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Lean Six Sigma


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Lean Six Sigma

  1. 1. What is Lean Six Sigma?How does it apply inHealthcare?InAHQ ConferenceMay 1, 2008
  2. 2. Lean Six Sigma PresentationIntroductionWhat is Lean and Six Sigma?‘Toast Kaizen’ videoExamples of LSS in SSFHSLean Six Sigma in Healthcare
  3. 3. Your PresenterBrian W. HudsonLean Six Sigma CoordinatorSt. Elizabeth Regional Healthbrian.hudson@ssfhs.org765-449-310216 years industrial experience as a Manufacturing Engineer8 years experience with Lean and Six Sigma
  4. 4. Corporate Office MishawakaInsert map of all ofour locations Franciscan Physicians Hospital Munster
  5. 5. St. Elizabeth Regional Health St. Elizabeth Medical Center Opened in 1876 183 Beds Facility includes comprehensive patient care facilities and the only hospital-based nursing school in the state Home Hospital Opened in 1869 365 Beds Facilities include education, rehabilitation, ambulatory surgery and patient care centersSt. Elizabeth and Home Hospital merged in 1998 to form St.Elizabeth Regional Health (2,600 employees)Currently building a new 150 bed facility to open in Fall 2009
  6. 6. What the organization wants What that leads to: • Available and prompt care• Smooth operations • Better patient outcomes• Ensure patient safety • Increased patient satisfaction • Improved financial viability• Provide quality care • Improved patient throughput• Effective patient treatment • Improved publicly reported information• Utilized staff and resources• Higher employee involvement and satisfaction • Reduced LOS
  7. 7. What do our Patients need?Favorable patient outcomesPatient safetyImplement new procedures and capabilitiesSlow rising healthcare costs
  8. 8. The pressure on HealthcareImproving patient careControlling costsGovernment regulationsIncreasing competitionImplement new procedures and capabilitiesTreatment reimbursement rates are capped based on diagnosisNumber of uninsuredGrowth in the number of people age 65 and olderHealthcare costs continue to rise.New technologies are “Expensive” and adoption in question.Staff shortages in some areas continue to drive up costs.“Report Cards” on providers – quality, cost, number of procedures
  9. 9. What is Lean?What is Six Sigma?
  10. 10. Lean Six Sigma BasicsThe Hospital as a System: feedback information information HospitalSuppliers Patients Processes feedback All work is a process . . . this is true of a hospital too!
  11. 11. What is Lean?Originated within Toyota in 1950’sIts use focuses on elimination of WasteEnhancing ‘Value-Added’ operationsA method to reduce complexity andimprove process flow
  12. 12. LSS in HealthcareIncludes a variety of improvement tools: 7 kinds of waste Flowcharting or process mapping 5S Changeover reduction Constraint Management Rapid Improvement Events Quick and Easy Kaizen Gemba or Genchi Genbutsu Value Value Flow Pull Perfection Stream
  13. 13. What is Six Sigma? Motorola is credited developing Six Sigma around 1985 Use focuses on reducing process variation Step One Lean Step Two Six SigmaMaterial and information Value added flow between process Step Three transformations steps occur within the process steps
  14. 14. Sources of Variation Y= f(X , X2, X3, …) 1= + + Yeast + + +…
  15. 15. Why Six Sigma level performance? Why 99% isn’t good enough Example 99% Good 99.99966% Good (3.8 Sigma) (6 Sigma)Unsafe drinking water per day 14.4 minutes 0.3 secondsElectricity power failure per month (30 days) 7.2 hours 8.8 secondsSevere turbulence on a 6 hour flight 3.6 minutes 0.1 secondImpurities in a kg of raw material 10 grams 0.0034 gramsLosses per $1,000,000 worth of business $10,000 $3.40Man days lost per 10,000 employees 100 man days 480 minutes 99% just isn’t good enough
  16. 16. How do we do it? By applying Six Sigma tools:CTQ Tree Hypothesis testing RegressionVOC Design of Experiments To reduce variation
  17. 17. Systems Analysis Framework… Six Sigma Daily Control Plan Statistical Process SIPOC Control Recognize Define Project Charter Simulation the problem Voice of the Customer Techniques exists Process Map Form Quality Continuous Improvement Improvement Teams Control Define the Ensure Problem Permanence Measure PDCA Develop Performance Measurement Plan Evaluate Measures FMEA Solution Ishikawa Diagram Statistical Process Control Select and Analyze Capacity Analysis Improve Implement problem/ Pareto Analysis Solution processLean Process Design DetermineFMEA Root Cause Correlation of KP variablesCorrelation Studies Analyze Confidence intervalsStatistical Process Control Hypothesis testingDesign of Experiments Regression analysisSimulation Techniques ANOVA
  18. 18. Outline Step 1: DEFINEGoal Cha ect rter Define the project’s j Pr o purpose and scope and get background on the process and customer 5 1Output CONTROL DEFINE A clear statement of the intended improvement and how it is to be 4 2 measured IMPROVE MEASURE A high level process map A list of what is important 3 to customer ANALYZE
  19. 19. Outline Step 2: MEASUREGoal Focus the improvement effort by gathering information on the 5 1 current situation CONTROL DEFINEOutput 4 2 Baseline data on IMPROVE MEASURE current process performance 3 Data that pinpoints ANALYZE problem location or occurrence A more focused problem statement
  20. 20. Outline Step 3: ANALYZEAsk What vital few process and 1 input variables affect CTQ 5 CONTROL DEFINE process performance or output measures?Goal 4 2 Develop theories of root IMPROVE MEASURE causes Confirm them with data 3 ANALYZEOutput DO A theory that has been Dat E aA tested and confirmed nal ysis
  21. 21. Outline Step 4: IMPROVEGoal Develop, try out, and implement 5 1 solutions that address CONTROL DEFINE root causes Soluti onsOutput FMEA 4 2 IMPROVE MEASURE Planned, tested actions that should t eliminate or reduce Pilo 3 the impact of the tio n ANALYZE ta en identified root causes plem Im
  22. 22. Outline Step 5: CONTROL Stan ControlGoal Do dard cum Use data to evaluate both ize M ent the solutions and the plans on Ev i to a lua r Maintain the gains by standardizing processes te Clos 5 1 ure Outline next steps for on- CONTROL DEFINE going improvement including opportunities for replicationOutput 4 2 IMPROVE MEASURE Before and After analysis Monitoring system 3 Completed documentation of ANALYZE results, learnings, and recommendations
  23. 23. Lean Six Sigma in Healthcare Combining the Stan Control Do dard Cha ect rter cu Quality of Six j Pro me ize OC M SIP nt on Ev ito a lua r Sigma with the te C VO Clos 5 ure 1 CONTROL DEFINE Process Speed of S o lu tio ns 2 4 Lean to drive FMEA t IMPROVE MEASURE Pilo 3 improvement and em en ta tio n ANALYZE pl achieve the best DO Im Da t E aA n alcompetitive position y s is
  24. 24. LSS ChallengesThis is not industry, we’re not Toyota,and we’re not making partsWe’re too busy to do thisHealthcare is very much silo driven
  25. 25. Toast Kaizen VideoBruce HamiltonGMBP
  26. 26. 7 Kinds of wasteInventory - unneeded stock or suppliesMotion - movement of staff and informationOverproduction - unnecessary testsOverprocessing - filling out extra paperworkTransportation -movement of patients or equipmentRework/Correction - paperwork, med errorsWaiting - delays in diagnosis and treatment
  27. 27. Lean Six SigmaProject Examples
  28. 28. CT and 7 Kinds of WasteInventory Overprocessing Set up tray for unneeded Paperwork procedures Films vs. disk Expired IR stock Multiple systems - RIS, PACS,etc Wasted contrast TransportationMotion Patients Transporting patients Ordering syringes and having extra boxes to Walking between procedure room store and control room Taking oral contrast to the floor Getting onto computer IV lockOverproduction Rework/Correction Supplies/tray Duplicate work Protocols Phone calls to communicate with Making contrast and Patient departments or units consumption of contrast Waiting On Toshiba scanner Waiting on ED patients to be ready On oral contrast
  29. 29. 5S Workplace Organization Before 5S Needed Not Needed Create Visual Workplace - S2: Set In Order (Seiton) - S3: Shine (Seiso) S1: Sort - S4: Simplify & standardize (Red Tagged) (Seiri) (Sieketsu) After 5S Remove from Workplace Discard after a defined time -S5: Sustain (Shitsuke)A place for everything and everything in its place
  30. 30. 3PCW Nurses station before 5S
  31. 31. Sort and Set in Order
  32. 32. Shine (Clean)
  33. 33. After - Sustain
  34. 34. Storeroom before & after color codingBefore After
  35. 35. Rehab Standard Room LayoutStandardized room layout willaid staff as they care forpatients and reduce roomturnaround time
  36. 36. Door to Balloon RIE
  37. 37. Project Example – Door to Balloon DefineProject goals: Achieve Door to TIMI 3 perfusion time of less than 90 minutes for all patientsProject scope: Start – Patient arrival at St. Elizabeth Stop – Establishment of TIMI 3 Flow Includes – ST elevated, non-transferred, primary PCI Excludes – All other cases
  38. 38. Project Example – Door to Balloon Measure Door to Balloon Time - St. Elizabeth Campus 3rd Qtr. 2006 - 1st Qtr. 2007 Door to Balloon time 250 Goal of 90 min. Average time of 112 min 200 AMI Process Flowchart 150 Patient EMS Emergency Cardiology or Cath LabMinutes Patient seeks medical attention Department Interventional Recognition patient having MI 100 2125 1713 Get 12-lead, IV, O2 Not utilizing 2300 Call MD and notify pre-hospital EKG Transport patient to ED Obtaining ECC EKG 50 Report-off to RN and MD and contact Registration Additional IV’s, get 15-lead EKG 1722 2125 9 0 Who gets the pt. Start Chart Who calls the info to registration Interventionalist Start meds & Call Cardiologist Who gets the labs on-call drawn and to Lab 0 Additional meds awaiting direction from Cardiologist 7/1/2006 8/1/2006 9/1/2006 10/1/2006 11/1/2006 12/1/2006 1/1/2007 2/1/2007 3/1/2007 4/1/2007 Variation of Cardiologist See patient in ECC or Cath Lab Date meds and x-ray Informed consent by Card. or sign/consented by RN Consent Give consent to get Cath Lab called Supervisor or Cath Lab called Who calls the Cath Lab Cath Lab confirms receiving the page/call Cath Lab calls when arrives RN gets patient ready for Standardization in transport Cath Lab supplies Cath Lab sets up and setup Cath Lab calls when ready - 2158 Cath Lab calls when ready & transport 33 talks to RN Patient arrives in Cath Lab Take patient stickers 1828 2202 to the Cath Lab 75 0014 38 Patient arrives in Cath Lab Pt. transported to bed and prepped 74 for procedure Pt. transported to bed and prepped Interventionalist meets with patient 0034 for procedure 94 Cath placed by MD 2215 50 Pictures taken Stent/balloon placed 2236 0911 MR# MR# MR# 0149 285366 060228 725868 72 118 169
  39. 39. Door to Balloon Project Analyze Phase Door to Balloon Time by Day of Week 250 225 222 224 200 175 150Minutes 125 104 105 100 Goal 90 minutes Door to Balloon Time by Time of Day 75 56 55 250 50 225 222 224 25 215 200 0 Fri-Sat-Sun Mon-Thu 175 Day of Week 150 Minutes 95 125 112 Day of Week Friday-Sunday 100 92.5 Goal 90 minutes 95 250 75 72 55 50 225 222 25 200 0 Midnight-0700 0700-1600 1600-Midnight 175 178 172 Time of DayMinutes 150 139 125 123 105 100 Goal 90 minutes 82 75 72 56 50 Midnight-0700 0700-1600 1600-Midnight Time of Day
  40. 40. Project Example – Door to Balloon AnalyzeThe D2B Alliance has developed six strategies to reduce door-to-balloon times:1. Have attending Interventional Cardiologist always on-site2. Have ED and Cath Lab staff use real-time data feedback3. Have ED activate the Cath Lab while the patient is still en route to the hospital4. Cath Lab team arrive and be ready to start procedure in 20 minutes5. ER medicine Physician activates the Cath Lab6. A single call to a central page operator activates the Cath Lab and Interventional Cardiologist
  41. 41. Strategy 2: Have ED and Cath Lab staff use real-time data feedbackBenefit 8.6 minutes faster door-to-balloon timeWhat it will take to implement Modify Chest pain and Quality records Copy of the completed form to the Cath Lab DirectorBarriers to implementation Staff education Compliance Trust and teamwork between all staff Legibility of information on the form
  42. 42. Project Example – Door to Balloon STEMI Flowchart Improve12-lead from Ambulancei-Stat testPaging systemRevised P & PStaff trainingED treatment plan
  43. 43. Project Example – Door to Balloon Control Door to Balloon Time - St. Elizabeth Campus July 2006 - February 2008 150 Door to Balloon time Goal of 90 min. 132 125 125 123 119 118 110 110Minutes 109 108 100 102 101 103 97 96 84 87 75 75 78 78 73 50 RIE Conducted 25 0 November November September September December December February February January January August August October October March June July July May April (7) (8) (9) (7) (3) (5) (5) (1) (8) (3) (3) (7) (7) (4) (4) (6) (5) (8) (3) (5) 2006 2007 2008 Month * number in brackets indicates the number of cases for that month
  44. 44. Surgery room changeover reduction
  45. 45. Home Hospital ED Patient Triage & Registration
  46. 46. Lean Six Sigma-Lab Specimen Labeling Process Flowchart Failure Mode and Effects Analysis Process Step Potential Effect(s) Recommended Responsibility & SEV OCC DET RPN SEV OCC DET RPN Patient arrives via Patient arrives via other Ambulance method Solution(s) Target Date Start Start Potential Failure Modes N. Collect specimen A Start IV with cath Assess patient M N.1Missing Specimen Delay in testing 3 3 1 9 0 Redraw specimen 6 3 1 18 0 Pt. dissatisfaction 8 3 1 24 0 Use syringe to No test results 8 3 1 24 0 B Collect specimen N draw blood N.2 Submitted unlabeled Delay in testing 3 6 1 18 0 Redraw specimen 6 6 1 36 0 Put needle on Manually label C syringe specimen on bag O No test results 8 6 3 144 0 Consuming resources/lab 6 6 1 36 0 Put specimen in Pt. dissatisfaction 8 3 1 24 0 D Blood in tubes P N.3 Submitted mislabeled Delay in testing 6 6 8 288 0 basket Redraw specimen 8 6 8 384 0 Receive Doctors Consuming resources/lab 8 6 8 384 0 E Put tubes in bag Q order Pt. dissatisfaction 8 3 1 24 0 Wrong results on wrong pt. 10 6 8 480 0 Write pt name, WS enter order R O. Manually label specimen on bag/specimen F date, & time, and into computer initial on the bag S O.1 Wrong name Results would be wrong for 8 3 6 144 0 T that patient Labels printed or Put blood with L100 used Collect specimen Confused with another patient 8 3 6 144 0 G patient Delay in testing 8 3 1 24 0 WS places labels U O.2 Misspelled name Delay in testing 8 3 1 24 0 H Take patient to ER on chart 0 0 0 0 0 Nurse places label O.3 Step omitted Wrong patient name 8 3 6 144 0 Transfer patient to V I on specimen Patient having to be redrawn 3 3 1 9 0 bed Sample sent to lab unlabeled 8 3 1 24 0 Specimen goes If unidentified into bag with extra W Delay in testing 8 3 1 24 0 J patient - write bed labels O.4 Illegible handwriting Patient having to be redrawn 3 3 1 9 0 number on bag Wrong patient name 8 3 6 144 0 Nurse/Tech tubes Delay in testing 8 3 1 24 0 X (SE) (HH) Put blood in specimen to labK Put blood into central L collection basket O.5 Missing some information Patient having to be redrawn 3 3 1 9 0 blood basket with bed like name, time, etc. End Wrong patient name 8 3 6 144 0 Delay in testing 8 3 1 24 0
  47. 47. Lean Six Sigma in Healthcare
  48. 48. What is a Lean Hospital? Housekeeping ED Lab Physicians Food Service Pharmacy Surgery Cath LabRadiology Nursing Units L&D Staff It all works together without waste HIM Materials Management
  49. 49. Lean Hospital – More specificallyWorking to eliminate waste through: Goals and measures leading to accountability and driving improvement Areas organized and arranged Trained and empowered staff Smooth and consistent processes working in unison Problem solving and proactive failure mode analysis Working to promote the value stream (service line) instead of silos Getting everyone involved
  50. 50. Application of Lean Six SigmaCan be used with: Dashboard or Scorecard metrics Quality measures Departmental operation Financial measuresLeading to: Improved patient care, safety, and satisfaction Improved quality Increased revenue and reimbursement Better employee satisfaction Improved capacity for patient flow
  51. 51. Additional Information on LSSwww.isixsigma.comAmerican Society for Quality ( What is Lean Six Sigma? George, Rowlands, and Kastle The Six Sigma Way Fieldbook Pande, Newman, & CavanaghLean Six Sigma hospital systems: Virginia Mason – Seattle, WA ThedaCare – Appleton, WIIUPUI – Laboratory for Enterprise ExcellenceToast Kaizen video, Bruce Hamilton, GBMP