harnessing the power of lean six sigma: military healthcare evaluation [institute of industrial...

Institute of Industrial & Systems Engineers (IISE) Engineering Lean & Six Sigma Conference 2015

Westin Atlanta Perimeter North I Atlanta, GA I October 1, 2015

Herren Associates, Inc. I 0

Harnessing the Power of Lean

Six Sigma: Military Medical Evaluation

Institute of Industrial & Systems Engineers

Engineering Lean Six Sigma Conference 2015

Westin Atlanta Perimeter North I Atlanta, GA

Lean Six Sigma Applications Track: Healthcare

Jeffrey Voth, Jennifer Derhaag, and Peggy Timmer October 1, 2015

FEDSIM – WMATA PHASE II (SYSTEM INTEGRATOR)



Herren Associates, Inc. 1

Agenda

Introduction

Optimizing Military Medical Evaluation

− Rethink current operations

− Redesign core processes

− Realign the business model

Summary

Presentation Agenda

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AgendaIntro | Rethink | Redesign | Realign | Summary




Introduction

We have been here before

Air Mobile

Operations

Deep Attack

Operations

Peace Keeping

Operations

Budget $229,908 $101,491 $180,520 $104,712 $155,733 $94,944 $256,109

Active 1,596,419 858,622 1,570,343 758,852 780,980 479,426 566,045

Reserves 349,649 695,603 633,421 536,964 732,050 562,580 567,296

Korean WarDesert Shield

Desert Storm

Operation Iraqi and

Enduring FreedomVietnam

FU

TU

RE

$M

* Budget figures represented in constant dollars (inflation adjusted) I Source: The Army Capabilities Integration Center

IntroductionIntro | Rethink | Redesign | Realign | Summary




The total Army has a vital role to the Nation

Active Guard Reserve

475,000 342,000 198,000Capable of many missions, at many

speeds and sizes, under any condition

40% of the Army’s

Combat Capability;

Rapid response for States

35% of the Army’s

Support Capability

= 50,000

75%

Operational

Institutional

Other

3/4 of the Army stand trained, equipped, and ready for deployment

while the remainder provide critical institutional support for these troops

IntroductionIntro | Rethink | Redesign | Realign | Summary

Source: U.S. Army FY2016 Budget Request

Introduction




Operations have increased and will continue to diversify

Soldiers deployed and forward stationed

143,540 soldiers in over 150 locations worldwide

Intro | Rethink | Redesign | Realign | Summary Introduction

Introduction

Number of Operations Since 1990

29 36 43 46 48 51

HaitiBalkans

Hurricane

Mitch

Noble

Eagle

Continuous support to civil authorities includes:

wild fires, hurricane, flood, tornado relief, etc. Source: 2015 Army Posture Statement




Agenda

Introduction





Summary

Presentation Agenda

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Most process optimization efforts begin with a common set of imperatives

Optimization Objective

Processing time and cost significantly increasing

Reduce the complexity,

time, and cost of

medical evaluation

Optimizing Military Medical EvaluationIntro | Rethink | Redesign | Realign | Summary

Optimization




Identify potential

opportunities

Conduct high-level

assessment

Prioritize

opportunities

Strategic initiatives to address this imperative were surfaced in a systematic and focused front-end effort

Strategic

Initiative

(A)

Strategic

Initiative

(A)Strategic

Initiative (A)

Prioritization of opportunities

− Benefits to Medical Evaluation− Benefit Timeline (in-year results)− Risk (no operational impact or quality reduction)− Early visible successes using existing resources− Interdependencies with external agencies

Conduct top-down profile of

opportunities – how large and

what changes are necessary

at the individual treatment

facilities

Generate initial set of

unconstrained

hypotheses

What:

Leadership

Senior management

Cross-functional team, SMEs,

and stakeholders from

treatment facilities

Cross-functional teamWho:

Collective discussion Targeted best practice

benchmarking

High-level Baselining

Interviews and

embedded knowledge

of team

How:

Most

Attractive

Least

Attractive

Cost: Resources

Benefit

High

Low

High Low


Optimization




Strategic

Initiative

(A)

Approaches to

Process Optimization

Strategic

Initiatives

Strategic

Initiative

(A)Strategic

Initiative (A)

Confusion

BPR

Lean

Management

Kaizen

Six

Sigma

TQM

Which

Approaches

For Which

Initiatives

In translating initiatives from ideas into action while remaining focused on delivering in-year results, we confronted an array of methodologies and tools

Design and

deploy a

solution using

only existing

resources


Optimization




We incorporated lessons learned from previous initiatives…committing to a “one size fits all” approach does not always yield the best outcome

Some approaches to process optimization are effective at solving well defined, narrow

problems (reducing waste or non value-added activity) but not at driving breakthrough thinking

Other methodologies assume that the existing process design is fundamentally sound and just

needs minor adjustments to perform more efficiently --- these approaches do not challenge

whether there may be an entirely different way to perform the process

Many do not align process stakeholders and their decision rights around common goals and

objectives --- they focus on using individual process optimization rather than core value

streams of the organization

Most process optimization approaches do not explicitly address the changes in culture,

performance measurement, organization structure, roles, and other management

systems necessary to support a high-performing organization


Optimization





We tailored our approach – segmenting initiatives by design complexity

How complex is the initiative

Focus on redesigning to maximize performance of the current model

Focus on multiple treatment facilities

Redesign processes using current configuration

Standardize software reporting and information technology investment

Redesign site level policies, procedures and decision rights

Operate within the constraints of the current processes

Focus on improvements at a single treatment facility

Design and deploy a solution using only existing resources (staff, facilities, equipment)

Leverage current technology

Minimize changes to organization, policies, procedures and decision rights

Rethink

Current Operations

Redefine the operating model construct - what is done and how it is executed

Focus on the enterprise

Reconstruct and build processes “clean-sheet”

Refresh technology platforms and enabling software applications

Restructure governance, organization, policies, procedures and decision rights

Low High

Redesign

Core Processes

Realign

the Business Model

Optimization




Service line operations

Individual treatment facility

HeadquartersMission

Vision

Goals/Objectives/Initiatives

Patient cycle time

Balance case workload

Standard processes

Common governance

Process Map

Process Integration

Measurement/Analysis

Tools

Forms/Templates

Job Aids

What Processes does each

strategic initiative map into?

Rethink

Current Operations

Redesign

Core Processes

Realign

the Business Model

How complex is the initiativeLow High

Incr

easi

ng

imp

act

on

th

e o

rgan

izat

ion

Frameworks for each strategic initiative were selected based on the business process or model being optimized


Optimization




Agenda

Introduction





Summary

Presentation Agenda

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Reduce the complexity,

time and cost of

medical evaluation

Apply smart cellular

design principles as

a proof of concept

Measure / Target

Objectives articulate components

of the overall strategy

Measures and targets track progress toward achieving

the target, and communicate the intent of the objective

Initiatives help close the gap

between current and desired

performance

Measure

Target

Turnaround

time

(# of days)

100 days

Gap

Strategic Initiative 156

100

Rethink current operationsIntro | Rethink | Redesign | Realign | Summary

Actual Target

Tim

e (

days)

Strategic initiatives were clearly defined to help close identified performance gaps

Rethink current operations




Visibility Insight Action

Baseline operations and

performance

Use process analytics and

modeling to drive optimization

Optimize, define performance

and continually improve

Applied lean principles (standardization, visual management, point of use, cellular flow) to deploy a site-level operational excellence proof of concept

Staffing Levels Process Times

Demand

Cas

es

Time

Case Complexity

High

LowMed.

Scenario AnalysisProcess Baseline Performance Dashboards

Modeling and Simulation



../../../My Documents/!Active Clients and Stuff/ADT II/Visual Portal Primer.ppt

../../../My Documents/!Active Clients and Stuff/ADT II/Visual Portal Primer.ppt




Site-level Improvements Implemented

Proof of Concept reduced case processing time by a factor of 5

People‒ Established cross organizational collaboration‒ Maximized resource utilization through predictive

modeling and simulation‒ Formed cell teams, performed team building activities

and provided hands-on training

Process‒ Maximized system throughput with scenario analysis‒ Developed Standard Operating Procedures‒ Provided on-site change management support

Technology‒ Eliminated redundancy through IT crosswalk

Performance Management‒ Eliminated individual throughput targets and

established team goals‒ Provided a performance management dashboard to

consolidate performance metrics for senior leaders

Prescribed a balanced set of improvements to achieve performance standard

-70%

-80%

Historical

Average

100 Day

Target

Proof of

Concept

Significant Cycle Time Reduction






Agenda

Introduction





Summary

Presentation Agenda

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DMAIC Define Measure I Analyze Improve Control

Activity • Engage

Stakeholders

• Review scope

and detailed

requirements

• Touch Time collection

through activity logs

• Takt time analysis

• Process mapping

• Interviews

• Process walk through

• Spaghetti diagramming

• Develop future state

• Advanced scheduling

• Critical path analysis

• Team design

• Visual management

incorporation

• Develop training plan and

materials

• Failure Modes & Effects

Analysis

• Leadership training

• Team member training

• Implement new process

• Develop sustainment plan

• Process corrections

• New process case

tracking and analysis

• Remote monitoring

Output • Current state process maps

• Touch Time analysis

• Workload and demand

analysis

• Standard Work

• RACI

• Standardized Future State

process map

• Visual Management Boards

• High Performance Team

Design

• Training materials and plan

• Day by the hour

• Process change record

• Operational definitions

• Checklists

• Cover Sheets

• New process

implementation at sites

• Sustainment plan

• Process addendums for site

unique information

Engage Build Implement Sustain

Process redesign activities will generate operational savings and improvements while exceeding established performance standards

RedesignIntro | Rethink | Redesign | Realign | Summary

Redesign




Critical Path Analysis Standardization Advanced Scheduling Team Based Design

Identified four key methods to drive efficiency and effectiveness throughout the process redesign effort


Redesign




Mapped the current process and its sequential requirements --- identified areas where process steps could be moved in parallel as opposed to in series

Critical Path Analysis

Step 1 Step 2 Step 3 Step 4

Step 4

Step 3

Step 2

Step 1


Redesign




Replication across sites creates the foundation for system optimization

Reduced activity count Reduced handoffs

80%

Eliminated non-value added activities

Defined roles & responsibilities

20% Unique

Design

Standard

Design

Standardization


Redesign




Calculated advanced scheduling timeline based on historical appointment lead time --- determined milestone dates based on historical actuals

Advanced Scheduling

Appointment lead time

Mile

ston

e

14 days

Appointment lead time

Mile

ston

e

Con

duct

appo

intm

ent

Con

duct

appo

intm

ent

14 days

Sch

edul

e

appo

intm

ent

Sch

edul

e

appo

intm

entWithout advanced scheduling…

14 days to appointment from milestone

Advanced Scheduling applied…

2 days to appointment from milestone


Redesign




Developed a high performance team structure based on touch time analysis and future state roles and responsibilities

Empower Proactive Performance

Visual Management Boards

Case Manager

Case Manager

Case Manager

Admin Assistant

Case Manager

Admin Assistant

Case Manager

Case Manager

Lead

High performance team work cells were

designed to match staffing to work requirements

Designed visual management boards and

instituted daily stand-up procedure to track

leading indicators of performance

Team structure and visual management

empowered employees to be proactive about

their (and the team’s) performance


Redesign




Agenda

Introduction





Summary

Presentation Agenda

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Customer orientation facilitated a shift from a task force to service line, introducing the concept of horizontal value flow

Traditional View (i.e. Vertical)‒ Based on hierarchy of units, departments, etc‒ The intent of the policy is lost or is impractical

at the point of impact‒ Change is hindered by the middle layers

trying to reconcile the intent

Process Line View (i.e. Horizontal)‒ Customer perspective drives

improvement and innovation‒ Roles and responsibilities are

aligned‒ Achieves same result, more cost

effectively

RealignIntro | Rethink | Redesign | Realign | Summary

Realign




Stakeholder Concerns Management Issues Performance

Measures

OutcomeIs the organization

effective?

OutputIs the organization

making progress?

ActivityIs the organization efficient?

• Are we making progress on improvement

initiatives?

• Are we meeting critical milestones?

• What is implementation status?

• How are we addressing

implementation issues?

Strategic Measures

• Link mission and strategic goals

• Provide focus for operational goals

and measures

Operational Measures

• Gauge business unit performance and

evaluate improvement initiatives

• Evaluate implementation progress

• Link organizational performance to

competency assessments/appraisals

Diagnostic Tools

• Review day-to-day operational

activities

• Support operational measures

• Are the right concerns addressed?

• Are we improving service as perceived

by the soldier?

• Are we addressing compliance issues?

• Are productivity and employee

satisfaction increasing?

• Status of case backlog?

• Customer service levels?

• Submissions processing

performance?

Link across

categories and shift

management focus

up

It was critical to design measures around outcomes and outputs rather than activities


Realign




Assessment Key Elements

Level of Competency

Lacking Initiating Progressing Refining Optimizing

People

Competency Model

Skills Assessment

Talent Strategy

Process

Frameworks

Conceptual

Executable

Performance

Measures

Defined

Aligned and linked

Used for review

Policy

Analyzed

Formal review

Performance links

Technology

Defined

Automated

Functionality

It was critical to design measures around outcomes and outputs rather than activities


Realign





Realign

0

5

10

15

20

25

30

People

ProcessPolicy

Performance

Measures

Technology

Current

Future

Based on the diagnostic, we implemented a series of action plans to shift from the original task force construct to a high performing service line organization





Realign

Our detailed task analysis revealed organization was concentrated around short-term tactics at the expense of longer term strategic endeavors

Frequency

Value Added

High

Low

Low High





Realign

Process maturity

Impr

oved

Effi

cien

cy

Process

People

Technology

OptimizedService

Line Enh

ance

d op

erat

iona

l val

ue Who supports

the processes and

technology?

How do we enable

these processes?

What needs to be done

and how do we do it?

To realize the full potential of military medical evaluation, optimization required organizational alignment of people, process, and technology

Organizational

led activities

Process

led activities

Building momentum with a blueprint for success




Agenda

Introduction





Summary

Presentation Agenda

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Optimized military medical evaluation processes through the application of lean, six sigma, and industrial engineering techniques

SummaryIntro | Rethink | Redesign | Realign | Summary

Summary




Intro | Analyze | Assess | Allocate | Summary

Comments/Questions

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Authors

Jeffrey Voth I President Jennifer Derhaag I Associate Peggy Timmer I Associate

Office: (202) 609-8441 Office: (202) 609-7297 Office: (202) 609-7287

[email protected] [email protected] [email protected]

About Herren

Founded in 1989, Herren Associates is an engineering and management consulting firm

with a proven record of maximizing the value of every taxpayer dollar. As trusted advisors

to federal executives, we partner with clients to drive operational improvements and

manage performance - maximizing efficiency and cost effectiveness.