Six Sigma: Defining the Problem

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Transcript of Six Sigma: Defining the Problem

  1. 1. Six Sigma in Healthcare: Defining and Measuring the Problem Leslie W. Hayes, MD Six Sigma Black Belt D M A I C
  2. 2. Six Sigma Greek letter, , used to denote variation (spread) around the central tendency of a process A term used to refer to a Cultural Value or Philosophy Goal Measurement System A process to drive out waste and improve quality, cost and time performance of any organization D M A I C
  3. 3. The letter f Count the number of times the letter f appears in the following: Finished files are the result of years of scientific study combined with the experience of years D M A I C
  4. 4. How is Six Sigma Different from other QI approaches? Strategically deployed Customer focused ROI calculations Statistically Based Y=f(x) Built-in project management Preoccupation with error proofing Quality improvement on steroids D M A I C
  5. 5. Six Sigma Some Terminology Sigma expression of process yield based on the number of defects per million opportunities (DPMO) Unit the item produced or processed CTQ Critical to Quality Truly critical to customers perception of quality Can be measured Can set specifications to know whether or not the CTQ has been achieved Defect any event that does not meet customer specification Defect Opportunity a measurable chance for a defect to occur Defective A unit with one or more defects D M A I C
  6. 6. What is Six Sigma Performance? Sigma Defects per Million Opportunities How Good is the performance? 1 688,680 31.1% 2 308,537 69.1% 3 66,807 93.3% 4 6,210 99.4% 5 233 99.98% 6 3.4 99.99966% 20,000 times improvement D M A I C
  7. 7. Sigma Level 1,000,000 100,000 10,000 1,000 100 10 1 0 1 2 3 4 5 6 Domestic Airline Fatality Rate (0.43 DPMO) Airline baggage handling IRS Tax Advice (phone in) Prescription Writing Healthcare associated harm Restaurant bill mistakes Reliable Performance is Elusive. DefectsperMillion 6 sigma accuracy = 3.4 defects per million LSL USL p(d) M 6 4 3 2 1 1 2 3 4 5 65 p(d) A 6 Sigma Process includes 6 standard deviations between the mean and the spec limit Sigma Values +/- 1 = 68.26% +/- 2 = 95.44% +/- 3 = 99.73% Six Sigma Point of Inflection s1 7 Anesthesia deaths ASA class I D M A I C
  8. 8. Would you be happy with 99.9% performance? 1 hour of unsafe drinking water every month 2 unsafe plane landings per day at OHare 16,000 pieces of mail lost by the USPS every hour 500 incorrect surgical operations every week 50 newborn babies dropped at birth by doctors each day 22,000 checks deducted from the wrong bank accounts each hour D M A I C
  9. 9. What is Six Sigma Quality? Quality Product Features That Customers Want Freedom from Defects At Six Sigma Levels D M A I C
  10. 10. The Methodology: DMAIC DEFINE Identify the right project MEASURE Identify and understand key process and outcome measures ANALYZE Identify key process determinants IMPROVE Establish new model and optimize performance CONTROL sustain the improvements D M A I C
  11. 11. Comparison of different models 11 D M A I C
  12. 12. Project Focus Phase DEFINE The right project with the right team MEASURE Process Problems Outputs (outcomes) ANALYZE IMPROVE CONTROL Process inputs The Vital Few xs the Y the xs Goal: Y = f(x) D M A I C
  13. 13. DEFINE: the goals Identify the actual problem Identifying the customers of the project, including their specifications Involve the right people Creating a team charter D M A I C
  14. 14. Overview of Define Define the business case Gain project approval Understand The customer Define the process Manage the project Problem statement Goals statements Costs of poor quality Project plan Stakeholder analysis Storyboards SIPOC VOC Kano analysis CTQ tree Project charter D M A I C
  15. 15. Overview of Define Define the business case Gain project approval Understand The customer Define the process Manage the project Problem statement Goals statements Costs of poor quality Project plan Stakeholder analysis Storyboards SIPOC VOC Kano analysis CTQ tree Project charter D M A I C
  16. 16. SMART Problem Statements Specific Measurable Achievable Relevant Time Bound D M A I C
  17. 17. Goal Statements Keep it brief Avoid technical language Use same metrics as your problem statement Be as specific as possible about dates D M A I C
  18. 18. Cost of Poor Quality Rework Rejects Inspection Testing Customer returns/complaints Excess inventory High employee turnover D M A I C
  19. 19. Voice of the Customer (VOC) Define your customer Frontline staff involvement Families/patients perspective Sampling methods D M A I C
  20. 20. Delighters More is better Must haves Kano Analysis D M A I C
  21. 21. S I P O C Step Process starts Step Step Step Process Ends Operations Sales Accounts Legal Patients Clinicians Patient data Specimens Equipment Supplies Outcomes Product Process Data Clinician Lab Tech Patient Family D M A I C
  22. 22. SIPOC Exercise 20 minutes D M A I C
  23. 23. CTQ Tree (Key Driver Diagram) Provides clarity and structure Turns the customers need into a measureable specification General steps VOC Key Drivers of the customers needs What element of the key driver is critical to a quality process/outcome Specifications D M A I C
  24. 24. D M A I C What the Customer needs What the Customer Means by good #1 How do we Define Critical element? How often Should this Occur? VOC Drivers CTQs Specifications What the Customer Means by good #2 What the Customer Means by good #3 How do we Define Critical element? How do we Define Critical element? How often Should this Occur? How often Should this Occur?
  25. 25. D M A I C GOOD PIZZA What the Customer Means by good #1 How do we Define Critical element? How often Should this Occur? VOC Drivers CTQs Specifications What the Customer Means by good #2 What the Customer Means by good #3 How do we Define Critical element? How do we Define Critical element? How often Should this Occur? How often Should this Occur?
  26. 26. D M A I C GOOD PIZZA TIMELY How do we Define Critical element? How often Should this Occur? VOC Drivers CTQs Specifications COOKED RIGHT ACCURATE How do we Define Critical element? How do we Define Critical element? How often Should this Occur? How often Should this Occur?
  27. 27. D M A I C GOOD PIZZA TIMELY 15 minutes 100% of the time VOC Drivers CTQs Specifications COOKED RIGHT ACCURATE Correct internal temperature Product matches order 100% of the time 100% of the time Cheese browned Crispy
  28. 28. D M A I C Good Pizza Timely 15 minutes 100% of the time VOC Drivers CTQs Specifications Cooked right Accurate Correct internal temperature Product matches order 100% of the time 100% of the time Cheese browned Crispy
  29. 29. CTQ Exercise 20 minutes D M A I C
  30. 30. Project Charter Output of Define (summary) An agreement between management and the team Your marching orders going forward Keeps the team focused D M A I C
  31. 31. Team Charter Name ______________________________ Title _______________________________ PURPOSE: (Includes Problem Statement) IMPORTANCE: (business case; benefits to business, customers, employees) SCOPE 1. This process starts with 2. This process ends with 3. Inside scope 4. Outside Scope Project Schedule 5. Project to start (date) 6. Project to end (date) 7. Define to end (date) 8. Measure to end (date) 9. Analyze to end (date) 10. Improve to end (date) 11. Control to end (date) Budgetary Needs Goals of Project DELIVERABLES: (List items delivered from the project team) Improved process, new process documentation, training, etc. MEASURES: (Key measures; how much improvement is needed?) 1. We have (3) key measures. They are : 2. Today we are operating at 3. Our target is to (increase or decrease) 4. We will produce these results by the end of (month and year project ends) Purpose Importance Scope/focus Measures Deliverables Resources Elements of a Charter D M A I C
  32. 32. Consider working on a Project Charter with your Team This Weekend D M A I C
  33. 33. Pulling Define Together D M A I C
  34. 34. Background We have a large number of critical lab values that must be reported by the lab techs in a timely fashion to prevent harm from occurring to patients and to maintain compliance with regulatory standards. In reality, it all started with a page one Monday morning D M A I C
  35. 35. S I P O C LT retrieves value Value resulted on machine LT determines if Critical Value LT determines who to call LT delivers results LT documents notification Patient Clinician Collector Order Enterer Transporter Lab Tech (LT) Order Specimen Workers Machine Log Book Telecommunications Documentation of the Critical Value Provider Knowledge of Critical Value Clinician Lab Tech Patient Family D M A I C
  36. 36. D M A I C Give and Record important information quickly Accurate Clinician information available Timely Notification of information Accurate Patient Information Important information communicated On-call list is accurate Correct service information is available Patient location is known Time from value available to initial call to clinician is short Complete notification of values done in stated time Values on Critical Value list are truly critical 100% of time 100% of time 100% of time Less than 30 minutes 100% of time 20% reduction in notifications VOC Drivers CTQs Specifications
  37. 37. Problem Statement Goal Statement Hospital critical lab values are reported by lab techs to the appropriate healthcare providers. Our standard is that notification occurs within 30 minutes of the resulted value. Our current rate of compliance with this standard is 89%. To increase notification within 30 minutes to 100% by January 31, 2010. Project Scope Business Case/Financial Impact Identify improvements to reduce cycle time. Reduce the amount of notifications made by analyzing the criticality of results and making adjustments. Reduce time spent in notification process by lab techs. Reduce the probability of a citation by regulatory agencies. D M A I C
  38. 38. Charter Customers and CTQs Project Team Lab Tech Clinician Patient/Family CTQs: See CTQ Slide Champion: Pathology MD Process Owner: Lab Director Team Leaders: Black Belt Core Team Members: Lab techs, prescribers D M A I C
  39. 39. Project Plan Start Finish Define 9/9/09 9/25/09 Measure 9/26/09 10/21/09 Analyze 10/22/09 10/28/09 Improve 10/29/09 12/14/09 Control 12/15/09 1/31/09 D M A I C
  40. 40. Questions? D M A I C
  41. 41. Break D M A I C
  42. 42. Measure D M A I C
  43. 43. Data helps us Separate what we think from what is real Confirm or disprove ideas Establish baseline Observe history of problem over time Understand variation Avoid solutions that dont solve the real problem D M A I C
  44. 44. Data helps us Separate what we think from what is real Confirm or disprove ideas Establish baseline Observe history of problem over time Understand variation Avoid solutions that dont solve the real problem D M A I C
  45. 45. Overview of Measure Develop Process measures Baseline process capability Collect Process data Check Data quality Understand Process behavior Metrics Operational definitions Data worlds Distributions Process stability Short/Long term variation Measurement system analysis Collection methods Collection plans Sampling Process capability DPMO Sigma Levels Sigma Shift D M A I C
  46. 46. Overview of Measure Develop process measures Baseline process capability Collect process data Check data quality Understand process behavior Metrics Operational definitions Data worlds Distributions Process stability Variation Measurement system analysis Collection methods Data not related to time Data related to time Process capability DPMO Sigma Levels Sigma Shift D M A I C
  47. 47. Approach to Measure Data Collection Data not related to time Pinpoint occurrence of problems Data related to time Identify variation (patterns) in process Create detailed process maps Calculate process sigma D M A I C
  48. 48. Elements to Discuss Operational Definitions Data Worlds Data not related to time Data related to time Variation DPMO Process sigma D M A I C
  49. 49. Metrics (KPIs) CTQs (Key Drivers) are the basis for your Key Performance Indicators Measurements that reflect the VOC Data collection Balance efficiency and effectiveness D M A I C
  50. 50. Please write down clipboard clock time for each of the following 1. Sign in _________________________ 2. Registration done_________________ 3. Called back & weighed_____________ 4. Placed in room to wait______________ 5. Nurse in room to see you____________ 6. Doctor in room to see you____________ 7. Discharge instructions done__________ 8. Leave Clinic_______________________ D M A I C
  51. 51. Granularity of data needed can determine collection methods D M A I C
  52. 52. What $20 and your patients families can do D M A I C
  53. 53. 2892572251931611299765331 200 150 100 50 0 Clinic Visit Timeinminutes _ X=84.8 UCL=156.0 LCL=13.7 Total GI Clinic Encounter Time D M A I C
  54. 54. Operational Definitions Specific and concrete Measurable Useful Questions: How will you measure your data? What related conditions will you record? Sampling technique? How or where will you record your data? D M A I C
  55. 55. Exercise: Creating an Operational Definition 20 minutes D M A I C
  56. 56. Taguchi Loss Function Matching process with specifications D M A I C
  57. 57. Taguchi Loss Function Matching process with specifications D M A I C
  58. 58. Taguchi Loss Function Matching process with specifications D M A I C
  59. 59. Desired Data Characteristics Useful, meaningful data are Typical problem Sufficient enough so the patterns you see are likely to be real Insufficient not enough data to reach reliable conclusions Relevant helps you solve/pinpoint the problem Irrelevant describes a characteristic that doesnt help you understand the problem Representative full range of actual process conditions seen Biased only represents certain process conditions Contextual collected along with other key information Isolated your data is the only information you have about the process D M A I C
  60. 60. Data Worlds Continuous AttributeCount Measuring something Classifying something Counting things Calculated averages and variation Resolution only limited by measurement system Counting whole things Data can only be integers Categories that do not necessarily have numerical value or order D M A I C
  61. 61. Continuous Data World How to spot continuous data Not limited to whole numbers Examples: Oven temperature Length of hospital stay Time to next available appointment Laboratory values Invoice processing time Caution: resolution of the measurement system can affect your data D M A I C
  62. 62. Count Data World (Poisson) How to spot count data Half units not possible No physical upper limit Data recorded for a specific area of opportunity Defects per unit Examples Calls to the IT helpdesk each hour Employee needle sticks Patient complaints D M A I C
  63. 63. Attribute Data World (Binomial) How to spot attribute data Classifications Often in percentages Examples Tossing a coin Proportion of patients experiencing harm D M A I C
  64. 64. Data NOT Related to Time Tally (check) sheets Pareto Cause and Effect Diagram Detailed Process Mapping D M A I C
  65. 65. Tally Sheets . Study subject PIB Type PIB Placement PIB Information: Name Correct PIB Information: Gender Correct PIB Information: DOB Correct Age Required Spanish interpreter (Y or N) 1 2 3 4 5 6 7 8 9 10 D M A I C
  66. 66. D M A I C Documented Sever Severity by s/s Daytime Symp Night Cough/Awa Activity Limits Beta Agonist use Exac in 2 NR Persistent by ICS NR NR NR NR NR Mild Pers Persistent 3/week None Some NR No NR Persistent NR None None No albuterol over 6 months Yes-1 NR Persistent NR NR NR NR Yes-1 NR Persistent by ICS NR NR NR NR No Moderate Pers Persistent NR None None 1/month winter None NR Persistent NR NR NR NR Yes-1 NR Persistent by ICS NR NR NR NR NR NR Persistent NR Nightly NR NR Yes >2 NR Intermittent 2 NR Persistent NR NR NR NR Yes-1 NR Persistent by ICS NR NR NR NR NR NR Persistent by ICS NR NR NR NR Yes >2 NR Persistent by ICS NR NR NR NR Yes-1 NR ? 2 NR Persistent by ICS NR NR NR NR Yes-1 NR ? 2 NR Persistent by ICS NR NR NR NR Yes-1 NR ?