Ricardo Leaño is a physician, anesthesiologist, and healthcare executive with extensive leadership training and certifications in business administration, quality improvement, and Lean Six Sigma. He advocates applying Lean and Six Sigma principles through the H.O.R.S.E. framework to empower healthcare organizations, reduce waste, and improve processes, patient outcomes, and financial sustainability. The presentation emphasizes eliminating variation through data-driven problem solving and focusing on continuous process improvement.

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2. Ricardo Leaño, MD, MBA, CSSBB2Physician. Board Certified Anesthesiologist

3. Master of Business Administration. Specialization in Health Administration and Policy. University Of Miami.

4. Leading Teams and Organizations, Effective Leadership, Executive Leadership Strategies. University of Notre Dame. Mendoza College of Business

5. American Society for Quality (ASQ) Certified Six Sigma Black Belt.

6. Co-Chair Educational Committee ASQ-HCD

7. American College of Healthcare Executives-ACHERicardo Leaño, MD, MBA, CSSBB3Clinical

8. Managerial

9. Leadership

10. Quality4“It is not the strongest that survive,nor the most intelligent,but the one most responsive to change” Charles Darwin (1809-82)

11. Why you are here5"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe] is right.“Jane GoodallInformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009

12. HealthcareorganizationsSix SigmaEmpowerment. H.O.R.S.E. LEANRicardo Leaño, MD, MBA, CSSBB6

13. 7Healthcare

14. ORganizations

15. Six sigma

16. EmpowermentH.O.R.S.E. Leanhorse [v. to haul or hoist energetically] Webster’s II New Riverside University Dictionary

17. H.O.R.S.E. Concept8The H.O.R.S.E. principles greatly emphasize leadership and strategic management together with Lean Six Sigma methodologies so as to hoist energetically our healthcare system in the right direction.

18. H.O.R.S.E. Concept9Every internal organization must understand how and why other individuals/organizations work, how and why they make decisions and unite them to keep the mission, vision and goals of their institution as part of their own missions, visions and goals. 10

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20. Lean, Six Sigma and Lean Six Sigma12Jing, G.G. “A Lean Six Sigma Breakthrough”Quality Progress. May 2009Lean:Improvement approach aimed at improving efficiency by removing wastesSix Sigma:Improvement approach aimed at improving process capability by reducing variationLean Six Sigma:Improvement approach aimed at combining both Lean and Six Sigma to improve efficiency and capability primarily by removing wastes and variation

21. primum non attero [first do no waste]primum non nocereFirst do no harmsecundus non atteroSecond do no waste13

22. ISO 26000 Defines Social Responsibility14“responsibility of an organization for the impacts of its decisions and activities on society and the environment, through transparent and ethical behavior that contributes to sustainable development, health and the welfare of society; takes into account the expectations of stakeholders; is in compliance with applicable law and consistent with international norms of behavior; and is integrated throughout the organization and practiced in its relationships”Vincent, C. “Back in Circulation”Quality Progress. May 2009

23. …in healthcare…15wasted

24. Margin16Revenue = Outputs x Prices Expenses = Inputs x Costs Profitability=ProductivityxPrice Recovery

25. MarginMargin Compression ↑Revenue = Outputs x Prices Expenses = Inputs x Costs ↑ ↑Margin Looseness↑↑ ↔ ↑Revenue = Outputs x Prices Expenses = Inputs x Costs ↓ ↓ ↓Profitability=ProductivityxPrice Recovery↑ ↑ ↑17

26. Budget18Profit is determined by revenue and expenditures

27. Financial position is determined by profit and capital expenditure

28. These are determined by

29. Market share

30. Price

31. Customer satisfaction

32. Quality

33. Worker satisfaction Griffith J, White K “The Well-Managed Healthcare Organization”. 6th Edition

34. DRA (Deficit Reduction Act of 2005)19Beginning October 1, 2008, Medicare will no longer pay the higher MS-DRG for these HACs (Hospital Acquired Conditions) pressure ulcer stages III and IV;

35. falls and trauma;

36. surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery

37. vascular-catheter associated infection;

38. catheter-associated urinary tract infection;

39. administration of incompatible blood;

40. air embolism; and

41. foreign object unintentionally retained after surgery. To err is human20“medical errors do not result from … a ‘bad apple’ problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. “I N S T I T U T E OF M E D I C I N E November 1999

42. Institute of Medicine21Six Aims for ImprovementSafety – Avoiding injuriesEffectiveness – Services based on scientific knowledgeEfficiency – Avoiding wastePatient-centered care – Care that is respectful of and responsive to individual patient preferences, needs and valuesTimeliness – Reducing waits and harmful delaysEquitable care – Equal care to all regardless of gender, ethnicity, location and socioeconomic status Institute of MedicineCrossing the Quality Chasm:A New Health System for the 21st Century

43. Healthy People 2010 goals…22“…safe, effective, patient-centered, timely, efficient, and equitable care that extends the quality [and length] of life and reduce health disparities”Griffith, J.R., White, K.R.“The Well-Managed Healthcare Organization” 6th ed. Health Administration Press

44. Concepts23Sigma (). Standard deviation. Provides an estimate of the variation in a set of measured data

45. Sigma level. Describe the performance of a process relative to the specification limits.

46. Process: Sequence of activities that transform inputs into Outputs

47. Quality: “Is a predictable degree of uniformity and dependability, at low cost and suited to the market”Deming, W.E.Defect: Failure to meet customer requirementsSigma24Wide VariationNarrow Variation

48. Sigma Level25Performance of a process relative to the specification limits

49. International Survey Supported by the Commonwealth Fund 200726One in three of U.S. respondents reported experiencing medical mistakes, medical errors, inaccurate or delayed lab results.

50. Highest rate of any of the six countries in the survey.

51. U.S. 32%

52. Canada 28%

53. Australia 26%

54. New Zealand 22%

55. Germany 16%

56. U.K. 24%

57. Most patients (61% - 83%) in each country said health care providers did not tell them about the errors.(Schoen, et. al. Health Affairs, Web Exclusive; W5-509-W5-525)

58. Process. Y = f(x) 27Everything is a Process“A systematic series of actions directed to the achievement of a goal” J.M. JuranMethod(x)Man(x)Material(x)PROCESSING(f)Output(Y)Machine(x)Environment(x)

59. Lean Six Sigma28Blame the processnot the individual

60. To err is human29“medical errors do not result from … a ‘bad apple’ problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. “I N S T I T U T E OF M E D I C I N E November 1999

61. Quality Definitions30“…a predictable degree of uniformity and dependability, at a low cost and suited to the market” W.E. Deming

62. “…any characteristic that improves the product or service in the eyes of the buyer.” J. Griffith, K. White

63. Hard to define, but you recognize it when you see it ACHE Congress 2008

64. “The least cost to Society” Genichi TaguchiLean Six Sigma Definitions31“A comprehensive and flexible system for achieving, sustaining and maximizing business success”MoreSteam University“…relentless and rigorous pursuit of the reduction of variation in all critical process … that impact the bottom line … and increase customer satisfaction”H. Gitlow. University of Miami“a disciplined, data-driven approach and methodology for eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process”iSixSigma.comAn objective journey toward process improvementRicardo Leaño

65. Lean Six Sigma32Structured methodologies for sustained process improvement

66. Both are complementary processes, not competitive approaches

67. Both represent a cautious compilation of previously developed quality tools and a framework for action with the particular and common objective of improving quality by performing relative to customer requirements and eliminating waste.How they work33Identify and eliminatenon value-added activities

68. Identify and reducevariation

69. Understand and optimize processes by focusing on inputsDMAIC34Define

70. Measure

71. Analyze

72. Improve

73. ControlDefine (DMAIC)35Dashboard - Scorecard

74. Project charter (Business Plan)

75. SMART project (specific, measurable, achievable, relevant, time bound)

76. SIPOC analysis

77. Process Flow Chart

78. Voice of the Customer (VoC) analysisAffinity DiagramOperational Definitions

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81. 38Charge RN sends for next patient (Surgery)Pt leaves the ORMSA leaves OR to pick up the patient (Surgery)OR tech removes instrumentsMSAs clean the roomPgt arrives to holding area (Floor or Same day Surgery)Bring new instruments to the roomHolding RN verify check list (Green Check List)Anesthesiologist OKs patient (Consent)X-Ray tech neededGet X-Ray techSurgeon sign consents and mark siteOR RN goes to Holding to verify if next pt is readyPatient in to the OR

82. Voice of the Customer – Affinity TestSurgeons (12)Anesthesia (4) MSAs (10)Lack of paper work readiness/Site not Marked. They are responsible for two different task (cleaning room and transportation)Lack of Pre-op evaluation on timeLack of adherence to original schedule.Short staff (3 MSA for 6 ORs)CTQ TAT (Door to Door)Delay in the tech availability Supply not stocked properly Lack of communication among OR RNs with floor RNs and ResidentsInsufficient C-arms Washer machine broken frequently Shortage of RNsRadiology (6)Instruments (8)Nurses (8)

83. Measure (DMAIC)40“If you can’t measure it, you can’t improve it”“Not everything that can be counted counts and not everything that counts can be counted”Albert Einstein

84. Measurement System Analysis41Identify what to measure

85. Determine how to measure

86. Develop sampling plan and reaction plan

87. Validate measurement system (Gage R & R)

88. Add to overall control planSPC charts42

89. Analyze (DMAIC)43Identify and understand causal relationshipsCharacterize the process (current state)

90. Fishbone, Box plots, Regression Analysis,

91. Validate the suspects and compare treatments (which action is more effective)

92. Hypothesis testing. Z-test, t-test, ANOVA, chi squared

93. Model the process (understand relationships, how X impact Y)

94. DOE (Design Of Experiments)Pareto Chart44

96. Improve (DMAIC)46Benchmarking

97. Brainstorming

98. FMEA (Failure, Mode, Effect, Analysis)

99. Poka-yoke (Error-Proofing)

100. Continuous flow

101. Quick changeovers

102. Theory of constrains

103. Pull scheduling/JIT (Just In Time)

104. Correction action matrix

105. Pilot a solution47

106. Improve - Benchmarking48Process of developing higher performance standards for your process based on a comparison to other processes, internal within your organization or external from competitors with better performance (most common)Industry publications & trade journals

107. Industry related meetings

108. Public financial reports

109. Third party studies

110. Company publications/ facility visitsImprove - Brainstorming49Brainstorming is a technique used to elicit a large number of ideas from a team using its collective thinking power”Gitlow, HS “Six Sigma for Green Belts and Champions”The foundation of brainstorming is an atmosphere of suspended judgment (no criticism) so that a large number of ideas freely flow from the participants.

111. Brainstorming is intended to encourage fresh thinking and ‘crazy’ ideasMoresteam.com/university

112. Improve - FMEA50Failure Mode Effect Analysis is a tool used to prioritize potential defects based on their severity, expected frequency, and likelihood of detection

113. Scores are assigned to each potential defect mode of a process in 3 categories: Severity, Occurrence, Detection

114. Scores will lead to a Risk Priority Number (RPN)

115. The highest RPN would be the highest priority for improvementImprove – F.M.E.A.51

116. Improve – Poka-yoke52Error-proofing or mistake proofing refers to the implementation of fail-safe mechanisms to prevent a process from producing defects

117. The philosophy: It is not acceptable to make even a very small number of defects, and the only way to achieve this goal is to prevent them from happening in the first place

118. FMEA, fishbone and brainstorming are used to organize effortsImprove – Quick Changeovers (SMORE) 53Single Minute Operating Room Exchange. From Shigeo Shingo’s SMED (Single Minute Exchange of Die)

119. The foundation is the distinction between Internal Setup (work that occurs when the system is idle) and External Setup (work that occurs while the system is running)moresteam.com/university

120. Improve – Quick Changeovers (SMORE)54Staged equipment (preference cards)

121. Operations conducted in parallel (emergence–bags out)

122. Standardization (same tools, stretchers, 5S)

123. Quick attachments (laparoscopic equipment)

124. No-Adjust equipment and tooling

125. Duplicate equipment and tooling (double instruments)

126. Assisted tool movement (for cleaning, equipment, patient, etc)moresteam.com/university

127. Improve – Continuous Flow55In many ways, the term Continuous Flow defines Lean Methods by improving the movement of material or information through a process

128. It means a service progresses through a series of value-added steps without delays (inventory), rework (defects) or non-value added operations

129. Reducing cycle time requires achieving a more continuous flow to match the pace of demand with the pace of productionFlow in a Healthcare EnvironmentFlow of patients

130. Flow of clinicians

131. Flow of medication

132. Flow of supplies

133. Flow of information

134. Flow of equipment

135. Flow of process engineering

136. [Flow of housekeeping]Black, J with Miller DThe Toyota Way to Healthcare ExcellenceACHE Management Series. 200856

137. Control (DMAIC)57The goals of the Control phase are

138. 1. Sustain the improvement

139. SPC

140. 5S [Sort, Set in order, Shine, Standardize, Sustain]

141. Total Productive Maintenance (TPM). Goal: Drive waste to zero

142. 2. Sharing the knowledge

143. Best practices & Lessons learned

144. Project Close-Out

145. Maintain LEAN education and LEAN ambiance Waste (Muda) - TaiichiOhno58Overproduction

146. Defects

147. Inventory

148. Motion primum non attero

149. Overprocessing

150. Transport

151. Waiting

152. [Underuse of talent]Black, J with Miller DThe Toyota Way to Healthcare ExcellenceACHE Management Series. 2008

153. primum non attero [first do no waste]primum non nocereFirst do no harmsecundus non atteroSecond do no waste59

154. 5 S60Sort (seiri): Sort out necessary from unnecessary items

155. Set in Order (seiton): Necessary items should be easily accessible

156. Shine (seiso): Dispose of unnecessary item

157. Standardize (seiketsu)

158. Sustain (shitsuke)The most essential tool61The least common of the senses..the Common Sense

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160. Barriers to Lean 663Lack of knowledge

161. Fearfulness of statistics

162. Lack of unification of information . ASQ

163. Stubborn

164. Fear of physicians desertionChange64Three types of Knowledge

165. Awareness knowledge. Information that innovation exist

166. How-to knowledge. Information to use it properly

167. Principles knowledge. Information dealing with the principles underlying how the innovation works

168. Equilibrium

169. Stable equilibrium. Status Quo

170. Dynamic Equilibrium. The rate of change occurs at a rate that is equal with the system’s ability to cope with it

171. Disequilibrium. The rate of change is too rapid to permit the system to adjustRogers, E. M. Diffusion of Innovations. 5th Edition

172. To Remember65Everything is a process

173. If you can’t measure it, you can’t improve it

174. Use data instead of ‘paper, scissors, rock’

175. Software will help with statistics

176. Maintain Lean ambience and education

177. primum non attero - First do no Waste

178. Be Socially Responsible

179. Start a dialogueWhy you are here66"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe] is right.“Jane GoodallInformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009

180. Be clear67TEACHER: Maria, go to the map and find America MARIA: Here it is. TEACHER: Correct. Class, who discovered America? CLASS: Maria. &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&TEACHER: What is the chemical formula for water? DONALD: H I J K L M N O. TEACHER: What are you talking about? DONALD: Yesterday you said it's H to O. 68ralmdmba@yahoo.com Thank You!

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