Six Sigma in Healthcare Training Model for Greenville Hospital Systems

1. Six Sigma in HealthcareTraining Model for Greenville Hospital Systems

2. Instructors • Ashley Kay Childers, PhD • BS, MS, Ph.D. in Industrial Engineering • Part-time with SCHA and HSSC • Researcher in healthcare improvement and emergency management • Faculty advisor of Clemson’s Chapter of IHI’s Open School for Health Professions • Rae Cho, PhD • BS in Chemical Engineering • MS in Systems Engineering • PhD in Industrial Engineering • Researcher in quality improvement • Editor-in-Chief, International Journal of Quality Engineering and Technology

3. What does Six Sigma mean? • Sigma is a measurement of how far a given process deviates from the target and measures the number of “defects.” • Six sigma correlates to just 3.4 defects per million opportunities (DPMO). Six Sigma… • Is a qualityimprovement methodology that applies statistics to measure and reduce variation in processes. • Is a management systemthat is comprehensive and flexible for achieving, sustaining, and maximizing success.

4. Six Sigma Lower Specification Limit Upper Specification Limit s 6.6% Defects 0% Defects Lower Specification Limit Upper Specification Limit s s 6 3

5. Six Sigma Benchmarks Goal Healthcare Manufacturing Industries Business Processes Airline s s s s 4.17 4.17 4 6

6. Healthcare How can Six Sigma Help?

7. Healthcare: Areas of Improvement • 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

8. “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, Institute for Healthcare Improvement (Time, 2006)

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

10. 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

11. 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.

12. Six Sigma Background and Basics

13. 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 • Successes lead to global deployment across a variety of companies and industries, including healthcare!

14. Define, Measure, Analyze, Improve, Control 1. Define What’s the problem? Who can fix it? What’s the process? 5. Control Did we improve? Let’s control the process! 2. Measure Can I explain a problemwith data? DMAIC Model 3. Analyze What’s the real problem? 4. Improve Let’s improve the process!

15. Key Concepts Critical to Quality (CTQ): Most important characteristics 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

16. 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 the performance? Registration Time to drive to facility Time to Park Car Lobby Time Walk to Procedure Area Procedure Time Hospital’s View of “Registration”

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 ~93.3% “Good” 99.99966% “Better” Goal

18. How good do we need to be ? The Six Sigma View of Quality “99.99966% Good” (Z = 6s) The Classical View of Quality “99% Good” (Z = 3.8s) 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. Sample fishbone diagram – poor x-ray quality

20. Key roles and responsibilities Champions: Trained business leaders who lead the deployment of Six Sigma in significant business areas 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

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

22. Linking Projects to Healthcare “Y”s World Class Team Clinical Quality Growth Excellent Service Top Financial Performance CTQ’s Quality Measures Reimbursement Productivity Patient Flow Wait Times/Delay 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

23. Perioperative Service Needs Performance Metrics Critical Factors Project Solutions 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

24. 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!

25. 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 !!!!!

26. Six Sigma Phases • Define the project goals and customer (internal and external) deliverables • Measure the process to determine current performance • Analyze and determine the root cause(s) of defects • Improve the process by eliminating the defects • Control future process performance

27. Six Sigma Phases- Overview Leadership Participation Project Team and Deliverables Oversight Documenting Process Support Project Charter Connecting with Customers Process Mapping SIPOC Kano Model Affinity Diagram Pareto Chart

28. Six Sigma Phases-Overview Measure Data Collection Data Evaluation Check Sheets Pareto Analysis Time Study Time Value Analysis

29. Six Sigma Phases-Overview Analyze Brainstorming and Other Techniques Data Analysis Brainstorming Scatter Diagram Affinity Diagram Statistics Cause and Effect Diagram Graphs Why and Why Diagram

30. Six Sigma Phases- Overview Improve Improvement Techniques Check Sheets Force Field Diagrams Design of Experiments

31. Six Sigma Phases-Overview Control Control Techniques Process Maps Control Charts Basic Statistics

32. Healthcare Six Sigma Case Study Reducing CVC-Related Bloodstream Infections at Florida Hospital

33. Six Sigma Phases In 2003-2005, Florida Hospital in Central Florida initiated a Six Sigma project to reduce the rate of bloodstream infections through central venous catheters

34. Six Sigma Phase-Define Define In Scope: Inpatients re-admitted within 2 weeks of confirmed BSI In Scope: Inpatients admitted within last 48 hours

35. Six Sigma Phases-Measure Measure Target: Reduction of BSI cases by 20% from avg. of 6.33 cases/month Length of the stay of BSI patient > Non BSI by 20.6 days

36. Six Sigma Phases-Analyze Analyze Fish bone diagram: Critical Xs SIPOC Chart Statistical Analysis

37. Six Sigma Phases- Improve Improve New Standard Operating Procedures Hand hygiene campaign Employee poster contest Error Proofing

38. Six Sigma Phases-Control Control Monthly infection rates BSI rates within limits Estimated savings

39. Results Results Overall BSI rates BSI cases Estimated savings

40. Lean Six Sigma • Finds its root from Six Sigma, but focuses on waste elimination. • How would this benefit GE Healthcare ? • On an average it requires 5-6 months for the complete implementation of the six sigma projects in healthcare. • With the inclusion of the lean philosophies the project duration could be brought down to 30-45 days.

41. Lean Six Sigma Each patient is unique but the processes around them are not. - American Society of Quality • What lean qualities would be included in the training modules ? • Developing a roadmap for effective ‘lean’ integration. • Sustaining the lean model. • Lean performances during budgetary restrains.

42. Lean Six Sigma Community Medical Center, Missoula, Mont Problem: The cardiology program was adding two more cardiologists, and the outpatient cardiac diagnostic lab had a capacity of only eight exams per day. Action: Work was redesigned, without adding staff or buying new technology. Results: In a single day, capacity was doubled to accommodate 16 exams.

43. Lean Six Sigma Pella Regional Health Center, Pella, Iowa Goal: To reduce the speed (cycle time) of the admissions process by 25%. Action: Reduced number of unnecessary questions on the fact sheet and provided information in "admissions packets. Results: Decreased admission cycle time by an average of 71%, from an average of 17 minutes to less than 5 minutes