Part 1Part 2Part 3 CB/NW/PM Ver 1.1 Six-Sigma in Health Care This presentation will: Provide an overview to the 6-sigma and the DMAIC framework6-sigma

CB/NW/PM Ver 1.1Part 1 Part 2 Part 3

Six-Sigma in Health Care

This presentation will:

Provide an overview to the 6-sigma and the DMAIC framework

Develop a practical appreciation of process variation (Based on an idea by Neil Westwood)

and outline progress made within the NW Wales NHS Trust in applying the methodology

Craig Barton (NHS Modernisation Director, NW Wales NHS Trust)


What is 6-Sigma? Six-Sigma is an integrated quality improvement

framework, which aims at ensuring no more than 3.4 defects per million opportunities.

At the heart of the Six-Sigma methodology lies a process improvement framework known as DMAIC (Define, Measure, Analyse, Implement, Control).

It brings a rigour to process redesign, which takes into account the detailed, and dynamic complexity found in today’s health care systems.


What is Six Sigma?

Six-Sigma is a data driven approach to service development, which provides a problem solving methodology, which allows you to get at the facts as the basis for informing decision-making.

“Facts are the bricks with which you will lay a path to your solution and

build pillars to support it. Don't fear the facts.”


DMIAC – An Overview

Pronounced (Duh-May-Ick). DMAIC refers to a data-driven quality strategy for improving processes, and is an integral part of the company's Six Sigma Quality Initiative. DMAIC is an acronym for five interconnected phases:•Define

•Measure

•Analyse

• Improve

•Control Each step in the cyclical DMAIC Process is required

to ensure the best possible results!!

Define Measure Analyse Improve Control


Overview to the DEFINE Phase

Define the Customer, their Critical to Quality (CTQ) issues, and the Core Business Process involved. • Define who customers are, what their

requirements are for products and services, and what their expectations are

• Define project boundaries the stop and start of the process

• Define the process to be improved by mapping the process flow


Overview to MEASURE

Measure the performance of the Core Business Process involved.

• Develop a data collection plan for the process

• Collect data from many sources to determine types of defects and metrics

• Compare to customer requirements and/or Mandated targets to determine shortfall


The ANALYSE Phase

Analyse the data collected and process map to determine root causes of defects and opportunities for improvement

• Identify gaps between current performance and goal performance

•Prioritise opportunities to improve• Identify sources of variation


The IMPROVE Phase

Improve the target process by designing creative solutions to fix and prevent problems.

•Create innovative solutions using technology and discipline

•Develop and deploy implementation plan


The CONTROL Phase

Control the improvements to keep the process on the new course.

•Prevent reverting back to the "old way"

•Require the development, documentation and implementation of an ongoing monitoring plan

• Institutionalise the improvements through the modification of systems and structures (staffing, training, roles, procedures, policies, incentives)


What do we mean by Sigma?

The chart below is a Histogram showing the time taken to get a GP appointment (all data is fictitious)! A basic understanding of statistics can help us understand the variation in the process.

0

5

10

15

20

1 2 3 4 5 6 7

Days

Fre

qu

en

cy

(N

o o

f O

cc

ura

nc

es

)


What do we mean by Sigma ()?

Sigma stands for the standard deviation, which represents the average variation from the mean (average) value

The smaller the standard deviation the smaller the amount of variation in the process.

MEANAverage


The Normal Distribution

5 Days 6 Days 7 Days

X

1 Day 2 Days 3 Days 4 Days

99.99999998%

99.999943%

99.9937%

99.73%

95.46%

68.26%

+1s +2s +3s +4s +5s +6s -1s -2s -3s -4s -5s -6s

Naturally occurring processes often

approximate to a normal frequency

distribution

The frequencies of events within a

normal distribution have

known probabilities.

The standard deviation about

the mean of a normal

distribution is given the Greek

letter (lower

case) Sigma, ()


Sigma () from the Customer’s (Pts) Perspective

Customer Specification

UPPER LOWER

Limits

X

7 Days 3 Days 2 Days 1 Days 4 Days 5 Days 6 Days

99.99999998%

99.999943%

99.9937%

99.73%

95.46%

68.26%

+1s +2s +3s +4s +5s +6s -1s -2s -3s -4s -5s -6s

Very Few Defects

Very Few Defects

If the patient is prepared to wait between 1 and 7

days then we have..

A Six-Sigma (6 ) Process!!


Sigma () from the Customer’s (Pts) ‘Changed’ Perspective…

Customer Specification Limits

UPPER LOWER

X

7 Days 3 Days 2 Days 1 Days 4 Days 5 Days 6 Days

99.99999998%

99.999943%

99.9937%

99.73%

95.46%

68.26%

+1s +2s +3s +4s +5s +6s -1s -2s -3s -4s -5s -6s

If the patient (or LHB) is now only prepared to wait between

1 and 3 days then we have..

Very High No of Defects on this

side of the distribution!!

Very Few Defects

No longer a Six-Sigma (6 ) Process!!


Improving Quality

We need to keep dong it so that the distribution curve gets tighter and tighter. And our customers (patients) get happier

and happier

Upper Service Specification

Lower Service Specification

6


From Decimals to Defects per Million Opportunities (DPM)

Probabilities are difficult to utilise eg 99.99999998% provides a confidence interval equivalent to 6 (Standard Deviations) about the mean.

Process Sigma Defects Per Million Opportunities (DPMO)

6 3.4

5 233

4 6,210

3 66,810

2 308,537


Process Yields and DPMO

These are Motorola’s adjusted Yields and DPMO, which are shifted 1.5 from the standard normal values to account for variation associated with repeated measures

Process Sigma Yield % Defects Per Million Opportunities (DPMO)

6 99.99966 3.4

5 99.977 233

4 99.379 6,210

3 93.32 66,810

2 69.20 308,537


‘Six-Sigma’ in Practice‘The Paper Aeroplane

Metaphor’Based on an Idea By Neil Westwood

Instructions: Make an aeroplane using the materials on your tables

(use only one type of material) When you have made it, bring the plane to the front

of the room When instructed throw the plane The planes go different distances – due to variation in

deigns, materials and the people making them.


Six-Sigma’ in Practice‘The Paper Aeroplane

Metaphor’Understanding Variation…..

Note the distances flown by each design, what is the mean and standard deviation.

What are causing the aeroplanes to fly different distances?

Why are they not flying the same distance?


Six-Sigma’ in Practice‘The Paper Aeroplane Metaphor’

Fishbone Diagrams are used to identify the root causes of variation


Causes

Causes Causes Causes

Causes Causes

Some aeroplanes fly different distances

The different types of paper

e.g. card, tracing paper,

No clear instructions

provided

The people have different

skills/ideas

Different throwing styles

Some Tables had

scissors and rulers to help

Problem



Metaphor’

How can we reduce variation? Train people [Improve] Provide Instructions [Improve] Provide the same materials [Improve] Develop process measures and use to control

process variance – apply SPC. [Control]




Metaphor’ Towards a solution (ie to reduction in

process variation)!! Make another aeroplane – following the

instructions. (Perhaps we have a master designer or Modernisation Director who is able to demonstrate)

Use the A4 white paper provided, 80g/m2 (everyone to use the same material.


Six-Sigma’ in Practice ’The Paper Aeroplane

Metaphor’ – INSTRUCTIONS (1 of 3)


Six-Sigma’ in Practice ’The Paper Aeroplane

Metaphor’ - INSTRUCTIONS (2 of 3)


Six-Sigma’ in Practice ’The Paper Aeroplane Metaphor’ - INSTRUCTIONS (3 of 3)



Metaphor’Analysing the results of the experiment

Now note the mean and standard deviation of the distances flown

Do we have a more stable process?

Is it capable?• We need to know the upper and lower service

specification!!


Six Sigma Implementation in the NW Wales NHS Trust – Why are we doing it?

Engendering Service Improvement by providing the impetuous for

sustainable Cultural Change!

The development of cost effective, patient (customer) centred & evidence based services derived form a rigours approach to systems

analysis and redesign.

Leading to …


What have we done?

Internal support • Appointment of Full time Senior Manager with strong

background in training, leadership & org’ development• Trained as Green Belt, will be trained as Black Belt!• Agreed protocols for reinvesting savings• Agreed criteria for the selection of projects

External Support (Catalyst Ltd)• Consultancy• Project Surgeries• Toll-gate reviews

Initial Logistics – Developing the Infrastructure:-


What have we done?

Workshop for Executive Group• Executive Directors• Directorate Managers

Workshop for Project Sponsors

First phase roll out• Training for 14 to Green Belt standard• Participants from a variety of settings

Estates and Facilities Human Resources Clinical - Surgery, Medicine and Mental Health Service Modernisation Business Modernisation

Awareness & Training:-


Surviving 1st Phase Projects:-

Reduction in inpatient length of stay (LOS) for stroke patients towards a target of <= 5 days [DMA - DOE Complete]

Reduction in the No of untouched patient meals within the Surgical Directorate [1.9 - 3.2]

Reduced cycle time for the recruitment & selection process within the Surgical Directorate [0.9 DMA - DOE Complete]

Reduce ‘trolley waits’ in A&E to ensure 100% compliance with the target of < 4 hours [3.0 - 3.3 (ENP Experiment)]

Improve processing of invoices from fuel cards to ensure 100% compliance with Financial Policy (F6b) [0.6 - 2.2 ]

Reduce occurrence of missing case notes at outpatient ENT & Dermatology O/Pt clinics to zero. [2.5 – 2.9 – 4.1 (Audit & Runner Experiment)]


Surviving 1st Phase Projects:-

Reduction in do not attend rates (DNAs) for compulsory patient handling training to ensure 100% compliance with Trust Policy and HSE (Statutory) guidelines. [Root Cause Analysis – Undertaken]

Reduce cycle time in relation to lease care application process ensuring 100% compliance with Trust Policy F6(a)

Reduction in the No of Non BACs transactions to zero. [2.5 – 3.2 ]

Improve contractor compliance with the audit requirements of the cleaning contract towards a target of 100% compliance with relevant clauses. [0.9 – 3.9 ]

Reduction in the time spent on pre & post payroll checks.


What have been the benefits?

Development of a universal approach to solving problems which enforces:-• Business led approach to the selection of improvement

projects, (Project charter incorporating an outline business case – facilitating strategic integration)

• Customer/Patient centred (VOC)• Systemic perspective (SIPOC, Process Mapping/Redesign)• Focus on measurement (SPC)• Scientific approach to Root Cause Analysis – Fact NOT

assumption! (Y = F(x1, x2, x3 … xn))• Rational DOE underpinning P-D-S-A (Fast prototyping)• Rational selection of solutions against a range of CTQs


Benefits …/Ctd

Empower managers & HCPs to solve problems• “I can make a difference”, “I have the tools to make a

difference”, “It is my duty to make a difference”

• “I understand the organisational consequences of my practice”!

Move away from ‘Assumptive/Solutionist’ thinking!! Move from task to process management Move from departmental to systems thinking

• from detailed complexity to dynamic complexity


Some Early Indicators:-

BACK

Utilisation of Audit & Runner to periodically

chase missing Case Notes



Improve contractor compliance with the audit requirements of the cleaning contract towards a target of 100% compliance with relevant clauses.

Jan 05 Feb 05 Mar 05

Process Sigma

0.9 0.95 3.9

Process Yield

30% 31% 99%BACK



Reduction in the No of Non electronic transactions (Cheques) to zero.

June 04 Feb 05 Mar 05

Process Sigma

2.5 2.8 3.2

Process Yield

84% 90% 95%

BACK



BACK

Utilisation of Trainee Emergency Nurse

Practitioners


What Have we Learnt from Phase I

The importance of developing a strong business case underpinning the improvement opportunity – strategic integration.

The critical importance of the project sponsors role – action not tokenism!

The importance of embedding black, green and yellow belt roles within job descriptions and other artefacts of culture – staff appraisal.

The importance of organising work to allow dedicated space and time for six-sigma practice.

Encouraging accountability for project outcomes by embedding the tollgate reviews within the directorate review process and local performance management arrangements.


What Have we Learnt from Phase I

Importance of measurement (SPC) – identifying a range of upstream and downstream process measures.• Avoid the ‘McNamara Fallacy’

Recognising the need to balance hard systems modelling with soft-systems approaches• Balancing the What and Why with the How?• The importance of E = Q x A• The importance of V x D x S x C > R


The Next Steps!!

Systematically select and train a further 14 project leaders from all clinical directorates and functional areas.• Ensure these are supported by sponsors & trained yellow belts

Identify and select projects (approx 2 per directorate/dept) which clearly impact on the achievement of KPIs & CIPs.

Develop accountability for project deliverables using existing organisational structures and processes.

Systematically exploit the learning of others whilst proactively sharing our experiences.

Develop the organisational capability wrt to the application of DMADV/DFSS.

Succession Plan for future black, green and yellow belts. Have some fun!!

• (Work shorter hours & take less work home, Quantity time with the kids)!!!

Documents

Part 1Part 2Part 3 CB/NW/PM Ver 1.1 Six-Sigma in Health Care This presentation will: Provide an overview to the 6-sigma and the DMAIC framework6-sigma