Workbook
A Review of Basic Concepts
with Exercises, Checklists, and Learning Guides
5.
Evelyn A. Catt, 2015
Lean Focus
Lean is focused on the constant
pursuit of perfection Perfection
added activities
Flow
6.
Evelyn A. Catt, 2015
Pursuit of Perfection
Lean is focused on the constant pursuit of
perfection using:
Evidence based practices/standard work Perfection
Continuous Improvement (PDSA cycle)
Monitoring quality & performance metrics
Waste
Value
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
8.
Evelyn A. Catt, 2015
Types of Waste (Muda)
Errors, poor quality, failure to meet
Defects customer requirements
Providing unnecessary products,
Overproduction services, or features. Perfection
Delays, periods of inactivity,
Waiting bottlenecks, or patient wait time.
Failure to fully utilize human potential
Waste
Non-Utilized Potential (time and talents of people).
Unnecessary movement of supplies,
Transportation equipment, or people. Flow
Excess inventory/supplies, batch
Inventory processing, queues, or backlogs of work.
Extra steps taken by employees because Value
Motion of inefficient layout, searching, hunting
and gathering.
Excess activity and processing steps
Excess Processing caused by poor process design.
Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.
Source URL: http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples
9.
Evelyn A. Catt, 2015
Create Flow
Flow is the continuous movement of
people, materials and supplies through a Perfection
process.
Flow ensures that patients have what they Waste
need exactly when they need it.
No delays or waiting Flow
One piece flow (instead of batching)
Well organized supplies and work space Value
Alignment of work volume and resources
Replenishment of only what is needed
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
10.
Evelyn A. Catt, 2015
Establish Pull
Pull is the timely transition of work from
one process step to the next. Perfection
Pull means performing work as it is
requested or needed by a step in the value Waste
stream so that demand triggers action.
Pull
When a downstream process is ready for
more supplies, patients, etc., a signal is
Value
made to pull more into the process just in
time (JIT).
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
11.
Evelyn A. Catt, 2015
Specify Value
Value is defined by the patient.
Perfection
Value may be tangible or intangible.
Every process should be designed Waste
to deliver what the patient values
and would be willing to pay for in the Flow
service/care that is being provided.
Value
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
12.
Evelyn A. Catt, 2015
Value Added
Example: Medication Administration
Value Added
Non-Value Added
13.
Evelyn A. Catt, 2015
Non-Value Added
Example: Medication Administration
Value Added
Non-Value Added
14.
Evelyn A. Catt, 2015
Impact of Non-Value Added Steps
Non-value added steps and waste
may result in: Value Added
15.
Evelyn A. Catt, 2015
Value Streams
16.
Evelyn A. Catt, 2015
Value Stream
A value stream includes all of the steps and
activities required to provide services and care
for a patient.
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
17.
Evelyn A. Catt, 2015
Value Stream Levels
Pre-certification
Assessments
Registration Transition Planning
Detailed Interventions
Scheduling Referrals
Medication Admin.
Room assignment Prescriptions
Diagnostic Testing
Home Care
Registration
o Step 1 Assessments
o Step 2 o Step 1 Transition Planning
Step by Step
o Step 3 o Step 2 o Step 1
o Step 3 o Step 2
o Step 3
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
18.
Evelyn A. Catt, 2015
Lean Goals
The goal of using Lean is to eliminate the non-value
added elements (waste) in each value stream and
retain only the value added components.
Safety Accuracy Timeliness Comfort Dignity Knowledge
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
19.
Evelyn A. Catt, 2015
Value Stream Analysis
Value stream analysis is used to identify & eliminate
non-value added elements (waste) in a process.
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
20.
Evelyn A. Catt, 2015
Value Steam Mapping
Scope
Current State
Future State
Action Plan
References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patients Voice. J Amer Board of Fam Med.
2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008.
Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
22.
Evelyn A. Catt, 2015
Navigating the Value Stream
What is the plan for my journey
Plan of Care
through the value stream?
Patients value being well informed about Schedule
their plan of care, knowing their schedule,
and having options and choices. Choices
Cost
References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patients Voice. J Amer Board of Fam Med.
2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008.
Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
23.
Evelyn A. Catt, 2015
What will happen during my journey?
What are the treatment goals?
Goals
What are the potential risks?
What outcomes will be achieved? Risks
References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patients Voice. J Amer Board of Fam Med.
2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008.
Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
24.
Evelyn A. Catt, 2015
Patient Expectations
Does the patient have realistic
expectations for their journey? Plan of Care
25.
Evelyn A. Catt, 2015
What The Patient Expected
Safety Knowledge
Timeliness
Accuracy
Comfort Dignity
Evelyn A. Catt, 2015
26.
What The Patient Experienced
S.S. Healthcare
Errors Pain
Delays
27.
Evelyn A. Catt, 2015
Safe Passage Through
the Value Stream
28.
Evelyn A. Catt, 2015
Silos
Instead of working together as a value stream we often
function as silos that work in isolation from each other.
Reference: Hajek AM. Crushing the Silos: A Leadership Imperative to Ensuring Healthcare Safety in the Era of Healthcare Reform. 2010 Clarity Group, Inc. Source
URL: http://www.claritygrp.com/media/1346/crushing-the-silos-white-paper.pdf
29.
Evelyn A. Catt, 2015
Risk Mitigation
The potential risk of silos in the value stream must
be mitigated, especially during patient hand-offs.
Reference: Hajek AM. Crushing the Silos: A Leadership Imperative to Ensuring Healthcare Safety in the Era of Healthcare Reform. 2010 Clarity Group, Inc. Source
URL: http://www.claritygrp.com/media/1346/crushing-the-silos-white-paper.pdf
30.
Evelyn A. Catt, 2015
Safe Hand-offs
Implementing tools such as SBAR (situation,
background, assessment, recommendation) helps
ensure consistent hand-off communications are
completed.
Value added = increased patient safety.
Reference: SBAR Technique for Communication: A Situational Briefing Model. Institute for Healthcare Improvement.
Source URL: http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx
31.
Evelyn A. Catt, 2015
Evidence-Based Standard Work
Standard work is the best known way of
performing a process today. Best Known Way
and implemented.
References: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
32.
Evelyn A. Catt, 2015
Standard Work - Value Added
Reduces variation in performance
Best Known Way
Creates balanced work load
Creative Problem
Solving
Promotes consistency of outcomes
Continuous
Exposes waste in the process Improvement
References: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
33.
Evelyn A. Catt, 2015
Continuous Improvement
Lean is a journey of continuous improvement in
pursuit of perfection using:
Evidence based practices/standard work
Continuous Improvement (PDSA cycle)
Monitoring quality & performance metrics
Rapid Improvement Events (RIEs), Kaizen Events
Value Stream Mapping & Value Analysis
Lean 5-S (sort, store, shine, standardize, sustain,+ safety)
Visual Management (color coding, visual cues)
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
34.
Evelyn A. Catt, 2015
Summary
Lean is focused on the constant pursuit of
perfection by eliminating waste and non- Perfection
value added activities to improve the flow of
value to the patient. Waste
Value is defined by the patient.
Flow
Every process in the value stream should be
designed to deliver what the patient values
Value
in the service/care that is being provided.
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
35.
Evelyn A. Catt, 2015
Safe Passage
Our shared goal is the safe passage of all
patients through the healthcare value streams!
36.
Evelyn A. Catt, 2015
Systems Thinking
39.
Evelyn A. Catt, 2015
Plan Do Study Act (PDSA)
The PDSA Model for Improvement serves as the foundation of A3
Thinking and the pursuit of continuous improvement.
The PDSA model guides rapid improvement cycles using small tests
of change driven by empowered employees.
Reference: Institute for Healthcare Improvement (IHI), 2011. Diagram Source: http://www.saferpak.com/images/pdsa.gif
40.
Evelyn A. Catt, 2015
Plan Do Study Act (PDSA)
The PDSA Cycle uses the following steps in an iterative cycle of
continuous improvement.
STEP ACTIVITY
PDSA
Model
A3
Problem
Solving Lean
Six Sigma
Tools, Analysis,
and Solution
Development
Reference: A3 Thinking
Source URL: http://a3thinking.com/ 42.
Evelyn A. Catt, 2015
Lean, Six Sigma, and A3 Thinking
The appropriate Lean and Six Sigma methods and tools are selected
based on the scope, complexity, and directional flow of each problem.
Horizontal flows (value stream mapping)
Vertical depth (root cause analysis)
Highly complex issues (statistical analysis)
Rapid cycle improvements (Kaizen)
Safety issues (mistake proofing, root cause analysis)
Supplies and equipment (Kanban, Lean 5-S, visual controls)
Throughput (standard work, value stream mapping)
Work flow and environment (Lean 5-S, flow, pull, cellular layout)
Reference: A3 Thinking
Source URL: http://a3thinking.com/
43.
Evelyn A. Catt, 2015
A3 Thinking
Why is it called A3 Thinking?
The term A3 refers to the 11x17 size of paper used for the A3 report.
The A3 report format is used for simplicity, consistency, and also serves
as a rapid communication tool to promote organizational learning.
*Countermeasures are proposed solutions to address the root cause of the problem and move the process closer to the target state.
SUSTAIN
OPTIMIZE
SIMPLIFY &
STANDARDIZE
CUSTOMER FOCUSED
46.
Evelyn A. Catt, 2015
Origin of Lean
Lean principles are based on a management philosophy derived
from the Toyota Production System (TPS).
This is achieved by getting the right things to the right place at the
right time in the right quantity to achieve perfect work flow, while
minimizing waste.
47.
Evelyn A. Catt, 2015
Lean Focus
48.
Evelyn A. Catt, 2015
Lean Thinking
Lean Thinking
creates a culture and practices
that continually improve
all functions by all people
at all levels in the organization.
49.
Evelyn A. Catt, 2015
Lean Rules
RULE 1: Clearly specify all activities. RULE 2: Clearly define all connections to
Mindful standardization of work. every customer and supplier.
Content: What is being done? No ambiguity.
Direct (no intermediary between)
Sequence: In what order?
Yes or No answers (no maybes)
Timing: How long should it take?
Outcomes: What clearly defined RULE 4: Continuously Improve.
measurable results are expected? Develop leaders who can apply the
scientific method to improve anything.
RULE 3: Clearly define all pathways. Direct response to any problem that arises.
Organize for uninterrupted flow.
By those doing the work - as close to the
Simple (with as few steps and people problem as possible.
as possible).
If feasible, start as an experiment.
Direct steps to deliver the requested
product or service. Supported by a coach.
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999
Source URL: http://www.systems2win.com/solutions/5s.htm
How will you communicate and prepare your staff for a Lean culture and
the new practices and expectations?
What tools or support will you need to make this a successful transition?
51.
Evelyn A. Catt, 2015
Lean
Key Concepts
52.
Evelyn A. Catt, 2015
Key Concepts
All work is a process and even the smallest change can
impact the entire organization.
53.
Evelyn A. Catt, 2015
Value Added Process
A value-added process:
Creates value for the patient/customer.
Produces a good result every time.
Does not cause delays.
Is satisfying:
for people to perform
for managers to manage
for patients to experience
Reference: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication
No. 08-0022, April 2008. Source URL: http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf
54.
Evelyn A. Catt, 2015
Waste
Waste is any activity that consumes time, resources,
or space but does not add value to the product or
service in the eyes of the patient.
And waste consumes resources!
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
Image Source URL: http://www.13dots.com/reddragon/trashcan/4.gif
55.
Evelyn A. Catt, 2015
The Cost of Quality
The Cost of Quality is the sum of four cumulative types of costs:
The Cost of Poor Quality is the cost associated with producing defects,
which includes internal failure costs and external failure costs.
57.
Evelyn A. Catt, 2015
Origin of Six Sigma
Six Sigma was originally developed by Motorola in 1986.
Motorola set a goal of "six sigma" (99.99966% perfect) for all of its
manufacturing operations, and this goal became a byword for the
methods used to achieve it.
Reference: http://en.wikipedia.org/wiki/Six_sigma
58.
Evelyn A. Catt, 2015
Six Sigma Focus
59.
Evelyn A. Catt, 2015
Lean Six Sigma Model
SUSTAIN
VALUE ACCURACY
OPTIMIZE
WASTE VARIATION
SIMPLIFY &
STANDARDIZE
CUSTOMER FOCUSED
60.
Evelyn A. Catt, 2015
Lean Six Sigma Methodology
Lean Six Sigma is a data-driven problem solving
methodology with a structured Roadmap (D-M-A-I-C).
61.
Evelyn A. Catt, 2015
NOTE: All projects
Lean Six Sigma Roadmap do not require the
use of every tool.
MEASURE Map and measure the process Detailed Value Stream Map Current state map created
to understand current Swim Lane Map Data collected & validated
performance. Spaghetti Diagram Baseline performance
Histograms/Frequency Plot measured and process
Control Charts/Process Capability capability evaluated
ANALYZE Identify amounts/types of waste Fishbone (Ishikawa) Diagram Waste & issues identified
and determine the root causes. Pareto Chart, Statistical Analysis Additional data collected
Hypothesis & Relationship Testing & critical factors identified
Capacity Analysis, Flow Analysis Root causes of errors,
Root Cause Analysis (5 Whys), FMEA waste & variation analyzed
IMPROVE Design the future state and Future State Value Stream Map Future state designed
select and test improvements. 5S, LEAN Tools, Kaizen Events Solutions selected, tested,
Visual Controls/Mistake Proofing and validated
Plan-Do-Study-Act (PDSA) Action plans created
Pilot Implementation Plan Pilot conducted
CONTROL Create a process control strategy Standard Work Instructions Control system in place
to sustain and spread the Control Charts & Control Plan Communication plan
improvements. Communication Plan implemented
Full Scale Implementation Plan Project celebration
Confidential/proprietary
Evelyn A. Catt, 2015 document 62.
Understanding Variation
Lean Six Sigma uses data:
To understand the sources of variation
o Reduce errors
o Increase safety
63.
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Variation & Reliability
Variation: A measure of change or difference.
64.
Evelyn A. Catt, 2015
Types of Variation
Common Cause Variation: Natural variation within a process
(expected or acceptable variation).
65.
Evelyn A. Catt, 2015
Variation in Healthcare Processes
Examples of variation in healthcare processes:
Quality
Accuracy of labeling blood tubes
Completeness of pre-op testing for surgery patients
High readmission rates for patients with diabetes
Timeliness
Turnaround time for test results
Length of time to get a clinic appointment
Waiting time in the Emergency Department
Cost
Variation in the cost of treating patients with the same diagnosis
Differences in the cost of supplies from multiple vendors
Fluctuations in employee turnover rates and the associated costs
66.
Evelyn A. Catt, 2015
Concept of a Function
Six Sigma changes the problem solving approach from trial and
error to Y = f (x).
A process is described by identifying the measurable output (Y)
and all known inputs (x).
The Six Sigma roadmap and tools are used to analyze the
relationship between the measurable output (Y) and the process
inputs (x).
Y = f (x)
The value of Y is a function of the value of x
67.
Evelyn A. Catt, 2015
Concept of a Function Example
Y (% of surgery on-time starts) = function of (x1, x2, x3, x4, x5,.)
68.
Evelyn A. Catt, 2015
Reducing Variation in Healthcare
To reduce variation in healthcare processes:
Identify the measurable output (Y) of the process.
Use LEAN Six Sigma tools to identify the few critical inputs that have
the greatest influence on the output.
Identify and correct the defects, errors, and variation associated with
these critical inputs. All possible inputs (xs)
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
70.
Evelyn A. Catt, 2015
Kaizen -
Continuous Improvements
71.
Evelyn A. Catt, 2015
Kaizen Continuous Improvements
Kaizen is Japanese for "improvement" or "change for the better. It refers to a
culture and practices that focus on continuous process improvements.
When applied in the daily workplace, Kaizen refers to activities that continually
improve all functions by people at all levels in the organization.
A Kaizen Event is an intense, rapid improvement event (RIE) with a team that
is focused on a specific process with a well defined scope.
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Evelyn A. Catt, 2015
Kaizen Agenda (Rapid Improvement Event)
DAY 3: Develop Solutions, Conduct Experiments, Develop Action Plans
Develop counter measures to address the root cause of the issues
Conduct rapid experiments to test the results of proposed solutions
Finalize solutions to implement; create 30-60-90 day action plans
Create a future state value stream map for the new process flow
Finalize improvement goals (target state) for each performance measure
74.
Evelyn A. Catt, 2015
A3 Structured Problem Solving Steps
DEFINE 1. PROBLEM STATEMENT MEASURE 4. INITIAL STATE METRICS IMPROVE 7. COUNTERMEASURES
*What changes can we make that will result in
*How will we know a change is an improvement?
Describe the background of the
improvement? Develop proposed solutions and counter measures.
current problem or opportunity.
Conduct rapid experiments to test/validate solutions.
Map and measure the current process
What business problem are we Create a future state value stream map for the new
performance.
trying to solve? process.
What metrics are used to evaluate this Create standard work and develop policies and
Why is this issue important now? process? (initial state) procedures to support the new process with clearly
defined accountability.
DEFINE 2. AIM STATEMENT MEASURE 5. TARGET STATE METRICS IMPROVE 8. ACTION PLAN
*What are we trying to accomplish? What are the improvement goals for each Develop an action plan to fully implement the
State your goals in measurable terms. metric? (target state) solutions, including details of who, what, and when.
What are the boundaries for this How are these metrics aligned with the o Identify Just-Do Its to be implemented immediately.
project? organizations strategic goals? o Implement Lean 5-S and visual controls, as needed.
o Included/excluded from scope:
o Process start point & end point: How will these metrics be monitored? o Create and implement a communication plan.
Identify waste within the current process: Confirm that actual results match the expected and
Describe the current conditions of this
o Gemba walk, waste worksheet, value desired results.
process using visual diagrams & charts.
added/non-value added analysis
Determine the customer requirements Identify any issues or barriers that still need to be
Analyze main issues, quantify their impact: addressed.
for this process.
o Pareto charts, control charts, statistical
Identify the measurable Critical to analysis, capability analysis Create a plan to monitor, sustain, and spread the
Quality (CTQ) elements of this process new process.
Identify the root cause of issues and gaps:
that are essential for customer o Fishbone diagram, Five Whys, Root Cause Summarize and share the insights gained from this
satisfaction. Analysis, Failure Modes Analysis (FMEA) project.
Evelyn A. Catt, 2015 *Reference: Institute for Healthcare Improvement (IHI), 2011. 75.
Exercise: Define Phase
DEFINE 1. PROBLEM STATEMENT
Evelyn A. Catt, 2015 *Reference: Institute for Healthcare Improvement (IHI), 2011.
76.
Exercise: Measure & Analyze Phases
MEASURE 4. INITIAL STATE METRICS
CONTROL 9. FOLLOW-UP
Confirm that actual results match the expected and desired results.
Evelyn A. Catt, 2015 *Reference: Institute for Healthcare Improvement (IHI), 2011. 78.
Action Plan Template
An Action Plan is used to document the deliverables, task ownership,
and timeline for the implementation of process improvements.
ITEM # ACTION ITEM OWNER DUE DATE STATUS
79.
Evelyn A. Catt, 2015
Communication Plan Template
A Communication Plan ensures that all stakeholders will be well
informed regarding the plan for implementing the new process.
TYPE OF INFORMATION & PURPOSE PREPARED BY DUE DATE DISTRIBUTION LIST STATUS
80.
Evelyn A. Catt, 2015
Control Plan Template
A Control Plan is a tool for tracking the on-going performance of a process to
monitor and sustain the improvements that have been implemented.
PROCESS NAME: PROCESS OWNER:
PROCESS STEP MEASUREMENT FREQ WHO MEASURES CORRECTIVE ACTION
81.
Evelyn A. Catt, 2015
Control Plan Checklist
A Control Plan is a tool for tracking the on-going performance of a process to
monitor and sustain the improvements that have been implemented and
respond to out of control measures. It includes the following elements:
82.
Evelyn A. Catt, 2015
Reflections
Have you ever participated in rapid improvement event?
Do you anticipate that your staff will be excited about being empowered
to make rapid cycle improvements?
83.
Evelyn A. Catt, 2015
Lean 5-S
84.
Evelyn A. Catt, 2015
What is Lean 5-S?
5-S is a workplace organization tool used to eliminate waste and
improve flow
Eliminates the need for searching
Reduces probability of error
Increases quality
Improves productivity
Expedites response time
Improves staff morale
Enhances professional image of an area
Increases efficiency of the supply replenishment process by using
visual cues such as a Kanban system
Kanban aligns inventory and consumption levels; a signal is sent to
deliver additional inventory when current supplies are consumed.
S
SUSTAIN A STORE
Create a 5-S culture and F Organize (set in order)
E
practices to sustain it. the remaining items
T
Y
STANDARDIZE SHINE
Simplify/standardize procedures Clean the area and create a
and monitor compliance. specific place for each item.
86.
Evelyn A. Catt, 2015
Lean 5-S Examples
BEFORE BEFORE BEFORE
87.
Evelyn A. Catt, 2015 Examples provided courtesy of Deb McCarter, Director of Nursing Practice & Quality, IU Health, University Hospital.
Visual Control Examples (simple signals)
Key Principle: Make it easy to see, use, and return.
Equipment, supplies/information should be available within 30 seconds.
BEFORE BEFORE AFTER
AFTER
LEVEL Cleaning schedules Minimal needed Work area cleaning, Proven methods for Sources, frequency
4 and responsibilities items arranged in inspection, and area arrangement of problems are
Focus On are documented manner based on supply restocking and practices are noted w/ root cause
Reliability and followed. retrieval frequency. done daily. used in the area. & corrective action.
LEVEL Initial cleaning is Needed items are Visual controls and Agreements on Work group is
3 done and mess outlined, dedicated indicators are set labeling, quantities, routinely checking
Make It sources are known locations are labeled and marked for and controls are area to maintain
Visual and corrected. in planned quantities. work area. documented. 5-S agreements.
LEVEL Necessary and un- Needed items are Key area items Work group has Initial 5-S level
2 necessary items are safely stored and are marked to check documented area is established and
Focus On identified; those not organized according and required level of arrangement and and is posted in
Basics needed are gone. to usage frequency. performance noted. controls. the area.
LEVEL Needed and not Key area items Work area methods Work area checks
Items are randomly
1 needed items are
placed throughout
checked are not are not always are randomly done
Just mixed throughout identified and are followed and are and there is no
the workplace.
Beginning the area. unmarked. not documented. 5-S measurement.
Sorting retains only the needed items. This allows for a smaller work
area resulting in reduced effort (walking, reaching, etc.) to do the
work.
Items have a definitive home location that is labeled and easily found.
We often have to walk/travel a long way (or frequent short trips) to obtain:
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Standard Work
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://www.systems2win.com/solutions/5s.htm
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://www.systems2win.com/solutions/5s.htm
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
Methods
Methods: What instructions are required?
Reference: Lean Healthcare: Implementing the Standard Work. Dave Munch, MD. August 9, 2012.
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System-wide Goals (example)
Patient
Centered
Design
Constant Data
Pursuit of Driven
Perfection Decisions
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Core Process Map
A Core Process Map helps an organization to:
Promote an understanding of your facility as a system rather than silos.
Learn to understand work as inter-related processes within a system.
Prioritize projects by identifying the pain points across the system that have
the greatest impact on organizational performance.
Identify key performance measures related to each areas primary function.
The Core
Process Map
contents can be
tailored for each
facility and
department
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Hospital Core Process Map
INPATIENT CARE TRANSITIONS (example)
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Defining the Process
Get the Plug in Put bread Set the dial Take toast Put butter
bread the toaster In the toaster and press out when it on the toast
down lever pops up
Note: The steps in the High Level Process Map are used as the center
column in the SIPOCS Diagram, which is covered later in this section.
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High Level Process Map Exercise
Exercise: Select a process from your work area and list the 4-6 high
level actions required to complete this process.
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Reflections
Did it take very long to complete the High Level Process Map?
Do your colleagues agree on the sequence of these 4-6 process steps?
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Process Flow Chart
A process flow chart is a graphic representation of the steps in a
process in sequential order. It uses standardized symbols to reflect
the different steps in the process.
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Process Flow Chart Symbols
Symbol Name Description
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Reference: http://www.breezetree.com/articles/what-is-a-flow-chart.htm
SIPOCS Diagram
A SIPOCS Diagram is a tool used at the beginning of a project to capture all the
relevant information about the process being studied.
The SIPOCS Diagram defines the high level process steps, required resources
and suppliers, and clearly identifies the outputs and customers of the process.
CUSTOMERS
SUPPLIERS INPUTS PROCESS OUTPUTS STAKEHOLDERS
Providers of the Resources required to Activity being Deliverable/Outcome Person who receives or
required resources. complete the process. completed. (verb) created by the process. benefits from outputs.
Reference: http://www.valuestreamguru.com/?p=131
Diagram Source: http://www.projectbuild.org.uk/images/sipoc.jpg
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SIPOCS Exercise
S I P O C
SUPPLIERS INPUTS PROCESS OUTPUTS CUSTOMERS
STAKEHOLDERS
Providers of the required Resources required to Activity being completed. Deliverables or outcomes Person/entity who receives
resources. complete the process. (verb) created by the process. or benefits from an output.
FIRST: Fill in process START
4 2 1 3 5
Complete Suppliers column Complete Inputs column Complete Process column Complete Outputs column Complete Customers column
Hospital: Dept: Process: Project Leader: Date:
Evelyn A. Catt, 2015 114.
X-Y Chart
The X-Y Chart helps to identify and prioritize the relationship between multiple
inputs and the resulting outcomes. All process outcomes (Ys) are achieved
based on the interaction of multiple inputs (Xs), which is often referred to as a
cause and effect relationship. Therefore, the X-Y Chart is also known as a
C&E Matrix. The most traditional use of an X-Y Chart is to help narrow down a
large number of inputs (Xs) to a manageable list for further evaluation. Steps:
Identify & rank customer critical to quality (CTQ) requirements across the top of the matrix.
List all of the inputs to the process down the left side of the matrix.
Rank the impact of each input on each CTQ requirement (1 = weak, 3 = moderate, 9 = strong) to
determine the correlation between each input and CTQ.
Cross multiply the input ranking with the CTQ value then add across each line for a total score.
Sort the total scores from highest to lowest to identify the inputs with the greatest impact.
Select a breaking point for items with scores that are too low to warrant further investigation.
Order details
incorrect
Tube system Printer not
Down/lack of working
supplies
Example
Wrong
Label Process: Accurate Lab Tube Labeling Wrong supplies/
Placement/ WHAT COULD GO WRONG Lack of supplies
Info
WITH THIS PROCESS?
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Murphys Analysis Exercise
Your Process:
WHAT COULD GO WRONG
WITH THIS PROCESS?
Were any issues identified related to the suppliers and inputs for this
process?
Murphys Analysis
Was as the Murphys Analysis an easy exercise to complete?
Were you already aware of all the issues documented during this
exercise?
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Customer Requirements
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Customer Requirements
Customer requirements refers to the qualities and features of products
and services that are needed to achieve customer satisfaction.
Develop a questionnaire
Conduct research
Reference: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University 121.
Evelyn A. Catt, 2015
Gemba is Everywhere!
Gemba is every location where work is being done!
Administrative Offices
Clinical Areas
Non-clinical Areas
Environmental Services
Facilities
Financial Counseling
Food Services
Health Information Services
Human Resources
I.T. Systems
Marketing
Patient Billing
Payroll
Quality & Risk Management
Security
Supply Chain Management
Other Areas..
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Foundation for Success
Observe the work in action.
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Brainstorming
Brainstorming is used to rapidly
generate ideas from multiple people
simultaneously regarding customer
requirements:
Write the name of your process on a
flipchart or whiteboard.
Without discussion, each person works
independently and writes their ideas on
sticky notes regarding potential
customer requirements.
Each person posts their sticky notes on
a flipchart or white board.
No comments, censoring, or criticism is
allowed during this process.
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Voice of the Customer/Stakeholder
Goals
Obtain direct Voice of the Customer/Stakeholder feedback from
patients, physicians, staff, and visitors about the current process.
Identify gaps between the current process and customer defined
requirements. Develop strategies to address any unmet needs.
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SWOT Exercise
Exercise: Create a SWOT Analysis for your area:
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Customer Requirements Exercise
Exercise: Create a list of customer requirements for your area.
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Customer Requirements Tree
A Customer Requirements Tree defines the key measurable
characteristics of a process that must be met to satisfy the customer.
It converts customer wants and needs into Critical to Quality (CTQ)
measurable requirements for the business to implement.
CRITICAL TO QUALITY (CTQ)
CUSTOMER WANTS/NEEDS DRIVERS (measurable requirement)
Accurate Charges 100% of the time
INCREASED SPECIFICITY
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Customer Requirements Exercise
CRITICAL TO QUALITY (CTQ)
CUSTOMER WANTS/NEEDS DRIVER (measurable requirement)
INCREASED SPECIFICITY
131.
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Kano Model
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Characteristics of Products & Services
The characteristics of products and services can be defined as:
The Kano Model can be used to organize and prioritize activities to design
and/or improve products and services to meet or exceed customer
requirements. Satisfaction Axis
Not necessarily expressed
Happy surprises, unexpected features!
Expressed needs
Strong source of satisfaction.
Achievement Axis
Usually unexpressed
DISSATISFIED Must haves, basic requirements.
CUSTOMERS
Delighters ( Exciters )
These requirements are not necessarily expressed. Sometimes theyre unconscious.
This is the happy surprise that can make a difference, and an important source of
satisfaction. If not there, no dissatisfaction, no frustration: theyre not expected.
Exciters are the keys to innovation!
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Value Stream Map (VSM)
A Value Stream Map (VSM) is a graphic representation of the process being
studied. Its used to identify value and lead time. It shows the sequence of
the major tasks performed during the process as it currently functions.
The VSM uses color coding to designate whether each step is value added,
non-value added, or a business requirement.
VALUE NON-VALUE
YELLOW
GREEN
BUSINESS
RED
ADDED ADDED
REQUIREMENT
(VA) (NVA)
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Value Stream Mapping Current State
Map the current work flow to identify the value stream within the
process and to measure the lead time for each process step.
YELLOW
GREEN
VALUE NON-VALUE
RED
BUSINESS
ADDED ADDED
REQUIREMENT
(VA) (NVA)
VALUE NON-VALUE
BUSINESS
ADDED TIME ADDED TIME
REQUIREMENT
(VA) (NVA)
TIME TIME TIME
Reference: Woodward-Haag, H. and Woodbridge, P.A. Rapid Process Improvement Workshops. Veterans Administration Systems Redesign, 2008.
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Value Stream Mapping Future State
The waste (waiting time) has been removed from the ideal future
state of the E.D. patient registration, triage, and placement process.
VALUE NON-VALUE
BUSINESS FLOW
ADDED ADDED
REQUIREMENT STOPPER
(VA) (NVA)
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Value Stream Mapping Exercise
Exercise: Select a process from your work area and list the major steps in this
process. Does every step provide value? How much lead time is required? Where
does the waste occur? At what points do you see flow stoppers in this process?
STEP 1: STEP 2: STEP 3: STEP 4: STEP 5:
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Waste in the Emergency Department
WASTE WASTE
WASTE
Unnecessary
forms Wrong test
ordered Travel time
WASTE to O.R.
WASTE
Waiting for
a room
Waiting to
return to E.D.
Travel to Waiting to be
Radiology transported
WASTE
WASTE
Delayed
test results
Redundant
questions
WASTE
WASTE
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Types of Waste (Muda)
Defects Errors, poor quality, failure to meet customer requirements.
Optimize each step by designing the work area to create uninterrupted flow.
Verify that clear expectations have been communicated to everyone who plays
a role in the process, including external areas.
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Flow
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Flow
Flow is the continuous movement of people, materials and supplies
through a process.
Flow ensures that patients have what they need exactly when they
need it.
No delays or waiting
One piece flow (instead of batching)
Well organized supplies and work space
Alignment of work volume and resources to meet customer demand
Takt time = available working time / customer demand
Takt time is often called the heartbeat of a Lean organization
Allows replenishment of only what is needed
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
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Patient Flow & Accountable Care
Patient flow the movement of patients through all levels and sites
of care is a critical component of accountable care.
Reference: Institute for Healthcare Improvement (IHI), 2011 151.
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What happens when the flow stops?
It slows down or stops the process!
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Lack of Flow Creates Waste
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Tools to Improve Flow
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Identifying Bottlenecks
A bottleneck occurs when the performance or capacity of an entire
process is constrained by a single step or limited number of resources.
Bottlenecks must be removed to improve flow and utilize the full
capacity of the system.
Reference: http://en.wikipedia.org/wiki/Bottleneck
Image Source: http://www.labcentrix.com/images/bottleneck_diagram.jpg 155.
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Reflections
What bottlenecks or constraints exist in your facility that affect
performance or limit capacity?
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Spaghetti Diagram
A Spaghetti Diagram is a map showing the movement of people, equipment,
materials, and total distance traveled. In order to decrease this type of waste:
o Redesign the work flow to reduce movement and search/travel time.
o Relocate frequently used supplies in closer proximity to work stations.
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Spaghetti Diagram Exercise
Exercise: Draw the layout of your work area.
Do people, equipment, and materials flow smoothly through this area?
How could the layout be improved?
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Simplify Process Flows
2. Providers*
3. Information
4. Medications
5. Supplies
6. Equipment/Instruments
All 7 Flows and their relationship to
7. Process Steps
one another must be clear and
understood in order to make
*Everyone working in the process is
considered a provider improvements in processes.
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
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Checklist for Improving Flow
1. Flow of Patients and Family/Relationships
Bring services to the patient whenever possible
Minimize patient walking if services cant be delivered to them
Respect the patients wishes for family involvement
Eliminate unnecessary movement or separation from the family
2. Flow of Providers
Ensure there is standard work for all tasks
Remove all wasted motion
Correlate supply locations to frequency of use
Do not isolate people in work silos
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
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Checklist for Improving Flow
3. Flow of Information
Include information flow in designing new processes
Information should flow with the patient
Convey information in simple visual or auditory signals
Avoid data overload; minimize to only necessary information
4. Flow of Medications
Bring services to the patient
Medications should arrive just-in-time
Get as close to the point of use as possible
Make smaller satellite pharmacies where possible
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
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Checklist for Improving Flow
5. Flow of Supplies
Make the flow simple and visual
Only needed materials should be on-hand
Supplies should arrive exactly when needed
Consider using two-bin strategies for point of use supplies
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
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Root Cause Analysis
http://www.thinkreliability.com/graphics/CauseMaps/PPT%20graphic%20-%20Root.gif
To use this technique, ask why 5 times to drill down to the underlying root
cause of the issue (next slide).
Discuss the analysis and pros & cons of each potential solution.
Reference: Ries, E. How to Conduct a Five Whys Root Cause Analysis. July 2, 2009. Source URL:
http://www.startuplessonslearned.com/2009/07/how-to-conduct-five-whys-root-cause.html
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Root Cause Analysis Exercise
Exercise: Describe an error or issue that has occurred in your work area.
Enter example here:
169.
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Fishbone Diagram Example
Medication Not
Administered
Per Guidelines
Example provided courtesy of Kourtney Kouns, Clinical Informatics Coordinator, IUH Methodist Hospital
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Fishbone Diagram Exercise
Measurements Materials Methods Machines
EFFECT
Reference: http://www.six-sigma-material.com/Mistake-Proofing.html
Image Source: http://www.exegens.com/media/incoming/0328.jpg
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Mistake Proofing (Poka Yoke) Examples
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Project Selection & Prioritization
Identify and prioritize projects that:
Are aligned with the organizations strategic goals.
Have the most significant enterprise-wide benefits.
Provide the greatest value to patients.
Ensure that projects have a manageable scope
Identify project metrics
Define key performance metrics.
Measure current initial state performance for each process being studied.
Establish well defined target state process improvement goals and return
on investment (ROI) goals. The percent Return on Investment (ROI) =
Gain from Investment Cost of Investment x 100
Cost of Investment
References: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University
Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL:
http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111 175.
Evelyn A. Catt, 2015
Project List Exercise
What are the pain points in your facility that have a significant impact on
quality, cost, efficiency, and satisfaction? Create a list of potential projects to
address these issues. How would you rank/prioritize these projects?
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Project Goal Exercise
Exercise: Define the goal for your project in measureable terms:
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Project Impact vs. Effort Grid
Place each potential project in High
the appropriate quadrant of
the impact/effort grid. Impact
Do Do
Now Over Time
Easy Hard
to Do to Do
Do
Never
As Time
Do
Permits
Low
Impact 178.
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Project Prioritization Matrix
A Project Prioritization Matrix aligns project selection decisions with value
based criteria and weighted scores. Each organization should develop a
prioritization matrix based on organizational pillars and strategic priorities.
PROJECT PRIORITIZATION MATRIX
Weighted Score
Weighted Score
Weighted Score
Weighted Score
Weighted Score
TOTAL Project
Finance/ Quality/ Service/ Resources Strategic Weighted Priority
Project # Project Description Growth Safety People Available Imperative Score Ranking
Weight Factors (EXAMPLES) Score 30 Score 10 Score 20 Score 15 Score 25
1. Example Project #1 6 180 6 60 3 60 6 90 9 225 615
2. 0 0 0 0 0 0
3. 0 0 0 0 0 0
4. 0 0 0 0 0 0
5. 0 0 0 0 0 0
6. 0 0 0 0 0 0
7. 0 0 0 0 0 0
8. 0 0 0 0 0 0
9. 0 0 0 0 0 0
10. 0 0 0 0 0 0
11. 0 0 0 0 0 0
12. 0 0 0 0 0 0
13. 0 0 0 0 0 0
14. 0 0 0 0 0 0
15. 0 0 0 0 0 0
Scoring: No Impact = 0, Low Impact = 3, Medium Impact = 6, High Impact = 9
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Goals Grid
A Goals Grid is a helpful tool to clarify strategic priorities for each area and
to create a shared vision for alignment with organizational strategic goals:
AVOID
What dont you have that you dont want?
ACHIEVE PRESERVE
What do you want What do you want to keep
that you dont have? that you already have?
ELIMINATE
What do you have now that you dont want?
ACHIEVE PRESERVE
ELIMINATE
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Project Charter
The project charter is a contract between the organizations
leadership and the project team. It is created at the beginning of
the project to clarify what is expected of the team.
Project charter elements include:
Project Team
Project Roles
Problem Statement
Aim Statement
Project Scope
Project Timeline
Project Milestones
Project Metrics
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Project Team Roles
PROJECT ROLES DESCRIPTION OF DUTIES
Senior management/leader who sponsors the project, authorizes resources, and reviews and approves project
Executive Sponsor deliverables. Holds the team accountable for meeting project goals and achieving measurable results.
Department based leader ultimately responsible for the process being improved and for monitoring and
Process Owner sustaining the process improvements over time.
Leader who drives project execution by developing plans, timelines, and assigning tasks; educates and leads the
team in the use of standardized tools and data analysis; maintains project documentation and ensures
Project Leader completion of project deliverables; coordinates effective communication with the team, stakeholders, and
leaders; and promotes collaboration, transparency, and trust.
Cross functional, high performing employees familiar with the process who participate in the project and
Team Members complete assigned tasks using standardized tools.
Individual who facilitates effective team meetings and helps with issues related to communication and problem
Team Facilitator solving, but does not contribute to the management of the project or completion of tasks and deliverables.
Project Coach/ An experienced and highly skilled professional coach who provides expert knowledge, strategic guidance, and
Mentor mentoring for projects using Lean Six Sigma concepts and tools.
Stakeholders are persons or groups with an interest in a project. Their interest may be based on the impact a
project may have on their areas processes, or because they have to supply resources to support the project. A
Key Stakeholders rule of thumb for identifying key stakeholders is to question whose support or lack of it may significantly
influence the success of the project.
Reference: Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL: 184.
Evelyn A. Catt, 2015 http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111
Project Team Worksheet
Project Name Charter Date:
Location Version:
Process Owner(s)
Project Leader
Team Members
Key Stakeholders
Project Mentor/Coach
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Problem Statement
The problem statement is the reason for action. It is a basic
description of the process to be worked on and the background of
the current problem or opportunity. Examples:
Only 20% of surgery patients are seen in the pre-admission
testing area, which results in delays on the day of surgery due to
additional testing that needs to be performed before the patient
goes to the O.R.
The Emergency Department average length of stay exceeds
benchmark standards and the Left Without Being Seen rate is
escalating due to the long waiting times in the E.D.
5% of laboratory specimens are submitted without a label, which
results in additional work to redraw the specimens, unnecessary
discomfort to patients, and delayed test results.
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Problem Statement Worksheet
Describe the background of the current problem/opportunity.
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Aim Statement
The Aim statement defines what the project is trying to accomplish.
A sound Aim statement is phrased using measurable terms.
The goals in the Aim statement should follow the SMART acronym:
ELEMENT DEFINITION
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Project Scope
The project scope statement defines which part of the process will
be investigated (process start and end points) and clearly specifies
the scope of what will be included and excluded in the project:
Process start & end points: The bookends for the part or
segment of the process that will be investigated
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Project Scope Worksheet
What part or segment of the process will be investigated in this
project?
What are the boundaries for the areas that will be addressed in this
project?
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Project Timeline & Milestones
A detailed schedule should be maintained by the Project Leader for
the key milestones of the project and the associated timelines.
Key Milestones Target Date Status
IMPLEMENTATION DATE
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Project Metrics
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Project Metrics - Definitions
Project Metric Definition Use in Improvement Project
Source: Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL:
http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/
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Project Metrics Initial & Target State
How will we know a change is an improvement?
Define key performance metrics for each process being evaluated.
Indicate which strategic area is aligned with each metric (quality/safety,
finance/growth, service, people, education, etc.)
Select one primary metric for the project team to focus on for each
improvement project.
o Use the primary metric to formulate the main project goal.
Brainstorm for possible secondary and consequential metrics.
o Construct a financial metric based on the primary & secondary metrics.
Confirm that all metrics meet the criteria to create a data collection plan.
o Measure current performance = initial state
o Establish well defined process improvement goals = target state
Source: Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL:
http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/
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Project Metrics Worksheet
Define key performance metrics for each process being evaluated.
Measure current performance = initial state
Establish well defined process improvement goals = target state
Indicate which strategic area is aligned with each metric (quality/safety,
finance/growth, service, people, education, etc.)
Source: Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL:
http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/ 196.
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Stakeholder
Analysis
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Stakeholder Analysis
Stakeholders are persons or groups with an interest in a project. Their
interest may be based on the impact a project may have on their areas
processes, or because they have to supply resources to support the project.
A rule of thumb for identifying key stakeholders is to question whose
support or lack of it may significantly influence the success of the project.
Stakeholder participation:
Gives people the opportunity to provide input regarding how projects or policies
may affect their areas
Generates a sense of ownership if initiated early in the development of the
project
Provides opportunities for learning and gaining a new perspective on the process
Enhances responsibility and accountability for achieving project milestones
Can reduce or reverse the threats to solutions that are developed by the team
Is essential for sustaining improvements that are implemented during the project
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Force Field Analysis
A Force Field Analysis can be used to depict the driving/helping forces that
support movement toward a goal, and the restraining/hindering forces that are
blocking movement toward a goal. This tool is helpful in evaluating key
stakeholders and their interests (positive or negative) in the project.
After assessing the importance of each stakeholder and their positive or negative
level of influence or impact on the project, a strategy should be developed to
effectively communicate and collaborate with each stakeholder.
Diagram Source: http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif
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Data Collection Plan
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Data Collection Plan 5 Steps
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Data Collection Plan
Step 1: Define clear goals and objectives for collecting the data.
Step 4: Collect data using a standardized format and unique identifier for
each observation (survey, questionnaire, incident report, etc.).
Step 5: Compile and enter data into a secure electronic database using pre-
defined codes for responses, ranking scales, etc. (immediate entry into an
electronic database is ideal, but not always possible).
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Operational Definitions
A clear, precise definition of each factor being measured must be
documented and confirmed with the process owner and key stakeholders.
OPERATING ROOM
SET UP PROCESS
ROOM READY PATIENT IN ANESTHESIA IN SURGEON IN TIME OUT
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Data Collection Methods
Direct Observation in the Gemba using Check Sheets
Interviews
Questionnaires
Surveys
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Check Sheet
The Check Sheet is a simple document that is used for collecting data in real-
time at the location where the data is generated in the Gemba.
The document is typically a simple form that is designed for the quick, easy, and
efficient recording of quantitative or qualitative information.
Reference: http://en.wikipedia.org/wiki/Check_sheet
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Check Sheet Example
The simplest form of check sheet is a table of categories where users add a
check as they collect the data. After the first data collection you may analyze
the data and modify the check sheet to better reflect and analyze the data.
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Measurement Systems
& Data Integrity
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Measurement Checklist
Initial state measurements should include the following steps:
Identify key process or outcome measures
Identify high frequency and high impact errors (defects) and variation
Secondary Data
Secondary data is data that was previously collected for another
purpose.
Statistical Analysis
When you perform statistical analysis on primary data then the
results become known as secondary data.
Reference: http://en.wikibooks.org/wiki/Statistics/Different_Types_of_Data/PS
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Data Integrity
In order to assess data integrity, the following questions should be
answered:
Where did the data come from?
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Data Audits & Validation
Data must be validated to ensure that it is accurate and to identify
and confirm or remove data that may be suspect.
Tools for the data audit and validation include (but are not limited to):
Manual Review
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Sampling Bias
Bias can occur in multiple ways, resulting in a sample that does not
represent the attributes of the population being studied. Care
should be taken to avoid or mitigate these types of bias:
Over coverage: Inclusion of data from outside the population.
Under coverage: Some members of the population are not
adequately represented in the sample.
Non-response bias: Individuals chosen for the sample may be
unwilling or unable to participate in the study.
Measurement systems: Variation in the measurement process
or tools.
Processing errors: Mistakes in coding or entering data.
Reference: http://stattrek.com/AP-Statistics-2/Data-Collection-Methods.aspx
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Tips to Avoid Data Disaster
Save a copy of the original database before you make any changes
so you can restore it, if necessary.
Use version control methods, such as adding a date to the file name
and initials of the person updating the file.
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Measurement System Analysis (MSA)
A measurement system analysis (MSA) is used to identify the components of variation
that exist in a measurement system. It is designed to test the measurements used to
collect data for a Lean Six Sigma project to ensure the accuracy of the data.
Total observed variation is made up of two parts: the actual variation that exists in an
item or process and the variation that is created by the measurement system itself.
An ANOVA Gauge R&R (repeatability & reproducibility) test is used to determine the
variability that comes from the measurement system and compares it to the total
observed variation to determine what portion of the variation can be attributed to the
measurement system itself. There are two essential components of a Gauge R&R test:
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Process, Outcome, Balancing Metrics
Improvement efforts should include process, outcome,
and balancing measures:
Process
Are the steps in the process being performed correctly and in
the right sequence?
Outcome
How does the system performance impact the health and well
being of patients and the things they value?
Balancing
Are changes designed to improve one part of the system
causing new problems in another area of the system?
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Outcome Measures
BIG DOTS
How does the system performance impact the health
and well being of patients and the things they value?
Total system or population measures
Tracking overall performance or impact
Publicly reported measures (mortality, pressure ulcers, etc.)
Examples of Big Dots:
Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
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Qualitative Data
Qualitative = Quality
Deals with descriptions.
Data can be observed, but not measured.
Colors, textures, tastes.
Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
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Categorical Data
NOMINAL ORDINAL
No natural ordering of the The categories can be ordered.
categories.
Small, medium, large
Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
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Interval Data
Intervals = equally spaced
Numeric values
Increments are known, consistent and measurable
No absolute zero (time, Celsius thermometer)
Cannot calculate ratios
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Parametric and Non-Parametric Data
Non-parametric: Parametric:
This type of data The analysis of this
can be analyzed type of data is based
without the mean on assumptions about
(average), standard probability distributions
deviation, or other using the mean
related parameters. (average) and
standard deviation.
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Measures of Central Tendency
Measures of central tendency include the mean, median, and mode.
Reference: Baker, N. Top 10 Critical Success Factors for Six Sigma-Part 3. Bright Hub. Dec. 18, 2009.
Source URL: http://www.brighthub.com/office/project-management/articles/7620.aspx Retrieved 3/30/10.
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Charts for Measuring
Variation & Change*
(LCL)
References: http://www.asq.org/learn-about-quality/data-collection-analysis-tools/overview/control-chart.html
http://www.six-sigma-material.com/SPC-Charts.html
Diagram Source: http://sixsigmaindonesia.com/blog/wp-content/uploads/2008/11/contchart1.gif
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Pareto Chart
The purpose of a Pareto Chart is to assess the most frequently occurring
errors/defects by category. It is used to highlight the most significant issues
among a large set of factors (often referred to as the 80/20 rule).
The Pareto Chart contains both a bar and a line graph.
Individual values are represented in descending order by bars.
The cumulative total is represented by the line.
Peak
Distribution
Y axis
X axis
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Interpreting Frequency Plot Data
Frequency Plots help us to understand if the variation that is present in a
process is the result of:
Common Cause Variation (natural variation within a process)
Outlier
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Impact of Outliers
Understanding the impact of outliers is important because just one
extreme outlier in either direction can distort the mean and give a
very erroneous impression of performance (positive or negative).
Outlier Outlier
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Process Capability &
Specifications
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Tools
If you only have a hammer, you tend to see every problem as a nail.
~ Abraham Maslow
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Process Capability
Process capability measures the ability of a process to produce output
within certain specifications.
Centering: Put the process on target (accuracy)
Spread: Reduce variation in the process (precision)
Reference: http://en.wikipedia.org/wiki/Process_capability_index
Diagram Source: http://www.qualitytrainingportal.com/resources/problem_solving/images/process_capability.gif
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Process Capability
As the process capability improves, the error rate (DPMO = defects per
million opportunities) will decrease and the Sigma level will increase:
6 Sigma = 3.4 DPMO CAPABLE
Cp = Process Capability
Note the Cp value listed under each
diagram, which is a simple measure
of process capability.
Reference: http://www.six-sigma-material.com/SPC-Charts.html
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Specification Limits Example
Employee Arrival Time
Outliers Outliers
6:52 6:53 6:54 6:56 6:57 6:58 6:59 7:01 7:02 7:03 7:04 7:06 7:07 7:08
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Accuracy vs. Precision
Accuracy: Is a measure of the average distance from the target.
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Improving Process Performance
There are two aspects of improving process performance:
Align the process to a target value (centering) = increased accuracy
Desired
Current
LSL USL
LSL = Lower Specification Limit USL = Upper Specification Limit
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The Normal Distribution
Over time, most processes tend to follow a Normal Distribution or bell
shaped curve.
Average
Y = (x)
Variation
Y axis
X axis
+/-1s =68.27%
+/-2s =95.45%
+/-3s =99.73%
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The Normal Distribution
Another property of the normal distribution is the area under the curve gives us
the probability of a data point being drawn from this portion of the distribution.
This allows us to predict how a process will perform over time.
Almost all of the area (99.73%) of the normal distribution is contained between -
3 sigma and +3 sigma from the mean. Only 0.27% of the data falls outside 3
standard deviations from the mean:
-3s -2s -1s +1s +2s +3s
+/-3s =99.7%
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What Lies Beneath
Although the average (mean) is commonly used for reporting key
performance metrics, it is imperative to understand the range of data
points that contribute to the mean value. This is essential to:
Understand the degree of variation in a process.
Recognize the impact of outliers on the mean.
Detect potential errors in the data.
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APPENDIX
Learning Guides for Review &
Deliverables by Project Phase
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Define Phase Deliverables
INITIATE THE PROJECT
Project charter created
Project team formed
Project metrics and performance goals defined
Stakeholder analysis completed
DEFINE THE PROCESS
High level process map created
SIPOCS diagram completed
Murphys analysis completed
Affinity diagram developed
DETERMINE CUSTOMER REQUIREMENTS
Voice of the Customer obtained (interviews, surveys, focus groups)
Customer Requirements Tree created with critical to quality requirements (CTQ)
Process observed in action (Go to Gemba)
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Define Phase Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
Lean & Six Sigma (DMAIC)
A3 Thinking
8 Types of Waste (Muda)
Specify Value
Value Added/Non-Value Added
Flow, Pull, Takt Time
Going to Gemba
Voice of the Customer/Stakeholder
SIPOCS Diagram
Project Charter & Roles
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Measure Phase Deliverables
MAP THE PROCESS
Current state Value Stream Map created
Swim Lane map created (if appropriate)
Spaghetti Diagram created (if appropriate)
MEASURE THE PROCESS
Key performance measures identified
Data collection plan created
Data collected and validated
Data compiled and summarized (descriptive statistics, graphs, control charts)
EVALUATE CURRENT PERFORMACE
Current initial state performance measured (baseline)
Process capability evaluated (desired performance vs. actual performance)
Baseline compared to industry standards and benchmarks (if available)
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Measure Phase Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
Value Stream Map
Process Flow Chart
Spaghetti Diagram
Data Collection Plan
Check Sheet
Operational Definitions
Measurement System Analysis (MSA)
Process Capability
Sigma Levels
Histogram (Frequency Plot)
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Analyze Phase Deliverables
IDENTIFY AMOUNTS & TYPES OF WASTE
Gemba walk, waste worksheet,
and value analysis (VA/NVA) completed
Issues and waste identified and categorized
Affinity Diagram
Critical factors quantified and prioritized
Pareto Chart
Control Charts
Statistical Analysis
DETERMINE ROOT CAUSE OF ERRORS, WASTE & VARIATION
Fishbone Diagram
Root Cause Analysis (5 Whys)
Failure Modes & Effects Analysis (FMEA), if appropriate
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Analyze Phase Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
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Improve Phase Deliverables
DESIGN THE FUTURE STATE
Develop proposed solutions and key interventions.
Create a future state value stream map to illustrate the new flow.
Identify quick hits that can be implemented immediately.
Implement Lean 5-S, visual controls, and error proofing (poka yoke)
CONDUCT RAPID EXPERIMENTS
Conduct rapid experiments to test the proposed solutions (PDSA cycles).
Evaluate results of experiments and select the final solutions.
DOCUMENT STANDARD WORK
Create standard work and accountability standards.
Develop policies and procedures to support the new process.
DEVELOP ACTION PLAN
Develop a detailed action plan to fully implement the solutions:
Actions/deliverables, owner, due date (30-60-90- days)
Create and implement a communication plan.
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Improve Phase Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
Current State, Future State
Lean 5-S (Sort, Store, Shine, Standardize, Sustain, + Safety)
Rapid Improvement Event (Kaizen)
Visual Controls
Mistake Proofing (Poka Yoke)
Plan-Do-Study-Act (PDSA)
Gemba Walk
Waste Worksheet
Action Plan
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Control Phase Deliverables
DEVELOP STANDARD WORK NOTE: All projects
do not require the
use of every tool.
Document and implement standardized process steps and update
related policies and procedures
DEVELOP PROCESS CONTROL STRATEGY
Utilize graphs and charts to track key performance metrics
Determine Process Capability and Sigma Level (if applicable)
Establish a Control Plan to monitor on-going process performance
PROJECT CLOSURE
Quantify project benefits and cost savings (or cost avoidance)
Transfer ownership/hand-off to process owner
Close project and complete final documentation
Communicate results to stakeholders
Celebrate project success!
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Control Phase Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
Control Plan
Initial State
Target State
Standard Work
Process Owner
Project Closure
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Project Hand-off
An important aspect of project closure involves the Project Leader
transferring ownership of the project back to the Process Owner.
This hand-off should be authorized by the Project Champion after all
project deliverables have been reviewed and approved, a Control Plan
is in place, and the final project documentation has been completed.
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Recognition & Celebration
Timely recognition of project teams
Communication of project results
Celebration of successful projects
Reference: Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL:
http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111.
Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care
2009; Volume 21, Number 5: pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Martin LA, Nelson EC, Lloyd RC, Nolan TW. Whole System Measures. IHI Innovation Series white paper. Cambridge,
Massachusetts: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)
Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper.
Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008. Source URL: http://planetree.org/wp-
content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care
(Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. (Available on www.ihi.org)
Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999. Source URL:
http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March
15, 2010. Source URL: http://www.createvalue.org/blog/post/?bid=148
Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patients
Voice. J Amer Board of Fam Med. 2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare
Improvement; 2005.
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References
Arthur, J. Six Sigma Tricks of the Trade: Less Tricks, More Trade. Quality Digest. Source URL:
http://www.qualitydigest.com/inside/quality-insider-article/tricks-trade.html Retrieved 3/29/10.
Baker, N. Top 10 Critical Success Factors for Six Sigma-Part 1. Bright Hub. Dec. 18, 2009. Source URL:
http://www.brighthub.com/office/project-management/articles/7845.aspx Retrieved 3/30/10.
Baker, N. Top 10 Critical Success Factors for Six Sigma-Part 2. Bright Hub. Dec. 18, 2009. Source URL:
http://www.brighthub.com/office/project-management/articles/7693.aspx Retrieved 3/30/10.
Baker, N. Top 10 Critical Success Factors for Six Sigma-Part 3. Bright Hub. Dec. 18, 2009. Source URL:
http://www.brighthub.com/office/project-management/articles/7620.aspx Retrieved 3/30/10.
Before You Approve a Six Sigma Implementation. A PQA Whitepaper. Source URL:
http://www.pqa.net/ProdServices/sixsigma/R4A0088A02.pdf Retrieved 3/29/10.
Key Success Factors in Six Sigma Deployments. ARV Excellence. Source URL:
http://www.arvexcellence.com/six-sigma-news-19.html Retrieved 3/29/10.
Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL:
http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111 Retrieved 3/29/10.
Ries, E. How to Conduct a Five Whys Root Cause Analysis. July 2, 2009. Source URL:
http://www.startuplessonslearned.com/2009/07/how-to-conduct-five-whys-root-cause.html Retrieved 3/30/10.
Using Quality Improvement Tools as Part of a Pandemic Flu Plan. Quality Digest. Oct. 8, 2009. Source URL:
http://www.qualitydigest.com/inside/health-care-article/using-quality-improvement-tools-part-pandemic-flu-plan.html
Retrieved 3/30/10.
Woodward-Haag, H. and Woodbridge, P.A. Lean Improvement Participant Fieldbook. Veterans Administration Systems Redesign,
2008
Woodward-Haag, H. and Woodbridge, P.A. Rapid Process Improvement Workshops. Veterans Administration Systems Redesign,
2008.
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Acknowledgments
The following individuals have generously shared their time, knowledge, and
resources, which greatly enriched the contents of this document:
Glenn Bingle, MD, PhD, Chairman (retired), Indianapolis Coalition for Patient Safety
Carol Birk, RPh, MS, President (retired), Indianapolis Coalition for Patient Safety
LEAN Work Group Members, Indianapolis Coalition for Patient Safety
Patricia Ebright, PhD, RN, FAAN, Associate Professor & Associate Dean for
Graduate Programs, Indiana University School of Nursing
Matthew Horn, Systems Redesign Coordinator, V.A. Hospital, Indianapolis
Betsy Lee, BSN, MSPH, Director, Indiana Patient Safety Center
Aadron Rausch, Administrative Director, IU Health Arnett
Gretchen Shook, Employee Education, IU Health Arnett
Mary Sitterding, PhD, RN, CNS, Executive Director, Nursing Research and
Professional Practice, Indiana University Health
Tim Tarnowski, VP, CIO, Indiana University Health
Ian Wedgwood, PhD, Co-Founder & Principal, Haelan Group, LLC
Heather Woodward-Hagg, Chief V.A. Systems Redesign Service and Director
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Questions