Using Lean Six Sigma Methodologies in Your Quality Program

Drew A. Snyder, MHA, FACHE

No Disclosures

Agenda

• Overview

• Lean Six Sigma at MHS

• Case Study

• Opportunities

Health System Affiliates and Locations

5

JACKSONVILLESPRINGFIELD

TAYLORVILLE

LINCOLN

Lincoln

TaylorvilleSpringfieldJacksonville

Memorial Medical Center—1991Memorial Medical Center—1991

Springfield Hospital and Training School—1897

Memorial Hospital—1943Memorial Hospital—1943Memorial Hospital—1943Memorial Hospital—1943

• Services include:

– Radiation Therapy

– Infusion

– Research (CCOP)

– Cancer Patient Navigation

– Palliative Care

– Community Outreach

– CT Lung Screening

Analytical Cases

0

500

1,000

1,500

2,000

2,500

2010 2011 2012 2013*

Top 80% of Case Type

0%

20%

40%

60%

80%

100%

0

200

400

600

800

1,000

1,200

What is Lean Six Sigma?Lean:• Aims to optimize flow and maximize value through the 

reduction or elimination of non‐value added activities (waste)

Six Sigma:• Philosophy: long term business strategy focused on the 

reduction or elimination of variation and defects.

• Measure: statistical definition of how far a process deviates from perfection; 3.4 defects per million opportunities; 99.99966% effective 

• At 99.9% quality in the United States:– 12 newborns will be given to the wrong parents daily

– 291 pacemaker operations will be performed incorrectly

– 22,000 checks will be deducted from the wrong bank accounts in the next 60 minutes

Facts….

• All work is a process

• All processes vary

• Variation is indicative of waste

• MMC quality centers around eliminating process and outcome variation

Why Lean Six Sigma?

Lean Overview

• Lean is a methodology that is used to accelerate speed and reduce costs by removing waste

• 8 types of Waste:1. Defects (re‐work)2. Over‐Production3. Waiting4. Not‐Clear 

(confusion)5. Transporting

6. Inventory7. Motion8. Excess Processing9. Unused Talent*

DMAIC Model(Da‐MAY‐ihk)

• Define the problem and what the customers require

• Measure the defects and process operation

• Analyze the data and discover causes of the problem

• Improve the process to remove the causes of defects

• Control the process to make sure the defects don’t recur

Avoidable Chemotherapy Delays

Providing chemotherapy to patients is not as efficient as the customers would like. The customer expects drug therapy to begin

within one hour of appointment time.

Problem Statement

19

Decrease wait times

Improved satisfaction from physicians, patients, caregivers, and staff

Improved teamwork

Increase infusion capacity

Goals

Chemotherapy Process

S •Physicians•Clinic nurses•Office staff•Infusion nurses•Pharmacy•Lab

•Lab results•Completed order (Height, Weight, BSA, final dose, and/or lab parameters)•Chair•Supply from pharmacy•Nursing assessment (toxicity or baseline issue)•IV access•Medical history/med list

I P C O Chemotherapy administered

•Medical Onc•Patient•Patient Family•Care givers•Staff•MMC

Scope of Project

In Scope

Chemotherapy

Medical Oncologists

Avoidable delays

MD Clinic and infusion nursing staff

Out-of-Scope

Chemo order template

Non-Chemotherapy Drug Infusions

Unavoidable delays

Measurement Assessment Tree

36.2% of patients with a delay (63.8% without a delay)

First Measuring Period

U (# of Units) 105 DPU (Defects per Unit) 0.36

D (# of Defects) 38 DPO (Defects per Opportunity) 0.36

O/U (Opportunities per Unit) PPM (Parts per Million)Default: O/U = 1, unless

proven otherwise)(Also called DPMO - Defects per

Million Opportunities)

Z(ST) 1.9

1 361,905

Data Entry Results

One of the physician groups decided to sign chemo orders quicker

Communicated to physician significance of avoidable delays in infusion

Improvements

22.2% of patients with a delay (77.8% without a delay)

Second Measuring Period

U (# of Units) 54 DPU (Defects per Unit) 0.22

D (# of Defects) 12 DPO (Defects per Opportunity) 0.22

O/U (Opportunities per Unit) PPM (Parts per Million)Default: O/U = 1, unless

proven otherwise)(Also called DPMO - Defects per

Million Opportunities)

Z(ST) 2.3

1 222,222

Data Entry Results

Ho: Period 1 is equal to Period 2

Ha: Period 1 is not equal to Period 2

Hypothesis Testing

Two-sample T for Period 1 vs Period 2

N Mean StDev SE MeanPeriod 1 105 -0.131 0.889 0.087Period 2 54 -0.353 0.630 0.086

Difference = mu (Period 1) - mu (Period 2)Estimate for difference: 0.22295% CI for difference: (-0.019, 0.463)T-Test of difference = 0 (vs not =): T-Value = 1.82 P-Value =

0.071 DF = 141

Two-Sample T-Test and CI: Period 1, Period 2

Chemo Control Chart

‐4

‐3

‐2

‐1

0

1

2

3

1 5 9

13

17

21

25

29

33

37

41

45

49

53

57

61

65

69

73

77

81

85

89

93

97

101

105

109

113

117

121

125

129

133

137

141

145

149

153

157

UCL+3

UCL+2

UCL+1

Mean

Actual

LCL‐1

LCL‐2

LCL‐3

170% improvement in average start 

time

Infusion Unit Visits vs. Average Expected Start Time

‐25

‐20

‐15

‐10

‐5

0

0100200300400500600700800900

1,000

Infusion Visits Expect Start Time Wait Time

171% decrease in the average 

29% increase in visits

One physician group started providing Infusion Unit with offsite scheduled MMC patients a week in advance.– Determine a point person at the other

physician group to compare schedules

– Fully implemented on April 1, 2013

Improvements

The Control Plan

Step MeasuresTargets &

SpecsData

CollectionData

displaySpecial Cause

ResponsePerson

responsible

Monitor compliance rate starting with pre-meds within one hour of appointment time

# of delayed start times over 1 hour / total # chemo cases

Target – 0%Spec – 20%

Infusion Audit Worksheet

Chemo Delays Report

Share physician needing improvement with physician leader

Drew Snyder

Monitor compliance with orders needing clarification

# of orders needing clarification / # of delayed start time

Target – 0%Spec – 20%

Infusion Audit Worksheet

Chemo Delays Report

Share physician needing improvement with physician leader

Drew Snyder

Monitor compliance with needed lab results

# of needed lab results / # of delayed start time

Target – 0%Spec – 20%

Infusion Audit Worksheet

Chemo Delays Report

Share physician needing improvement with physician leader

Drew Snyder

Monitor compliance with delayed chemo patients average delay

Average minutes after the 1 hour it takes to start pre-meds

Target – 0 minutesSpec – 5 minutes

Infusion Audit Worksheet

Chemo Delays Report

Share physician needing improvement with physician leader

Drew Snyder

Monitor compliance ratestarting patients with premedswithin one hour ofappointment time byphysician group

# of delayed starttimes over 1 hour byphysician group /total # chemo casesby physician group

Target – 0%Spec – 20%

Infusion Audit Worksheet

Chemo Delays Report

Share physician needing improvement with physician leader

Drew Snyder

U (# of Units) 26 DPU (Defects per Unit) 0.23

D (# of Defects) 6 DPO (Defects per Opportunity) 0.23

O/U (Opportunities per Unit) PPM (Parts per Million)Default: O/U = 1, unless

proven otherwise)(Also called DPMO - Defects per

Million Opportunities)

Z(ST) 2.2

1 230,769

Data Entry Results

Opportunities for Improvement

• Complete FMEA earlier in DMAIC process

– Provide a focus on orders and lab values

• Provides physicians with personal compliance rate (compare to peers)

• Communication method with all physicians

Using Lean Six Sigma Methodologies in Your Quality Program

Drew A. Snyder, MHA, FACHE