PERFORMANCE IMPROVEMENT THE LEAN SIX SIGMA WAY

Karen Miller, RN, BSN, MBALean Six Sigma Master Black Belt

Charleston Area Medical Center• 7,000 employees• 800 physicians• Highest level newborn & pediatric ICU’s• Level 1 Trauma Center• WV only free standing women and

children’s hospital• Annual community benefit more than

$115 million

Objectives• Understand how six sigma methodology & lean

pinciples are used for continuous improvement• Learn how using continuous improvement

methodologies affect Value Based Purchasing (VBP) reimbursement

• Learn how the process can prevent readmissions within 30 days for targeted patient population of CHF, Pneumonia, and COPD

• Understand how to link process improvements with financial benefits

What is Six Sigma?Measure of QualityStatistical measure that expresses how close a service comes to its quality goal

Process for Continuous Improvement Follow DMAIC methodology to identify how root cause factors impact outcomes and results

Enabler for Culture ChangeAim to be nearly flawless in executing our key processes with customer focus.

Six Sigma Methodology DMAIC: To improve any existing product or process

Define Measure Analyze Improve Control

Who are the customers and what are their priorities?

How is the process performing and how is it measured?

What are the most important causes of the defects?

How do we remove the causes of the defects?

How can we maintain the improvements?

Six Sigma Methodology ExampleSix Sigma Methodology Example

Example: Angioplasty Balloon Inflation

Define the ProblemDefine the Problem

Doctors are Doctors are expecting 2.5 mm, expecting 2.5 mm, but will allow some but will allow some variation within the variation within the

upper & lower upper & lower specifications. specifications.

10% of patients 10% of patients have a repeat have a repeat

angioplasty within 3 angioplasty within 3 months, which months, which

exceeds the national exceeds the national average of 5% average of 5%

UpperSpecification

Limit

Lower Specification

Limit

Target

2.5 mm

No Less Than

2.25mm

No More Than

2.75mm

Measure to See if Meeting SpecificationsMeasure to See if Meeting Specifications

UpperSpecification

Limit

No Less Than

2.25mm

Lower Specification

Limit

No More Than

2.75mm

Extruded BalloonExtruded BalloonInflation data plotted Inflation data plotted

ininActual MicrometersActual Micrometers

MeasurementsMeasurements

Measure the Data & Determine DefectsMeasure the Data & Determine Defects

Variation in the Variation in the process caused data process caused data

points outside the points outside the specification limits specification limits

(Defects). (Defects).

UpperSpecification

Limit

No Less Than

2.25mm

Lower Specification

Limit

No More Than

2.75mm

DefectDefect

Current inflation rate within spec

limits is 80%

Analyze the Data Using StatisticsAnalyze the Data Using Statistics

Basic StatisticsBasic Statistics

Mean Inflation = 2.50mm

St. Deviation = 0.125mm

UpperSpecification

Limit

Lower Specification

Limit

Mean

2.50mm

Standard Deviation

0.125mm

On Average it’s OK - it’s a Variation issue

Improve the Process by Identifying the Improve the Process by Identifying the Key Variables (Root Causes)Key Variables (Root Causes)

Reducing Variation is Reducing Variation is the Key to Improvingthe Key to ImprovingProcess CapabilityProcess Capability

UpperSpecification

Limit

Lower Specification

Limit

Std Dev

Spec Width

220.5 mm

0.125 mm

2.25mm 2.75mm

2.5mm

0.25mm0.25mm

Improve the Process by Implementing Improve the Process by Implementing Solutions to Control the Key VariablesSolutions to Control the Key Variables

UpperSpecification

Limit

Lower Specification

LimitReducing Variation is Reducing Variation is the Key to Improvingthe Key to ImprovingProcess CapabilityProcess Capability

Std Dev

Spec Width

330.5 mm

0.083 mm

Improve the Process by Implementing Improve the Process by Implementing Solutions to Control the Key VariablesSolutions to Control the Key Variables

UpperSpecification

Limit

Lower Specification

LimitReducing Variation is Reducing Variation is the Key to Improvingthe Key to ImprovingProcess CapabilityProcess Capability

Std Dev

Spec Width

440.5 mm

0.062 mm

Improve the Average and Improve the Average and Reduce the VariationReduce the Variation

UpperSpecification

Limit

Lower Specification

LimitReducing Variation is the Reducing Variation is the

Key to ImprovingKey to ImprovingProcess CapabilityProcess Capability

Std Dev

Spec Width

550.5 mm

0.05 mm

Improve the Process by Implementing Mistake Improve the Process by Implementing Mistake Proofing Solutions to Control the Key VariablesProofing Solutions to Control the Key Variables

UpperSpecification

Limit

Lower Specification

Limit

Reducing Variation is Reducing Variation is Clearly the Key to Clearly the Key to

ImprovingImprovingProcess CapabilityProcess Capability

Std Dev

Spec Width

660.5 mm

0.041 mm

Defect Production is significantly reduced - but by how much?

Sustain the Improvement

UpperSpecification

Limit

Lower Specification

Limit

Spec Standard Sigma DPMO %Width Deviation Level In Spec

0.5 0.125 2 308,538 69.15

66

0.5 0.083 3 66,807 93.32

0.5 0.062 4 6,210 99.38 0.5 0.05 5 233 99.98

0.5 0.041 6 3.4 99.99966

Monitor improvements by capturing data and displaying on graphs or tables to ensure goal continues to be met and investigate defects

Understanding Six SigmaUnderstanding Six Sigma

Business Strategy : An overall strategy that encompasses your hospital’s quality philosophy. It sets the vision for achieving Six Sigma levels of quality in key processes and services.

Tools and Tactics: A set of statistical tools and a disciplined methodology used by specially trained individuals to improve processes by reducing variation and defects.

Goal

Six Sigma refers to a process that produces only 3.4 defects per million opportunities

2 308,5373 66,8074 6,2105 2336 3.4

Sigma DPMO StatisticallyMost U.S. Businesses

3,660 Patients With Misplaced Personal

Items Every Day

340 Patients With Misplaced Personal

Items Every Day

12 Patients With Misplaced Personal

Items Every Day

6 Patients With Misplaced Personal Items Every Month

770 Coding Errors Every Day Require

Correction

72 Coding Errors Every Day Require

Correction

13 Coding Errors Every Week

Require Correction

During The Year, Only 10 Coding Errors

Require Correction

257 Calls Each Day Exceed The Two

Minute On-Hold Time

24 Calls Each Day Exceed The Two

Minute On-Hold Time

5 Calls Each Week Exceed The Two

Minute On-Hold Time

During The Year, 3 Calls Exceed The Two Minute On-Hold Time

66,800

6,210

230

3.4

93.32000%

99.3490%

99.97700%

99.99966%

3

4

5

6

SigmaPatient Billing

Errors Coding

Processing Scheduling Time DPMO % Yield

Sometimes 99% is just not good enough

Processes needs to be Better than you think!Processes needs to be Better than you think!

Lean is…The relentless pursuit of waste

Why Reduce Waste?Make Work: Safer, Faster, Cheaper, Easier

Lean vs. Six Sigma

• Six Sigma = Use of statistical tools to reduce VARIATION in a process.

• Lean = Use of basic change management tools to reduce WASTE in a process.

Types of WasteDefects Medication errors, wrong patients, wrong procedure, redraws, missing or

inaccurate information, no hot water

Over Production Standing orders that outlast patient needs, tests or procedures beyond requirements, duplicate documentation

Waiting Waiting for supplies, instruments, information, test results, instructions, tools, materials, resources

Not Using People’s K/S Under utilization of human resources. Failing to incorporate staff suggestions or ensure internal best practices are shared by all

Transportation Conveying patients, supplies, or materials from one area to another.

Inventory Pharmacy stock, lab supplies, materials & supplies in store rooms, patients in holding areas, discharged patients in beds

Motion Excessive reaching, bending, twisting, walking, etc. while attempting to complete a task

Excess Processing Multiple bed moves, redundant or unnecessary paperwork, multiple approval signatures

Foundational Lean Tools/Concepts5S Workplace Organization

A place for everything and everything in its place1. Sort2. Set in Order3. Shine4. Standardize5. Sustain

Visual ManagementInstantly identify “normal” vs. “abnormal” conditions

StandardizationReliable, repeatable results

Problem SolvingHidden problems now revealed; staff engaged in structured approach to

identify, address, and permanently eliminate root causes or problems.Human Centered Work

Creating a culture for patient centered care, best place to refer patients, best place to work, etc.

1S) Sort: Red Tagging Excess Inventory of Forms

2S) Set in Order & 3S) Shine

4S) Standardize Process

Each form has a number and arrow pointing you which direction to flow to build the chart.

5S) Sustain: Re-order card placed

Prevent excess inventory (waste)Layered audits by management to ensure sustainment

• 17 separate readmission initiatives/projects • Specific patient population data is extracted using

Healthcare Intelligence• Patient specific population discharge call scripts developed• Automated discharge calls• Patient responses to specific questions triggers a call from a

Transitions Coach• Readmissions tracked with reason for admission

Patient Population Management

Award Winning QualityAward Winning Quality

Source Data - Comparion Medical Analytics

Award Winning Quality Award Winning Quality PlusPlus Financial BenefitsFinancial Benefits

Finance Validated Cumulative Savings = $172,826,596FY 2015 Savings = $ 15,971,216

Healthgrades Distinguished Hospital Award: 2014 & 2015

5 Star Ratings: •Coronary Intervention•Neurosurgery•Hip Replacement•Prostate Removal Surgery•COPD•Pneumonia•Stroke•Heart Attack•Heart Failure•Pulmonary Embolism•Sepsis•Esophageal/Stomach Surgeries•Colorectal Surgeries

Questions?