THEF November 29, 2007 Six Sigma for Performance Improvement Duke University Hospital.

THEF

November 29, 2007

Six Sigma for Performance Improvement

Duke University Hospital

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Why Six Sigma?

• Six Sigma is a disciplined, data-driven approach to process improvement aimed at the near-elimination of defects from every product, process, and transaction.

• The purpose of Six Sigma is to gain breakthrough knowledge on how to improve processes to do things BETTER, FASTER, and at LOWER COST. Six Sigma can be used for any activity that is concerned with cost, timeliness, and quality of results.

Years

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What is the Six Sigma Methodology?• Six Sigma is based on . . .

– Statistical process control techniques– Data analysis methods– Systematic training of all personnel involved in the activity or

process targeted by the program

• The Six Sigma goal is to . . .– Eliminate defects, waste and/or quality problems– Improve bottom-line results, and customer satisfaction

• Six Sigma can be applied to . . .– Manufacturing– Sales and customer service– Management– Any process

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Six Sigma Focal Points

• Focus on the customer

• Focus on teamwork

• Focus on reducing variation

• Focus on results

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Focus on Customers

CTQ’s(Critical To Quality)

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Focus on Teamwork

Process Owners

Process Owners

Team Members

Team Members

• Manages Day to Day Operations

• Controls Resources

• Leads Team • Partners with

Process Owner

• 3-5 Process/Product Experts

• Part Time• Works Projects

Project Champion

Project Champion

• Breaks Down Barriers

• Owns Project Cluster

Green Belt

Green Belt

BlackBelt

BlackBelt

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Focus on Reducing Variation

• Highly variable processes result in a high number of defects

• If an ADE is a defect and DUH administers 5 meds to each patient per day on average, at:

– 2 Sigma – 1,001 ADE’s would occur each day (69.2% good)

– 3 Sigma – 217 ADE’s would occur each day (93.3%)

– 4 Sigma – 20 ADE’s would occur each day (99.4%)

– 5 Sigma – 3 ADE’s would occur every 4 days (99.98%)

– 6 Sigma – 1 ADE would occur every 3 months (99.9997%)

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Hand Tools

• Brainstorming• Cause-and-effect Diagrams • Graphs and Charts

– Box Plot

– Dot Plot

– Histogram

– Pareto Chart

– Run Chart

– Scatter Plot

• Process Flow Diagrams• Statistical Process Control• Stratification

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Power Tools

• Value Stream Analysis• Analysis of Variance (ANOVA)• Correlation & Regression• Design Of Experiments

– Full Factorial Designs– Fractional Factorial Designs– 2k Designs

• FMEA• Hypothesis Testing• Measurement System Analysis• Process Capability Studies• Response Surface Methods

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Focus on Results

Y = f(X)

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Focus on Results

Patient Safety

Cost Avoidance

Cost Savings

Revenue Generation

Quality Care

Public Confidence

Include hidden cost

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Technical Definition of a Six Sigma ProcessOff-Target

Too Much Variation

Process is centered around the target with 6

standard deviations between the mean and

upper and lower specification limits.

LSL USL

6σ 6σ

A Six Sigma ProcessA Six Sigma Process

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What does a Six Sigma Program look like?

StructureStructure• Leadership• Direction• Resources

ToolsTools• DMAIC• FMEA• Workout• LEAN

StrategicStrategicAlignmentAlignment• Business Objectives• Customer Requirements

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The Tools of Six Sigma

• Analysis Tools– The Scientific Method

(DMAIC)– LEAN

• Improvement Tools– Mistake-Proofing– Design of Experiments– FMEA

• Analysis Tools– The Scientific Method

(DMAIC)– LEAN

• Improvement Tools– Mistake-Proofing– Design of Experiments– FMEA

• Process Monitoring Tools– Audits– Control Charts

• Facilitation and Project Management Tools– Workout and Kaizen– Brainstorming

• Process Monitoring Tools– Audits– Control Charts

• Facilitation and Project Management Tools– Workout and Kaizen– Brainstorming

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DMAIC – Scientific Method

Improvements are evaluated and monitored.Control

Measure

Information about the current situation is gathered in order to obtain baseline data on current process performance and identify problem areas.

AnalyzeRoot causes of quality problems are identified and confirmed with appropriate data analysis tools.

ImproveSolutions are implemented to address the root causes of problems identified during the analyze phase.

Project goals and boundaries are set, and issues are identified that must be addressed to achieve an improved quality level (i.e., defect rate).

Define

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What does a Six Sigma Program look like?

StructureStructure• Leadership• Direction• Resources

ToolsTools• DMAIC• FMEA• Workout• LEAN

StrategicStrategicAlignmentAlignment• Business Objectives• Customer Requirements

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Sources for Nominating Projects

• Balanced Scorecards

• Patient complaints, responses to surveys

• Regulatory Issues

• Benchmarking shortfalls

• Critical items in financial reports

• Strategic business plans

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Alignment

CMS Evidence-Based Care Score

Adherence to AMI Process Measures

Improve Time to PCI

Be a top performing hospital for publicly reported data

1. Improve median PCI time to 54 min2. Leadership of State-Wide RACE Project3. Research Studies4. Process Recommendations to ACC

DUH Priority

CSU Measure

Improvement Opportunity

Six Sigma Project

Outcome

Research supports that

measure adherence drives

outcome.

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What does a Six Sigma Program look like?

StructureStructure• Leadership• Direction• Resources

ToolsTools• DMAIC• FMEA• Workout• LEAN

StrategicStrategicAlignmentAlignment• Business Objectives• Customer Requirements

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The Structure of a Six Sigma Program

• Executive/Owner Involvement– Top-level support is the most important factor leading

to success– Organizational leaders must

• Set the vision for success• Create an environment demanding of improvement• Review all projects and expect results

• Resource Allocation– Utilize your best employees– Make time for them to do the work

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The Structure of a Six Sigma Program

• Structured project review process– Review projects regularly– Develop clear guidelines for success and completion

• Training– Ensure all involved employees understand their roles

in the improvement process– Invest in advanced training for project leaders

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Resource Model

• 45 trained black belts; 123 trained green belts • Centrally placed

– Organize and execute the deployment plan– Lead organizational projects– Support operationally placed black belts– Located in Performance Services

• Operationally placed– Aligned with Clinical Service Units (CSU) and targeted

Departments– Primary reporting relationship with the departmental / CSU

leadership

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Six Sigma Oversight Committee

• Accountable to DUH Executive Committee• Oversight of projects and organizational project

selection• Structured review format

– Approval of projects– Tollgate reviews

• Oversight members– COO, CFO, CNO, Director of HR, Director of

Accreditation/Clinical Quality/PSO, Senior AOO

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Six Sigma Black Belt Council

• Coordinate and collaborate as a collection of key subject matter experts to review analysis and provide input for other black belt projects

• Provide input to Six Sigma Oversight Committee regarding potential black belt projects

• Review and recommend improvements to the Six Sigma training programs

Project ExampleOrthopedic Patient Satisfaction

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CTQsWhat is “Critical to Quality” (CTQ)?

– Patient Outcome– Patient Safety– Positive Experience

• Appropriate Response to Concerns• Inclusion in Decisions about Treatment• Address Emotional Needs• Sensitive to Inconvenience• Attention to Personal Needs• Information and Communication

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Problem StatementThe FY05 average overall patient satisfaction mean

score for Duke University Hospital Orthopedics Specialty was a .6 deviation from the target. Orthopedics Specialty ranks in the 65th percentile compared to COTH hospitals.

Mission StatementImprove overall mean satisfaction score to 84.1,

increasing the specialty ranking to approximately the 74th percentile compared to COTH and orthopedic specialty hospitals, for discharges starting April 2006.

Problem and Mission Statements

Rank based on Jul 04 – March 05

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78.7

82.581.4

85.3 84.9

76.5

80.8 81

78.9

83.5 83.1 82.8

75767778798081828384858687888990

2005-07 2005-08 2005-09 2005-10 2005-11 2005-12 2006-01 2006-02 2006-03 2006-04 2006-05 2006-06

Actual Target Linear (Actual)

Initial PerformanceOverall Mean Score

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Measure/ControlIP Overall Mean Score

6100 Mean Score by Unit and Question

Hospital Level SAS Scorecard

CSU Level SAS Scorecard

Unit Level Nursing BSC

Unit Level Press Ganey Report

Detail Press Ganey

6100 Overall Mean Score

6100 Overall Mean Score

Patient Surveys and Comments

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X1 = Age

X2 = Gender X3 = Procedure

X4 = Race

X5 = Timeframe

X6 = Discharge Disposition

X7 = Procedure

X8 = PG Question X8a = Task

X9 = Pre-op Education

X10 = Staffing

X11 = Turnover

Potential FactorsY=f (x1)+f(x2)+f(x3)+f(x4)+f(Xu)

ProcessInpatient

Mean Score

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Productivity Correlation

75

77.5

80

82.5

85

87.5

sat

75 80 85 90 95

prod

RSquare

RSquare Adj

Root Mean Square Error

Mean of Response

Observations (or Sum Wgts)

0.227417

0.150159

2.413577

82.32117

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Summary of Fit

Model

Error

C. Total

Source

1

10

11

DF

17.147515

58.253522

75.401037

Sum of Squares

17.1475

5.8254

Mean Square

2.9436

F Ratio

0.1170

Prob > F

Analysis of Variance

Satisfaction Increases as Efficiency Increases No correlation between Census and Satisfaction

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• Response to concerns and complaints• Include in decisions re: treatment• Staff addresses emotional needs• Staff sensitivity to inconvenience• Nurses kept you informed• Attention to special/personal needs

A B

Work-OutTM February 23, 2006

Staff Chose Option A:

More concrete concept, staff able to control, easier to create processes to improve

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Implementation of Action Items• Communicate with Patient About their Care

– Develop process for shift goal ID during assessment (Vanita)– Develop call light process (Lisa H & Lisa W)– Develop scripting messages (Lisa H)– Develop & implement training for basic rehab skills (Jennie &

Kathy)– Display mobility on white boards (Kathy)

• Communication Between Staff– Communicating assignment in report process (Vanita)– Implement process for posting PRM & PT assignments

(Joyce & Kathy)– Identify patients that will be seen early by PT/OT (Kathy)– Develop infrastructure for complaint resolution (Carey)– Communicate recommendations from team related to report

process (Vanita)

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Implementation of Action Items• Expectation Setting for the Inpatient Experience

– Create “Welcome to 6100” document (Shane)– Communicate with MDs about classes (Carey & Jennie)– Implement incentive for class (Jennie)

• Training/Behaviors for Staff– Communicate performance expectations as outlined in PPS

(Linda)– Develop schedule and plan for training (Joyce, Alene, Linda &

Shane)• Culture of the Unit

– Develop structure and avenue to implement peer feedback (Monica)

– Posting Press Ganey Scores and Comments (Carey)– Ensure peer support for breaks (Monica)– Develop award system for staff (Alicia)

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Control Process• Measure Reviews by Nurse

Manager/Clinical Operations Director– Overall Score monthly– Question review monthly– Good/Very Good review monthly

• Reaction Point– 2 points below target requires follow-up at

Musculoskeletal CSU Executive Meeting• Rounding/Leadership Follow-Up• Staff awareness through storyboards• Pay and performance Link at Management

and Staff Level

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Performance SummaryOverall Mean

82.5

81.4

84.9

76.5

78.9

82.8 82.7

81

83.3

81.3

83.1

84.8

85.4

82.8 82.7

85.2

83.4

87.9

8685.6

83.5

80.8 81

83.1

85.3

78.7

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-07 Feb-07

Actual Target Linear (Actual)

Project StartWork-Out

Implementation of Action Items

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Performance SummaryPercentile Ranking

Questions?