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    SixSigma

    rocess mprovement

    PresentedbyContentExpert:BethLanham,RN,BSN,MBA

    ,

    FroedtertHospital,Milwaukee,WI

    Thispresentation

    is

    part

    of

    an

    on

    line

    series,

    brought

    to

    you

    through

    a

    collaboration

    between

    the

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

  • 8/10/2019 Lean six sigma for healthcare

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    SixSigma

    is

    a

    projectfocused

    resultsdriven

    a roachto ualit

    Thispresentation

    is

    part

    of

    an

    on

    line

    series,

    brought

    to

    you

    through

    a

    collaboration

    between

    the

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    Originatedby

    Motorola

    (1986)

    electronicmanufacturingprocesses

    Heavilyinspired

    by

    Previousqualityimprovementmethodologies QualityControlManagement,CQI,TQM

    Basedontheworkofqualitypioneers

    Deming,Juran,

    Ishikawa,

    Taquchi

    and

    others

    Thispresentation

    is

    part

    of

    an

    on

    line

    series,

    brought

    to

    you

    through

    a

    collaboration

    between

    the

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    B late1990s

    2/3Fortune

    500

    companies

    Aimedatreducingcostsandimprovingquality

    o ay Utilizedallovertheworld

    Local overnments risons hos itals thearmedforces banksmanufacturing,etc.

    Inrecentyears

    x

    w

    u uyieldamethodologycalled LeanSixSigma.

    Thispresentation

    is

    part

    of

    an

    on

    line

    series,

    brought

    to

    you

    through

    a

    collaboration

    between

    the

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    atwewere o ngwasn twor ngwe enoug

    Incrementalimprovementsnotgoodenough

    :

    Focusoncustomerrequirements

    Basedecision

    on

    data,

    not

    anecdotal

    information

    BeProactivevs.Reactive

    Establishacultureofownershipvs.culpability

    Itstheprocesses,notthepeople

    Effectrapid

    and

    effective

    change

    Improvementeffortswerefragmented

    Largesystemwi eprocesses ro en

    Notholding

    the

    gains

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    Or anizational

    Datadrivendecisionmaking Benefits:Competitiveedge

    Focusesoncustomerrequirements

    Afocused/organized

    approach

    Service

    Excellence

    Redefinesprocessesforlongtermresults

    Becomesingrainedinworkandthought

    Leadership

    Development

    processes

    Reliesonevidencebasedsolutions

    Quality/Safety

    HealthcareCosts

    Rapid/effectivechange

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    Methodologyaimed

    at

    Errorreduction

    Goal Design/improve

    processes

    so

    it

    is

    impossible

    to

    make

    an

    error

    Relianceonperformancemeasurementsand

    y

    Thispresentation

    is

    part

    of

    an

    on

    line

    series,

    brought

    to

    you

    through

    a

    collaboration

    between

    the

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    ..

    servicesin

    terms

    of

    averages:

    Averagecost

    Averagetimetodelivery

    Averagenumber

    infections

    verageusage

    Averagewaittime

    Thispresentation

    is

    part

    of

    an

    on

    line

    series,

    brought

    to

    you

    through

    a

    collaboration

    between

    the

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    Are

    These

    Processes

    the

    Same?Process1 Process2

    20 9

    5 11 Goal=lessthan10

    Aretheyperformingwell?

    17 8

    5 10 Process1 Process

    2

    15 10

    5 9 Mean9.4 Mean9.4

    5 11

    5 10Areallthecustomersha ?

    5 8

    12 8

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    Variation=

    O ortunities

    for

    Errors

    Process1 Process2

    Average

    9.4

    9.4Minimum 5 8

    Maximum 20 11

    Standarddeviation 6.0 1.17

    Customersfeelthevariation,

    nottheaverage!!!!!!

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    Process1 Process2

    100

    80

    Mean 9.540

    StDev 6.149

    N 1000

    Histogram of Process 1Normal

    80

    70

    60

    Mean 9.412

    StDev 1.193

    N 1000

    Histogram of Process 2Normal

    60

    40Frequency 50

    40

    30

    20

    Frequency

    24181260-6-12

    20

    0

    Process 1

    24181260-6-12

    10

    0

    Process 2

    Many

    Defects

    Fewer

    Defects

    expectations!

    Exact

    capability

    can

    be

    measured!

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    Howthe

    customer

    judges

    our

    products/services

    Y=Theoutcomemeasureoftheprocess

    Xs=InputsorvariablesthataffecttheY

    Defect

    Failure

    to

    deliver

    what

    the

    customer

    expects

    Variation Theenemyofpredictableoutputandcustomersatisfaction

    Sigma

    Anexpressionofprocessyield,basedonthenumberof

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    SixSi ma

    APhilosophy of

    Operational

    Excellence

    AsetofProblem

    Tools/Tactics

    AMeasure ofProcess

    Capability

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    Greekletter

    Ameasureofprocesscapability Howcapableisourprocessofmeetingourcustomer s

    expectations?

    Arigorous,

    structured

    approach

    to

    problem

    solving

    Includesadefinedmethodologywithspecifictoolsandtactics

    Amanagementphilosophy

    Definitionscomplimentary,notcontradictory!

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    Astatisticalconcept

    Representsthevariationthatexistsinaprocess

    Relativetothecustomerrequirements

    A

    process

    operating

    at

    a

    6

    Sigma

    level o tt evar at on,t att eprocessoutcomesare

    99.9997%defectfree

    = , , .

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    Amoresensitiveindicatorthan%yieldor%good

    Sigma Defects Yield DPMO

    1 69.1% 30.9% 691,4622 30.8% 69.1% 308,538

    3 6.7% 93.3% 66,807

    4 0.62% 99.38% 6,210

    5 0.02% 99.977% 233

    6 0.0003% 99.9997% 3.4

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    WhenComparedtoBestinClass

    Antibiotic

    at ona

    ata

    1000000

    InpatientMedication

    Accuracy

    Overuse

    Post

    MI

    10000

    100000

    llion

    44,00098,000

    PreventableHospital

    Deaths(IOM

    Report)

    100

    1000

    efects/M

    Anesthesia

    1

    10D DuringSurgery

    Sigma DomesticAirline

    FatalityRate

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    1Si ma

    5 &6

    4Sigma

    4

    to5

    Sigma

    27

    fold

    Performance

    Improvement

    5 to 6 Si maAnother 69fold Performance Im rovement

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    customerCriticalto ualit CT s

    ThisisgenerallyreferredtoastheYoroutcomevariable

    Examples:

    waittime,

    response

    time,

    turn

    around

    time,

    %

    newvisits,%mederrors,%falls,etc.

    MeasuretheYagainstthetarget

    Target=

    customer

    expectations

    or

    specifications

    This

    presentation

    is

    part

    of

    an

    on

    line

    series,

    brought

    to

    you

    through

    a

    collaboration

    between

    the

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    Process

    Ca abilit

    Lower

    SpecificationUpper

    Specification

    10

    y

    Limit m t

    5Frequenc

    AverageAverageDefectDefect DefectDefect

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    Focusedon

    identifying

    the

    root

    causes

    Rootcauseanalysis

    Processvariables

    are

    called

    Xs

    Y = x1 + x2 + x3 + x4, etc.

    r mary me r c = com na onof a variety of variables (xs)

    Whatarethevariablesthatinfluence

    themain

    metric?

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    Understandingthe

    customers

    needs

    Anal zin business rocesses

    Institutingappropriatemeasurementmethods

    Em hasison

    mana ement

    of

    rocesses

    Wedonthavefaultypeople,wehavefaultyprocesses!

    Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    Define Measure Analyze Improve Control

    Establish

    current

    capability

    SelectKey

    CTQs**

    Developdata

    Charter

    project

    Optimization

    Cycletime

    Variability

    Determine

    capability

    ofnew

    rocessIdentifykey

    sourcesof

    variability

    co ectionp an

    Define

    performance

    ProcessMap

    CollectVOC

    ost

    Validationof

    Improvements

    Implement

    process

    controls

    Define

    performance

    objectives

    s an ar s

    Validate

    measurement

    ent y

    CustomerCTQs

    Review

    Implementation EnsureGainsare

    Sustainedsys emss or ca a a

    *VOCVoiceofCustomer

    **CTQCritical

    to

    Quality

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    Tools

    of

    Six

    Si ma= ,

    ProcessMap Regression

    FMEA(FailureModeand HypothesisTest

    EffectsAnalysis) 95%ConfidenceInterval

    Cause EffectDiagram ANOVA

    are o agram es gno xper men s

    GageR&R ControlPlan

    ProcessCa abilit StatisticalProcessControl

    Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe

    WisconsinOfficeofRuralHealthandthe WisconsinHospitalAssociation.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    Six

    Si ma Ke

    Pla ers Oversee or

    StrategicProjects

    SkilledinSixSigma

    chooseprojects

    ResolveIssuesChampionsBlack

    BeltsToo s

    TeachGreenBelts

    Leadership

    Executive

    FullTime

    Strategic PartTime

    ponsors

    Master

    BlackBeltsProjects

    Program

    Administration

    o

    Projects

    Helptochange

    GreenBelts

    TeachBlack

    BeltsandGreen

    Belts

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    Pr

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    Launchin

    a

    Pro ect

    Identifya Sponsor Champion Energy/passiontosolvetheproblem

    Defineboundaries/scope

    Establishstretchgoals

    Providedirectionandsupporttotheteam

    Removebarriers

    Accountablefor

    completion,

    implementation

    and

    sustaining

    resultsfromtheproject

    Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe

    WisconsinOffice

    of

    Rural

    Health

    and

    the

    Wisconsin

    Hospital

    Association.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    Define Measure Analyze Improve Control

    CharterprojectProblemstatementHowdoweknowwehaveaproblem?

    improvement?

    ProjectScopeandTeam

    g

    eve

    rocess

    ap IdentifyCustomerCTQs

    Reviewhistoricaldata

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    ExampleProjectCharterQMS Project Team Charter

    Business Process Team/Svc Line: Project Team Members Review Timing

    Project Name: Target Completion Date: Project Type:

    CAP WO PDSA Lean DMAIC

    Process Owner: Milestones TBD based on methodology

    Black Belt:

    Finance Representative:

    Project Overview

    Problem Statement (*MOMS criteria):

    In Sco e:

    Out of Scope:

    Customers and Stakeholders:

    Goal (s): (**SMART criteria)

    Target Performance Indicators and levels:

    Expected Benefits/Business Case (target savings, target metric reduction):

    Assumptions:

    Signatures

    Project Chair(s) Signature: Champion Signature: Master Black Belt signature:

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    ProblemStatement Howdoweknowwehaveaproblem?

    Measureable,Observable,Manageable,Significant

    GoalStatement

    Howwillweknowifwehavemadeanimprovement?

    SMARTcriteria pec c, easurea e, a na e, ea s c, me y

    Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe

    WisconsinOffice

    of

    Rural

    Health

    and

    the

    Wisconsin

    Hospital

    Association.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    urpose: ograp ca y sp ay eprocessma oreven s

    Suppliers Whoprovidestheinputstoyourprocess?

    Inputs Whatmaterials,resourcesanddataareneededtoexecuteprocess?

    ProcessSte s

    57stepsthatuseinputstochangeintooutputs. Useveryspecificstartandstoppoints!

    Out uts What

    is

    the

    output

    of

    the

    process?

    What

    did

    the

    customer

    receive?

    Customers Who receives the out uts of the rocess?

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    SIPOCExample

    Suppliers-Who providesthe inputs?

    Inputs-Materials,

    resources,

    data

    Process Steps Outputs-What did thecustomer

    receive?

    Customers- Who benefits?

    Infection Control

    H.C P roviders

    (Physicians, nurses,

    nursing assistants,therapists,

    Policies &

    Procedures

    CDC guidelines

    So ap

    High quality

    care

    Avoidance /

    reduction ofhospital

    Pat ients

    CMS

    Third Party

    PayorsWash hands

    n er pa en

    room

    technicians,

    emergency medicalstaff, dental staff,

    pharmacists,laboratory staff,

    autopsy staff,students and

    trainees, contractual

    Alcohol hand rub

    Dispensers

    Sinks

    Paper towels

    acquired

    infections

    Clean hands

    Decrease in

    skin irritation

    Other patients

    S ta ff

    Famil ies

    upon en er ng

    Patient

    Encounterstaff not employed

    by the healthcarefacilit y, and persons

    not directly involvedin patient care but

    potentially exposedto inf ect ious agents.)

    Clinical Routine

    Degree of urgent

    care required

    Extent of contact

    Increased

    patientconfidence

    Wash hands

    upon exiting

    Operations

    Patient con dition

    or ers

    Call lights

    Operational

    routines

    Leave patient

    room

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    What outhink Whatitactuall is What ouwouldlikeit

    itis tobe.

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    Identifyand

    prioritize

    all

    customers

    Whoisimpactedthe mostbytheprocess?

    Whoisthemostdissatisfiedwiththecurrentprocess?

    Solicitfeedback

    How does the customer view the rocess?

    Whatdoesthecustomervaluefromtheprocess?

    Whatdoesthecustomerexpectfromtheprocess?

    Whatdoes

    the

    customer

    want

    most

    of

    the

    time?

    Whatisthelimitthecustomeriswillingtotolerate?

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    a e o er na ys s

    StronglyModeratelyNeutralModeratelyStrongly

    Whowill

    be

    affectedbyany

    chan es from this

    project?

    Beginaddressing

    issuesearl !

    Noteveryone

    needstobestrongly

    supportive!

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    Define Measure Analyze Improve Control

    DefinePerformanceStandards

    DataCollection

    MeasurementSystemAnalysis

    ProcessXs(Variables) OutputsorYs

    X2

    X3

    Y2

    Y3TheProcess

    X4 Y4

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    usesto

    judge

    your

    performance

    SixSi malin o:Thebi Y

    HowwillIknowifIhavemadeanimprovement?

    Howwill

    the

    Y

    be

    defined

    and/or

    measured?

    VOC CTQ Y

    Expecttobeseen WaitTime Pt.checkinatfrontdesktofirst

    within

    15

    min

    of

    appt. contact

    with

    staff

    physician.

    Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe

    WisconsinOffice

    of

    Rural

    Health

    and

    the

    Wisconsin

    Hospital

    Association.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    TranslatetheCustomerexpectationsintoMetricsTarget:

    SpecificationLimits:

    What

    are

    the

    limits

    the

    patient

    is

    willing

    to

    tolerate?

    VOC CTQ Y Target UpperLimit

    Expecttobeseen Wait Pt.checkinatfront 15min 30min

    within

    15

    min

    of

    appt.Unhappyif>30min

    Time desk

    to

    first

    contact

    withstaffphysician.

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    Process Env ironment Management

    Managers not accountableClutter o bstructing sink

    i i i li

    - -

    Don't have adequate resources

    No communication r e: pt impact if non-compliant

    Lack motivation to set an example

    No incentives/rewards to comply

    No corrective a ction for non-compliance

    Spot checks not currently done

    Divisions not accountable

    Lack of institutional safety climate

    Understaffing/Overcrowding

    Carrying items into patient room

    Need to take care of patient and can't

    No ongoing education on process for

    No reminders posted

    No sin k i n t he r oo m

    Difficulty monitoring process

    regularlyEquipment is not wiped down

    before/after contactPeople are not aware to wash hands

    i i i li

    during pt

    compliance

    hygiene

    Lack hand

    Inadequate org. structure for accountability

    No role model for hand hygiene

    Lack of institutional priority for hand hygiene

    Delays in getting needed equipment

    No alcohol wipes

    No t e no u h h an d dis e nse rs

    Low risk of acquiring infe ctions fro m

    No lotion accessible

    Lack immediate feedback/outcomes

    processNot part of the yearly evaluation

    Skeptical abo ut e ffectivenessInterf eres w/HCW relationship with pts

    Disagree w/recommendationsFamily/visitors una ware re:han dwashing

    i

    Soap/alcohol dispenser empty

    Broken dispenser

    Overflowing garbage

    No towels

    Staff work areas are dirty

    Too many people in room, in way of sink

    E ui ment in wa of sink

    hgyiene on the rate of HAINo data to show the impact of hand

    Skin irritation by hand hygiene agents

    Inconvenient location of hand sanitizer

    Lack of e ducation mate rials

    Family/visitors don't see being part of PCOther personnel not aware

    Pts/visitors insulted when asked t o w ashPts not at ease asking someone to wash

    People forgetPeople set in their ways

    Not part of the Froedtert cultureNot seen as a priority

    Concerned w/skin irritationDon't understand nee d fo r handwa shing

    Feel that no need to wash w/gloves

    Sponsoredby

    the

    Wisconsin

    Office

    of

    Rural

    Health

    and

    the

    Wisconsin

    Hospital

    Association.

    CopyrightoftheWisconsinOfficeofRuralHealth.

    People Materials Equipment

    i i i

    Not enough sinks available

    Sinks don't wo rk

    Patient room is out of gloves

    Don't know proper handwashingOnly touch equip., no need to wash

    Feel that wash hands enoughToo busy/Not enough time

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    Data Collection Sam lin

    Datamust

    be

    representative

    of

    the

    process

    Datamustbereliable

    Mustcapturemeasurementsofimportance

    ENTRY EXIT

    OBS # Role(s) Hand Hygiene Notes Hand Hygiene Notes

    1 Sink Y / N Gloves On Sink Y / N Gloves On

    Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves

    None Y / N Full Hands? None Y / N Full Hands?

    Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access

    Direct Exit to Enter?

    2 Sink Y / N Gloves On Sink Y / N Gloves On

    Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves

    None Y / N Full Hands? None Y / N Full Hands?

    Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access

    Direct Exit to Enter?

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    Measurement

    S stem

    Anal sis

    MSA

    owaccura e s emeasuremen process

    Howmuch

    variation

    is

    there

    in

    the

    measurement

    Attempttominimizecontrollablefactorsthatcould

    exaggerate

    the

    amount

    of

    variation

    in

    the

    dataExample:

    Iwanttomeasureseconds. Theclockonly measuresminutes

    Result:Thevariationofthemeasurementsystemistoolargetostudy

    the current level of rocess variation

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    Performedby

    all

    RNs

    Patientsgivenscores,basedonassessmentcriteria

    DoortoBalloonTime Clocks

    1. ReproducibilityDoesRN#1getthesamescoreasRN#2?

    2. RepeatabilityDoesRN#1alwaysgetthesamescorewhen

    ace w esame n ngs

    Totalmeasurementsystemvariabilityshouldbeassmallas

    possible,butalwayslessthan30%.

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    Define Measure Analyze Improve Control

    Establishcurrentcapability

    Identifykeysourcesofvariability

    e neper ormanceo ect ves

    Howistheprocessperformingtoday?

    Dowe

    need

    to

    shift

    the

    mean

    or

    reduce

    variation?

    WhatarethekeyXsthataredrivingtheY?

    Howdoyouknow?

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    Graphical

    Tools Flowdiagrams,frequencyplots,Paretocharts,etc.

    StatisticalTesting DescriptiveStatistics,ProcessCapabilityHypothesistesting,Regression

    DesignedExperiments

    Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe

    WisconsinOffice

    of

    Rural

    Health

    and

    the

    Wisconsin

    Hospital

    Association.

    PropertyoftheWisconsinOfficeofRuralHealth.

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    Dis la in theData

    Variable: Pt Wait Time

    Descriptive StatisticsBoxplots of Pt Wait Tim e by CL INIC

    ( means are indicated by solid cir cles)

    10 35 60 85 110 135 160

    A-Squared:P-Value:

    Mean

    StDevVarianceSkewnessKurtosisN

    i i

    32.0180.000

    23.1551

    15.3332235.1081.251964.39234

    2559

    Anderson-Darli ng Normal ity T es t

    100

    150

    (inmin)

    95% Confidence Interval for Mu

    20 21 22 23 24

    i i1st QuartileMedian

    3rd QuartileMaximum

    22.561

    14.924

    .11.00021.000

    33.000153.000

    23.750

    15.765

    95% Confidence Interval for Mu

    95% Confidence Interval for Sigma

    95% Confidence Interval for Median

    50

    PtWaitTim

    OverallStatisticsByPatient:

    95% Confidence Interval for Median20.000 22.000

    i l i

    HAC

    ORO

    ORT

    0

    40

    Scatterplot of Hand Hygiene Events vs Time of Day

    Metric Wait Time Exam Time Total TimeMean 23.16 18.94 42.10

    Median 21 16 40

    30

    20

    and

    Hygiene

    Events

    . . .

    Sample Size 2559 2559 2559

    Min 0 0 3

    Max 153 99 18316141210860

    Time of Day

    H

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    Howisthe rocess erformin toda ?

    Dowe needtoshiftthemeanorreducevariation?

    T T

    1.235 1.239 1.241 1.245 1.233 1.235 1.239 1.241 1.245

    USL USLLSL LSL

    Hypothesis Testing

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    HypothesisTesting

    e ng

    o

    e

    oo

    auses

    Test Details P-ValueRole DTY, EVS, Lab, LCs, PCAs, RNs, RTs 0.002

    PValues