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# Is it as Simple as Picking a Performance Tool from Manufactoring and Applying it in Healthcare

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• The “Q”: the “quality” or technical aspect of the change, Six Sigma is a great example. Give other examples if possible. The “A”: the acceptance of the change/six sigma project by the people who will make it happen or not happen. The “E”: the effectiveness of the change/project. The “*” - multiplier factor: ask they to rate their organization on “Q” and “A” on the scale of 1 to 10 and do the math, e.g.,: Q * A = E Q * A = E 8 * 2 = 16 7 * 7 = 49 9 * 2 = 18 7 * 8 = 56 Some may ask why “*” , not “+”. the answer is anything times zero is zero which reflects real life better.
• Here is an example to illustrate our point. A patient has a question about their care, and they call the main hospital number to get more information. Even though we are working very hard to get that information, the patient only knows how long it took to get the answer to his question; he doesn’t particularly care how difficult or how many people needed to be involved in obtaining it.
• Don’t forget that the time it takes to complete any process is made up of two parts: actual processing time and delay time. Adding those two together will give you the total cycle time for a process. It’s always illuminating to add up the time we spend waiting for things – supplies, people, information – and see what percentage of our day is really non-value-added.
• Stability allows processes to produce results that can be predicted over time. Going back to the module on variation, we discussed using control charts to see if a process was in control. A stable process will have all outcomes fall within your control limits (be “in control”), but it might not be capable. Capable means that all of your output is satisfying your customer, the ultimate goal of Six Sigma projects. Getting your process to be stable can put you a long way towards meeting your customer needs. The ultimate goal is having a process that is both stable and capable, which is why Lean and Six Sigma tools are often intertwined.
• Also, don’t forget how Lean tools fit in with DMAIC and DMADV and hybridize into the Lean Six Sigma approach. The first three steps of Six Sigma – Define, Measure, and Analyze – correlate with defining the current state of a Lean project, and the improvement/design part of a Six Sigma project aligns well with the future state part of a Lean project.
• The above grid is a tool that can help to assess where each of the key stakeholders stand in terms of support. You can use this tool at several points in your project, but it most important to assess your stakeholders’ views of your proposed solutions during the Improve Phase. Once the key stakeholders are identified and confirmed, current and/or needed commitment for the team&apos;s solutions can be tracked. This grid can be completed as a team exercise.
• A stakeholder analysis can be very helpful at this point, as well as at any point during your project. If you list all possible stakeholders, remembering that stakeholders can be either internal or external customers of the process as well as regulators and other outside entities, your team can help to rate where they stand in terms of support for the project and improvement recommendations. If you find that an important constituency is strongly against the project work plan, the team should brainstorm ways to improve their support, or at least reduce resistance to change.
• The three D’s matrix was developed to show how different people are motivated by different things. Your team will need to determine which approach will have the largest impact on motivating each stakeholder group. This matrix was used very successfully for a project to increase the number of patients discharged before noon each day. Most of the physicians needed to be shown data that the new process wouldn’t adversely harm their patient or their own practice. Many of the nurses preferred to be shown through observation how the process would work and impact their work flow. Still another group would only respond to the administration’s demands that this new process would be followed or negative consequences would follow.
• The Pay-Off Matrix is another tool that was introduced in the Piloting module and can be useful for choosing among potential solutions. This tool looks at the amount of effort required to implement a solution (along the horizontal axis) and compares it to the amount of payoff that solution will produce (along the vertical axis). Once you have a list of potential solutions or ideas, your team would decide which box each one belongs in. The goal would be to choose solutions that reside in the green box (green light equals GO), which would include solutions that are easy to implement but also have high payoffs. You should definitely avoid solutions that end up in the red box (red light means STOP): it doesn’t make sense to spend time on a solution that is difficult to implement and won’t lead to much payoff.
• Total Productive Maintenance is another Lean concept that impacts stability of a process or work environment. In TPM, each person is responsible for making sure their area is stocked, clean, and all equipment is in working order. No one should be able to say “that isn’t my job.” The goal in TPM is to have an effective workplace, ensuring that everything needed to complete a process is available and in good working order. To accomplish this, a company using TPM has a plan for dealing with preventive maintenance (routine inspections), corrective maintenance (redesigning or bringing in new equipment to result in fewer breakdowns), breakdown maintenance (to deal with unscheduled downtime), and maintenance prevention (using equipment that doesn’t need much maintenance). Any downtime, whether it involves equipment breakdowns, stoppages in the work process, or defects leads to reduced process yield and poor outcomes and should be avoided if possible.
• You probably have many ideas about what kind of project you would like to undertake. Finding projects is usually not a problem – picking ones that will be successful requires much more skill. Try to select a project where the outcome of interest happens frequently, preferably at least daily, but more often would be better. If there are already established measures and data collection tied to the process, then you have a great foundation. Make sure that you are choosing a project that can be done in a reasonable amount of time and that you and your team have some authority to make necessary changes. Don’t try to “fix” the discharge process at your hospital unless you have been give a timeline of two years and the ability to make decisions that cross departments. It would be much better to select a project that deals only with one department or one part of the process rather than taking on the entire universe.
• Here are some very typical pitfalls in project identification to avoid. If you or your sponsor has a predetermined solution, it is best to not pursue the topic as a project - go ahead and implement. You might realize that the predetermined route won’t work out, leading you back to having the topic as a potential project again. Don’t try to make everything a project; sometimes solutions just require a management decision, no matter how painful or unpopular they may be. Finally, don’t try to do a project that focuses on improving other departments or other businesses external to you. The chance for success is very small.
• Now you are ready to look at potential project topics and ask the hard questions – why this project now? What is truly the problem, and how do we know it’s a problem? What if we have too many potential projects and need to prioritize them?
• Here is a tool designed to aid you in selecting projects. It uses a rating of 1 to 5 (the definition of the scale is described for each category); the ratings are added up to give you a “score” for each project. The project receiving the highest score would also have the highest priority, and should be considered first as your potential project.
• Take your list of potential projects (or brainstorm a list if you don’t have one) and use the Project Selection tool to help prioritize your choices. You can either do this on your own or with your potential team members.

## Is it as Simple as Picking a Performance Tool from Manufactoring and Applying it in HealthcarePresentation Transcript

• Is it as Simple as Picking a Performance Tool from Manufacturing and Applying it in Healthcare? Wendy M. Novicoff, Ph.D. Six Sigma Master Black Belt and Lean Sensei Associate Partner, Creative Healthcare USA Assistant Professor, Departments of Public Health Science and Department of Orthopedic Surgery, University of Virginia Health System
• Quality Improvement Process
• Problem identification
• Team selection
• Improvement model (PDCA, Six Sigma, Lean, etc.)
• Improvement tools
• Implement solutions
• Hold the gains
• Making It Work Technical Attack Team / Organization / Cultural Attack Q x A = E Business Results Quality of solution times its Acceptance = Effectiveness
• What is Lean?
• Lean is a methodology that is used to accelerate the speed and reduce the cost of any process by removing waste (non-value-added activities)
• What Is Lean Thinking?
• Providing “a way to do more and more with less and less – less human effort, less equipment, less time, and less space – while coming closer and closer to providing customers with exactly what they want.
• JP Womack and DT Jones
• Lean Thinking (1996)
Be “Lean,” Not “Mean”
• Types of Waste Motion Any motion of the worker that does not add value Waiting Waiting on parts, waiting on information Inventory Any more than the minimum to get the job done Over Production Producing more than is needed Defects/Rework Product or service not meeting customer requirement Transportation Unnecessary movement of materials from one place to another Over Processing Adding more value than the customer is paying for Intellect Any failure to fully utilize the time and talents of people
• Signs of Non-Value Added Steps Large file areas & frequent archiving Multiple approvals Waiting time and multiple hand offs Process is seen as complex (mystical) Frequent rework Written correspondence required for the process to complete Procedures passed on by word of mouth, no SOP’s or SOP’s don’t reflect actual process
• Five Principles of Lean Thinking
• Value
• Value Stream
• Flow
• Pull
• Perfection
• Value
• Value can only be defined by the ultimate customer
• Value is created by the producer
• We must fundamentally rethink value from the perspective of the customer – a conscious attempt to define value in terms of specific products with specific capabilities offered at specific prices through a dialogue with specific customers
What is REALLY needed by the customer? This does not equal what WE think the customer needs !
• Viewpoint: Who is the Customer?
• Perception becomes reality and is therefore is a judgment of our service
Customer asks for information Customer gets answer Long delay perceived by customer! Our hard work at maximum efficiency – are All Steps Really Necessary?
• Value Stream
• The value stream is the set of ALL actions required to bring a product (or process) from concept to finished product
• Value stream analysis shows the value of each process step
• Steps that unambiguously create value
• Steps that create no value but are currently unavoidable (Type 1 Muda)
• Steps that create no value and can be immediately eliminated (Type 2 Muda)
• Flow
• All activities needed to design, order, and provide a product or service occur in continuous flow – no stoppages, scrap, or backflow
• Batch-and-queue is the dominant set-up today; Flow thinking is counterintuitive to our culture of “departments”
The questions to ask (and hopefully answer) are: How does the entire process work together (or not)? How can we impact the work of our suppliers to help with continuous flow? What if we don’t have control over all parts of the value stream?
• Flow of Work Cycle Time Process Time Delay Time +
• Pull
• No supplier should produce a good or service until the customer downstream asks for it
• Make the customer tell you what they need instead of trying to “sell” something that you already have (Pull vs. Push)
• The demands of customers become much more stable when they know they can get what they want when they want it
• Perfection
• Perfection is achieved with the complete elimination of muda so that all activities along the value stream create value
• Transparency in the entire value stream is needed before perfection can be obtained
• Stable vs. Capable
• In Lean, we strive for stable, standardized processes that can be replicated at any time by any worker and give roughly the same result
• In Six Sigma, we want a stable process that is also capable , that is – it satisfies the customer specifications every time
• The ultimate goal is a process that is stable and capable with as little variation as possible either in process or the ultimate product
• DMAIC, DMADV, & Lean Design Verify NO YES Familiarize Define Work Elements Time Study Work Elements Develop New Process Maps Overall Fixture Needs # of Work Stations Balance the Flow Station Fixture / Tool Needs Lay Out New Line Define Measure Analyze DFSS ? Improve Control
• Getting Started – Guiding Principles
• The primary guiding principle should be that a quality process is safe, evidence-based, customer-focused, and efficient
• Guiding Principle #1
• Incorporate Lean Thinking where possible
• Define Value in terms of the customer. Always define in terms of the patient being the greatest priority.
• Identify all parts of the Value Stream for potential impact on process
• Change batch processes to continuous flow
• Move to a “pull” model instead of “push”
• Strive for a defect-free process
• Employ rapid identification & abatement of errors
• Apply mistake-proofing techniques
• Consider cross training opportunities
• Guiding Principle #2
• Use a selected data-driven methodology with measurable performance goals and objectives that is applicable and appropriate.
• Six Sigma DMAIC or DMADV
• Rapid Action Planning (RAP)
• PDCA
• FMEA
• Guiding Principle #3
• Consider Human Factors
• Reduce noise
• Minimize interruptions
• Minimize fatigue/boredom
• Simplify
• Use forcing factors
• Employ recovery factors
• Use affordances and natural mapping
• Guiding Principle 4 and 5
• Assure visibility
• Know locations of customers, staff, inventory, equipment
• Involve customers in the process
• Automate where possible
• Bar coding, automated forms
• Scheduling
• Guiding Principles 6, 7, and 8
• Standardize wherever possible
• Make it scalable, adaptable, flexible (for new technology or systems)
• Assure accessibility of information, close to point of service
• Guiding Principles 9 and 10
• Incorporate fiscal accountability
• Define project as cost savings, revenue increase, or “soft dollars” only
• Take into account budget issues (ability to add staff or equipment)
• Consider impact on current list of precarious events/regulatory requirements
• Stakeholder Analysis                                                             Strongly Supportive Moderately Supportive Neutral Moderately Against Strongly Against Key Stakeholder
• Stakeholder & Resistance Analysis – Example Stakeholders Strongly Against Moderately Against Neutral Moderately Supportive Strongly Supportive Strategies to Improve Support and Reduce Resistance O X Scheduling O X Surgical Techs O X Physicians O X Nurses O X Administrators X Executives
• Three D’s Matrix Negative consequences if actions aren’t followed Demand Show how project will positively impact people and processes Demonstrate Charts, graphs, statistics Data Examples Approach
• Pay-Off Matrix High payoff Low payoff Easy effort High effort
• Common Tools & Underlying Principles
• Tools
• 5S
• Kaizen “Blitz”
• Takt Time
• Standard Work
• Spaghetti Diagram
• Visual Controls
• Mistake-Proofing
• Value Stream Map
• Set-up Time Reduction
• Principles
• A bad process beats a good employee nearly every time
• Those closest to the problem have the greatest knowledge
• No excuses given or accepted
• Small, quick fixes add up faster than than big, slow ones
• Improvement is the journey, not a destination
• 5S: Work Place Organization
• Sort : separate locally needed from unneeded items
• Simplify : establish a specific “home” for each item
• Sweep : throughout each day, constantly tidy the work place
• Standardize : ensure that processes are consistent among all
• Sustain : repeat the loop, always improving
2. Simplify 5. Sustain 1. Sort 3. Sweep 4. Standardize
• Kaizen “Blitz”
• Designated team attacks a specific “line of sight” problem: throughput, cycle time, etc.
• 2-3 days of learn-by-doing
• Team sees tools and immediately applies them on the specific problem
• Report out with solutions
• Process managers attend
• Solutions classified: immediate / medium term / long term
• Every suggestion must receive response:
• Approval
• Rejection with specific reason
• Specific conditions needed before implementation
• Takt Time
• Lean strives to make each unit of work happen as identically as possible
• Takt time provides an ideal target for how often a unit of work should be completed, using the formula below
• Available time: total minutes (or seconds) per day, during which workers are expected to be at their stations – leave out breaks, standard meetings, meals, etc.
• Demand: average number of times the process operates during a day
Takt Time = Available Time Demand
• Standard Work
• If everyone does the “same” work his or her unique way, the outcomes will experience unacceptable variation
• Standard work identifies the best-current-knowledge way to perform a process, and then ensures that everybody does it that way
• It works when those closest to the problem are given:
• Accountability to develop and sustain standard processes
• Guidelines to know what must never be changed (usually outcomes, only occasionally procedures)
• Tools & techniques to make it happen
• Autonomy to implement changes that don’t require additional resource
• Support for changes requiring additional resources
• Standard work is developed by consensus, and then enforced strictly
• Improvements always permissible and encouraged, within the above guidelines
• Spaghetti Diagram
• Compelling map of movements associated with a process
• Can represent workers or the “work” (samples, patients, etc.)
• Be sure to show backtracking, loops, etc.
• Simple rearrangements can lead to big improvements
• Improved layout of work stations
• Identify where to keep physical items
• Example at right: fast food
• Try to ensure that work is spread out over a work period to decrease overburdening, decrease fluctuations – balance is key!
• Example: Products B and C take longer to make/process than Product A
Product 1 2 3 4 5 6 7 8 A X X X X X X X X B O O O O C OO OO OO OO
• Visual Controls
• Visual displays can make people’s jobs easier
• Images, not words
• Simple is better
• Mistake-Proofing
• Simple tools to minimize likelihood of errors
• Usually < \$100
• Wait until root cause of problem is known
• Hierarchy of solutions
• Eliminate step altogether
• Replace step with error-proof one
• Design step to prevent error from happening
• Detect error before it moves on
• Mitigate impact of error
Sticker
• Value Stream Map (VSM)
• Straightforward to create, a little complex to interpret
• Includes process steps and much more:
• Queues
• Times (value-added & NVA)
• Usage rates
• Shipment quantities & frequencies
• Flow of information (orders, forecasts, etc.)
• Current State map exposes primary areas of waste
• Future State map provides plan of attack for improvement
• Immediate / medium term / long term
• Shows where further evaluation is needed
• VSM Example: Insurance Claims Future State Current State
• Total Productive Maintenance
• Each operator is charged with maintaining their supplies and equipment
• Key issues in TPM
• Preventive maintenance
• Corrective maintenance
• Breakdown maintenance
• Maintenance prevention
• Six big “losses” in TPM: Equipment breakdowns, set-up and adjustment delays, minor stoppages, reduced machine speed, process defects, reduced yield
• Quick Change-Over
• Objective: minimize NVA time that customers, equipment, or facilities are in transition between tasks
• Basic concept: classify setup tasks as “internal” or “external”
• Internal setup: activities that happen when equipment is out of service: cleaning rooms
• External setup: activities that can be done while equipment is actively in use: delivering or replenishing supplies
• Objective is to convert as much internal to external as feasible, and then to speed up remaining internal time
• Example: NASCAR pit stops
• Productivity
• Quick Change-Over
• TPM
• Spaghetti Diagram
• Inventory Control
• Just-in-Time
• Flow Processing
• Kanban
• Enterprise Wide:
• Work Place Management:
• 5S
• Value Stream Map
• Localized:
• Standard Work
• 5S
• Kaizen
• Visual Controls
• Mistake-Proofing
• Elements for Successful Projects
• High frequency events (hourly, daily, weekly)
• Established measures and data collection
• Narrow scope
• Jurisdiction – authority to make changes
• Significant business impact (\$\$, satisfaction, growth etc…)
• But What Is Really Needed?
• Support from Management
• Owner
• The “right” team
• Problems In Project Identification
• Having a predetermined solution
• Trying to make “everything” a project instead of making reasonable or necessary changes (Just Do It)
• Projects that focus on improving inputs exterior to the department or company
• Increases complexity and time for project
• Great likelihood that solution may not be implemented unless project partnering exists
• What concerns you the most about the current process?
• Why should we do this project NOW instead of later?
• How do we prioritize multiple projects?
• Project Selection & Rating Tool Directions: rate each category on a 1 to 5 scale (see below for definitions). Add the category scores to get a final rating. The goal is to get a project with the highest score. Category Project #1 Project #2 Project #3 Project #4 Current performance gap (1 = gap is small; 5 = large gap with ideal performance)         Cost to business if NO changes made (1 = low cost; 5 = high cost)         Impact on customer satisfaction (1 = low impact; 5 = high impact)         Degree of waste (1 = little or no waste; 5 = lots of waste)         Customers can be defined (1 = not easily defined; 5 = easy to define)         Inputs can be identified (1 = hard to identify; 5 = easy to identify)         Outputs can be identified (1 = hard to identify; 5 = easy to identify)         Data is available (1 = difficult to collect or manual; 5 = easy to obtain, electronic)         Team needed to understand / identify solutions (1 = team NOT needed; 5 = team definitely needed)         Team has authority to implement solutions (1 = little or no authority; 5 = has authority to implement)         Manageable project scope (1 = very large scope; 5 = contained, narrow scope)         Alignment with Strategic Plan ( = not aligned; 5 = good alignment) Total Score
• Discussion
• What is the process of project and student selection at your institution?
• How does project selection tie to the strategic plan/business goals of your institution?
• What is the Executive Team’s role in project development?
• How are Sponsors/Champions selected, supported, and held accountable?
• The Good, the Bad, and the Ugly (Names have been removed to protect the guilty)
• The Bad and the Ugly
• Not preparing the organization for change
• Switching priorities (customer satisfaction vs. saving/generating money)
• Lack of accountability
• “Flavor of the month” approach
• The Good (to Great)
• CEO and leadership engaged in rollout, project selection, and accountable for follow-up
• All leadership (managers and above) required to have at least two-hour training session
• All leaders required to participate in one project per year as either Project Champion or “support” person
• All employees required to attend at least 20-minute introductory session
• Core group of employees trained as project leaders
• Broad-based, multi-modal communication plan
• Semi-annual project fairs in public areas
• Presentation Summary
• Much potential for a combined Lean and Six Sigma approach to projects – don’t forget to consider a “retooling” of previous projects
• Keys to success: manageable projects, the “right” people, management support
• Leadership support is critical no matter what the improvement methodology – are your leaders willing to ask and answer the tough questions?