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Lean Six Sigma in Healthcare Lean Six Sigma in Healthcare 4 ... Presentation Transcript

  • 1. Lean Six Sigma in Healthcare 4 Simple BFO’s that Change Everything Presented By: Joseph Duhig Senior Vice President Juran Institute, Inc. February 23, 2008
  • 2. BFO’s = Blinding Flashes of the Obvious 8005 Lean Overview 2 .PPT All Rights Reserved, Juran Institute, Inc.
  • 3. BFO’s from the Great Guru’s of Quality “Establish an environment in which Quality can thrive” Jim Reinertsen, MD “Our business is clinical medicine” & “Quality improvement is the science of process management” Brent James, MD “Every system is perfectly designed to achieve the results it gets” Don Berwick, MD 8005 Lean Overview 3 .PPT All Rights Reserved, Juran Institute, Inc.
  • 4. BFO #1 – Establish an environment in which quality can thrive The Medical Profession is changing from: craft-based practice individual physicians, working alone handcraft a customized solution for each patient based on a core ethical commitment to the patient and vast personal knowledge gained from training and experience To Profession-based Practice groups of peers, treating similar patients in a shared setting plan coordinated care delivery processes (e.g., standing order sets) which individual clinicians adapt to specific patient needs 8005 Lean Overview 4 .PPT All Rights Reserved, Juran Institute, Inc.
  • 5. History of Manufacturing 8005 Lean Overview 5 .PPT All Rights Reserved, Juran Institute, Inc.
  • 6. History Timeline For Lean Manufacturing 8005 Lean Overview 6 .PPT All Rights Reserved, Juran Institute, Inc.
  • 7. Key Principles of Lean Thinking - adapted from James Womack Specify value in the eyes of the customer Identify the value stream for each product Make value flow without interruptions Let customers pull value Pursue perfection Becoming a Lean Enterprise requires a fundamental rethinking of the design of our production system ...A Value Stream / Kaizen approach will not give us the transformation we need. 8005 Lean Overview 7 .PPT All Rights Reserved, Juran Institute, Inc.
  • 8. The Language of Lean Thinking… Batch-and-Queue – the mass production practice of making large lots of a part and then sending the batch to wait in the queue before the next operation in the production process. In health care we batch-and-queue people. Single-piece-flow – a situation where products (or people) proceed one complete product at a time through various operations. 8005 Lean Overview 8 .PPT All Rights Reserved, Juran Institute, Inc.
  • 9. The Language of Lean Thinking… Other Terms: andon boards, cells, process villages, five whys, five S’s, JIT, monuments, poka-yoke, Quality Function Deployment QFD, milk runs, right-sized tool, pull vs, push, flow, changeover, level schedule, takt time,visual control, kanban, value streams, turnback analysis All these terms apply in healthcare, but some translation is required. 8005 Lean Overview 9 .PPT All Rights Reserved, Juran Institute, Inc.
  • 10. BFO # 2 – Our Business is Clinical Medicine The health system of the future must transform from a batch and queue production-like system to a continuous flow, lean enterprise. In healthcare the product lines are the clinical programs and we must design delivery systems that provide value as patient’s access and utilize our services for specific diseases or conditions. We work in a complex and highly specialized world and our healthcare providers, facilities, work processes and information system must be designed to support the delivery of services in a process oriented vs. a financial / administrative model. Placing a patient “off-service” increases risk of harm 8005 Lean Overview 10 .PPT All Rights Reserved, Juran Institute, Inc.
  • 11. BFO # 2 – Our Business is Clinical Medicine Required Changes: 1. Clinical program “Door” Theory – we need to help patients find the right door to access the system and then that should be the last door they have to find. 2. Professional practice model. 3. Universal beds / Every bed is capable of being converted to an intensive care bed. 4. Hospitalist and Intensivist who drive the quality agenda Hand-offs between levels of care not only causes safety problems, but results in a 30% loss of bed capacity each day 8005 Lean Overview 11 .PPT All Rights Reserved, Juran Institute, Inc.
  • 12. The Dilemma of Adopting Professional Standards of Practice Failure to adopt nationally accepted standards such as 100,000 lives, Leapfrog, CMS place organizations at increased liability risk. Adoption of professional standards without ensuring compliance to standards increases the liability risk. The largest repository of professional standards are nursing policies and procedures. The EHR can dramatically increase compliance with standards. Charting by exception, use of standard orders, immediate access to current evidence (Zynx, CPMRC) offers opportunities to improve outcomes and reduce costs. 8005 Lean Overview 12 .PPT All Rights Reserved, Juran Institute, Inc.
  • 13. BFO # 3 – Quality Improvement is the Science of Process Management Healthcare must adopt a “Process Mental Model” For Example: Each morning we prepare the operating rooms for a busy day of cases, but most lack a “Mental Model” of how we get the cases to roll. Healthcare has been slow to adopt the process discipline for understanding how we do the things we do every day. 8005 Lean Overview 13 .PPT All Rights Reserved, Juran Institute, Inc.
  • 14. BFO # 3 – Quality Improvement is the Science of Process Management Evidence Based Medicine is conceptually the same as Mass Customization in Manufacturing If processes are redesigned and standardized, the Electronic Health Record offers the potential to significantly reduce the largest contributor to Costs of Poor Quality in Hospitals...the unexplained variation in clinical practice. processes systems (processes interacting together) Managing human psychology variation a system for ongoing learning 8005 Lean Overview 14 .PPT All Rights Reserved, Juran Institute, Inc.
  • 15. The Hierarchical Nature of Process Level 1: This is where Macro Process EBM is implemented Level 2 – Business Process Level 3 – Sub-process Level 4 – Activity & Decision Level 5 – Task A documented written model for each level is essential for consistent, low risk performance of a process. 8005 Lean Overview 15 .PPT All Rights Reserved, Juran Institute, Inc.
  • 16. BFO # 4 - “Every system is perfectly designed to achieve the results it gets” Y = f(x) Mortality = f(x) Surgical Infections = f(x) Patient Satisfaction = f(x) Beta Blocker Compliance = f(x) Medication Errors = f(x) Define the Translate to Solve the Translate Practical Statistical Statistical back to the Problem Problem Problem Practical Y = f(x) Problem 8005 Lean Overview 16 .PPT All Rights Reserved, Juran Institute, Inc.
  • 17. What is Six Sigma? Defects per Million Defects per Million Sigma Sigma opportunities opportunities 2 308,537 (69.1% good) 3 66,807 (93.3% good) 4 6,210 (99.4% good) 5 233 (99.98% good) 6 3.4 (99.99966% good) . 3s to 6s - 20,000 Times Improvement... A True Quantum Leap 8005 Lean Overview 17 .PPT All Rights Reserved, Juran Institute, Inc.
  • 18. Pareto Principle – Focus on the Vital Few Travel expenses Inventory turns Pharmacy usage Misc. 100% $200MM rejections MRI Claims OR Rework (Lab transcription) Area B Inspection/rework Unnecessary visits Utilization Diag. Rad. Unbillable write-offs 80 Employee drug plan Secondary Opportunities CT head Administrative staff levels and procedures & Body 60 Brand scope reduction & standardization Area A Coding/charge collection Diag. Radiology Hospital patient 40 Inspection/rework (Completion Desk) cost variation Hospital Work around Utilization Diag. 20 Radiology Duplicate coding 0 20 40 60 80 Med. Records Billing Admin. Staff Misc. Supply Desk Unit Radiology Patient Care Practice Variation Hospital Utilization Primary Opportunities 8005 Lean Overview 18 .PPT All Rights Reserved, Juran Institute, Inc.
  • 19. OR First Case Start Time Process Capability Analysis for Case Rolled USL Process Data USL 30.0000 Within Target * LSL * Overall Mean 37.1050 Sample N 238 StDev (Within) 8.4564 StDev (Ov erall) 10.0149 Potential (Within) Capability Cp * CPU -0.28 CPL * Cpk -0.28 0 10 20 30 40 50 60 70 80 Cpm * Ov erall Capability Observ ed Perf ormance Exp. "Within" Perf ormance Exp. "Ov erall" Perf ormance Pp * PPM < LSL * PPM < LSL * PPM < LSL * PPU -0.24 PPM > USL 710084.03 PPM > USL 799601.67 PPM > USL 760977.44 PPL * PPM Total 710084.03 PPM Total 799601.67 PPM Total 760977.44 Ppk -0.24 8005 Lean Overview 19 .PPT All Rights Reserved, Juran Institute, Inc.
  • 20. Glucose Levels of Diabetic Cardiac Surgery Patients Process Capability Analysis for Blood Sugar LSL USL Process Data USL 150.000 Within Target * LSL 80.000 Overall Mean 193.386 Sample N 329 StDev (Within) 30.8392 StDev (Overall) 55.9094 Potential (Within) Capability Cp 0.38 CPU -0.47 CPL 1.23 Cpk -0.47 0 100 200 300 400 Cpm * Overall Capability Observed Performance Exp. "Within" Performance Exp. "Overall" Performance Pp 0.21 % < LSL 0.30 % < LSL 0.01 % < LSL 2.13 PPU -0.26 % > USL 76.60 % > USL 92.03 % > USL 78.11 PPL 0.68 % Total 76.90 % Total 92.04 % Total 80.24 Ppk -0.26 8005 Lean Overview 20 .PPT All Rights Reserved, Juran Institute, Inc.
  • 21. Hoshin Planning, Strategic Deployment Annual Projects/ Strategic Sub-Goals Goals Initiatives Quality Goals Key Strategy Vision Key Strategy Objectives - Means 5 Years 5 Years 1 Year 1 Year Time Time 8005 Lean Overview 21 .PPT All Rights Reserved, Juran Institute, Inc.
  • 22. In Conclusion... “Trying is just a noisy way of not doing something.” – Ken Blanchard “Try?! There is no try! There is just do … and not do.” – Yoda 8005 Lean Overview 22 .PPT All Rights Reserved, Juran Institute, Inc.
  • 23. BFO # 5 – No Good Deed Goes Unpunished Impact on Net Income Change to cost Discounted Per Case Per Diem Shared Risk structure FFS Decreased cost/unit Decreased # units/case Decreased LOS Decreased # of cases 8005 Lean Overview 23 .PPT All Rights Reserved, Juran Institute, Inc.
  • 24. Who Pays for the Cost of Error? CLABS Scorecard Optimal Less than Less than Care optimal care optimal + CLAB Patient + -- --- Payor + -- --- Provider Hospital ++ + --- Provider Physician + ++ +++ 8005 Lean Overview 24 .PPT All Rights Reserved, Juran Institute, Inc.
  • 25. New Rules to Redesign and Improve Care Creating a Lean Healthcare System Care based on continuous healing relationships Customization based on patient needs and values The patient as the source of control Shared knowledge and the free flow of information Evidenced-based Decision Making Safety as a system priority The need for transparency Anticipation of needs Continuous decrease in waste Cooperation among clinicians IOM Report – Crossing the Quality Chasm 8005 Lean Overview 25 .PPT All Rights Reserved, Juran Institute, Inc.