an introduction to lean six sigma what gets measured gets done…… but not always in the way we...

An Introduction to Lean Six Sigma

What gets measured gets done……

But not always in the way we want

Process Improvement

2. Clarify the Problem (e.g. Pareto diagram)

The “Real” Problem

3. Locate the Point of Cause (e.g., Fishbone

diagram)

Why?

Why?

Why?

Why?

Why?

Root Cause

5. Develop countermeasure

6. Measure effectiveness

4. Root Cause Analysis

7. Standardize

1. Initial Problem Perception (large, vague, complicated)

Plan

DoStudy

Act

• Initial problem perception

• Clarify problem• Locate point of cause• Root cause analysis• Design solutions• Test to see if worked• Standardize

What are Lean and Six Sigma?

• A statistical measurement• A measure of quality• A goal• A methodology• A quality improvement initiative• A management philosophy focused on

customer satisfaction• A strategy for organizational transformation

Lean Six Sigma Process Improvement

• Lean Six Sigma Seeks to improve the quality of manufacturing and business process by:– identifying and removing the causes of defects

(errors) and variation.– Identifying and removing sources of waste

within the process– Focusing on outputs that are critical to

customersDefine

Measure

AnalyzeImprove

Control

Lean Six Sigma Process Improvement• LSS is a management philosophy that seeks to drive a

quality culture change through a multi-level based program

Level Training

Green Belt LSS Methodology and basic tool set

Black Belt Green Belt content plus advanced data analysis

Master Black Belt Black belt content plus program management, leadership skills, some advanced tools

L6s

1930 19501900

L E A N

S i x S i g m a

Ford Assembly Line

Guinness Brewery

Shewhart Introduces SPC

Gilbreth, Inc.•Management Theory•Industrial Engineering

Deming•14 Points•7 Deadly Diseases

Toyota Production System

Lean Six Sigma Timeline

L6s

1990 20001980

Motorola Introduces Six Sigma

S i x S i g m a

L E A N

Just – in–Time

SPC

Lean Mfg.

TQMAlliedSIgnalGE Adapt LSS to Business Processes Lean

Six Sigma


L6s

20132000

S i x S i g m a

L E A N

Lean

Six Sigma


Lean Six Sigma is … An Evolution!

• Continuous Improvement can be traced to Taylor’s time studies

• Toyota created Lean to achieve Henry Ford’s low cost with GM’s variety of product

• Motorola initiated “six sigma” to meet the challenge of Japanese chip quality and cost

• Deming, Baldrige and Shingo Prize’s are Descriptive of success

• GE Prescribed the Six Sigma infrastructure of success connected to business strategy

• Lean Six Sigma integrates Lean lead time and cost reduction with Six Sigma quality and sustaining infrastructure of success

CraftProductionEli Whitney -

ProductStandards

Shewhart –StatisticalMethods

Juran –ProcessAnalysis

IndustrialProduction

StatisticalProcess Control

QualityControl

Taguchi –Customer

Focus

QualityEngineering

Deming –SystemsThinking

TQM -Total QualityManagement

Smith(Motorola) –

StatisticalRigor Six

Sigma v1Welch/

Bossidy –OrganizationalInfrastructure Six

Sigma v2

Taylor –Time/Motion

Studies

ScientificManagement

Ford –Work

Analysis

AssemblyLine Manufacturing

Sloan –Modern

Management

Prof. Mayo –“Hawthorne

Effect”

MassProduction

Toyoda,Ohno,Shingo

ToyotaProduction

System

Womack& Jones

LeanEnterprise George, ITT

Industries, CAT, Xerox

Lean SixSigma

Harry –DMAIC

Gilbreth

ZeroDefects

Lean vs. Six Sigma

• Lean tends to be used for shorter, less complex problems. Often time driven. Focus is on eliminating wasteful steps and practices.

• Six Sigma is a bigger more analytical approach – often quality driven – it tends to have a statistical approach. – reduce defects.

• Some argue Lean moves the mean, SixSigma moves the variance.– Waste elimination eliminates an opportunity to make a defect– Less rework means faster cycle times

• Six Sigma training might be specialized to the “quality” department, but everyone in the organization should be trained in Lean

VOC vs. VOP

Voice of Customer

Voice of Process

The Voice of the Process is independent of the Voice of the Customer

SigmaCapability

Defects per Million Opportunities

% Yield

2 308,537 69.15%

3 66,807 93.32%

4 6,210 99.38%

5 233 99.98%

6 3.4 99.99966%

What’s good enough?

99% Good (3.8 Sigma) 99.99966% Good (6 Sigma)

20,000 lost articles of mail per hour (based on 2,000,000/hr)

7 articles lost per hour

Unsafe drinking water for almost 15 minutes each day

1 unsafe minute every 7 months

5,000 incorrect surgical operations per week

1.7 incorrect operations per week

2 short or long landings daily at an airport with 200 flights/day

1 short or long landing every 5 years

2,000,000 wrong drug prescriptions each year

680 wrong prescriptions per year

No electricity for almost 7 hours each month

1 hour without electricity every 34 years

Goals of Lean Six SigmaLSL USL

Customer Target

DefectsDefects

Prevent Defects byReducing Variation

LSL USL

Customer Target

Defects

Prevent Defects byCentering ProcessLSL USL

Customer Target

Meet Customer Requirements

Background on Lean

• Lean comes out of the industrial engineering world• Taiichi Ohno – Toyota Production System.

– 1940s-1950s company was on verge of bankruptcy– Dynamics of industry were changing – moving from mass

production to more flexible, shorter, varied batch runs (people wanted more colors, different features, more models, etc).

• Ohno was inspired by 3 observations on a trip to America– Henry Ford’s assembly line inspired the principle of flow (keep

products moving because no value is added while it is sitting still)– The Indy 500 – Rapid Changeover– The American Grocery Store – led to the Pull system – material use

signals when and how stock needs to be replenished

What is Lean?

• Lean Enterprise Institute:– “Lean is a set of concepts, principles and tools

used to create and deliver the most value from the customers’ perspective while consuming the fewest resources and fully utilizing the knowledge and skills of the people performing the work”

What is Lean?

• Taiichi Ohno:– “all we are doing is looking at the timeline from

the moment a customer gives us an order to the point when we collect the cash. And we are reducing that timeline by removing the non-value-added wastes”

– It is about eliminating waste and showing respect for people

Lean Thinking

• Lean is about making the right work easier to do• Work is designed as a series of ongoing

experiments that immediately reveal problems• Problems are addressed immediately through

rapid experimentation• Solutions are disseminated adaptively through

collaborative experimentation• People at all levels of the organization are taught

to become experimentalists

Path To LeanTheory Waste is Deadly

Application 1. Define Value – act on what is important to the customer

2. Identify Value Stream – understand what steps in the process add value and which don’t

3. Make it flow – keep the work moving at all times and eliminate waste that creates delay

4. Let customer pull -- Avoid making more or ordering more inputs for customer demand you don’t have

5. Pursue perfection -- there is no optimum level of performance

Focus Flow Focused

Assumptions Non-Value added steps exist

Results Reduced cycle time

Waste DefinedWastes Healthcare Examples

Transport 1. Moving pati ents from room to room2. Poor workplace layouts, for pati ent services3. Moving equipment in and out of procedure room or operati ng room

Inventory 1. Overstocked medicati ons on units/fl oors or in pharmacy2. Physician orders building up to be entered 3. Unnecessary instruments contained in operati ng kits

Motion 1. Leaving pati ent rooms to:• Get supplies or record• Documents care provided

2. Large reach/walk distance to complete a process step

Waiting 1. Idle equipment/people2. Early admissions for procedures later in the day3. Waiti ng for internal transport between departments

Over-Production 1. Multi ple signature requirements2. Extra copies of forms3. Multi ple informati on systems entries4. Printi ng hard copy of report when digital is suffi cient

Over-Processing 1. Asking the pati ent the same questi ons multi ple ti mes2. Unnecessary carbon copying3. Batch printi ng pati ent labels

Defects 1. Hospital-acquired il lness2. Wrong-site surgeries3. Medicati on errors4. Dealing with service complaints5. Illegible, handwritt en informati on6. Collecti on of incorrect pati ent informati on

Skills 1. Not using people’s mental, creati ve, and physical abiliti es2. Staff not involved in redesigning processes in their workplace3. Nurses and Doctors spending ti me locati ng equipment and supplies4. Staff rework due to system failures

Applying Lean in Real Life

• Toast Kaizan• 3:28 – Current Condition• 20:10 – Target Condition

The Lean HouseGoals: Safety, Quality, Time, Cost, Morale

Heijunka Standardized Work Kaizen(level loading (employee empowerment) (Continuous Improvement)

• Prevent Delays

• Value Stream Focus

• Pull Systems• Right care,

right place, right time

• Identify root Cause

• Prevent errors at the source

• Involve employees

• Avoid blame

Developing People

Flow Quality

Lean Foundations

• Standardized Work – people should analyze their work and define the way that best meets the needs of all stakeholders. – “The current one best way to safely complete an

activity with the proper outcome and the highest quality, using the fewest possible resources”

– Standardized not Identical – mindless conformity and the thoughtful setting of standards should not be confused

– Written by those who do the work.

Lean Foundations

• Heijunka -- Level loading – smoothing the workflow and patient flow throughout the hospital.

• Kaizen – continuous improvement• Employee Empowerment

– Andon Cord• Jidoka – problems are fixed at the source instead of

being passed along and fixed at the end

– “Suggestion Box”

Lead Time and Value Added

Types of Work

• Value Added Work– Activities that transform materials or information into

something that the customer cares about• Non-Valued Added Work

– Necessary• Room changeover• Testing• Administration?

– Unnecessary (pure waste)• Re-testing• Waiting for a test• Walking

Value Added; 18

Non-Value Added (required); 25

Non-Value Added (pure waste); 57

Value Stream Mapping

• A value stream map is a type of process map– But shows how long each step takes– As well as the wait time between each step

• Current State VSM– Helps identify waste and opportunity for

improvement• Future State Map

– Target for where we want to be

CompileFolderwithDocs

Receiving:Open &

Array DocsVerifyClaim

CalculateAmount &Address

Print,Stuff &MailCheck

Policy Holder’sFamilyInsurance Co.

FIFO FIFO FIFO

2 Min 5 Min 10 Min 1 Min 1 Min

P/T = L/T = # inputs = Reliability =

P/T = L/T = %C&A = # ops =

P/T = L/T = % rejects = Reliability =

P/T = L/T = % rework = # ops =

P/T = L/T = Reliability = % errors =

7 Days7 Days7 Days7 Days

FIFO

28 Days19 Min

email mail

manualfinan

Process Box

Process DataBox

TechnologyUsed

Work Priority

System Metric

Insurance Claim Processing

Swim Lane

• Processes and decisions are grouped visually by placing them in lanes.

• Parallel lines divide the chart into lanes, with one lane for each person, group or subprocess.

• Arrows between the lanes represent how information or material is passed between the subprocesses.

Spaghetti Diagram

• A spaghetti diagram is a visual representation using a continuous flow line tracing the path of an item or activity through a process.

• Decide what you are going to observe eg product, staff or patient flow.

• Draw the layout of the area and then draw lines on the diagram to represent the main flows of the staff member or patient.

• By analyzing the lines, you can identify any areas with unnecessary movement. This helps staff decide whether to bring two points closer together and optimizes the flow.

Lean Methods• Kaizen Events (or SCORE events)

– Planned and structured process that enables a small group of people to improve some aspect of their business in a quick, focused manner.

• Select• Clarify• Organize• Run• Evaluate

• 5S – this methodology reduces waste through improved workplace organization and visual management– Sort, Store, Shine, Standardize and Sustain

• Kanban – a Japanese term that can be translated as “signal,” “card,” or “sign.”– Most often a physical signal (paper card of plastic bin), that indicates when it is

time to order more, from whom, and in what quantity.

5S and the Visual Healthcare Workplace

• Sort– Get rid of unneeded items

• Straighten– Organize and label the location for items that are needed in the area

• Shine– Clean the workspace– Equipment clean and prepped for use

• Standardize– Develop cleaning methods and cleanliness standards to maintain

the first 3 S’s• Sustain

– Review the workplace regularly. Make it a habit

Lean Daily Management

• The LDM process promotes employee ownership of their operational performance

• Creates a no-fault culture• Reinforces continual improvement efforts.• Physicians often respond well to its

transparent, data-oriented nature.

Lean Daily Management

• Each day, a team (composed of all operational stakeholders) gathers for a 5-minute discussion to review a dashboard

• four categories: safety, quality, cost, and efficiency.

• To help focus and prioritize its improvement efforts, the team should place only one metric in each category.

The Glass Wall

Departmental Boards

London 2015???

Errors per Worked Hour by Month

• Special Causes in March 2012, and July-Sept 2012

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2011 2012

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Errors per hourUbarUCLLCL

Correcting the “Bad Apples”

• Error rate falls from .00090 to .00082

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When we “changed the process”

• When we changed the process, rate fell to .0049

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Sample Sizes

Six Sigma Overview• Diligent attention to managing, improving, and

reinventing business processes• Disciplined use of facts, data, and statistical

analysis• A close understanding of both internal and

external customer needs• Standard deviation (σ) is used to measure the

amount of process variation• As sigma gets larger, process variation increases• Variation is the enemy

Six Sigma is a Quality Measure and a Goal

Six Sigma as a Methodology

• Underlying methodology called DMAIC• Empowerment of trained professionals• Formal project charters set the scope and

objectives• Various basic quality tools and statistical

tools applied during project• Project champion/sponsor both approve

project tollgates

Lean & Six Sigma are Synergistic

LeanGoal: Improve process performance

through waste elimination & cycle time reduction

Focus: Bias for action Method: Implement Lean tools such as

Kaizen events, Value Stream Mapping, 5S, TPM etc.

Deployment: Implicit infrastructure

Speed, Flow, Cost

Six SigmaGoal: Improve process performance in

relation to what is critical to the customer

Focus: Bias for analysisMethod: Uses the DMAIC method and

quality tools

Deployment: Explicit Infrastructure

Customer Satisfaction

Lean Focus on Waste Elimination supports Six Sigma Quality(waste elimination eliminates an opportunity to make a defect)

Six Sigma Quality supports Lean Speed (less rework means faster cycle times)

What Tool do I use?Complexity of tool

Complexity of Issue

Variation Reductio

n

Waste and Flow Issues

Simple Problems

6σ

Lean

What Makes a Good Six Sigma Project?

• There is no known solution• The root cause is not known• The problem is complex and needs statistical

analysis• The problem is part of a process• The process is repeatable• A defect can be defined • Project will take 3-6 months• There are data available

The DMAIC Methodology

• Define – describe the problem quantifiably and the underlying process to determine how performance will be measured.

• Measure – use measures or metrics to understand performance and the improvement opportunity.

• Analyze – identify the true root cause(s) of the underlying problem.

• Improve – identify and test the best improvements that address the root causes.

• Control – identify sustainment strategies that ensure process performance maintains the improved state.

Define

• Define Scope of the Problem– Document the Process– Collect and Translate the Voice of the Customer

• Determine Project Objective and Benefits– Define Metrics and Defects– Establish Preliminary Baseline– Develop Problem & Objective Statements– Estimate Financial Benefit

Define (continued)

• Create Project Charter– Confirm Improvement Methodology– Define Project Roles and Responsibilities– Identify Risks– Establish Timeline– Managerial Buy-in

• Focus here is on the problem

Measure Measure what is measurable, and make measurable what is not so” – Galileo

• Define “As Is” process– Value stream map/process flow diagram

• Validate Measurement System for Outputs– Don’t assume your measurements are accurate –

measuring system must accurately tell what is happening

• Quantify Process Performance– Collect data (Y’s)– Examine process stability/capability analysis

“Before”

Analyze

• Identify Potential Causes (X’s)• Investigate Significance of X’s

– Collect data on x’s– Graphical/Quantitative analysis

• Pareto Chart• Fishbone Diagram (cause and effect)• Chi Square Test• Regression Analysis• Failure Mode Effects Analysis

• Identify Significant Causes to focus on (y=f(X))– Evaluate the impact of x’s on y

• Here you identify the critical factors of a “good” output and the root causes of defects or “bad” output.

Fishbone (Cause and Effect) Diagram

Requesting MD

Bed Assignment

Facility Patient

Admitting MD

Admission NOT meeting IQ criteria

No appropriate workup

alternatives

documentation

Ability to follow recommendations

Know criteria

Medical necesity Outpatient option

LOC available documentation

alternatives

workup

Use of IQ tool

Know Criteria

Appropriate admit

Know criteria

Know criteria

Orders written

Bed Flow not contacted

Cause and Effect Matrix (Root Cause Analysis)CT order to exam

time

Exam to Complete

time

Accuracy of CT order

Accuracy of CT

Report<-- Process Outputs

10 8 6 9 <-- Importance

Process Step Process Input Correlation of Input to Output Totalorder-exam allergy assess 3 0 5 0 60order-exam Cr assessed 3 0 7 0 0 72order-exam order print 7 0 2 0 0 82order-exam order approval 9 0 9 0 0 144order-exam appropriate order 4 0 9 7 0 157order-exam communication to RN 10 0 0 0 0 100order-exam RN availability 10 0 0 0 0 100order-exam Pt availability 8 0 0 0 0 80order-exam Pt acuity 9 90order-exam IV access 6 0 0 0 0 60order-exam Oral contrast ordered 4 0 0 0 0 40order-exam contrast available 3 0 0 0 0 30order-exam supervision 8 0 0 0 0 80order-exam transport 8 0 0 0 0 80order-exam wc stretcher avail 8 0 0 0 0 80order-exam check in 2 0 0 0 0 20order-exam ordering resident education 6 0 7 0 0 102exam IV contrast infusion 2 0 0 0 0 20exam transfer to CT scanner 1 0 0 0 0 10exam release of images 0 2 0 1 0 25exam CT tech avail 9 0 0 0 0 90exam Ct scan availability 9 0 0 0 0 90exam-complete radiology resident availability 4 8 3 0 0 122exam-complete queue of exams 0 7 0 0 0 56exam-complete PACS availability 0 7 0 0 0 56exam-complete radiology attending availability 3 9 0 0 0 102exam-complete radiology resident education 0 2 1 6 0 76exam-complete radiology attending education 0 0 0 9 0 81

Improve

• Generate Potential Solutions• Select & Test Solution• Develop Implementation Plan

Control

• Create Control & Monitoring Plan– Mistake proof the process– Determine the x’s to control and methods– Determine Y’s to monitor

• Implement Full Scale Solution– Revise/develop process– Implement and evaluate solution

• Finalize Transition– Develop transition plan– Handoff process to owner

“After”

191715131197531

0.9

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Sample

Pro

port

ion

_P=0.8012

UCL=0.8589

LCL=0.7435

baseline PFC Handoff Control

1

Tests performed with unequal sample sizes

P Chart of Combined Number Meeting Criteria by phase