Six-Sigma in Health Care

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Six-Sigma in Health Care

• This presentation will
• Provide an overview to the 6-sigma and the DMAIC
  framework
• Develop a practical appreciation of process
  variation (Based on an idea by Neil Westwood)
• and outline progress made within the NW Wales NHS
  Trust in applying the methodology
• Craig Barton (NHS Modernisation Director, NW
  Wales NHS Trust)

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What is 6-Sigma?

• Six-Sigma is an integrated quality improvement
  framework, which aims at ensuring no more than
  3.4 defects per million opportunities.
• At the heart of the Six-Sigma methodology lies a
  process improvement framework known as DMAIC
  (Define, Measure, Analyse, Implement, Control).
• It brings a rigour to process redesign, which
  takes into account the detailed, and dynamic
  complexity found in todays health care systems.

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What is Six Sigma?

• Six-Sigma is a data driven approach to service
  development, which provides a problem solving
  methodology, which allows you to get at the facts
  as the basis for informing decision-making.

Facts are the bricks with which you will lay a
path to your solution and build pillars to
support it. Don't fear the facts.
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DMIAC An Overview

• Pronounced (Duh-May-Ick). DMAIC refers to a
  data-driven quality strategy for improving
  processes, and is an integral part of the
  company's Six Sigma Quality Initiative. DMAIC is
  an acronym for five interconnected phases
• Define
• Measure
• Analyse
• Improve
• Control
• Each step in the cyclical DMAIC Process is
  required to ensure the best possible results!!

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Overview to the DEFINE Phase

• Define the Customer, their Critical to Quality
  (CTQ) issues, and the Core Business Process
  involved.
• Define who customers are, what their requirements
  are for products and services, and what their
  expectations are
• Define project boundaries the stop and start of
  the process
• Define the process to be improved by mapping the
  process flow

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Overview to MEASURE

• Measure the performance of the Core Business
  Process involved.
• Develop a data collection plan for the process
• Collect data from many sources to determine types
  of defects and metrics
• Compare to customer requirements and/or Mandated
  targets to determine shortfall

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The ANALYSE Phase

• Analyse the data collected and process map to
  determine root causes of defects and
  opportunities for improvement
• Identify gaps between current performance and
  goal performance
• Prioritise opportunities to improve
• Identify sources of variation

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The IMPROVE Phase

• Improve the target process by designing creative
  solutions to fix and prevent problems.
• Create innovative solutions using technology and
  discipline
• Develop and deploy implementation plan

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The CONTROL Phase

• Control the improvements to keep the process on
  the new course.
• Prevent reverting back to the "old way"
• Require the development, documentation and
  implementation of an ongoing monitoring plan
• Institutionalise the improvements through the
  modification of systems and structures (staffing,
  training, roles, procedures, policies,
  incentives)

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What do we mean by Sigma?

• The chart below is a Histogram showing the time
  taken to get a GP appointment (all data is
  fictitious)! A basic understanding of statistics
  can help us understand the variation in the
  process.

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What do we mean by Sigma (?)?

• Sigma stands for the standard deviation, which
  represents the average variation from the mean
  (average) value
• The smaller the standard deviation the smaller
  the amount of variation in the process.

MEAN Average
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The Normal Distribution
The frequencies of events within a normal
distribution have known probabilities.
Naturally occurring processes often approximate
to a normal frequency distribution
The standard deviation about the mean of a normal
distribution is given the Greek letter (lower
case) Sigma, (?)
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Sigma (?) from the Customers (Pts) Perspective
If the patient is prepared to wait between 1 and
7 days then we have..
A Six-Sigma (6 ?) Process!!
Very Few Defects
Very Few Defects
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Sigma (?) from the Customers (Pts) Changed
Perspective
If the patient (or LHB) is now only prepared to
wait between 1 and 3 days then we have..
No longer a Six-Sigma (6 ?) Process!!
Very High No of Defects on this side of the
distribution!!
Very Few Defects
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Improving Quality
?6?
Upper Service Specification
Lower Service Specification
We need to keep dong it so that the distribution
curve gets tighter and tighter. And our customers
(patients) get happier and happier
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From Decimals to Defects per Million
Opportunities (DPM)

• Probabilities are difficult to utilise eg
  99.99999998 provides a confidence interval
  equivalent to ? 6? (Standard Deviations) about
  the mean.

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Process Yields and DPMO

• These are Motorolas adjusted Yields and DPMO,
  which are shifted 1.5? from the standard normal
  values to account for variation associated with
  repeated measures

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Six-Sigma in PracticeThe Paper Aeroplane
Metaphor

• Based on an Idea By Neil Westwood
• Instructions
• Make an aeroplane using the materials on your
  tables (use only one type of material)
• When you have made it, bring the plane to the
  front of the room
• When instructed throw the plane
• The planes go different distances due to
  variation in deigns, materials and the people
  making them.

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Six-Sigma in PracticeThe Paper Aeroplane
Metaphor

• Understanding Variation..
• Note the distances flown by each design, what is
  the mean and standard deviation.
• What are causing the aeroplanes to fly different
  distances?
• Why are they not flying the same distance?

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Six-Sigma in PracticeThe Paper Aeroplane
Metaphor
Fishbone Diagrams are used to identify the root
causes of variation
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Six-Sigma in PracticeThe Paper Aeroplane
Metaphor

• How can we reduce variation?
• Train people Improve
• Provide Instructions Improve
• Provide the same materials Improve
• Develop process measures and use to control
  process variance apply SPC. Control

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Six-Sigma in PracticeThe Paper Aeroplane
Metaphor

• Towards a solution (ie to reduction in process
  variation)!!
• Make another aeroplane following the
  instructions. (Perhaps we have a master designer
  or Modernisation Director who is able to
  demonstrate)
• Use the A4 white paper provided, 80g/m2 (everyone
  to use the same material.

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Six-Sigma in Practice The Paper Aeroplane
Metaphor INSTRUCTIONS (1 of 3)
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Six-Sigma in Practice The Paper Aeroplane
Metaphor - INSTRUCTIONS (2 of 3)
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Six-Sigma in Practice The Paper Aeroplane
Metaphor - INSTRUCTIONS (3 of 3)
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Six-Sigma in PracticeThe Paper Aeroplane
Metaphor

• Analysing the results of the experiment
• Now note the mean and standard deviation of the
  distances flown
• Do we have a more stable process?
• Is it capable?
• We need to know the upper and lower service
  specification!!

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Six Sigma Implementation in the NW Wales NHS
Trust Why are we doing it?

• Engendering Service Improvement by providing the
  impetuous for sustainable Cultural Change!

Leading to
The development of cost effective, patient
(customer) centred evidence based services
derived form a rigours approach to systems
analysis and redesign.
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What have we done?
Initial Logistics Developing the
Infrastructure-

• Internal support
• Appointment of Full time Senior Manager with
  strong background in training, leadership org
  development
• Trained as Green Belt, will be trained as Black
  Belt!
• Agreed protocols for reinvesting savings
• Agreed criteria for the selection of projects
• External Support (Catalyst Ltd)
• Consultancy
• Project Surgeries
• Toll-gate reviews

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What have we done?
Awareness Training-

• Workshop for Executive Group
• Executive Directors
• Directorate Managers
• Workshop for Project Sponsors
• First phase roll out
• Training for 14 to Green Belt standard
• Participants from a variety of settings
• Estates and Facilities
• Human Resources
• Clinical - Surgery, Medicine and Mental Health
• Service Modernisation
• Business Modernisation

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Surviving 1st Phase Projects-

• Reduction in inpatient length of stay (LOS) for
  stroke patients towards a target of lt 5 days
  DMA - DOE Complete
• Reduction in the No of untouched patient meals
  within the Surgical Directorate 1.9? - 3.2?
• Reduced cycle time for the recruitment
  selection process within the Surgical Directorate
  0.9? DMA - DOE Complete
• Reduce trolley waits in AE to ensure 100
  compliance with the target of lt 4 hours 3.0? -
  3.3? (ENP Experiment)
• Improve processing of invoices from fuel cards
  to ensure 100 compliance with Financial Policy
  (F6b) 0.6 ? - 2.2 ?
• Reduce occurrence of missing case notes at
  outpatient ENT Dermatology O/Pt clinics to
  zero. 2.5 2.9 4.1 ? (Audit Runner
  Experiment)

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Surviving 1st Phase Projects-

• Reduction in do not attend rates (DNAs) for
  compulsory patient handling training to ensure
  100 compliance with Trust Policy and HSE
  (Statutory) guidelines. Root Cause Analysis
  Undertaken
• Reduce cycle time in relation to lease care
  application process ensuring 100 compliance with
  Trust Policy F6(a)
• Reduction in the No of Non BACs transactions to
  zero.
• 2.5 3.2 ?
• Improve contractor compliance with the audit
  requirements of the cleaning contract towards a
  target of 100 compliance with relevant clauses.
  0.9 3.9 ?
• Reduction in the time spent on pre post payroll
  checks.

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What have been the benefits?

• Development of a universal approach to solving
  problems which enforces-
• Business led approach to the selection of
  improvement projects, (Project charter
  incorporating an outline business case
  facilitating strategic integration)
• Customer/Patient centred (VOC)
• Systemic perspective (SIPOC, Process
  Mapping/Redesign)
• Focus on measurement (SPC)
• Scientific approach to Root Cause Analysis Fact
  NOT assumption! (Y F(x1, x2, x3 xn))
• Rational DOE underpinning P-D-S-A (Fast
  prototyping)
• Rational selection of solutions against a range
  of CTQs

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Benefits /Ctd

• Empower managers HCPs to solve problems
• I can make a difference, I have the tools to
  make a difference, It is my duty to make a
  difference
• I understand the organisational consequences of
  my practice!
• Move away from Assumptive/Solutionist
  thinking!!
• Move from task to process management
• Move from departmental to systems thinking
• from detailed complexity to dynamic complexity

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Some Early Indicators-
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Some Early Indicators-

• Improve contractor compliance with the audit
  requirements of the cleaning contract towards a
  target of 100 compliance with relevant clauses.

Jan 05 Feb 05 Mar 05
Process Sigma 0.9 0.95 3.9
Process Yield 30 31 99
BACK
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Some Early Indicators-

• Reduction in the No of Non electronic
  transactions (Cheques) to zero.

June 04 Feb 05 Mar 05
Process Sigma 2.5 2.8 3.2
Process Yield 84 90 95
BACK
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Some Early Indicators-
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What Have we Learnt from Phase I

• The importance of developing a strong business
  case underpinning the improvement opportunity
  strategic integration.
• The critical importance of the project sponsors
  role action not tokenism!
• The importance of embedding black, green and
  yellow belt roles within job descriptions and
  other artefacts of culture staff appraisal.
• The importance of organising work to allow
  dedicated space and time for six-sigma practice.
• Encouraging accountability for project outcomes
  by embedding the tollgate reviews within the
  directorate review process and local performance
  management arrangements.

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What Have we Learnt from Phase I

• Importance of measurement (SPC) identifying a
  range of upstream and downstream process
  measures.
• Avoid the McNamara Fallacy
• Recognising the need to balance hard systems
  modelling with soft-systems approaches
• Balancing the What and Why with the How?
• The importance of E Q x A
• The importance of V x D x S x C gt R

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The Next Steps!!

• Systematically select and train a further 14
  project leaders from all clinical directorates
  and functional areas.
• Ensure these are supported by sponsors trained
  yellow belts
• Identify and select projects (approx 2 per
  directorate/dept) which clearly impact on the
  achievement of KPIs CIPs.
• Develop accountability for project deliverables
  using existing organisational structures and
  processes.
• Systematically exploit the learning of others
  whilst proactively sharing our experiences.
• Develop the organisational capability wrt to the
  application of DMADV/DFSS.
• Succession Plan for future black, green and
  yellow belts.
• Have some fun!!
• (Work shorter hours take less work home,
  Quantity time with the kids)!!!