Six Sigma P I T Process Improvement Methodology Methodology: Presented by Content Expert

SixSigma
P
ProcessImprovement
I
t
Methodology
PresentedbyContentExpert:
BethLanham,RN,BSN,MBA
Director Six Sigma
Director,SixSigma
FroedtertHospital,Milwaukee,WI
Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
What is Six Sigma?

WhatisSixSigma?
SixSigmaisa
customerfocused
customer focused
projectfocused
resultsdriven
app oac to Qua ty
approachtoQuality
Six Sigma Overview

SixSigmaOverview
Arigorousmethodology
A rigorous methodology
OriginatedbyMotorola(1986)
A
Astatisticallybasedmethodtoreducevariationin
statisticallybased method to reduce variation in
electronicmanufacturingprocesses
Heavilyinspiredby
Previousqualityimprovementmethodologies
QualityControlManagement,CQI,TQM
Basedontheworkofqualitypioneers
q
yp
Deming,Juran,Ishikawa,Taquchiandothers
Six Sigma Overview

SixSigmaOverview
Bylate1990s
y
2/3Fortune500companies
Aimedatreducingcostsandimprovingquality
Today
T d
Utilizedallovertheworld
Localgovernments,prisons,hospitals,thearmedforces,banks,
g
,p
,
p
,
,
,
manufacturing,etc.
Inrecentyears
Si
SixSigmaoftencombinedwithLeanManufacturingto
Sigma often combined ith Lean Man fact ring to
yieldamethodologycalledLeanSixSigma.
Why Six Sigma?

WhySixSigma?
Whatweweredoingwasntworkingwellenough!
Wh
d i
ki
ll
h!
Incrementalimprovementsnotgoodenough
Needto/Desireto:
Need to /Desire to:
Focusoncustomerrequirements
Basedecisionondata,notanecdotalinformation
BeProactivevs.Reactive
Establishacultureofownershipvs.culpability
Itstheprocesses,notthepeople
Effectrapidandeffectivechange
Improvementeffortswerefragmented
Largesystemwideprocessesbroken
L
id
b k
Notholdingthegains
What does Six Sigma offer?

WhatdoesSixSigmaoffer?
Augmentstraditionalqualitytools
Augments traditional quality tools
Datadrivendecisionmaking
Focusesoncustomerrequirements
Afocused/organizedapproach
Redefinesprocessesforlongtermresults
Becomesingrainedinworkandthought
processes
Reliesonevidencebasedsolutions
Rapid/effectivechange
Organizational
g
Benefits:
Competitiveedge
Service
Excellence
Empowered staff
Empoweredstaff
Leadership
Development
Quality/Safety
HealthcareCosts
Six Sigma
SixSigma
Methodologyaimedat
Errorreduction
Eliminatingvariation
Eliminating variation
Goal
Design/improveprocessessoitisimpossibletomakean
error
Relianceonperformancemeasurementsand
statistical analysis
statisticalanalysis
Traditionally..
Traditionally
Businesses
Businesseshavedescribedtheirproductsor
have described their products or
servicesintermsofaverages:
Averagecost
g
Averagetimetodelivery
Averagenumberinfections
A
Averageusage
Averagewaittime
AreTheseProcessestheSame?
Process1 Process2
20
11
17
10
15
10
11
10
12
Aretheyperformingwell?
Goal=lessthan10
Process1
Process2
Mean9.4Mean9.4
Areallthecustomershappy?
ppy
Variation=OpportunitiesforErrors
pp
Process1
Process2
Average9.49.4
Minimum58
Maximum2011
Median
Median59.5
5
9.5
Standarddeviation6.01.17
Customersfeelthevariation,
nottheaverage!!!!!!
Variation in the Process

VariationintheProcess
Process1
Process2
Histogram of Process 1
Histogram of Process 2
Normal
Normal
Mean
StDev
N
100
80
9.540
6.149
1000
70
9.412
1.193
1000
60
Frequency
80
Frequency
Mean
StDev
N
60
40
50
40
30
20
20
10
0
-12
-6
6
12
Process 1
Many
Defects
18
24
-12
-6
6
Process 2
12
18
24
Fewer
Defects
Process1islesscapableofmeetingourcustomer
Process
1 is less capable of meeting our customerss
expectations!
Exactcapabilitycanbemeasured!
Six Sigma Central Concepts

SixSigmaCentralConcepts
CriticaltoQuality(CTQ)
Critical to Quality (CTQ)
Howthecustomerjudgesourproducts/services
Y=Theoutcomemeasureoftheprocess
Xs=InputsorvariablesthataffecttheY
Defect Failuretodeliverwhatthecustomerexpects
DPMO Defectspermillionopportunities
DPMO
Defects per million opportunities
Variation
Theenemyofpredictableoutputandcustomersatisfaction
Sigma
Anexpressionofprocessyield,basedonthenumberof
defects per million opportunities (DPMO)
defectspermillionopportunities(DPMO)
SixSigma
g
APhilosophy
p y of
f
OperationalExcellence
AsetofProblem
Solving
Solving
Tools/Tactics
A Metric
AMetric
AMeasure ofProcess
Capability
Definitions of Six Sigma?

DefinitionsofSixSigma?
Ametric
A metric
Greekletter
Ameasureofprocesscapability
Howcapableisourprocessofmeetingourcustomers
expectations?
Arigorous,structuredapproachtoproblemsolving
g
pp
p
g
Includesadefinedmethodologywithspecifictoolsandtactics
Amanagementphilosophy
Operationalexcellenceandcontinuousimprovement
Operational excellence and continuous improvement
Definitionscomplimentary,notcontradictory!
p
y
y
Six Sigma as a Metric

Astatisticalconcept
Representsthevariationthatexistsinaprocess
Relativetothecustomerrequirements
l
h
Aprocessoperatingata6 Sigmalevel
SSolittlevariation,thattheprocessoutcomesare
li l
i i
h h
99.9997%defectfree
SixSigma=6,6Sigma,or6s.
Six Sigma = 6 6 Sigma or 6s
Process Sigma
ProcessSigma
DPMO = Defects per Million Opportunities
DPMO=DefectsperMillionOpportunities
Amoresensitiveindicatorthan%yieldor%good
Sigma
Defects
Yield
DPMO
69.1%
30.9%
691,462
30.8%
69.1%
308,538
6.7%
93.3%
66,807
0.62%
99.38%
6,210
0.02%
99.977%
233
0.0003%
99.9997%
3.4
WhenComparedtoBestinClass
(N i
(NationalData)
lD )
Antibiotic
Overuse
BetaBlockerUse
Beta
Blocker Use
PostMI
InpatientMedication
Accuracy
Defects / Miillion
1000000
000000
44,000 98,000
PreventableHospital
Deaths(IOMReport)
100000
10000
1000
100
Anesthesia
DuringSurgery
10
1
1
4
Sigma
6
DomesticAirline
FatalityRate
Traditional Process Improvement

TraditionalProcessImprovement
5&6
Sigma
1Sigma
g
2 Sigma
2Sigma
3 Sigma
3Sigma
4Sigma
4to5Sigma 27foldPerformanceImprovement
5 to 6 Sigma Another69
5to6Sigma
Another 69fold
foldPerformanceImprovement
Performance Improvement
Measure of Process Capability

MeasureofProcessCapability
Focus
Focusonimprovingwhatisimportanttothe
on improving what is important to the
customer
CriticaltoQuality(CTQs)
Q
y( Q )
ThisisgenerallyreferredtoastheY oroutcomevariable
Examples:waittime,responsetime,turnaroundtime,%
newvisits,%mederrors,%falls,etc.
MeasuretheY againstthetarget
Target=customerexpectationsorspecifications
ProcessCapability
p
y
Upper
Specification
Li i
Limit
Lower
Specification
Limit
Frequency
10
Defect
Average
Defect
A Problem Solving Approach

AProblemSolvingApproach
Highlystructuredmethodology
Highly structured methodology
Focusedonidentifyingtherootcauses
Process variables impact or influence the Y
ProcessvariablesimpactorinfluencetheY
Rootcauseanalysis
ProcessvariablesarecalledXs
Y = x1 + x2 + x3 + x4, etc.
Primary
P
i
metric
t i (Y) = combination
bi ti
of a variety of variables (xs)
Whatarethevariablesthatinfluence
themainmetric?
A Management Philosophy
AManagementPhilosophy
Focusisoncontinuousimprovementby
Focus is on continuous improvement by
Understandingthecustomersneeds
Analyzingbusinessprocesses
Analyzing business processes
Institutingappropriatemeasurementmethods
Emphasisonmanagementofprocesses
p
g
p
Wedonthavefaultypeople,wehavefaultyprocesses!
We canttmanagewhatwedon
Wecan
manage what we donttmeasure!
measure!
Six Sigma Model DMAIC

SixSigmaModel
DMAIC
Define
Charter
project
HighLevel
High Level
ProcessMap
CollectVOC
Identify
Id if
CustomerCTQs
Review
hi t i l d t
historicaldata
Measure
Analyze
SelectKey
CTQs**
Establish
current
capability
Developdata
collectionplan
ll i
l
Define
performance
standards
t d d
Validate
measurement
systems
Identifykey
sourcesof
variability
Define
performance
objectives
Improve
Control
Optimization
Cycletime
Variability
Cost/LOS
C /LOS
Determine
capability
ofnew
process
p
Validationof
Improvements
Implement
process
controls
Implementation
*VOC VoiceofCustomer
**CTQCriticaltoQuality
Ensure
Gainsare
Sustained
ToolsofSixSigma
g
Y
Y =f(X,x)
f(X x)
Multi
MultiVari
Vari Charts
ProcessMap
Regression
FMEA(FailureModeand
HypothesisTest
EffectsAnalysis)
95%ConfidenceInterval
Cause EffectDiagram
ANOVA
ParetoDiagram
P t Di
DOE(DesignofExperiments)
DOE (D i
fE
i
t )
GageR&R
ControlPlan
ProcessCapability
p
y
StatisticalProcessControl
SixSigma
g
KeyPlayers
y y
Overseeor
Full time
Fulltime
StrategicProjects
SkilledinSixSigma
T l
Tools
chooseprojects
Black
Belts
TeachGreenBelts
Champions
Provide
Provide
Leadership
Executive
S
Sponsors
FullTime
PartTime
SmallerScope
Smaller
Scope
Projects
Helptochange
culture
ResolveIssues
Green
Belts
Master
BlackBelts
Strategic
Projects
j
Program
Administration
TeachBlack
BeltsandGreen
Belts
TheSixSigma
The
Six Sigma
Process
LaunchingaProject
g
j
IdentifyaSponsor/Champion
/
Energy/passiontosolvetheproblem
Sponsor/ChampionRole
Sponsor/Champion Role
Defineboundaries/scope
Establishstretch goals
Providedirectionandsupporttotheteam
Removebarriers
Recognize and celebrate successes
Recognizeandcelebratesuccesses
Accountableforcompletion,implementationandsustaining
resultsfromtheproject

SixSigmaModelDMAIC
Define
Measure
Analyze
Improve
Control
Charterproject
Problemstatement Howdoweknowwehaveaproblem?
Goal
GoalStatement
Statement Howwillweknowifwehavemadean
How will we know if we have made an
improvement?
ProjectScopeandTeam
HighLevelProcessMap
Hi h L l P
M
IdentifyCustomerCTQs
Stakeholderanalysis
Stakeholder analysis
Reviewhistoricaldata
ExampleProjectCharter
QMS Project Team Charter
Business Process Team/Svc Line:
Project Name:
Project Team Members

Target Completion Date:
Review Timing
Project Type:
CAP WO PDSA Lean DMAIC
Project Champion:
Start Date:
Process Owner:
Milestones TBD based on methodology
Black Belt:
Finance Representative:
Project Overview
Problem Statement (*MOMS criteria):

p
In Scope:
Out of Scope:
Customers and Stakeholders:
Goal (s): (**SMART criteria)
Current Performance Indicators and Levels:
Target Performance Indicators and levels:
Expected Benefits/Business Case (target savings, target metric reduction):
Assumptions:
Constraints:
Signatures
Project Chair(s) Signature:
Champion Signature:
Master Black Belt signature:
Problem and Goal Statements

ProblemandGoalStatements
ProblemStatement
Howdoweknowwehaveaproblem?
MOMScriteria
MOMS criteria
Measureable,Observable,Manageable,Significant
GoalStatement
Howwillweknowifwehavemadeanimprovement?
SMARTcriteria
Specific,Measureable,Attainable,Realistic,Timely
S ifi M
bl Att i bl R li ti Ti l
High Level Process Map SIPOC

HighLevelProcessMap
P
Purpose:Tographicallydisplaytheprocessmajorevents
T
hi ll di l th
j
t
Suppliers
Whoprovidestheinputstoyourprocess?
Inputs
Whatmaterials,resourcesanddataareneededtoexecuteprocess?
ProcessSteps
p
57stepsthatuseinputstochangeintooutputs.Useveryspecificstart
andstoppoints!
Outputs
p
Whatistheoutputoftheprocess?Whatdidthecustomerreceive?
Customers
Whoreceivestheoutputsoftheprocess?
Who receives the outputs of the process?
SIPOCExample
Hand Hygiene SIPOC
Suppliers
-Who provides
the inputs?
Infection Control
H.C Prov iders
(Physicians, nurses,
nursing assistants,
therapists,
technicians,
emergency medical
staff, dental staff,
pharmacists,
laboratory staff,
autopsy staff,
students and
trainees, contractual
staff not employed
by the healthcare
facilit y, and persons
not directly involved
in patient care but
potentially exposed
to inf ectious agents.)
Plant
Operations
Patient condition
InputsMaterials,
res ources,
data
Policies &
Procedures
Process Steps
Enter
E
t patient
ti t
room
CDC guidelines
Soap
Alcohol hand rub
Wash hands
upon entering
t i
Dispensers
Sinks
Paper towels
Conscious thought
Extent of contact
Patient
Encounter
Wash hands
upon exiting
MD orders
Call lights
Operational
routines
What did the

customer
receive?
High quality
care
Avoidance /
reduc tion of
hospital
acquired
infections
Clean hands
Clinical Routine
Degree of urgent
care required
Outputs-
Leave patient
room
Dec rease in
skin irritation
Increased
patient
confidenc e
Customers
- Who benefits?
Patients
CMS
Third Party
Pay ors
O ther patients
Staff
Families
Process Maps aTip!

ProcessMaps
a Tip!
Each process has at least 3 versions
Eachprocesshasatleast3versions
Whatyouthink
y
itis
Whatitactuallyis
y
Whatyouwouldlikeit
y
tobe.
Voice of the Customer

VoiceoftheCustomer
Establish Voice of the Customer (VOC)
EstablishVoiceoftheCustomer(VOC)
Identifyandprioritizeallcustomers
Whoisimpactedthemostbytheprocess?
Whoisthemostdissatisfiedwiththecurrentprocess?
Solicitfeedback
Howdoesthecustomerviewtheprocess?
How
does the customer view the process?
Whatdoesthecustomervaluefromtheprocess?
Whatdoesthecustomerexpectfromtheprocess?
Whatdoesthecustomerwantmostofthetime?
Whatisthelimitthecustomeriswillingtotolerate?
Stakeholder Analysis form?

StakeholderAnalysisform?
Whowillbe
affectedbyany
changes from this
changesfromthis
project?
Beginaddressing
y
issuesearly!
Noteveryone
needstobestrongly
supportive!
pp
St k h ld A
Stakeholder
Analysis
l i
Names
Strongly
Against
Moderately
Against
Neutral
(0)
Moderately
Supportive
Strongly
Supportive

SixSigmaModelDMAIC
Define
Measure
Analyze
Improve
SelectCTQcharacteristics
Select CTQ characteristics
DefinePerformanceStandards
DataCollection
MeasurementSystemAnalysis
ProcessXs(Variables)
OutputsorYs
X1
Y1
X2
Y2
TheProcess
X3
Y3
X4
Y4
Control
CTQ characteristics
CTQcharacteristics
Select
Selectthemaincharacteristicthatthecustomer
the main characteristic that the customer
usestojudgeyourperformance
SixSigmalingo:ThebigY
g
g
g
HowwillIknowifIhavemadeanimprovement?
HowwilltheYbedefinedand/ormeasured?
/
VOC
Expecttobeseen
within15minofappt.
CTQ
WaitTime Pt.checkinatfrontdesktofirst
contactwithstaffphysician.
Define Performance Targets

DefinePerformanceTargets
TranslatetheCustomerexpectationsintoMetrics
Target:
What
Whatdoesthecustomerwantmostofthetime?
does the customer want most of the time?
SpecificationLimits:
Whatarethelimitsthepatientiswillingtotolerate?
VOC
Expecttobeseen
within15minofappt.
Unhappyif>30min
CTQ
Wait
Time
Y
Pt.checkinatfront
desktofirstcontact
withstaffphysician.
Target
UpperLimit
15min
30min
Identify the Key X variables

IdentifytheKeyXvariables
Cause and Effect Diagram
Cause-and-Effect
P ro cess
E n v iro n men t
M an ag emen t
Clu t t e r o b st ru ct in g sin k
No t ra in in g o n p ro ce ss t ime lin e
P e o p le a re n o t a w a re t o w a sh h a n d s
b e f o re /a f t e r co n t a ct
M a n a g e rs n o t a cco u n t a b le
No sin k in t h e ro o m
Divisio n s n o t a cco u n t a b le
S p o t ch e cks n o t cu rre n t ly d o n e
No re min d e rs p o st e d
No o n g o in g e d u ca t io n o n p ro ce ss f o r
No co rre ct ive a ct io n f o r n o n -co mp lia n ce
Ne e d t o t a ke ca re o f p a t ie n t a n d ca n 't
E q u ip me n t is n o t w ip e d d o w n
re g u la rly
Ca rryin g it e ms in t o p a t ie n t ro o m
Dif f icu lt y mo n it o rin g p ro ce ss
Un d e rst a f f in g /O ve rcro w d in g
La ck o f in st it u t io n a l sa f e t y clima t e
No t p a rt o f t h e ye a rly e va lu a t io n
p ro ce ss
Lo w risk o f a cq u irin g in f e ct io n s f ro m
No in ce n t ive s/re w a rd s t o co mp ly
La ck mo t iva t io n t o se t a n e xa mp le
No co mmu n ica t io n re : p t imp a ct if n o n -co mp lia n t
Do n 't h a ve a d e q u a t e re so u rce s
La ck o f in st it u t io n a l p rio rit y f o r h a n d h yg ie n e
No ro le mo d e l f o r h a n d h yg ie n e
La ck imme d ia t e f e e d b a ck/o u t co me s
In a d e q u a t e o rg . st ru ct u re f o r a cco u n t a b ilit y
S ke p t ica l a b o u t e f f e ct ive n e ss
In t e rf e re s w /HCW re la t io n sh ip w it h p t s
Disa g re e w /re co mme n d a t io n s
F a mily/visit o rs u n a w a re re :h a n d w a sh in g
F a mily/visit o rs d o n 't se e b e in g p a rt o f P C
O t h e r p e rso n n e l n o t a w a re
P t s/visit o rs in su lt e d w h e n a ske d t o w a sh
P t s n o t a t e a se a skin g so me o n e t o w a sh
P e o p le f o rg e t
P e o p le se t in t h e ir w a ys
No t p a rt o f t h e F ro e d t e rt cu lt u re
No t se e n a s a p rio rit y
Co n ce rn e d w /skin irrit a t io n
Do n 't u n d e rst a n d n e e d f o r h a n d w a sh in g
F e e l t h a t n o n e e d t o w a sh w /g lo ve s
Do n 't kn o w p ro p e r h a n d w a sh in g
O n ly t o u ch e q u ip . , n o n e e d t o w a sh
F e e l t h a t w a sh h a n d s e n o u g h
To o b u sy/No t e n o u g h t ime
P eo p le
De la ys in g e t t in g n e e d e d e q u ip me n t
No lo t io n a cce ssib le
No a lco h o l w ip e s
No t e n o u g h h a n d d isp e n se rs
No d a t a t o sh o w t h e imp a ct o f h a n d
h g yie n e o n t h e ra t e o f HAI
S kin irrit a t io n b y h a n d h yg ie n e a g e n t s
In co n ve n ie n t lo ca t io n o f h a n d sa n it ize r
La ck o f e d u ca t io n ma t e ria ls
S o a p /a lco h o l d isp e n se r e mp t y
Bro ke n d isp e n se r
O ve rf lo w in g g a rb a g e
No t o w e ls
S t a f f w o rk a re a s a re d irt y
To o ma n y p e o p le in ro o m, in w a y o f sin k
E q u ip me n t in w a y o f sin k
P a t ie n t ro o m is o u t o f g lo ve s
No t e n o u g h sin ks a va ila b le
S in ks d o n 't w o rk
M aterials
E q u ip men t
SponsoredbytheWisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
CopyrightoftheWisconsinOfficeofRuralHealth.
Lack h an d
h y g ien e
co mp lian ce
d u rin g p t
in terac io n
Data Collection/Sampling
DataCollection/Sampling
Keyconsiderations
Key considerations
Datamustberepresentativeoftheprocess
Datamustbereliable
Mustcapturemeasurementsofimportance
ENTRY
OBS #
1
Group
2
Group
Role(s)
Hand Hygiene
Sink
Hand Rub
None
Did Not Observe
Direct Exit to Enter?
Sink
Hand Rub
None
Did Not Observe
Direct Exit to Enter?
EXIT
Notes
Y
Y
Y
Y
/
/
/
/
N
N
N
N
Gloves On
Y
Y
Y
Y
/
/
/
/
N
N
N
N
Gloves On
Urgent
Full Hands?
Blocked Access
Urgent
Full Hands?
Blocked Access
Hand Hygiene
Notes
Sink
Hand Rub
None
Did Not Observe
Y
Y
Y
Y
/
/
/
/
N
N
N
N
Gloves On
Sink
Hand Rub
None
Did Not Observe
Y
Y
Y
Y
/
/
/
/
N
N
N
N
Gloves On
Removed gloves
Full Hands?
Blocked Access
Removed gloves
Full Hands?
Blocked Access
Measurement System Analysis (MSA)

MeasurementSystemAnalysis(MSA)
H
Howaccurateisthemeasurementprocess?
t i th
t
?
Howmuchvariationisthereinthemeasurement
process?
Attempttominimizecontrollablefactorsthatcould
exaggeratetheamountofvariationinthedata
Example:
Iwanttomeasureseconds.Theclockonlymeasuresminutes
Result:
Thevariationofthemeasurementsystemistoolargetostudy
the current level of process variation
thecurrentlevelofprocessvariation
MSA Examples
MSAExamples
FallRisk/PressureUlcerRiskAssessments
Fall Risk/Pressure Ulcer Risk Assessments
PerformedbyallRNs
Patientsgivenscores,basedonassessmentcriteria
DoortoBalloonTime
Clocks
1. Reproducibility DoesRN#1getthesamescoreasRN#2?
2. Repeatability DoesRN#1alwaysgetthesamescorewhen
f d ith th
facedwiththesamefindings?
fi di ?
Totalmeasurementsystemvariabilityshouldbeassmallas
possible,butalwayslessthan30%.

SixSigmaModelDMAIC
Define
Measure
Analyze
Improve
Control
Establishcurrentcapability
Identifykeysourcesofvariability
Defineperformanceobjectives
D fi
f
bj i
Howistheprocessperformingtoday?
p
p
g
y
Doweneedtoshiftthemeanorreducevariation?
WhatarethekeyXsthataredrivingtheY?
Howdoyouknow?
Analyze
GraphicalTools
Flowdiagrams,frequencyplots,Paretocharts,etc.
StatisticalTesting
DescriptiveStatistics,ProcessCapabilityHypothesistesting,Regression
Analysis, etc.
Analysis,etc.
DesignedExperiments
DisplayingtheData
p y g
Descriptive Statistics
Bo xp lots o f Pt Wa it Tim e b y C L IN IC
Variable: Pt Wait Time
( means are indicated by solid cir cles)
Anderson-Darling Normality T est
10
35
60
85
110
135
160
95% Confidence Interval for Mu
32.018
0.000
Mean
StDev
Variance
Skewness
Kurtosis
N
23.1551
15.3332
235.108
1.25196
4.39234
2559
Minimum
1st Quartile
Median
3rd Quartile
Maximum
0.000
0
000
11.000
21.000
33.000
153.000
95% Confidence Interval for Mu

22.561
20
21
22
23
24
23.750
95% Confidence Interval for Sigma

14.924
150
Pt Wait Ti me
e (i n min)
A-Squared:
P-Value:
100
50
15.765
95% Confidence Interval for Median
Scatterplot of Hand Hygiene Events vs Time of Day

40
ORT
22.000
ORO
20.000
HAC
95% Confidence Interval for Median
Ha
and Hygiene Events
OverallStatisticsByPatient:
30
Metric
20
10
0
6
10
12
Time of Day
14
16
Mean
Median
Std Deviation
Sample Size
Min
Max
Wait Time
23.16
21
15.33
2559
0
153
Exam Time
18.94
16
11.54
2559
0
99
Total Time
42.10
40
19.76
2559
3
183
Current Process Capability

CurrentProcessCapability
Howistheprocessperformingtoday?
p
p
g
y
Doweneedtoshiftthemeanorreducevariation?
T
1.235
1.239
LSL
1.241
1.245
USL
1.233
1.235
1.239
LSL
1.241
1.245
USL
HypothesisTesting
G tti t th R t C
GettingtotheRootCauses
Which XsshadthegreatestaffectontheY?
WhichX
had the greatest affect on the Y?
Test
Details
Role
RNs
LCs
DTY
EVS
TSP
THP
Day of Week
Time of Day
Groups
p
Method
Full Hands
Urgency
Gloves
Timing
Access
DTY, EVS, Lab, LCs, PCAs, RNs, RTs

RNs vs. All others
Long Coats vs. All others
Dietary vs. All others
EVS vs. All others
Transport vs
vs. All others
Therapists vs. All others
Mon vs. Tues vs. Wed vs. Thu vs. Fri
Observation Hours 7-16
Single
g HCW vs. Groups
p
Sink vs. Alcohol Based Hand Rub
Empty vs. Full Hands
Normal vs. Urgent
Wearing gloves vs. No gloves
Entry vs. Exit
Clear access to Sink/ABHR vs. Blocked Access
P-Value
0.002
0.422
0.004
0.005
0.056
0 020
0.020
0.020
0.285
0.039
0.868
0.000
0.000
n/a
0.463
0.000
0.965
PValues<0.05are
signficantfactors
Mustusethe
correctstatistical
testsbasedon
types of data
typesofdata

SixSigmaModelDMAIC
Define
Measure
Analyze
Improve
Control
OptimizationofY(Cycletime,Variability,Cost/LOS)
/
ValidationofImprovements
Implementation
p
ControlPlan
% compliance
1
Generatealternatives
Testthealternative
UCL=0.852
0.8
0.7
Individual Value
Assesstherisks
0.9
0.6
_
X=0.471
0.5
0.4
0.3
0.2
S l t th b t lt
Selectthebestalternative
ti
0.1
LCL=0.090
0.0
Wk 12 Wk13 Wk 14 Wk 15 Wk 16 Wk 17 Wk 24 Wk25 Wk 26 Wk 27 Wk 28 Wk 29 Wk 30
C22
Evaluating solutions
Evaluatingsolutions
Pugh Matrix
Evaluatehow
eachoption
meetsCTQs
Utilizes RN critical Thinking

FTE neutral
Good judgement regarding whether to take patient
off tele when off unit
te
ce
Efficient trouble shooting
Te
l
Key Criteria
RN accountable for patient
Im
po
rt
an
Generate
multiple
multiple
options!
at
in
g
co ch
nt on
in
uo flo
m us or
on c w
ito en ith
rin tra
te
le
g l
te
ch
of o n
ce flo
nt or
ra a
l m nd
Sh
on de
re ift
ito le
st co
rin tio
ru or
ct di
g n
ur na
ed t o
pa po r w
tie sit ith
n t ion
R
s
aw
-n
o
lin
in s c
st a
al ll
le lig
d
in ht s
te y s
le t e
ro m
om
Alternatives
Overall high standard of care maintained
Continuous observation
10
2
8
18
2
0
1
0
19
RN knowledge of when patient leaves unit

RN knowledge of when patient returns
Assurance that p
patient placed
p
back on tele when
returned to floor
30 Second response to sustained lethal rhythms or
rate alarms
Documentation of rate/rhythm changes
Consistent/accurate interpretation of rate/rhythm
Timely recognition of rate/rhythm changes
Misc. benefits
enhance current shift coor. Responsibilities
Increased awareness of unit "big" picture
Increase resources avail. to unit RNs
Increase unit teamwork
Increase staff satisfaction
Increase coordination of care
Sum of Positives
Sum of Negatives
Sum of Sames
8
1
11
Key
Better
Same
Worse
= 10
= 8
=5
= 3
=1
Pilot/Validate Results
Pilot Planning
PilotPlanning
FailureModeandEffectsAnalysis
Assureadequatesamplesize
Validateimprovements
Validate improvements
throughdataandstatistical
analysis
S ICU confirm ed Glucose levels < 70 on insulin byy m onth

Sept
02
June-Aug 2002
Jan Feb
03 03
Dec
02
March
03
90
Indiv idua l Vaa lue
80
UCL=84.41
Baseline
70
Mean=60.25
60
50
Pilots
40
LCL=36.09
30
0
10
20
30
40
50
60
Observation Number
70
80
90

SixSigmaModelDMAIC
Define
Measure
Analyze
Improve
Control
% compliance
1.2
Interim
Pilot
UCL=1.119
1.0
Individual Value
Determinecapabilityofnewprocess
Implementprocesscontrols
EnsureGainsareSustained
Closetheproject
Pre
_
X=0.823
0.8
0.6
LCL=0.528
0.4
0.2
0.0
W k12 W k13 W k14 Wk 15 W k16 W k17 W k24 W k25 W k26 Wk27 W k28 W k29 W k30
Isthenewmeasurementsystemmeasurewhatitissupposetomeasure?
Doesthenewprocessmeetthegoal?
How can you sustain the gains?
Howcanyousustainthegains?
Mistakeproofing,Robustdesign,ProcessMonitoring
Celebratesuccesses!
Control
Determinenewprocesscapability
p
p
y
Developcontrolplan
MonitorInputsandOutputs(YsandXs)
EnsurethatGainsareSustained
ShareBestPractices
700
600
500
400
300
200
100
0
-1 0 0
S u b g ro u p
B a s e line
1
1
1
1
200
100
0
1
U C L = 2 6 3 .8
L C L = -7 3 .7 8
0
50
P ilo t
100
P ilo t
500
400
P o s t P ilo t
M e an= 9 5
600
300
P ilo t
C 16
Moving R
Range
Maintainthe
gains!
Indivvidual Value
C o n tro l C h a rt: tim e to 1 s t a n tib io tic
1
1
1
U C L = 2 0 7 .3
R = 6 3 .4 6
LC L=0
ExampleSixSigmaProjects
p
g
j
Safety/Quality
Insulin/Diabetes
Falls
Anticoagulation
TelemetryResponse
PatientIdentification
PriorityMedication
HandHygiene
Medication
VerificationProcess
Communicationof
Addi i
AdditionalRadiology
l R di l
Findings
Service/ProcessEfficiencies
Patientflow
Ortho/Radiology
Ortho/OR
PulmonaryFunctionsLab
Pulmonary Functions Lab
Hem/OncLabProcess
Hem/OncTreatmentRoom
GILab
PatientThroughput
DischargeProcess
A
Access
DiabetesClinic
UrologyClinic
Waittime:
W it ti
HandCenter
OPLab
OPRegistration
OP R i
i
Delaysinsurgeryd/t
missingInstruments
Lessons Learned
LessonsLearned
OrganizationalVision
Organizational Vision
SeniorManagementmust lead
Befocused strategicalignment,cascadingofgoals,havea
plan!
Holdpeopleaccountable!
InvolveMedicalStaff
Stayfocused
y
fforalongtime!
g
AdministrativeStructure
Clearrolesandresponsibilities
Methodologyforprojectselection,scoping,approvaland
resourceallocation
Donttakekeythingsoutofscope!
y
g
p
Establishownership,reportingandtrackingmechanisms
Lessons Learned
LessonsLearned
CultureChange
g
Dontunderestimatetheresistance!Expectit!Manageit!
StayFocused Countertheflavoroftheday
Top down visible leadership Walkthetalk!
Topdownvisibleleadership
Walk the talk!
Address ChangeManagementStrategy fromthebeginning!
EconomicImplications
Decidewhethereconomics
Decide whether economics lead
leadorfollow
or followasadriver
as a driver
Organizationalfocus
Projectfocus
Other.
Therearenosilverbullets!!!Itstakesplainhardwork!
Leadersnotinherentlygoodsponsors!
Challengingtofindtime,resources,data
Difficulttofindtherightstaff
Facilitationskills,projectmanagement,healthcareknowledge,problem
solving,movers/shakers
How will we know when we get there?

Howwillweknowwhenwegetthere?
The following elements will occur on a daily basis:
Thefollowingelementswilloccuronadailybasis:
Highperforminghospitalprocesses
Datadrivendecisionsandproblemsolving
Focusonprocessesnotpeopleordepartments
Recognitionofwidespreadvariationanditsimpacts
Acceptanceofrapidchange
Enthusiasmaboutfindingbetterwaysofdoingthings
For More Information

ForMoreInformation
BethLanham
Beth
Lanham
Froedtert Hospital,Milwaukee,WI
P: 414
4148058685
805 8685
E: blanham@fmlh.edu
WisconsinOfficeofRuralHealth
Wi
i Offi
f R l H lth
KathrynMiller
RuralHospitals&ClinicsProgramManager
P:8003850005
E kmiller9@wisc edu
E:kmiller9@wisc.edu
WisconsinHospitalAssociation
Wi
i H it l A
i ti
DanaRichardson
VicePresident,QualityInitiatives
P:6082741820
E drichardson@wha org
E:drichardson@wha.org

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SixSigma

What is Six Sigma?

Six Sigma Overview

Six Sigma Overview

Why Six Sigma?

What does Six Sigma offer?

Variation in the Process

Six Sigma Central Concepts

Definitions of Six Sigma?

Six Sigma as a Metric

Traditional Process Improvement

Measure of Process Capability

A Problem Solving Approach

Six Sigma Model DMAIC

Six Sigma Model DMAIC

Project Team Members

Milestones TBD based on methodology

Problem Statement (*MOMS criteria):

Master Black Belt signature:

Problem and Goal Statements

High Level Process Map SIPOC

What did the

Process Maps aTip!

Voice of the Customer

Stakeholder Analysis form?

Six Sigma Model DMAIC

Define Performance Targets

Identify the Key X variables

No co rre ct ive a ct io n f o r n o n -co mp lia n ce

Dif f icu lt y mo n it o rin g p ro ce ss

Measurement System Analysis (MSA)

Six Sigma Model DMAIC

( means are indicated by solid cir cles)

Anderson-Darling Normality T est

95% Confidence Interval for Mu

95% Confidence Interval for Mu

95% Confidence Interval for Sigma

95% Confidence Interval for Median

Scatterplot of Hand Hygiene Events vs Time of Day

95% Confidence Interval for Median

Current Process Capability

DTY, EVS, Lab, LCs, PCAs, RNs, RTs

Six Sigma Model DMAIC

Utilizes RN critical Thinking

Overall high standard of care maintained

RN knowledge of when patient leaves unit

S ICU confirm ed Glucose levels < 70 on insulin byy m onth

Indiv idua l Vaa lue

Six Sigma Model DMAIC

C o n tro l C h a rt: tim e to 1 s t a n tib io tic

How will we know when we get there?

For More Information

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