understanding variation: statistical process control...

34
Understanding Variation: Statistical Process Control (SPC) Brent C. James, M.D., M.Stat. Executive Director, Institute for Health Care Delivery Research Intermountain Healthcare Salt Lake City, Utah, USA

Upload: trinhkiet

Post on 06-Feb-2018

257 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Understanding Variation:Statistical Process Control (SPC)

Brent C. James, M.D., M.Stat.Executive Director, Institute for Health Care Delivery ResearchIntermountain HealthcareSalt Lake City, Utah, USA

Page 2: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

A process

... a series of linked steps, often but not necessarily sequential, designed to ...

some set of outcomes to occurtransform inputs into outputsgenerate useful informationadd value

cause

Walter Shewhart: a system of causes

Page 3: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

A system of causesWalter Shewhart was a student of, above all, causes. He believed that results in complex systems did not just happen but were the consequences of lawful relationships; maybe it was because he was a physicist that he chose to interpret production that way. He believed that, properly analyzed, experience in real causal systems could teach a great deal about those systems, and he devoted much of his professional career to developing methods through which the study of variation in measured results could teach the observer about the causal systems that led to those results. If he had been a physician, he would have been called an applied epidemiologist, or a clinical researcher—and a master at it.

The causal systems that intrigued Shewhart (the most) he called "systems of chance cause," but he used the word "chance" in a most unusual way: to Shewhart, "chance causes" meant, exactly, "unknown causes." It dawned on him that real, unknown causes were of two distinct types: as he put it, not all systems of chance causes are alike. In particular, some such causal systems produced effects that obeyed understandable mathematical laws. That was fortunate, since, because they obeyed mathematical laws, that permitted one to make predictions based on experience. He called these "constant systems of chance causes," and they are the same as Deming later called "common causes" and Juran called "random causes."

1. Shewhart WA. Economic Control of Quality of Manufactured Product. New York, NY: D. Van Nostrand Company, Inc., 1931. (Available from Quality Press, American Society for Quality Control, 310 West Wisconsin Avenue, Milwaukee, WI 53203)

2. Deming WE. Out of the Crisis. Cambridge, MA: MIT Center for Applied Engineering Studies, 1986.3. Juran JM, Gryna FM, eds. Juran's Quality Control Handbook, 4th ed. New York, NY: McGraw-Hill, 1988.

1

2 3

Berwick, DM. Controlling variation in health care: a consultation from Walter Shewhart. Medical Care 1991; 29(12):1212-25.

Page 4: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Constant (convergent) systems

follow the laws of mathematical probability:

How the process behaved in the pastpredicts how it should behave in the future

non-constant (divergent) systems follow the laws of chaos theory:

How the process behaved in the pastdoes not predict how it should behave in the future

Page 5: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Random variation

different processes have different levels of random variationrandom variation is a matter of measurement, not goal setting

represents "appropriate" variation

is a physical attribute of the process

represents the sum of many small variations, arising from real but small causes that are inherent in -- and part of -- any real processfollows the laws of probability -- behaves statistically as a random probability functionbecause random variation represents the sum of many small causes, it cannot be traced back to a root cause

Page 6: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Assignable variation

represents "inappropriate" variation

represents variation arising from a single cause that is not part of the process (system of causes)

therefore can be traced, identified, and eliminated (or implemented)

Page 7: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Managing assignable variation

Find a data point that probably represents assignable variation (usually a statistical outlier)

track it to root causes

eliminate (or implement) the assignable cause

(React to individual fluctuations in the data)

Page 8: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Managing random variation

Act (either implement the tested alternative, modify it and test again, or discard it)

Study the results (does the new process have a level of performance and/or random variation that is superior to that displayed by the old process?)

Do it in a trial (on a small test group)

Plan a change (design a new process)

(The Shewhart PDSA cycle is a simple application of the scientific method)

Usually, the new process is a variant of the old process. Therefore

The level of random variation is a physical attribute of a process. Therefore, in order to reduce random variation one must find a new process with a new level of random variation, that is superior to that of the original process.

Page 9: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Tampering:

using assignable methods in an attempt to manage

random variation

Shewhart proved that tampering does not just waste time and effort --

it seriously harms process performance

Page 10: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

A frequency distribution

tracks the performance of a process across a group of observations / measurements

shows the number of times (y axis -- count, rate, percentage,

proportion) each possible value occurred (X axis)

while it is not possible to exactly predict any single future observation for the process, the frequency distribution gives an envelope within which nearly all of the process's future measures should fallwhen Shewhart talked about processes that obeyed "understandable mathematical laws," he meant convergent processes for which it is possible to generate a frequency distribution:

How the process behaved in the past, predicts how it should behave in the future

Page 11: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Empiric frequency distribution

Value observed

Num

ber o

f tim

es o

bser

ved

(Num

ber,

rate

, per

cent

age,

pro

porti

on)

Page 12: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Parametric frequency distribution

Value observed

Num

ber o

f tim

es o

bser

ved

(Num

ber,

rate

, per

cent

age,

pro

porti

on)

Page 13: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Parametric frequency equation

Value observed

Num

ber o

f tim

es o

bser

ved

(Num

ber,

rate

, per

cent

age,

pro

porti

on)

Page 14: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Statistical resolution

How well a statistical test can detect true differencescalled "statistical power"directly related to Type II (beta) statistical error

Determined bydata typespecific statistical testsample size (statistical significance vs. clinical significance)

In general, parametric statistical tests are more powerful than non-parametric statistical tests

(but they make assumptions about underlying frequency distributions, which may or may not be true)

Page 15: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Parameters: mean and variance

center (mean, median)

spread (variance, standarddeviation, range)

Value observed

Num

ber o

f tim

es o

bser

ved

(Num

ber,

rate

, per

cent

age,

pro

porti

on)

Page 16: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Probability-based boundaries

2.575 std. devs. 2.575 std. devs.

0.5% 0.5%

99%

Value observed

Num

ber o

f tim

es o

bser

ved

(Num

ber,

rate

, per

cent

age,

pro

porti

on)

Frequency Distribution

Page 17: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Time

Observed value

Statistical Process Control Chart

Page 18: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Random variation

Time

(How the process behaves over time)

T1 T2 T3 T4 T5 T6 T7 T8 T9

Observed value

Process Control Chart

Page 19: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Assignable variation

TimeT1 T2 T3 T4 T5 T6 T7 T8 T9

(How the process behaves over time)

Observed value

Process Control Chart

Page 20: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Statistical process control charts

Show the probability that an observation arose from the underlying process -- that is,

the probability that a particular point's deviation from the center represents only "random" variation arising from the system of causes that make up the process, as opposed to "assignable" variation representing an identifiable, intruding cause.

Theyseparate random from assignable variationbased on statistical probabilityusing control limits, runs, trends, and other patterns in the longitudinal data.

Page 21: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

are action / decision thresholds (along with runs, trends, and other patterns in the data)

are measured in units of standard deviations: 5% limits 1.96 std. devs. 1% limits 2.575 std. devs..1% limits 3.08 std. devs.

must balance three costs:The Cost of Tampering -- Type I ( ) statistical error: the

probability that a point is actually random, when the SPC chart classifies it as assignable

The Cost of Failure to Detect -- Type II ( ) statistical error: the probability that a point is actually assignable, when the SPC chart classifies it as random

The Cost of Analysis (usually relatively unimportant)

Control limits

Page 22: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Two types of control limits

a priori control limits ("standards given"):

empiric control limits:there is no a priori knowledge of the process's center or

spread;so we estimate them from the observed data themselvesthen update them each time we obtain more observations

(eliminating assignable points when calculating center and spread)

the process's measured center or spread are known before hand, a priori, from some outside source --

so the control limits can be calculated before hand, then each new performance observation added to the graph as it is generated, over time.

Page 23: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Outpatient anticoagulation

0

1

2

3

4

5

6

7

0

1

2

3

4

5

6

7

INR

process capability = 60%

5.02.5

4.13.0

2.53.3

3.04.0

3.53.0

Patient LL: warfarin anticoagulation

warfarindose

courtesy of Dr. Larry Staker

INR

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

2.9 6.0 2.8 2.7 4.7 3.7 3.4 3.3 2.3 2.6 2.9 3.4 3.4 3.7 2.0 2.7 3.3 1.8 4.7 3.8 2.7 3.2 3.1 5.0 2.3

Page 24: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Anticoagulation XmR Chart - before

UCL 6.25

LCL 0.36

3.304

UCL 3.623

LCL 0.000

1.108

Patient LL: warfarin anticoagulation

INRs(X)

movingRange

(anterior MI - spec range = 2.5 - 3.5)

courtesy of Dr. Larry Staker

Page 25: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Stop tampering!

0

1

2

3

4

5

6

7

0

1

2

3

4

5

6

7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

2.9 2.8 2.7 3.7 3.4 3.3 2.6 2.9 3.4 3.4 2.7 3.3 2.7 3.2 3.1 2.5

INR

process capability = 94%Patient LL: warfarin anticoagulation

warfarindose

3.0

courtesy of Dr. Larry Staker

INR

Page 26: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Sources of measured INR variation

1. the INR test itself- variation between different types of analyzers / batches of analyte- variation within a particular analyzer / batch of analyte

2. individual pill drug content, batch potency

3. patient differences- compliance- diet (e.g., green, leafy vegetables high in Vitamin K)- prescription medications, OTC medications, herbals- underlying genetic and physiologic differences (e.g., liver metabolism rates)

4. clinician dose tamperingIn this example, the initial process capability shortfall was 40% (100% - 60%); eliminating just one source of assignable variation - clinician tampering -

dropped the shortfall to 6% (a move of 34 percentage points); in other words, clinician tampering accounted for 85% (34/40) of the total shortfall

Page 27: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Choosing an SPC chart

Choice of SPC chart depends on the underlying frequency distribution of the data being analyzed

Parametric distributions give better power/resolution than nonparametric distributions, but contain risks associated with underlying assumptions

Frequency distribution usually depends on data type

Page 28: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Types of data

Data come in different "flavors" (types):NominalOrdinalIntervalRatio

Data type determines analysis

Different types of data contain different amounts of information

Page 29: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Choosing a parametric SPC chartBinary attribute data (nominal or ordinal) = binomial distribution

- asymtotically Gaussian (normal; bell-shaped) at large sample sizes;- turns into Poisson distribution if np < 5

use a P ("proportion") chart

Discrete ratio "# of between" data = geometric distribution- useful for very rare events; estimates point proportions at every event

use a g / h ("geometric") chart

Discrete ratio "# of per" data = Poisson distribution- asymptotically Gaussian (normal; bell-shaped) when mean > 25-30

use a C / U (think "count per unit") chart

Continuous ratio data = normal (Gaussian) distribution- very often doesn't fit, though ...

use an X ("mean") chart

Page 30: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Binomial distribution

y = Pr{X=k} = p (1-p)k n-kn!k!(n-k)!

Binary attribute data

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

# observed

0

0.05

0.1

0.15

Prop

ortio

n

mean = 0.19204n = 100

Page 31: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Red bead game

67

89

1011

1213

1415

1617

1819

2021

2223

2425

2627

2829

3031

3233

# red / 100

0

0.05

0.1

0.15

Prop

ortio

n

mean = 0.19204 n = 100

Page 32: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Red bead game

Sample #0

10

20

30

40

# re

d be

ads

/ 100

mean = 0.19204 n = 100

Page 33: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

Red bead game

Sample #0

10

20

30

40

# re

d be

ads

/ 100

mean = 0.19204 n = 100

Page 34: Understanding Variation: Statistical Process Control (SPC)ep50.eventpilotadmin.com/doc/clients/IHI/IHI2011/library/M8... · Understanding Variation: Statistical Process Control (SPC)

What if nothing fits?

Transform the datalog transformspower transformsseverity transformslinear, cyclic, or non-linear transforms

1.

Use Shewhart's method2.

Use a non-parametric control chart3.

generate control limits directly from the known frequency distribution

Use some other known frequency distribution4.