Six Sigma in Healthcare:

A prescription for change?

DR. BINITA SINGH PRADEEP JAIN DR. SWATI NALWADE

Objectives
Articulate the case for organizational
transformation in healthcare

Acquire high-level understanding of Six Sigma

and related change management methods

Learn from case study examples Know the keys to a successful deployment

The Need for Change in Healthcare

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

Time cover story - May 1, 2006

Q: What Scares Doctors?

A: Being the Patient

chnology alone isnt the answer

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

Overcoming the barriers

Culture Alignment and accountability Control

Getting there from here

Transformation in healthcare wont happen without transparency. Transparency cant happen without culture change. Culture change wont happen without a bold vision, a common toolset and unwavering commitment.

Six Sigma Background and Basics

Where did Six Sigma Come From? developed at Motorola Initially

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

What does Six Sigma mean?

The term Sigma is a measurement of how far a given process deviates from perfection a measure of the number of defects. Six Sigma correlates to just 3.4 defects per million opportunities. A quality improvement methodology that applies statistics to measure and reduce variation in processes. A management system that is comprehensive and flexible for achieving, sustaining, and maximizing success. BB DPMO DPMO 2 308,537 3 4 5 6 66,807 6,210 233 3.4

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

An Enabler for Cultural Change customer view my Patients View How does the
process? What does the customer look at to measure performance?
Registratio n Time to Time to drive to Park Car facility Lobby Time Walk to Procedur Procedure e Time Area

of Registration

Hospitals View of Registration

How good do we need to be?

The Classical View of Quality 99% Good (Z = 3.8 )
20,000 lost articles of mail per hour Unsafe drinking water almost 15 minutes each day 5,000 incorrect surgical operations per week 2 short or long landings at most major airports daily 200,000 wrong drug prescriptions each year No electricity for almost 7 hours each month

The Six Sigma View of Quality 99.99966% Good (Z = 6 )

Seven lost articles of mail per hour One minute of unsafe drinking water every seven months 1.7 incorrect surgical operations per week One short or long landing at most major airports every five years 68 wrong drug prescriptions each year One hour without electricity every 34 years

DMAIC METHOD:
Define CTQs Practical Problem Statistical Problem Statistical Solution Practical Solution
... define the problem, clarify and relate it to the customer..,

...measure your target metric and know your measure is good...

look for root causes and generate a prioritized listing of them.

... determine and confirm the optimal solution ...

be sure the problem doesnt come back sustain it

Translating Goals into Results The Big Ys

Clinical excellence Patient safety Financial results Patient satisfaction Physician/staff satisfaction Community service
ALL DRIVEN BY

PROCESSES

In simple terms
Listen to the customer

Define their expectations Measure how many times we get it wrong Fix it Prove the fix is real and meaningful Make it stick !!!!!

Large scale improvements require precise coordination and a common cadence to advance smoothly

62% of initiatives fail due to lack of leadership commitment

Healthcare Case Study Examples

Healthcare Project Examples Improving process/safety for medication administration

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

Case Study: Improving ED

Project Title: ED Throughput Project Title: ED Throughput Project Scope: Project Scope:
In Scope - - Treat to Street pts, Staffing patterns (ED MDs & In Scope Treat to Street pts, Staffing patterns (ED MDs & RNs), Equipt, FTEs, Registration, Lab, X-R. RNs), Equipt, FTEs, Registration, Lab, X-R. Out of Scope - - ED Admits, ED Hold Hours, Bed Control, Out of Scope ED Admits, ED Hold Hours, Bed Control, Housekeeping, Transport to Floor, MR, US, CT, Pharm. Housekeeping, Transport to Floor, MR, US, CT, Pharm.

Customer(s): Customer(s):

Patients, Physicians Patients, Physicians

Potential Benefits: Potential Benefits:

Project Description :: Project Description

Decrease LWBS Decrease LWBS Increase patient satisfaction (Press Ganey #s) Increase patient satisfaction (Press Ganey #s) Reduce ED LOS (Soft Dollars) Reduce ED LOS (Soft Dollars)

PS - - Moving Treat-to-Street patients through the ED PS Moving Treat-to-Street patients through the ED takes too long. PD - - One-third of our patients wait takes too long. PD One-third of our patients wait longer than 60 minutes to be seen by aa physician. longer than 60 minutes to be seen by physician.

Alignment with Strategic Plan: Alignment with Strategic Plan:

Customer Service Customer Service Growth Growth Efficiency Efficiency

Measure
What is the Right Y (CTQ) to Measure? How will it be measured? What is the Right Y (CTQ) to Measure? How will it be measured?

Y = Door to Doc Time. From the time a patient enters through the door until the physician Y = Door to Doc Time. From the time a patient enters through the door until the physician enters the exam room to assess the patient, measured in minutes. enters the exam room to assess the patient, measured in minutes.

What is our goal? What is our goal?

We will improve the average ED Throughput Time for Treat and Street Patients by 40%. We will improve the average ED Throughput Time for Treat and Street Patients by 40%. This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes. This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes. We will improve our throughput yield of patients seeing a physician within 60 minutes We will improve our throughput yield of patients seeing a physician within 60 minutes (USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over (USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over 7,500 customers. 7,500 customers.

What are the specification limits? (LSL, USL) What is the Target? What are the specification limits? (LSL, USL) What is the Target?

Based upon our VOC data, we have set aaUSL of 60 minutes and aaTarget Mean of 40 Based upon our VOC data, we have set USL of 60 minutes and Target Mean of 40 minutes. minutes.

Analyze
Value Stream Map Opportunities for Performance Improvements: Value Stream Map Opportunities for Performance Improvements:
Door-to-Doc Subcycle
Front Desk / QR Triage
EKG, Draw Blood, UA, Order X-Ray, administer Pain med 2- RNs 1 Tech

X-Ray In ED Portable Team Area

Fax written report/ ED

Patient Flow People Flow (RN, E-Info MD, etc.) Flow Other Flow Phone (blood, Call etc.) Patient Wait Time

ED Waiting Room

Treatment

Call critical values

Lab

Tube/bloo d MD

Arr

QR

QR

Triage

Triage

Bed

Bed

MD

6.3 min

11.6 min

23.5 min

22.9 min

Current Average Cycle Times

Analyze
Statistical Analysis Statistical Analysis

Door -to-Doc Causes (Xs)

Measurements Materials People
r de en G ge

Hypothetical Driver (X) Statistically Proven (X)

A y it cu

ut in M es M ly th on

s th on M

ks ee W

Triage Sheets Time

ts if Sh t n t ie Pa

ys Da A s rn tt e Pa

Patient Attributes

g Re r ra ist

k uic Q g Re

Chart
ion er yp H

an ci si hy P

Registration

te c ia o ss

Satisfaction LWBS

T r ia

e rg ha

ED T

e) c an in (F on si vi In

ge

Bed Available

Nurses

Nurses Physicians

g in ck ra

Software

ce n rie pe Ex il Sk

e nu ve Re

Census

d ee Sp

Env ironment

t os C ls ve Le
y Da of W ee k

I RO

Financial Metrics

Supplies

Associate Attributes

Door-to-Doc
Triage Level
x Fa
y y Ra XRa b La

r pie Co

Office Equipt Pyxis

b La

Ancillary Svcs

Staffing EKG Transportation Computers (screens) Advanced T riage Dynamap

ay ift D Sh of e im T k ee fW o ay s D ay id ol H ly er rt ua Q

Seasonality

Methods

Machines

Analyze
What Xs (inputs) are causing most of our variation? What Xs (inputs) are causing most of our variation?
Results for: Historical DOE Door to Doctor Time Results for: Historical DOE Door to Doctor Time Factorial Fit: D2D versus Express Care, X-Ray, Bed Open` Factorial Fit: D2D versus Express Care, X-Ray, Bed Open` Estimated Effects and Coefficients for D2D (coded units) Term Constant Express Care X-Ray Bed Open Express Care*X-Ray Express Care*Bed Open X-Ray*Bed Open Express Care*X-Ray*Bed Open S = 10.1865 R-Sq = 96.87% Effect 35.56 36.06 -37.81 33.69 32.56 14.06 5.19 Coef 87.34 17.78 18.03 -18.91 16.84 16.28 7.03 2.59 SE Coef 2.547 2.547 2.547 2.547 2.547 2.547 2.547 2.547 T 34.30 6.98 7.08 -7.42 6.61 6.39 2.76 1.02 P 0.000 0.000 0.000 0.000 0.000 0.000 0.025 0.338

R-Sq(adj) = 94.12%

Analysis of Variance for D2D (coded units) Source Main Effects 2-Way Interactions 3-Way Interactions Residual Error Pure Error Total DF 3 3 1 8 8 15 Seq SS 15979.9 9571.7 107.6 830.1 830.1 26489.4 Adj SS 15979.9 9571.7 107.6 830.1 830.1 Adj MS 5326.6 3190.6 107.6 103.8 103.8 F 51.33 30.75 1.04 P 0.000 0.000 0.338

Improve

What do we want to know? What do we want to know?

Screen Potential Causes? Screen Potential Causes? Discover Variable Relationships? Discover Variable Relationships? Establish Operating Tolerances? Establish Operating Tolerances?

What Xs (inputs) have we chosen to improve? What Xs (inputs) have we chosen to improve?
1. 1.

1. 1.

Bed Availability Bed Availability The Measure Phase data demonstrated that Door-to-Doctor time increased by two to The Measure Phase data demonstrated that Door-to-Doctor time increased by two to three times when there is no bed open for the patient. three times when there is no bed open for the patient. Ancillary Services Ancillary Services The data further showed that the time it takes to perform an X-Ray or Lab testing is The data further showed that the time it takes to perform an X-Ray or Lab testing is statistically significant in relation to Door-to-Doctor time. statistically significant in relation to Door-to-Doctor time.

3. 3.

Express Care Express Care Lower acuity patients (i.e. Level 33/ /Express Care) wait longer to see aaphysician than Lower acuity patients (i.e. Level Express Care) wait longer to see physician than do higher acuity patients (i.e. Level 1). do higher acuity patients (i.e. Level 1).

Improve
Value Stream Map Key Points / /Opportunities for Improvement: Value Stream Map Key Points Opportunities for Improvement:
Bedside Registration
Triage Front Desk / QR
EKG, Draw Blood, UA, Order X-Ray, administer Pain med 2- RNs 1 Tech

Registration If rooms ful may reg pt while waiting.

Non-value added Non-value added step removed step removed

Patient Flow People Flow (RN, MD, etc.) E-Info Flow Patient Wait Time

ED Waiting Room

Impacts: 1 Inc. Patient Satisfaction 2 Red. time by 8.7 minutes 3 Red. variability in process

Improve

What is the mean and median of our process? What is the standard What is the mean and median of our process? What is the standard deviation? deviation?
Mean score Mean score Median Median Standard Deviation Standard Deviation HI/LO HI/LO Range Range Measure Phase Measure Phase 64.3 minutes 64.3 minutes 38.5 minutes 38.5 minutes 44.7 minutes 44.7 minutes 241 / /11 minutes 241 11 minutes 230 minutes 230 minutes Control Phase Control Phase 39.8 minutes 39.8 minutes 34.0 minutes 34.0 minutes 27.7 minutes 27.7 minutes 129 / /44minutes 129 minutes 125 minutes 125 minutes

+ % + % 38.1% 38.1% 11.7% 11.7% 38.0% 38.0% 46.5% (HI; outliers) 46.5% (HI; outliers) 45.7% 45.7%

What is our process capability (Z score, DPMO, Yield %)? What is our process capability (Z score, DPMO, Yield %)?
Z Short-Term Score == Z Short-Term Score DPMO = DPMO = Yield % == Yield % 1.91 2.35 1.91 2.35 333,333 333,333 66.7% 66.7% 0.44 0.44 175,000 175,000 82.5% 82.5% <109,523> <109,523> 15.8% 15.8%

Control
What are our financial results? How were they calculated? What are our financial results? How were they calculated?

Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and the Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and the corresponding admissions as well as aaconservative (5%) recognition as aaresult of corresponding admissions as well as conservative (5%) recognition as result of throughput improvement. throughput improvement.

What is the plan for monitoring/ auditing the process? What is the Control What is the plan for monitoring/ auditing the process? What is the Control Plan? Plan?
T a rg e t V a lu e s

M e a su re m e n t U p p e r/ L o w e r C o n tro l R e sp o n sib ili ty M e a su re m e n t D e fin itio n M e th o d S p e c L i m its M e th o d F re q u e n c (W h o w ill m e a su re ) A le rt F la g s y Tim e b e g in s w h e n a p a t ie n t c ro s s e s t h e re a c h e s Q u ic k Tw o o u t o f t h re e w e e k s w R e g is tra t io n . Th is tim e is 8 0 % o f p a tie n ts a re n o t s < 6 0 m in u tecso m p le te d w h e n a p h y s ic ia n ; D a s h b o a rd ; b y a p h y s ic ia n w it h in 6 0 D o o r t o D o c to r Timie ld = 8 0 %g re e t s th e p a tie n t a t th e b eM s idu a l - C D R W e b = 6 0 m in u te s a r-R C h aW e e k ly Y e d an e. USL Xb rt M . K e lly -N ic h o ls m in u te s . P a t ie n t le a ve s th e E D a fte r a t le a s t c o m p le tin g th e Q u ic k R e g p ro c e s s b u t b e fo re p h y s ic ia n to m a te d - U S L = 1 .0 % o f D a s h b o a rd ; Au Tw o o u t o f t h re e w e e k s w LW B S % < 1.0% p e rfo rm s e x a m in a tio n . E D Tra c k in g E D vis its Xb a r-R C h aW e e k ly rt M . K e lly -N ic h o ls L W B S % e x c e e d s 1 .0 % . M e tric

Summary and Keys to Success

The Big Why

Achieving 35% higher take home baby rate with increase in successful implantation at hospital in Northeast

Better patient safety with 91% improvement in post-surgery antibiotic use, delivering annual savings over $1 million at hospital in Southeast

Shorter ED wait times allow 28 more patients per day to be seen, with potential financial impact over $13 million annually at hospital in Southern

Culture Change
Think about it. Are the mission, vision and values of your health system merely bullet points on a web site, or are they clearly understood and activated across the organization? Are people empowered to drive change and accountable for results?

Keys to implementing Six Sigma in Healthcare

Gain leadership support Identify opportunities Ensure strategic alignment Develop a business case Establish measurements and evaluate performance Manage change Monitor results and sustain improvement and network with others who have

embarked on similar initiatives!

ZERO ERROR SIX SIGMA ?

CAN WE ACHIEVE IT IN INDIAN HEALTHCARE SECTOR ? THANK YOU !