Lean Six Sigma & A3 Thinking Workbook

Evelyn A. Catt, 2015

Lean Six Sigma & A3 Thinking

Workbook

06-01-15 v21

Evelyn A. Catt, MHA, BSPH, CSSBB

Principal, TTAC Consulting, LLC

Adjunct Professor, Indiana University

Fairbanks School of Public Health

A Review of Basic Concepts

with Exercises, Checklists, and Learning Guides

Evelyn A. Catt, 20152.

SUBJECT SLIDE SUBJECT SLIDE SUBJECT SLIDE

Title Page 1 Safe Hand-offs 31 Lean Six Sigma Methodology 61

Index pg. 1-90 2 Evidence-Based Standard Work 32 Lean Six Sigma Roadmap 62

Index pg. 91-180 3 Standard Work - Value Added 33 Understanding Variation 63

Index pg. 181-270 4 Continuous Improvement 34 Variation & Reliability 64

Value Stream View of Patient Journey 5 Summary 35 Types of Variation 65

Lean Focus 6 Safe Passage 36 Variation in Healthcare Processes 66

Pursuit of Perfection 7 Systems Thinking Section 37 Concept of a Function 67

Identify and Eliminate Waste 8 Origin of Systems Thinking 38 Concept of a Function Example 68

Types of Waste 9 A3 Thinking 39 Reducing Variation in Healthcare 69

Create Flow 10 Plan – Do – Study – Act (PDSA) 40 Y = f (x) EXERCISE 70

Establish Pull 11 Lean, Six Sigma, and A3 Thinking 41 Kaizen Continuous Improvements 71

Specify Value 12 Lean, Six Sigma, and A3 Thinking 42 Kaizen - Continuous Improvements 72

Value Added 13 Lean, Six Sigma, and A3 Thinking 43 Kaizen Event Agenda 73

Non-Value Added 14 A3 Thinking 44 Kaizen Event Agenda 74

Impact of Non-Value Added Steps 15 A3 Structured Problem Solving Format 45 A3 Structured Problem Solving Steps 75

Value Streams Section 16 Lean Principles Section 46 A3 Exercise: Define Phase 76

Value Stream 17 Origin of Lean 47 A3 Exercise: Measure/Analyze Phases 77

Value Stream Levels 18 Lean Focus 48 A3 Exercise: Improve/Control Phases 78

Lean Goals 19 Lean Thinking 49 Action Plan Template 79

Value Stream Analysis 20 Lean Rules 50 Communication Plan Template 80

Value Steam Mapping 21 Reflections 51 Control Plan Template 81

Patient Journey 22 Lean Key Concepts Section 52 Control Plan Checklist 82

Navigating the Value Stream 23 Key Concepts 53 Reflections 83

What will happen during my journey? 24 Value Added Process 54 Lean 5-S Section 84

Patient Expectations 25 Waste 55 What is Lean 5-S? 85

What The Patient Expected 26 The Cost of Quality 56 Lean 5-S 86

What The Patient Experienced 27 Six Sigma Principles Section 57 Lean 5-S Examples 87

Safe Passage Through Value Stream 28 Origin of Six Sigma 58 Visual Control Examples 88

Silos 29 Six Sigma Focus 59 Lean 5-S Achievement Levels 89

Risk Mitigation 30 Lean Six Sigma Model 60 Lean 5-S Benefits 90



Keys To Lean 5-S Success 91 First: Go to “Gemba” 121 Patient Flow & Accountable Care 151

Lean 5-S EXERCISE 92 “Gemba” is Everywhere! 122 What happens when the flow stops? 152

Standard Work Section 93 Foundation for Success 123 Lack of Flow Creates Waste 153

Standard Work 94 Brainstorming 124 Tools to Improve Flow Section 154

Why Standard Work? 95 Affinity Diagram 125 Identifying Bottlenecks 155

Standard Work Goals 96 Reflections 126 Reflections 156

Standard Work Components 97 Voice of the Customer/Stakeholder 127 Spaghetti Diagram 157

Creating Standard Work 98 SWOT EXERCISE 128 Spaghetti Diagram EXERCISE 158

Standard Work Example 99 Customer Requirements EXERCISE 129 Simplify Process Flows 159

Viewing Your Facility as a System 100 Customer Requirements Tree 130 The 7 Flows 160

System-wide Goals 101 Customer Requirements Tree EXERCISE 131 Checklist for Improving Flow 161

System-wide Benefits 102 Kano Model Section 132 Checklist for Improving Flow 162

Core Process Map 103 Characteristics of Products & Services 133 Checklist for Improving Flow 163

Hospital Core Process Map 104 Kano Model 134 Checklist for Improving Flow 164

Department Core Process Map 105 Kano Model Elements 135 Root Cause Analysis Section 165

Core Process Map EXERCISE 106 Kano Model Uses & Strengths 136 Root Cause Analysis 166

Defining the Process Section 107 Value Stream Mapping Section 137 Root Cause Analysis (5 Whys) 167

High Level Process Map 108 Value Stream Map (VSM) 138 Root Cause Analysis EXERCISE 168

High Level Process Map EXERCISE 109 Value Stream Mapping – Current State 139 Fishbone Diagram 169

Reflections 110 Design the Ideal “Future State” 140 Fishbone Diagram Example 170

Process Flow Chart 111 Value Stream Mapping – Future State 141 Fishbone Diagram EXERCISE 171

Process Flow Chart Symbols 112 Value Stream Mapping EXERCISE 142 Mistake Proofing (Poka Yoke) 172

SIPOCS Diagram 113 Value Stream Measurements EXERCISE 143 Mistake Proofing (Poka Yoke) Examples 173

SIPOCS EXERCISE 114 Identifying Waste Section 144 Project Selection Section 174

X-Y Chart (C&E Matrix) 115 Waste in the Emergency Department 145 Project Selection & Prioritization 175

Murphy’s Analysis 116 Types of Waste 146 Project List EXERCISE 176

Murphy’s Analysis EXERCSE 117 Waste Walk Worksheet EXERCISE 147 Project Goal EXERCISE 177

Reflections 118 Checklist for Removing Waste 148 Project Impact vs. Effort Grid 178

Customer Requirements Section 119 Flow Section 149 Project Prioritization Matrix 179

Customer Requirements 120 Flow 150 Goals Grid 180



Goals Grid EXERCISE 181 Measurement Systems 211 Impact of Outliers 241

Project Charter Section 182 Primary & Secondary Data 212 Process Capability Section 242

Project Charter 183 Data Integrity 213 Tools 243

Project Team Roles 184 Data Audits & Validation 214 Process Capability 244

Project Team Worksheet 185 Sampling Bias 215 Process Capability 245

Problem Statement 186 Tips to Avoid Data Disaster 216 Specification Limits 246

Problem Statement Worksheet 187 Measurement System Analysis (MSA) 217 Specification Limits Example 247

Aim Statement 188 Data Types & Display Section 218 Accuracy vs. Precision 248

Aim Statement Worksheet 189 Process, Outcome, Balancing Metrics 219 Improving Process Performance 249

Project Scope 190 Process Measures 220 The Normal Distribution 250

Project Scope Worksheet 191 Outcome Measures 221 The Normal Distribution 251

Project Timeline & Milestones 192 Balancing Measures 222 The Normal Distribution 252

Project Metrics Section 193 Quantitative Data 223 What Lies Beneath 253

Project Metrics – Definitions 194 Qualitative Data 224 Sub-Populations 254

Project Metrics – Initial/Target State 195 Categorical Data 225 Reflections 255

Project Metrics Worksheet 196 Interval Data 226 Learning Guides & Deliverables 256

Stakeholder Analysis Section 197 Parametric and Non-Parametric Data 227 Define Phase Deliverables 257

Stakeholder Analysis 198 Measuring Data Consistency 228 Define Phase – Learning Guide 258

Force Field Analysis 199 Measures of Central Tendency 229 Measure Phase Deliverables 259

Force Field Analysis Worksheet 200 Meaningful Uses of Data 230 Measure Phase – Learning Guide 260

Data Collection Plan Section 201 Value of Data Display 231 Analyze Phase Deliverables 261

Data Collection Plan – 5 Steps 202 Questions to Guide Data Display 232 Analyze Phase – Learning Guide 262

Data Collection Plan 203 Charts for Measuring Variation Section 233 Improve Phase Deliverables 263

Operational Definitions 204 Using Run Charts for Data Display 234 Improve Phase – Learning Guide 264

Data Collection Methods 205 Benefits of Run Charts 235 Control Phase Deliverables 265

Check Sheet 206 Control Chart 236 Control Phase – Learning Guide 266

Check Sheet Example 207 Pareto Chart 237 Project Hand-off 267

Check Sheet Template 208 Pareto Chart Example 238 Recognition & Celebration 268

Measurement Systems Section 209 Frequency Plot 239 References 269

Measurement Checklist 210 Interpreting Frequency Plot Data 240 References 270


A Value Stream View

of the Patient Journey

5.


Lean Focus

• Lean is focused on the constant

pursuit of perfection

• By eliminating waste and non-value

added activities

• To improve the flow of value to the

patient

Perfection

Waste

Flow

Value

References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5: pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/

Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.

6.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/


Pursuit of Perfection

• Lean is focused on the constant pursuit of

perfection using:

– Evidence based practices/standard work

– Continuous Improvement (PDSA cycle)

– Monitoring quality & performance metrics

– Rapid Improvement Events (RIEs), Kaizen Events

– Value Stream Mapping & Value Analysis

– Lean 5-S (sort, store, shine, standardize, sustain, + safety)

– Visual Management (color coding, visual cues)

Perfection

Waste

Flow

Value



7.



Identify and Eliminate Waste (Muda)

• Waste is any activity that consumes

time, resources, or space but does

not add value to the product or

service in the eyes of the patient.

Perfection

Waste

Flow

Value



8.



Types of Waste (Muda)

Perfection

Waste

Flow

Value

Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.Source URL: http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples

DefectsErrors, poor quality, failure to meet customer requirements

Overproduction Providing unnecessary products, services, or features.

Waiting Delays, periods of inactivity, bottlenecks, or patient wait time.

Non-Utilized Potential Failure to fully utilize human potential (time and talents of people).

Transportation Unnecessary movement of supplies, equipment, or people.

Inventory Excess inventory/supplies, batch processing, queues, or backlogs of work.

MotionExtra steps taken by employees because of inefficient layout, searching, hunting and gathering.

Excess Processing Excess activity and processing steps caused by poor process design.

9.

http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples


Create Flow

Perfection

Waste

Flow

Value

• Flow is the continuous movement of

people, materials and supplies through a

process.

• Flow ensures that patients have what they

need exactly when they need it.

– No delays or waiting

– One piece flow (instead of batching)

– Well organized supplies and work space

– Alignment of work volume and resources

– Replenishment of only what is neededReferences: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5: pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/

Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005. 10.



Establish Pull

Perfection

Waste

Pull

Value

• Pull is the timely transition of work from

one process step to the next.

• Pull means performing work as it is

requested or needed by a step in the value

stream so that demand triggers action.

• When a downstream process is ready for

more supplies, patients, etc., a signal is

made to pull more into the process “just in

time” (JIT).



11.



Specify Value

• Value is defined by the patient.

• Value may be tangible or intangible.

• Every process should be designed

to deliver what the patient values

and would be willing to pay for in the

service/care that is being provided.

Perfection

Waste

Flow

Value



12.



Value Added

• Example: Medication Administration

• The “value added” elements in this

process include:

Value Added

Non-Value Added

13.

Accuracy Timeliness Comfort DignitySafety Knowledge


Non-Value Added

• Example: Medication Administration

• “Non-value added” elements and waste

(muda) may also occur in this process.

Value Added

Non-Value Added

AnxietyErrors Delays Pain

14.


Impact of Non-Value Added Steps

• Non-value added steps and waste

may result in:

– Decreased value to the patient

– Decreased satisfaction

– Decreased quality

– Decreased productivity

– Increased risk

– Increased cost

Value Added

Non-Value Added



15.



Value Streams

16.


Value Stream

• A value stream includes all of the steps and

activities required to provide services and care

for a patient.



17.

Admission Care Delivery DischargeHigh Level



Value Stream Levels

Admission Care Delivery Discharge

•Pre-certification•Registration•Scheduling•Room assignment

•Assessments•Interventions•Medication Admin.•Diagnostic Testing

•Transition Planning•Referrals•Prescriptions•Home Care

High Level

Detailed

• Registrationo Step 1o Step 2o Step 3

• Assessmentso Step 1o Step 2o Step 3

• Transition Planningo Step 1o Step 2o Step 3

Step by Step



18.



Lean Goals

• The goal of using Lean is to eliminate the “non-value

added” elements (waste) in each value stream and

retain only the “value added” components.



19.

Accuracy Timeliness Comfort DignitySafety Knowledge



Value Stream Analysis

• Value stream analysis is used to identify & eliminate

“non-value added” elements (waste) in a process.

Overproduction Waiting Non-Utilized Potential

Defects

Transportation Inventory Motion Excess Processing



20.



Value Steam Mapping

Scope

Current State

Future State

Action Plan

Diagram Source URL: http://www.bing.com/images/search?q=lean+value+stream&FORM=HDRSC2#view=detail&id=2E7FAF5B08108784A719AFBEC3F50DA5E24C0902&selectedIndex=30

21.

http://www.bing.com/images/search?q=lean+value+stream&FORM=HDRSC2#view=detail&id=2E7FAF5B08108784A719AFBEC3F50DA5E24C0902&selectedIndex=30


• In a value stream view of the patient journey:

– The patient is an active participant in their

own care.

– The patient makes informed choices

regarding their healthcare options and goals.

– In partnership with the patient, the care team

helps the patient safely navigate through their

journey to achieve their goals.

Patient Journey

References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patient’s Voice. J Amer Board of Fam Med. 2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf

Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008. Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf

22.

http://www.jabfm.org/content/25/2/192.full.pdf

http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf


Navigating the Value Stream

• What is the plan for my journey

through the value stream?

– Patients value being well informed about

their plan of care, knowing their schedule,

and having options and choices.

Plan of Care

Schedule

Choices

Cost



23.




What will happen during my journey?

Goals

Risks

Outcomes

• What are the treatment goals?

• What are the potential risks?

• What outcomes will be achieved?

• How will this journey end?

– Patients value clear and timely

information, respect, compassion,

and reassurance.


Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008. Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf 24.




Patient Expectations

• Does the patient have realistic

expectations for their journey?

• Have they been given clear

information to make well informed

choices?

• Do they understand their treatment

options and the associated costs?

Plan of Care

Schedule

Choices

Cost



25.




What The Patient Expected

26.

Timeliness

Dignity

Safety

ComfortAccuracy

Knowledge


What The Patient Experienced

S.S. Healthcare

Errors Pain

Delays

27.


Safe Passage Through

the Value Stream

S.S. Safe Passage

28.


Silos

• Instead of working together as a value stream we often

function as silos that work in isolation from each other.

•Pre-certification•Registration•Scheduling•Pre-Admit Testing•Room Assignment

•Assessments•Interventions•Medication Admin.•Diagnostic Testing•Surgery/Recovery

•Transition Planning•Referrals•Prescriptions•Home Care•Transportation

Admission Care Delivery Discharge

Reference: Hajek AM. Crushing the Silos: A Leadership Imperative to Ensuring Healthcare Safety in the Era of Healthcare Reform. 2010 Clarity Group, Inc. Source URL: http://www.claritygrp.com/media/1346/crushing-the-silos-white-paper.pdf

29.

http://www.claritygrp.com/media/1346/crushing-the-silos-white-paper.pdf


Risk Mitigation

• The potential risk of silos in the value stream must

be mitigated, especially during patient hand-offs.

Reference: Hajek AM. Crushing the Silos: A Leadership Imperative to Ensuring Healthcare Safety in the Era of Healthcare Reform. 2010 Clarity Group, Inc. Source URL: http://www.claritygrp.com/media/1346/crushing-the-silos-white-paper.pdf

30.



Safe Hand-offs

• Implementing tools such as SBAR (situation,

background, assessment, recommendation) helps

ensure consistent hand-off communications are

completed.

• Value added = increased patient safety.

Reference: SBAR Technique for Communication: A Situational Briefing Model. Institute for Healthcare Improvement.Source URL: http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx

31.

http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx


Evidence-Based Standard Work

• Standard work is the best known way of

performing a process today.

• Standard work is based on creative

problem solving and continuous

improvement.

• Standard work evolves over time as new

evidence-based practices are identified

and implemented.

References: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.Source URL: http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf

Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.Source URL: http://www.createvalue.org/blog/post/?bid=148

Best Known Way

Creative Problem Solving

Continuous Improvement

Evidence Based Practices

32.

http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf

http://www.createvalue.org/blog/post/?bid=148


Standard Work - Value Added

• Reduces variation in performance

• Creates balanced work load

• Promotes consistency of outcomes

• Exposes waste in the process

• Reveals opportunities for improvement

Best Known Way

Creative Problem Solving


Evidence Based Practices

References: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.Source URL: http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf


33.





• Lean is a journey of continuous improvement in

pursuit of perfection using:

– Evidence based practices/standard work

– Continuous Improvement (PDSA cycle)

– Monitoring quality & performance metrics

– Rapid Improvement Events (RIEs), Kaizen Events

– Value Stream Mapping & Value Analysis

– Lean 5-S (sort, store, shine, standardize, sustain,+ safety)

– Visual Management (color coding, visual cues)



34.



Summary

• Lean is focused on the constant pursuit of

perfection by eliminating waste and non-

value added activities to improve the flow of

value to the patient.

• Value is defined by the patient.

• Every process in the value stream should be

designed to deliver what the patient values

in the service/care that is being provided.

Perfection

Waste

Flow

Value



35.



Safe Passage

• Our shared goal is the safe passage of all

patients through the healthcare value streams!

36.

S.S. Safe Passage


Systems Thinking

37.


Origin of Systems Thinking

“A fault in the interpretation of observations, seen everywhere, is to suppose

that every event is attributable to someone (usually the one closest at hand),

or is related to some special event.

The fact is that most troubles……. lie in the system and not the people”.

Dr. W. Edwards Deming, The New Economics

Image Source: http://www.pixshock.net/pic_b/6f9e0c8cb7c046a59b86ff4d7fccfee0.jpg38.

http://www.pixshock.net/pic_b/6f9e0c8cb7c046a59b86ff4d7fccfee0.jpg


A3 Thinking

• A3 Thinking is a structured, collaborative problem solving process.

• The A3 process uses the PDSA (plan-do-study-act) model as the

foundation of an iterative cycle of continuous improvement.

• This cycle promotes “systems thinking” and the development of

people as “problem solvers”.

39.


Plan – Do – Study – Act (PDSA)

• The PDSA “Model for Improvement” serves as the foundation of A3

Thinking and the pursuit of continuous improvement.

• The PDSA model guides rapid improvement cycles using small tests

of change driven by empowered employees.

• The PDSA cycle starts by asking three questions:

– What are we trying to accomplish?

– How will we know that a change is an improvement?

– What changes can we make that will result in improvement?

Reference: Institute for Healthcare Improvement (IHI), 2011. Diagram Source: http://www.saferpak.com/images/pdsa.gif

40.

http://www.saferpak.com/images/pdsa.gif


• The PDSA Cycle uses the following steps in an iterative cycle of

continuous improvement.

41.

Plan – Do – Study – Act (PDSA)

STEP ACTIVITY

PLANIdentify the opportunity and plan the

improvements.

DO Carry out the plan.

STUDYCompare actual results to predicted

results and summarize what has

been learned.

ACTIdentify any changes that are

required and/or develop a plan to

spread improvements.

Reference: Institute for Healthcare Improvement (IHI), 2011.

Diagram Source: http://www.advancingrecovery.net/Images/Misc/RollingPDSA.jpg

http://www.advancingrecovery.net/Images/Misc/RollingPDSA.jpg


Lean, Six Sigma, and A3 Thinking

42.

LeanSix Sigma

Tools, Analysis, and Solution Development

A3 Problem Solving

PDSA Model

Reference: A3 Thinking

Source URL: http://a3thinking.com/

• Lean and Six Sigma provide the methods and tools to facilitate the

appropriate level of analysis and solution development based on the

complexity of the problem being addressed with the A3 process.

http://a3thinking.com/


Lean, Six Sigma, and A3 Thinking

• The appropriate Lean and Six Sigma methods and tools are selected

based on the scope, complexity, and directional flow of each problem.

– Horizontal flows (value stream mapping)

– Vertical depth (root cause analysis)

– Highly complex issues (statistical analysis)

– Rapid cycle improvements (Kaizen)

– Safety issues (mistake proofing, root cause analysis)

– Supplies and equipment (Kanban, Lean 5-S, visual controls)

– Throughput (standard work, value stream mapping)

– Work flow and environment (Lean 5-S, flow, pull, cellular layout)

43.Reference: A3 Thinking

Source URL: http://a3thinking.com/



A3 Thinking

• Why is it called “A3” Thinking?

• The term “A3” refers to the 11x17 size of paper used for the A3 report.

• The A3 report format is used for simplicity, consistency, and also serves

as a rapid communication tool to promote organizational learning.

44.Reference: A3 Thinking Source URL: http://a3thinking.com/



A3 Structured Problem Solving Format

45.Reference: A3 Thinking . Source URL: http://a3thinking.com/

*Countermeasures are proposed solutions to address the root cause of the problem and move the process closer to the “target state”.



LEAN Principles

46.

SUSTAIN

OPTIMIZE

SIMPLIFY &

STANDARDIZE

CUSTOMER FOCUSED


Origin of Lean

• Lean principles are based on a management philosophy derived

from the Toyota Production System (TPS).

• TPS is focused on the identification and steady elimination of

waste to preserve value with less work.

• This is achieved by getting the right things to the right place at the

right time in the right quantity to achieve perfect work flow, while

minimizing waste.

• When applied in the daily workplace, “Lean thinking” is used to

continually improve all functions by people at all levels in the

organization.

47.

Reference: Source URL http://en.wikipedia.org/wiki/Kaizen, http://www.strategosinc.com/kaizen.htmhttp://en.wikipedia.org/wiki/Lean_manufacturing

http://en.wikipedia.org/wiki/Kaizen

http://www.strategosinc.com/kaizen.htm

http://en.wikipedia.org/wiki/Lean_manufacturing


Lean Focus

Lean is focused on the

constant pursuit of perfection

by eliminating waste and

non-value added activities to

improve the flow of value to the customer.

48.


Lean Thinking

“Lean Thinking”

creates a culture and practices

that continually improve

all functions by all people

at all levels in the organization.

49.


Lean Rules

RULE 1: Clearly specify all activities.

Mindful standardization of work.

• Content: What is being done?

• Sequence: In what order?

• Timing: How long should it take?

• Outcomes: What clearly defined

measurable results are expected?

RULE 3: Clearly define all pathways.

Organize for uninterrupted flow.

• Simple (with as few steps and people

as possible).

• Direct steps to deliver the requested

product or service.

Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999

Source URL: http://www.systems2win.com/solutions/5s.htm

RULE 2: Clearly define all connections to

every customer and supplier.

No ambiguity.

• Direct (no intermediary between)

• Yes or No answers (no maybes)

RULE 4: Continuously Improve.

Develop leaders who can apply the

scientific method to improve anything.

• Direct response to any problem that arises.

• By those doing the work - as close to the

problem as possible.

• If feasible, start as an experiment.

• Supported by a coach.

50.

http://www.systems2win.com/solutions/5s.htm


Reflections

• What type of benefits and competitive advantage could Lean create for

your facility?

• How will you communicate and prepare your staff for a Lean culture and

the new practices and expectations?

• What tools or support will you need to make this a successful transition?


Lean

Key Concepts

52.


Key Concepts

• All work is a process and even the smallest change can

impact the entire organization.

• Every process should be designed with the patient in

mind, to deliver what the patient values in the process.

• Lean organizations are continually improving and

looking for new opportunities to:

– Eliminate waste

– Increase value to the patient

– Achieve efficient work flow

Reference: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication

No. 08-0022, April 2008. Source URL: http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf

53.

http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf


Value Added Process

A value-added process:

• Creates value for the patient/customer.

• Produces a good result every time.

• Does not cause delays.

• Is satisfying:

– for people to perform

– for managers to manage

– for patients to experience

54.

Reference: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication

No. 08-0022, April 2008. Source URL: http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf

http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf


Waste

• Waste is any activity that consumes time, resources,

or space but does not add value to the product or

service in the eyes of the patient.

• And waste consumes resources!



Image Source URL: http://www.13dots.com/reddragon/trashcan/4.gif55.


http://www.13dots.com/reddragon/trashcan/4.gif


The Cost of Quality

56.

• The Cost of Quality is the sum of four cumulative types of costs:

– Appraisal, Detection, Internal Failure, External Failure

• The Cost of Poor Quality is the cost associated with producing defects,

which includes internal failure costs and external failure costs.

Diagram Source URL: iSix Sigma http://www.isixsigma.com/implementation/financial-analysis/cost-quality-not-only-failure-costs/

http://www.isixsigma.com/implementation/financial-analysis/cost-quality-not-only-failure-costs/


Six Sigma Principles

57.


Origin of Six Sigma

• Six Sigma was originally developed by Motorola in 1986.

• Motorola set a goal of "six sigma" (99.99966% perfect) for all of its

manufacturing operations, and this goal became a byword for the

methods used to achieve it.

• Six Sigma seeks to improve the quality of process outputs by

identifying and removing the causes of defects (errors) and

minimizing variation.

• Reducing variation in a process is the key to reducing errors and

waste, which increases reliability.

• Increased reliability results in safe, high quality care.

Reference: http://en.wikipedia.org/wiki/Six_sigma

58.

http://en.wikipedia.org/wiki/Six_sigma


Six Sigma Focus

Six Sigma is focused on

identifying and correcting errors (defects)

to minimize variation

and increase accuracy.

59.


Lean Six Sigma Model

60.

SUSTAIN

OPTIMIZE

SIMPLIFY &

STANDARDIZE

VALUE ACCURACY

WASTE VARIATION

LEANEliminate waste and non-value

added activities in a process.

SIX SIGMACorrect errors and defects to

minimize variation in a process.

CUSTOMER FOCUSED


Lean Six Sigma Methodology

Define the process & determine customer

requirements

DEFINE MEASURE ANALYZE IMPROVE CONTROL

Map and measure the process to

understand current performance

Identify amounts & types of waste and

determine theroot causes

Design the future state; select and test

improvements

Create a process control strategy to sustain and spread improvements

Reference: Source URL http://business901.com/wp-content/uploads/2009/10/DMAIC.JPG

• Lean Six Sigma is a data-driven problem solving

methodology with a structured Roadmap (D-M-A-I-C).

61.

http://business901.com/wp-content/uploads/2009/10/DMAIC.JPG


Lean Six Sigma Roadmap

Confidential/proprietary document

PHASE STEPS TOOLS DELIVERABLES

DEFINE Initiate the project, define the process, and determine customer requirements.

•Project Charter•SIPOCS, I&O, High Level Process Map•Murphy’s Analysis/Affinity Diagram•Voice of the Customer/Go to Gemba•Customer Requirements Tree (CTQ)

•Project charter created•Project team formed•Project goals defined•Customer requirements•Project metrics identified

MEASURE Map and measure the process to understand current performance.

•Detailed Value Stream Map•Swim Lane Map•Spaghetti Diagram•Histograms/Frequency Plot•Control Charts/Process Capability

•Current state map created•Data collected & validated•Baseline performance measured and process capability evaluated

ANALYZE Identify amounts/types of waste and determine the root causes.

•Fishbone (Ishikawa) Diagram•Pareto Chart, Statistical Analysis•Hypothesis & Relationship Testing•Capacity Analysis, Flow Analysis•Root Cause Analysis (5 Whys), FMEA

•Waste & issues identified•Additional data collected & critical factors identified•Root causes of errors, waste & variation analyzed

IMPROVE Design the future state and select and test improvements.

•Future State Value Stream Map•5S, LEAN Tools, Kaizen Events•Visual Controls/Mistake Proofing•Plan-Do-Study-Act (PDSA)•Pilot Implementation Plan

•Future state designed•Solutions selected, tested, and validated •Action plans created•Pilot conducted

CONTROL Create a process control strategy to sustain and spread the improvements.

•Standard Work Instructions•Control Charts & Control Plan•Communication Plan•Full Scale Implementation Plan

•Control system in place•Communication plan implemented•Project celebration

NOTE: All projects do not require the use of every tool.

62.


Understanding Variation

63.

Lean Six Sigma uses data:

• To understand the sources of variation

• To target factors that have the most influence on performance

• To design evidence-based improvements

• To monitor and sustain results over time

• To conduct proactive analysis of potential failure modes to:

o Reduce risks

o Reduce errors

o Increase safety


Variation & Reliability

• Variation: A measure of change or difference.

• Reliability: Consistently giving the same result.

64.


Types of Variation

• Common Cause Variation: Natural variation within a process

(expected or acceptable variation).

• Special Cause Variation: Unpredictable or extreme variation

(unexpected or unacceptable variation).

65.

http://www.easy-cake-ideas.com/image-files/ice-cream-cone-cupcakes.jpg

http://www.easy-cake-ideas.com/image-files/ice-cream-cone-cupcakes.jpg


Variation in Healthcare Processes

Examples of variation in healthcare processes:

• Quality

– Accuracy of labeling blood tubes

– Completeness of pre-op testing for surgery patients

– High readmission rates for patients with diabetes

• Timeliness

– Turnaround time for test results

– Length of time to get a clinic appointment

– Waiting time in the Emergency Department

• Cost

– Variation in the cost of treating patients with the same diagnosis

– Differences in the cost of supplies from multiple vendors

– Fluctuations in employee turnover rates and the associated costs

66.


Concept of a Function

67.

• Six Sigma changes the problem solving approach from trial and

error to Y = f (x).

• A process is described by identifying the measurable output (Y)

and all known inputs (x).

• The Six Sigma roadmap and tools are used to analyze the

relationship between the measurable output (Y) and the process

inputs (x).

Y = f (x)

The value of Y is a function of the value of x

Y (measurable output) = function of x (process inputs)

Y (measurable output) is sometimes referred to as the “Big Y”


Concept of a Function Example

68.

Y (% of surgery on-time starts) = function of (x1, x2, x3, x4, x5,…….)

x1 = Patient shows up on time

x2 = Admitting office registers patient quickly

x3 = History and physical form (H&P) form received

x4 = Signed, current consent form received

x5 = Required professionals present (RN, surgeon,

anesthesiologist, etc.)


Reducing Variation in Healthcare

To reduce variation in healthcare processes:

• Identify the measurable output (Y) of the process.

• Identify the inputs (x’s) of the process.

• Use LEAN Six Sigma tools to identify the few critical inputs that have

the greatest influence on the output.

• Identify and correct the defects, errors, and variation associated with

these critical inputs. All possible inputs (x’s)

Few critical inputs (x’s)

DEFINE

MEASURE

ANALYZE

IMPROVE

CONTROL

69.


Y = f (x) Exercise

• Select a process from your facility for this exercise.

• Identify the measurable output (Y) of the process.

• Identify the inputs (x’s) of the process.

70.


Kaizen -

Continuous Improvements

71.


Kaizen – Continuous Improvements

• Kaizen is Japanese for "improvement" or "change for the better“. It refers to a

culture and practices that focus on continuous process improvements.

• When applied in the daily workplace, Kaizen refers to activities that continually

improve all functions by people at all levels in the organization.

• Individual Kaizen improvements can be implemented quickly by one person.

• A Kaizen Event is an intense, rapid improvement event (RIE) with a team that

is focused on a specific process with a well defined scope.

Reference: Source URL http://en.wikipedia.org/wiki/Kaizen, http://www.strategosinc.com/kaizen.htm 72.

Individual

Kaizen

Kaizen Event

with a Team

http://en.wikipedia.org/wiki/Kaizen

http://www.strategosinc.com/kaizen.htm


Kaizen Agenda (Rapid Improvement Event)

DAY 1: Define the Current State

• Set goals and expectations for the event

• Review Lean, Six Sigma, and A3 Thinking concepts

• Review reason for action (problem statement) and AIM statement

• Review data for current performance levels (initial state)

• Define customer requirements & critical to quality standards (CTQs)

DAY 2: Map/Measure the Process, Conduct Root Cause Analysis

• Go to Gemba to map and measure the current process

• Identify amounts and types of waste and quantify their impact

• Analyze issues and barriers to determine their root cause

• Implement “Just Do It” and Lean 5-S improvements

73.


Kaizen Agenda (Rapid Improvement Event)

DAY 3: Develop Solutions, Conduct Experiments, Develop Action Plans

• Develop counter measures to address the root cause of the issues

• Conduct rapid experiments to test the results of proposed solutions

• Finalize solutions to implement; create 30-60-90 day action plans

• Create a “future state” value stream map for the new process flow

• Finalize improvement goals (target state) for each performance measure

DAY 4/5: Create Standard Work, Complete the A3 Project Summary

• Document standard work and accountability standards

• Develop policies and procedures to support the new process

• Complete the A3 project summary

• Communicate results and celebrate project success

74.


DEFINE 1. PROBLEM STATEMENT MEASURE 4. INITIAL STATE METRICS IMPROVE 7. COUNTERMEASURES

Describe the background of the

current problem or opportunity.

What business problem are we

trying to solve?

Why is this issue important now?

*How will we know a change is an

improvement?

• Map and measure the current process

performance.

• What metrics are used to evaluate this

process? (initial state)

*What changes can we make that will result in

improvement?

Develop proposed solutions and counter measures.

Conduct rapid experiments to test/validate solutions.

Create a future state value stream map for the new

process.

Create standard work and develop policies and

procedures to support the new process with clearly

defined accountability.

DEFINE 2. AIM STATEMENT MEASURE 5. TARGET STATE METRICS IMPROVE 8. ACTION PLAN

*What are we trying to accomplish?

State your goals in measurable terms.

What are the boundaries for this

project?

o Included/excluded from scope:

o Process start point & end point:

• What are the improvement goals for each

metric? (target state)

• How are these metrics aligned with the

organization’s strategic goals?

• How will these metrics be monitored?

Develop an action plan to fully implement the

solutions, including details of who, what, and when.

o Identify “Just-Do Its” to be implemented immediately.

o Implement Lean 5-S and visual controls, as needed.

o Create and implement a communication plan.

DEFINE 3. CURRENT CONDITIONS ANALYZE 6. GAP ANALYSIS CONTROL 9. FOLLOW-UP

• Describe the current conditions of this

process using visual diagrams & charts.

• Determine the customer requirements

for this process.

• Identify the measurable Critical to

Quality (CTQ) elements of this process

that are essential for customer

satisfaction.

• Identify waste within the current process:

o Gemba walk, waste worksheet, value

added/non-value added analysis

• Analyze main issues, quantify their impact:

o Pareto charts, control charts, statistical

analysis, capability analysis

• Identify the root cause of issues and gaps:

o Fishbone diagram, Five Whys, Root Cause

Analysis, Failure Modes Analysis (FMEA)

• Confirm that actual results match the expected and

desired results.

• Identify any issues or barriers that still need to be

addressed.

• Create a plan to monitor, sustain, and spread the

new process.

• Summarize and share the insights gained from this

project.

*Reference: Institute for Healthcare Improvement (IHI), 2011.

A3 Structured Problem Solving Steps


DEFINE 1. PROBLEM STATEMENT

Describe the background of the current problem

or opportunity.

What business problem are we trying to solve?


DEFINE 2. AIM STATEMENT

*What are we trying to accomplish?

State your goals in measurable terms.

What are the boundaries for this project?o Included/excluded from scope:

o Process start point & end point:

DEFINE 3. CURRENT CONDITIONS

• Describe the current conditions of this process

using visual diagrams & charts.

• Determine the customer requirements for this

process.

• Identify the measurable Critical to Quality (CTQ)

elements of this process that are essential for

customer satisfaction.


Exercise: Define Phase


MEASURE 4. INITIAL STATE METRICS

*How will we know a change is an improvement?

• Map and measure the current process

performance.

• What metrics are used to evaluate this process?

(initial state)

MEASURE 5. TARGET STATE METRICS

• What are the improvement goals for each metric?

(target state)

• How are these metrics aligned with the

organization’s strategic goals?

• How will these metrics be monitored?

ANALYZE 6. GAP ANALYSIS

• Identify waste within the current process:

o Gemba walk, waste worksheet, value

added/non-value added analysis

• Analyze main issues, quantify their impact:

o Pareto charts, control charts, statistical analysis,

capability analysis

• Identify the root cause of issues and gaps:

o Fishbone diagram, Five whys, Root Cause

Analysis, Failure Modes Analysis (FMEA)


Exercise: Measure & Analyze Phases

Evelyn A. Catt, 2015 78.

IMPROVE 7. COUNTERMEASURES

*What changes can we make that will result in improvement?

Develop proposed solutions and counter measures.

Conduct rapid experiments to test/validate solutions.

Create a future state value stream map for the new process.

Create standard work and develop policies and procedures to

support the new process with clearly defined accountability.

IMPROVE 8. ACTION PLAN

Develop an action plan to fully implement the solutions, including

details of who, what, and when.

o Identify “Just-Do Its” to be implemented immediately

o Implement Lean 5-S and visual controls, as needed.

o Create and implement a communication plan.

CONTROL 9. FOLLOW-UP

• Confirm that actual results match the expected and desired results.

• Identify any issues or barriers that still need to be addressed.

• Create a plan to monitor, sustain, and spread the new process.

• Summarize and share the insights gained from this project.


Exercise: Improve & Control Phases


Action Plan Template

• An Action Plan is used to document the deliverables, task ownership,

and timeline for the implementation of process improvements.

79.

ITEM # ACTION ITEM OWNER DUE DATE STATUS


Communication Plan Template

• A Communication Plan ensures that all stakeholders will be well

informed regarding the plan for implementing the new process.

TYPE OF INFORMATION & PURPOSE PREPARED BY DUE DATE DISTRIBUTION LIST STATUS

80.


Control Plan Template

• A Control Plan is a tool for tracking the on-going performance of a process to

monitor and sustain the improvements that have been implemented.

PROCESS NAME: PROCESS OWNER:

PROCESS STEP MEASUREMENT FREQ WHO MEASURES CORRECTIVE ACTION

81.


Control Plan Checklist

• A Control Plan is a tool for tracking the on-going performance of a process to

monitor and sustain the improvements that have been implemented and

respond to “out of control” measures. It includes the following elements:

Define the parameters to measure (key performance metrics).

Measure current performance as a baseline = “initial state”

Define goals for key performance metrics = “target state”

Compare future performance to the baseline and goals.

Assign task ownership and time intervals for tracking metrics.

Adjust tracking frequency based on process performance.

Establish feedback loop and response plan for out-of-control measures.

Develop and document standard work and related policies & procedures.

Assign accountability for achieving goals.

82.


Reflections

• Have you ever participated in rapid improvement event?

• Do you anticipate that your staff will be excited about being empowered

to make rapid cycle improvements?

83.


Lean 5-S

84.


What is Lean 5-S?

• 5-S is a workplace organization tool used to eliminate waste and improve flow

– Eliminates the need for searching

– Reduces probability of error

– Increases quality

– Improves productivity

– Expedites response time

– Improves staff morale

– Enhances professional image of an area

– Increases efficiency of the supply replenishment process by using visual cues such as a Kanban system

• Kanban aligns inventory and consumption levels; a signal is sent to

deliver additional inventory when current supplies are consumed.

85.


Lean 5-S

86.

• 5-S produces a workplace that is clean, uncluttered, and safe.

• 5-S environments have “a place for everything & everything in its place”.

• 5-S uses visual controls to make every item easy to locate and return.

SORTIdentify needed items and remove the rest.

STOREOrganize (set in order) the remaining items

SHINEClean the area and create a specific place for each item.

STANDARDIZESimplify/standardize procedures

and monitor compliance.

SUSTAINCreate a 5-S culture and practices to sustain it.

S

A

F

E

T

Y


Lean 5-S Examples

Examples provided courtesy of Deb McCarter, Director of Nursing Practice & Quality, IU Health, University Hospital.87.

BEFORE

AFTER

BEFORE BEFORE

AFTER AFTER


• Key Principle: Make it easy to see, use, and return.

• Equipment, supplies/information should be available within 30 seconds.

Visual Control Examples (simple signals)

88.

AFTER

BEFORE BEFORE AFTER

Examples courtesy of IU Health Small Rural Hospitals


Lean 5-S Achievement Levels

LEVEL

5Continuous

Improvement

LEVEL

4Focus On

Reliability

LEVEL

3Make It

Visual

LEVEL

2Focus On

Basics

LEVEL

1Just

Beginning

Sort Store Shine Standardize Sustain

Cleanliness problem

areas are identified

and mess prevention

actions are in place.

Cleaning schedules

and responsibilities

are documented

and followed.

Initial cleaning is

done and mess

sources are known

and corrected.

Necessary and un-

necessary items are

identified; those not

needed are gone.

Needed and not

needed items are

mixed throughout

the area.

Items are randomly

placed throughout

the workplace.

Needed items are

safely stored and

organized according

to usage frequency.

Needed items are

outlined, dedicated

locations are labeled

in planned quantities.

Minimal needed

items arranged in

manner based on

retrieval frequency.

Needed items can

be retrieved in 30

seconds with

minimum steps.

Potential problems

are identified and

countermeasures

documented.

Work area cleaning,

inspection, and

supply restocking

done daily.

Visual controls and

indicators are set

and marked for

work area.

Key area items

are marked to check

and required level of

performance noted.

Key area items

checked are not

identified and are

unmarked.

Proven methods for

area arrangement

and practices are

shared and used.

Proven methods for

area arrangement

and practices are

used in the area.

Agreements on

labeling, quantities,

and controls are

documented.

Work group has

documented area

arrangement and

controls.

Work area methods

are not always

followed and are

not documented.

Root causes are

eliminated and

improvement actions

include prevention.

Sources, frequency

of problems are

noted w/ root cause

& corrective action.

Work group is

routinely checking

area to maintain

5-S agreements.

Initial 5-S level

is established and

and is posted in

the area.

Work area checks

are randomly done

and there is no

5-S measurement.

Reference: Uptime Magazine Source URL: http://www.uptimemagazine.com/uptime/AugSept09/augsep09precmaint03.jpg89.

http://www.uptimemagazine.com/uptime/AugSept09/augsep09precmaint03.jpg


Lean 5-S Benefits

• Pride in the workplace and supports team development.

• Sorting means removing unnecessary items that congest the work

area.

• Clean equipment allows everyone to notice problems.

• Sorting retains only the needed items. This allows for a smaller work

area resulting in reduced effort (walking, reaching, etc.) to do the

work.

• Reduced changeover times result from being organized and

minimizing search time.

• Items have a definitive home location that is labeled and easily found.

90.


Keys To Lean 5-S Success

• Get everyone involved.

• Integrate 5-S principles into daily work requirements.

• Communicate need for 5-S, roles of all participants, how it is

implemented.

• Be consistent in following 5-S principles in all areas.

• Periodic senior management involvement is absolutely required.

• Follow through and finish what is started, 5-S takes effort and

persistence.

• Link 5-S activities with all other improvement initiatives.

• Commitment to the process, a few individuals cannot undermine the

efforts of the entire team.

91.


Lean 5-S Exercise

• We often have to search for (equipment, supplies, information, people):

• We often have to transport (equipment, supplies, etc.):

• We often have to walk/travel a long way (or frequent short trips) to obtain:

• Some areas are cluttered, unorganized, and/or need a good cleaning:

92.


Standard Work

93.


• Standard work is the best known way of performing a

process today.

• Standard work is based on creative problem solving

and continual improvement.

• Standard work evolves over time as new evidence-

based practices are identified and implemented.

Standard Work

94.

Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.






• Reduces variation in performance

• Creates balanced work load

• Promotes consistency of outcomes

• Exposes waste & opportunities for improvement

Why Standard Work?

95.







Standard Work Goals

96.

• The goal of standard work is to

develop the most reliable methods

to consistently achieve the best

outcomes for each process.

• This is accomplished by defining

the best known way to perform the

process today.




Steps

Sequence

Task Ownership

Methods

Materials

Outcomes




Standard Work Components

97.

• Steps: What is being done?

• Sequence: In what order? How long should it take?

• Task Ownership: Who is responsible for each step

in the process?

• Methods: What instructions are required?

• Materials: What equipment & supplies are needed?

• Outcomes: What clearly defined measurable results

are expected?




Steps

Sequence

Task Ownership

Methods

Materials

Outcomes




Creating Standard Work

• Keep it simple

• Include all info on one, easy-

to-read document

• Include key points to optimize

technique

• Make it accessible

• Always look for ways to

improve the process

• Make it overly complicated

• Put it away in a binder or in a

desk drawer

• Allow people to make one-off

changes on a whim

• Make it too rigid or difficult to

change

DO: DON’T:

98.







Standard Work Example

Reference: Lean Healthcare: Implementing the Standard Work. Dave Munch, MD. August 9, 2012.

Source URL http://www.leanhealthcareexchange.com/wp-content/uploads/2012/08/JIT.jpg 99.

http://www.leanhealthcareexchange.com/wp-content/uploads/2012/08/JIT.jpg


Viewing Your Facility

as a System

Diagram Source URL: http://www.hah-emergency.net/Puzzle%20-%20full%20hospital.JPG

100.

http://www.hah-emergency.net/Puzzle - full hospital.JPG


System-wide Goals (example)

Quality & Safety

Improve quality outcomes and

promote clinical systemness

Service & People

Improve patient, physician, and

employee satisfaction

Education & Research

Promote and facilitate education

and clinical research

Finance & Growth

Increase system efficiency and

reduce total cost of care per person

101.


System-wide Benefits

102.

• Leadership development using

common language and tools for

making process improvements

• Working smarter vs. harder

• Time savings for caregivers

• Evidence based improvements

• Mindful standardization of work

• Reduced variation in key processes

• Improved quality & safety outcomes

• Increased capacity & throughput

• Increased productivity & profitabilityEmpowered Employees

Constant Pursuit of Perfection

Patient Centered

Design

Data Driven

Decisions


Core Process Map

• A Core Process Map helps an organization to:

– Promote an understanding of your facility as a system rather than “silos”.

– Learn to understand work as inter-related processes within a system.

– Prioritize projects by identifying the “pain points” across the system that have

the greatest impact on organizational performance.

– Identify key performance measures related to each area’s primary function.

103.

The Core Process Map

contents can be tailored for each

facility and department


Hospital Core Process MapINPATIENT CARE TRANSITIONS (example)

104.


Department Core Process Map - Surgery

105.© I.U. Health Operational Improvement Group 2012, 2013

PATIENT INTAKE OPERATING ROOM RECOVERY/EXIT

O.R. RESOURCE PROCESS PT DISCHARGE

PRE-OPTESTING

ADMITDAY OF

SURGERY

PT. PREPSAME DAY

SERVICES

RECOVERIN

PACU

RECOVERIN

ICU

FAMILY MEMBER TRANSPORT

EMS TRANSPORT

POLICE TRANSPORT

OBTAIN PHYSICIAN

ORDERS

OBTAIN PATIENT

INFO.

OBTAIN MEDICAL RECORDS

ASSEMBLE PATIENT CHART

CREATE PRE-OP STAFF

SCHEDULE

CREATE REG. STAFF SCHEDULE

CREATE SDS STAFF SCHEDULE

CONFIRM SURGEON AVAILABLE

CONFIRM PATIENT

AVAILABLE

CONFIRM O.R. ROOM AVAILABLE

SCHEDULING PROCESS IDENTIFY REQUIRED RESOURCES (ROOM, STAFF, EQUIPMENT,

INSTRUMENTS, SUPPLIES)

CREATE O.R. ROOM SCHEDULE

CREATE O.R. STAFF SCHEDULE

OBTAIN SUPPLIES & MEDS

ASSEMBLE CASE

CARTS

CHART ASSEMBLY

STAFF TRANSPORT

CLINICS

HX/PHYSICAL FORM

CONSENT FORM

PRE-OP ORDERS

COORDINATE SCHEDULING WITH CLINICS

SURGERY DATE

PT. PRE-OP PREP INSTR.

MEDICATION RECONCIL.

INSURANCE PRE-CERT

SURGICAL PROCED. DETAILS

HRC TRANSPORT

INSTRUMENT PROCESSING & REPAIRS

SURGICAL CARE TRANSITIONS (example)

BLOCK TIME

SCHEDULE

TURNOVER

TRANSFERTO IP UNIT

DISCHARGEDHOME

STAFF SCHEDULESROOM READY

PATIENT IN

ANESTH IN

SURGEON IN

TIME OUT

CUT -CLOSE

PT OUT

POSITION/PREP PT PROCEDURE

SET UP

INSTRUMENT ORDERING & PURCHASING

SELECT PREFERENCE

LIST

MD DECISION

TO OPERATE

105.


Core Process Map Exercise

106.

Exercise: What would your Core Process Map look like?

• What are the main functions or areas in your facility?

• How does work flow from one area to the next?

• Which issues create the greatest impact in each area?

• What measures are used to evaluate performance?


Defining the Process

107.


STEP 1:

Get thebread

STEP 2:

Plug inthe toaster

STEP 3:

Put breadIn the toaster

STEP 4:

Set the dial and press

down lever

STEP 5:

Take toast out when it

pops up

STEP 6:

Put butter on the toast

High Level Process Map

In order to understand the process being evaluated, the first step is to

create a High Level Process Map with 4-6 high level actions required to

complete the process. More detailed mapping will be completed later.

108.

Example: Making toast

Note: The steps in the High Level Process Map are used as the center

column in the SIPOCS Diagram, which is covered later in this section.


STEP 1: STEP 2: STEP 3: STEP 4: STEP 5: STEP 6:

High Level Process Map Exercise

109.

Your process name:

Exercise: Select a process from your work area and list the 4-6 high

level actions required to complete this process.


110.

Reflections

• Did it take very long to complete the High Level Process Map?

• Do your colleagues agree on the sequence of these 4-6 process steps?


Process Flow Chart

• A process flow chart is a graphic representation of the steps in a

process in sequential order. It uses standardized symbols to reflect

the different steps in the process.

Image Source: http://www.bpminstitute.org/images/contributors/Sweet_November10_Image1.jpg

111.

http://www.bpminstitute.org/images/contributors/Sweet_November10_Image1.jpg


Process Flow Chart Symbols

Reference: http://www.breezetree.com/articles/what-is-a-flow-chart.htm

Symbol Name Description

Terminator Indicates the start and stop points in a process.

Process Indicates a process or action step.

DecisionIndicates a decision or branch in the process flow when

there are 2 options (Yes/No, etc.)

Delay Depicts any waiting period that is part of a process.

Connector Line connector shows the direction the process flows.

Document Indicates a process step that produces a document.

Data I/O Indicates data inputs to and outputs from a process.

112.

http://www.breezetree.com/articles/what-is-a-flow-chart.htm


SIPOCS Diagram

• A SIPOCS Diagram is a tool used at the beginning of a project to capture all the

relevant information about the process being studied.

• The SIPOCS Diagram defines the high level process steps, required resources

and suppliers, and clearly identifies the outputs and customers of the process.

Reference: http://www.valuestreamguru.com/?p=131

Diagram Source: http://www.projectbuild.org.uk/images/sipoc.jpg

INPUTS PROCESS OUTPUTSCUSTOMERS

STAKEHOLDERSSUPPLIERS

Resources required to complete the process.

Activity being completed. (verb)

Deliverable/Outcomecreated by the process.

Person who receives or benefits from outputs.

Providers of the required resources.

113.

http://www.valuestreamguru.com/?p=131

http://www.projectbuild.org.uk/images/sipoc.jpg


SIPOCS Exercise

INPUTS PROCESS OUTPUTS CUSTOMERSSTAKEHOLDERSSUPPLIERS

I P O CSResources required to complete the process.

Activity being completed. (verb)

Deliverables or outcomescreated by the process.

Person/entity who receives or benefits from an output.

Providers of the required resources.

FIRST: Fill in process START

THIRD: Fill in MIDDLE steps

Dept: Process: Project Leader: Date:Hospital:

SECOND: Fill in process END

Complete Inputs column Complete Process column Complete Outputs columnComplete Suppliers column

1 324Complete Customers column

5

114.


115.

X-Y Chart

• The X-Y Chart helps to identify and prioritize the relationship between multiple

inputs and the resulting outcomes. All process outcomes (Y’s) are achieved

based on the interaction of multiple inputs (X’s), which is often referred to as a

“cause and effect” relationship. Therefore, the X-Y Chart is also known as a

C&E Matrix. The most traditional use of an X-Y Chart is to help narrow down a

large number of inputs (X’s) to a manageable list for further evaluation. Steps:

– Identify & rank customer “critical to quality” (CTQ) requirements across the top of the matrix.

– List all of the inputs to the process down the left side of the matrix.

– Rank the impact of each input on each CTQ requirement (1 = weak, 3 = moderate, 9 = strong) to

determine the correlation between each input and CTQ.

– Cross multiply the input ranking with the CTQ value then add across each line for a total score.

– Sort the total scores from highest to lowest to identify the inputs with the greatest impact.

– Select a breaking point for items with scores that are too low to warrant further investigation.

Diagram Source URL:http://www.bing.com/images/search?q=CE+Matrix+Templates&FORM=HDRSC2#view=detail&id=4517A5CB24A308023435F67DB409264C36CFAD55&selectedIndex=2

http://www.bing.com/images/search?q=CE+Matrix+Templates&FORM=HDRSC2#view=detail&id=4517A5CB24A308023435F67DB409264C36CFAD55&selectedIndex=2


Murphy’s Analysis

• Murphy’s Analysis is a brainstorming tool that helps to identify problem

areas and common ways that the current process breaks down or fails.

116.

ExampleProcess: Accurate Lab Tube Labeling

WHAT COULD GO WRONGWITH THIS PROCESS?

Tube systemDown/lack of

supplies

Printer not working

Order of draw/Too little blood

Inconsistent Patient ID process

Wrong supplies/Lack of supplies

Wrong Label

Placement/Info

Labeling at Bedside

Order detailsincorrect


Murphy’s Analysis Exercise

Your Process: WHAT COULD GO WRONG

WITH THIS PROCESS?

117.Note: Additional circles may be added, as needed.


Reflections

• SIPOCS

– What new insights did the SIPOCS exercise provide regarding the inputs,

outputs, suppliers, and customers associated with your process?

– Were any issues identified related to the suppliers and inputs for this

process?

• Murphy’s Analysis

– Was as the Murphy’s Analysis an easy exercise to complete?

– Were you already aware of all the issues documented during this

exercise?

118.


Customer Requirements

119.


Customer Requirements

• Customer requirements refers to the qualities and features of products

and services that are needed to achieve customer satisfaction.

• It’s important to obtain direct “Voice of the Customer/Stakeholder”

input from patients, physicians, staff, and visitors to define customer

requirements and determine if the current process meets their needs.

• Several methods can be used to obtain the “Voice of the Customer”:

– Conduct interviews

– Establish a focus group

– Develop a questionnaire

– Conduct research

Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html120.

http://www.six-sigma-material.com/Kano.html


First: Go to “Gemba”

• Gemba in Japanese means “the actual place” or “the real place”.

• Go to “Gemba” to observe the current process in action.

• Talk to the people who actually perform the process.

• Identify gaps between the current process and customer defined

requirements and develop a strategy to address unmet needs.

• Identify opportunities to eliminate waste and improve flow.

Reference: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University 121.


“Gemba” is Everywhere!

• Gemba is every location where work is being done!

– Administrative Offices

– Clinical Areas

– Non-clinical Areas

– Environmental Services

– Facilities

– Financial Counseling

– Food Services

– Health Information Services

– Human Resources

– I.T. Systems

– Marketing

– Patient Billing

– Payroll

– Quality & Risk Management

– Security

– Supply Chain Management

– Other Areas………………..122.


Foundation for Success

• Observe the work in action.

• Honor everyone’s contribution.

• Establish relationships based on trust and transparency.

• Design every process with the patient in mind!

123.


Brainstorming

• Brainstorming is used to rapidly

generate ideas from multiple people

simultaneously regarding customer

requirements:

– Write the name of your process on a

flipchart or whiteboard.

– Without discussion, each person works

independently and writes their ideas on

sticky notes regarding potential

customer requirements.

– Each person posts their sticky notes on

a flipchart or white board.

– No comments, censoring, or criticism is

allowed during this process.

Diagram Source: http://jwsokol.files.wordpress.com/2010/07/brainstorming.jpg

124.

http://jwsokol.files.wordpress.com/2010/07/brainstorming.jpg


Affinity Diagram

Diagram Source: http://www.six-sigma-material.com/images/AffinityDiagram.GIF

• An Affinity Diagram is a group decision-making technique designed to sort a large

number of ideas/concepts/opinions into naturally related groups. Affinity

Diagrams are often used to sort customer requirements into logical categories.

125.

Nominal Voting Technique

Each person is then given a

limited number of colored dots

(usually 5-8) and votes by

placing a dot on the items they

consider the highest priority.

http://www.six-sigma-material.com/images/AffinityDiagram.GIF


Reflections

• What type of leadership style will be required to create a culture that

honors everyone’s contribution?

• Are relationships based on trust and transparency in your current work

environment?

• How will the practice of “going to Gemba” be received by the areas

being observed?

126.


Voice of the Customer/Stakeholder

Goals

• Obtain direct “Voice of the Customer/Stakeholder” feedback from

patients, physicians, staff, and visitors about the current process.

• Identify gaps between the current process and customer defined

requirements. Develop strategies to address any unmet needs.

Questions To Ask (SWOT Analysis)

• What do you like about our services? (Strengths)

• What do you think needs improvement? (Weaknesses)

• What Opportunities do you feel we could take advantage of?

• What could potentially Threaten our success?

References: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University.Woodward-Haag, H. and Woodbridge, P.A. Rapid Process Improvement Workshops. Veterans Administration Systems Redesign, 2008.

127.


Exercise: Create a SWOT Analysis for your area:

SWOT Exercise

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

128.


Customer Requirements Exercise

QUALITY TIMELINESS COST

• Response time, procedure time, test turnaround time, appointment availability, etc.

• Quality and excellence standards that are required

• Cost issues or barriers that impact patient access, choice, and satisfaction

OTHER

• Other services or features that are desired or required

Exercise: Create a list of customer requirements for your area.

129.


Customer Requirements Tree

CUSTOMER WANTS/NEEDS DRIVERSCRITICAL TO QUALITY (CTQ) (measurable requirement)

Accurate Charges 100% of the time

Invoices that are on time and correct Bill received within 3 days

Timely Processing

Insurance filed within 5 days

• A Customer Requirements Tree defines the key measurable

characteristics of a process that must be met to satisfy the customer.

• It converts customer wants and needs into Critical to Quality (CTQ)

measurable requirements for the business to implement.

INCREASED SPECIFICITY

130.


Customer Requirements Exercise

CUSTOMER WANTS/NEEDS DRIVERCRITICAL TO QUALITY (CTQ) (measurable requirement)

INCREASED SPECIFICITY

131.


Kano Model

132.


Characteristics of Products & Services

• The characteristics of products and services can be defined as:

– Dissatisfying: annoying features - avoided characteristics

– Mandatory expectations: basics - must have characteristics

– Customer needs: reasonable expectations - performing features

– Delighters: surprise - innovators - unexpected features

• To find out which characteristics deliver on which level of

satisfaction it is necessary to develop a questionnaire, interview,

or focus group; or conduct research to find the customer defined

characteristics and the associated level of satisfaction.

Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html

133.



• The Kano Model is used to visually depict the customer defined

characteristics (for products and services) versus the level of satisfaction

each characteristic delivers.

• The Kano Model can be used to organize and prioritize activities to design

and/or improve products and services to meet or exceed customer

requirements.

Kano Model

Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html 134.

DISSATISFIEDCUSTOMERS

Achievement Axis

Satisfaction AxisNot necessarily expressed

Happy surprises, unexpected features!

Expressed needs

Strong source of satisfaction.

Usually unexpressed

“Must haves”, basic requirements.


http://www.six-sigma-material.com/store.html

http://www.six-sigma-material.com/store.html


Must Haves ( “Basic Needs”)

These basic requirements are not always expressed but they are obvious to the

customer and must be met. These requirements are not a source of satisfaction

but can cause major disappointment if they are not met.

Examples: brakes of a car; bed in a hotel room.

Performance Needs (”Linear”)

The need is expressed and customer satisfaction is proportional to the level of

performance (and quality) of what is implemented. It is a strong source of

customer satisfaction and a priority for development. Customer feedback on these

products and services is crucial.

Delighters ( “Exciters “)

These requirements are not necessarily expressed. Sometimes they’re unconscious.

This is the happy surprise that can make a difference, and an important source of

satisfaction. If not there, no dissatisfaction, no frustration: they’re not expected.

Exciters are the keys to innovation!

Kano Model Elements

Reference URL: http://www.agile-ux.com/tag/kano-model/ 135.

http://www.agile-ux.com/tag/kano-model/


Kano Model Uses & Strengths

• Kano Model Uses:

- To understand customer needs

- To benchmark services

- To prioritize product/service development

- To drive your vision and strategy

• Kano Model Strengths:

- Simplicity

- Direct user feedback

- User-centered design tool

- Valuable decision-making tool

Reference URL: http://www.agile-ux.com/tag/kano-model/

136.

http://www.agile-ux.com/tag/kano-model/


Value Stream Mapping

137.


Value Stream Map (VSM)

• A Value Stream Map (VSM) is a graphic representation of the process being

studied. It’s used to identify value and lead time. It shows the sequence of

the major tasks performed during the process as it currently functions.

• The VSM uses color coding to designate whether each step is value added,

non-value added, or a business requirement.

138.

VALUE

ADDED

(VA)

NON-VALUE

ADDED

(NVA)

BUSINESS

REQUIREMENT

•Delays•Errors•Extra steps•Waste

•Good results•No mistakes•Safe and timely•Valued by patient

•Accreditation•Legal compliance•Regulatory req.•Safety standards

GR

EEN

RED

YELLO

W


Value Stream Mapping – Current State

• Map the current work flow to identify the “value stream” within the

process and to measure the lead time for each process step.

Reference: Source URL http://www.archfield.com/how_to_increase_profit_using_lean_enterprise.htm

139.

FLOW STOPPER

FLOW STOPPER

FLOW STOPPER

VALUE

ADDED

(VA)

NON-VALUE

ADDED

(NVA)

BUSINESS

REQUIREMENT

GR

EEN

RED

YELLO

W

http://www.archfield.com/how_to_increase_profit_using_lean_enterprise.htm


Design the Ideal “Future State”

• Analyze the “current state” value stream map.

• Measure the time for each step and between steps.

• Identify value added steps.

• Eliminate waste and non-value added steps.

• Design the ideal “future state”.

Reference: Woodward-Haag, H. and Woodbridge, P.A. Rapid Process Improvement Workshops. Veterans Administration Systems Redesign, 2008.

VALUE

ADDED

(VA)

NON-VALUE

ADDED

(NVA)

BUSINESS

REQUIREMENTTIME

TIME

TIME

TIME TIME

140.


• The waste (waiting time) has been removed from the ideal “future

state” of the E.D. patient registration, triage, and placement process.

VALUE

ADDED

(VA)

NON-VALUE

ADDED

(NVA)

BUSINESS

REQUIREMENTFLOW

STOPPER

Value Stream Mapping – Future State

141.


Exercise: Select a process from your work area and list the major steps in this

process. Does every step provide value? How much lead time is required? Where

does the waste occur? At what points do you see “flow stoppers” in this process?

Value Stream Mapping Exercise

STEP 1: STEP 2: STEP 3: STEP 4: STEP 5:

STEP 6: STEP 7: STEP 8: STEP 9: STEP 10:

VALUE

ADDED (VA)

?

NON-VALUE

ADDED (NVA)

?

BUSINESS

REQUIREMENT

?

Are each of these steps:

FLOW STOPPER

142.


Measurements in the Value Stream

Reference: Six Sigma for Dummies. 2005, Wiley Publishing, Inc., Hoboken, NJ. 143.

METRIC METRIC DEFINITION

Defects per Unit (DPU) Total Number of Defects

Total Number of Product Units

Total Opportunities (TO) Total Number of Product Units x Opportunities per Unit

Defects per Opportunity

(DPO)

Total Number of Defects

Total Opportunities

Defects per Million

Opportunities (DPMO)DPO x 1,000,000

Percent DefectiveTotal Number of Defective Units x 100

Total Number of Units

Rolled Throughput Yield

(RTY)

The number of good units produced divided by the number of total units going into the process. Calculate the yield (number coming out of each step/number going into each step). This is the First Pass Yield. Rolled Throughput Yield is created by multiplying all First Pass Yields together.

Takt Time

Defined as the rate of customer demand, often called “the heartbeat” of the process. It is how often a product or service needs to be completed to meet customer demand.• Formula = Effective Working Time / Average Customer Demand (for that time period).• Effective Working Time = Hours Worked minus non-productive periods (lunch, etc.).


Identifying Waste

144.


Waste in the Emergency Department

Waiting for a room

Travel to Radiology

Waiting to return to E.D.

Waiting to be transported

Unnecessary forms

Redundant

questions

Travel time

to O.R.

WASTE

WASTE

WASTE

WASTE

WASTE

WASTE

WASTE

Delayed

test results

WASTE

Wrong test ordered

WASTE

145.


Types of Waste (Muda)

Errors, poor quality, failure to meet customer requirements.

Providing unnecessary products, services, or features.

Delays, periods of inactivity, bottlenecks, or patient wait time.

Failure to fully utilize human potential (time and talents of people).

Unnecessary movement of supplies, equipment, or people.

Excess inventory/supplies, batch processing, queues, or backlogs of work.

Extra steps taken by employees because of inefficient layout, searching, hunting and gathering.

Excess activity and processing steps caused by poor process design.

146.Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.

Source URL: http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples

Defects

Over Production

Waiting

Non-utilized Potential

Travel/Transportation

Inventory/Scrap

Motion (search time)

Excess Processing



Waste Walk Worksheet Exercise

Errors, poor quality, failure to meet customer requirements.Example:

Providing unnecessary products, services, or features.Example:

Delays, periods of inactivity, bottlenecks, or wait time.Example:

Failure to fully utilize human potential (time and talents of people). Example:

Unnecessary movement of supplies, equipment, or people.Example:

Excess inventory/supplies, batch processing, queues, or backlogs of work. Example:

Extra steps taken by employees because of inefficient layout, searching. Example:

Excess activity and processing steps caused by poor process design. Example:

Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.

Source URL: http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples

Defects

Over Production

Waiting

Non-utilized Potential

Travel/Transportation

Inventory/Scrap

Motion (search time)

Excess Processing

147.



Simplify the process to remove unnecessary or redundant steps.

Standardize equipment, supply locations, and stocking procedures.

Optimize each step by designing the work area to create uninterrupted flow.

Develop and document standard work and provide appropriate education.

Modify the sequence of activities to increase efficiency.

Identify and remove bottlenecks and constraints.

Clarify roles and responsibilities for each process step.

Introduce new deliverables and/or accountability standards.

Verify that clear expectations have been communicated to everyone who plays

a role in the process, including external areas.

Checklist for Removing Waste

148.


Flow

149.


Flow

• Flow is the continuous movement of people, materials and supplies

through a process.

• Flow ensures that patients have what they need exactly when they

need it.

– No delays or waiting

– One piece flow (instead of batching)

– Well organized supplies and work space

– Alignment of work volume and resources to meet customer demand

• Takt time = available working time / customer demand

• Takt time is often called “the heartbeat” of a Lean organization

– Allows replenishment of only what is needed



150.



Patient Flow & Accountable Care

SAFE – EFFECTIVE – TIMELY – PATIENT CENTERED – EQUITABLE – EVIDENCE BASED CARE

Patient flow – the movement of patients through all levels and sites

of care – is a critical component of accountable care.

Reference: Institute for Healthcare Improvement (IHI), 2011 151.


What happens when the flow stops?

It slows down or stops the process!

152.


Lack of Flow Creates Waste

153.


Tools to Improve Flow

154.


Identifying Bottlenecks

• A bottleneck occurs when the performance or capacity of an entire

process is constrained by a single step or limited number of resources.

• Bottlenecks must be removed to improve flow and utilize the full

capacity of the system.

Reference: http://en.wikipedia.org/wiki/Bottleneck

Image Source: http://www.labcentrix.com/images/bottleneck_diagram.jpg 155.

http://en.wikipedia.org/wiki/Bottleneck

http://www.labcentrix.com/images/bottleneck_diagram.jpg


Reflections

• What bottlenecks or constraints exist in your facility that affect

performance or limit capacity?

156.


Spaghetti Diagram

• A Spaghetti Diagram is a map showing the movement of people, equipment,

materials, and total distance traveled. In order to decrease this type of waste:

o Redesign the work flow to reduce movement and search/travel time.

o Relocate frequently used supplies in closer proximity to work stations.

157.


Spaghetti Diagram Exercise

Exercise: Draw the layout of your work area.

• Do people, equipment, and materials flow smoothly through this area?

• How could the layout be improved?

158.


Simplify Process Flows

by untangling process complexityPublic Domain Image

159.


The 7 Flows

1. Patients & Family

2. Providers*

3. Information

4. Medications

5. Supplies

6. Equipment/Instruments

7. Process Steps

*Everyone working in the process is

considered a provider

All 7 Flows and their relationship to

one another must be clear and

understood in order to make

improvements in processes.

Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.

160.


Checklist for Improving Flow

1. Flow of Patients and Family/Relationships

Bring services to the patient whenever possible

Minimize patient walking if services can’t be delivered to them

Respect the patient’s wishes for family involvement

Eliminate unnecessary movement or separation from the family

2. Flow of Providers

Ensure there is standard work for all tasks

Remove all wasted motion

Correlate supply locations to frequency of use

Do not isolate people in work “silos”


161.


3. Flow of Information

Include information flow in designing new processes

Information should flow with the patient

Convey information in simple visual or auditory signals

Avoid data overload; minimize to only necessary information

4. Flow of Medications

Bring services to the patient

Medications should arrive just-in-time

Get as close to the point of use as possible

Make smaller “satellite” pharmacies where possible



162.


5. Flow of Supplies

Make the flow simple and visual

Only needed materials should be on-hand

Supplies should arrive exactly when needed

Consider using two-bin strategies for point of use supplies

6. Flow of Equipment & Instruments

Arrange equipment in a sequence that facilitates flow

All equipment should be on wheels, if possible

Use mistake-proofing to avoid waste and errors

Buy only what you need, avoid unnecessary features



163.


7. Flow of Process Steps

Maintain simplicity of the work process

Include standard work

Include mistake-proofing principles

Evaluate process size, scope, speed, and quality



164.


Root Cause Analysis

165.


Root Cause Analysis

http://www.thinkreliability.com/graphics/CauseMaps/PPT%20graphic%20-%20Root.gif

166.

http://www.thinkreliability.com/graphics/CauseMaps/PPT graphic - Root.gif


Root Cause Analysis (5 Whys)

• A Root Cause Analysis is a standardized method used to identify the real

cause of a problem, rather than the superficial, easily identified cause.

• To use this technique, ask “why” 5 times to drill down to the underlying root

cause of the issue (next slide).

• Brainstorm solutions and corrective actions.

• Discuss the analysis and pros & cons of each potential solution.

• Additional questions to consider after you complete the “5 whys” exercise.

– Why wasn’t the error prevented by our current system?

– Why do our tools, rules, or procedures allow the problem to occur?

– Why didn’t our system immediately catch the problem?

– Why wasn’t it obvious how to fix the problem?

Reference: Ries, E. How to Conduct a Five Whys Root Cause Analysis. July 2, 2009. Source URL: http://www.startuplessonslearned.com/2009/07/how-to-conduct-five-whys-root-cause.html

167.

http://www.startuplessonslearned.com/2009/07/how-to-conduct-five-whys-root-cause.html


Root Cause Analysis Exercise

Enter example here:

1st Question Why:

Answer:

2nd Question Why:

Answer:

3rd Question Why:

Answer:

4th Question Why:

Answer:

5th Question Why:

Answer:

Exercise: Describe an error or issue that has occurred in your work area.

168.


Fishbone Diagram

• A Fishbone Diagram (Ishikawa Diagram) is used to identify, explore,

and display the potential causes of a problem and the resulting effects.

Diagram source: http://www.juliasilvers.com/embok/Risk/RiskAssessmentMgmt/CauseEffect.gif

169.

http://www.juliasilvers.com/embok/Risk/RiskAssessmentMgmt/CauseEffect.gif


Fishbone Diagram Example

Medication Not

Administered

Per Guidelines

170.

Example provided courtesy of Kourtney Kouns, Clinical Informatics Coordinator, IUH Methodist Hospital


Fishbone Diagram Exercise

EFFECT

Measurements

Cause

Cause

Cause

Materials

Environment Policies/Procedures People (Man)

Methods

Cause

Cause

Cause Cause

Cause

Cause

Cause CauseCause

Cause

Cause Cause

Cause

Cause

Cause

Machines

Cause

Cause

Cause

Physical Plant

Cause

Cause

Cause

171.


Mistake Proofing

• Mistake Proofing is about adding controls to prevent errors,

reduce their severity, and detect them if they can occur. These

mistake proofing mechanisms are called “Poka Yokes”.

• Replacing inspection and correction with true quality is known as

“Quality at the Source”.

GOOD: Detect errors/defects before proceeding to the next step.

BETTER: Detect errors/defects during the actual process.

BEST: Prevent errors/defects from occurring at all.

Reference: http://www.six-sigma-material.com/Mistake-Proofing.html

Image Source: http://www.exegens.com/media/incoming/0328.jpg 172.

http://www.six-sigma-material.com/Mistake-Proofing.html

http://www.exegens.com/media/incoming/0328.jpg


Mistake Proofing (Poka Yoke) Examples

Image Source: http://www.leanblog.org/2010/04/quaid-patient-safety-documentary-airs-saturday-morning/

173.

http://www.leanblog.org/2010/04/quaid-patient-safety-documentary-airs-saturday-morning/


Project Selection

174.


Project Selection & Prioritization

• Identify and prioritize projects that:

– Are aligned with the organization’s strategic goals.

– Have the most significant enterprise-wide benefits.

– Provide the greatest value to patients.

• Ensure that projects have a manageable scope

• Identify project metrics

– Define key performance metrics.

– Measure current “initial state” performance for each process being studied.

– Establish well defined “target state” process improvement goals and return

on investment (ROI) goals. The percent Return on Investment (ROI) =

Gain from Investment – Cost of Investment x 100Cost of Investment

References: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University

Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111 175.

http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111


Project List Exercise

• What are the “pain points” in your facility that have a significant impact on

quality, cost, efficiency, and satisfaction? Create a list of potential projects to

address these issues. How would you rank/prioritize these projects?

Rank Project NameQuality

GoalCostGoal

EfficiencyGoal

SatisfactionGoal

176.


Exercise: Define the goal for your project in measureable terms:

We want to improve ____________________________________

from ______________________________________ (initial state)

to ________________________________________ (target state)

by ________________________________________ (target date).

• Example: We want to improve surgery on-time starts from 20%

(initial state) to 50% (target state) by June 2016 (target date).

• Clarify Definitions: How would you define an “on-time start”?

Project Goal Exercise

177.


Easy

to Do

Hard

to Do

Low

Impact

High

Impact

Do

Over Time

Do

Now

Do

As Time

Permits

Never

Do

178.

Place each potential project in

the appropriate quadrant of

the impact/effort grid.

Project Impact vs. Effort Grid


Project Prioritization Matrix

• A Project Prioritization Matrix aligns project selection decisions with value

based criteria and weighted scores. Each organization should develop a

prioritization matrix based on organizational pillars and strategic priorities.

179.

PROJECT PRIORITIZATION MATRIX

Project # Project DescriptionFinance/ Growth

We

igh

ted

Sco

re

Quality/ Safety

We

igh

ted

Sco

re

Service/ People

We

igh

ted

Sco

re

Resources Available

We

igh

ted

Sco

re

Strategic Imperative

We

igh

ted

Sco

re

TOTAL Weighted

Score

Project Priority Ranking

Weight Factors (EXAMPLES) Score 30 Score 10 Score 20 Score 15 Score 25

1. Example Project #1 6 180 6 60 3 60 6 90 9 225 615

2. 0 0 0 0 0 0

3. 0 0 0 0 0 0

4. 0 0 0 0 0 0

5. 0 0 0 0 0 0

6. 0 0 0 0 0 0

7. 0 0 0 0 0 0

8. 0 0 0 0 0 0

9. 0 0 0 0 0 0

10. 0 0 0 0 0 0

11. 0 0 0 0 0 0

12. 0 0 0 0 0 0

13. 0 0 0 0 0 0

14. 0 0 0 0 0 0

15. 0 0 0 0 0 0

Scoring: No Impact = 0, Low Impact = 3, Medium Impact = 6, High Impact = 9


Goals Grid

A Goals Grid is a helpful tool to clarify strategic priorities for each area and

to create a shared vision for alignment with organizational strategic goals:

180

Diagram Source: http://home.att.net/~nickols/goals_grid.htm

ACHIEVE PRESERVE

ELIMINATE

AVOID

What do you want

that you don’t have?

What don’t you have that you don’t want?

What do you have now that you don’t want?

What do you want to keep

that you already have?

Reference URL: http://home.att.net/~nickols/goals_grid.htm

180.

http://home.att.net/~nickols/goals_grid.htm



Exercise: Create a Goals Grid together as a team. Discuss how each

item on the completed grid aligns with organizational strategic priorities.

Goals Grid Exercise

Reference URL: http://home.att.net/~nickols/goals_grid.htm181.

ACHIEVE PRESERVE

ELIMINATE

AVOID



Project Charter

182.


Project Charter

• The project charter is a contract between the organization’s

leadership and the project team. It is created at the beginning of

the project to clarify what is expected of the team.

• Project charter elements include:

– Project Team

– Project Roles

– Problem Statement

– Aim Statement

– Project Scope

– Project Timeline

– Project Milestones

– Project Metrics

183.


Project Team Roles

Reference: Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111

184.

PROJECT ROLES DESCRIPTION OF DUTIES

Executive SponsorSenior management/leader who sponsors the project, authorizes resources, and reviews and approves project

deliverables. Holds the team accountable for meeting project goals and achieving measurable results.

Process OwnerDepartment based leader ultimately responsible for the process being improved and for monitoring and

sustaining the process improvements over time.

Project Leader

Leader who drives project execution by developing plans, timelines, and assigning tasks; educates and leads the

team in the use of standardized tools and data analysis; maintains project documentation and ensures

completion of project deliverables; coordinates effective communication with the team, stakeholders, and

leaders; and promotes collaboration, transparency, and trust.

Team MembersCross functional, high performing employees familiar with the process who participate in the project and

complete assigned tasks using standardized tools.

Team FacilitatorIndividual who facilitates effective team meetings and helps with issues related to communication and problem

solving, but does not contribute to the management of the project or completion of tasks and deliverables.

Project Coach/

Mentor

An experienced and highly skilled professional coach who provides expert knowledge, strategic guidance, and

mentoring for projects using Lean Six Sigma concepts and tools.

Key Stakeholders

Stakeholders are persons or groups with an interest in a project. Their interest may be based on the impact a

project may have on their area’s processes, or because they have to supply resources to support the project. A

rule of thumb for identifying key stakeholders is to question whose support or lack of it may significantly

influence the success of the project.



Project Team Worksheet

Project Name Charter Date:

Location Version:

Timeline Start Date: Target End Date:

TEAM MEMBERS Name/Title Name/Title

Executive Sponsor(s)

Process Owner(s)

Project Leader

Team Members

Key Stakeholders

Project Mentor/Coach

185.


• The problem statement is the reason for action. It is a basic

description of the process to be worked on and the background of

the current problem or opportunity. Examples:

– Only 20% of surgery patients are seen in the pre-admission

testing area, which results in delays on the day of surgery due to

additional testing that needs to be performed before the patient

goes to the O.R.

– The Emergency Department average length of stay exceeds

benchmark standards and the Left Without Being Seen rate is

escalating due to the long waiting times in the E.D.

– 5% of laboratory specimens are submitted without a label, which

results in additional work to redraw the specimens, unnecessary

discomfort to patients, and delayed test results.

Problem Statement

186.


Describe the background of the current problem/opportunity.

What business problem are you trying to solve?


Problem Statement Worksheet

187.


Aim Statement

• The Aim statement defines what the project is trying to accomplish.

• A sound Aim statement is phrased using measurable terms.

• The goals in the Aim statement should follow the SMART acronym:

ELEMENT DEFINITION

Specific: Clear and focused to avoid misinterpretation.

Measurable: Can be quantified and compared to other data.

Attainable: Achievable, reasonable, and credible under current conditions.

Realistic: Fits into the organization’s constraints and is cost effective.

Timely: Can be accomplished within the time frame given.

Reference : Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL: http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/

188.

http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/


Aim Statement Worksheet

• What are you trying to accomplish?

• State your goals in measurable terms:

189.


Project Scope

• The project scope statement defines which part of the process will

be investigated (process start and end points) and clearly specifies

the scope of what will be included and excluded in the project:

– Process start & end points: The “bookends” for the part or

segment of the process that will be investigated

– Included in scope (areas that will be addressed)

– Excluded from scope (areas that will not be addressed)

o Aspects of the problem that are intentionally excluded

o Areas of the business that will not be included

o Related issues that will be addressed at a later time

190.


• What part or segment of the process will be investigated in this

project?

– Process starting point:

– Process ending point:

• What are the boundaries for the areas that will be addressed in this

project?

– Included in the scope:

– Excluded from the scope:

Project Scope Worksheet

191.


• A detailed schedule should be maintained by the Project Leader for

the key milestones of the project and the associated timelines.

Project Timeline & Milestones

Key Milestones Target Date Status

INITIATE the project, form the team, develop the charter

DEFINE the process and customer requirements

MEASURE and map the current process

ANALYZE main issues and identify root causes

IMPROVE the process and test solutions

CONTROL plan to sustain/spread the new process

RAPID IMPROVEMENT EVENT (2-5 days)

5-S EVENT (sort/store/shine/standardize/sustain/safety)

IMPLEMENTATION DATE

192.


Project Metrics

193.


Project Metric Definition Use in Improvement Project

Primary Metric

Defines the project goal: “improve

(primary metric) from (baseline) to

(target) by (date)”

Measure baseline “initial state” and

improvement level when the project ends

Secondary MetricCaptures, validates and tracks

welcome side effects of the project

Measure baseline and impacts of project

after improvements. Monitor during and

after project if linked to financial metric.

Financial Metric

Links progress in the primary and

secondary metrics to financial

advantage. Most often this metric is

tailor-made for the specific project

Evaluate at project milestones and at

regular intervals for one year after the

project ends to calculate project ROI.

Consequential

Metric

Captures, validates and tracks

unwelcome side effects of the project

Collect data before, during and after the

project to confirm that no collateral

damage was caused by the project.

Project Metrics - Definitions

Source: Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL: http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/

194.



• How will we know a change is an improvement?

– Define key performance metrics for each process being evaluated.

– Indicate which strategic area is aligned with each metric (quality/safety,

finance/growth, service, people, education, etc.)

– Select one primary metric for the project team to focus on for each

improvement project.

o Use the primary metric to formulate the main project goal.

– Brainstorm for possible secondary and consequential metrics.

o Construct a financial metric based on the primary & secondary metrics.

– Confirm that all metrics meet the criteria to create a data collection plan.

o Measure current performance = “initial state”

o Establish well defined process improvement goals = “target state”

Project Metrics – Initial & Target State


195.



• Define key performance metrics for each process being evaluated.

– Measure current performance = “initial state”

– Establish well defined process improvement goals = “target state”

– Indicate which strategic area is aligned with each metric (quality/safety,

finance/growth, service, people, education, etc.)

Project Metrics Worksheet


StrategicAlignment

Metric NameCurrent Value(initial state)

Goal(target state)

Quality/Safety Value: Time period:

Finance/Growth Value: Time period:

Service Value: Time period:

People Value: Time period:

Education Value: Time period:

196.



Stakeholder

Analysis

197.


Stakeholder Analysis• Stakeholders are persons or groups with an interest in a project. Their

interest may be based on the impact a project may have on their area’s

processes, or because they have to supply resources to support the project.

• A rule of thumb for identifying key stakeholders is to question whose

support or lack of it may significantly influence the success of the project.

• Stakeholder participation:

– Gives people the opportunity to provide input regarding how projects or policies

may affect their areas

– Generates a sense of ownership if initiated early in the development of the

project

– Provides opportunities for learning and gaining a new perspective on the process

– Enhances responsibility and accountability for achieving project milestones

– Can reduce or reverse the threats to solutions that are developed by the team

– Is essential for sustaining improvements that are implemented during the project

198.


Force Field Analysis• A Force Field Analysis can be used to depict the driving/helping forces that

support movement toward a goal, and the restraining/hindering forces that are

blocking movement toward a goal. This tool is helpful in evaluating key

stakeholders and their interests (positive or negative) in the project.

Diagram Source: http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif

199.

http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif


Force Field Analysis Worksheet

Diagram Source: http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif200.

• List stakeholders with

a positive interest in

your project:

__________________

__________________

__________________

__________________

__________________

• List stakeholders who

could have a negative

impact on your project:

__________________

__________________

__________________

__________________

__________________

• After assessing the importance of each stakeholder and their positive or negative

level of influence or impact on the project, a strategy should be developed to

effectively communicate and collaborate with each stakeholder.

Evaluate key stakeholders and their +/- impact on your project.

http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif


Data Collection Plan

201.


Data Collection Plan – 5 Steps

STEP 1

DEFINEClear goals

CLARIFYDefinitions

DEVELOPMethods

COLLECTData

COMPILEData

STEP 2 STEP 3 STEP 4 STEP 5

Reference: Building a Sound Data Collection Plan. Source URL: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-sound-data-collection-plan&Itemid=217

202.

http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-sound-data-collection-plan&Itemid=217


Data Collection Plan

• Step 1: Define clear goals and objectives for collecting the data.

• Step 2: Clarify operational definitions (examples: procedure starting point,

procedure ending point, time segments during the procedure).

• Step 3: Develop methods to ensure accurate measurements (examples:

synchronized clocks, calibrated instruments, ranking scales, codes for

responses, abbreviations, naming conventions).

• Step 4: Collect data using a standardized format and unique identifier for

each observation (survey, questionnaire, incident report, etc.).

• Step 5: Compile and enter data into a secure electronic database using pre-

defined codes for responses, ranking scales, etc. (immediate entry into an

electronic database is ideal, but not always possible).

Reference: Building a Sound Data Collection Plan. Source URL: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-sound-data-collection-plan&Itemid=217

203.

http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-sound-data-collection-plan&Itemid=217


Operational Definitions

• A clear, precise definition of each factor being measured must be

documented and confirmed with the process owner and key stakeholders.

• Example of challenges with operational definitions: Measuring time

segments in the Operating Room.

OPERATING ROOM

ROOM READY

SET UPPROCESS

CUT TOCLOSE

PATIENTOUT

CLEANUP

PATIENT IN ANESTHESIA IN

TURNOVER

SURGEON IN TIME OUT

SET UP PROCESS

204.


Data Collection Methods

• Direct Observation in the “Gemba” using Check Sheets

• Data Mining (from data previously collected)

• Electronic Data Extraction and Interfaces

• Interviews

• Questionnaires

• Surveys

• Web Based Tools (“Survey Monkey”)

205.


Check Sheet

• The Check Sheet is a simple document that is used for collecting data in real-

time at the location where the data is generated “in the Gemba”.

• The document is typically a simple form that is designed for the quick, easy, and

efficient recording of quantitative or qualitative information.

• 5 Basic types of Check Sheets:

― Classification (defect/error or failure mode, classified by category)

― Location (physical location of a trait indicated on a picture of a part or item)

― Frequency (the presence or absence of a trait or combination of traits)

― Measurement Scale (measures indicated on a scale divided into intervals)

― Check List (items to be performed for a task are listed in sequence)

Reference: http://en.wikipedia.org/wiki/Check_sheet

206.

http://en.wikipedia.org/wiki/Check_sheet


Check Sheet Example

Reference & Diagram Source: http://quality-management-tools.com/check_sheet-template.png

• “The simplest form of check sheet is a table of categories where users add a

check as they collect the data. After the first data collection you may analyze

the data and modify the check sheet to better reflect and analyze the data.”

207.

http://quality-management-tools.com/check_sheet-template.png


Check Sheet Template

Check Sheet

Department: Date:

Employee Name: Phone:

PROBLEM FREQUENCY NOTESList the categories you want to measure such as

problems, errors, number of calls, etc.

Add a check mark in the

appropriate category.

Add more information to clarify the

details for each type of problem.

Problem 1

Problem 2

Problem 3

Problem 4

Problem 5

Problem 6

Problem 7

Problem 8

Problem 9

Problem 10

208.


Measurement Systems

& Data Integrity

209.


Measurement Checklist

“Initial state” measurements should include the following steps:

Identify key process or outcome measures

Obtain agreement from key stakeholders on key measures

Confirm the operational definition of each key measure

Conduct a Measurement System Analysis to validate measurement accuracy

Create and implement a data collection plan

Calculate high level performance metrics and compare to benchmarks

Identify measures that require additional data or drill-down

Display process variation data using appropriate charts and graphs

Identify high frequency and high impact errors (defects) and variation

Communicate findings to key stakeholders

210.


Measurement Systems

• “If measurements are used to guide decisions, then it follows logically

that the more error there is in the measurements, the more error there

will be in the decisions based on those measurements.”

Errors in measurements = Errors in decisions

Reference: Measurement Systems http://www.moresteam.com/toolbox/t403.cfm

Bad Data = Bad Decisions

Garbage In Garbage Out

211.

http://www.moresteam.com/toolbox/t403.cfm


Primary & Secondary Data

• Primary Data

– Primary data is original data that has been collected for the first

time for a specific study.

• Secondary Data

– Secondary data is data that was previously collected for another

purpose.

• Statistical Analysis

– When you perform statistical analysis on primary data then the

results become known as secondary data.

Reference: http://en.wikibooks.org/wiki/Statistics/Different_Types_of_Data/PS

212.

http://en.wikibooks.org/wiki/Statistics/Different_Types_of_Data/PS


Data Integrity

• In order to assess data integrity, the following questions should be

answered:

– Where did the data come from?

– Who has been accessing or manipulating the data?

– Has the data been edited or modified in any way?

– Is there a unique identifier for each entry?

– Are the naming conventions, codes, etc. consistent?

– Are the scoring and ranking tools consistent and valid?

– Has the accuracy of the measurement process been validated?

– Who developed the benchmarking standards?

213.


Data Audits & Validation

• Data must be validated to ensure that it is accurate and to identify

and confirm or remove data that may be suspect.

• Tools for the data audit and validation include (but are not limited to):

– Manual Review

– Frequency Plot (histogram)

– Evaluation of Outliers & Standard Deviations

– Control Charts & Pareto Charts

– Drilling Down by Subpopulations

– Measurement System Analysis (MSA) to validate measurement accuracy

– Common Sense! Does the data appear reasonable?

214.


Sampling Bias

• Bias can occur in multiple ways, resulting in a sample that does not

represent the attributes of the population being studied. Care

should be taken to avoid or mitigate these types of bias:

─ Over coverage: Inclusion of data from outside the population.

─ Under coverage: Some members of the population are not

adequately represented in the sample.

─ Non-response bias: Individuals chosen for the sample may be

unwilling or unable to participate in the study.

─ Measurement systems: Variation in the measurement process

or tools.

─ Processing errors: Mistakes in coding or entering data.

Reference: http://stattrek.com/AP-Statistics-2/Data-Collection-Methods.aspx

215.

http://stattrek.com/AP-Statistics-2/Data-Collection-Methods.aspx


Tips to Avoid Data Disaster

• Save a copy of the original database before you make any changes

so you can restore it, if necessary.

• Assign a unique identifier to each observation to:

– Audit for duplicates

– Link de-identified data back to source documents

– Sort data back to the original state

• Limit access to the database, to keep the data secure and avoid the

potential for data corruption or file deletion.

• Use version control methods, such as adding a date to the file name

and initials of the person updating the file.

216.


Measurement System Analysis (MSA)

• A measurement system analysis (MSA) is used to identify the components of variation

that exist in a measurement system. It is designed to test the measurements used to

collect data for a Lean Six Sigma project to ensure the accuracy of the data.

• Total observed variation is made up of two parts: the actual variation that exists in an

item or process and the variation that is created by the measurement system itself.

• An ANOVA Gauge R&R (repeatability & reproducibility) test is used to determine the

variability that comes from the measurement system and compares it to the total

observed variation to determine what portion of the variation can be attributed to the

measurement system itself. There are two essential components of a Gauge R&R test:

– Repeatability: The variation in repeat measurements taken by one person or

instrument on the same item and under the same conditions.

– Reproducibility: The variation in measurements that occurs when different

people measure the same item.

• A Gauge R&R value of < 0.1 reflects a good measurement system; 0.1 to < 0.3 is

considered marginal; and > 0.3 is an unacceptable measurement system.

Reference: Six Sigma for Dummies. 2005, Wiley Publishing, Inc., Hoboken, NJ. pp. 156-61.


Data Types & Display

218.


Process, Outcome, Balancing Metrics

• Improvement efforts should include process, outcome,

and balancing measures:

– Process

• Are the steps in the process being performed correctly and in

the right sequence?

– Outcome

• How does the system performance impact the health and well

being of patients and the things they value?

– Balancing

• Are changes designed to improve one part of the system

causing new problems in another area of the system?

Source URL: Institute for Healthcare Improvement (IHI)

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx

219.



Process Measures

• Little Dots

– Are the steps in the process being performed correctly

and in the right sequence?

• Monitor performance

• Understand variation

• Initiate process improvements



220.



Outcome Measures

• BIG DOTS

– How does the system performance impact the health

and well being of patients and the things they value?

• Total system or population measures

• Tracking overall performance or impact

• Publicly reported measures (mortality, pressure ulcers, etc.)

• Examples of “Big Dots”:



Average

Length

of Stay

Nursing

Hrs. per

Pt. Day

Falls per

1,000 Pt.

Days

221.



Balancing Measures

• Are changes designed to improve one part of the system

causing new problems in another area of the system?



Image URL: http://healthinformatics.wikispaces.com/Whack-a-mole+healthcare+delivery

222.


http://healthinformatics.wikispaces.com/Whack-a-mole+healthcare+delivery


Quantitative Data

• Quantitative = Quantity

– Deals with numbers.

– Data can be measured and is continuous.

– Length, cost, weight, height.

– Not all numbers are continuous and measurable

(ex: social security number).

Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm

223.

http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm


Qualitative Data

• Qualitative = Quality

– Deals with descriptions.

– Data can be observed, but not measured.

– Colors, textures, tastes.


224.



Categorical Data


NOMINAL

No natural ordering of the

categories.

• Gender

• Race

• Religion

• Sports

ORDINAL

The categories can be ordered.

• Small, medium, large

• Strongly agree, agree, neutral,

disagree, strongly disagree

• May not know which value is best

• Distance between categories

cannot be measured

225.



Interval Data

• Intervals = equally spaced

– Numeric values

– Increments are known, consistent and measurable

– No absolute zero (time, Celsius thermometer)

– Cannot calculate ratios

226.


Parametric and Non-Parametric Data

Source URL: http://www.six-sigma-material.com/images/DataMeasurements.GIF

Non-parametric:

This type of data

can be analyzed

without the mean

(average), standard

deviation, or other

related parameters.

Parametric:

The analysis of this

type of data is based

on assumptions about

probability distributions

using the mean

(average) and

standard deviation.

227.

http://www.six-sigma-material.com/images/DataMeasurements.GIF


Measuring Data Consistency

• A simple way of measuring the level of consistency in a data set is by

calculating the Minimum, Maximum, and Range.

Reference: Measures of Central Tendency http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm

Minimum: The smallest value in a data set.

Maximum: The largest value in a data set.

Range:The difference between the Maximum and the

Minimum.

228.

http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm


Measures of Central Tendency

• Measures of central tendency include the mean, median, and mode.

Reference: Measures of Central Tendency http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm

Mean:

The mean (average) is a measure of central tendency,

that is the “center” of the data. The mean is the sum of a

set of data divided by the number (count) of the data. It is

often referred to as “x-bar” using the symbol

Median:

The median is the middle value (or the mean of the

middle two values, when the data is arranged in numerical

order). The median is calculated by listing the data in

ascending order and then finding the value in the middle of

the list. Think of the median as the middle of a highway.

Mode:

The mode is the value (number) that appears the most.

It is possible to have more than one mode, and it is

possible to have no mode.

229.

http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm


Meaningful Uses of Data

• Identify trends and patterns.

• Measure the impact of process changes.

• Monitor and sustain improvements.

• Compare organizational performance to industry

benchmarks and government mandated standards.

• Increase understanding and take action!

Reference: Baker, N. Top 10 Critical Success Factors for Six Sigma-Part 3. Bright Hub. Dec. 18, 2009.

Source URL: http://www.brighthub.com/office/project-management/articles/7620.aspx Retrieved 3/30/10.

230.

http://www.brighthub.com/office/project-management/articles/7620.aspx


Value of Data Display

• Graphs can be used to visually summarize relationships between

variables, especially if the data set is large.

• They can be used in reports to enhance readability or underscore a

particular statement about a data set.

• Graphs can appeal to visual memory in ways that plain summary

tables cannot.

• Graphs can misrepresent relationships between variables or promote

inaccurate conclusions if not used correctly.

Source URL: http://www.preciousheart.net/chaplaincy/Auditor_Manual/11grphd.pdf

231.

http://www.preciousheart.net/chaplaincy/Auditor_Manual/11grphd.pdf


Questions to Guide Data Display

• What is the target problem?

• What are the target measures?

– Process (Little dots) focused on process steps

– Outcome (BIG dots) system or population measures

– Balancing (new problems caused by process changes)

– Are the measures quantitative or qualitative?

• Who is the target audience?

• What are the key points to be illustrated?

232.


Charts for Measuring

Variation & Change*

*Not inclusive of all chart types233.


Using Run Charts for Data Display

• “Improvement takes place over time. Determining if

improvement has really happened and if it is lasting

requires observing patterns over time.

• Run charts are graphs of data over time and are one of

the most important tools for assessing the effectiveness of

change.”

Source URLs: http://www.ihi.org/resources/Pages/Tools/RunChart.aspx

http://app.ihi.org/Workspace/tracker/

234.

http://www.ihi.org/resources/Pages/Tools/RunChart.aspx



Benefits of Run Charts

• They help improvement teams formulate aims by depicting

how well (or poorly) a process is performing.

• They help in determining when changes are truly

improvements by displaying a pattern of data that you can

observe as you make changes.

• They give direction as you work on improvement and

information about the value of particular changes.

Source URLs: http://www.ihi.org/resources/Pages/Tools/RunChart.aspx


235.

http://www.ihi.org/resources/Pages/Tools/RunChart.aspx



Control Chart

• A Control Chart is used to monitor performance and draw conclusions

about whether the process is in control (common cause variation only)

or is out of control (affected by special cause variation, unpredictable).

• An X-Bar control chart is used to monitor variable data.

• A P-Chart control chart is used to monitor attribute data and error rates.

References: http://www.asq.org/learn-about-quality/data-collection-analysis-tools/overview/control-chart.html

http://www.six-sigma-material.com/SPC-Charts.html

Diagram Source: http://sixsigmaindonesia.com/blog/wp-content/uploads/2008/11/contchart1.gif

236.

(LCL)

http://www.asq.org/learn-about-quality/data-collection-analysis-tools/overview/control-chart.html


http://sixsigmaindonesia.com/blog/wp-content/uploads/2008/11/contchart1.gif


Pareto Chart

• The purpose of a Pareto Chart is to assess the most frequently occurring

errors/defects by category. It is used to highlight the most significant issues

among a large set of factors (often referred to as the “80/20” rule).

• The Pareto Chart contains both a bar and a line graph.

– Individual values are represented in descending order by bars.

– The cumulative total is represented by the line.

Reference & Diagram Source: http://en.wikipedia.org/wiki/Pareto_chart 237.

http://en.wikipedia.org/wiki/Pareto_chart


Pareto Chart Example

• A Pareto Chart showing reasons for arriving late at work.

Reference & Diagram Source: http://en.wikipedia.org/wiki/Pareto_chart 238.

http://en.wikipedia.org/wiki/Pareto_chart

http://upload.wikimedia.org/wikipedia/commons/8/8a/Pareto.PNG

http://upload.wikimedia.org/wikipedia/commons/8/8a/Pareto.PNG


Frequency Plot (Histogram)

• A Frequency Plot (histogram) depicts the frequency of

observations occurring in a certain range of values.

• An important way of summarizing data is by measuring the average

“spread” or variation between each data point and the mean.

• A commonly used term in statistics for measuring this variation is

the standard deviation.

Spread

Peak

Distribution

Y axis

X axis239.


Interpreting Frequency Plot Data

Common Cause Variation Special Cause – BimodalSpecial Cause – Outlier

Outlier

• Frequency Plots help us to understand if the variation that is present in a

process is the result of:

– Common Cause Variation (natural variation within a process)

– Special Cause Variation (unpredictable or extreme variation)

– Special Cause - Bimodal Variation (one system is using 2 different processes)

240.


Impact of Outliers

• Understanding the impact of outliers is important because just one

extreme outlier in either direction can distort the mean and give a

very erroneous impression of performance (positive or negative).

• A high standard deviation (sigma) value is an indication there may

be extreme outliers that warrant further investigation and validation.

LOW outlier pulls the

mean value DOWN

HIGH outlier pulls

the mean value UP

Always investigate extreme

outliers to validate the data

Special Cause – Outlier

OutlierOutlier

241.


Process Capability &

Specifications

242.


Tools

“If you only have a hammer, you tend to see every problem as a nail.”

~ Abraham Maslow

243.


Process Capability

Reference: http://en.wikipedia.org/wiki/Process_capability_index

Diagram Source: http://www.qualitytrainingportal.com/resources/problem_solving/images/process_capability.gif

• Process capability measures the ability of a process to produce output

within certain specifications.

– Centering: Put the process on target (accuracy)

– Spread: Reduce variation in the process (precision)

244.

http://en.wikipedia.org/wiki/Process_capability_index

http://www.qualitytrainingportal.com/resources/problem_solving/images/process_capability.gif


Process Capability• As the process capability improves, the error rate (DPMO = defects per

million opportunities) will decrease and the Sigma level will increase:

6 Sigma = 3.4 DPMO

5 Sigma = 233 DPMO

4 Sigma = 6,210 DPMO



Diagram Source: http://picsdigger.com/image/53a16da4/ 245.

CAPABLE

NOT

CAPABLE

METRIC METRIC DEFINITION

Defects per Unit (DPU) Total Number of Defects

Total Number of Product Units

Total Opportunities (TO) Total Number of Product Units x Opportunities per Unit

Defects per Opportunity (DPO)Total Number of Defects

Total Opportunities

Defects per Million Opportunities (DPMO) DPO x 1,000,000

Sigma Calculator http://www.isixsigma.com/process-sigma-calculator/

http://picsdigger.com/image/53a16da4/

http://sixsigmatutorial.com/images/SixSigma-Capability-Improvement.GIF

http://sixsigmatutorial.com/images/SixSigma-Capability-Improvement.GIF

http://www.isixsigma.com/process-sigma-calculator/


Specification Limits

Reference: http://www.six-sigma-material.com/SPC-Charts.html

Diagram Source: http://www.competitivexpert.com/files/Image/processvariationa.jpg

• Specification Limits are defined by the customer. They are one element

of the “Voice of the Customer” and may be modified over time.

• LSL = Lower Specification Limit USL = Upper Specification Limit

246.

Cp = Process Capability

• Note the Cp value listed under each

diagram, which is a simple measure

of process capability.

• A process is capable if almost all of

the measurements fall within the

upper and lower specification limits.


http://www.competitivexpert.com/files/Image/processvariationa.jpg


Specification Limits Example

7:00am6:55am 7:05am

Employee Arrival Time

6:56 6:57 6:58 6:59 7:01 7:02 7:03 7:04

Outliers

7:06 7:07 7:08

Outliers

6:52 6:53 6:54

247.


Accuracy vs. Precision

• Accuracy: Is a measure of the average distance from the target.

• Precision: Is a measure of the average distance from each other.

Image Source: http://www.cmg.org/measureit/issues/mit70/m_70_4_2.jpg

248.

http://www.cmg.org/measureit/issues/mit70/m_70_4_2.jpg


Improving Process Performance

• There are two aspects of improving process performance:

– Align the process to a target value (centering) = increased accuracy

– Reduce variation (spread) = increased precision

• Achieving one without the other is of limited value.

Desired

Current

USLLSL

Desired

Current

USLLSL

LSL = Lower Specification Limit USL = Upper Specification Limit

249.


The Normal Distribution

• Over time, most processes tend to follow a Normal Distribution or bell

shaped curve.

• The Normal Distribution is important in statistics because of the relationship

between the shape of the curve and the standard deviation.

Y = ƒ(x)

Variation

Average

Y axis

X axis

250.



• One way of demonstrating the relationship between the standard deviation

(sigma) and the shape of the curve is to use sigma as a “measuring rod” to

describe how far we are away from the mean (average).

-3s -2s -1s +1s +2s +3s

+/-3s =99.73%

+/-2s =95.45%

+/-1s =68.27%

251.



• Another property of the normal distribution is the area under the curve gives us

the probability of a data point being drawn from this portion of the distribution.

– This allows us to predict how a process will perform over time.

• Almost all of the area (99.73%) of the normal distribution is contained between -

3 sigma and +3 sigma from the mean. Only 0.27% of the data falls outside 3

standard deviations from the mean:

-3s -2s -1s +1s +2s +3s

+/-3s =99.7% 252.


What Lies Beneath

• Although the average (mean) is commonly used for reporting key

performance metrics, it is imperative to understand the range of data

points that contribute to the mean value. This is essential to:

– Understand the degree of variation in a process.

– Recognize the impact of outliers on the mean.

– Detect potential errors in the data.

Diagram Source: http://aviationhumor.net/wp-content/uploads/2010/11/shark-fin.jpg

253.

http://aviationhumor.net/wp-content/uploads/2010/11/shark-fin.jpg


Sub-Populations

• Many performance metrics are a combined average for multiple sub-

populations. It is important to review the data for each sub-population,

to understand the level of performance and sources of variation in

each area (example: patient satisfaction scores by nursing unit).

Diagram Source: http://ophinions.com/images/columns/bellcurveex02.jpg

Nursing Unit A

Nursing Unit B

Nursing Unit C

Nursing Unit D

Nursing Unit E

254.

http://ophinions.com/images/columns/bellcurveex02.jpg


Reflections

• What type of data do you use most often to inform your decisions?

• What resources or training will be needed to use data more effectively?


APPENDIXLearning Guides for Review &

Deliverables by Project Phase

256.


Define Phase Deliverables

INITIATE THE PROJECT

Project charter created

Project team formed

Project metrics and performance goals defined

Stakeholder analysis completed

DEFINE THE PROCESS

High level process map created

SIPOCS diagram completed

Murphy’s analysis completed

Affinity diagram developed

DETERMINE CUSTOMER REQUIREMENTS

Voice of the Customer obtained (interviews, surveys, focus groups)

Customer Requirements Tree created with critical to quality requirements (CTQ)

Process observed in action (Go to Gemba)

257.


Define Phase – Learning Guide

The learner should understand and be able to describe the meaning of

the following terms and tools:

• Lean & Six Sigma (DMAIC)

• A3 Thinking

• 8 Types of Waste (Muda)

• Specify Value

• Value Added/Non-Value Added

• Flow, Pull, Takt Time

• Going to “Gemba”

• Voice of the Customer/Stakeholder

• SIPOCS Diagram

• Project Charter & Roles

258.


Measure Phase Deliverables

MAP THE PROCESS

“Current state” Value Stream Map created

Swim Lane map created (if appropriate)

Spaghetti Diagram created (if appropriate)

MEASURE THE PROCESS

Key performance measures identified

Data collection plan created

Data collected and validated

Data compiled and summarized (descriptive statistics, graphs, control charts)

EVALUATE CURRENT PERFORMACE

Current “initial state” performance measured (baseline)

Process capability evaluated (desired performance vs. actual performance)

Baseline compared to industry standards and benchmarks (if available)

259.


Measure Phase – Learning Guide



• Value Stream Map

• Process Flow Chart

• Spaghetti Diagram

• Data Collection Plan

• Check Sheet

• Operational Definitions

• Measurement System Analysis (MSA)

• Process Capability

• Sigma Levels

• Histogram (Frequency Plot)

260.


Analyze Phase Deliverables

IDENTIFY AMOUNTS & TYPES OF WASTE

Gemba walk, waste worksheet,

and value analysis (VA/NVA) completed

Issues and waste identified and categorized

• Affinity Diagram

Critical factors quantified and prioritized

• Pareto Chart

• Control Charts

• Statistical Analysis

DETERMINE ROOT CAUSE OF ERRORS, WASTE & VARIATION

Fishbone Diagram

Root Cause Analysis (“5 Whys”)

Failure Modes & Effects Analysis (FMEA), if appropriate

261.


Analyze Phase – Learning Guide



• Accuracy & Precision

• Reliability

• Variation

• Frequency Plot (Histogram)

• Pareto Chart (80/20 rule)

• Process Specifications

• Control Chart & Control Limits

• Root Cause Analysis & Five Whys

262.


Improve Phase Deliverables

263.

DESIGN THE FUTURE STATE

Develop proposed solutions and key interventions.

Create a “future state” value stream map to illustrate the new flow.

Identify “quick hits” that can be implemented immediately.

Implement Lean 5-S, visual controls, and error proofing (poka yoke)

CONDUCT RAPID EXPERIMENTS

Conduct rapid experiments to test the proposed solutions (PDSA cycles).

Evaluate results of experiments and select the final solutions.

DOCUMENT STANDARD WORK

Create standard work and accountability standards.

Develop policies and procedures to support the new process.

DEVELOP ACTION PLAN

Develop a detailed action plan to fully implement the solutions:

• Actions/deliverables, owner, due date (30-60-90- days)

Create and implement a communication plan.


Improve Phase – Learning Guide



• Current State, Future State

• Lean 5-S (Sort, Store, Shine, Standardize, Sustain, + Safety)

• Rapid Improvement Event (Kaizen)

• Visual Controls

• Mistake Proofing (Poka Yoke)

• Plan-Do-Study-Act (PDSA)

• Gemba Walk

• Waste Worksheet

• Action Plan

264.


Control Phase Deliverables

DEVELOP STANDARD WORK

Document and implement standardized process steps and update

related policies and procedures

DEVELOP PROCESS CONTROL STRATEGY

Utilize graphs and charts to track key performance metrics

Determine Process Capability and Sigma Level (if applicable)

Establish a Control Plan to monitor on-going process performance

PROJECT CLOSURE

Quantify project benefits and cost savings (or cost avoidance)

Transfer ownership/hand-off to process owner

Close project and complete final documentation

Communicate results to stakeholders

Celebrate project success!

NOTE: All projects do not require the use of every tool.

265.


Control Phase – Learning Guide



• Control Plan

• Key Performance Metrics

• Initial State

• Target State

• Standard Work

• Process Owner

• Project Closure

266.


Project Hand-off

• An important aspect of project closure involves the Project Leader

transferring ownership of the project back to the Process Owner.

• This hand-off should be authorized by the Project Champion after all

project deliverables have been reviewed and approved, a Control Plan

is in place, and the final project documentation has been completed.

267.


Recognition & Celebration

• Timely recognition of project teams

• Communication of project results

• Celebration of successful projects

Reference: Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL:

http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111.

268

268.



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Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patient’s Voice. J Amer Board of Fam Med. 2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf


269.


http://leanhealthcareperformance.com/page.php?page=8 Wastes with Healthcare Examples


http://www.ihi.org/

http://www.ihi.org/


http://www.ihi.org/





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Acknowledgments

The following individuals have generously shared their time, knowledge, and

resources, which greatly enriched the contents of this document:

― Glenn Bingle, MD, PhD, Chairman (retired), Indianapolis Coalition for Patient Safety

― Carol Birk, RPh, MS, President (retired), Indianapolis Coalition for Patient Safety

― LEAN Work Group Members, Indianapolis Coalition for Patient Safety

― Patricia Ebright, PhD, RN, FAAN, Associate Professor & Associate Dean for

Graduate Programs, Indiana University School of Nursing

― Matthew Horn, Systems Redesign Coordinator, V.A. Hospital, Indianapolis

― Betsy Lee, BSN, MSPH, Director, Indiana Patient Safety Center

― Aadron Rausch, Administrative Director, IU Health Arnett

― Gretchen Shook, Employee Education, IU Health Arnett

― Mary Sitterding, PhD, RN, CNS, Executive Director, Nursing Research and

Professional Practice, Indiana University Health

― Tim Tarnowski, VP, CIO, Indiana University Health

― Ian Wedgwood, PhD, Co-Founder & Principal, Haelan Group, LLC

― Heather Woodward-Hagg, Chief – V.A. Systems Redesign Service and Director


Evelyn Catt, MHA, BSPH, CSSBB

Principal, TTAC Consulting, LLC

Adjunct Professor, Indiana University

Fairbanks School of Public Health

[email protected]

Cell: 317.442.2837Permission from the author is required to reproduce or distribute any part of this document.

Questions

mailto:[email protected]

Documents

Lean Six Sigma & A3 Thinking Workbook