Taking Your Improvement to the Next Level
March 3, 2005
Chuck DeBusk and Ben Miles
Real-World Usage of Six Sigma, Lean and Change Management Techniques in Healthcare
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Objectives
Learning valuable lessons from the successes and failures involved with creating a project funnel
Distinguishing between various methods and tools, and understanding when to use alone or in combination
Exploring actual case study examples
Acquiring tips on engaging all levels of the organization in driving change (executive, physician, staff, etc.)
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St. John Health – Who We Are
• St. John Health comprised of 8 hospitals and over 100 medical facilities in southeast Michigan
• History in Detroit area from 1844
• Guided by our Mission; Shaped by our Values Committed to providing spiritually centered, holistic care Sustain and improve the health of individuals in the communities we
serve, with special attention to the poor and vulnerable
• SJH – Vision for the Future To provide the highest quality patient care experience each time,
every time
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Performance Solutions
GE People GE Discipline150 Top
Clinical and Business Talent
GE Tools Lean
Six SigmaCAP
Work-OutTM
FocusedFact-Based
Values-Driven
Pragmatic
Applying GE’s Proven Approach to Transform Healthcare
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Perspective on the Basics
“Gentlemen, this is a football…”
Vince Lombardi(Stated at the beginning of training camp each year.)
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How is Six Sigma organized at St. John
System COO directs deployment of Six Sigma
System MBB’s directly report to the System COO
Steering Committee made up of COO, CMO, CFO, EVP-HR, EVP-OE, System VP of Quality, and MBBs
Each hospital has an Executive Sponsor (Champion) with a reporting relationship to the System COO in addition to the Hospital CEO
Hospital BB’s directly report to Executive Sponsors with dotted lines to System MBB’s
System COO
MBB’s Executive Sponsor
Hospital BB’s
SteeringCommittee
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ProjectBrainstorming
ProjectScoping
Executive CouncilReview / Approval
Value Stream Map& Data Pull
DMAIC
Project ExecutionFinance
Prelim Review
Finance Review& Validation
Project Sponsor &Team Selection
Operations/StrategicPlanning
FinanceQuality 6
Mission
Six Sigma Project Selection Cycle
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How do we start creating a funnel?
ReadTranscribe
Results Available
Level 1Key Business Metric Length of StayLength of Stay
Level 2 BusinessProcesses
Feeder to BedFeeder to Bed ProvideProvideInpatient CareInpatient Care
Discharge Planning Discharge Planning ProcessProcess
Execute Discharge Execute Discharge OrderOrder
Level 5Detailed Subprocess Map
Lab OrdersImaging Order TAT
Pharmacy Orders
Level 4High LevelProcess Map
Doc Order
Schedule Exam/Study
Prep Patient
Patient Transport
Complete Exam/Study
Nursing Care
Order Turn Around Time
Physician Referral Process
Practice Patterns
Level 3High-LevelProcesses
Where the pain is
or Focus Areas
Where the
projects are
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The Approach
IdentificationIdentification
ScopingScoping
SelectSelect
Identification• Key metrics/line of sight• Financial Opportunity Estimate• Sponsorship • Conflicts/other efforts
Select• Determine mix of projects & Work-Outs• Choose project sponsors• Identify team members• Set tentative goals
Scoping• Data Analysis• Process mapping • Calculate financial opportunity• Identify project potential
Select:Determine array of projects and Work-Outs that can be done in the next 6 months. Assure that array of projects and Work-Outs are aligned with organizational goals
Scoping: Break down a Focus Area to understand the many specific processes, sub-divisions of the business and/or segments that drive the performance of the Focus Area. Uncover multiple potential “projects”, or processes requiring improvement.Determine specific financial opportunity
Identification: Determine focus areas* or “sources of pain”High level evaluation of potential, support, conflicts.
* Focus Area: An area of the business, a high-level process, a department or function, or an important performance metric that has potential to be improved. Focus areas typically yield more than one Work-OutTM and/or Six Sigma“project”.
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Common Characteristics of Six Sigma Project*
While each healthcare organization has specific needs and issues to resolve, the most successful Six Sigma projects usually share common characteristics:
• Feasibility from a resource and data standpoint • Unambiguous parameters and clearly defined goals • Alignment with critical hospital issues and strategic initiatives • Provision of visible benefits for the customer • Inclusion of a Green Belt or Black Belt working within the project area • Ability to show measurable improvement • Linkage with other projects for a combined effect • Personal connection for the project leader
*Source: Guidelines for Six Sigma Healthcare Project Selection by Wendy Catalani-Davies and Carl Vieth – iSix Sigma Healthcare
Admittance to the funnel requires these characteristics
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Project Contact
Finance Contact
Recommendation Why/Why not? Estimated Financial Impact
Robust Data System
Ease of Implem-entation
1 IP Discharge E Yoder S Maxwell Yes
Big $; however, difficult from data and behavioral standpoint H N L
2 IP Discharge P Lamb S Maxwell YesSolid $ and data system available. M Y H
3 IP Transfer
D Thomas (IT) - data from Invision S Maxwell Pending
Further scoping needed to validate data system and $. M Y (?) L/M
4 LOS C Trembath S Maxwell Yes
Lines up nicely with strengths of Six Sigma project. Good $. M Y M
5 Readmission M Klobucar S Maxwell Pending
Readmit rate 7.5% (15 day); 10.7% (31 day). Need to validate $. M Y M
Utilization
6Blood Bank Utilization by doc B Herschman S Maxwell Yes
Potential for decent return with minimal, targeted resistance. L/M Y M
7Hospitalist - LOS by doc E Yoder S Maxwell Pending
New group recently in place. Metrics improving - wait. L Y H
8Monitored bed utilization D McLean S Maxwell Yes
Strong financial impact. Potential for M or H resistance H Y L/M
Utilization in targeted areas (Onc, Card, etc)
Project NameIn Preparation of Project Selection MeetingTo Be Filled In After Project Brainstorming Meeting
Project Description
Improve efficiency and discharge IP earlierBed clean / TAT for Housekeeping. Use of Bed Tracking Mitigate # of IP transfers between departments
LOS by DRGReadmission to hospital within 15 & 31 days
St. John Health - Providence Hospital Project Identification
Financial Impact: L < $100K, M $100K - $500K, H > $500K
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Project Identification/Funnel Screen Example
Project Description/Project Name Data Requirements Metric(s) Impacted hospitals Project ROICompeting Priorities
Team Availability Sponsor
Alignement w/strategic plan ROI Value
Operating Room Thruput
1st Case start informationTurn Around TimeOR UtilizationBlock UtilizationCost Per CaseVolumes/Day/Month
Cases/Day Hospital A TBD 3 3
LOS Reduction (initial focus on outliers)>$50K ReportLOS by DRG
Dollars in Outliers?
Hospital B TBD 3 3
Revenue Cycle
Days in ARDenialsRegistration ErrorsCo-pays/Con-Insurance CollectionsCharge CaptureWrite-offs/collection agency
Days in ARDenialsPOS Collections
System TBD 7 7
Registry Usage (Radiology & Nursing)
Staffing/hourRegistry costs/day/monthOvertime/day/monthDepart/Registry usage
System TBD 3 7
Test Edits (Revenue Cycle - prior to bill drop)
Any/all test edit data Days in AR Med Group TBD 3 3
Call Centercall abondanment ratecall lengthwait times
Med Group TBD 3 1
Inventory Reductions & Supply Standardizations
TBD
Inventory CostsSupply Cost/Case
Hospital B TBD 1 1
Ancillary Service Utilization TBD System TBD 1 1
Staffing Variances buget vs actual costsVariance (Budget-Actual)/Mo
Hospital C 7 3
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Model for Project Generation - A Better Way?
Operations Plan
Strategic Plan
Project ScopingWhat is the right operational area for a project?
DMAIC
Project Conclusion
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Common Problems in Creating a Funnel
Little or no executive involvement• Fear or the “No problems here” syndrome• Six Sigma (quality / process improvement) is someone else’s
responsibility• No personal connection
Projects are driven from the bottom up
Not enough time to scope properly
Not truly a Six Sigma project (Classification)
No clear line of sight to organizational metrics that are important to the executives
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Lead Time Defect Rate
M Work-OutTM
“Expert Driven” “Data Driven”
H
Type of ChallengeN
on
Val
ue
Co
st R
edu
ctio
n
Six Sigma
Lean“Waste Elimination”
[Months]
[Weeks]
Lean Six Sigma
Uncommon Tools for Healthcare Challenges
Lean + Six Sigma = Speed + QualityLean + Six Sigma = Speed + Quality
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Comparison of Lean and Six Sigma
Lean Six Sigma
Goal Create flow and eliminate waste Improve process capability and eliminate variation
Application Primarily manufacturing processes* All business processes
Approach Teaching principles and "cookbook style" implementation based on best practice
Teaching a generic problem-solving approach relying on statistics
Project Selection
Driven by Value Stream Map Various approaches
Length Of Projects
1 week to 3 months 2 to 6 months
Infrastructure Mostly ad-hoc, no or little formal training
Dedicated resources, broad-based training
Training Learning by doing Learning by doing
Retrieved from: www.isixsigma.com
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Case Study - ED Throughput
Value Stream Map illustrates various “flows” within the ED
Bottlenecks are flagged for analysis to determine whether Lean opportunities are present
Flow issues Value Analysis
Concurrently, VOC data is collected to determine direction for formal efforts in a Six Sigma project(s)
♦ The appropriate use of Lean and Six Sigma will allow maximum efficiency and effort to be realized
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Case Study - ED Throughput
Lean is predicated upon the identification and elimination of waste
7 Wastes addressed by Lean1. Multiple processes2. Incomplete information3. Communication gaps4. Waiting5. Incorrect data6. Lack of standards7. Unnecessary approvals
Technique used = 5S Red TagSort-Standardize-Simplify-Sweep-Sustain Express Care Mini Kaizen
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Case Study - ED Throughput
Six Sigma employs a data-driven methodology to systematically break a problem down into key drivers, based upon various statistical analyses
Estimated Effects and Coefficients for D2D (coded units)
Term Effect Coef SE Coef T PConstant 87.34 2.547 34.30 0.000Express Care 35.56 17.78 2.547 6.98 0.000X-Ray 36.06 18.03 2.547 7.08 0.000Bed Open -37.81 -18.91 2.547 -7.42 0.000Express Care*X-Ray 33.69 16.84 2.547 6.61 0.000Express Care*Bed Open 32.56 16.28 2.547 6.39 0.000X-Ray*Bed Open 14.06 7.03 2.547 2.76 0.025Express Care*X-Ray*Bed Open 5.19 2.59 2.547 1.02 0.338
S = 10.1865 R-Sq = 96.87% R-Sq(adj) = 94.12%
Analysis of Variance for D2D (coded units)
Source DF Seq SS Adj SS Adj MS F PMain Effects 3 15979.9 15979.9 5326.6 51.33 0.0002-Way Interactions 3 9571.7 9571.7 3190.6 30.75 0.0003-Way Interactions 1 107.6 107.6 107.6 1.04 0.338Residual Error 8 830.1 830.1 103.8 Pure Error 8 830.1 830.1 103.8Total 15 26489.4
Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open
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Case Study - ED Throughput
Dual approach of Six Sigma and Lean enabled achievement of the goal for this project
Accomplishments Mean reduced by 25 min (38%) Std Dev reduced by 17 min (38%) Range reduced by 46% Z-score improved by 0.44DPMO reduced by 158,333 Flow improved with elimination of Non-Value Added process steps Standards created to sustain change Financial Impact ~ $1 million
Phase
95% Bonferroni Confidence Intervals for StDevs
Measure
Control
50454035302520
Phase
Data
Measure
Control
250200150100500
F-Test
0.002
Test Statistic 0.37P-Value 0.000
Levene's Test
Test Statistic 9.67P-Value
Test for Equal Variances (Measure-Control)
250
200
150
100
50
0
250
200
150
100
50
0
Measure Control
Individual Value Plot of Measure Data, Control Data
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Case Study – Sustaining Change
(Week of)
Sam
ple
Mean
10/ 2510/ 1810/ 1110/ 49/ 279/ 209/ 139/ 68/ 30
80
60
40
20
0
__X=42.43
UCL=81.88
LCL=2.97
(Week of)
Sam
ple
Ran
ge
10/ 2510/ 1810/ 1110/ 49/ 279/ 209/ 139/ 68/ 30
160
120
80
40
0
_R=68.4
UCL=144.6
LCL=0
Xbar-R Chart of Door to Doc Time
Door to Doctor Time
R1 (04-04) R4 (09-04) 12-04
Mean 64.3 min 39.8 min 42.4 min
St Dev 44.7 min 27.7 min 28.6 min
LWBS 2.0% 1.0% 1.2%
ZST 1.91 2.35 2.22
Project Opportunities• Increase Patient Satisfaction (Press Ganey)
12-03 09-04 ED Top Box 51.6 53.4
• Financial Impact Hard Dollar Opportunity = $948,063 Based upon 444 visits & 186 admits
Captured 175 visits & 40 admits YTD
• Throughput / ED Volume Nov YTD Visits over budget by 744
(+1,043 PY) Nov YTD Admits over budget by 497
(+516 PY) FY 2004 Nov YTD LWBS% = 2.1% vs
1.2%
Lessons Learned
+ Associate participation Need all “vital” Xs forand empowerment complete sustainability
Consistent message and Heavy volume and shiftfocus to IP strains system
Six Sigma works
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Wave II – The Cycle ContinuesE D T hro ug hp ut
(D isp o to E D D isch arg e)
K a thy RyanP ro je ct S p o nsor
M K e lly -N icho lsG ree n B e lt
L eadP ro ce ss O w n er
S tev e M cG rawG e org e H ig heY e llo w B e lts
Je n C arp en te rR o se L ow ryY e llo w B e lts
L isa P lecha
Y e llo w B e lt
B e n M ilesS ix S igm a B lack B e lt
E D T hro ug hp u t(D isp o to IP A d m is sio n )
P r is c illa L am bP ro je ct S p o nsor
Ju lie B e llL y nn C h ie saG ree n B e lt
K a tr ina S v o bo daD e n ise M cLe an
Y e llo w B e lts
Ja n H u gh esW e nd y C o leY e llo w B e lts
S u e T uck erC . T re m b a th , M D
Y e llo w B e lts
B e n M i lesS ix S igm a B lac k B e lt
ED T hroughput(R adio logy P rocedure T AT)
M ar i lou ise R iskaP ro je ct S p o nsor
M a rty Ha r r is, M DG ree n B e lt
L ead
R o g er G o n d a, M DY ello w B e lt
P ro ce ss O w n er
C h ris t ine C ro skeyS e rb a n D utica
S ue B ir liY e llo w B e lts
L isa B ur ryD e n ise H o hn er
G e ra rd Surm an n, MDY ello w B e lts
B e n M ilesS ix S igm a B lack B e lt
Tied to improvementstrategies of Phase IDoor-to-Doc Project
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Engaging Executives at All Levels
Engagement as a function of knowledge
Engagement as a function of accountability
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Engagement as a Function of Knowledge
Not all executives created equal (Power/Influence tool)
Tools for increasing knowledge:• Six Sigma Awareness Day
• Executive Briefings
• Project Reviews
• Articles in hospital newsletter
• Posters
• Medical staff meeting presentations and project recaps
• Physicians on project teams (Green Belts or Team Members)
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Engagement as a Function of Accountability
Organizational level goals and expectations• ROI or Savings• Increases in patient/customer satisfaction• Tied to strategic or operational goals and accountability
Executives responsible for moving metrics• Black Belts responsible for solutions / project sponsors
accountable for results• Project Sponsors lead Report-Outs• Executive Sponsors (Champions) responsible for
organizational metrics and Six Sigma’s contribution
For questions regarding the presentation contact:
Chuck DeBusk, GE Healthcare
763 561 9263
Ben Miles, St. John Health
248 849 5823
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