achieving and sustaining excellence transforming the health care system

Biography – Jennifer Ralston• Jennifer Ralston is the Health Care Subject Matter Expert for The Quality Groups Master Champion Network.

Ralston is a Multifaceted Manager with unique blend of experience in quality, process improvement, process engineering, regulatory, pharmaceutical, quality auditing, software quality, project and program management, change management and lean six sigma.

• Ralston has worked with American Red Cross Bio Medical Services Headquarters and Organ Transplant Team, United States Postal Service (USPS), the Naval Yard, Genentech part of the Roche Family, The Project Management Institute (PMI), Merck Pharmaceuticals, The Army, Reston Hospital, The National Security Agency (NSA), American Association of Blood Banks (AABB), Medical College of Virginia, University of Maryland Medical System, Georgetown University Cellular Engineering, Department of State, and iJet Travel Intelligence. She has presented Quality Concepts to places such as the University of Cairo in Egypt, conducting an International Audit of the Vascera, in Cairo, Egypt in 2001. This was a unique opportunity to teach regulatory concepts to a pharmaceutical company overseas. Ralston has also won the American Red Cross Spirit of Excellence Award, which is an award for individuals that achieve major results.

• During her time working for American Red Cross, Jennifer was the Director of Process Improvement for Biomedical Services at American Red Cross National Headquarters. She is a certified Master Black Belt, Lean Sensei, and managed the Red Cross’ Lean Six Sigma Program and Computer Simulations. Ralston began her seven (7) year career at Red Cross in 2002, serving as Senior Change Engineer, Change Management, Senior Quality Design Engineer, and Systems Design Engineering. She was also the organization’s first Black Belt and Master Black Belt in the Six Sigma program. In this role, she introduced and implemented Six Sigma and Project Management tools in support of the continuous improvement program and in compliance with FDA regulations, applicable laws, cGMP, CLIA/CMS, as well as AABB, JCAHO and ISO Standards. Ralston is also an auditor for several organizations such as AABB, CAP and ISO. She has also trained with the American Society of Quality as a Certified Quality Auditor and Certified Quality Engineer. Ralston has also worked as a Clinical Technologist, Medical Technologist and Microbiologist when she first started her career in Health Care.

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Biography – Kathy Price• Kathy Price is the Director, Clinical Effectiveness, Sisters of Charity of Leavenworth Health System (SCLHS), KS, and a Master

Lean Sensei responsible for implementing, training, facilitating and leading Lean Six Sigma quality improvement teams and methods for the 11 hospital system and University. She trains, coaches and mentors Lean Thinking Change Leaders and performance improvement teams in the use of quality improvement tools and methods focused on an innovative blend of Lean Six Sigma. First year deployment trained 439 employees and mentored 110 teams to produce $1,299,803 lean savings to exceed target by 133%. Second year deployment trained 256 employees and mentored 150 teams to produce $8,389,778 savings to exceed target by 113%. She trains and mentors local Lean Sensei to become ASQ Six Sigma Black Belt certified. She is responsible for curriculum development, standardization and deployment. She has created curriculum and blended e‐learning modules. She has designed and created 1 day, 9 day, 20 day and blended e‐learning modules along with just in time (JIT) materials. She is a presenter at national, state and local conventions and meetings. She is published in a peer reviewedjournal. She is a leader in Strategy, Vision, and Mission planning. She is successful in Team Building, Negotiating, Consensus Building and Change Management. She is competent in Data Management and Analysis.

• As a Six Sigma Black Belt and Master Lean Sensei she has led, facilitated, and/or coached projects involving: Organizational Assessments, including Baldridge Self Assessment, Operational Efficiency Improvements, Patient Care Management, i.e. Stroke Care and Transforming Care at the Bedside (TCAB), Nursing Documentation, Patient Satisfaction Improvements (HCAHPS), Integration of Electronic Medical Records into Workflows, Redesign of Work Areas and Build Outs, Design for Six Sigma for new construction, Improvement of Patient Billing and Revenue Cycle, Throughput and Cycle Time Reductions, 6S for operations and supplies, and Root Cause Analysis.

• Prior to SCLHS she was a Sr. Improvement Advisor at the University of Texas MD Anderson Cancer Center in Houston, TX. She previously worked with Quest Diagnostics, SmithKline Beecham Clinical Labs and Richards Laboratories and teaches Biology at the university level. Kathy has been in the Healthcare profession for 30 years. Kathy has a bachelor’s degree in Science from Stephen F. Austin State University, Nacogdoches, Texas; a medical technology certification from St. Paul Hospital, Dallas, Texas; and her master’s in science education from the University of Texas in Dallas. She has ASQ Six Sigma Black Belt, Project Management, Lean, and TeamStepps Master Trainer certifications. Her professional affiliations include the American Society for Quality, the Quality Institute for Healthcare and the Institute of Healthcare Improvement.

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• We will focus on Delivery of Services and Patient Safety can be enhanced by reducing waste and using a data‐driven methodology

• Applying next Generation Quality Management Philosophy and Methodology in Health Care

• Successful Improvement Projects undertaken in the field

• Achieving Quality and Organizational Performance Effectiveness

• BONUS: You will learn how to use The Quality Group’s new Lean Six Sigma Blended e‐Learning Series for Healthcare professionals to drive process improvement initiatives throughout their organizations and take your deployment to the next generation.

Pre-Summit Workshop Objectives:

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Interactive Discussion is a Must

Please Participate in Discussion

Ask Questions

Open Dialogue is Welcome

Others?

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Ground Rules for Workshop

American Red Cross Biomedical Services

Mission & Vision

American Red Cross Biomedical Services will fulfill the needs of the American people for the safest, most reliable, most cost-effective blood, plasma, and tissue services through voluntaryDonations.

Our Mission Our VisionTo be recognized by the people and organizations we serve, as well as others in our field, as theprovider of choice for blood, plasma and tissue services. This will be accomplished bycommitment to quality, safety and use of the best medical, scientific, manufacturing and business practices.

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Aligning strategy to focus theorganization on shared priorities

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Related Initiative Status Summary

Executive Review: M4 Performance Summary (SDP)

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M4: Analysis, Opportunities and Issues

• SDP sales continue to exceed target: demand and our ability to collect on DOW has been excellent!

• Still some mismatch of DOW requirement, but overall volumes are sufficient

M4: Achieve market share >50% (Collections)Owner: Greg Ballish

M4: Forward Looking Actions

NOTE: These projects identified “Increase donations” as at least one of their strategic goals

• Six sigma projects aligned to SDP collections are underway

• Managing SDP collections for splits and machine/staff utilization can increase efficiencies

System - Daily Collections Goal Achievement (% of total)

Mon Tue Wed Thu Fri Sat Sun

Target 16.1% 14.9% 9.8% 11.5% 16.3% 15.7% 15.7%

July 16.3% 15.6% 13.0% 13.7% 16.3% 14.8% 10.3%

August 16.3% 15.4% 13.3% 13.5% 15.9% 15.1% 10.5%

Description Timing Status

CRM/DRM strategy execution Will close to new CR

IDEO donor environment design project TBD

Donor recruitment development TBD

SDP strike force (also 6σ) TBD

Donor assertions Pending best practice assessment

Increasing Apheresis donor frequency Pending best practice assessment

Determining best choice donor pre-count Pending best practice assessment

CAGR = 7.5%

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• Began Six Sigma Deployment August 2005– Trained 78 BBs– Trained 40 GBs– Trained 350 Champions– Hired 3 MBBs– Self Sustaining

• Began Lean Deployment October 2007– Lean 101 Awareness Training– Hired 2 Lean Engineers at the beginning and supplemented with consultants to gain velocity

– Hiring 6 Lean Engineers, 1 Lean Sensei/Program Manager– Self Sustaining in March 2009

ARC Deployment History

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Six Sigma Lean

Quality Enables Speed

Speed Enables Quality

Culture + Quality Speed + Low Cost

Goal Improve performance Outliers on Customer Critical to Quality requirement

Focus DMAIC with Total Quality Management tools to eliminate variation

Method Management engagement, dedicated Champions and Black Belts

Goal Reduce waste, increase process speed, and Standard Work

Focus Identify non-value added steps and cause for delay

Method Kaizen events, Value Stream Maps

How we use Lean & Six Sigma

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ExecutionPrioritizationDefinitionIdea Generation

X2 = Project Selections

Projects Planned

Potential Projects

Current Projects

Available Resources

All Projects Must Pass Through a Strategic Filter.

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Leadership Team

Project Champion

Project Champion

Master Black Belt

Black Belt

Green Belt

Black Belt

Green BeltYellow Belts

A Sustaining Infrastructure Must Have Senior Management’s Support and Guidance.

X8 = Sustaining Infrastructure

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Key Belt Attributes

Career Ladder

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Y = Successful Deployment

),...,,( 21 kxxxfY =

X1 = Leadership CommitmentX2 = Project SelectionX3 = Black Belts SelectionX4 = Fully Dedicated Black BeltsX5 = Champion EngagementX6 = Master Black Belt SupportX7 = Organizational Tools X8 = Sustaining Infrastructure

Scale

100 %

75%

50% or less17

Sisters of Charity Mission & Vision

“We will, in the spirit of the Sisters of Charity, reveal God’s

healing love by improving the health of individuals and

communities we serve, especially those who are

poor or vulnerable.”

Our Mission

Our VisionSCLHS Mission realized through unyielding pursuit of performance excellence, innovative growth and health care for all

SCLHS Core ValuesSCLHS carries out Jesus' healing ministry today through its

commitment to the following core values:• Excellence

We offer excellent and compassionate care.

• RespectWe recognize the sacred worth and dignity of each person.

• Response to NeedThe health care we offer is based on community need, with a special concern for the poor.

• StewardshipWe are mindful that we hold our resources in trust.

• WholenessWe value the health of the whole person‐spiritual, psycho‐social, emotional and physical.

Beyond 2011 Under Health Reform

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The Prelude2010-2013

MarketExpansion2014-2017

Regulation and Restructuring

2018-2020+

Chase theIncentives –Get Ready

Manage theChange

ConsolidateYour Position

• Medicare Breakeven Targets

• Clinical Integration• New Service Line Models

• Operating Company Model

• Systems of Care• Prepare for Medicare 3.0?• Agile & Adaptable to Change

• Able to Manage Risk

• Lean Initiatives/MAP• Physician Alignment• ACO & Medical Home• Performance Excellence Plan

• EHR & Meaningful Use

Cost Reduction Efforts: Health Care vs. Other Industries

Source: Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Available on www.IHI.org)

Inputs to Core Processes

• Supplies• Staff• Equipment

Core Processes

• Evaluating• Diagnosing• Treating• Communicating

Outputs

• Quality Results• Safety Results• Costs

Where Other Industries’ Go to Reduce Cost

Where Health CareGo to Reduce Cost

• Move away from mindset that “lower cost implies poor quality”

• Get to the “dark green dollars”

- Go beyond notional or potential savings to taking real money out of budgets

• Set a cost reduction target (1-3%)?

- . . . A new approach!

A New focus on Kano?

Reduce costs significantly while maintaining or improving quality

Customer-defined value

Map and understand

value stream

Make value stream flow

Continuous process

improvement

Goals: • Increase productivity• Eliminate waste• Maximize resource

utilization

Waste includes• Scrap • Rework • Inspection • Inventory• Queuing time • Transporting materials

or products • Redundant motion• Anything for which a

final customer would not want to pay

is focused on the elimination of all non value-adding activities and waste from the organization’s processes.

Lean

Lean Deployment ArchitectureCulture Transformation• Self‐sustained model

• Longer deployment time

• Improvement is a daily event for everyone

• Accountability

• Structured education

• Way of life

Project Based • Consultant‐led

• Shorter deployment time

• Hobbies

• Little accountability

• Selected education

• Flavor of the month attitude

Lean Accountabilities & Disciplines

• Waste reduction 2% per year using 2008 cost figures

• Focus on Directors and Managers• System Office certification is good for one calendar year

• Certification requires yearly renewal• Must provide evidence of Lean Thinking proficiency every year for continuing certification

• Sensei will be certified by American Society for Quality (ASQ) Black Belt, Lean Six Sigma

SIX SIGMASix Sigma concentrates on variationreduction by using statisticalmethods to lower process defectrates to less than 3.4 defects per million opportunities.

Six Sigma Methodologies:• DMAIC - define, measure, analyze, improve, and control• DMADV - define, measure, analyze, design, and verify

Cascading Effect of Performance Excellence

Big Dots(Pillars, BSC…)

Drivers(Core Theory of

Strategy)

Projects(Ops Plan)

What are your key strategic aims? How good must we be, by when? What are the system-level measures of those aims?

Down deep, what really has to be changed, or put in place, in order to achieve each of these goals? What are you tracking to know whether these drivers are changing?

What set of projects will move the Drivers far enough, fast enough, to achieve your aims? How will we know if the projects are being executed?

Advance Training Program (ATP)

• Advance Training Program for Performance Excellence

• Focus on Leadership ‐ Vice Presidents and Above

• 10 days SCLHS Affiliate Program

• 20 days Intermountain Healthcare

• Both includes completion of a project

• Basic PI sciences and 1 day Lean Champion Training

Lean Thinking Change/Project Leader

• 9 days training

• Require 2 projects – learning and certification project in the magnitude of $25K waste elimination

• DMAI2C Methodology

• Commitment to continue deployment of lean at their facility

Lean Foundation Training

• 6 hours training

• Basics of Lean

• “Airplane exercise”

• Commitment to recognize waste

Lean Sensei Training• 1 week/per month for 6 months (25 days), with one month off in December

• ASQ Body of Knowledge (BOK) for Six Sigma Black Belt Certification & SME BOK for

Lean Sensei

• “People side”

• Coaching and Teaching

• PT/FT Local Sensei

Mini Courses - Lunch n Learns• Tool Reviews

– VSM

– Spaghetti Diagrams

– Visual Controls

– 6S

• Facilitation Skills

• Committees vs. Lean Teams

• Observation Skills

• Data Management Skills

• Case Studies

• Mentoring / Coaching Skills

Advance Courses

• Minitab – working with data

• TeamSTEPPS – Master Trainer Training

• Statistics for Performance Analysts

• Facility Design and Simulations

Changing the oldMaking the future attractive

Framework: Leadership for Improvement

Establish the Foundation

Setting Direction: Mission, Vision and Strategy

PULLPUSH

Source: IHI

Will Ideas Execution

PULLPUSH1. Set Direction: Mission, Vision and Strategy

Make the status quo uncomfortableMake the future attractive

3. Build Will• Plan for Improvement• Set Aims/Allocate Resources• Measure System Performance• Provide Encouragement• Make Financial Linkages• Learn Subject Matter• Work on the Larger System

5. Execute Change• Use Model for Improvement for

Design and Redesign• Review and Guide Key Initiatives• Spread Ideas• Communicate results• Sustain improved levels of

performance

4. Generate Ideas• Read and Scan Widely, Learn from

other Industries & Disciplines• Benchmark to Find Ideas• Listen to Customers• Invest in Research & Development• Manage Knowledge• Understand Organization as a

System

2. Establish the Foundation• Personal Preparation• Choose and Align the Senior Team

• Build Relationships• Develop Future Leaders

• Reframe Operating Values• Build Improvement Capability

Source: IHI

Framework: Leadership for Improvement

SCLHS Strategic Framework

Component One:

• Care Reliability• Patient & Environmental

Safety• Excellent Care Experience• Cost-Effective Care• Clinical Transformation

Component Two:• Finance

Source: SCLHS SPPECD

• Culture & Talent

• Performance Excellence

• Physician Partnership

• Strategic Growth

How do we nominate projects?

ProblemsOpportunitiesMandates

Projects Selected to Move to the Initiation Stage

Strategic Goals

Financial Expectations and Goals

Potential Nonfinancial Benefits

Organizational Politics

Current Project Portfolio Mix

Resource Constraints

Project Risk

Organization Risk Preferences

Project Selection Process

KAIZEN EVENTS

• 1 ‐ 3 day Rapid Improvement Events

• ED Throughput

• Patient Flow

• Pharmacy Group

• Physician Group

Challenges• “It’s not Lean to fill out all the paperwork”

• “Lean is about getting rid of my job”

• “What I can improve does not save $25K”

• “I don’t have time to be on a Lean team”

• “We’re already ‘lean’, we don’t have enough people”

• “We can’t do Lean while ____ is going on”

• Knowledge Management software

Results As of 2009 ………………

• Achieved > 1.0% (target ~ $11M) waste reduction through deployment of LEAN project teams

– Preliminary Dark Green $ 9.8M

– Preliminary Light Green $ 5.7M

– 400 projects in Improve or Control Phases

– 140 Directors are certified by the System Office as Lean Thinking Team Leaders

– 16 Lean Six Sigma Sensei will graduate in March 2010

• Redesigned multiple work flows to enhance efficiency at care sites and in system office

• Improved patient flow in many care sites

2010 Successes

Innovation

• “Innovate and design” have naturally been separated from “improvement work”

• But, design is interwoven with existing products and processes

• Improvement often means revisiting fundamental design

Barriers to Innovative Thinking

• Physiological– Perceptual

– Emotional

– Cultural

– Environmental

These barriers restrict our left brain (analytical) and right brain (creative) to– Properly collect the information necessary

– Choose and calculate which information is important

– Communicate those ideas to our consciousness

for an innovative solution

Value Innovation• Focus on making the competition irrelevant by creating a leap in value for buyers and your company, thereby opening up new and uncontested market space

Value Innovation

Costs

Buyer Value

Value + Innovation

• Value without innovation– Focuses on value creation at an incremental scale

– May improve value, but is not sufficient to make you stand out in the marketplace

• Innovation without value– Tends to be technology‐driven

– Frequently shoots beyond what customers are ready to accept and pay for

Kim, W. C., and Mauborgne, R. (2005) Blue ocean strategy. Boston: Harvard Business Review Press.

Red vs. Blue Ocean Strategy

Red Ocean Strategy• Compete in existing market space

• Beat the competition

• Exploit existing demand

• Make the value‐cost trade‐off

• Align the whole system of a firm’s activities with its strategic choice of differentiation or low cost

Blue Ocean Strategy• Create uncontested market space

• Make the competition irrelevant

• Create and capture new demand

• Break the value‐cost trade‐off

• Align the whole system of a firm’s activities in pursuit of differentiation and low cost


Blue Ocean Analytical Tools: Four Actions Framework

New Value Curve

Eliminate:Which of the factors that

the industry takes for granted should be

eliminated?

Create:Which factors should be created that the industry

has never offered?

Reduce:Which factors should be reduced well below the

industry’s standard?

Raise:Which factors should be

raised well above the industry’s standard


Exercise: Eliminate-Reduce-Raise-Create Grid

Eliminate Raise

Reduce Create Value

What we both found was…

• TQG’s Blended e‐Learning model helped us to leverage our MBB resources better and to save money in the long run as we were training up our resources and ramping up our Lean Six Sigma Deployments….

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The Quality Group (TQG) has been developing and deploying technology‐based solutions to address Lean Six Sigma / Process Improvement

(LSS/PI) training challenges, since 1992.

1) Our e-Learning makes ‘Quality Principles’ come alive for everyday people.

2) Our portal platform powers effective implementation of blended e-Learning.

3) Our processes enable e-Learning solutions that fit your needs, not vice versa.

Why a complete blended e-Learning solution for healthcare

quality? • LSS/PI is needed throughout the healthcare industry

• LSS/PI experts are spread thin and need to scale their impact

• Healthcare organizations need a less disruptive way to teach LSS/PI

• LSS/PI training costs must be high quality and low cost

Healthcare Course Content: Phase Module

Intro •Six Sigma Introduction•Introduction to Lean Six Sigma for Healthcare

•Lean Six Sigma Fusion

Define •Project Charter•Voice of the Customer•Managing the Project -Teamwork

•Pareto Analysis•SIPOC•Introduction to Process Mapping

•Eight Wastes

Measure •Current State Value Stream Mapping

•What is Statistics?•Organization of Data•Measures of Central Tendency•Measures of Dispersion•Descriptive Statistics: Self-Assessment

•Calculating Process-Based Costs

•Validating the Measurement System

Phase ModuleMeasure •Types of Control Charts

• Introduction to Process Capability and Process Capability Assessments

•Confidence Intervals•Normal Curve

Analyze •Cause & Effect Diagrams•Scatter Diagrams•Failure Mode & Effects Analysis•Future State Value Stream Mapping

•Hypothesis Testing

Improve •Maximizing ROI•Kaizen Event•5S/6S•Visual Management•Standard Work•Error Proofing•Changeover Reduction•Total Productive Maintenance•Workplace Design & Layout•Flow & Pull Systems

Control •Sustaining ROI•Extending ROI

Phlebotomy Kits Before:

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Phlebotomy Kits After:

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Spaghetti Diagram:

Before & After

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Phlebotomist Point of Use Shadow Boards:

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Before Visual Management After Visual Management

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Before Lab Storage Room

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After Lab Storage Room

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Blended e-Learning• Experienced in 2010

• Develop all face to face learning modules into blended e‐learning

What if you don’t use the Blended e-Learning?

• Schedule 9 days of classroom instruction

• Costs

– Employee Time/Instructor Time

– Meeting location

– Lunch/snacks

• Mixed classes/Adult education

– Different learning styles

– Lecture/activities/group work

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With Blended e-Learning• 24/7 online learning access. Prior to class, participants learn the core

concepts and tools, then ‘search’ and ‘review’ them later, on the job. . • Consistent training delivery. If you teach everyone the same, your course

roadmaps have more integrity and your organization alignment increases. • More effective use of classroom time. With participants on the same level,

class sessions focus on discussion, hands on exercises and project work. • Higher retention & better mentoring. Retention increases when users

control their pace, ability to review etc. Good e‐Learning is flexible for users. Learning more outside class, sets up better mentoring in class.

• Reduces Costs

Lean Thinking

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Road Map to Performance Excellence

• Roadmap of implementing Lean thinking as an innovative blend Improvement methods included: Lean, Six Sigma, TOC, PDSA & Queuing Theory.

• Successes and challenges in our Lean Thinking journey to change culture

• Tools to improve patient safety and outcomes, reduce waste, enhance efficiency and increase overall effectiveness.

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Look forward to the good that is yet to be.

- Mother Xavier Ross

“

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Q&A

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Our Contact Information

• Rob Stewart: [email protected]

• Jennifer Ralston: [email protected]

• Kathy Price: [email protected]

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mailto:[email protected]



achieving and sustaining excellence transforming the health care system

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