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9/20/2012

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IHI Expedition:Integrating Improvement Approaches

Robert Lloyd, PhD

Jill Duncan, RN, MS, MPH

Tuesday, September 25, 2012

These presenters have nothing to disclose

Today’s Host

Kayla DeVincentis, Project Coordinator, has worked at IHI since 2009, starting as an intern in the Event Planning department. Since then, Kayla has contributed to the STAAR Initiative, the IHI Summer Immersion Program, and the IHI Expeditions. Kayla obtained her Bachelor’s in Health Science from Northeastern University and brings her interest in health and wellness to IHI’s Health and Fitness team.

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What is YOUR goal

for participating in this Expedition?

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Join Passport to:

• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements.

• Train your middle managers to effectively lead quality improvement initiatives.

. . . and much, much more for $5,000 per year!

• Visit www.IHI.org/passport for details.

• To enroll, call 617-301-4800 or email [email protected].

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What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some specific purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

Expedition Support

• All sessions are recorded

• Materials are sent one day in advance

• Listserv address for session communications: [email protected]

─To add colleagues, email us at [email protected]

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Where are you joining from?

Expedition Director

Jill Duncan, RN, MS, MPH, Director, Institute for Healthcare Improvement (IHI), is responsible for leading the strategic planning and daily operations for IHI’s Impacting Cost + Quality initiative as well as serving as faculty for IHI’s Leading Quality Improvement: Essentials for Managers. Jill is also the Director for a variety of new IHI Expedition programs in 2012-13. With nearly 20 years of clinical nursing experience, Jill draws from her learning as a Clinical Nurse Specialist, pediatric nurse educator and front line nurse. Her clinical interests have developed through experiences in a variety of settings including Neonatal ICU, pediatric ER, clinical research and Early Head Start health programming. Ms. Duncan has contributed to a variety of collaborative publications in The Journal of Pediatrics and she is co-author of Pediatric High-Alert Medications: Evidence-Based Safe Practices for Nursing Professionalsand Stressed Out About Your Nursing Career.

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Agenda

• Welcome

• Expedition overview

• Building an Integrated Approach to Improvement with Lean, Six Sigma and the Model for Improvement

─ Robert Lloyd, PhD, Executive Director , IHI

• Resources

• Next steps

Ground Rules

We learn from one another – “All teach, all learn”

Why reinvent the wheel? - Steal shamelessly

This is a transparent learning environment

All ideas/feedback are welcome and encouraged!

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Expedition Aim

Introduce participants to various improvement methodologies and guide

participants in building an integrated quality improvement strategy for their unit,

department or organization

Expedition ObjectivesParticipants will be able to . . .

• Describe the similarities and differences among Lean, Six Sigma (which includes DMAIC) and the Model for Improvement.

• Determine which approach(es) are most appropriate for their organization.

• Initiate a plan to build an integrated quality improvement strategy.

• Define a customized approach for crafting projects and hardwiring discipline into improvement processes across participant’s organization.

• Plan small tests of change they can test throughout the Expedition.

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Today’s Faculty

Robert Lloyd, Executive Director of Performance Improvement, Institute for Healthcare Improvement, provides leadership in the areas of performance improvement strategies, statistical process control methods, development of strategic dashboards, and quality improvement training. He also serves as faculty for various IHI initiatives and demonstration projects in the US and abroad. Before joining IHI, Dr. Lloyd served as the Corporate Director of Quality Resource Services for Advocate Health Care, Director of Quality Measurement for Lutheran General Health System, and spent ten years with the Hospital Association of Pennsylvania in various leadership roles. He is author of numerous articles, reports, and books.

© 2011 Institute for Healthcare Improvement

Building an Integrated Approach to Improvement with Lean, Six Sigma and

the Model for Improvement

Robert Lloyd, Ph.D.

Tuesday 25 September 2012

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Discussion Topics

• The foundation for improvement

• Compare and contrast Lean, Six Sigma and the Model for Improvement

• Case Studies on integrating various models

• Assessing where you are in the journey


One approach will not necessarily solve all your challenges!

Oh no…you mean I’m

going to have to think?

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Self Assessment Questions

What improvement methodology(s) are you currently using?

Are you happy with your results?

Go to Poll

© 2011 Institute for Healthcare Improvement20

Theoretical

Concepts

(ideas & hypotheses)

Interpretation

of the Results

(asking why?)

Information

for Decision

Making

Data

Analysis and

Output

Select &

Define

Indicators

Data

Collection (plans & methods)

Deductive Phase

(general to specific)

Inductive Phase

(specific to general)

Source: R. Lloyd Quality Health Care, 2004, p. 153.

Theory

and Prediction

The Scientific Method provides the foundation for all improvement

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Source: Moen, R. and Norman, C. “Circling Back: Clearing up myths about the Deming cycle and seeing how it keeps evolving,” Quality Progress November, 2010:22-28.

Understanding the Timeline is Critical


Adapted from R. Scoville, Ph.D., IHI Improvement Advisor

19th century Pragmatism played a major role in building knowledge for improvement

• Darwinian notions of variation, population, and selection infiltrated a wide range of disciplines:

• Epistemology – C.S. Pierce

• Psychology – William James, Edward Thorndike

• Sociology and education – George Mead, John Dewey

• Development – J.Baldwin, J.Piaget

• Law – Oliver Wendell Holmes

• Philosophy – B. Russell, K. Popper, L. Wittgenstein

• Some key notions

• Belief is observable only through action

• Action is inherently a ‘bet’ on its results

• Routinely successful action = ‘habit’ = ‘knowledge’

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Charles S. Peirce (1839–1914) The founder of American pragmatism. He wrote on a wide range of topics, from mathematics, to logic, semiotics and psychology.

William James (1842–1910) An influential psychologist and theorist of religion, as well as philosopher and a physician. First to be widely associated with the term "pragmatism" due mainly to Charles Peirce’s difficult personality.

“As a rule we disbelieve all the facts and theories for which we have no use.”

William James

Classical Pragmatists (1850-1950)


C. I. Lewis (1883-1964)Perhaps the most important American academic philosopher active in the 1930s and 1940s. He was the founder of conceptual pragmatism and made major contributions in epistemology and logic, and, to a lesser degree, ethics. Lewis was also a key figure in the rise of analytic philosophy in the US. He also had a profound impact on Walter Shewhart and subsequently Edwards Deming. His classic book, Mind and the

World Order, served as a foundation for the work of Walter Shewhart and Edwards Deming.

John Dewey (1859–1952)Prominent philosopher of education, referred to his brand of pragmatism as “instrumentalism. “

Classical Pragmatists (1850-1950)

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Source: Moen, R. and Norman, C. “Circling Back: Clearing up myths about the Deming cycle and seeing how it keeps evolving,” Quality Progress November, 2010:22-28.

Understanding the Timeline is Critical

©Copyright 2009 IHI

1939

The Deming Wheel1. Design the product (with appropriate tests).2. Make it; test it in the production line and in the laboratory.3. Sell the product.4. Test the product in service, through market research. Find out

what user think about it and why the nonusers have not bought it.

1950

Development of the Shewhart Cycle

1986

Source: Moen, R. and Norman, C. “Circling Back” Quality progress, November 2010: 22-28.

Walter A. Shewhart(1891 – 1967)

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The Shewhart Cycle for Learning and Improvement

Act Plan

Study Do

Act – Adopt the change, abandon it or run through the cycle again.

Plan – plan a change or test aimed at improvement.

Study – Examine the results. What did we learn? What went wrong?

Do – Carry out the change or test (preferably on a small scale).

(Deming, 1993)


In the spring of 2010 the BMJ sponsored the Vin McLoughlin Symposium on the

Epistemology of Improving Health Care. The papers that grew out of this symposium are freely available online under the BMJ journal’s unlock scheme:

http://qualitysafety.bmj.com/site/about/unlocked.xhtml

Knowledge for Improvement Continues to Evolve

BMJ Quality & SafetyApril 2011 Vol. 20, No Suppl. 1

Epistemology (from Greek epistēmē), meaning "knowledge, science", and (logos), meaning "study of" is the branch of philosophy concerned with the nature and scope (limitations) of knowledge.

It addresses the questions:

• What is knowledge?

• How is knowledge acquired?

• How do we know what we know?

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History of Six Sigma & Lean

History of Six Sigma & Lean

Bill Smith (1986)Motorola

Mikel Harry (1988)Motorola- MAIC

Forrest Breyfogle 111(1992)- Integration

Michael George (1991)- Integration

F.Taylor-The Principles of Scientific Method (1911)

Toyoda Family Taiichi Ohno 1950-1980Toyota Production System

Womack & Jones

Reference: Wortman 2001

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Variations on a Theme

• Baldrige Performance Excellence Program

• European Foundation for Quality Management (EFQM)

• International Organization for Standardization (ISO)

• Lean Enterprise (Toyota Production System, TPS)

• Six Sigma Methodologies (Design for Six Sigma, DFSS)

• Model for Improvement (MFI)

Six Sigma, Lean, MFI

Define

Six Sigma

Analyze

Measure

Improve

Control

Identify

Value

Understand

Value Stream

Eliminate

Waste

Establish

Flow

Enable Pull

Pursue

Perfection

Lean

Source: The Improvement Guide, API

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Similarities

• Have disciplined processes and approaches

• Rely heavily on detailed measures

– Lean– process steps, value

– Six Sigma – Defects per 1,000,000 opportunities

– MFI – Process, outcome & balancing measures

• Have a specific language and tools

• Have a long history in the field

– Lean – Japanese production –Toyota Production System (TPS)-healthcare

– Six Sigma – Japanese – Motorola, GE-healthcare

– MFI – Shewhart, Deming, Japanese Union of Scientists and Engineers (JUSE),

Associates in Process Improvement (API)

DefineEstablish problem statement, governance and team,

Voice of customer, scope, stakeholders

MeasureIdentify current performance baseline, validate

measurement system, define capability and stability

AnalyseIdentify root causes validate with data, hypothesis

testing

ImproveIdentify improvements based on analyse phase, pilot run

PDSA cycles, implement solutions, confirm improvement

ControlEnsure systems and process are in place to sustain

new performance

Tools: Project charter, process maps, cause and effect, SPC, hypothesis testing, FMEA, PDSA

Six Sigma Steps

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Lean Specifics

• What is “Value” from the customer’s point of view

• Develop “Value Stream (VS)” to determine steps, value added, identify waste

• Improve flow, cycle time and value

• Establish process controls and high reliability

Identify

Value

Understand

Value Stream

Eliminate

Waste

Establish

Flow

Enable Pull

Pursue

Perfection

Model for Improvement (MFI)

• What are you trying to solve?

• How will you know?

• What changes will you make?

• Predict-Test-Observe

• Shewart cycle

• Reach your “aim”, Implement

• Hold the gain, Spread

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better for patients, better for staff

Why, when and what?

Approach What’s the problem Focus and strengths

Lean • Waste, rework,

redundancies

• Poor flow

• Multiple process steps,

• Non Value added activities

• Elimination of waste

• Improvement of flow

• Simplifying and mistake

proofing processes

Six Sigma • Poor quality and variation

• Complex and multiple

system interactions

• Minimizes variation

• Based on facts and data

• Robust sustain controls

Model for

Improvement

• Quality or flow issues

• Localized problems

• Few improvement resources

but skilled local staff and

leaders

• Aim, tests, multiple cycles,

learning

• Works in multiple

situations – including large

and small scale projects

Wow…I have actually found

organization’s that have integrated

the various approaches!

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KP Healthcare Performance Improvement

40

We Lead with a Principles and Systems Approach based

on the Attributes of a High Performing Organization

Best qualityBest service

Most affordableBest place to

work

KP needs to build capability in these six areas in order to achieve breakthrough performance

© Kaiser Permanente 2011 reproduce by permission only

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Rapid Improvement Events

• Employee involvement in developing and implementing recommendations

• Solutions will be generated via front line knowledge

• Root causes are known

• Simple tools used (fishbone, process map, Pareto)

• Data analysis, statistical tools not required

• Often involve Lean 6S & mistake proofing projects in workplace – Set, Sort, Shine, Standardize, Sustain, Safety

• Management commits to quickly making decisions on team recommendations (yes / no / further study required)

• 1-3 days of team meetings required w/ facilitator

• Less than 30 days to implement recommendations

• Little or no capital required

Improve Transport Response

Radiology Patient Flow

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Lean

• Solution not known or obvious

• Typically end-to-end process issues

• Extensive data & statistical analysis not required

• Reduce obvious waste: scrap, inventory, waiting, motion, etc.

• Often involves mistake proofing, and 6S – Set, Sort, Shine, Standardize, Sustain, Safety

• Improve product flow / path

� Reduce process lead time / inventory

� Eliminate non-value added steps

� Reduce set up or change over time

� Reduce push versus pull scheduling

• Goal is to achieve “Future State Value Stream”

Operating Room Utilization

Testing Turnaround Time

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Six Sigma

• Solution unknown

• Long standing, complex problem, existing process

• New data & statistical analysis required

• Project types: defect reduction, reduced consumption,

• Process performance/savings measurable & directly tied to project

• 3-6 months or more to project completion

Reduce Never EventsReduce Inventory

ObsolescenceReduce Billing Errors

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What are our first steps?

• Assessment: problem statement, identification of root causes or flow charts and levers for improvement with drivers, prioritization of projects, scoping and resourcing using a charter

• Select/plan: defining what the focus will be – flow, defect reduction, redesign?

• Test: changes and application in real time before implementation

• Implement/control: Apply to processes locally to make part of core work and macro process standardization (ie. training, procedures)

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Performance Improvement Project Checklist

� Org/Team Charter� Problem Statement

� Goal Statement

� Scope

� Team roles and time commitments

� Timeline/Milestones

� Project Prioritization

� Driver Diagram

Assess Develop/ ID Changes Test Implement/Control

� 6 S

� Identify Waste

� Cause and Effect (Fishbone)

� OPI (Output –Process – Input)

� FMEA (Failure Modes & Effects Analysis)

� Evidence-based Practice

� PDSA Action plan

� Test using PDSA Action Plan

� Annotated Run Charts

� PI Leadership Report

� Solutions Tested

� Work Instructions

� Visual Display

� Control Charts/ SPC

� Sustainability Plan with annotated run and control charts

� ROI Template

� Storyboard

� Project Closure Form

� Stakeholder Analysis

� Value Stream (with metrics)

� Process Flow Map

� Voice of the Customer

� Baseline measures

What are we trying to accomplish?How will we know the change is an improvement?What change can we make that will result in improvement?

Name:Medical Center/Region:Project Title:

Signed by:

<insert name>

(HP Sponsor)

<insert name>

(Labor Sponsor)

<insert name>

(Finance Sponsor)

<insert name>

(Med Group Sponsor if applicable)

<insert name>

(IA)

� These subjects are taught in the Regular Institute (our version of

Green Belt training)

�We teach Spread & Scale, Patient Safety, Advanced Change

Management, Management Systems, Planned Experimentation,

Management Engineering, and Innovation in the Advanced Institute

(our version of Black Belt training)

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Greg Balla

Director Performance & Innovation

Auckland District Health Board

Title: Building an Integrated

approach to improvement at ADHB


We lead with a values and systems approach based on the

characteristics of high performing organisations

Leadership

Measurement &

Analysis

Engaged Workforce

Strategy & Planning

Patients & community

Improved processes

Results:

• Patient Safety

• Quality care

• Healthy Community

• Economic sustainability

• Best place to work

We need to continue to build organisation capability in these six

areas to achieve sustainably superior results because our patients

and staff deserve this.

Based on the Baldrige Performance Excellence Framework

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The problem

It was taking too long for patients to get from the Emergency

Department onto the ward after the decision to admit had been made.


So which model do we use

It was taking too long for patients to get from the Emergency


So, which model do we use?

Lean?

Six Sigma?

Model for Improvement?

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The problem

It was taking too long for patients to get from the Emergency Department onto the

ward after the decision to admit had been made.

• It Impacts 35,000 patients each year

• It involves multiple specialties

• There are multiple steps in the process

• The time it takes was an average of 8 hours

• The time we wanted to do this in was less

than 1hour


So which model do we use

The problem: It was taking too long for patients to get from the Emergency


So which model do

we use? Lean Six

Sigma or MFI

• It Impacts 35,000 patients each

year

• It involves multiple specialties

• There are multiple steps in the

process

• The time it takes was an average of

8 hours

• The time we wanted to do this in

was less than 1hour

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Answer: All of them!

Multiple

Improvement

Projects

Implemented using

lean, six sigma &

MFI

Rapid

Improvement

Event


ADHB Continuous Improvement Methodologies

Current process

completely broken/ not

available

Multiple end-to-end

value streams

Breakthrough focus –

larger scope

Tactical or

operational

Levels Environment Structure

• Steering Group

• Programme

• Collaboratives

• Steering Group

• Multiple project

teams

• Project Sponsor

• Project Team

• Team Leader

• Team membersIn team problem solving

Focused Improvement

Service

Improvement or

re-design

System

re-think

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Tools for Continuous Improvement

PDSAChange

managementBasic Lean

RIEDMAICChange

management

DFSS Change

managementCo-design

Service

Improvement

Framework

IDEO 3PsChange

managementCollaboratives

In team problem solving

Focused Improvement

Service

Improvement or

re-design

System

re-think


Our Improvement approach encompasses,

Lean, Six Sigma, MFI, TOC

• Develop a common language for improvement

• The problem type defines the tools required not the tools a consultant sells

• Very few problem types are just lean, six sigma or model for improvement

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Are Quality Tools Enough for Success?

R = Q x AResults Quality of solution Acceptance of solution

ADKAR

Change Acceleration ProcessCreate Urgency

Form a powerful coalition

Create a vision for change

Communicate for buy in

Empower others to act

Create short term wins

Build on the change

Anchor the change in your culture

Kotters Change Model


Integrating Quality & Change Mgmt Tool

•Increase urgency

•Build the guiding team

•Increase urgency

•Build the guiding team

• Develop the change

vision

• Deliver short term wins

• Develop the change

vision


• Communicate for buy-in


• Communicate for buy-in


• Empower others to act

• Deliver Short term wins

• Don’t let up

• Empower others to act

• Deliver Short term wins

• Don’t let up

• Anchor the change

in your culture

• Build on the change

• Anchor the change

in your culture

• Build on the change

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5 day Rapid Improvement Event

Aim: Reduce the time from bed allocated to patient transferred while

improving patient safety from an average of 66 min to 9 min

420360300240180120600

2000

1500

1000

500

0

USL

LSL *

Target *

USL 30

Sample Mean 66.8289

Sample N 10479

StDev (Within) 48.0047

StDev (O verall) 59.4343

Process Data

% < LSL *

% > USL 75.32

% Total 75.32

O bserv ed Performance

Process Capability of Scheduled to Att EndPre Event Tools Used:• Project charter completed

• Stakeholder analysis

• Team selection

• Extensive communication

• Analysis of current performance: distribution, Control

Charts, Box Plots

• Cross functional process map

• Walk the process

• Team & Sponsor training

• Implemented a Quick Win


Rapid Improvement Event: Example

• Day One: cross-functional process map

- Failure Modes Effects Analysis

(FMEA).- Data analysis - VA/NVA

analysis.

• Day Two : MFI - Lean: prototyping and

piloting improvements - PDSA cycles

• Day Three: MFI (PDSA cycles)

• Day Four: Preparing communication

plans and completing implementation

• Day Five: Documenting improved

processes and completing action plans

for next 30, 60 and 90 days

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Rapid Improvement Event: Results

16-May-11

21-Mar-11

24-Jan-11

29-Nov-10

04-Oct-10

09-Aug-10

14-Jun-10

19-Apr-10

22-Feb-10

28-Dec-09

90

80

70

60

50

40

30

Admit Week Beginning Monday

Minutes (W

eekly Avera

ge)

1111

111

1

111111

111

1

1111

1

1

1

111

1

AED to Ward - Patient Transfer TimesFrom Ward Bed Ready to ED Discharge

Low Is Good

Our Goal = 30 MinRapid

Improvement

Event

• Ensure you are working on something important

• Decide which model(s) are most appropriate

• Develop a common language for improvement

• Skill development is required

• Expert help in partnership with Clinical Champions

• Quality improvement tools & skills are not enough

• No problem is pure lean, six sigma or MFI

• Constancy of purpose!

Key Points to Consider

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Exit Poll

How confident are you that you are using the right improvement methodology(s) to

address the right problems?

Go to Poll


“It should be fairly obvious that no single quality system, set of quality criteria or even quality philosophy is ever going to be the solution by itself to a firm’s

quality problems.”

H. Scott Tonk. “Integrating ISO 9001:2000 and Baldrige Criteria”Quality Progress August, 2000.

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“The greatest thing in the “The greatest thing in the “The greatest thing in the “The greatest thing in the world is not so much where world is not so much where world is not so much where world is not so much where

you stand, as in what you stand, as in what you stand, as in what you stand, as in what direction we are moving.”direction we are moving.”direction we are moving.”direction we are moving.”

~Oliver Wendell Holmes

Where are you headed?

Questions?

Raise your hand

Use the Chat

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Resources & Suggested Reading

• BMJ Quality & Safety. Papers from the Vin McLaughlin Symposium on the Epistemology of Improving health Care. April 12-16, 2010. BMJ Quality &

Safety, April 2011, Vol. 20, No. Supplement 1.

• Edmonds, D. and Eidinow. Wittgenstein’s Poker: The Story of a Ten-Minute

Argument between Two Great Philosophers. Harper Collins Publishers, 2001.

• Lastrucci, C. The Scientific Approach: Basic principles of the Scientific Method. Schenkman Publishing Company, Inc., 3rd printing 1967.

• Lewis, C. I. Mind and World Order. Reprinted by Dover Press, 1929.

• Moen, R. and Norman, C. “Circling Back: Clearing up myths about the Deming cycle and seeing how it keeps evolving,” Quality Progress November, 2010:22-28.

• Shewhart, W. A. Statistical Method from the Viewpoint of Quality Control. US Department of Agriculture. Dover Publications, 1939 (reprinted 1986).

• Wallace, W. The Logic of Science in Sociology. Aldine Publishing Company, 1971.

Homework for Next Call

• Complete the IHI Improvement Capability Self-Assessment Tool─ Does your assessment suggest one or more actions you can take

now to increase your hospital’s capabilities?

─ Does your assessment suggest a need for more information to help you determine specific actions to help you increase your improvement capabilities?

Send ‘Tweet-like’ summary of 140 characters or less to Jill at [email protected] by Friday, October 5th

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IHI Improvement Capability Self-Assessment Tool

http://www.ihi.org/knowledge/Pages/Tools/IHIImprovementCapabilitySelfAssessmentTool.aspx

Expedition Listserv

If you would like additional people to receive session notifications please send their email addresses to

[email protected]

We have set up a listserv for participants in this Expedition to share improvement strategies, and

pose questions to one another and faculty.

To use the listserv, address an email to

[email protected]

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Upcoming Calls

• Session 2 – Tuesday, October 9th 1:00 – 2:00 ET─ The Model for Improvement

─ Kevin Little, Improvement Advisor, IHI; Principal, Informing Ecological Design

• Session 3 – Tuesday, October 23rd 1:00 – 2:00 ET─ Lean

─ Helen Zak, President and COO, Healthcare Value Leaders Network

• Session 4 – Tuesday, November 6th 1:00 – 2:00 ET─ Six Sigma

─ Dennis Deas, Senior Director Clinical and Operational Improvement Implementation Team, The Center for Health System Performance, Care Management Institute, Kaiser Permanente

• Session 5 – Tuesday, November 20th 1:00 – 2:00 ET─ Sustaining an Effective Quality Improvement Strategy

─ Robert Lloyd, Executive Director of Performance Improvement, IHI

Thank You

Please let us know if you have any questions or feedback following today’s Expedition webinar

Jill [email protected]

Robert [email protected]

ihi expedition integrating improvement approaches … expedition... · ihi expedition: integrating...

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