At the University of Utah, we use a general value improvement methodology based on Lean and Six Sigma with the following phases: Project Definition, Baseline Analysis, Investigation, Design, Implement, Monitor. Problem-solving runs into challenges when an immediate solution is implemented as a reaction to the problem. Following a proven, structured, and balanced improvement methodology forces reflection on a problem.

1. Methodology

2. Methodologies: Lean / Six Sigma / PDSA
Create
Flow
Improve
Quality*
Eliminate
Waste
Lean
6s
D M A I C
PDSA PLAN
DO
ACT
STUDY

3. Lean: The Toyota Production System Decoded
Each of these can be achieved alone or in conjunction with the other two.
*poor quality is a form of waste.
Create
Flow
Improve
Quality
Eliminate
Waste “It’s not the big that eat the
small. It’s the fast that eats
the slow.”
– Jennings and Haughton

4. • Map your Value Streams
• Identify Value vs. Waste
• Value is defined by our patient
Lean Value Principles
Value =
Quality + Service
Cost

5. Healthcare Quality Cost Curve
As HC Quality Increases Costs Decrease
Cost
Quality
A
B
• Spending too much on healthcare doesn’t
just waste money. It lowers quality.
• GOOD NEWS: When we focus on quality,
costs come down.
Optimal Value
US Healthcare Today
Focus on Value

6. Value Stream: Every activity required to
deliver your product or service, from very first
to very last.
DIRT $$
FIRST
CONTACT
$$

7. Value Stream:
Applying Lean to
healthcare value
streams means
making it easier for
patients and their
information to
move between our
silos.

8. Patients come to us for two reasons:
1. Information about their health
2. Care provision
Identify Value & Eliminate Waste
Manufacturing Value-Added:
An activity which changes the form,
fit, or function of the product.
Everything else is non-value added
(NVA).
Healthcare Value-Added:
An activity that builds on a patient's
information or is directly involved in
care provision. Everything else is
non-value added (NVA).
“Okay, but where is all this waste? I don’t see it.”

9. Non Value Added: The 7 Wastes
NVA ≠ “UNNECESSARY”
A taxonomy for seeing NVA
1.Defects / Mistakes
2.Waiting
3.Over-processing
4.Over-production
5.Transportation
6.Inventory
7.Motion
-Taiichi Ohno
“Eliminating waste
is easy. Seeing
waste is hard.”

10. How much waste is in our system?

11. Old Adage  Lean Adage
Create
Flow
Improve
Quality
Eliminate
wasteBefore Lean:
• You can have it fast.
• You can have it high quality.
• You can have it low cost.
Pick 2.
Lean says, “Pick 3.”

12. • Map your Value Streams
• Identify Value vs. Waste
• Value is defined by our patient
• Eliminate delays
• Create Standard Work
• Design Error-Proof Systems
• Use pull to avoid over-production
• Design Out the Complexity you can…
• Use Visual Controls to manage the
remaining complexity
• Track process performance
Lean Principles

13. 6s
Define
Measure
Analyze
Improve
Control

14. Taguchi
Shewhart
Deming
Juran
Ishikawa
Six Sigma in Nothing New

15. • Variation is the Enemy
• The answers are in your data
• Listen to the Voice of the Process
• For consistent output, control your inputs
• Listen to the Voice of the Customer
• Your problems are in your processes,
NOT your people
Six Sigma Principles

16. Mean
Process Improvement with Six Sigma
Step 1: Control Step 2: Shift
Before
TargetLower
Spec
Upper
Spec
Target,Lower
Spec
Upper
Spec
TargetMeanLower
Spec
Upper
Spec Mean

17. Six Sigma follows a methodology called
DMAIC (“duh-MAY-ick”).
Define • Define the project with a chartering document.
• Map the process in low-detail, maybe with SIPOC.
• Gather VOC (Voice Of the Customer) data.
Measure • Quantitatively describe the current situation.
• Identify the appropriate process metrics and establish a baseline.
You will compare these against post-implementation metrics.
• Map the process in greater detail.
Analyze • Determine the root causes with a variety of methods.
• Most of your statistical analysis happens here.
• Tie the root causes to the problems you are solving.
Improve • Design improvements
• Model improvements
• Pilot improvements
• Estimate post-implementation process metrics
Control • Design control systems to ensure gains are sustained.
• Establish metrics collection systems.
• Design elements that reduce the cognitive load while ensuring the
new process is followed: visual cues, electronic cues, etc.
• Transfer ownership back to original process owner.

18. DMAIC is sometimes shown as a cycle, sometimes as a
linear project progression.
Improve
Control
Define Measure
Analyze
Six Sigma Project Plan (aka “best intentions”)
Define
Measure
Analyze
Improve
Control
X weeks
What actually happens.
Defi
Meas
Analy
Imp
Control
Define
Measure
Analysis
Re-Define
Improve
X + 50% weeks

19. Plan-Do-Study-Act
When a change is deemed worthy of implementing:
• The team turns toward spreading and adapting the
change to all appropriate places in the
organization.
• Continued monitoring.
• The scientific method applied to
process improvement
• What are we trying to improve?
• What are the baseline measures?
• What are the goals?
• Who are the right people to evaluate
the improvement?
PLAN
DO
ACT
STUDY

20. •Orderly
•Controlled
•Time-consuming
•Expensive • Rapid implementation,
multiple iteration
• In this sense, you are
experimenting, but…
• If you shortchange the
methodology, you’re NOT
engaged in continuous quality
improvement; you’re chasing
hunches.
• Throw things against the
wall to see what sticks
• Go with your gut
• Rely on common sense
(a myth)
PDSA:
Clinical
Research
Shotgun
Approach
P
D
A
S

21. • Needs to be tolerance for not getting it perfect
on the first try
• This is how innovation works
• But remember that “change fatigue”
is a threat.
• This image does not
mean constant
tinkering.
Potential Issues with PDSA
PLAN
DO
ACT
STUDY
PLAN
DO
ACT
STUDY
PLAN
DO
ACT
STUDY
PLAN
DO
ACT
STUDY

22. Value improvement methodology at UUHC
1. Project Definition
2. Baseline Analysis
3. Investigation
4. Improvement Design
5. Improvement Implementation
6. Monitoring
Lean 6s PDSA

23. Project Life Cycles
Project Progress
ResourcesRequired&
BusinessDisruption
Project
Def.
Baseline
Analysis
Investigation
Improvement
Design
Improvement
Implementation
Monitoring
Define Measure
Analyze Improve
Control
6s
PDSA
MonitoringPLAN DO STUDY ACT

24. • A process of incremental resource allocation.
• At the end of every phase progress is reviewed.
• A stop/redirect/continue business decision is made.
Project Gating: Incremental Project Approval
ResourcesRequired&
BusinessDisruption
Project
Def.
Baseline
Analysis
Investigation
Improvement
Design
Improvement
Implementation
Monitoring

25. Bottom Line Benefit
EffortandComplexity
Project Selection: Align with strategic priorities
and go for the green.