Six Sigma in Healthcare: A prescription for change?

1. Six Sigma in Healthcare: A prescription for change? Carolyn Pexton October 24, 2007 CAHPMM Annual Conference

2. Objectives • Articulate the case for organizational transformation in healthcare • Acquire high-level understanding of Six Sigma and related change management methods • Learn from case study examples • Know the keys to a successful deployment 2

4. The Need for Change in Healthcare

5. A Perfect Storm • Patient safety and quality concerns • Demographic changes • Rapidly changing technologies and treatment • Digital transition • Workforce issues • Financial constraints • Rising consumerism • Un and Under-insured • Leadership challenges

6. Time cover story - May 1, 2006 Q: What Scares Doctors? A: Being the Patient “To a large extent, health care systems were not designed with any scientific approaches in mind. Too often there are long waits, high levels of waste, frustration for patients and clinicians alike, and unsafe care. A bold effort to design health care scheduling systems, process flows, safety procedures, and even physical space will pay off in better, less expensive, safer experiences for patients and staff alike.” – Don Berwick, IHI

7. The high cost of poor quality: New payment rules from CMS • Along with human suffering, treating medical errors such as hospital-acquired infections come with a high financial cost. • Roughly 1 in 10 Americans will acquire an infection as a result of their hospital stay, and this stay will be lengthened in order to provide appropriate treatment. • Hospitals will no longer be reimbursed by CMS for certain errors and the additional resources they require. • Change is imperative! Centers for Medicare and Medicaid Services (CMS), HHS CMS-1533-FC, Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates.

8. Technology alone isn’t the answer… Simply overlaying 21st century technologies on top of 20th century workflow will not yield the necessary cost, quality and efficiency benefits. Hospitals must also redesign processes and address the human side of change.

9. Overcoming the barriers • Culture • Overcome resistance • Shape common goals • Alignment and accountability • Ensure clear linkage between improvement initiatives, performance and strategic goals • Develop consistent management structure • Control • Put mechanisms in place to monitor and maintain results long-term

10. Getting there from here • Transformation in healthcare won’t happen without transparency. • Transparency can’t happen without culture change. • Culture change won’t happen without a bold vision, a common toolset and unwavering commitment.

11. Six Sigma Background and Basics

12. Where did Six Sigma Come From? • Initially developed at Motorola in the 1980s to improve processes, meet customer expectations and maintain market leadership • During the first five years, even suppliers were required to participate in the process • Six Sigma was adopted by Allied Signal and GE and further developed into a true management system • Success led to global deployment across a variety of companies and industries – including healthcare!

13. 308,537 2 3 66,807 6,210 4 5 233 6 3.4 What does Six Sigma mean? DPMO ZB • The term “Sigma” is a measurement of how far a given process deviates from perfection – a measure of the number of “defects”. Six Sigma correlates to just 3.4 defects per million opportunities. A qualityimprovement methodology that applies statistics to measure and reduce variation in processes. A management systemthat is comprehensive and flexible for achieving, sustaining, and maximizing success.

14. Key Concepts • Critical to Quality (CTQ): Attributes most important to the customer • Defect: Failing to deliver what the customer wants • Process Capability: What your process can deliver • Stable Operations: Ensuring consistent, predictable processes to improve what the customer perceives

15. An Enabler for Cultural Change Patient’s View of “Registration” • How does the customer view my process? • What does the customer look at to measure performance? Registration Time to drive to facility Time to Park Car Lobby Time Walk to Procedure Area Procedure Time Hospital’s View of “Registration”

16. Six Sigma illustrated Target CustomerSpecification BEFORE 3s 3s 6.6% Defects w i d e v a r i a n c e Target CustomerSpecification AFTER 6s 6s No Defects slim variance Patients don’t feel the averages, they feel the variability

17. How good are we today? Sigma Level Statistically... DPMO Six Sigma refers to a process that produces only 3.4 Defects Per Million Opportunities 2 308,537 3 66,807 4 6,210 5 233 6 3.4 Goal ~93.3% “Good” 99.99966% “Good”

18. How good do we need to be? The Classical View of Quality “99% Good” (Z = 3.8s) The Six Sigma View of Quality “99.99966% Good” (Z = 6s) 20,000 lost articles of mail per hour Seven lost articles of mail per hour Unsafe drinking water almost 15 minutes each day One minute of unsafe drinking water every seven months 5,000 incorrect surgical operations per week 1.7 incorrect surgical operations per week 2 short or long landings at most major airports daily One short or long landing at most major airports every five years 200,000 wrong drug prescriptions each year 68 wrong drug prescriptions each year No electricity for almost 7 hours each month One hour without electricity every 34 years

19. The DMAIC Methodology and relate it to the customer.., ... define the problem, clarify Define CTQs Practical Problem ...measure your target metric and know your measure is good... Statistical Problem …look for root causes and generate a prioritized listing of them. Statistical Solution ... determine and confirm the optimal solution ... Practical Solution …be sure the problem doesn’t come back… sustain it

20. Sample fishbone diagram – poor x-ray quality • Form cross-functional team • Construct cause-and-effect diagram, listing potential causes on each branch • Prioritize causes on each branch – select important causes and ignore trivial ones • Conduct detailed analysis and develop an action plan • Follow up until action is completed and results are verified • If results are unsatisfactory, use statistical tools (such as Regression Analysis) to further analyze the problem

21. Key roles and responsibilities Champions/Sponsors: Trained business leaders who lead the deployment of Six Sigma in a significant business area Master Black Belts: Fully-trained quality leaders responsible for Six Sigma strategy, training, mentoring, deployment and results Black Belts: Fully-trained Six Sigma experts who lead improvement teams, work projects across the business and mentor Green Belts Green Belts: Fully-trained individuals who apply Six Sigma skills to projects in their job areas Team Members: Individuals who receive specific Six Sigma training and who support projects in their areas

22. Translating Goals into Results The Big Ys Clinical excellence Patient safety Financial results Patient satisfaction Physician/staff satisfaction Community service ALL DRIVEN BY PROCESSES

23. Linking Projects to Healthcare “Y”s CTQ’s World Class Team Clinical Quality Growth Excellent Service Top Financial Performance Quality Measures Reimbursement Productivity Patient Flow Wait Times/Delays Core Measures Performance (CHF) Accuracy of Patient Info Nursing Documentation Discharge Process Lab TAT Communication of Quality-Public Pain Management ICU Throughput Medical Necessity Validation Radiology TAT Certifications/ Accreditations On Base Implementation Appropriate Placement PACU/ED Admit to Bed POS Collections ICU Clinical Effectiveness Cath Lab Scheduling System Patient Classification Process Reconciliation of Patient Medicine Reduce FPC No Shows

24. Perioperative Service Needs Project Solutions Performance Metrics Critical Factors Core Business Metrics • Preop delays • Surgeon NA • Anesthesia NA • Equipment/ Supplies NA • Lean Preop Process • Staffing/anesthesia time • Preference Cards • Equipment replenishment First Case Start Time • Quality • Capacity • Net Revenue Room Turnover Time • Staff roles • Setup/Cleanup process • Communication • Work-Out: Work Process, Roles, Responsibilities, Communication • Kaizan Event: TAT • Level Loading Blocks/ Cases across days/time by clinical service • Match sched to staffing • New guidelines: Add-ons • Block Time Allocation/Util • Case Time Alloc • Add-on Mgmt • Scheduling Guidelines Room Utilization Patient Safety • Process for identifying, reporting, taking corrective action • Anesthesia Time • Right Side • Instrument Counts

25. Hospital Management Processes Clinical Care Processes Business Processes The Ultimate Goal Becoming a Better Healthcare Provider Outcome Patient Safety Patient Satisfaction Physician – Staff Satisfaction Community Relationship Financial Viability Performance Excellence Tools Projects and Work-Outs It’s really not about projects – they are a means to an end!

26. In simple terms… • Listen to the customer • Define their expectations • Measure how many times we get it wrong • Fix it • Prove the fix is real and meaningful • Make it stick !!!!!

27. Related Methodologies and Change Management Techniques

28. Large scale improvements require precise coordination and a common “cadence” to advance smoothly 62% of initiatives fail due to lack of leadership commitment

29. Leading Change Creating a Shared Need Shaping a Vision Mobilizing Commitment Current State Transition State Improved State Making Change Last Monitoring Progress Changing Systems & Structures Change Acceleration Process (CAP)

30. Stakeholder Analysis Dr. XYZ x Influence loop Dr. R

31. Exercise: Stakeholder Analysis • Take home assignment for your current project: • Brainstorm key stakeholders by name • Plot where individuals currently are with regard to desired change ( = current). • Plot where individuals need to be at the minimum level (X = desired) in order to successfully accomplish desired change-identify gaps between current and desired. • Indicate how individuals are linked to each other, draw lines to indicate an influence link, using an arrow to indicate who influences whom. • Plan action steps for closing gaps with influence strategy.

33. Ground Rules, Introductions, Roles, etc Brainstorm Issues/Barriers Kick-Off Define the Problem What: Who: When: Resources Mission Prioritize Categories Categorize Issues/Barriers Define “Headers” for Categories Brainstorm Potential Solutions 2 10 9 4 6 votes Develop Action Plans Share Action Plans Report-Out Action Plans Assess Potential Solutions Pay-off Work-OutTypical Session

34. What is Lean? • The relentless pursuit of the perfect process through waste elimination… We Spend 75-95% of Our Time Doing Things That Increase Our Costs and Create No Value for the Customer! In healthcare, Lean is about shortening the time between the patient entering and leaving a care facility by eliminating all non-value added time, motion, and steps.

35. Lean Thinking Process The 5 steps to Lean Thinking … 2 Map the Value Stream Map all of the steps…value added & non-value added…that bring a product of service to the customer Define value from the customer’s perspective and express value in terms of a specific product 1 Specify Value 3 Establish Flow The complete elimination of waste so all activities create value for the customer 5 Work to Perfection The continuous movement of products, services and information from end to end through the process 4 Implement Pull Nothing is done by the upstream process until the downstream customer signals the need What are your customers willing to pay for?

36. Project funnel and tool selection Best practice, patient satisfaction results, benchmarks, suggestions, complaints Voice of Customer Inefficient processes, waits, rework, errors, substandard performance Opportunities Scoping How do you know you have a problem? Is data available? What is expected performance or CTQ’s? What is payback/benefits of project? Do you have the appropriate sponsor? Low Hanging Fruit Projects Priority Setting Mgmt Engineering Study Work-Out Six Sigma DMAIC Lean Tool Selection CQI Team CAP

37. Synergistic Tools and Processes • Change Acceleration Process (CAP)– a process that proactively plans for change acceptance for successful implementation • Work-Out - a process that promotes rapid problem solving via involvement and accountability • Lean - an improvement methodology focused on eliminating waste through detailed analysis of workflow in relation to time • Six Sigma – an improvement methodology driven by the statistical analysis of data to identify causes of unwanted variation and defects

38. Healthcare Case Study Examples

39. Healthcare Project Examples • Improving process/safety for medication administration • Reduction in Blood Stream Infections in ICU • Reducing ventilator acquired pneumonia • Emergency Department Patient Wait Time • Improved Patient Throughput in Radiology • Reduction in Lost Films • MR Exam Scheduling Improvement • Staff Recruitment and Retention • Operating Room Case Cart Accuracy • Physician (Professional Fee) Billing Accuracy • Appointment Backlog for Hospital-Based Orthopedic Clinic • Quality of Care and Satisfaction of Families in Newborn ICU

40. Pioneers in Six Sigma for Healthcare • In March 1998, John C. Desmarais, Commonwealth Health Corporation's President and Chief Executive Officer, introduced CHC to Six Sigma, a quality initiative program developed by Motorola and perfected by General Electric. • By the end of 2001, over 2000 employees had attended at least one full day of Six Sigma awareness training, • Initial projects generated annualized savings of $276,188 in billing, decreased annual radiology expenses by $595,296, and reduced errors in the MR ordering process by 90%. • Within 18 months, CHC had increased efficiency, improved the patient experience, eliminated over $800,000 in costs and reenergized the culture. Commonwealth Health Corporation web site – www.chc.net

41. Case Study: Improving ED Throughput Project Title: ED Throughput Project Scope: In Scope - Treat to Street pts, Staffing patterns (ED MDs & RNs), Equip’t, FTEs, Registration, Lab, X-R. Out of Scope - ED Admits, ED Hold Hours, Bed Control, Housekeeping, Transport to Floor, MR, US, CT, Pharm. Customer(s): Patients, Physicians • Potential Benefits: • Decrease LWBS • Increase patient satisfaction (Press Ganey #s) • Reduce ED LOS (Soft Dollars) Project Description : PS - Moving “Treat-to-Street” patients through the ED takes too long. PD - One-third of our patients wait longer than 60 minutes to be seen by a physician. • Alignment with Strategic Plan: • Customer Service • Growth • Efficiency

42. Measure • What is the Right Y (CTQ) to Measure? How will it be measured? • Y = Door to Doc Time. From the time a patient enters through the door until the physician enters the exam room to assess the patient, measured in minutes. • What is our goal? • We will improve the average ED Throughput Time for Treat and Street Patients by 40%. This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes. • We will improve our throughput yield of patients seeing a physician within 60 minutes (USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over 7,500 customers. • What are the specification limits? (LSL, USL) What is the Target? • Based upon our VOC data, we have set a USL of 60 minutes and a Target Mean of 40 minutes.

43. Analyze Value Stream Map Opportunities for Performance Improvements: Door-to-Doc Subcycle Triage EKG, Draw Blood, UA, Order X-Ray, administer Pain med 2- RNs 1 Tech Fax written report/ED X-Ray – In ED Front Desk / QR Portable Team Area Lab ED Waiting Room Call critical values Patient Flow Treatment People Flow (RN, MD, etc.) Tube/blood E-Info Flow MD Other Flow (blood, etc.) Phone Call Arr QR QR Triage Triage Bed Bed MD 6.3 min Patient Wait Time 11.6 min 23.5 min 22.9 min Current Average Cycle Times

44. Analyze Statistical Analysis Hypothetical Driver (X) Statistically Proven (X) Bed Available Nurses Census X-Ray Lab Shift Day of Week

45. Analyze What X’s (inputs) are causing most of our variation? Results for: Historical DOE Door to Doctor Time Factorial Fit: D2D versus Express Care, X-Ray, Bed Open` Estimated Effects and Coefficients for D2D (coded units) TermEffectCoefSE CoefTP Constant 87.34 2.547 34.30 0.000 Express Care 35.56 17.78 2.547 6.98 0.000 X-Ray 36.06 18.03 2.547 7.08 0.000 Bed Open -37.81 -18.91 2.547 -7.42 0.000 Express Care*X-Ray 33.69 16.84 2.547 6.61 0.000 Express Care*Bed Open 32.56 16.28 2.547 6.39 0.000 X-Ray*Bed Open 14.06 7.03 2.547 2.76 0.025 Express 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) SourceDFSeq SSAdj SSAdj MSFP Main Effects 3 15979.9 15979.9 5326.6 51.33 0.000 2-Way Interactions 3 9571.7 9571.7 3190.6 30.75 0.000 3-Way Interactions 1 107.6 107.6 107.6 1.04 0.338 Residual Error 8 830.1 830.1 103.8 Pure Error 8 830.1 830.1 103.8 Total 15 26489.4

46. Improve • What do we want to know? • Screen Potential Causes? • Discover Variable Relationships? • Establish Operating Tolerances? • What X’s (inputs) have we chosen to improve? • Bed Availability • – The Measure Phase data demonstrated that Door-to-Doctor time increased by two to • three times when there is no bed open for the patient. • Ancillary Services • – The data further showed that the time it takes to perform an X-Ray or Lab testing is statistically significant in relation to Door-to-Doctor time. • Express Care • – Lower acuity patients (i.e. Level 3 / Express Care) wait longer to see a physician than do higher acuity patients (i.e. Level 1).

47. Improve Value Stream Map Key Points / Opportunities for Improvement: Bedside Registration Triage EKG, Draw Blood, UA, Order X-Ray, administer Pain med 2- RNs 1 Tech Non-value added step removed Registration If rooms ful may reg pt while waiting. Front Desk / QR ED Waiting Room Patient Flow People Flow (RN, MD, etc.) Impacts: 1 – Inc. Patient Satisfaction 2 – Red. time by 8.7 minutes 3 – Red. variability in process E-Info Flow Patient Wait Time

48. Improve • What is the mean and median of our process? What is the standard deviation? Measure PhaseControl Phase+D % • Mean score 64.3 minutes 39.8 minutes 38.1% • Median 38.5 minutes 34.0 minutes 11.7% • Standard Deviation 44.7 minutes 27.7 minutes 38.0% • HI/LO 241 / 11 minutes 129 / 4 minutes 46.5% (HI; outliers) • Range 230 minutes 125 minutes 45.7% • What is our process capability (Z score, DPMO, Yield %)? • Z Short-Term Score = 1.91s 2.35s 0.44s • DPMO = 333,333 175,000 <109,523> • Yield % = 66.7% 82.5% 15.8%

49. Control • What are our financial results? How were they calculated? • Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and the corresponding admissions as well as a conservative (5%) recognition as a result of throughput improvement. What is the plan for monitoring/ auditing the process? What is the Control Plan?

50. Case Study: Linen Utilization Project Title: Linen Utilization Project Description: To Identify opportunities within the organization which allows for better linen utilization without compromising quality or patient care. Problem Statement: Currently, our linen usage is higher than what is expected for a facility of our size and acuity level. We need to look for ways to better utilize our daily linen supply and lower our overall pounds per patient day as well as our cost per patient day. Project Scope: The use of linen for inpatients.