value added

steps in the process• Data Collection Points• Complexity• Redundancy and bottlenecks.

54

Let’s review 3 types of process maps:

• High Level Process Map• Detailed Process Map• “Swim Lane” Map

55

High-level process map

Characteristics:• High-level snapshot of an organization.• Benefits of the “Bird’s-Eye” view:

– Helps avoid getting stuck in detail too early.– Helps plan and target the critical measurements.– Identifies the major categories of activities and processes first.

Plan Source Review Approve Close Monitor

56

Detailed process mapA graphic representation of the sequence of sub-processes, tasks or decisions. It is used when you need more detail to understand a problem.

High Level Map Plan Source Review Approve Close

CALL WRITEUP

TOMGRREVIEW

REJECT

DECIDEAPPIN

MOREINFO

CALLCUST

NO

57

Use process mapping symbols, if you can

Operation — an action step, a task or activity.

Operation — an alternative method for an action step.

Decision — a decision point where a “yes” follows a different path than a “no.”

Direction of work flow — shows the flow of the work from one task or person to another.

Start and end points — indicates the beginning (start) and end of the process.

Storage/Inventory — inventory materials, filed documents, work in process or finished goods.

Delay — a delay in the process caused by waiting for information, approvals, or materials.

Preparation — preparation of machine, raw materials, systems, documentation.

Off page connector — used to connect the flow from one page to another.

Symbol Symbol

58

Hospital Employee

givesform to

Administrative Assistant

Document your detailed process map

Step 1: Document all the tasks, decisions and actions that may occur in the process. Arrange them sequentially.

Hospital employee

requires office supplies

Hospital employee

fillsout form

Hospital employeesearches

for and selects appropriate form

Administrative Assistant checks to

see that allfields are

filled out

59

Detailed process map Step 2: Identify Value-added and Nonvalue-added steps in the process.

Value Added

Non - Value Added

Hospital Employee

givesform to


Hospital employee

fillsout form

Hospitalemployeesearches




filled out

60

Hospital Employee

givesform to


Hospital employee

fillsout form

Hospitalemployeesearches




filled out

Step 3: Show Key Outputs at each step.

Employee has appropriate

form

All relevant fields of form are completed

accurately

Administrative Assistant has complete form

Verified completed

form

Detailed process map

61

Key Process Input Variables (KPIVs) /Key Process Output Variables (KPOVs).

• Controllable Inputs: KPIV’s that can be changed to see the effect on KPOV’s. Sometimes called “Knob” Variables.

• Critical Inputs: KPIV’s that have been statistically shown to have a major impact on the variability of the KPOV’s.

• Noise Inputs: Input variables that impact the KPOV’s but are difficult or impossible to control. Example: Environmental variables such as humidity, temperature.

• Standard Operating Procedures: A standard procedure for running the process.

Classification of process variables

62


Critical ParameterNoise

SOP

Controllable

Form cabinet & displayForms availableDistributor of forms

Surface to write onFormWriting instrumentInstructionsLightingKnowledge of employee

Waiting queue to get the Admin’sattention Administrative Assistant

FormEmployee handwriting

Administrative Assistant checks

to see that allfields are

filled out


form


accurately


Verifiedcompleted

form

Hospital Employee

gives form to Administrative

Assistant

Hospital employee

fills out form

Hospitalemployee searches


Step 4: List key inputs and classify process inputs.

63

Administrative AssistantFormEmployee handwriting

Step 5: Add the operating specifications and process targets for the controllable and critical inputs.

Input Variable Target Spec

Form cabinet& display

visual surface area no less then 12sqft with a minimum height of 48in

Pen Min of 3 black ballpoint pens anchored to table

Instructions Instructions available at table in both Spanish & English

Lighting Minimum illumination of 50 candles

Critical ParameterNoise

SOP

Controllable

Form cabinet & displayForms availableDistributor of forms

Surface to write onFormWriting instrumentInstructionsLightingKnowledge of employee

Waiting queue to get the Admin’sattention

Administrative Assistant checks

to see that allfields are

filled out


form


accurately


Verifiedcompleted

form

Hospital Employee

gives form to Administrative

Assistant

Hospital employee

fills out form

Hospitalemployee searches



64

Swim Lane Map

Used for large, complex processes when:• Multiple departments/functions are involved,

including outside the firm• Sequence and time of operations is important

(as in cycle time reduction)• Can show information and process flows if needed.

65

Attributes of Swim Lane Maps:• Rows or columns represent departments — not persons.• Activities fall in appropriate “bands.”• Concurrent activities grouped “side-by-side.”• Shows handoffs, groups involved.• Sometimes called “Functional” or “Cross-Functional” flowchart or map.

Organized in columns Organized in rows

Swim Lane Map (cont.)

66

Process mapping — in summaryStep 1:• Agree on the boundaries of the process (start and finish of the map)Step 2:• Involve all people who actually perform in the process.Step 3:• Map the process “as is” rather than “should be” or the “to be.”Step 4:• Start each step with an action verb such as “Interview patient” or “Pick up chart.”Step 5:• Clearly indicate inputs and outputs of the process and what directly touches

the customer of the process.Step 6:• Use colored Post-It notes or a flip-chart to record the process steps;

documentation in Visio or some other software can be done later.Step 7: • Confirm the process map with those who do the process

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So far, the process maps identified activities that are no longer necessary and work that Is non-value added but what are those “vital few”problems that are contributing to the process costs and variation.

Next steps - identify the Root Causes (deep underlying causes of a problem in a process

Look for those critical inputs (x’s) that are causing the output (Y) with either these tools:

•Fishbone diagram

•5 Whys?

•Cause and effect diagrams or cause and effect matrix's

Understanding the real root cause of your process problems.

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The benefits of using the tools• Helps to organize the many causes or factors (critical X’s)

that contribute to the outcome (critical Y)• Provides a structure to understand the relationships

between many possible causes of a problem• Eliminates personal agendas and changes based on one –

time event• Involves groups of people in developing a common

understanding of the causes• Helps plan for the measurement and verification of potential

causes and test for solutions• Documents the potential causes that have been investigated

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1. Works best in a meeting / brainstorming session setting

2. Place the problem statement in the head of the fish

3. Choose the cause categories that contribute to the outcome. Use 6 Ms if you have trouble identifying categories.

4. For each identified cause category, ask the question: Why?

5. Place answers (deeper causes) as sub-bones connected to main cause categories.

6. Keep drilling into deeper causes by asking the same question (Why?)

7. Look for comments that keep coming up again and again. These may be your root causes

How to Construct a Fishbone Diagram

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Materials

Mother Nature\ Policies

Methods /Process

Man / People

Machines / Place

Measurements

The categories of causes –(bones of the fish)

• 6 M’S or 4 P’s• Should be flexible• Only those that contribute to the problem Effect

• Everyone agrees on it

• Include if possible “what”, “where”, “when” and “how much”

Backbone

Components of a Fishbone Diagram

ProblemStatement

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Materials

ProblemStatement

Mother Nature\ Policies

Methods /Process

Man / People

Machines / Place

Measurements

Look for causes that appear repeatedly within or across major cause categories

Fishbone Diagram – Interpretation

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How to Construct the Five (5) Whys1. Similar in purpose to the Fishbone diagram. 2. Select any problem from your process map3. Ask “why does this outcome occur?”4. By asking “why?” five times, you can move beyond

symptoms of a problem to the true root cause.5. Five whys are usually sufficient to get to the bottom of the

issue.6. Continue until the team feels that a potential root cause is

identified.

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Receivers are

out of office for lunch

Back-ups don’t know

job well

Why?

Why?

Policy to only do phones at lunch as

back-ups

Why?

Job training not a priority; seen as a

cost

Why?

Why?

Back-ups take longer

to make connections

No lunch coverage

policy

Receivers are

out of office

Less practice

No job aids

No job aids

High Turnover

No training

No job aids in administration

areas


areas

No lunch coverage policy

Newest employees get this job

No recognition of training needs

No training for managers in process

improvement

Assume coverage not needed

No system to ID training needs

Perceive the job as simple

No one likes the job

No job flexibility plan


cost


cost

Serving customers not a priority

Management doesn’t know job

Difficult, stressful job

Job training and development not

a priority

Too long to

connect calls

during lunch hour


improvement

AH-011

Quality problem

1

23 4

5


A 5 Whys Diagram

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Receivers are

out of office for lunch

Back-ups don’t know

job well

Why?

Why?

Policy to only do phones at lunch as

back-ups

Why?


cost

Why?

Why?

Back-ups take longer

to make connections

No lunch coverage

policy

Receivers are

out of office

Less practice

No job aids

No job aids

High Turnover

No training


areas


areas

No lunch coverage policy

Newest employees get this job

No recognition of training needs


improvement

Assume coverage not needed

No system to ID training needs

Perceive the job as simple

No one likes the job

No job flexibility plan


cost


cost

Serving customers not a priority

Management doesn’t know job

Difficult, stressful job

Job training and development not

a priority

Too long to

connect calls

during lunch hour


improvement

AH-011

Quality problem

1

23 4

5


A 5 Whys Diagram

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Cause & Effect (C&E) matrix — what is it?

Purpose• To identify the few key

process input variables that must be addressed to improve the key process out variable(s).

• Similar in purpose to a Fishbone diagram, but allows us to see what effect various inputs and outputs have on ranked customer priorities.

To identify which key process input variables (causes) most influence the key process output variable (effect).

Input

Input

Input

InputInput

Input

Input

Input

Key ProcessOutput

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How to create a C&E matrix1. Identify key customer requirements (outputs) from the process map or VOC studies.

List the outputs across the top of top of the matrix.2. Assign a priority score to each out according to importance to the customer.

Usually on a 1 to 10 scale, with 10 being most important (review customer data).3. Identify all process steps and key inputs from the process map. List down the side of the

matrix.4. Rate each input against each output based on the strength of their relationship:

Blank — no correlation, 1 — Low, 3 — Moderate, 9 — Strong.5. Cross multiply correlation scores with priority scores and add across for each input.

12

3

4

5

Customer Requirement #1



Process Outputs

Importance 6 10 9

Process Steps Process Inputs

Total

Step A 3 30Step B 9 3 117Step C 1 1 1 25Step D 9 3 9 165Step E 3 3 57

Correlation of Input to Output

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The Hospital Coffee Shop example

Example:• A team has been asked by the coffee shop

to improve customer satisfaction with the coffee they serve.

• The team has completed aprocess map and they areready to create a C&E matrixto identify the inputs that havethe largest impact oncustomer satisfaction.

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Inputs OutputsInputs Outputs

Hot WaterSoapScrubberClean CarafeCold WaterMeasuring MarkFull Carafe

Cleaned CarafeDirty WaterWet Scrubber

Full Carafe

Filled MakerEmpty Carafe

Maker w/Filter

Maker w/Filter& Coffee

Operating MakerHeatBrewed Coffee

Hot Coffee

CustomerOrderSize Specification

Complete OrderHot CoffeeCup

Filled CupCustomerCreamSugarAmount Desired

Complete OrderMoney

Coffee Delivery

Filter

Maker w/FilterFresh CoffeeDosing ScoopMaker w/Filter& Coffee

Brewing Coffee

Complete Order

Filled Cup

Customer ReplyAmount SpecifiedComplete Order

Make ChangeCup to CustomerTemperatureTaste, Strength

SmileHappy Customer

Pour Coffeeinto Cup

Offer Cream & Sugar/Add &

Deliver

Complete Transaction

SayThank You

Receive Coffee Order

CleanCarafe

Fill Carafew/Water

Pour Water into Maker

Place Filterin Maker

Put Coffeein Filter

Select Temperature

Setting

Turn MakerOn

Coffee shop process map

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Coffee shop

• 3 key outputs were obtained by asking 100% of the customers who purchased coffee the week before.

• The CTQ’s that received the highest priority were: taste, strength and temperature.

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Taste Temp Strength

10 8 6

Process Step Process Input

1 Clean Carafe 3 0 1 362 Fill Carafe with Water 9 0 9 1443 Pour Water in Maker 1 0 1 164 Place Filter in Maker 3 0 1 365 Put Coffee in Filter 9 0 9 1446 Turn Maker On 1 3 0 347 Select Temperature Setting 3 9 3 1208 Receive Coffe Order 0 0 1 69 Pour Coffee into Cup 1 3 3 52

10 Offer Cream and Sugar/Deliver 9 3 3 13211 Complete Transaction 1 1 1 2412 Say Thank You 0 0 0 0


Process Output

Importance

CTQs

Importance RatingA higher score

indicates the output is more important to the

customer

Coffee shop (cont.)

81

Taste Temp Strength

10 8 6





Process Output

Importance

Correlation Scores(Voted by customers)

A higher score indicatesstronger correlation

Coffee shop (cont.)

82

Taste Temp Strength

10 8 6





Process Output

Importance

Process Step’s Total ScoresBy Step

(Taste * Correlation) + (Temp * Correlation) +(Strength * Correlation)

Coffee shop (cont.)

83

700

600

500

400

300

200

100

0

100

80

60

40

20

0Defect

132 2224343636521201441443.03.24.64.84.87.016.117.719.419.4

100.097.093.889.284.479.672.656.538.719.4

CountPercentCum %

Fill Carafe

with Water

Put Coffee in Filter

Offer Cream

&Sugar

Select Temperature

Setting

Pour Coffee

into Cup

Clean Carafe

Place Filter in Maker

Turn Maker

On

Complete Transaction

Others

Cou

nt

Per

cent

Pareto Chart for Step

Coffee shop (cont.)

84

• The Pareto chart shows us that four process steps have the most impact on our CTQ’s.– Fill carafe with water.– Put coffee in filter.– Offer cream and sugar.– Select temperature setting.

• We would follow this up with another C&E matrix using the process inputs from these four process steps.

Taste Temp Strength

10 8 6


2 Fill Carafe with Water 9 9 9 2165 Put Coffee in Filter 9 0 9 1447 Select Temperature Setting 9 9 0 162

10 Offer Cream and Sugar/Deliver 9 0 9 144


Process Output

Importance

Coffee shop (cont.)

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End of Video #3: Summary We have now taken you on a journey to understand more about your

processes and introduce you to some quality concepts. At this time you should be able to:

• Take on a project that is meaningful to the customer and meaningful to the management – PROJECT Y

• You have understood the need to collect the metrics of your process through DATA COLLECTION

• You should be able to DISPLAY the metrics and CALCULATE the variation

• Then you can Map out the process using any one of the 4 techniques and eliminate the Non-value added activities

• Finally, you can drill down to the real root cause of the problem with a Fish bone Diagram or Cause and Effect tools

• In Video #4 – you will learn how to come up with the best solution and implement those ideas.

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Thank you

All rights reserved: 2008 Business Excellence Group, Inc in conjunction with the Nebraska Hospital Association. Any reproduction of the slides used must receive permission from Business Excellence Group, Inc. Contact Monica Seeland at the Nebraska Hospital Association at 402-742-8152 or Business Excellence Group, Inc at 319-822-7011 or 914-319-1382 for additional support or questions.