Six Sigma Project Work

8/2/2019 Six Sigma Project Work

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Six Sigma inHealthcare:

A prescription forchange?

DR. BINITA SINGH

PRADEEP JAINDR. SWATI NALWADE


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Objectives

2

Articulate the case for organizationaltransformation in healthcare

Acquire high-level understanding of Six Sigma

and related change management methods

Learn from case study examples

Know the keys to a successful deployment


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The Need for

Change inHealthcare


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A Perfect Storm

Patient safety and qualityconcerns

Demographic changes

Rapidly changingtechnologies and treatment

Digital transition

Workforce issues

Financial constraintsRising consumerism

Un and Under-insured

Leadership challenges


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Time cover story - May 1,2006

Q: What ScaresDoctors?

A: Being thePatient


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Hospitals must alsoredesign processes andaddress the human side ofchange.

Simply overlaying 21st

century technologies on topof 20th century workflow willnot yield the necessarycost, quality and efficiencybenefits.

hnology alone isnt the answer


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Overcoming the barriers

Culture

Alignment and accountability

Control


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Getting there from here

Transformation inhealthcare wont happenwithout transparency.

Transparency cant happenwithout culture change.

Culture change wont happen

without a bold vision, a commontoolset and unwaveringcommitment.
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Six Sigma

Background andBasics


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Where did Six Sigma ComeFrom?

During the first five years, even supplierswere required to participate in the process

Six Sigma was adopted by Allied Signaland GE and further developed into a true

management system

Success led to global deployment across avariety of companies and industries

including healthcare!

Initially developed at Motorola

in the 1980s to improveprocesses, meet customerexpectations and maintainmarket leadership
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What does Six Sigma mean?

The term Sigma is a measurement

of how far a given process deviatesfrom perfection a measure of thenumber of defects. Six Sigmacorrelates to just 3.4 defects per millionopportunities.

A qualityimprovement methodologythat applies statistics to measure andreduce variation in processes.

A management systemthat iscomprehensive and flexible forachieving, sustaining, and maximizingsuccess.

2

3

4

5

6

308,537

66,807

6,210

233

3.4

BB DPMODPMO


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Key Concepts

Critical to Quality (CTQ)Critical to Quality (CTQ):: Attributes most

important to the customer

DefectDefect:: Failing to deliver what the customer

wants

Process CapabilityProcess Capability:: What your process can

deliver

Stable OperationsStable Operations:: Ensuring consistent,

predictable processes to improve what the


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How does the customer view myprocess?

What does the customer look at tomeasure performance?

Time to

Park Car

Registration

Walk to

ProcedureArea

Procedur

e Time

Time to

drive tofacility

Hospitals Viewof Registration

Patients View

ofRegistration

An Enabler for CulturalChange

Lobby

Time


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20,000 lost articles of mail per hour

The Classical View of Quality

99% Good (Z = 3.8)

Seven lost articles of mail per hour

The Six Sigma View of Quality

99.99966% Good (Z = 6)

One hour without electricity every

34 years

68 wrong drug prescriptionseach year

No electricity for almost

7 hours each month

200,000 wrong drug prescriptionseach year

One short or long landing at most

major airports every five years

2 short or long landings at most

major airports daily

5,000 incorrect surgical operationsper week 1.7 incorrect surgical operationsper week

One minute of unsafe drinking water

every seven months

Unsafe drinking water almost

15 minutes each day

How good do we need to be?


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Define

CTQs

StatisticalProblem

PracticalProblem

Statistical

Solution

PracticalSolution

DMAIC METHOD:

...measure your target metricand know your measure is good...

look for root causes andgenerate a prioritized listing of them.

... determine and confirm the

optimal solution ...

be sure the problem doesntcome back sustain it

and relate it to the customer..,... define the problem, clarify


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Translating Goals intoResultsThe Big Ys

Clinical excellence

Patient safety

Financial results

Patient satisfaction

Physician/staff

satisfaction

Community service

ALL DRIVEN BY

PROCESSES


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In simple terms

Listen to the customer

Define their expectations

Measure how many times we get it wrong

Fix it

Prove the fix is real and meaningful

Make it stick !!!!!


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Large scaleimprovementsrequire precise

coordination anda commoncadence

to advancesmoothly

62% of

initiatives fail

due to lack ofleadership

commitment


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Healthcare Case StudyExamples


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Improving process/safety for medication administration

Reduction in Blood Stream Infections in ICU

Reducing ventilator acquired pneumonia

Emergency Department Patient Wait Time

Improved Patient Throughput in Radiology

Reduction in Lost Films

MR Exam Scheduling Improvement

Staff Recruitment and RetentionOperating Room Case Cart Accuracy

Physician (Professional Fee) Billing Accuracy

Appointment Backlog for Hospital-Based Orthopedic Clinic

Quality of Care and Satisfaction of Families in Newborn ICU

Healthcare Project

Examples


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Project Description :PS - Moving Treat-to-Street patients through the EDtakes too long. PD - One-third of our patients waitlonger than 60 minutes to be seen by a physician.

Project Description :PS - Moving Treat-to-Street patients through the EDtakes too long. PD - One-third of our patients waitlonger than 60 minutes to be seen by a physician.

Project Scope:In Scope - Treat to Street pts, Staffing patterns (ED MDs &

RNs), Equipt, FTEs, Registration, Lab, X-R.

Out of Scope - ED Admits, ED Hold Hours, Bed Control,Housekeeping, Transport to Floor, MR, US, CT, Pharm.

Project Scope:In Scope - Treat to Street pts, Staffing patterns (ED MDs &

RNs), Equipt, FTEs, Registration, Lab, X-R.Out of Scope - ED Admits, ED Hold Hours, Bed Control,Housekeeping, Transport to Floor, MR, US, CT, Pharm.

Potential Benefits:

Decrease LWBS Increase patient satisfaction (Press Ganey #s) Reduce ED LOS (Soft Dollars)

Potential Benefits:

Decrease LWBS Increase patient satisfaction (Press Ganey #s) Reduce ED LOS (Soft Dollars)

Alignment with Strategic Plan: Customer Service Growth Efficiency

Alignment with Strategic Plan:

Customer Service Growth Efficiency

Project Title: ED ThroughputProject Title: ED Throughput

Customer(s):Patients, Physicians

Customer(s):Patients, Physicians

Case Study: Improving ED


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What is the Right Y (CTQ) to Measure? How will it be measured? Y = Door to Doc Time. From the time a patient enters through the door until the physicianenters the exam room to assess the patient, measured in minutes.

What is the Right Y (CTQ) to Measure? How will it be measured?

Y = Door to Doc Time. From the time a patient enters through the door until the physicianenters the exam room to assess the patient, measured in minutes.

What is our goal?

We will improve the average ED Throughput Time for Treat and Street Patients by 40%.This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes.

We will improve our throughput yield of patients seeing a physician within 60 minutes(USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over7,500 customers.

What is our goal?

We will improve the average ED Throughput Time for Treat and Street Patients by 40%.This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes.

We will improve our throughput yield of patients seeing a physician within 60 minutes(USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over7,500 customers.

Measure

What are the specification limits? (LSL, USL) What is the Target? Based upon our VOC data, we have set a USL of 60 minutes and a Target Mean of 40minutes.

What are the specification limits? (LSL, USL) What is the Target? Based upon our VOC data, we have set a USL of 60 minutes and a Target Mean of 40minutes.


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Value Stream Map Opportunities for Performance Improvements:Value Stream Map Opportunities for Performance Improvements:

Analyze

Door-to-Doc Subcycle

Other

Flow

(blood,

etc.)Patient WaitTime

PhoneCall

ED

Waiting

Room

Triage

EKG, Draw

Blood, UA,

Order X-Ray,

administer Pain

med

2- RNs

1 Tech

Front

Desk / QR

Treatment

X-Ray

In ED

Lab

Team Area

Tube/blood

MD

Portable

Faxwrittenreport/

ED

Call criticalvalues

Arr QR QR Triage Triage Bed Bed MD

6.3 min 11.6 min 23.5 min 22.9 min

Current Average Cycle Times

PatientFlowPeople

Flow (RN,

MD, etc.)E-Info

Flow


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Analyze

Statistical AnalysisStatistical Analysis

Door-to-Doc

Environment

Measurements

Methods

Materials

Machines

People

Associate Attributes

Physicians

Nurses

Registration

Patient Attributes

Office Equipt

Pyxis

EKG

Computers (screens)

Dynamap

Supplies

Software

Chart

Triage Sheets

Ancillary Svcs

Transportation

Advanced Triage

Financial Metrics

LWBS

Satisfaction

Time

Triage Level

Staffing

Seasonality

Acuity

GenderAge

Registrar

QuickReg

ChargeTriage

Speed

ExperienceSkill

CopierFax

Hyperion (Finance)Invision

EDTracking

XRayLab

Months

WeeksDays

Shifts

Minutes

Physician

Associate

Patient

ROICost

Revenue

TimeofDay

DayofWeek

Holidays

Quarterly

Monthly

Levels

Patterns

Door-to-Doc Causes (Xs )Hypothetical

Driver (X)

Statistically

Proven (X)

Nurses

X-Ray

DayofW

eek

Shift

Bed Available

Census

Lab


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Analyze

What Xs (inputs) are causing most of our variation?

Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open`

What Xs (inputs) are causing most of our variation?

Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open`

Estimated Effects and Coefficients for D2D (coded units)

Term Effect Coef SE Coef T P

Constant 87.34 2.547 34.30 0.000

Express Care 35.56 17.78 2.547 6.98 0.000

X-Ray 36.06 18.03 2.547 7.08 0.000

Bed Open -37.81 -18.91 2.547 -7.42 0.000Express Care*X-Ray 33.69 16.84 2.547 6.61 0.000

Express Care*Bed Open 32.56 16.28 2.547 6.39 0.000

X-Ray*Bed Open 14.06 7.03 2.547 2.76 0.025

Express Care*X-Ray*Bed Open 5.19 2.59 2.547 1.02 0.338

S = 10.1865 R-Sq = 96.87% R-Sq(adj) = 94.12%

Analysis of Variance for D2D (coded units)

Source DF Seq SS Adj SSAdj MS F P

Main Effects 3 15979.9 15979.9 5326.6 51.33 0.000

2-Way Interactions 3 9571.7 9571.7 3190.6 30.75 0.000

3-Way Interactions 1 107.6 107.6 107.6 1.04 0.338

Residual Error 8 830.1 830.1 103.8

Pure Error 8 830.1 830.1 103.8

Total 15 26489.4


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What Xs (inputs) have we chosen to improve?

1. Bed Availability

The Measure Phase data demonstrated that Door-to-Doctor time increased by two tothree times when there is no bed open for the patient.

1. Ancillary Services The data further showed that the time it takes to perform an X-Ray or Lab testing isstatistically significant in relation to Door-to-Doctor time.

3. Express Care

Lower acuity patients (i.e. Level 3 / Express Care) wait longer to see a physician thando higher acuity patients (i.e. Level 1).

What Xs (inputs) have we chosen to improve?

1. Bed Availability

The Measure Phase data demonstrated that Door-to-Doctor time increased by two tothree times when there is no bed open for the patient.

1. Ancillary Services

The data further showed that the time it takes to perform an X-Ray or Lab testing isstatistically significant in relation to Door-to-Doctor time.

3. Express Care

Lower acuity patients (i.e. Level 3 / Express Care) wait longer to see a physician thando higher acuity patients (i.e. Level 1).

What do we want to know?Screen Potential Causes?

Discover Variable Relationships?

Establish Operating Tolerances?

What do we want to know?Screen Potential Causes?

Discover Variable Relationships?

Establish Operating Tolerances?

Improve


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Value Stream Map Key Points / Opportunities for Improvement:Value Stream Map Key Points / Opportunities for Improvement:

Improve

Registration

If rooms ful

may reg ptwhile

waiting.

ED

Waiting

Room

Triage

EKG, Draw

Blood, UA,

Order X-Ray,

administer Pain

med2- RNs

1 Tech

Front

Desk / QR

Bedside Registration

Patient

Flow

People

Flow (RN,

MD, etc.)E-InfoFlow

Patient WaitTime

Impacts:1 Inc. Patient Satisfaction2 Red. time by 8.7 minutes3 Red. variability in process

Non-value added

step removed

Non-value addedstep removed


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What is the mean and median of our process? What is the standard

deviation?

Measure Phase Control Phase + % Mean score 64.3 minutes 39.8 minutes 38.1%

Median 38.5 minutes 34.0 minutes 11.7% Standard Deviation 44.7 minutes 27.7 minutes 38.0% HI/LO 241 / 11 minutes 129 / 4 minutes 46.5% (HI; outliers) Range 230 minutes 125 minutes 45.7%

What is the mean and median of our process? What is the standard

deviation?

Measure Phase Control Phase + % Mean score 64.3 minutes 39.8 minutes 38.1% Median 38.5 minutes 34.0 minutes 11.7% Standard Deviation 44.7 minutes 27.7 minutes 38.0% HI/LO 241 / 11 minutes 129 / 4 minutes 46.5% (HI; outliers) Range 230 minutes 125 minutes 45.7%

What is our process capability (Z score, DPMO, Yield %)? Z Short-Term Score = 1.91 2.35 0.44 DPMO = 333,333 175,000 Yield % = 66.7% 82.5% 15.8%

What is our process capability (Z score, DPMO, Yield %)? Z Short-Term Score = 1.91 2.35 0.44

DPMO = 333,333 175,000 Yield % = 66.7% 82.5% 15.8%

Improve


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What are our financial results? How were they calculated?

Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and thecorresponding admissions as well as a conservative (5%) recognition as a result ofthroughput improvement.

What are our financial results? How were they calculated?

Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and thecorresponding admissions as well as a conservative (5%) recognition as a result ofthroughput improvement.

Control

What is the plan for monitoring/ auditing the process? What is the ControlPlan?

What is the plan for monitoring/ auditing the process? What is the ControlPlan?

M e t r i c

T a r g e t

V a lu e s M e a su re m e n t De fin itio n

M e a s u r e m e

M e t h o d

U p p e r / L o w e

S p e c L i m i ts

C o n t r o l

M e th o d F re q u e nc y

R e s p o n s i b i l i t

(W h o w il l m e a s A le rt F la g s

D o o r t o D o c t o r T im e

< 6 0 m i n u t

Y i e l d = 8 0

T i m e b e g i n s w h e n a p a t i e n

c r o s s e s t h e r e a c h e s Q u i c

Reg is t r a t ion . Th is t im e is

c o m p l e te d w h e n a p h y s i c i

g r ee t s t h e p at ie n t a t th e b M a n u a l - C D R W e bU S L = 6 0 m i n u t e s

D a s h b o a r d

Xb ar-R C h W e ek ly M . K e lly -N ic ho ls

Two ou t o f t h ree week s

8 0 % o f p a t i e n t s a r e n o t

b y a p h y s i c i a n w i t h in 6

m i n u t e s .

L W B S % < 1 . 0%

P a t i e n t le a ve s t h e E D a ft e

l e a s t c o m p l e t in g t h e Q u i c

p r o c e s s b u t b e fo r e p h y s i c i

p e r fo r m s e x a m i n a t io n .

A u t o m a t e d -

E D T r a c k i n g

U S L = 1 . 0 % o f

E D v is i t s

D a s h b o a r d

Xb ar-R C h W e ek ly M . K e lly -N ic ho ls

Two ou t o f t h ree week s

L W B S % e x c ee ds 1 .0


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Summary and Keys

to Success


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Better patientsafety with 91%improvement in

post-surgeryantibiotic use,delivering annualsavings over $1million at hospital inSoutheast

Achieving 35%higher take homebaby rate with

increase insuccessfulimplantation athospital inNortheast

The Big Why

Shorter ED waittimes allow 28more patients

per day to beseen, withpotentialfinancial impactover $13 millionannually at

hospital inSouthern


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Think about it.Are the mission, vision and values ofyour health system merely bullet points

on a web site, or are they clearlyunderstood and activated across theorganization?

Are people empowered to drive changeand accountable for results?

Culture Change


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Gain leadership support

Identify opportunities

Ensure strategic alignment

Develop a business case

Establish measurements and evaluate

performance Manage change

Monitor results and sustain improvement

Keys to implementing Six Sigma in

Healthcare

and network with others who have

embarked on similar initiatives!


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ZERO ERROR SIX SIGMA ?

CAN WE ACHIEVE IT IN INDIAN

HEALTHCARE SECTOR ?

THANK YOU !

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Six Sigma Project Work