the next generation of lean six sigma innovation in healthcare

The Next Generation of LSSI in Healthcare © 2010 GOAL/QPC 1

Lean, Six Sigma & Process Improvement in

Healthcare Summit

The next generation ofLean Six Sigma Innovation (LSSI)

In Healthcareby Bob King

WCBF


Survival is not mandatory! - W. Edwards Deming 1984

Lean

Speed

Innovation

New ideas

Common Objective

Best PracticesSix SigmaError &

variation reduction


LSSI Culture

• Shifts focus to customer, not service provider or organization structure

• Uses common methodology for process improvement and decision making

• Uses common metrics• Ensures decisions are data driven• Aligns projects with strategy and business objectives• Focuses on waste, variation, and defect reduction• Increases effectiveness of investments• Improves ability to meet expectations of customers

Overview -


Factors Supporting Project Success

• Regular management reviews• Team knowledge of process• Adequate measurement system• Constant environment• Bias for urgent action• Measurable goals• 90-day maximum execution timeframe

Overview -


Objectives of this talk• Help participants develop a roadmap of

improvement for their organization

– Clarify strategy and get alignment of all levels of staff and physicians.

– Enrich lean six sigma with innovation

– Pick the projects and tools that will best help you achieve your strategy.

– Use time management to free up time for improvement efforts


Simplify and map strategy –Southwest example

Increase profitability




Fewer planes

More passengers




Fewer planes

More passengers

Lowest cost

On time flights

Fast turn around


Simplify and Map Strategy - Hospital

Profitably Improve Health of the Community


Simplify and Map Strategy – Hospital


Patient SatisfactionPayer Satisfaction

Good Outcomes Economical


Simplify and Map Strategy –Hospital


Patient SatisfactionPayer Satisfaction

Good Outcomes Economical

Patient Safety

Patients Get Better

Reduce Waste in Processes

Transparency


Barriers

• Joint Commission

• Medicare – CMS

• Strategy Plan written by outside consultant


Enriching Lean Six Sigma with Innovation

• Improve the improve step of DMAIC• Need to choose process and tools by experience of

your team.• Need to choose process by type of change

– If some other part of organization has done it, then the 7MP tools will work

– To do something that you haven’t done, but another organization has, use 7 Creativity tools

– To do something that no one else has done before, use Advanced Innovation TRIZ.


Pick strategic projects and tools

• The more your projects are tied to strategy the better the chance of success.

• Pick the elements of six sigma, lean and innovation that will help you succeed in your improvement effort.


Example 1: Reducing Falls

• Reducing falls during the hospital stay.

• Reducing falls when the person returns home after being in the hospital to treat a previous fall.


Prevalence of Falls

• Data shows fall related injuries in older adults are the largest number of trauma admissions at the hospital.

• Falls are also the leading cause of injury EMS runs.

• Falls are the leading cause of injury visits in the emergency department.

• Falls are the leading cause of injury death in those over 65.


Selecting tools for falls teams• Six Sigma applications.

– Kinds of falls, causes of falls

• Lean applications.

– Processes of care, lag time from coding a person as a fall risk to taking action

• Innovation applications.

– Identify ways of preventing falls, preventing harm

– Ways to educate families, discharge instructions.


Example 2: Improve IT Capital Asset Tracking

• Number of items purchased vs. number of items tagged.

• Relevance?• Six Sigma: # of variances from process• Lean: What are unnecessary steps and delays in

the process? Mistake-proofing.• Innovation: Analogies of dependable processes.


Example 3: Reduce time to transfer Paper Medical Record to EMR

– Issues of quality of information that is being transferred. Easier to access wrong information

– Understanding the differences between ED reports and in-patient reports.

– How long to process an inch of rehab, an inch of cardio, to see if there are efficiencies that can be gained there as well.


Electronic Medical Records• Six Sigma: What is the quality of the original

records, quality of transmission? Who are the customers of the records? What do they want?

• Lean: What are the steps in developing the records, what are the steps in transcribing the records? Where are the delays?

• How can innovation help find the best ideas for these questions?


Pharmacy Project

• Wide variation on special formulations

• One patient expected a 30 minute wait and left after 75 minutes resulting in a $3,000 loss to the hospital.


5911171058Venofer13

18113371156Xolair12

1713451328Remicade11

31855824Orencia10

2014451425Remicade9

1211351123Orencia8

2413281304Remicade7

1114201409Venofer6

2113501329Remicade5

4210451003Xolair4

811101102Venofer3

30814501142Remicade2

2214291407Remicade1

ElapsedTime

ACC DeliveryTime

Rx EntryTimeMedicationPatient


Affinity Chart of ideas

•Have a hood in ACC so pharmacy can compound on the floor.•Have premixed items (lovenox) available in pyxis•Less expensive generics available to be made prior to patient arrival•Make sure pharmacy has enough inventory•Have pharmacy pre mix meds like daptomycin and Xolair and study how much med is actually wasted •Have a dedicated ACC order section in the IV room•Have all ACC orders delivered to RPh for checking once compounded

•Get all orders in pharmacy prior to day of visit•Enter all meds at 7am and deliver all at once•No bar scanner issues (is it med or IV)•Enter all orders prior to patient arrival. Then keep labels ready to go•Change Remicade throughout the house. Med or IV no choice. Then there will be no barcoding problem•ACC protocol with the meds usually used in ACC (build in HMM)

•Have patient continue to call ahead•Better communication between shift change•Dedicated RN in ACC for communication with pharmacy•Getting the patient from registration in a timely fashion•Have registration call the pharmacy•Electronic check in that notifies ACC and pharmacy of patient arrival•RN/pharmacy to shadow each other’s department to have a better understanding of workflow

•If meds are sitting in the delivery bin, then deliver to patient room•Keep ACC orders fast tracked. Don’t wait for next IV to be made before delivery•ACC patient pick up their own meds from the pharmacy •Move ACC and pharmacy closer together •Continue with bringing up premade meds in the morning•Have the RN come to the pharmacy to pick up meds when pharmacy is short runners

•Have a scheduling system viewable by ACC and pharmacy•Compound Xolair if more than two patients are coming there is less a chance of waste•Posted calendar of schedule in the IV room•Have dedicated days for designated drugs•Juggle scheduling if possible- early morning Xolair, etc.

•Have all medications made during the overnight shift•Have a full time barcode and packaging tech that is IV room trained and floats in IV room during busy ACC times• Have a dedicated tech to coordinate heavy ACC load days to days with extra pharmacy tech coverage•Have a tech assigned to ACC meds/orders•Consider ACC meds a STAT in the IV room-pull another tech if needed

Coordinate pharmacy inventory, workflow and compounding with ACC

orders9

Maintain consistent accurate medication orders to improve

efficiency of pharmacist order

entry13

Early/real time notification that the patient has arrived

13

Consistent delivery times and locations

to increase awareness of when

medications are available

11

Dispersing workload by scheduling

patients according to their medications

5

Pharmacy staff assignment to better

handle ACC workload

10


Dispersing workload by scheduling patients according to their

medications

1 in 4 out

Consistent delivery times and locations to increase

awareness of when medications are available

4 in 1 out

Coordinate pharmacy inventory, workflow and compounding with ACC

orders

2 in 3 out

Early/real time notification that the patient has

arrived

2 in 3 out

Pharmacy staff assignment to better handle ACC workload

5 in 0 out

Maintain consistent/accurate med

orders to improve efficiency of RPh entry

1 in 4 out

Green = Process DriversNov. 12, 2008

ID for drivers


Heuristic Redefinition for focus

8323We coordinate pharmacy inventory, workflow and compounding with ACC orders

5311We dispersing workload by scheduling patients according to their medications

8323We maintain consistent/accurate medication orders to improve efficiency of RPh order entry

Total

Expected im

pact on the goal

Ease of im

plementation

Likelihood of reaching the goal

Good/High = 3Average/Medium = 2

Poor/Low = 1

Problem Statement“How can we ensure that…”


55504540353025

50

40

30

20

10

Tot wait time

Idle time

Scatter Plot of idle time vs Total wait time

For patients that DID NOT call ahead


Using Innovation to Correct the Problem of delay time

• Level 1 – Use the 7 Management and Planning tools to get ideas from people working in the system and from similar problems that has been addressed in the hospital

• Level 2 – Use the 7 creativity tools to adopt other solutions to lag time in other hospitals and other industries.


Using Innovation to Correct the Problem of delay time, cont.

• Advanced Innovation TRIZ – Use advance methods to create new ways of eliminating pharmacy that have never been tried or used before. Find the ideal solution.

• Note: Team members need to become proficient at levels 1 and 2 before they should attempt level 3 of innovation tools.


How innovation will help your organization

• Lean Six Sigma has one key weak point coming up with the best idea of how to improve.

• Healthcare organizations who learn and use basic creativity and innovation tools will improve every aspect of their improvement effort.

• Better process improvement

• Better planning

• Better products and services


How innovation will help your healthcare organization cont.

• Use AFD – Advance Failure Determination– Most organizations use a whack a mole approach to patient safety

– jumping from one outbreak or mistake to another.

– Human factors methodology uses airline safety which is based on building redundant systems. It is an important contribution.

– AFD maps all the possible ways of harming a patient and uses innovation to prevent them at the most economic cost.

– Healthcare costs will prove human factors alone too expensive; it will need to be supplemented with AFD to get to the next level at lower costs.


Other Advanced Approaches• In addition to these ideas there are other processes

to improve the health system.

– Transformation: This refers to alignment of people in the organization around a goal. In pharmacy different individuals and departments are responsible for different steps. One of the transformation tools is appreciative inquiry which looks at times when the process worked really well and focuses on making that happen more often.


How Transformation will help your healthcare organization

• Healthcare is based on silos. Transformation helps build alignment of each groups’ priorities into one unified approach

• The change that will be required in healthcare will be significant. There is already an epidemic of physician frustration and resignations.


Other Advanced Approaches Getting to the Essential

• 100X Healthcare Improvement

– Reduce deaths due to errors by 95%

– Reduce healthcare costs below Medicare reimbursements.

– Increase chronic illness self-care from 25% to 95%.


Jouslin-King Hierarchy

1.Getting to the Essentials: Preserving the company while preserving the planet. Recognizing the spirituality in each person. Facing global issues.2.Transformation: Alignment of individual and company visions.

Customer focus

Total participation

Continuous improvement

Unique org. capability

Societal networking

CQM (Shiba) Triangle

GOAL/QPC (King) Wheel

Gettingto the

Essentials1

Transformation &

Breakthrough Management2

Creativity & InnovationIdea generationIdea selectionIdea implementation

7 Creativity ToolsTRIZ, QFDImplementation steps

Lean Six SigmaDMAIC

DMADVEliminate waste & unnecessary steps

Emphasis of company planIncreased DOEIncreased reliability

TQM: Total Quality Management

Customer drivenMaster planRoadmap for improvement

Daily ManagementHoshin PlanningQFD, CFM

7 QC Tools7 MP Tools

SPC: Statistical Process ControlShiba Four Revolutions

DemingProfound knowledge

Seven step process

Control ChartsDesign of experiments


What levels mean• Level 0 - Chasing regulations/standards

• Level 1 - SPC, fixing special causes, get rid of noise then fix system problems

• Level 2 - TQM, get all employees involved

• Level 3 - Lean Six Sigma V=f(x)

• Level 4 – Creativity and innovation for all

• Level 5 – Aligning employee passions with hospital passions


Level 6 Getting to the essential• 100X improvement in Healthcare and public health

quality

• Making the US the world’s healthiest nation

• Eliminate unnecessary deaths

• Reduce hospital costs below Medicare reimbursements

• Increase Chronic Illness self care to 98+ %


Author may be contacted at

• Bob King, GOAL/QPC 12 Manor Parkway, Salem, NH 03079

• E-mail: [email protected]

• Cell phone: 603.275.0555

• For additional slides containing information on how LSSI can help health care organizations respond to the upcoming new health systems, please go to www.goalqpc.com/healthreform.


Appendix – Additional slides for discussion


Where Six Sigma came from

• HP 1983 commits to 10X quality improvement• Motorola 1985 commits to 10X better that HP or 100x

improvement in quality.• Calls it 6 sigma• Six Sigma is a 100X improvement• We need a 100X improvement in healthcare and public

health quality


Where we are today• US ranked 29th as a nation on health care results

• US pays double what the nearest country pays

• Takes average of 17 years to implement best practice.

• 300K to 500K die in US each year due to errors.

• Healthcare 15 years behind industry in Quality.

• Perfectly organized for health needs of 1950s.

• Chronic illness 50-75% of patient needs today.


So where is healthcare and public health today?

• Many hospitals are at level zero with a growing number at levels two to three and a few leaders at levels 4-5.

• Public health is mostly at level zero.

• RWJ has funded a project to help 15 states to go from level zero to level 1.

• So there is lots of room to grow.


Healthcare and Innovation• Healthcare even further behind on creativity and innovation• Some experiments over the last three years• Mayo Clinic and Massachusetts General Hospital reporting

creativity centers teaching brainstorming three years ago.• Memorial hospital in South Bend, Indiana is at level three for last

three years, benchmarking nations most innovative companies.


Where quality technology is going• We are at level four on the quality hierarchy in some leading

hospitals today.

• Innovation has hit the tipping point in 2007 (have you ideated your ideating yet? – IBM television ad) and will be the next major phase in healthcare. It will be a major force in solving the patient safety and cost crisis.

• Transformation, the next phase, will help with the human dimension, coaching and alignment.


Healthiest nation plans

• Infant mortality

• Life expectancy

• Obesity


So what does all this mean for your hospital? Would you like to:

• cut your employee healthcare costs by 25%,

• free up beds currently occupied by low margin patients to create space for high margin patients,

• reduce the need for capital expenditures to get more beds?

• The following example will tell you how.


Controllable Health Care Costs

• Lack of Chronic illness self-care causes over 50% of total health care costs

• Cost shifting from Medicare, Medicaid, uninsured is almost 25% of healthcare premiums.


Successful chronic illness self care programs

• Hannaford Bros. supermarket stores

• City of Asheville, North Carolina

• Increased self care participation levels from 25% to 80% +

• Reduced total cost of treatment by 50%


Areas for research by the world’s top quality and innovation experts

1. Getting public health organizations to the cutting edge of quality, innovation and transformation.

2. Getting JACCHO on the cutting edge of quality, innovation and transformation.

3. Help CMS better support a continuous improvement model and reduce unnecessary paper work and too frequent procedure changes with lack of lead time.

4. Helping public health organizations implement lean and other quality improvement, innovation, and transformation methods. Provide the training for this.


Areas for research by the world’s top quality and innovation experts

5. Redesign national health report cards so they reflect the best of performance management and improvement technology.

• For further information on the preceding themes see: www.Thehealthiestnation.com


Getting hospital costs in line with Medicare reimbursements

• The new CEO of Dartmouth Hitchcock Medical Center in Hanover, NH had the foresight to coin this challenge.

• It is akin to the peak of the Quality Hierarchy “Getting to the essential”.

• Current proposals for Medicare cuts would put 10% of America’s hospitals out of business.

• Current gap between costs of service and Medicare reimbursements is considerable and is cost shifted to those who are paying, contributing to runaway healthcare costs.


The hospital quality and cost national demonstration project

• Twenty years ago, Don Berwick brought in industrial quality experts to see if industrial quality would work in healthcare. It does and that is why you are here.

• However, today's methods are not adequate to solve tomorrow’s problems. That is why we need a new demonstration project to bring the most advanced quality and innovation tools to a dozen hospitals.

• There are still openings for your hospital to participate in thefirst round.


Who is involved?

• An advisory panel of the top quality and innovation people in the world has agreed to donate their time to this effort.

• Local consultants around the country will use the top quality and innovation tools as outlined in this talk.


Making U.S. patient safetythe best in the world

• This will be part of the national demonstration project and will begin with 12 hospitals.

• Participants will learn the first 5 levels of innovation on the innovation hierarchy.

• Focus will be on the AFD tool to map all possible ways to harm patients and eliminate these situations effectively and efficiently using the appropriate innovation tools.


Ten tasks for the new U.S. President to improve healthcare

1. Commit to making the U.S the healthiest nation and put the resources behind it.

2. Develop a plan to transform the healthcare system into a health system.

3. Fix the national report cards based on where we need to improve to be number one.

4. Help CMS better support a continuous improvement model and reduce unnecessary paper work.

5. Save money by insuring everyone: a job for the states.


Ten tasks for the next U.S. President to improve healthcare, cont.

6. Help redesign the healthcare system so it better meets the need of the chronically ill.

7. Get public health organizations to the cutting edge of quality and innovation.

8. Put resources and energy behind reversing the obesity epidemic.

9. Expand the federal effort to do research on alternative medicines and make findings widely available.

10. Take control of the FDA away from the pharmaceutical companies.


References for further study• The Six Sigma Memory Jogger™ II • The Black Belt Memory Jogger™• The Lean Enterprise Memory Jogger™• AFD Manual• Coaching in the Workplace pocket guide• The Transformation Desktop Guide• The Transformation Fieldbook• The Transformation Case Study Book


Author may be contacted at

• Bob King, GOAL/QPC 12 Manor Parkway, Salem, NH 03079

• E-mail: [email protected]

• Cell phone: 603.275.0555

• For additional slides containing information on how LSSI can help health care organizations respond to the upcoming new health systems, please go to www.goalqpc.com/healthreform.

the next generation of lean six sigma innovation in healthcare

Documents

continuous

map strategy

public health

advanced innovation

health systems

additional

advanced approaches

100x improvement