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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
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.

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
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 Organizational
g
Benefits:
Datadrivendecisionmaking
Competitiveedge
Focusesoncustomerrequirements Service
Excellence
Afocused/organizedapproach
Empowered staff
Empoweredstaff
Redefinesprocessesforlongtermresults
Leadership
Becomesingrainedinworkandthought Development
processes Quality/Safety
Reliesonevidencebasedsolutions HealthcareCosts

Rapid/effectivechange
 Six Sigma
SixSigma

Methodologyaimedat
Errorreduction
Eliminatingvariation
Eliminating variation
Goal
Design/improveprocessessoitisimpossibletomakean
error
Relianceonperformancemeasurementsand
statistical analysis
statisticalanalysis

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 Traditionally..
Traditionally
Businesses
Businesseshavedescribedtheirproductsor
have described their products or
servicesintermsofaverages:
Averagecost
g
Averagetimetodelivery
Averagenumberinfections
A
Averageusage
Averagewaittime

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 AreTheseProcessestheSame?
Process1 Process2
Aretheyperformingwell?
20 9
5 11 Goal=lessthan10
17 8
5 10 Process1 Process2
15 10
5 9 Mean9.4Mean9.4
5 11
5 10
Areallthecustomershappy?
ppy
5 8
12 8
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 9.540 80 Mean 9.412
100 StDev 6.149 StDev 1.193
N 1000 70 N 1000

80 60

50
Frequency

Frequency
60
40

40 30

20
20
10

0 0
-12 -6 0 6 12 18 24 -12 -6 0 6 12 18 24
Process 1 Process 2

Many Fewer
Defects 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
A Metric
AMetric Solving
Solving
Tools/Tactics

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
1 69.1% 30.9% 691,462
2 30.8% 69.1% 308,538
3 6.7% 93.3% 66,807
4 0.62% 99.38% 6,210
5 0.02% 99.977% 233
6 0.0003% 99.9997% 3.4
 WhenComparedtoBestinClass
(N i
(NationalData)
lD )
BetaBlockerUse
Beta Blocker Use Antibiotic
PostMI Overuse InpatientMedication
Accuracy
1000000
000000
44,000 98,000
100000 PreventableHospital
Defects / Miillion

Deaths(IOMReport)
10000

1000

100 Anesthesia
DuringSurgery
10

1
1 2 3 4 5 6
Sigma DomesticAirline
FatalityRate
 Traditional Process Improvement
TraditionalProcessImprovement
5&6
1Sigma
g
Sigma

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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
ProcessCapability
p y

Lower Upper
Specification Specification
Limit Li i
Limit
10
Frequency

Average
Defect Defect
 A Problem Solving Approach
AProblemSolvingApproach
Highlystructuredmethodology
Highly structured methodology
Focusedonidentifyingtherootcauses
ProcessvariablesimpactorinfluencetheY
Process variables impact or influence the Y
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!

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 Six Sigma Model DMAIC
SixSigmaModel DMAIC

Define Measure Analyze Improve Control

SelectKey Establish Optimization Determine

Charter capability
CTQs** current Cycletime
project ofnew
Developdata capability Variability
HighLevel
High Level process
p
collectionplan
ll i l Identifykey Cost/LOS
C /LOS
ProcessMap Implement
Define sourcesof Validationof
CollectVOC variability process
performance Improvements
controls
Identify
Id if standards
t d d Define Implementation
CustomerCTQs performance Ensure
Validate
objectives Gainsare
Review measurement
Sustained
hi t i l d t
historicaldata systems
*VOC VoiceofCustomer
**CTQCriticaltoQuality
 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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 SixSigma
g KeyPlayers
y y
Full time
Fulltime Overseeor
chooseprojects
StrategicProjects Black Champions ResolveIssues
SkilledinSixSigma Belts
T l
Tools Provide
Provide
Leadership
TeachGreenBelts
Executive
S
Sponsors
FullTime
PartTime
Strategic
SmallerScope
Smaller Scope Green Projects
j
Projects Master
Belts BlackBelts Program
Helptochange Administration
culture
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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 Six Sigma Model DMAIC
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 Team Members Review Timing
Project Name: Target Completion Date: 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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 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 Inputs- Outputs- Customers
Materials, Process Steps What did the
-Who provides res ources, customer
- Who benefits?
the inputs?
data receive?
Enter
E t patient
ti t
Infection Control Policies & High quality Patients
Procedures
room care
H.C Prov iders CMS
(Physicians, nurses, CDC guidelines Avoidance /
Third Party
nursing assistants,
therapists,
Soap Wash hands reduc tion of
hospital
Pay ors
technicians,
emergency medical
Alcohol hand rub upon entering
t i acquired O ther patients
staff, dental staff,
infections
Dispensers Staff
pharmacists, Clean hands
laboratory staff, Sinks Families
autopsy staff,
Paper towels
Patient Dec rease in
students and skin irritation
trainees, contractual
Conscious thought
Encounter
staff not employed Increased
by the healthcare Clinical Routine patient
facilit y, and persons
confidenc e
not directly involved
in patient care but
Degree of urgent Wash hands
care required
potentially exposed
to inf ectious agents.) Extent of contact
upon exiting
Plant MD orders
Operations
Patient condition
Call lights
Leave patient
Operational
routines
room
 Process Maps aTip!
ProcessMaps a Tip!
Each process has at least 3 versions
Eachprocesshasatleast3versions

Whatyouthink
y Whatitactuallyis
y Whatyouwouldlikeit
y
itis 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?

St k h ld A
Stakeholder Analysis
l i
Whowillbe
affectedbyany Strongly Moderately Neutral Moderately Strongly
changes from this
changesfromthis Names Against Against (0) Supportive Supportive
project?
Beginaddressing
y
issuesearly!
Noteveryone
needstobestrongly
supportive!
pp
 Six Sigma Model DMAIC
SixSigmaModelDMAIC
Define Measure Analyze Improve Control

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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 Define Performance Targets
DefinePerformanceTargets

TranslatetheCustomerexpectationsintoMetrics
Target:
What
Whatdoesthecustomerwantmostofthetime?
does the customer want most of the time?
SpecificationLimits:
Whatarethelimitsthepatientiswillingtotolerate?

VOC CTQ Y Target UpperLimit

Expecttobeseen Wait Pt.checkinatfront 15min 30min
within15minofappt. Time desktofirstcontact
Unhappyif>30min withstaffphysician.
 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 M a n a g e rs n o t a cco u n t a b le

No t ra in in g o n p ro ce ss t ime lin e
No sin k in t h e ro o m Divisio n s n o t a cco u n t a b le

No re min d e rs p o st e d S p o t ch e cks n o t cu rre n t ly d o n 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 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

E q u ip me n t is n o t w ip e d d o w n Ne e d t o t a ke ca re o f p a t ie n t a n d ca n 't No in ce n t ive s/re w a rd s t o co mp ly

re g u la rly
Ca rryin g it e ms in t o p a t ie n t ro o m La ck mo t iva t io n t o se t a n e xa mp le
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 No co mmu n ica t io n re : p t imp a ct if n o n -co mp lia n t

La ck o f in st it u t io n a l sa f e t y clima t e Do n 't h a ve a d e q u a t e re so u rce s

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 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
Lack h an d
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 h y g ien e
S ke p t ica l a b o u t e f f e ct ive n e ss
co mp lian ce
De la ys in g e t t in g n e e d e d e q u ip me n t
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 No lo t io n a cce ssib le No a lco h o l w ip e s
d u rin g p t
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
No t e n o u g h h a n d d isp e n se rs in terac io n
O t h e r p e rso n n e l n o t a w a re No d a t a t o sh o w t h e imp a ct o f h a n d
S o a p /a lco h o l d isp e n se r e mp t y
h g yie n e o n t h e ra t e o f HAI
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 Bro ke n d isp e n se r
S kin irrit a t io n b y h a n d h yg ie n e a g e n t s
P e o p le f o rg e t O ve rf lo w in g g a rb a g e
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 o w e ls
In co n ve n ie n t lo ca t io n o f h a n d sa n it ize r
No t se e n a s a p rio rit y S t a f f w o rk a re a s a re d irt 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 To o ma n y p e o p le in ro o m, in w a y o f sin k
La ck o f e d u ca t io n ma t e ria ls
F e e l t h a t n o n e e d t o w a sh w /g lo ve s E q u ip me n t in w a y o f sin k
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 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
F e e l t h a t w a sh h a n d s e n o u g h
S in ks d o n 't w o rk
To o b u sy/No t e n o u g h t ime

P eo p le M aterials E q u ip men t
SponsoredbytheWisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
CopyrightoftheWisconsinOfficeofRuralHealth.
 Data Collection/Sampling
DataCollection/Sampling
Keyconsiderations
Key considerations
Datamustberepresentativeoftheprocess
Datamustbereliable
Mustcapturemeasurementsofimportance
ENTRY EXIT
OBS # Role(s) Hand Hygiene Notes Hand Hygiene Notes
1 Sink Y / N Gloves On Sink Y / N Gloves On
Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves
None Y / N Full Hands? None Y / N Full Hands?
Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access
Direct Exit to Enter?
2 Sink Y / N Gloves On Sink Y / N Gloves On
Hand Rub Y / N Urgent Hand Rub Y / N Removed gloves
None Y / N Full Hands? None Y / N Full Hands?
Group Did Not Observe Y / N Blocked Access Did Not Observe Y / N Blocked Access
Direct Exit to Enter?
 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%.
 Six Sigma Model DMAIC
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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 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
A-Squared: 32.018
P-Value: 0.000 150
Mean 23.1551

e (i n min)
StDev 15.3332
Variance 235.108
Skewness 1.25196
Kurtosis 4.39234
N 2559
10 35 60 85 110 135 160 100

Pt Wait Ti me
Minimum 0.000
0 000
1st Quartile 11.000
Median 21.000
3rd Quartile 33.000
95% Confidence Interval for Mu Maximum 153.000
95% Confidence Interval for Mu
50
22.561 23.750
20 21 22 23 24 95% Confidence Interval for Sigma
14.924 15.765
95% Confidence Interval for Median
95% Confidence Interval for Median
20.000 22.000
0

ORO

ORT
HAC
Scatterplot of Hand Hygiene Events vs Time of Day
40

OverallStatisticsByPatient:
30
and Hygiene Events

Metric Wait Time Exam Time Total Time

20
Mean 23.16 18.94 42.10
Median 21 16 40
Std Deviation 15.33 11.54 19.76
Ha

10

Sample Size 2559 2559 2559

0 Min 0 0 3
6 8 10 12 14 16
Time of Day
Max 153 99 183
Current Process Capability
CurrentProcessCapability
Howistheprocessperformingtoday?
p p g y
Doweneedtoshiftthemeanorreducevariation?

T T
1.235 1.239 1.241 1.245 1.233 1.235 1.239 1.241 1.245
LSL USL LSL USL
 HypothesisTesting
G tti t th R t C
GettingtotheRootCauses
Which XsshadthegreatestaffectontheY?
WhichX had the greatest affect on the Y?
PValues<0.05are
Test Details P-Value
Role DTY, EVS, Lab, LCs, PCAs, RNs, RTs 0.002
signficantfactors
RNs RNs vs. All others 0.422
Mustusethe
LCs Long Coats vs. All others 0.004
DTY Dietary vs. All others 0.005
correctstatistical
EVS EVS vs. All others 0.056 testsbasedon
TSP Transport vs
vs. All others 0 020
0.020 types of data
typesofdata
THP Therapists vs. All others 0.020
Day of Week Mon vs. Tues vs. Wed vs. Thu vs. Fri 0.285
Time of Day Observation Hours 7-16 0.039
Groups
p Single
g HCW vs. Groups p 0.868
Method Sink vs. Alcohol Based Hand Rub 0.000
Full Hands Empty vs. Full Hands 0.000
Urgency Normal vs. Urgent n/a
Gloves Wearing gloves vs. No gloves 0.463
Timing Entry vs. Exit 0.000
Access Clear access to Sink/ABHR vs. Blocked Access 0.965
 Six Sigma Model DMAIC
SixSigmaModelDMAIC
Define Measure Analyze Improve Control

OptimizationofY(Cycletime,Variability,Cost/LOS)
/
ValidationofImprovements
Implementation
p
ControlPlan
% compliance
1

Generatealternatives 0.9

0.8
1
UCL=0.852

0.7

Assesstherisks
Individual Value
0.6

0.5 _
X=0.471

Testthealternative 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
Alternatives

g n
rin tio
ito le

ro m
on de

-n
tie sit ith

le t e
om
ito en ith

l m nd

n t ion

te y s
pa po r w
g l
rin tra
on c w

in ht s
ra a
g

ed t o
m us or
in

nt or

s
ur na
uo flo
at

le lig
ce flo
R

ct di
Generate

nt on

al ll
of o n

ru or
ce

st a
d
in s c
st co
co ch
an

ch
in

lin
te
rt

re ift
te
po

aw
Sh
e

le
l
Key Criteria

Im

Te

te

R
multiple
multiple RN accountable for patient
Efficient trouble shooting







Key
Utilizes RN critical Thinking Better
options! FTE neutral
Good judgement regarding whether to take patient
Same
Worse
off tele when off unit
RN knowledge of when patient leaves unit
Evaluatehow RN knowledge of when patient returns
Assurance that ppatient placed
returned to floor
p back on tele when

= 10
eachoption 30 Second response to sustained lethal rhythms or
rate alarms
Documentation of rate/rhythm changes








= 8
=5
meetsCTQs Consistent/accurate interpretation of rate/rhythm
Timely recognition of rate/rhythm changes
Overall high standard of care maintained

= 3
=1
Continuous observation
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 8 10 18 1
Sum of Negatives 1 2 2 0
Sum of Sames 11 8 0 19
 Pilot/Validate Results
Pilot Planning
PilotPlanning
FailureModeandEffectsAnalysis
Assureadequatesamplesize
Validateimprovements
Validate improvements S ICU confirm ed Glucose levels < 70 on insulin byy m onth
June-Aug 2002
Sept Dec Jan Feb March
03 03 03

throughdataandstatistical
02 02
90
UCL=84.41
80

analysis Baseline

Indiv idua l Vaa lue

70

60 Mean=60.25

50
Pilots
40
LCL=36.09
30
0 10 20 30 40 50 60 70 80 90
Observation Number
 Six Sigma Model DMAIC
SixSigmaModelDMAIC
Define Measure Analyze Improve Control

% compliance

Determinecapabilityofnewprocess 1.2

1.0
Pre Interim Pilot

UCL=1.119

Implementprocesscontrols 0.8
_
X=0.823

Individual Value
0.6

EnsureGainsareSustained
LCL=0.528

0.4

0.2

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

Maintainthe 700
B a s e line 1 P ilo t P o s t P ilo t
Indivvidual Value

600
1
500
400 1 1
1 1

gains!
300 1
U C L = 2 6 3 .8
200
100 M e an= 9 5
0
-1 0 0 L C L = -7 3 .7 8

S u b g ro u p 0 50 100
C 16 P ilo t P ilo t

600
1
Range

500
1 1
400
Moving R

300 1 1
1
200 U C L = 2 0 7 .3
100
R = 6 3 .4 6
0 LC L=0
 ExampleSixSigmaProjects
p g j

Safety/Quality Service/ProcessEfficiencies

Insulin/Diabetes
Falls Patientflow A
Access
Anticoagulation Ortho/Radiology DiabetesClinic
TelemetryResponse Ortho/OR UrologyClinic
PulmonaryFunctionsLab
Pulmonary Functions Lab Waittime:
W it ti
PatientIdentification Hem/OncLabProcess
PriorityMedication HandCenter
Hem/OncTreatmentRoom
HandHygiene GILab OPLab
Medication PatientThroughput OPRegistration
OP R i i
VerificationProcess DischargeProcess Delaysinsurgeryd/t
Communicationof missingInstruments
Addi i
AdditionalRadiology
l R di l
Findings
 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

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.
 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 WisconsinHospitalAssociation
Wi i H it l A i ti
KathrynMiller DanaRichardson
RuralHospitals&ClinicsProgramManager VicePresident,QualityInitiatives
P:8003850005 P:6082741820
E kmiller9@wisc edu
E:kmiller9@wisc.edu E drichardson@wha org
E:drichardson@wha.org

Thispresentationispartofanonlineseries,broughttoyouthroughacollaborationbetweenthe
WisconsinOfficeofRuralHealthandtheWisconsinHospitalAssociation.
PropertyoftheWisconsinOfficeofRuralHealth.