Click here to view this Lean Six Sigma in Healthcare ...

Taking Six Sigma & Lean beyond projects

North Shore-LIJ Health System

Nancy Riebling, MS., MT(ASCP)Director of Operational Performance Solutions

Health System HospitalCompetitor Hospital

Key:

North Shore-LIJ Overview

15 Hospitals* -3 Tertiary

-10 Community

-Children

-Psychiatric

16 Long Term Care Facilities* Home Care (539,800 visits) Hospice Core Lab Ambulance Transport Research Institute

-200 Scientists

-$36 Million in Grants

31% Market Share 5.5 M Population Served 1.7 M Ambulatory Visits 239,400 Discharges 473,100 Emergency Visits 1,216 Residents

-99 Residency Programs

-5 Medical School Affiliations

-1,300 Medical Students

7,500 Nurses 8,000 Physicians

1,380 Faculty

$4.5 Billion in Revenue –

A-Rated Oblig. Grp.

3rd Largest Secular Health

System in U.S.

38,000 Employees

-L.I.’s Largest Employer

Ambulatory Care Network

Physician Network

Developing a Medical

School in Partnership with

Hofstra University* Includes affiliates

State of QualityState of Quality

Despite our best efforts, serious quality and safety Despite our best efforts, serious quality and safety

problems persist. Many problems are highly visible and problems persist. Many problems are highly visible and

stakeholders are demanding excellence.stakeholders are demanding excellence.

Mark Chassin, MD, FACP, MPP, Mark Chassin, MD, FACP, MPP, MPHMPH

President, The Joint Commission President, The Joint Commission

The Big Challenge

To transform health care to high reliability---

with rates of adverse events and breakdowns

in safety processes comparable to the best

high reliability organizations in the world

Mark Chassin, MD, FACP, MPP, MPH

President, The Joint Commission

The Question Becomes..….The Question Becomes..….

• How do we become aligned with this new environment?

• What are the Human Capital requirements essential for organizational success?

Becoming A Responsive Learning Organization…

• Directing

• Controlling

• Decision Making

• Change Initiating

• “Turf”

• Silos

Top Down Top Down

Bottom Up

Lead

ership

Lead

ership

Em

plo

yee

sE

mp

loye

es

Le

ade

rsh

ipL

ead

ers

hip

Traditional

• Guiding

• Leading

• Communicating Vision

• Developing Strategy

• A system approach to team decision making

• Disciplined Problem-solving

• Systematic organizational change

• Empowered cross functional teams and individuals

Ideal

The Path To Integration And StandardizationThe Path To Integration And Standardization

Progress to Date

Non-Clinical Clinical

• Human Resources• Employee/Development• Finance/Audit• Strategic Planning• Compliance• Legal• Contracting• Real Estate/Construction• Community Health Investment

• Quality Standards• Leadership• Nursing Strategy• Departmental

Integration• Academic Affairs• Clinical Service Line

Strategy• Faculty Practice

Emerging Process Improvement Methodologies: Six Sigma, Lean, ISO, Baldrige

Each possess a distinct philosophy, vocabulary and method but all emphasize the need to make all aspects of care better and more reliable than they currently are.

High reliability concepts help focus attention on the mindset and culture that is essential for any of these approaches to work.

Agency for Healthcare Research and Quality, 2008

http://www.ahrq.gov/qual/hroadvice/hroadvice1.htm

Deployment Timeline for Operational Performance Solutions

2001 -2003

• Planning • Six Sigma, • CAP • FTD

• Learning • Six Sigma• CAP• FTD

• Developing• Capstone

2003 -2005

• Deploying & Integrating• Six Sigma• CAP• FTD• Capstone

• Learning Lean

2006 -2009

• Deploying & Integrating• Lean

• Integrating and Refining• Six Sigma• CAP• FTD• Capstone•System Value Analysis Teams•Labor Management Process Improvement Teams

How: From Theory to Practice• Essential Requirements

Focus on people at the ground level Build teams – teach tools Directly connect with companies’ business imperatives Promote and mandate transferability of “best practices”

• The Tools – (In context of overall employee development program)

• The Report-Out

FTD

LEAN

Capstone

Six Sigma

Fast Track Decision making facilitates problem solving activities with stakeholders to identify solutions in a compressed time frame.

Taking the Fat Out – process improvement methodology focusing on value-added activities and removal of those activities which undermine optimal performance

At the conclusion of core management training, participants study real problems and create solutions in their home facilities

Data driven, statistically validated methodology for quality measurement and improvement based upon customer needs and reduction of variation and process defects

Standardized processes are the foundation for continuous improvement, quality, and employee empowerment

• Standardize Best Practices

• Allow creative and individual expression to improve upon a standard

• Use repeatable, stable methods to maintain predictability of the output of your processes

• Add value to the organization by developing people and grow leaders who understand the work, live the philosophy and teach it to others.

• Innovators go outside the comfort zone – learn from multiple industries (e.g.. Toyota, GE, etc.)

GOAL

FTD Lean Capstone Six Sigma

Issues      

How Much Time Is Needed 1 day <30 days 6-8 Weeks 4-6 months

Excessive Waste X X  

Need to Increase Flexibility   X  

Data Available   X X X

Data Needs to be Collected X X

Chronic Issue X X X

Long Cycle Times   X X X

Excessive Process Defects   X X

Excessive Motion   X  

Excess Inventory   X  

Need to Increase Capacity X X X X

Multidisciplinary Team Available X X

Complex Problem     X

Multiple Step Process   X X  X

Excessive Or Hidden Rework   X X

Excessive Process Variation     X

Asses Value-added Activities   X  

Excessive Bureaucracy X X X  

Rapid Implementation Needed X  X  

Know Current Process Capability      X

Long Term Control Mechanism X XThe Center for Learning & Innovation c

Operational Performance Solutions Decision Matrix

LEAN / LEAN / Six Sigma Six Sigma

MethodologyMethodology

LEAN / LEAN / Six Sigma Six Sigma

MethodologyMethodology

Change Change Acceleration Acceleration

ProcessProcess

Change Change Acceleration Acceleration

ProcessProcessEffective Effective ResultsResults

Effective Effective ResultsResults

Fast Track Decision-MakingFast Track Decision-MakingFast Track Decision-MakingFast Track Decision-Making

Lean Six Sigma and Fast Track Decision-Making ensure a quality solution, while CAP greatly increases the organization’s acceptance of change.

The Effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea and the degree of Accountability (A).

Proven method for results

Q Q x x  A A22 = E = EQuality X Acceptance & Accountability =

Effectiveness

Systematic Approaches to Process Improvement

Role of the MBB/BB

• Full-time position, 100% dedicated to supporting improvement teams

• Expert resources for multiple teams

• Provide coaching, training on a periodic basis, technical tools, process improvement methods, and teamwork issues

HOW DO WE GO BEYOND A PROJECT MENTALITY?

Value AnalysisProcess

TSI/S

IS/R

IS

Data

System D

irector Team

s

Site Leadership

Pro

cure

men

t

Cor

pora

te

Fina

nce

CMO &

COO

Value Analysis Process

Category/MetricService

Skill of person who took blood-IP

Quality

1 hr TAT from time of draw - IP

Financial Performance

Salary dollars compared to budgetSupply expense compared to budget

Service

Skill of person who took blood-IP Press Ganey Scores based on Press Ganey

Quality

1 hr TAT from time of draw - IP Lean Analysis

Operational Performance

Salary dollars compared to budgetSupply expense compared to budget

+-=

Trend

XXXXXXXX Hospital

Source Definition

Annual GoalYTD Actual

YTD ActualYTD

Stretch Goal

YTD Actual Annual Goal Stretch Goal

%ile Score %ile

Budget Variance

Score

# Top PerfsTotal

Indicators Top 10% Top 10%

84

# Top PerfsTotal

Indicators

Score %ile

# Top PerfsTotal

Indicators Top 10%

60min

DRAFT

Trend

Trend

North Shore-Long Island Jewish Health System

Departmental Metrics (Ancillary)For the Period Ending mm/dd/yyyy

87

DecliningConstant

People Soft Monthly Expense ReportsPeople Soft Monthly Expense Reports

Source Definition

Source Definition

Trend LegendImproving

Time of draw to time resulted

LEANLEAN

Project Title: Laboratory 60 min Turn Around Time from Point of Draw to Result ReleaseProject Description: Utilizing Lean-Six Sigma methodologies we analyzed all three phases involved with blood specimen collection to result release. The first phase, phlebotomy process had extended turn around times well beyond our target upper specification limit (USL) of 20 minutes. Both the accessioning and technical (analytical) components also had elevated TATs above our target USL of 40 minutes. Hospital/Organization: Franklin, Forest Hills, Southside, Plainview, Syosset

Process Owner: Joe Castagnaro / Mike Eller / Bob Filangeri / Nick Videtto

Black Belt: Laure TriaMaster Black Belt: Nancy RieblingTeam: Multiple team members from all facilities (Hospitals and Core)

Project Title: Laboratory 60 min Turn Around Time from Point of Draw to Result ReleaseProject Description: Utilizing Lean-Six Sigma methodologies we analyzed all three phases involved with blood specimen collection to result release. The first phase, phlebotomy process had extended turn around times well beyond our target upper specification limit (USL) of 20 minutes. Both the accessioning and technical (analytical) components also had elevated TATs above our target USL of 40 minutes. Hospital/Organization: Franklin, Forest Hills, Southside, Plainview, Syosset

Process Owner: Joe Castagnaro / Mike Eller / Bob Filangeri / Nick Videtto

Black Belt: Laure TriaMaster Black Belt: Nancy RieblingTeam: Multiple team members from all facilities (Hospitals and Core)

Six Sigma/LeanSustainability Report out

Project Status

December 2007

Labor Management Projects

• In unionized hospitals incorporating the tools of six sigma & lean to solve issues.

• Collaborative teams- union & management

• Breakthrough Strategy

Rapid Cycle

Projects

Methods to Achieve Results

ImprovedPerformance

Improverelations

Sponsor: Donna KubeProcess Owners: Virginia Dignam

Donna Kube Project Mentors: Antz Joseph

Clyde Riggins

Sponsor: Donna KubeProcess Owners: Virginia Dignam

Donna Kube Project Mentors: Antz Joseph

Clyde Riggins

Team Co-Leaders:Virginia Dignam

•Team Members:Gerry Baldwin, MaterialsMilton Dykes, LabEllen Farber, RespiratoryErin Granville, DietarySteven Meier, TransportJarid Paehter, MD - ResidentGail Ruben, RNRob Voce, RadiologyTara Zahtila, MD - Resident

Team Co-Leaders:Virginia Dignam

•Team Members:Gerry Baldwin, MaterialsMilton Dykes, LabEllen Farber, RespiratoryErin Granville, DietarySteven Meier, TransportJarid Paehter, MD - ResidentGail Ruben, RNRob Voce, RadiologyTara Zahtila, MD - Resident

Project Scope:The project will focus on 1 east PCU unit on all shifts

Project Scope:The project will focus on 1 east PCU unit on all shifts

Project Description / Problem Statement:Low Press Ganey scores reflect our customer’s dissatisfaction regarding noise. Current the db noise level on the PCU can reach a high of 65 db. This has contributed to a Press Ganey score of 65.4

Project Description / Problem Statement:Low Press Ganey scores reflect our customer’s dissatisfaction regarding noise. Current the db noise level on the PCU can reach a high of 65 db. This has contributed to a Press Ganey score of 65.4

Potential Benefits:• Improve patients ability to rest and heal• improve satisfaction scores

Potential Benefits:• Improve patients ability to rest and heal• improve satisfaction scores

Project Goal:Reduce the current high db noise level from 65 to 59 as well as increasing the Press Ganey score on the unit on noise level.

Project Goal:Reduce the current high db noise level from 65 to 59 as well as increasing the Press Ganey score on the unit on noise level.

Plainview

North Shore-Long Island Jewish Health System

The Effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea and the degree of Accountability (A).

Q Q x x  AA22 = E = EQuality X Acceptance & Accountability =

Effectiveness

SYSTEM QUALITY INITIATIVES

“Just in time learning”

Population health improvementPopulation health improvementPopulation health improvementPopulation health improvement

IMPERATIVESIMPERATIVES

Reduce unnecessary variationReduce unnecessary variationand overuse in careand overuse in care

Reduce unnecessary variationReduce unnecessary variationand overuse in careand overuse in care

ACTIONABLE INITIATIVESACTIONABLE INITIATIVES Increase use of evidence based medicine and

national protocols and guidelines (Sepsis)

Reduce healthcare acquired infections (central line)

Eliminate wrong site surgery and retained

foreign bodies

Improve care coordination andImprove care coordination andpatient safetypatient safety

Improve care coordination andImprove care coordination andpatient safetypatient safety

Increase Mammography screening

Increase Colonoscopy screening

Increase Diabetes screening

Integrate the continuum of careIntegrate the continuum of careIntegrate the continuum of careIntegrate the continuum of care

Deployment of Collaborative Care Model

Implementation of “Who’s in charge?”

Team STEPPS Deployment

Improved medication management

Increase medication reconciliation on

admission and discharge Increase appropriate use of post acute care

Improve discharge planning and follow-up

Increase stakeholder trust byIncrease stakeholder trust byengaging patients and familiesengaging patients and familiesIncrease stakeholder trust byIncrease stakeholder trust by

engaging patients and familiesengaging patients and families

Enhanced Transparency Create a Culture of Safety Involve patients and families in all decisions

Improve Palliative and End-of-Life care

Reduce unnecessaryReduce unnecessaryvariation and overusevariation and overuse

in carein care

Reduce unnecessaryReduce unnecessaryvariation and overusevariation and overuse

in carein care

Who is In Charge?Who is In Charge?

North Shore Long Island Jewish Health North Shore Long Island Jewish Health SystemSystem

September 2008September 2008

Sponsor •Michael Dowling

National Center for Healthcare Leadership

Team: Top Physician & Nursing leaders

ProblemPatient safety, service excellence and operational efficiency were being adversely affected by both the inability to clearly identify the name of the individual responsible for coordinating and directing the care provided to a patient as well as the inconsistency of that individual assuming the responsibilities inherent in that designation

Core Management-Future Leaders

The North Shore-LIJ WayMyers-Briggs Type IndicatorEffective Leadership Communicating with Impact & Influence Quality Management Tools for Operational Improvement

Four Required Classes from your Leadership Track One example:Performance Management Business WritingSystems ThinkingThe OZ Principle

To Graduate from Program:

• Complete all ten classes within 12 months of start of 1st program class

• Full participation on a Capstone project including reporting-out

• Participation, completion and submission to CLI of a three (3) month follow-up template

Project Goal:

• Reduce the inappropriate PT referral rate from 18% to 5%.

Project Goal:

• Reduce the inappropriate PT referral rate from 18% to 5%.

Potential Benefits:• Increase operational efficiencies of PT resources• Improve response time for required services• Increase patient, staff, and physician satisfaction• Decrease length of stay

Potential Benefits:• Increase operational efficiencies of PT resources• Improve response time for required services• Increase patient, staff, and physician satisfaction• Decrease length of stay

Project Scope:

• 3 Cohen and 3 DSU

• All Physical Therapy Referrals

• 7 days a week

Project Scope:

• 3 Cohen and 3 DSU

• All Physical Therapy Referrals

• 7 days a week

Project Description/Problem Statement:Inappropriate Physical Therapy (PT) referrals are defined as those occurrences where PT has been ordered and subsequently been determined by thetherapist as unnecessary. Consequently, this leads to inefficiencies in the use of PT resources as well as delay of service for those patients requiring PT. Currently, 18% of all referrals ordered are consideredinappropriate.

Project Description/Problem Statement:Inappropriate Physical Therapy (PT) referrals are defined as those occurrences where PT has been ordered and subsequently been determined by thetherapist as unnecessary. Consequently, this leads to inefficiencies in the use of PT resources as well as delay of service for those patients requiring PT. Currently, 18% of all referrals ordered are consideredinappropriate.

Team Members:• Jackie Baranowski-Guido• Mary Christman• Gloria Lopez• Joan Matthews• Keith Saunders

Team Members:• Jackie Baranowski-Guido• Mary Christman• Gloria Lopez• Joan Matthews• Keith Saunders

Facility: Manhasset Project Title: Reduction of Inappropriate

Physical Therapy Referrals Sponsor: Darice Brodsky Process Owner: Richie Singson, PT Department

Penelope McGuinness, 3 DSU Mary Ellen Meehan, 3 Cohen Mentor: Antz JosephProject Start Date: June 18, 2007

Facility: Manhasset Project Title: Reduction of Inappropriate

Physical Therapy Referrals Sponsor: Darice Brodsky Process Owner: Richie Singson, PT Department

Penelope McGuinness, 3 DSU Mary Ellen Meehan, 3 Cohen Mentor: Antz JosephProject Start Date: June 18, 2007

Other Programs

• Hofstra University/NSLIJ MBA

• Pediatric Fellow’s Critical Care Program

• Administrative Fellows Program

Operational Performance

Solutions

Six Sigma Lean

FTD System Initiatives

Labor Management

Value Analysis

Simulation

LOS of ortho patients

OR infection rate

Transfer of monitored patients

Role of the MT

Employee Health Service TAT

HR-Termination Process

LIJ

Plainview

Syosset

Forest Hills

Southside

Zucker/Hillside

Franklin

Housekeeping

Lab

Radiology

Linen

Periop

Lab Accessionin

Zucker-Hillside/LIJ ED TAT

Bed Management

Who’s in charge

Sepsis

Forest Hills ED

2009 Initiatives

Capstone

Infectious Disease

Number of phlebotomy sticks on Ped Patients

HRRetirement Process

QUESTIONS ?QUESTIONS ?