lean, six sigma and emotional intelligence

The shortest distance between You and Improved

Lean, Six Sigma & Emotional Intelligence

Medical Staff Presentation

April 15, 2015


Program Overview

• Introduction to Lean & Six Sigma

• Case Study

• What we’ve learned from 16 years in supporting health systems


We believe that healthcare leaders should have all the tools they need to excel in their mission.

Segment Leadership:• Founded 1998• ACHE, ASQ, & UM solutions• Prolific publishing activity• Average tenure per staff > 12 years• Full suite of PI technologies• Pure production in healthcare space• 3 Baldrige Award winning clients


Insert your own horror story here

The time I was abandoned by Air China in BeijingThe time(s) Delta lost my luggage in ItalyThe time United changed my flight without telling meThe time I was stuck on the tarmac in Denver for hours…The time I was stuck on the tarmac in Phoenix for hours..The time I was stuck on the tarmac in Boston for hours….The time I was…….


Why improve processes

when you can simply apologize nonstop?


Why improve processes

when you can simply apologize nonstop?

Is this an option for

your Organization

?


Better idea: “Learn to Lean”

Accelerate the speed and reduce the cost of any process by removing non-value-added activities

“Re-examine the way you think about waste, as it is often difficult to recognize.

Start by making waste obvious to everyone.”Taiichi Ohno, Founder

Toyota Production System


Cost of Quality

© All Rights Reserved.

Up to 40%Productive

Quality

Adding

Features

• Preventing

problems

• Detecting and

correcting

problems before

the customer

sees them

• Dealing with

problems after

they occur

The shortest distance between You and Improved9

Cost of Poor Quality

• 20% to 50% = not always valued by the customer

• Up to 40% of the expense budgets in an organization are associated with COPQ (it may be even higher in health care)

• Every 4% reduction in waste increases operating margin by 1%

• - Murphy Leadership Institute


Why is it difficult to eradicate waste?

Patient

Asks for

Information

Patient

Gets

Answer

PERCEIVED WAIT TIMEPatients over estimate their wait

time by 50% or more;

PERCEPTION IS REALITY

A B C D

ACTUAL WAIT TIMEDetermined by the process to

retrieve information


Bottlenecks

Flow of work = process time + delay time = cycle time!


Hand-offs

“Lessons from DMV”


PULL

PERFECTION

Principles of Lean Thinking


VALUE1.

VALUE STREAM2.

FLOW3.

4.

5.


“The Hidden Hospital”

Rework

Hidden Hospital

NOT OK

OperationInputs First Time Yield

OK

98% Customer

Quality

Described below is any process that meets a customer need

98% Yield After Inspection or Test

65%

35%

Inspect

Exposing waste made more difficult by the way we map, and the way we measure

This classic approach

does not account for the

“Hidden Hospital”

Rework:

20-30%


VALUE-ADDED

• Alters the work

• Meets customer

wants or needs

• Is done right the first

time

NON-VALUE ADDED

• Eliminate it

• Consolidate it

• Automate it

Protocol to Eradicate Waste


Mastectomy Mistake: 'You Don't Have Cancer‘ Woman Told She Has Breast Cancer, but Learns After Operation Her Biopsy Slide Was Mixed Up

Darrie Eason talked to "Good Morning America" about undergoing a double mastectomy after a lab mix-up. (ABC News) Oct. 4, 2007

A state report blames Eason's mix-up on a former technician at CBLPath lab who mislabeled her biopsy results. The report said the technician "cut corners."

“The technician was batching the specimens”

They could not confirm that the other person, who did have breast cancer was ever notified.

Stakes are High in Healthcare


Two Six Sigma “blackbelts” sitting at a bar...


Six Sigma is Process Improvement

Process

X1

X2Y

X3

Process InputVariables

Process OutputVariable

CustomerRequirements

In-ProcessVariables

X1 X2 X3

X…n

Six Sigma focuses on the “critical X” that drives process performance more than any other variable.

The aim of Six Sigma is to fix the problem “for the last time”


Six Sigma is Project Management

Who is the customer?What do they want? Is the data clean or dirty?

What is the baseline performance?What is the project objective?What are the various x’s?

What are the critical x’s?What solutions will control the x’s?What are the specs for the x’s?

What is the data integrity of x’s?What is the capability of the x’s?Can the improvement stand the test of time?

Y

x

Define

Measure

Analyze

Improve

Control

Describe

The customer

experience

Optimize

The customer

experience


Six Sigma is a Metric

s s s s s s

LSL m

A six-sigma (6s) process

The distance between the mean (m) and the inflection

point is the standard deviation (s).


A Six Sigma Project

“Home Run”

Identify and eliminate NVA activity

Identify and reduce variation


System Performance

0

100

200

300

400

500

600

700

800

900

50.00% 60.00% 70.00% 80.00% 90.00%

(Utilization (Throughput / Max. Theoretical Throughput)

Cy

cle

Tim

e O

R W

ork

in

Pro

ce

ss

What’s Going On Here? Understanding The Role Of Variation In Process Performance


System Performance

0

100

200

300

400

500

600

700

800

900

50.00% 60.00% 70.00% 80.00% 90.00%

(Utilization (Throughput / Max. Theoretical Throughput)

Cy

cle

Tim

e O

R W

ork

in

Pro

ce

ss

Impact

of variation

What’s Going On Here? Understanding The Role Of Variation In Process Performance


Linking Lean and Six Sigma

• While Six Sigma will focus on the “critical few,” Lean focuses on the “trivial many”

• Lean focuses on speed, efficiency, and waste

• Six Sigma focuses, defects, variation and quality of products and processes

LEAN Six Sigma

Six SigmaLEAN

Either method provides a prescriptive approachto performance improvement

24


USLLSL

CenterProcess

Reduce spread

USLLSL

Off-Center

USLLSL

Unpredictable

Centered

A BTarget

Remember... customers experience our variation,

not our averages

Lean/Six Sigma Improvement Strategy


Case Study:

Lean Project in Hospital Lab


Problem Statement: Survey data from the American College of Pathologists shows that

physicians think troponin TAT should be 45 mins or less, while laboratories strive for 60 mins or less.

Currently, the hospital is incapable of meeting its goal consistently, failing over 50% of the time.

Failure can frustrate physicians, threaten patient safety and erode the hospital’s commitment to

quality care.

Who Are The Customers? COPQ: Treatment delays, physician and patient

disatisfaction, potential impact on morbidity

ED physician and patients & mortality

What is Critical To their Satisfaction (CTS): Defect Definition: TAT > 60 minutes

Consistent and timely delivery of results (CTD)

Baseline Sigma: - 0.48

Project Scope

Test ordered Result delivered

0

10

20

30

40

50

60

70

80

OD DR RV Total

Hema

Panel

Troponin

Project Charter: Lab Cycle Time


• Phlebotomist not available (28)

• Locating patient (26)

• Patient refusal/not available (26)

• Phone interruptions (19)

• Staff attitudes (17)

• Accuracy of labeling (16)

• Multiple draws (15)

• Poor communication (13)

• Poor workflow (10)

Only 17%

of the total

TAT is

impacted by

these obstacles…

Q. What are the obstacles to improved TAT in delivering

Lab results to ED?

What they said first, and next


• Phlebotomist not available (28)

• Locating patient (26)

• Patient refusal/not available (26)

• Phone interruptions (19)

• Staff attitudes (17)

• Accuracy of labeling (16)

• Multiple draws (15)

• Poor communication (13)

• Poor workflow (10)

Only 17%

of the total

TAT is

impacted by

these obstacles…

…but observations

and data reinforce

the impact of these issues

Q. What are the obstacles to improved TAT in delivering

Lab results to ED?

What they said first, and next


Measure Phase

Determining Stability of Process

Establishing Baseline Performance

Ensuring Data Integrity

Establishing Capability

Integrating Subjective Input


Whether Lean or Six Sigma,

it all begins with Current State


Process Flow Diagram - Troponin

ED

Lab1

Lab 2

ED

Start

Physician

Writes OrderOrder Given To

Unit Clerk

Input Sent

Order

Arrives In

Outpt. Lab

Order Has

Correct

Information?

Phl. Goes To

Outpt. Or ED

Computer For

Another Patient

Phl. Draws

Specimen

Phl. Tries

To See

Another

Patient?

Phl. Makes

Multiple

Draws?

Specimen

Arrives In Lab

Specimen

To

Hematology

Blood RolledBlood Spun

Specimen

Processed

Specimen To

Instrument

Specimen To

Instrument

Specimen

To

Chemistry

Results

Verified And

Sent To ED

Results Sent

To Chart

Physician

Reviews

Results

End

Unit Clerk

Immediately

Inputs

Order?

Draw Complete

Results

Arrive In ED

Results Reviewed

Immediately?

No

Specimen To

Instrument

Specimen Sent

For Troponin

Analysis

Yes

Pt. in

room?

Yes

Yes No

No

Phl. Tubes

Specimen

To Lab?

NoNo

Yes

Specimen

Logged In?

Yes

Input Delay

No

Yes

Specimen

Walked To Lab

Specimen

Delayed

Getting To Lab

Yes

Specimen

Movement

Delayed

No

Delay in

reviewing

results

NO

Yes

What’s wrongwith this picture?


30 90 150 210 270 330 390

95% Confidence Interval for Mu

66 71 76 81

95% Confidence Interval for Median

TAT Troponin First Qtr 2003

A-Squared:

P-Value:

Mean

StDev

Variance

Skewness

Kurtosis

N

Minimum

1st Quartile

Median

3rd Quartile

Maximum

76.037

38.863

67.000

74.078

0.000

78.7104

40.6673

1653.83

4.03449

22.2818

891

36.000

57.000

68.000

86.000

419.000

81.384

42.649

70.000

Anderson-Darling Normality Test


95% Confidence Interval for Sigma


Descriptive Statistics

Turnaround Time: Troponin


Analysis Phase

“Rounding up the usual suspects”

Hypothesis testing

Identification of Critical X’s


In search of “X”Analysis of Troponin Process

• Ho: No significant delay due to multiple draws

• Ho: No impact from use of pneumatic tube

• Ho: No significant time loss from end of

instrument processing to delivery of results


Does a multiple draw cause cycle time to increase or

decrease, or is it unrelated to cycle time?

60 160 260 360 460 560


35 36 37 38 39 40 41 42 43 44


Variable: TAT - Phlebotomist

A-Squared:

P-Value:

Mean

StDev

Variance

Skewness

Kurtosis

N

Minimum

1st Quartile

Median

3rd Quartile

Maximum

41.335

23.945

35.000

73.588

0.000

42.5212

24.7560

612.861

3.55094

26.7708

1675

10.000

27.000

36.000

51.000

334.000

43.708

25.624

38.000

M Draw: Single Draw






60 160 260 360 460 560


41 46 51


Variable: TAT-Phlebotomist

A-Squared:

P-Value:

Mean

StDev

Variance

Skewness

Kurtosis

N

Minimum

1st Quartile

Median

3rd Quartile

Maximum

45.173

29.554

41.000

50.475

0.000

47.5972

31.1758

971.933

10.4494

171.578

638

11.000

33.000

43.000

54.000

608.000

50.021

32.987

44.000

M Draw: Mult. Draw







Mood Median Test: TAT for Multiple vs Single Draw

Chi-Square = 37.60 DF = 1 P = 0.000

Individual 95.0% CIs

M Draw N<= N> Median Q3-Q1 ----------+---------+---------+------

Mult. Draw 256 382 43.00 21.00 (-------+---)

Single Draw 911 764 36.00 24.00 (---+-------)

----------+---------+---------+------

37.5 40.0 42.5

Overall median = 38.00

A 95.0% CI for median(Mult. Dr) - median(Single D): (4.00,8.00)

Does a multiple draw cause cycle time to increase or decrease, or is it unrelated to cycle time?


Does it make a difference if Phlebotomist utilizes

Tube System or drops sample direct at the Lab?

6454443424144


151311


Troponin "Draw to Receive"

11.0000

8.7175

13.5792

Maximum

3rd Quartile

Median

1st Quartile

Minimum

N

Kurtosis

Skewness

Variance

StDev

Mean

P-Value:

A-Squared:

13.0000

10.0532

15.4629

66.0000

18.0000

12.0000

8.0000

0.0000

380

4.92349

1.79371

87.1895

9.3375

14.5211

0.000

11.930





Check in by Accessioning


6454443424144


11.810.89.88.87.8


Troponin "Draw to Receive"

8.0000

7.3894

10.0289

Maximum

3rd Quartile

Median

1st Quartile

Minimum

N

Kurtosis

Skewness

Variance

StDev

Mean

P-Value:

A-Squared:

9.0000

8.4410

11.5124

50.0000

15.0000

9.0000

5.0000

0.0000

436

2.61618

1.38520

62.0944

7.8800

10.7706

0.000

11.184





Check in by Phlebotomist



Does it take a significant amount

of time for the Technician to inspect and

release results?

0 40 80 120 160 200 240


3 4 5 6 7 8 9 10 11 12


Perform to Verify -Positive Results Only

A-Squared:

P-Value:

Mean

StDev

Variance

Skewness

Kurtosis

N

Minimum

1st Quartile

Median

3rd Quartile

Maximum

4.263

19.493

3.000

30.710

0.000

7.8732

21.7640

473.672

8.69490

86.5909

142

0.000

2.000

3.000

7.250

235.000

11.484

24.638

5.000







Improve Phase

FMEA Initiation

Brainstorming solutions

Fundamentally changing the Process


Easy Hard

Ensure draw for

Troponin 100%

of the time

Leverage

Nurse-initiated

orders for Trop

Implement

best practices

in Phlebotomy

Ensure room

or location ID

on ED orders

Eliminate

Multiple DrawsDrop off

at Lab for

Troponin Expedite attention

to instrument

4 Quadrant Analysis - A Brainstorming Tool

Effort


Trial Summary: Overall Performance

(new draws only)

• Troponin Before

– Order to Draw

• μ = 13.1

• σ = 14

– Draw to Receive

• μ = 12.4

• σ = 9.2

– Receive to Verify

• μ = 51.4

• σ = 40

– Total TAT

• μ = 76.9

• σ = 40.7

• Troponin Trial Only

– Order to Draw

• μ = 11.0

• σ = 8.3

– Draw to Receive

• μ = 7.9

• σ = 6.7

– Receive to Verify

• μ = 40.1

• σ = 11.4

– Total TAT

• μ = 59.0

• σ = 17.6


30 60 90 120 150 180 210


55 59 63


Troponin TAT: June 1 - 20

A-Squared:

P-Value:

Mean

StDev

Variance

Skewness

Kurtosis

N

Minimum

1st Quartile

Median

3rd Quartile

Maximum

58.418

19.792

54.000

15.916

0.000

60.6562

21.2614

452.048

2.49118

11.0310

349

24.000

48.000

56.000

67.500

219.000

62.895

22.968

57.000






Conducting the trial

enabled the organization

to anticipate impact of

expansion


6305805304804303803302802301801308030


51.550.549.548.547.546.545.544.543.5


TAT ALL TESTS - 2002

44.000

29.520

49.605

Maximum

3rd Quartile

Median

1st Quartile

Minimum

N

Kurtosis

Skewness

Variance

StDev

Mean

P-Value:

A-Squared:

45.000

30.508

51.002

656.000

60.000

44.000

33.000

8.000

7085

58.9612

5.06223

900.358

30.0060

50.3035

0.000

308.720






30 80 130 180 230 280 330


37 38 39 40 41 42 43 44 45


TAT ALL TESTS: JUNE 1 - 20

A-Squared:

P-Value:

Mean

StDev

Variance

Skewness

Kurtosis

N

Minimum

1st Quartile

Median

3rd Quartile

Maximum

42.342

25.256

37.000

91.965

0.000

43.4421

26.0115

676.600

4.81157

44.4322

2149

7.000

28.000

38.000

52.000

365.000

44.542

26.813

39.000






Were improvements at the expense of other tests?

Turnaround Time: All Tests Pre-Project

Turnaround Time: All Tests Post-Project


Control Phase

Celebrating Success

Holding the Gains

Looking Ahead


Process StepWhat's

Controlled?

Spec. Limits /

RequirementsMeasurement Method Sample Size Frequency

Who/What

Measures

Decision Rule/

Corrective ActionSOP

Order to Draw Patient Room ID In Process In Process In Process In Process In Process

I

n

P

In Process

Order to Draw Multiple DrawsNo mult draw when

one or more Trop

ordered

Compare check in time for

different samples by

Phlebotomist500-1000 Monthly Cerner* TAT > 13.0 min

Draw to ReceiveCheck in to

Chemistry

Check in to Chem

when Trop is ordered

Compare Draw ID to

Receive ID for Trop500-1000 Monthly Cerner TAT > 10 min

Draw to ReceiveCheck in to

Chemistry

Phlebotomist logs on

to PC

Compare Draw ID to

Receive ID for Trop500-1000 Monthly Cerner Compliance < 75%

Receive to Verify In ProcessI

n In Process In Process In Process In Process In Process TAT > 50

Perform to VerifyAttention to

Instrument

Use alarm to indicate

instrument completion

Monitor Peform to Verify

from instrument500-1000 Monthly Cerner TAT > 5

Troponin TAT TAT 60 mins or lessCerner stats, adjusted for

drawn before ordered500-1000 Monthly Cerner TAT > 65

*Need to identify staff person to process Cerner data Approved by:

Approved by:

Control Plan


How we’ve evolved as an

organization, and

what we’ve learned


Performance Improvement

Training&

Credentialing

How we’ve evolved as an organization, and what we’ve learned


“Culture Eats Lunch”

Q x A = EBusinessResults

Quality of solution times its Acceptance = EffectivenessSee “The Missing Link to Improvement Capability,”

Becker’s Hospital Review, February 2013


The ”burning platform” approach to

change management



• A man working on an oil platform in the North Sea awakened one night by an explosion. Amidst the chaos, he made his way to the edge of the platform. As a plume of fire billowed behind him, he decided to jump from the burning platform even though jumping is a risky option for the following reasons:o It was a 150 – foot drop to the water.o There was burning oil on the surface of the

water.o If jumping into 40°F water did not kill him, he

would die of exposure within 15 minutes.

• Luckily, the man survived the jump and was hauled aboard a rescue boat shortly thereafter. When asked why he jumped, he replied, “Better probable death than certain death.”

The ”burning platform” approach to

change management


The Golden Rule has Limits!


EQ Leadership

• EQ leaders create resonance (connection) among their followers

• EQ leadership creates trust

• EQ leaders can empathize with their followers

• Ineffective leadership creates dissonance (disconnect) and mistrust among followers


Why EQ Leadership?


EQ Leadership

• How to recognize the behavioral styles of peers and subordinates

• How to recognize the needs of each behavioral style

• How to adapt behavior to give staff “what they need”

• How to create more harmonious and productive relationships


Champion Training

&CandidateSelection

Performance Improvement

Training&

Credentialing

PortfolioManagement

System(“COMPASS”)

How we’ve evolved as an organization, and what we’ve learned


• Number of CHC Clients = 10

• Number of Projects = 150

• Average Cost per Project = $45,000

• Average Return per Project = $327,058

• Median Project Return = $160,675

• Range of Returns from $60 to $3.75M

• Average ROI = 7:1

Does our approach work?


$-

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

$140,000,000

$160,000,000

$180,000,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

CAMC Financial Impact2001 - 2013

Cumulative Total Annual Improvements

CHC Online

Training


What Success Looks Like

A statistically significant improvement in “Corporate Culture”

Performance Improvement Scores

3.75

3.43

3.18

2.65

2.73

3.12

2.5

3.0

3.5

4.0

1998 1999 2000 2001 2002 2003 2004 2005

Year

Averag

e


Thank you for the opportunity to be with you today!Ian R. Lazarus

[email protected]

lean, six sigma and emotional intelligence

Leadership & Management