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Engaging the Leadership Triad in AcceleratingChange Using Lean Six Sigma

Stephen Mayfield, Dr. H.A., MBA, MBBSenior Vice President

American Hospital [email protected]

Several Themes from High Performing Organizations

Seeing differently – especially using variation and error as welcome feedback.

Engaging two levels of leadership for collaboration which means:

embracing system thinking which cultivates process excellence in which the human factors tendencies within the system are attended.

Use of tools that facilitate the dialogue between levels of leadership.

Establishing the value proposition, or the Business Case for Quality

Using Lean / Six Sigma as methods to Reduce Waste and Eliminate Defects

It All Starts With:

Create awareness for transformative change that focuses on the Patient’s Experience

Grow capacity for Robust Performance Improvement

Executive Leadership owns Common Cause Variation

Aspects of the Situation

• Humans are fallible • Healthcare is a high-risk environment • Faulty communication and hierarchal

barriers are common root causes of medical error

• Healthcare providers do not receive adequate training in communication, teamwork, and assertiveness skills

• Errors can be reduced through a definable set of teamwork concepts and skills

From Check Six Training

Observations from High Performing Organizations

Learning to SEE differently – it’s not about more data, it’s how you look at existing information.

DeKalb, IllinoisDeKalb, Georgia

How Did Healthcare Become So Unsafe?

Number Of Deaths

Years

Disease

Treatment

From P. Gluck

“Medicine used to be simple, ineffective and relatively safe.

Now it is complex, effective and potentially dangerous.”

Cyril ChantlerLancet, 1999

Lessons from Other Fields

It’s About Leadership

Executive Leaders – Administrators, Trustees & Physician Leaders

Patient Care Leaders – those close to the delivery of care to the patient

Executives have to “own” common cause” variation !

PI Hospitals in Pursuit of Excellence

PI Hospitals in Pursuit of Excellence

Core Principles

Focus on the Patient’s Experience - Care must be respectful of, and responsive to, individual preferences, needs and values

Create a Culture of Reliability - Culture defines the values and behaviors of organizations. Highly reliable cultures are known to be the safest organizations in the world

Manage Organizational Variability - Achieve consistency wherever possible in what you do and how you do it

Core Principles

Remove Inefficiency and Waste - Removing waste, including in the form of unnecessary steps, has a direct, positive impact on clinical and financial performance

Eliminate Harm and Defects - Finding and resolving problem points will result in greater efficiency and better health outcomes

Reduce Process Variation - Using quality tools and frameworks can increase consistency in processes of care and administration, thus reducing the risk of errors

PI Hospitals in Pursuit of Excellence

More Important than ever: The New Realities

Moody’s has a negative outlook for the US not-for-profit hospital sector, as virtually all rated healthcare credits are facing some degree of credit stress due to a combination of impaired access to the capital markets, soaring credit spreads, counterparty downgrades, and a slowdown in the global economy.

Moody’s Investors Service

Dec. 2008

The New Realities

= Margin

Non payment adverse events

Medicare pressures

Non payment readmissions

Waste & Inefficiency

“20% to 50% of all health care efforts are attributable to waste and inefficiency.”

Rework, work arounds, defects, errors, unnecessary

harm, delays, misuse, overuse, underuse.

- COSTSREVENUES

A Physician CEO Sees Differently

Seeing Differently 1847

See

Patients Deaths Percent

4,010 459 11.4

Dr. Ignaz Semmelweiz

General Hospital of Vienna

Patients Deaths Percent

3,754 105 2.7

First WardSecond Ward

Outward Visible Signals of Culture

Outward Visible Signals of Culture

Jump From 1847 to 2009

Number One National Patient Safety Goal of the Joint Commission for reducing Healthcare Associated Infection:

Seeing Differently 1986

Challenger Disaster resulted from decisions made in 1972

Individual competence in a poorly designed system

Seeing Differently 2003

•Successful transplant surgery (twice)•No verification system for “matching blood type”

Jesica Santillan

Individual competence in a poorly designed system

Optimizing the System – Context and Content

Premise:

All patient care is a system, every system has processes and every process has waste and variability.

Corollary:

Separating all the processes and optimizing each one and then combining them DOES NOT optimize system performance

Four Major Components of Care Delivery

Patient Information

Clinical Decisions

Care Processes

Patient Flow

Systems of Care and Simple MetricsAt the Operational Level

Information -> Clinical Decisions -> Care Processes -> Patient Flow

Clinical Information SystemFinancial System

Patient Patient Patient Patient

Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….

CD CD CD

Evidenced Based

Medicine

Clinical Best

Practices

Outcome

Indicators

(LOS, Mortality, Infection, Readmits)

Patient Flow

Process Measures(Waste, SMR,

Cycle Time Variances, etc.)

Charges

On a Cruise who has the most impact on your safety?

What is Human Factors Science?

“…..Concerned primarily with the performance of one or more persons in a task-oriented environment interacting with equipment, other people, or both.”

National Academy of Sciences

The Study of factors that contribute to errors including:

• Human Vulnerabilities related to memory

• Situational or environmental aspects

• Cognitive Lapses

Perception and Communication

An Example

Perception and CommunicationHow Many Squares Do You Count?

Silently count, and write down your total

Image One

Say the Color of the word

Say the Color of the word

Mistake Proofing

Perception and Communication

An Example of How Technologies Impact System Performance

In Short – Performance is affected by Human Tendencies related to cognitive processing attributes and limitations and the effects of system variability and interactions, ESPECIALLY those associated with decisions and communication.

PI Hospitals in Pursuit of Excellence

Core Principles

Focus on the Patient’s Experience - Care must be respectful of, and responsive to, individual preferences, needs and values

If it starts with the Patient’s Experience, what does the system deliver?

ConsumerismBook:

New Book I’m Working On:

“If a Hospital Ran Your McDonald’s”

Are we getting the message?“American industry has become very

accustomed to running their businesses by watching each other. In fact many of them are still focusing on the competition, only this time it is Japan. In a few years it will be Korea, then China, then some other country. If you just try to meet the competition, you will not survive in this new economic age. You must try to meet the customer, not just the competition.

And it is you who must change, not the competition.”

-- William Scherkenbach, 1986, excerpted from a presentation to General Motors

Engage Leaders

-Systemness

-Culture

-Structure

-Strategy

-Process Field

-Process Excellence

-Competencies

-Team

-Training

-Process Improvement

Healthcare Excellence Requires Collaborative LeadershipSystem Thinking that Supports Process

Excellence Context Leaders

(executive, trustee, physician leaders)

Content Leaders(clinical and non-

clinical)

Culture

StrategyS

truc

ture P

rocess

Leadership Creates the Framework for a System that Supports Process Excellence

Mayfield/1995

UCL

UCL

Standardize

Ho

urs

.5

1.0

1.5

2.0

Standardize

Weeks

Stabilize

Innovation

Stabilize

ContinuousImprovement

ContinuousImprovement

LCL

LCL

Standardize....Stabilize....Improve....Innovate

Process Excellence

Performance Improvement is a function of standardizing the methods, stabilizing the performance, reducing variation until the next innovation moves performance

to a new level

Mayfield/1995

UCL

UCL

Standardize

Ho

urs

.5

1.0

1.5

2.0

Standardize

Weeks

Stabilize

Innovation

Stabilize

ContinuousImprovement

ContinuousImprovement

LCL

LCL

Standardize....Stabilize....Improve....Innovate

Iceberg of Ignorance: What % of the Organization’s Problems are known to….

4 %

9 %

74 %

100%

Top Management

Middle Managers

Supervisors

Front-line

Employees

Problems hidden from management

Adopted from Sydney Toshida

Five Important Questions for Trustees:

What are we trying to accomplish with respect to our performance?

What level of quality and safety are we pursuing?

How do we measure it?How is our performance

changing?Is what we’re doing making a

difference?

Trustees have a Right and a Responsibility to ask:

How do we know if care in our hospital is –

Safe?Timely?Efficient?Effective?Equitable?Patient-Centered

(The Six Institute of Medicine Aims: STEEP )

Five Important Questions for Physicians:

How do we know if our care processes are reliable?

How do we embrace and promote evidence-based practices?

Are we eliminating preventable harm?

Am I managing the care of my patients and their flow through the system, or have I assigned that to others?

Are we actively engaged in peer review learning?

Seven Important Questions for Executive Leaders:

Are we developing Systems of Care?Are we providing efficient

processes?What indicators of quality and

safety are we bringing to our Board and Physicians?

How are we engaging our Physicians?

What are our Costs of Poor Quality?How is the CFO involved?How are we continually reducing

variation?

Hierarchy of Activities for High Performers:

Engage the Triad

Has the organization clearly established what is important?

Has the organization determined expected performance levels for: (a) Clinical outcomes(b) Operational performance(c) Safety(d) Satisfaction?

Has the organization developed a Balanced Measurement System?

Has the existing performance been assessed?

Hierarchy of Activities for High Performers

Has the Business Case for Quality been established clearly?

Are departments/functional areas aligned with the organization’s performance expectations?

Are priorities for process improvement identified?

Are appropriate tools and methods used to bring about successful change and improved performance?

Outpatient Surgery

Process Oriented – Results Driven

“The Toyota mind develops brilliant processes in which average employees may excel.” (Taiichi Ohno)

Process Oriented – Results Driven

“The Toyota mind develops brilliant processes in which average employees may excel.” (Taiichi Ohno)

Healthcare Analogue - “Healthcare systems have

discontinuous processes in which brilliant staff struggle to produce average results.”

Six Sigma Example:High Level Phlebotomy Flow

MQC

Retrieve Order

Print Label

Travel to Patient

Collect Specimen

Deliver Specimen

Detailed Phlebotomy FlowMQC

Over 40 specific defects identified in 5 classes:

Label defects (unlabeled, misplaced, wrong patient labels, misaligned, etc.)

Patient ID band defects ( improper matching, no label, wrong label, etc.)

Unsuccessful draw (not first stick, second phlebotomist required)

Unacceptable specimen/recollect (wrong tube, clotted, hemolyzed, insufficient quantity, contaminated, overfilled, etc.)

Order entry defects (time, test, patient)

Surrounded by Defects !

The System will get you if you Choose

Sub-Optimal Solutions !

Cost of Poor Quality and DefectsFor Error that can lead

to harm - What is the:Possibility?Availability?Probability?Liability?Opportunity Cost?

It’s About Leadership

Executive Leaders – Administrators, Trustees & Physician Leaders

Patient Care Leaders – those close to the delivery of care to the patient

PI Hospitals in Pursuit of Excellence

Leaders must ask:

How do we know if care in our hospital is –

Safe?Timely?Efficient?Effective?Equitable?Patient-Centered

(The Six Institute of Medicine Aims: STEEP )

Several Themes from High Performing Organizations

Seeing differently – especially using variation and error as welcome feedback.

Engaging two levels of leadership for collaboration:

embracing system thinking which cultivates process excellence in which the human factors tendencies within the system are attended.

Use of tools that facilitate the dialogue between levels of leadership.

Establishing the value proposition, or the Business Case for Quality

Becoming a Learning Organization