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Hugh Rogers FRCSAssociate, Service Transformation
NHS Institute for Innovation & Improvement
Healthcare Events26th February 2008
Lean thinking and Six sigma at the level of
Clinical Service Delivery
Don’t worry about the jargon!
Evolution of Quality Improvement
W Shewhart – Statistical Process Control
W E Deming – System of Profound Knowledge
JuranToyota
Taichi Ohno
Goldratt
1920’s
1950’s
Toyota Production System
‘Lean thinking’
Motorola &
6 SigmaTheory of
Constraints
2008‘Lean 6 Sigma’
TQM
BPR
2
Six Sigma
• Focuses on improving processes by reducing variation and minimising error
• Uses a systematic approach: DMAIC
• Relies heavily on statistical methods
• Emphasises ‘Voice of the Customer’
• Works best where there is a clear process to be improved
IMPROVEDEFFECTIVENESSDEFINE IMPROVE CONTROLMEASURE ANALYZE
Focus on Variation
Natural variation
Inevitable characteristic
of any healthcare system
Variation in patient
characteristics
Take steps to manage it
Artificial variation
Created by the way the
system is managed
Variation in the way the
service is provided
Take steps to eliminate it
© NHS Institute for Innovation and Improvement 2006
Applying systems thinking to mortality:
Crude weekly deaths on SPC chart
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UCL Median W eekly deaths LCL
3
Six sigma core tools
• DMAIC
• SPC
• Voice of the Customer
• Analysis of variance
• Balanced scorecards
• Process management
• Continuous improvement
• Design of experiments“Six sigma has not been widely
applied to patient care”
Revere 2004
Some Criticisms of Six sigma
• Systems interactions not considered – uncoordinated projects
• Lack of consideration of human factors
• Significant infrastructure investment required
• Over detailed and complicated for some issues
• The goal (6Σ = 3.4 defects per million) is not always appropriate
Lean Sigma: some basic concepts
H Bevan et al, 2006: NHS Institute for Innovation and Improvement
We spend 75-95% of our time doing things that increase our costs -
and create no value for the customer
What is Lean?
Lean is the process of identifying the least wasteful way to provide value (better, safer care, with no unnecessary delays at lower cost) to our customers.
Value must always be determined by the customer
What is value? Who is the customer?
4
Lean – focuses on dramatically improving flow in
the ‘value stream’ and eliminating waste
IMPROVEDEFFICIENCY AND
SPEED
SPECIFY VALUE
PULL PERFECTIONPERFECTIONUNDERSTAND UNDERSTAND
DEMANDFLOW
Lean Sigma –complementary not competing
Value Stream Mapping
Visual workplace/5s
Work standardisation
Staff involvement
Match resources to demand
Pull signals
Rapid Improvement Events
LEAN TOOLS/PRINCIPLES
© NHS Institute for Innovation and Improvement
Multi functional staff
Lean thinking:7 wastes
• Overproduction
• Waiting
• Transport
• Inappropriate processing
• Unnecessary Inventory
• Unnecessary motion
• Defects
What does this mean for healthcare??
5
Direct Care Time
Motion Admin Discussion Handovers OtherOther
The Productive Ward: releasing time to care
Reducing wastesReducing wastes
Opportunity to increase safety and reliability of
care
Role
Tim
e (
e.g
. nurs
e)
Total Time
Sort
Straighten/Simplify (Set in order)
Shine
Standardise
Sustain
5 S standards
Not Used
Sustain the gains
1 2 3 4 5
5S
5s work in the sluice ….
reduced the distance travelled to collect commodes and dispose waste on return
reduced time spent in fetching commode as they are now ‘ready to go’
Wipes near sluice puts all needed items together
6
There were some surprises!
BEFORE LEAN
AFTER LEAN
What changes can we make that will
result in improvement?
1. Pay attention to patients’ wants and needs
2. Improve flow and reduce delays
3. Organise your workplace
4. Improve the safety & reliability of care
What are we trying toWhat are we trying toaccomplish?accomplish?
How will we know that aHow will we know that achange is an improvement?change is an improvement?
What changes can we make that willWhat changes can we make that willresult in the improvements we seek result in the improvements we seek
??
Act Plan
Study Do
What is reliability?
The capacity to perform a given function under given conditions for a specified period of time
A reliable health care system is one that is designed to ensure that every patient consistently receives evidence-based, effective care every time he or she needs it
� “Reliability means keeping a promise” (Don Berwick)
7
Compare Reliability and Safety
SafetyErrors of commission
Special cause strategies
Reactive
Focused projects
ReliabilityErrors of omission
Common cause strategies
Proactive
Design of reliable systems
High frequency low impact Low frequency high impact
OverlapFailure has high impact
Increasing Reliability of Clinical Observations
Mortality Project Improvement All observations 'complete'
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20
sets
of
no
tes r
ev
iew
ed
ea
ch
mo
nth
First step in a system to retrieve the deteriorating patient:
• Recognise
• Report
• Respond
Example 1Increase the reliability of therapeutic interventions
through a “care bundle” approach
Example for reducing ventilator associated pneumonia:
– Elevating the head of the bed >30o (Drakulovic 1999)
– DVT prophylaxis (Cook et al 2001)
– Peptic ulcer prophylaxis (Yang & Lewis 2003)
– Managing sedation effectively with sedation Holds (Kress 2000)
– Tight Control of Blood glucose 4.4-6.1 mils (Van den Berghe 2001)
Can be applied to
• Surgical site infection
• Central line management
• Myocardial Infarction
• etc etc
8
Defect rates in Healthcare
The latest large study in US health care (McGlynn,et al The quality of healthcare delivered to adults in
the United States NEJM 2003; 348) concluded thatthe “defect rate” in the technical quality of Americanhealthcare is approximately 45%.
© NHS Institute for Innovation and Improvement
Reliable Care Reduces Complications
also reduces length of stay and readmissions
Reliable Care Lowers Mortality Rates
9
Succeed
- Experts produce final product
- Takes 2 years
- No changes allowed
- Measure before and after
- No new learning
- Experts produce draft for testing
- Takes 2 hours
- Changes are expected
- Measurement over time
- Continuous learning and improvement
Standardisation:
Fail
Financial Realism & transparent accountability
Clinical purism &
Opaque accountabilityMedicine, management, and modernisation; a “danse macabre”?
Pieter Degeling et al BMJ 2003;326:649-652
Sys
tem
atised
conceptions o
f clin
ical w
ork
Nurse
clinicians
Nurse
managersMedical
clinicians
General
managersMedical
managers
Indiv
idualis
t conceptio
ns o
f clin
ical w
ork
10
Level 1 Reliability Personal Intent, Vigilance and
Hard Work:(80% to 95 % success)
Feedback of information on compliance
Awareness and training
Personal check lists
Common equipment, standard order sheets
Level 2 Reliability Reliability Science, System design
and Human Factors (95% to 99.5% success)
Standardise processes
Make the desired action the default
“Opt-out” – The desired action = flow of work
Build design aids into the system
Create redundancies and time lapses
Principles for increasing reliability
Length of Stay and MortalityWest Middlesex Hospital
Weekly average LOS
Monthly HSMR
11
Synergy for quality:
Quality care
Reliability
Lean & Flow
Safety & Mortality
High quality error free care is the most cost-effective
“A key function of hospitals is to save lives, so it’s surprising how little attention is paid to hospital mortality. Our work in Bradford shows that
a hospital mortality reduction programme can make a big impact by significantly reducing mortality. It’s a natural top priority.” John Wright, Clinical Director, Bradford Teaching Hospitals Trust
Learning from death: a hospital mortality reduction programme Wright J et al. J R Soc Med 2006;99:04-20.1-6
Bradford calendar year hsmrs
0
20
40
60
80
100
120
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
HS
MR
(9
5%
CIs
)
For more on reducing avoidable mortality in Hospitals see:
www.institute.nhs.uk/ram
Six Sigma – focuses on eliminating defects and reducing
variation in processes
IMPROVEDEFFECTIVENESSDEFINE IMPROVE CONTROLMEASURE ANALYZE
IMPROVEDEFFICIENCY AND
SPEED
SPECIFY VALUE
LEVEL PERFECTIONPERFECTIONUNDERSTANDUNDERSTAND
DEMANDFLOW
Lean – focuses on dramatically improving
flow in the value stream and eliminating
waste
© NHS Institute for Innovation and Improvement 2006
http://www.institute.nhs.uk/quality_and_value/lean_thinking/lean_six_sigma.html
12
Use 20% of Tools to Achieve 80% of Benefits
Value Stream Mapping
Visual workplace/5s
Standard work
Employee involvement
Match resources to demand
Kanban signals
Rapid Improvement Events
DMAIC
SPC/Measures
Voice of the customer
Pareto charts
LEAN SIX SIGMA
© NHS Institute for Innovation and Improvement 2006
Failure Modes and Effects Analysis (FMEA)
http://www.institute.nhs.uk/quality_and_value/lean_thinking/lean_six_sigma.html
Common themes
• The Process view
• The Systems view
• Variation (and use of SPC)
• Flow
• Identifying the customer
• Links to Human Factors ?
“I am quite happy to be promiscuous… what insights does Lean tell me,
what does theory of constraints tell me on the same problem and then I can reconcile those two. But people are not good at that at the moment,
they don’t understand either well enough to be able to reconcile.”
Boaden et al: 2006
Quality improvement: Theory and practice in the NHS
http://www.institute.nhs.uk/quality_and_value/lean_thinking/lean_six_sigma.html
Institute publications from:
www.institute.nhs.uk
• Going lean in the NHS
• Releasing time to care
– The productive ward
• The NHS Productive Leader Programme
• The Productive Operating Theatre /theatres
• Reducing avoidable deaths in hospital /ram
– Chief executives lead the way
– Medical directors drive improvement
• Focus on: productivity and efficiency
• Lean Simulation
http://www.institute.nhs.uk/quality_and_value/lean_thinking/lean_six_sigma.html
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