Anda di halaman 1dari 272

Lean Six Sigma & A3 Thinking

Workbook
A Review of Basic Concepts
with Exercises, Checklists, and Learning Guides

Evelyn A. Catt, MHA, BSPH, CSSBB


Principal, TTAC Consulting, LLC
Adjunct Professor, Indiana University
Fairbanks School of Public Health
06-01-15 v21
Evelyn A. Catt, 2015
SUBJECT SLIDE SUBJECT SLIDE SUBJECT SLIDE
Title Page 1 Safe Hand-offs 31 Lean Six Sigma Methodology 61
Index pg. 1-90 2 Evidence-Based Standard Work 32 Lean Six Sigma Roadmap 62
Index pg. 91-180 3 Standard Work - Value Added 33 Understanding Variation 63
Index pg. 181-270 4 Continuous Improvement 34 Variation & Reliability 64
Value Stream View of Patient Journey 5 Summary 35 Types of Variation 65
Lean Focus 6 Safe Passage 36 Variation in Healthcare Processes 66
Pursuit of Perfection 7 Systems Thinking Section 37 Concept of a Function 67
Identify and Eliminate Waste 8 Origin of Systems Thinking 38 Concept of a Function Example 68
Types of Waste 9 A3 Thinking 39 Reducing Variation in Healthcare 69
Create Flow 10 Plan Do Study Act (PDSA) 40 Y = f (x) EXERCISE 70
Establish Pull 11 Lean, Six Sigma, and A3 Thinking 41 Kaizen Continuous Improvements 71
Specify Value 12 Lean, Six Sigma, and A3 Thinking 42 Kaizen - Continuous Improvements 72
Value Added 13 Lean, Six Sigma, and A3 Thinking 43 Kaizen Event Agenda 73
Non-Value Added 14 A3 Thinking 44 Kaizen Event Agenda 74
Impact of Non-Value Added Steps 15 A3 Structured Problem Solving Format 45 A3 Structured Problem Solving Steps 75
Value Streams Section 16 Lean Principles Section 46 A3 Exercise: Define Phase 76
Value Stream 17 Origin of Lean 47 A3 Exercise: Measure/Analyze Phases 77
Value Stream Levels 18 Lean Focus 48 A3 Exercise: Improve/Control Phases 78
Lean Goals 19 Lean Thinking 49 Action Plan Template 79
Value Stream Analysis 20 Lean Rules 50 Communication Plan Template 80
Value Steam Mapping 21 Reflections 51 Control Plan Template 81
Patient Journey 22 Lean Key Concepts Section 52 Control Plan Checklist 82
Navigating the Value Stream 23 Key Concepts 53 Reflections 83
What will happen during my journey? 24 Value Added Process 54 Lean 5-S Section 84
Patient Expectations 25 Waste 55 What is Lean 5-S? 85
What The Patient Expected 26 The Cost of Quality 56 Lean 5-S 86
What The Patient Experienced 27 Six Sigma Principles Section 57 Lean 5-S Examples 87
Safe Passage Through Value Stream 28 Origin of Six Sigma 58 Visual Control Examples 88
Silos 29 Six Sigma Focus 59 Lean 5-S Achievement Levels 89
Risk Mitigation 30 Lean Six Sigma Model 60 Lean 5-S Benefits 90
Evelyn A. Catt, 2015
2.
SUBJECT SLIDE SUBJECT SLIDE SUBJECT SLIDE
Keys To Lean 5-S Success 91 First: Go to Gemba 121 Patient Flow & Accountable Care 151
Lean 5-S EXERCISE 92 Gemba is Everywhere! 122 What happens when the flow stops? 152
Standard Work Section 93 Foundation for Success 123 Lack of Flow Creates Waste 153
Standard Work 94 Brainstorming 124 Tools to Improve Flow Section 154
Why Standard Work? 95 Affinity Diagram 125 Identifying Bottlenecks 155
Standard Work Goals 96 Reflections 126 Reflections 156
Standard Work Components 97 Voice of the Customer/Stakeholder 127 Spaghetti Diagram 157
Creating Standard Work 98 SWOT EXERCISE 128 Spaghetti Diagram EXERCISE 158
Standard Work Example 99 Customer Requirements EXERCISE 129 Simplify Process Flows 159
Viewing Your Facility as a System 100 Customer Requirements Tree 130 The 7 Flows 160
System-wide Goals 101 Customer Requirements Tree EXERCISE 131 Checklist for Improving Flow 161
System-wide Benefits 102 Kano Model Section 132 Checklist for Improving Flow 162
Core Process Map 103 Characteristics of Products & Services 133 Checklist for Improving Flow 163
Hospital Core Process Map 104 Kano Model 134 Checklist for Improving Flow 164
Department Core Process Map 105 Kano Model Elements 135 Root Cause Analysis Section 165
Core Process Map EXERCISE 106 Kano Model Uses & Strengths 136 Root Cause Analysis 166
Defining the Process Section 107 Value Stream Mapping Section 137 Root Cause Analysis (5 Whys) 167
High Level Process Map 108 Value Stream Map (VSM) 138 Root Cause Analysis EXERCISE 168
High Level Process Map EXERCISE 109 Value Stream Mapping Current State 139 Fishbone Diagram 169
Reflections 110 Design the Ideal Future State 140 Fishbone Diagram Example 170
Process Flow Chart 111 Value Stream Mapping Future State 141 Fishbone Diagram EXERCISE 171
Process Flow Chart Symbols 112 Value Stream Mapping EXERCISE 142 Mistake Proofing (Poka Yoke) 172
SIPOCS Diagram 113 Value Stream Measurements EXERCISE 143 Mistake Proofing (Poka Yoke) Examples 173
SIPOCS EXERCISE 114 Identifying Waste Section 144 Project Selection Section 174
X-Y Chart (C&E Matrix) 115 Waste in the Emergency Department 145 Project Selection & Prioritization 175
Murphys Analysis 116 Types of Waste 146 Project List EXERCISE 176
Murphys Analysis EXERCSE 117 Waste Walk Worksheet EXERCISE 147 Project Goal EXERCISE 177
Reflections 118 Checklist for Removing Waste 148 Project Impact vs. Effort Grid 178
Customer Requirements Section 119 Flow Section 149 Project Prioritization Matrix 179
Customer Requirements 120 Flow 150 Goals Grid 180
Evelyn A. Catt, 2015
3.
SUBJECT SLIDE SUBJECT SLIDE SUBJECT SLIDE
Goals Grid EXERCISE 181 Measurement Systems 211 Impact of Outliers 241
Project Charter Section 182 Primary & Secondary Data 212 Process Capability Section 242
Project Charter 183 Data Integrity 213 Tools 243
Project Team Roles 184 Data Audits & Validation 214 Process Capability 244
Project Team Worksheet 185 Sampling Bias 215 Process Capability 245
Problem Statement 186 Tips to Avoid Data Disaster 216 Specification Limits 246
Problem Statement Worksheet 187 Measurement System Analysis (MSA) 217 Specification Limits Example 247
Aim Statement 188 Data Types & Display Section 218 Accuracy vs. Precision 248
Aim Statement Worksheet 189 Process, Outcome, Balancing Metrics 219 Improving Process Performance 249
Project Scope 190 Process Measures 220 The Normal Distribution 250
Project Scope Worksheet 191 Outcome Measures 221 The Normal Distribution 251
Project Timeline & Milestones 192 Balancing Measures 222 The Normal Distribution 252
Project Metrics Section 193 Quantitative Data 223 What Lies Beneath 253
Project Metrics Definitions 194 Qualitative Data 224 Sub-Populations 254
Project Metrics Initial/Target State 195 Categorical Data 225 Reflections 255
Project Metrics Worksheet 196 Interval Data 226 Learning Guides & Deliverables 256
Stakeholder Analysis Section 197 Parametric and Non-Parametric Data 227 Define Phase Deliverables 257
Stakeholder Analysis 198 Measuring Data Consistency 228 Define Phase Learning Guide 258
Force Field Analysis 199 Measures of Central Tendency 229 Measure Phase Deliverables 259
Force Field Analysis Worksheet 200 Meaningful Uses of Data 230 Measure Phase Learning Guide 260
Data Collection Plan Section 201 Value of Data Display 231 Analyze Phase Deliverables 261
Data Collection Plan 5 Steps 202 Questions to Guide Data Display 232 Analyze Phase Learning Guide 262
Data Collection Plan 203 Charts for Measuring Variation Section 233 Improve Phase Deliverables 263
Operational Definitions 204 Using Run Charts for Data Display 234 Improve Phase Learning Guide 264
Data Collection Methods 205 Benefits of Run Charts 235 Control Phase Deliverables 265
Check Sheet 206 Control Chart 236 Control Phase Learning Guide 266
Check Sheet Example 207 Pareto Chart 237 Project Hand-off 267
Check Sheet Template 208 Pareto Chart Example 238 Recognition & Celebration 268
Measurement Systems Section 209 Frequency Plot 239 References 269
Measurement Checklist 210 Interpreting Frequency Plot Data 240 References 270
Evelyn A. Catt, 2015
4.
A Value Stream View
of the Patient Journey

5.
Evelyn A. Catt, 2015
Lean Focus
Lean is focused on the constant
pursuit of perfection Perfection

By eliminating waste and non-value Waste

added activities
Flow

To improve the flow of value to the


Value
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.

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

Rapid Improvement Events (RIEs), Kaizen Events


Flow
Value Stream Mapping & Value Analysis
Lean 5-S (sort, store, shine, standardize, sustain, + safety)
Value
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.
7.
Evelyn A. Catt, 2015
Identify and Eliminate Waste (Muda)
Waste is any activity that consumes
Perfection
time, resources, or space but does
not add value to the product or
Waste
service in the eyes of the patient.
Flow

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

The value added elements in this


process include:

Safety Accuracy Timeliness Comfort Dignity Knowledge

13.
Evelyn A. Catt, 2015
Non-Value Added
Example: Medication Administration
Value Added

Non-Value Added

Non-value added elements and waste


(muda) may also occur in this process.

Errors Delays Pain Anxiety

14.
Evelyn A. Catt, 2015
Impact of Non-Value Added Steps
Non-value added steps and waste
may result in: Value Added

Decreased value to the patient


Non-Value Added
Decreased satisfaction
Decreased quality
Decreased productivity
Increased risk
Increased cost
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.

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.

High Level Admission Care Delivery Discharge

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

High Level Admission Care Delivery Discharge

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.

Defects Overproduction Waiting Non-Utilized


Potential

Transportation Inventory Motion Excess


Processing

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

Diagram Source URL:


http://www.bing.com/images/search?q=lean+value+stream&FORM=HDRSC2#view=detail&id=2E7FAF5B08108784A719AFBEC3F50DA5E24C0902&selectedIndex=30
21.
Evelyn A. Catt, 2015
Patient Journey
In a value stream view of the patient journey:
The patient is an active participant in their
own care.
The patient makes informed choices
regarding their healthcare options and goals.
In partnership with the patient, the care team
helps the patient safely navigate through their
journey to achieve their goals.

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

How will this journey end?


Outcomes
Patients value clear and timely
information, respect, compassion,
and reassurance.

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

Have they been given clear Schedule


information to make well informed
choices? Choices

Do they understand their treatment Cost


options and the associated costs?
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

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

S.S. Safe Passage

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.

Admission Care Delivery Discharge


Pre-certification Assessments Transition Planning
Registration Interventions Referrals
Scheduling Medication Admin. Prescriptions
Pre-Admit Testing Diagnostic Testing Home Care
Room Assignment Surgery/Recovery Transportation

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

Standard work is based on creative Creative Problem


Solving
problem solving and continuous
improvement. Continuous
Improvement

Standard work evolves over time as new Evidence Based


evidence-based practices are identified Practices

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

Reveals opportunities for improvement Evidence Based


Practices

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!

S.S. Safe Passage

36.
Evelyn A. Catt, 2015
Systems Thinking

Evelyn A. Catt, 2015 37.


Origin of Systems Thinking
A fault in the interpretation of observations, seen everywhere, is to suppose
that every event is attributable to someone (usually the one closest at hand),
or is related to some special event.
The fact is that most troubles. lie in the system and not the people.
Dr. W. Edwards Deming, The New Economics

Image Source: http://www.pixshock.net/pic_b/6f9e0c8cb7c046a59b86ff4d7fccfee0.jpg


38.
Evelyn A. Catt, 2015
A3 Thinking
A3 Thinking is a structured, collaborative problem solving process.

The A3 process uses the PDSA (plan-do-study-act) model as the


foundation of an iterative cycle of continuous improvement.

This cycle promotes systems thinking and the development of


people as problem solvers.

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.

The PDSA cycle starts by asking three questions:

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

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

Identify the opportunity and plan the


PLAN
improvements.
DO Carry out the plan.
Compare actual results to predicted
STUDY results and summarize what has
been learned.

Identify any changes that are


ACT required and/or develop a plan to
spread improvements.
Reference: Institute for Healthcare Improvement (IHI), 2011.
Diagram Source: http://www.advancingrecovery.net/Images/Misc/RollingPDSA.jpg 41.
Evelyn A. Catt, 2015
Lean, Six Sigma, and A3 Thinking
Lean and Six Sigma provide the methods and tools to facilitate the
appropriate level of analysis and solution development based on the
complexity of the problem being addressed with the A3 process.

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.

Reference: A3 Thinking Source URL: http://a3thinking.com/ 44.


Evelyn A. Catt, 2015
A3 Structured Problem Solving Format

*Countermeasures are proposed solutions to address the root cause of the problem and move the process closer to the target state.

Reference: A3 Thinking . Source URL: http://a3thinking.com/


45.
Evelyn A. Catt, 2015
LEAN Principles

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).

TPS is focused on the identification and steady elimination of


waste to preserve value with less work.

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.

When applied in the daily workplace, Lean thinking is used to


continually improve all functions by people at all levels in the
organization.
Reference: Source URL http://en.wikipedia.org/wiki/Kaizen,
http://www.strategosinc.com/kaizen.htmhttp://en.wikipedia.org/wiki/Lean_manufacturing

47.
Evelyn A. Catt, 2015
Lean Focus

Lean is focused on the


constant pursuit of perfection
by eliminating waste and
non-value added activities to
improve the flow of value to the customer.

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

Evelyn A. Catt, 2015 50.


Reflections
What type of benefits and competitive advantage could Lean create for
your facility?

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.

Every process should be designed with the patient in


mind, to deliver what the patient values in the process.

Lean organizations are continually improving and


looking for new opportunities to:
Eliminate waste
Increase value to the patient
Achieve efficient work flow
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

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:

Appraisal, Detection, Internal Failure, External Failure

The Cost of Poor Quality is the cost associated with producing defects,
which includes internal failure costs and external failure costs.

Diagram Source URL: iSix Sigma http://www.isixsigma.com/implementation/financial-analysis/cost-quality-not-only-failure-costs/


56.
Evelyn A. Catt, 2015
Six Sigma Principles

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.

Six Sigma seeks to improve the quality of process outputs by


identifying and removing the causes of defects (errors) and
minimizing variation.

Reducing variation in a process is the key to reducing errors and


waste, which increases reliability.

Increased reliability results in safe, high quality care.

Reference: http://en.wikipedia.org/wiki/Six_sigma
58.
Evelyn A. Catt, 2015
Six Sigma Focus

Six Sigma is focused on


identifying and correcting errors (defects)
to minimize variation
and increase accuracy.

59.
Evelyn A. Catt, 2015
Lean Six Sigma Model

LEAN SIX SIGMA


Eliminate waste and non-value Correct errors and defects to
added activities in a process. minimize variation in a process.

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).

DEFINE MEASURE ANALYZE IMPROVE CONTROL

Map and measure Identify amounts &


Define the process & Design the future Create a process control
the process to types of waste and
determine customer state; select and test strategy to sustain and
understand current determine the
requirements improvements spread improvements
performance root causes

Reference: Source URL http://business901.com/wp-content/uploads/2009/10/DMAIC.JPG

61.
Evelyn A. Catt, 2015
NOTE: All projects
Lean Six Sigma Roadmap do not require the
use of every tool.

PHASE STEPS TOOLS DELIVERABLES


DEFINE Initiate the project, define the Project Charter Project charter created
process, and determine SIPOCS, I&O, High Level Process Map Project team formed
customer requirements. Murphys Analysis/Affinity Diagram Project goals defined
Voice of the Customer/Go to Gemba Customer requirements
Customer Requirements Tree (CTQ) Project metrics identified

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

To target factors that have the most influence on performance

To design evidence-based improvements

To monitor and sustain results over time

To conduct proactive analysis of potential failure modes to:


o Reduce risks

o Reduce errors

o Increase safety

63.
Evelyn A. Catt, 2015
Variation & Reliability
Variation: A measure of change or difference.

Reliability: Consistently giving the same result.

64.
Evelyn A. Catt, 2015
Types of Variation
Common Cause Variation: Natural variation within a process
(expected or acceptable variation).

Special Cause Variation: Unpredictable or extreme variation


(unexpected or unacceptable 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

Y (measurable output) = function of x (process inputs)


Y (measurable output) is sometimes referred to as the Big Y

67.
Evelyn A. Catt, 2015
Concept of a Function Example
Y (% of surgery on-time starts) = function of (x1, x2, x3, x4, x5,.)

x1 = Patient shows up on time

x2 = Admitting office registers patient quickly

x3 = History and physical form (H&P) form received

x4 = Signed, current consent form received

x5 = Required professionals present (RN, surgeon,


anesthesiologist, etc.)

68.
Evelyn A. Catt, 2015
Reducing Variation in Healthcare
To reduce variation in healthcare processes:
Identify the measurable output (Y) of the process.

Identify the inputs (xs) 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

Few critical inputs (xs)


69.
Evelyn A. Catt, 2015
Y = f (x) Exercise
Select a process from your facility for this exercise.

Identify the measurable output (Y) of the process.

Identify the inputs (xs) of the process.

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.

Individual Kaizen improvements can be implemented quickly by one person.

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.

Individual Kaizen Event


Kaizen with a Team
Reference: Source URL http://en.wikipedia.org/wiki/Kaizen, http://www.strategosinc.com/kaizen.htm 72.
Evelyn A. Catt, 2015
Kaizen Agenda (Rapid Improvement Event)
DAY 1: Define the Current State
Set goals and expectations for the event
Review Lean, Six Sigma, and A3 Thinking concepts
Review reason for action (problem statement) and AIM statement
Review data for current performance levels (initial state)
Define customer requirements & critical to quality standards (CTQs)

DAY 2: Map/Measure the Process, Conduct Root Cause Analysis


Go to Gemba to map and measure the current process
Identify amounts and types of waste and quantify their impact
Analyze issues and barriers to determine their root cause
Implement Just Do It and Lean 5-S improvements

73.
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

DAY 4/5: Create Standard Work, Complete the A3 Project Summary


Document standard work and accountability standards
Develop policies and procedures to support the new process
Complete the A3 project summary
Communicate results and celebrate project success

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.

DEFINE 3. CURRENT CONDITIONS ANALYZE 6. GAP ANALYSIS CONTROL 9. FOLLOW-UP

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

Describe the background of the current problem


or opportunity.

What business problem are we trying to solve?

Why is this issue important now?

DEFINE 2. AIM STATEMENT

*What are we trying to accomplish?


State your goals in measurable terms.
What are the boundaries for this project?
o Included/excluded from scope:
o Process start point & end point:

DEFINE 3. CURRENT CONDITIONS

Describe the current conditions of this process


using visual diagrams & charts.

Determine the customer requirements for this


process.

Identify the measurable Critical to Quality (CTQ)


elements of this process that are essential for
customer satisfaction.

Evelyn A. Catt, 2015 *Reference: Institute for Healthcare Improvement (IHI), 2011.
76.
Exercise: Measure & Analyze Phases
MEASURE 4. INITIAL STATE METRICS

*How will we know a change is an improvement?


Map and measure the current process
performance.
What metrics are used to evaluate this process?
(initial state)

MEASURE 5. TARGET STATE METRICS


What are the improvement goals for each metric?
(target state)

How are these metrics aligned with the


organizations strategic goals?

How will these metrics be monitored?

ANALYZE 6. GAP ANALYSIS

Identify waste within the current process:


o Gemba walk, waste worksheet, value
added/non-value added analysis
Analyze main issues, quantify their impact:
o Pareto charts, control charts, statistical analysis,
capability analysis
Identify the root cause of issues and gaps:
o Fishbone diagram, Five whys, Root Cause
Analysis, Failure Modes Analysis (FMEA)
Evelyn A. Catt, 2015 *Reference: Institute for Healthcare Improvement (IHI), 2011. 77.
Exercise: Improve & Control Phases
IMPROVE 7. COUNTERMEASURES
*What changes can we make that will result in improvement?
Develop proposed solutions and counter measures.
Conduct rapid experiments to test/validate solutions.
Create a future state value stream map for the new process.
Create standard work and develop policies and procedures to
support the new process with clearly defined accountability.
IMPROVE 8. ACTION PLAN
Develop an action plan to fully implement the solutions, including
details of who, what, and when.
o Identify Just-Do Its to be implemented immediately
o Implement Lean 5-S and visual controls, as needed.
o Create and implement a communication plan.

CONTROL 9. FOLLOW-UP

Confirm that actual results match the expected and desired results.

Identify any issues or barriers that still need to be addressed.

Create a plan to monitor, sustain, and spread the new process.

Summarize and share the insights gained from this project.

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:

Define the parameters to measure (key performance metrics).


Measure current performance as a baseline = initial state
Define goals for key performance metrics = target state
Compare future performance to the baseline and goals.
Assign task ownership and time intervals for tracking metrics.
Adjust tracking frequency based on process performance.
Establish feedback loop and response plan for out-of-control measures.
Develop and document standard work and related policies & procedures.
Assign accountability for achieving goals.

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.

Evelyn A. Catt, 2015 85.


Lean 5-S
5-S produces a workplace that is clean, uncluttered, and safe.
5-S environments have a place for everything & everything in its place.
5-S uses visual controls to make every item easy to locate and return.
SORT
Identify needed items
and remove the rest.

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

AFTER AFTER AFTER

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

Examples courtesy of IU Health


Small Rural Hospitals
88.
Evelyn A. Catt, 2015
Lean 5-S Achievement Levels
LEVEL Cleanliness problem Needed items can Potential problems Proven methods for Root causes are
5 areas are identified be retrieved in 30 are identified and area arrangement eliminated and
Continuous
and mess prevention seconds with countermeasures and practices are improvement actions
Improvement actions are in place. minimum steps. documented. shared and used. include prevention.

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.

Sort Store Shine Standardize Sustain

Reference: Uptime Magazine Source URL: http://www.uptimemagazine.com/uptime/AugSept09/augsep09precmaint03.jpg


89.
Evelyn A. Catt, 2015
Lean 5-S Benefits
Pride in the workplace and supports team development.

Sorting means removing unnecessary items that congest the work


area.

Clean equipment allows everyone to notice problems.

Sorting retains only the needed items. This allows for a smaller work
area resulting in reduced effort (walking, reaching, etc.) to do the
work.

Reduced changeover times result from being organized and


minimizing search time.

Items have a definitive home location that is labeled and easily found.

Evelyn A. Catt, 2015 90.


Keys To Lean 5-S Success
Get everyone involved.
Integrate 5-S principles into daily work requirements.
Communicate need for 5-S, roles of all participants, how it is
implemented.
Be consistent in following 5-S principles in all areas.
Periodic senior management involvement is absolutely required.
Follow through and finish what is started, 5-S takes effort and
persistence.
Link 5-S activities with all other improvement initiatives.
Commitment to the process, a few individuals cannot undermine the
efforts of the entire team.

Evelyn A. Catt, 2015 91.


Lean 5-S Exercise
We often have to search for (equipment, supplies, information, people):

We often have to transport (equipment, supplies, etc.):

We often have to walk/travel a long way (or frequent short trips) to obtain:

Some areas are cluttered, unorganized, and/or need a good cleaning:

92.
Evelyn A. Catt, 2015
Standard Work

Evelyn A. Catt, 2015 93.


Standard Work

Standard work is the best known way of performing a


process today.

Standard work is based on creative problem solving


and continual improvement.

Standard work evolves over time as new evidence-


based practices are identified and implemented.

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

Evelyn A. Catt, 2015 94.


Why Standard Work?
Reduces variation in performance

Creates balanced work load

Promotes consistency of outcomes

Exposes waste & opportunities for improvement

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

Evelyn A. Catt, 2015 95.


Standard Work Goals
The goal of standard work is to Steps
develop the most reliable methods
Sequence
to consistently achieve the best
Task Ownership
outcomes for each process.
Methods
This is accomplished by defining Materials
the best known way to perform the
Outcomes
process today.
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

Evelyn A. Catt, 2015 96.


Standard Work Components
Steps Steps: What is being done?

Sequence Sequence: In what order? How long should it take?

Task Ownership: Who is responsible for each step


Task Ownership
in the process?

Methods
Methods: What instructions are required?

Materials Materials: What equipment & supplies are needed?

Outcomes Outcomes: What clearly defined measurable results


are expected?
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

Evelyn A. Catt, 2015 97.


Creating Standard Work
DO: DONT:
Keep it simple Make it overly complicated
Include all info on one, easy- Put it away in a binder or in a
to-read document desk drawer
Include key points to optimize Allow people to make one-off
technique changes on a whim
Make it accessible Make it too rigid or difficult to
change
Always look for ways to
improve the process
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

Evelyn A. Catt, 2015 98.


Standard Work Example

Reference: Lean Healthcare: Implementing the Standard Work. Dave Munch, MD. August 9, 2012.

Evelyn A. Catt, 2015


Source URL http://www.leanhealthcareexchange.com/wp-content/uploads/2012/08/JIT.jpg 99.
Viewing Your Facility
as a System

Diagram Source URL: http://www.hah-emergency.net/Puzzle%20-%20full%20hospital.JPG

100.
Evelyn A. Catt, 2015
System-wide Goals (example)

Quality & Service & Education & Finance &


Safety People Research Growth
Improve quality Improve patient, Promote and Increase system
outcomes and physician, and facilitate education efficiency and
promote clinical employee and clinical reduce total cost of
systemness satisfaction research care per person

Evelyn A. Catt, 2015 101.


System-wide Benefits
Leadership development using
common language and tools for
making process improvements
Working smarter vs. harder
Time savings for caregivers

Improved quality & safety outcomes Evidence based improvements


Increased capacity & throughput Mindful standardization of work
Empowered
Increased productivity & profitability Employees Reduced variation in key processes

Patient
Centered
Design

Constant Data
Pursuit of Driven
Perfection Decisions

102.
Evelyn A. Catt, 2015
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

103.
Evelyn A. Catt, 2015
Hospital Core Process Map
INPATIENT CARE TRANSITIONS (example)

Evelyn A. Catt, 2015


104.
Department Core Process Map - Surgery
SURGICAL CARE TRANSITIONS (example)
CLINICS PATIENT INTAKE OPERATING ROOM RECOVERY/EXIT
MD
DECISION ADMIT PT. PREP SET UP
TO PRE-OP RECOVER
DAY OF SAME DAY TRANSFER
OPERATE TESTING IN
SURGERY SERVICES TO IP UNIT
PACU
POSITION/PREP PT PROCEDURE
RECOVER
PRE-OP ROOM PATIENT ANESTH SURGEON TIME CUT - PT
ORDERS STAFF SCHEDULES READY IN IN IN OUT CLOSE OUT
IN
ICU
CREATE CREATE CREATE
PT. PRE-OP PRE-OP STAFF REG. STAFF SDS STAFF DISCHARGED
PREP INSTR. SCHEDULE SCHEDULE SCHEDULE HOME
TURNOVER
INSURANCE
PRE-CERT

CHART ASSEMBLY O.R. RESOURCE PROCESS PT DISCHARGE


HX/PHYSICAL
FORM CREATE CREATE OBTAIN ASSEMBLE
ASSEMBLE PATIENT CHART O.R. ROOM O.R. STAFF SUPPLIES CASE STAFF
CONSENT SCHEDULE SCHEDULE & MEDS CARTS TRANSPORT
OBTAIN OBTAIN OBTAIN
FORM
PHYSICIAN PATIENT MEDICAL BLOCK
ORDERS INFO. RECORDS TIME FAMILY MEMBER
MEDICATION
RECONCIL. SCHEDULE TRANSPORT

IDENTIFY REQUIRED RESOURCES INSTRUMENT EMS


SCHEDULING PROCESS (ROOM, STAFF, EQUIPMENT, PROCESSING TRANSPORT
SURGERY INSTRUMENTS, SUPPLIES) & REPAIRS
DATE POLICE
COORDINATE SCHEDULING WITH CLINICS
TRANSPORT
SURGICAL CONFIRM CONFIRM CONFIRM
PROCED. SELECT INSTRUMENT HRC
SURGEON PATIENT O.R. ROOM
DETAILS PREFERENCE ORDERING &
AVAILABLE AVAILABLE AVAILABLE TRANSPORT
LIST PURCHASING
I.U. Health Operational Improvement Group 2012, 2013 105.
Evelyn A. Catt, 2015 105.
Core Process Map Exercise
Exercise: What would your Core Process Map look like?
What are the main functions or areas in your facility?
How does work flow from one area to the next?
Which issues create the greatest impact in each area?
What measures are used to evaluate performance?

106.
Evelyn A. Catt, 2015
Defining the Process

Evelyn A. Catt, 2015 107.


High Level Process Map
In order to understand the process being evaluated, the first step is to
create a High Level Process Map with 4-6 high level actions required to
complete the process. More detailed mapping will be completed later.

Example: Making toast

STEP 1: STEP 2: STEP 3: STEP 4: STEP 5: STEP 6:

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.

108.
Evelyn A. Catt, 2015
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.

Your process name:

STEP 1: STEP 2: STEP 3: STEP 4: STEP 5: STEP 6:

109.
Evelyn A. Catt, 2015
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?

110.
Evelyn A. Catt, 2015
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.

Image Source: http://www.bpminstitute.org/images/contributors/Sweet_November10_Image1.jpg

111.
Evelyn A. Catt, 2015
Process Flow Chart Symbols
Symbol Name Description

Terminator Indicates the start and stop points in a process.

Process Indicates a process or action step.

Indicates a decision or branch in the process flow when


Decision there are 2 options (Yes/No, etc.)

Delay Depicts any waiting period that is part of a process.

Connector Line connector shows the direction the process flows.

Document Indicates a process step that produces a document.

Data I/O Indicates data inputs to and outputs from a process.

112.
Evelyn A. Catt, 2015
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
113.
Evelyn A. Catt, 2015
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

THIRD: Fill in MIDDLE steps

SECOND: Fill in process END

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.

Diagram Source URL:


http://www.bing.com/images/search?q=CE+Matrix+Templates&FORM=HDRSC2#view=detail&id=4517A5CB24A308023435F67DB409264C36CFAD55&selectedIndex=2 115.
Evelyn A. Catt, 2015
Murphys Analysis
Murphys Analysis is a brainstorming tool that helps to identify problem
areas and common ways that the current process breaks down or fails.

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?

Order of draw/ Inconsistent


Too little blood Patient ID process
Labeling at
Bedside

116.
Evelyn A. Catt, 2015
Murphys Analysis Exercise

Your Process:
WHAT COULD GO WRONG
WITH THIS PROCESS?

Evelyn A. Catt, 2015


Note: Additional circles may be added, as needed. 117.
Reflections
SIPOCS
What new insights did the SIPOCS exercise provide regarding the inputs,
outputs, suppliers, and customers associated with your 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?

118.
Evelyn A. Catt, 2015
Customer Requirements

119.
Evelyn A. Catt, 2015
Customer Requirements
Customer requirements refers to the qualities and features of products
and services that are needed to achieve customer satisfaction.

Its important to obtain direct Voice of the Customer/Stakeholder


input from patients, physicians, staff, and visitors to define customer
requirements and determine if the current process meets their needs.

Several methods can be used to obtain the Voice of the Customer:


Conduct interviews

Establish a focus group

Develop a questionnaire

Conduct research

Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html


120.
Evelyn A. Catt, 2015
First: Go to Gemba
Gemba in Japanese means the actual place or the real place.
Go to Gemba to observe the current process in action.
Talk to the people who actually perform the process.
Identify gaps between the current process and customer defined
requirements and develop a strategy to address unmet needs.
Identify opportunities to eliminate waste and improve flow.

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..
122.
Evelyn A. Catt, 2015
Foundation for Success
Observe the work in action.

Honor everyones contribution.

Establish relationships based on trust and transparency.

Design every process with the patient in mind!

123.
Evelyn A. Catt, 2015
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.

Diagram Source: http://jwsokol.files.wordpress.com/2010/07/brainstorming.jpg


124.
Evelyn A. Catt, 2015
Affinity Diagram
An Affinity Diagram is a group decision-making technique designed to sort a large
number of ideas/concepts/opinions into naturally related groups. Affinity
Diagrams are often used to sort customer requirements into logical categories.

Nominal Voting Technique


Each person is then given a
limited number of colored dots
(usually 5-8) and votes by
placing a dot on the items they
consider the highest priority.

Diagram Source: http://www.six-sigma-material.com/images/AffinityDiagram.GIF 125.


Evelyn A. Catt, 2015
Reflections
What type of leadership style will be required to create a culture that
honors everyones contribution?

Are relationships based on trust and transparency in your current work


environment?

How will the practice of going to Gemba be received by the areas


being observed?

126.
Evelyn A. Catt, 2015
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.

Questions To Ask (SWOT Analysis)


What do you like about our services? (Strengths)
What do you think needs improvement? (Weaknesses)
What Opportunities do you feel we could take advantage of?
What could potentially Threaten our success?
References: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University.
Woodward-Haag, H. and Woodbridge, P.A. Rapid Process Improvement Workshops. Veterans Administration Systems Redesign, 2008.

127.
Evelyn A. Catt, 2015
SWOT Exercise
Exercise: Create a SWOT Analysis for your area:

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

128.
Evelyn A. Catt, 2015
Customer Requirements Exercise
Exercise: Create a list of customer requirements for your area.

QUALITY TIMELINESS COST OTHER

Quality and Response time, Cost issues or Other services or


excellence procedure time, barriers that features that are
standards that are test turnaround impact patient desired or
required time, access, choice, required
appointment and satisfaction
availability, etc.

129.
Evelyn A. Catt, 2015
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

Invoices that are on time


and correct Bill received within 3 days
Timely Processing
Insurance filed within 5 days

INCREASED SPECIFICITY

130.
Evelyn A. Catt, 2015
Customer Requirements Exercise
CRITICAL TO QUALITY (CTQ)
CUSTOMER WANTS/NEEDS DRIVER (measurable requirement)

INCREASED SPECIFICITY

131.
Evelyn A. Catt, 2015
Kano Model

132.
Evelyn A. Catt, 2015
Characteristics of Products & Services
The characteristics of products and services can be defined as:

Dissatisfying: annoying features - avoided characteristics

Mandatory expectations: basics - must have characteristics

Customer needs: reasonable expectations - performing features

Delighters: surprise - innovators - unexpected features

To find out which characteristics deliver on which level of


satisfaction it is necessary to develop a questionnaire, interview,
or focus group; or conduct research to find the customer defined
characteristics and the associated level of satisfaction.

Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html


133.
Evelyn A. Catt, 2015
Kano Model
The Kano Model is used to visually depict the customer defined
characteristics (for products and services) versus the level of satisfaction
each characteristic delivers.

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

Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html 134.


Evelyn A. Catt, 2015
Kano Model Elements
Must Haves ( Basic Needs)
These basic requirements are not always expressed but they are obvious to the
customer and must be met. These requirements are not a source of satisfaction
but can cause major disappointment if they are not met.
Examples: brakes of a car; bed in a hotel room.

Performance Needs (Linear)


The need is expressed and customer satisfaction is proportional to the level of
performance (and quality) of what is implemented. It is a strong source of
customer satisfaction and a priority for development. Customer feedback on these
products and services is crucial.

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!

Reference URL: http://www.agile-ux.com/tag/kano-model/ 135.


Evelyn A. Catt, 2015
Kano Model Uses & Strengths
Kano Model Uses:
- To understand customer needs
- To benchmark services
- To prioritize product/service development
- To drive your vision and strategy

Kano Model Strengths:


- Simplicity
- Direct user feedback
- User-centered design tool
- Valuable decision-making tool
Reference URL: http://www.agile-ux.com/tag/kano-model/
136.
Evelyn A. Catt, 2015
Value Stream Mapping

137.
Evelyn A. Catt, 2015
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)

Good results Delays Accreditation


No mistakes Errors Legal compliance
Safe and timely Extra steps Regulatory req.
Valued by patient Waste Safety standards

138.
Evelyn A. Catt, 2015
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)

FLOW FLOW FLOW


STOPPER STOPPER STOPPER

Reference: Source URL http://www.archfield.com/how_to_increase_profit_using_lean_enterprise.htm


139.
Evelyn A. Catt, 2015
Design the Ideal Future State
Analyze the current state value stream map.
Measure the time for each step and between steps.
Identify value added steps.
Eliminate waste and non-value added steps.
Design the ideal future state.

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.

140.
Evelyn A. Catt, 2015
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)

141.
Evelyn A. Catt, 2015
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:

STEP 6: STEP 7: STEP 8: STEP 9: STEP 10:

Are each of these steps:

VALUE NON-VALUE BUSINESS FLOW


ADDED (VA) ADDED (NVA) REQUIREMENT STOPPER
? ? ?
142.
Evelyn A. Catt, 2015
Measurements in the Value Stream
METRIC METRIC DEFINITION
Total Number of Defects
Defects per Unit (DPU)
Total Number of Product Units
Total Opportunities (TO) Total Number of Product Units x Opportunities per Unit
Defects per Opportunity Total Number of Defects
(DPO) Total Opportunities
Defects per Million
DPO x 1,000,000
Opportunities (DPMO)
Total Number of Defective Units x 100
Percent Defective
Total Number of Units
The number of good units produced divided by the number of total units going
Rolled Throughput Yield into the process. Calculate the yield (number coming out of each step/number
(RTY) going into each step). This is the First Pass Yield. Rolled Throughput Yield is
created by multiplying all First Pass Yields together.
Defined as the rate of customer demand, often called the heartbeat of the
process. It is how often a product or service needs to be completed to meet
Takt Time customer demand.
Formula = Effective Working Time / Average Customer Demand (for that time period).
Effective Working Time = Hours Worked minus non-productive periods (lunch, etc.).
Reference: Six Sigma for Dummies. 2005, Wiley Publishing, Inc., Hoboken, NJ. 143.
Evelyn A. Catt, 2015
Identifying Waste

144.
Evelyn A. Catt, 2015
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
145.
Evelyn A. Catt, 2015
Types of Waste (Muda)
Defects Errors, poor quality, failure to meet customer requirements.

Over Production Providing unnecessary products, services, or features.

Delays, periods of inactivity, bottlenecks, or patient wait


Waiting time.
Failure to fully utilize human potential (time and talents of
Non-utilized Potential people).

Travel/Transportation Unnecessary movement of supplies, equipment, or people.

Excess inventory/supplies, batch processing, queues, or


Inventory/Scrap backlogs of work.
Extra steps taken by employees because of inefficient
Motion (search time) layout, searching, hunting and gathering.
Excess activity and processing steps caused by poor process
Excess Processing design.
Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.
Source URL: http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples
Evelyn A. Catt, 2015 146.
Waste Walk Worksheet Exercise
Errors, poor quality, failure to meet customer requirements.
Defects Example:

Providing unnecessary products, services, or features.


Over Production Example:
Delays, periods of inactivity, bottlenecks, or wait time.
Waiting Example:
Failure to fully utilize human potential (time and talents of
Non-utilized Potential people). Example:
Unnecessary movement of supplies, equipment, or people.
Travel/Transportation Example:
Excess inventory/supplies, batch processing, queues, or
Inventory/Scrap backlogs of work. Example:
Extra steps taken by employees because of inefficient
Motion (search time) layout, searching. Example:
Excess activity and processing steps caused by poor process
Excess Processing design. Example:
Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.
Source URL: http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples 147.
Evelyn A. Catt, 2015
Checklist for Removing Waste
Simplify the process to remove unnecessary or redundant steps.

Standardize equipment, supply locations, and stocking procedures.

Optimize each step by designing the work area to create uninterrupted flow.

Develop and document standard work and provide appropriate education.

Modify the sequence of activities to increase efficiency.

Identify and remove bottlenecks and constraints.

Clarify roles and responsibilities for each process step.

Introduce new deliverables and/or accountability standards.

Verify that clear expectations have been communicated to everyone who plays
a role in the process, including external areas.
148.
Evelyn A. Catt, 2015
Flow

149.
Evelyn A. Catt, 2015
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.
150.
Evelyn A. Catt, 2015
Patient Flow & Accountable Care

SAFE EFFECTIVE TIMELY PATIENT CENTERED EQUITABLE EVIDENCE BASED 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.
Evelyn A. Catt, 2015
What happens when the flow stops?
It slows down or stops the process!

152.
Evelyn A. Catt, 2015
Lack of Flow Creates Waste

153.
Evelyn A. Catt, 2015
Tools to Improve Flow

154.
Evelyn A. Catt, 2015
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.
Evelyn A. Catt, 2015
Reflections
What bottlenecks or constraints exist in your facility that affect
performance or limit capacity?

156.
Evelyn A. Catt, 2015
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.

157.
Evelyn A. Catt, 2015
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?

158.
Evelyn A. Catt, 2015
Simplify Process Flows

by untangling process complexity


Public Domain Image
159.
Evelyn A. Catt, 2015
The 7 Flows
1. Patients & Family

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.

160.
Evelyn A. Catt, 2015
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.
161.
Evelyn A. Catt, 2015
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.
162.
Evelyn A. Catt, 2015
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

6. Flow of Equipment & Instruments


Arrange equipment in a sequence that facilitates flow
All equipment should be on wheels, if possible
Use mistake-proofing to avoid waste and errors
Buy only what you need, avoid unnecessary features
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
163.
Evelyn A. Catt, 2015
Checklist for Improving Flow
7. Flow of Process Steps
Maintain simplicity of the work process
Include standard work
Include mistake-proofing principles
Evaluate process size, scope, speed, and quality

Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
164.
Evelyn A. Catt, 2015
Root Cause Analysis

Evelyn A. Catt, 2015 165.


Root Cause Analysis

http://www.thinkreliability.com/graphics/CauseMaps/PPT%20graphic%20-%20Root.gif

Evelyn A. Catt, 2015 166.


Root Cause Analysis (5 Whys)
A Root Cause Analysis is a standardized method used to identify the real
cause of a problem, rather than the superficial, easily identified cause.

To use this technique, ask why 5 times to drill down to the underlying root
cause of the issue (next slide).

Brainstorm solutions and corrective actions.

Discuss the analysis and pros & cons of each potential solution.

Additional questions to consider after you complete the 5 whys exercise.


Why wasnt the error prevented by our current system?
Why do our tools, rules, or procedures allow the problem to occur?
Why didnt our system immediately catch the problem?
Why wasnt it obvious how to fix the problem?

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
167.
Evelyn A. Catt, 2015
Root Cause Analysis Exercise
Exercise: Describe an error or issue that has occurred in your work area.
Enter example here:

1st Question Why:


Answer:

2nd Question Why:


Answer:

3rd Question Why:


Answer:

4th Question Why:


Answer:

5th Question Why:


Answer:
168.
Evelyn A. Catt, 2015
Fishbone Diagram
A Fishbone Diagram (Ishikawa Diagram) is used to identify, explore,
and display the potential causes of a problem and the resulting effects.

Diagram source: http://www.juliasilvers.com/embok/Risk/RiskAssessmentMgmt/CauseEffect.gif

169.
Evelyn A. Catt, 2015
Fishbone Diagram Example

Medication Not
Administered
Per Guidelines

Example provided courtesy of Kourtney Kouns, Clinical Informatics Coordinator, IUH Methodist Hospital

170.
Evelyn A. Catt, 2015
Fishbone Diagram Exercise
Measurements Materials Methods Machines

Cause Cause Cause Cause

Cause Cause Cause Cause

Cause Cause Cause Cause

EFFECT

Cause Cause Cause Cause

Cause Cause Cause Cause

Cause Cause Cause Cause

Environment Policies/Procedures People (Man) Physical Plant


171.
Evelyn A. Catt, 2015
Mistake Proofing
Mistake Proofing is about adding controls to prevent errors,
reduce their severity, and detect them if they can occur. These
mistake proofing mechanisms are called Poka Yokes.

Replacing inspection and correction with true quality is known as


Quality at the Source.

GOOD: Detect errors/defects before proceeding to the next step.

BETTER: Detect errors/defects during the actual process.

BEST: Prevent errors/defects from occurring at all.

Reference: http://www.six-sigma-material.com/Mistake-Proofing.html
Image Source: http://www.exegens.com/media/incoming/0328.jpg
172.
Evelyn A. Catt, 2015
Mistake Proofing (Poka Yoke) Examples

Image Source: http://www.leanblog.org/2010/04/quaid-patient-safety-documentary-airs-saturday-morning/


173.
Evelyn A. Catt, 2015
Project Selection

174.
Evelyn A. Catt, 2015
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?

Quality Cost Efficiency Satisfaction


Rank Project Name
Goal Goal Goal Goal

176.
Evelyn A. Catt, 2015
Project Goal Exercise
Exercise: Define the goal for your project in measureable terms:

We want to improve ____________________________________

from ______________________________________ (initial state)

to ________________________________________ (target state)

by ________________________________________ (target date).

Example: We want to improve surgery on-time starts from 20%


(initial state) to 50% (target state) by June 2016 (target date).

Clarify Definitions: How would you define an on-time start?

177.
Evelyn A. Catt, 2015
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.
Evelyn A. Catt, 2015
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

179.
Evelyn A. Catt, 2015
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?

Diagram Source: http://home.att.net/~nickols/goals_grid.htm

Evelyn A. Catt, 2015 180.


Reference URL: http://home.att.net/~nickols/goals_grid.htm 180
Goals Grid Exercise
Exercise: Create a Goals Grid together as a team. Discuss how each
item on the completed grid aligns with organizational strategic priorities.
AVOID

ACHIEVE PRESERVE

ELIMINATE

Evelyn A. Catt, 2015 181.


Reference URL: http://home.att.net/~nickols/goals_grid.htm
Project Charter

182.
Evelyn A. Catt, 2015
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
183.
Evelyn A. Catt, 2015
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:

Timeline Start Date: Target End Date:

TEAM MEMBERS Name/Title Name/Title


Executive Sponsor(s)

Process Owner(s)

Project Leader

Team Members

Key Stakeholders

Project Mentor/Coach

185.
Evelyn A. Catt, 2015
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.
186.
Evelyn A. Catt, 2015
Problem Statement Worksheet
Describe the background of the current problem/opportunity.

What business problem are you trying to solve?

Why is this issue important now?

187.
Evelyn A. Catt, 2015
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

Specific: Clear and focused to avoid misinterpretation.

Measurable: Can be quantified and compared to other data.

Attainable: Achievable, reasonable, and credible under current conditions.

Realistic: Fits into the organizations constraints and is cost effective.

Timely: Can be accomplished within the time frame given.


Reference : 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/
188.
Evelyn A. Catt, 2015
Aim Statement Worksheet
What are you trying to accomplish?

State your goals in measurable terms:

189.
Evelyn A. Catt, 2015
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

Included in scope (areas that will be addressed)

Excluded from scope (areas that will not be addressed)


o Aspects of the problem that are intentionally excluded
o Areas of the business that will not be included
o Related issues that will be addressed at a later time

190.
Evelyn A. Catt, 2015
Project Scope Worksheet
What part or segment of the process will be investigated in this
project?

Process starting point:

Process ending point:

What are the boundaries for the areas that will be addressed in this
project?

Included in the scope:

Excluded from the scope:

191.
Evelyn A. Catt, 2015
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

INITIATE the project, form the team, develop the charter

DEFINE the process and customer requirements

MEASURE and map the current process

ANALYZE main issues and identify root causes

IMPROVE the process and test solutions

CONTROL plan to sustain/spread the new process

RAPID IMPROVEMENT EVENT (2-5 days)

5-S EVENT (sort/store/shine/standardize/sustain/safety)

IMPLEMENTATION DATE
192.
Evelyn A. Catt, 2015
Project Metrics

193.
Evelyn A. Catt, 2015
Project Metrics - Definitions
Project Metric Definition Use in Improvement Project

Defines the project goal: improve


Measure baseline initial state and
Primary Metric (primary metric) from (baseline) to
improvement level when the project ends
(target) by (date)

Measure baseline and impacts of project


Captures, validates and tracks
Secondary Metric after improvements. Monitor during and
welcome side effects of the project
after project if linked to financial metric.

Links progress in the primary and


Evaluate at project milestones and at
secondary metrics to financial
Financial Metric regular intervals for one year after the
advantage. Most often this metric is
project ends to calculate project ROI.
tailor-made for the specific project

Collect data before, during and after the


Consequential Captures, validates and tracks
project to confirm that no collateral
Metric unwelcome side effects of the project
damage was caused by the 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/
194.
Evelyn A. Catt, 2015
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/
195.
Evelyn A. Catt, 2015
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.)

Strategic Current Value Goal


Metric Name
Alignment (initial state) (target state)
Quality/Safety Value: Time period:

Finance/Growth Value: Time period:

Service Value: Time period:

People Value: Time period:

Education Value: Time period:

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.
Evelyn A. Catt, 2015
Stakeholder
Analysis

197.
Evelyn A. Catt, 2015
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
198.
Evelyn A. Catt, 2015
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.

Diagram Source: http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif


199.
Evelyn A. Catt, 2015
Force Field Analysis Worksheet
Evaluate key stakeholders and their +/- impact on your project.

List stakeholders with List stakeholders who


a positive interest in could have a negative
your project: impact on your 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
200.
Evelyn A. Catt, 2015
Data Collection Plan

201.
Evelyn A. Catt, 2015
Data Collection Plan 5 Steps

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

DEFINE CLARIFY DEVELOP COLLECT COMPILE


Clear goals Definitions Methods Data Data

Reference: Building a Sound Data Collection Plan. Source URL: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-


sound-data-collection-plan&Itemid=217

202.
Evelyn A. Catt, 2015
Data Collection Plan
Step 1: Define clear goals and objectives for collecting the data.

Step 2: Clarify operational definitions (examples: procedure starting point,


procedure ending point, time segments during the procedure).

Step 3: Develop methods to ensure accurate measurements (examples:


synchronized clocks, calibrated instruments, ranking scales, codes for
responses, abbreviations, naming conventions).

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).

Reference: Building a Sound Data Collection Plan. Source URL:


http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-sound-data-collection-plan&Itemid=217

203.
Evelyn A. Catt, 2015
Operational Definitions
A clear, precise definition of each factor being measured must be
documented and confirmed with the process owner and key stakeholders.

Example of challenges with operational definitions: Measuring time


segments in the Operating Room.

OPERATING ROOM

SET UP CUT TO PATIENT CLEAN TURN


PROCESS CLOSE OUT UP OVER

SET UP PROCESS
ROOM READY PATIENT IN ANESTHESIA IN SURGEON IN TIME OUT

204.
Evelyn A. Catt, 2015
Data Collection Methods
Direct Observation in the Gemba using Check Sheets

Data Mining (from data previously collected)

Electronic Data Extraction and Interfaces

Interviews

Questionnaires

Surveys

Web Based Tools (Survey Monkey)

205.
Evelyn A. Catt, 2015
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.

5 Basic types of Check Sheets:

Classification (defect/error or failure mode, classified by category)

Location (physical location of a trait indicated on a picture of a part or item)

Frequency (the presence or absence of a trait or combination of traits)

Measurement Scale (measures indicated on a scale divided into intervals)

Check List (items to be performed for a task are listed in sequence)

Reference: http://en.wikipedia.org/wiki/Check_sheet

206.
Evelyn A. Catt, 2015
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.

Reference & Diagram Source: http://quality-management-tools.com/check_sheet-template.png


207.
Evelyn A. Catt, 2015
Check Sheet Template
Check Sheet
Department: Date:
Employee Name: Phone:

PROBLEM FREQUENCY NOTES


List the categories you want to measure such as Add a check mark in the Add more information to clarify the
problems, errors, number of calls, etc. appropriate category. details for each type of problem.
Problem 1
Problem 2
Problem 3
Problem 4
Problem 5
Problem 6
Problem 7
Problem 8
Problem 9
Problem 10

208.
Evelyn A. Catt, 2015
Measurement Systems
& Data Integrity

209.
Evelyn A. Catt, 2015
Measurement Checklist
Initial state measurements should include the following steps:
Identify key process or outcome measures

Obtain agreement from key stakeholders on key measures

Confirm the operational definition of each key measure

Conduct a Measurement System Analysis to validate measurement accuracy

Create and implement a data collection plan

Calculate high level performance metrics and compare to benchmarks

Identify measures that require additional data or drill-down

Display process variation data using appropriate charts and graphs

Identify high frequency and high impact errors (defects) and variation

Communicate findings to key stakeholders


210.
Evelyn A. Catt, 2015
Measurement Systems
If measurements are used to guide decisions, then it follows logically
that the more error there is in the measurements, the more error there
will be in the decisions based on those measurements.

Errors in measurements = Errors in decisions

Bad Data = Bad Decisions

Garbage In Garbage Out

Reference: Measurement Systems http://www.moresteam.com/toolbox/t403.cfm


211.
Evelyn A. Catt, 2015
Primary & Secondary Data
Primary Data
Primary data is original data that has been collected for the first
time for a specific study.

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

212.
Evelyn A. Catt, 2015
Data Integrity
In order to assess data integrity, the following questions should be
answered:
Where did the data come from?

Who has been accessing or manipulating the data?

Has the data been edited or modified in any way?

Is there a unique identifier for each entry?

Are the naming conventions, codes, etc. consistent?

Are the scoring and ranking tools consistent and valid?

Has the accuracy of the measurement process been validated?

Who developed the benchmarking standards?

213.
Evelyn A. Catt, 2015
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

Frequency Plot (histogram)

Evaluation of Outliers & Standard Deviations

Control Charts & Pareto Charts

Drilling Down by Subpopulations

Measurement System Analysis (MSA) to validate measurement accuracy

Common Sense! Does the data appear reasonable?

214.
Evelyn A. Catt, 2015
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
215.
Evelyn A. Catt, 2015
Tips to Avoid Data Disaster
Save a copy of the original database before you make any changes
so you can restore it, if necessary.

Assign a unique identifier to each observation to:


Audit for duplicates
Link de-identified data back to source documents
Sort data back to the original state
Limit access to the database, to keep the data secure and avoid the
potential for data corruption or file deletion.

Use version control methods, such as adding a date to the file name
and initials of the person updating the file.

216.
Evelyn A. Catt, 2015
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:

Repeatability: The variation in repeat measurements taken by one person or


instrument on the same item and under the same conditions.
Reproducibility: The variation in measurements that occurs when different
people measure the same item.
A Gauge R&R value of < 0.1 reflects a good measurement system; 0.1 to < 0.3 is
considered marginal; and > 0.3 is an unacceptable measurement system.
Reference: Six Sigma for Dummies. 2005, Wiley Publishing, Inc., Hoboken, NJ. pp. 156-61.
217.
Evelyn A. Catt, 2015
Data Types & Display

218.
Evelyn A. Catt, 2015
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?

Source URL: Institute for Healthcare Improvement (IHI)


http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
219.
Evelyn A. Catt, 2015
Process Measures
Little Dots
Are the steps in the process being performed correctly
and in the right sequence?
Monitor performance
Understand variation
Initiate process improvements

Source URL: Institute for Healthcare Improvement (IHI)


http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx

220.
Evelyn A. Catt, 2015
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:

Average Nursing Falls per


Length Hrs. per 1,000 Pt.
of Stay Pt. Day Days

Source URL: Institute for Healthcare Improvement (IHI)


http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
221.
Evelyn A. Catt, 2015
Balancing Measures
Are changes designed to improve one part of the system
causing new problems in another area of the system?

Source URL: Institute for Healthcare Improvement (IHI)


http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx

Image URL: http://healthinformatics.wikispaces.com/Whack-a-mole+healthcare+delivery


222.
Evelyn A. Catt, 2015
Quantitative Data
Quantitative = Quantity
Deals with numbers.
Data can be measured and is continuous.
Length, cost, weight, height.
Not all numbers are continuous and measurable
(ex: social security number).

Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
223.
Evelyn A. Catt, 2015
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
224.
Evelyn A. Catt, 2015
Categorical Data
NOMINAL ORDINAL
No natural ordering of the The categories can be ordered.
categories.
Small, medium, large

Gender Strongly agree, agree, neutral,


disagree, strongly disagree
Race
May not know which value is best
Religion
Distance between categories
Sports
cannot be measured

Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
225.
Evelyn A. Catt, 2015
Interval Data
Intervals = equally spaced
Numeric values
Increments are known, consistent and measurable
No absolute zero (time, Celsius thermometer)
Cannot calculate ratios

226.
Evelyn A. Catt, 2015
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.

Source URL: http://www.six-sigma-material.com/images/DataMeasurements.GIF


227.
Evelyn A. Catt, 2015
Measuring Data Consistency
A simple way of measuring the level of consistency in a data set is by
calculating the Minimum, Maximum, and Range.

Minimum: The smallest value in a data set.

Maximum: The largest value in a data set.

The difference between the Maximum and the


Range:
Minimum.

Reference: Measures of Central Tendency http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm

228.
Evelyn A. Catt, 2015
Measures of Central Tendency
Measures of central tendency include the mean, median, and mode.

The mean (average) is a measure of central tendency,


that is the center of the data. The mean is the sum of a
Mean:
set of data divided by the number (count) of the data. It is
often referred to as x-bar using the symbol
The median is the middle value (or the mean of the
middle two values, when the data is arranged in numerical
Median: order). The median is calculated by listing the data in
ascending order and then finding the value in the middle of
the list. Think of the median as the middle of a highway.
The mode is the value (number) that appears the most.
Mode: It is possible to have more than one mode, and it is
possible to have no mode.
Reference: Measures of Central Tendency http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm

Evelyn A. Catt, 2015 229.


Meaningful Uses of Data
Identify trends and patterns.

Measure the impact of process changes.

Monitor and sustain improvements.

Compare organizational performance to industry


benchmarks and government mandated standards.

Increase understanding and take action!

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.

Evelyn A. Catt, 2015 230.


Value of Data Display
Graphs can be used to visually summarize relationships between
variables, especially if the data set is large.

They can be used in reports to enhance readability or underscore a


particular statement about a data set.

Graphs can appeal to visual memory in ways that plain summary


tables cannot.

Graphs can misrepresent relationships between variables or promote


inaccurate conclusions if not used correctly.

Source URL: http://www.preciousheart.net/chaplaincy/Auditor_Manual/11grphd.pdf


231.
Evelyn A. Catt, 2015
Questions to Guide Data Display
What is the target problem?
What are the target measures?
Process (Little dots) focused on process steps
Outcome (BIG dots) system or population measures
Balancing (new problems caused by process changes)
Are the measures quantitative or qualitative?

Who is the target audience?


What are the key points to be illustrated?

232.
Evelyn A. Catt, 2015
Charts for Measuring
Variation & Change*

*Not inclusive of all chart types


233.
Evelyn A. Catt, 2015
Using Run Charts for Data Display
Improvement takes place over time. Determining if
improvement has really happened and if it is lasting
requires observing patterns over time.
Run charts are graphs of data over time and are one of
the most important tools for assessing the effectiveness of
change.

Source URLs: http://www.ihi.org/resources/Pages/Tools/RunChart.aspx


http://app.ihi.org/Workspace/tracker/
234.
Evelyn A. Catt, 2015
Benefits of Run Charts
They help improvement teams formulate aims by depicting
how well (or poorly) a process is performing.

They help in determining when changes are truly


improvements by displaying a pattern of data that you can
observe as you make changes.

They give direction as you work on improvement and


information about the value of particular changes.

Source URLs: http://www.ihi.org/resources/Pages/Tools/RunChart.aspx


http://app.ihi.org/Workspace/tracker/
235.
Evelyn A. Catt, 2015
Control Chart
A Control Chart is used to monitor performance and draw conclusions
about whether the process is in control (common cause variation only)
or is out of control (affected by special cause variation, unpredictable).
An X-Bar control chart is used to monitor variable data.
A P-Chart control chart is used to monitor attribute data and error rates.

(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
236.
Evelyn A. Catt, 2015
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.

Reference & Diagram Source: http://en.wikipedia.org/wiki/Pareto_chart 237.


Evelyn A. Catt, 2015
Pareto Chart Example
A Pareto Chart showing reasons for arriving late at work.

Reference & Diagram Source: http://en.wikipedia.org/wiki/Pareto_chart 238.


Evelyn A. Catt, 2015
Frequency Plot (Histogram)
A Frequency Plot (histogram) depicts the frequency of
observations occurring in a certain range of values.
An important way of summarizing data is by measuring the average
spread or variation between each data point and the mean.
A commonly used term in statistics for measuring this variation is
the standard deviation.
Spread

Peak

Distribution

Y axis

X axis
239.
Evelyn A. Catt, 2015
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)

Special Cause Variation (unpredictable or extreme variation)

Special Cause - Bimodal Variation (one system is using 2 different processes)

Outlier

Common Cause Variation Special Cause Outlier Special Cause Bimodal

240.
Evelyn A. Catt, 2015
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).

A high standard deviation (sigma) value is an indication there may


be extreme outliers that warrant further investigation and validation.
Always investigate extreme
outliers to validate the data

Outlier Outlier

LOW outlier pulls the HIGH outlier pulls


mean value DOWN the mean value UP

Special Cause Outlier

241.
Evelyn A. Catt, 2015
Process Capability &
Specifications

242.
Evelyn A. Catt, 2015
Tools
If you only have a hammer, you tend to see every problem as a nail.
~ Abraham Maslow

243.
Evelyn A. Catt, 2015
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
244.
Evelyn A. Catt, 2015
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

5 Sigma = 233 DPMO


4 Sigma = 6,210 DPMO NOT
CAPABLE
3 Sigma = 66,800 DPMO
2 Sigma = 308,540 DPMO
METRIC METRIC DEFINITION
Total Number of Defects
Defects per Unit (DPU) Total Number of Product Units
Total Opportunities (TO) Total Number of Product Units x Opportunities per Unit
Total Number of Defects
Defects per Opportunity (DPO) Total Opportunities
Defects per Million Opportunities (DPMO) DPO x 1,000,000
Sigma Calculator http://www.isixsigma.com/process-sigma-calculator/

Diagram Source: http://picsdigger.com/image/53a16da4/ 245.


Evelyn A. Catt, 2015
Specification Limits
Specification Limits are defined by the customer. They are one element
of the Voice of the Customer and may be modified over time.
LSL = Lower Specification Limit USL = Upper Specification Limit

Cp = Process Capability
Note the Cp value listed under each
diagram, which is a simple measure
of process capability.

A process is capable if almost all of


the measurements fall within the
upper and lower specification limits.

Reference: http://www.six-sigma-material.com/SPC-Charts.html
Diagram Source: http://www.competitivexpert.com/files/Image/processvariationa.jpg 246.
Evelyn A. Catt, 2015
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

6:55am 7:00am 7:05am

247.
Evelyn A. Catt, 2015
Accuracy vs. Precision
Accuracy: Is a measure of the average distance from the target.

Precision: Is a measure of the average distance from each other.

Image Source: http://www.cmg.org/measureit/issues/mit70/m_70_4_2.jpg

248.
Evelyn A. Catt, 2015
Improving Process Performance
There are two aspects of improving process performance:
Align the process to a target value (centering) = increased accuracy

Reduce variation (spread) = increased precision

Achieving one without the other is of limited value.

Desired
Current

LSL USL
LSL = Lower Specification Limit USL = Upper Specification Limit

249.
Evelyn A. Catt, 2015
The Normal Distribution
Over time, most processes tend to follow a Normal Distribution or bell
shaped curve.

The Normal Distribution is important in statistics because of the relationship


between the shape of the curve and the standard deviation.

Average
Y = (x)

Variation
Y axis

X axis

Evelyn A. Catt, 2015 250.


The Normal Distribution
One way of demonstrating the relationship between the standard deviation
(sigma) and the shape of the curve is to use sigma as a measuring rod to
describe how far we are away from the mean (average).

-3s -2s -1s +1s +2s +3s

+/-1s =68.27%
+/-2s =95.45%
+/-3s =99.73%

251.
Evelyn A. Catt, 2015
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%
252.
Evelyn A. Catt, 2015
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.

Diagram Source: http://aviationhumor.net/wp-content/uploads/2010/11/shark-fin.jpg


253.
Evelyn A. Catt, 2015
Sub-Populations
Many performance metrics are a combined average for multiple sub-
populations. It is important to review the data for each sub-population,
to understand the level of performance and sources of variation in
each area (example: patient satisfaction scores by nursing unit).
Nursing Unit C

Nursing Unit B Nursing Unit D

Nursing Unit A Nursing Unit E

Diagram Source: http://ophinions.com/images/columns/bellcurveex02.jpg 254.


Evelyn A. Catt, 2015
Reflections
What type of data do you use most often to inform your decisions?

What resources or training will be needed to use data more effectively?

255.
Evelyn A. Catt, 2015
APPENDIX
Learning Guides for Review &
Deliverables by Project Phase

256.
Evelyn A. Catt, 2015
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)

257.
Evelyn A. Catt, 2015
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
258.
Evelyn A. Catt, 2015
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)

259.
Evelyn A. Catt, 2015
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)
260.
Evelyn A. Catt, 2015
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

261.
Evelyn A. Catt, 2015
Analyze Phase Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:

Accuracy & Precision


Reliability
Variation
Frequency Plot (Histogram)
Pareto Chart (80/20 rule)
Process Specifications
Control Chart & Control Limits
Root Cause Analysis & Five Whys

262.
Evelyn A. Catt, 2015
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.

263.
Evelyn A. Catt, 2015
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

264.
Evelyn A. Catt, 2015
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!
265.
Evelyn A. Catt, 2015
Control Phase Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:

Control Plan

Key Performance Metrics

Initial State

Target State

Standard Work

Process Owner

Project Closure

266.
Evelyn A. Catt, 2015
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.

267.
Evelyn A. Catt, 2015
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.

Evelyn A. Catt, 2015 268.


268
References
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

Healthcare Performance Partners, 8 Wastes with Healthcare Examples. Source URL:


http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples

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.

269.
Evelyn A. Catt, 2015
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.
270.
Evelyn A. Catt, 2015
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
271.
Evelyn A. Catt, 2015
Questions

Evelyn Catt, MHA, BSPH, CSSBB


Principal, TTAC Consulting, LLC
Adjunct Professor, Indiana University
Fairbanks School of Public Health
evelyncatt@aol.com
Cell: 317.442.2837
Permission from the author is required to reproduce or distribute any part of this document.
272.
Evelyn A. Catt, 2015

Anda mungkin juga menyukai