driving success and lessons learned
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Mary O. Cramer, CPHQ, MBAMary O. Cramer, CPHQ, MBAMaster Black Belt Master Black Belt
Director, Performance ExcellenceDirector, Performance ExcellenceAugust 2006August 2006
Mary O. Cramer, CPHQ, MBAMary O. Cramer, CPHQ, MBAMaster Black Belt Master Black Belt
Director, Performance ExcellenceDirector, Performance ExcellenceAugust 2006August 2006
Design for Six SigmaDesign for Six Sigma
NewYork-Presbyterian HospitalNewYork-Presbyterian HospitalDriving Success and Lessons LearnedDriving Success and Lessons Learned
Full Asset Merger of The New York Hospital, 2nd Oldest Hospital in the US, Founded in 1771, and the Presbyterian Hospital of New York, Founded in 1868, into One Article 28 Corporation with:
2,224 Certified Beds 102,000 Discharges 11,000 Births 1,036,000 Ambulatory Visits 14,500 Employees (plus 1,400 Housestaff) $2.3 Billion Operating Budget NYP Health Care System: 58 Facilities, US and Abroad
NewYork-Presbyterian HospitalNewYork-Presbyterian Hospital
NewYork-PresbyterianNewYork-Presbyterian HospitalNewYork-Presbyterian HospitalVisionVision
To Be Among the Very Top
Academic Medical Centers
in Clinical and Service Excellence,
Patient Safety,
Research and Education
To Be Among the Very Top
Academic Medical Centers
in Clinical and Service Excellence,
Patient Safety,
Research and Education
MOVING TOWARD A NEW ORGANIZATION
A + B = “AB”
A + B = “C”
Initially The Sum Of Two Academic Health Care Systems
Evolving Toward A Wholly New Entity With A New Culture
A New OrganizationA New Organization
Awards & RecognitionAwards & Recognition
# 1 in New York # 1 in New York #6 in Nation#6 in Nation
Challenges We Face
Clean and Safe Hospital
Patient, Physician, and Employee Satisfaction
LOS Reduction to Build Capacity
Advancing Standards Based Clinical Practices
Financial Performance
ChallengesChallenges
Improve Communication Accountability Decision Making
Enhance Cross Department Teamwork/Cooperation
Reduce Bureaucracy
Increase Management Skills
What We Heard From Our Employees
Nimbleness
We Must Be Responsive to Our:• Patients and
• to Our Employees
Without Change We Cannot Reach Our Goals
Achieving Objectives Requires Changing Skills
It’s More than Bricks & Mortar – It’s About Investing in Our People
Importance of Culture ChangeImportance of Culture Change
PERFORMANCE EXCELLENCEPERFORMANCE EXCELLENCE:
DMAIC, DFSS, LEAN AND CAP / WORKOUTDMAIC, DFSS, LEAN AND CAP / WORKOUT
ASAS
PERFORMANCEPERFORMANCE
EXCELLENCE TOOLSEXCELLENCE TOOLS
Examples of Non-Value Activities in Hospital Operations
Wasted Wasted MotionMotion
Example:Example:Pharmacy tech spends 20 Pharmacy tech spends 20 minutes looking in multiple minutes looking in multiple places for a particular medplaces for a particular med
Unnecessary Unnecessary TransportationTransportation
Example:Example:Patient gets wheeled back and Patient gets wheeled back and forth between the floor and forth between the floor and radiology due to a scheduling radiology due to a scheduling mix-upmix-up
Excess Excess ProcessingProcessing
Example:Example:Nurse records Nurse records respiratory rate on 4 respiratory rate on 4 different forms in the different forms in the chartchart
Waiting TimeWaiting Time
Example:Example:OR tech waits 20 minutes OR tech waits 20 minutes for a case to begin, and is for a case to begin, and is not free to do other tasksnot free to do other tasks
Wasted Wasted IntellectIntellect
Example:Example:Numerous ideas are Numerous ideas are “lost” only to be “lost” only to be rediscovered laterrediscovered later
Excess InventoryExcess Inventory
Example:Example:Medicines held over the shelf-Medicines held over the shelf-life because of excess orderinglife because of excess ordering
OverproductionOverproduction
Example:Example:There are too many There are too many unnecessary paper reportsunnecessary paper reports
ReworkRework
Example:Example:Lab tests are performed Lab tests are performed twice because of errorstwice because of errors
Performance Excellence
• Patient/Family Is Focus• Enhanced Care Experience• Commitment to Patient, • Physician & Employee • Satisfaction
QualityQuality• Embraces All Aspects of
Performance• Continuous Improvement• Patient Safety• Innovation Practice
• Best Practices• Streamlined Clinical &
Operational Workflows• Revenue Enhancement• Resource Management
EfficiencyEfficiency
Performance ExcellencePerformance Excellence
ServiceService
Performance Excellence
Six SigmaSix Sigma• DDefine• Measure• AAnalyze• IImprove• CControl
• DDefine• MMeasure• AAnalyze• DDesign• VValidate
DFSSDFSS
Performance ExcellencePerformance ExcellenceToolsTools
CAP/WO• Change Acceleration Process• WorkOut
CAP/WO• Change Acceleration Process• WorkOut
LEANLEAN
Tools Leveraged For SuccessTools Leveraged For Success
DDMAICMAICDDFSSFSSLLEANEAN
DDMAICMAICDDFSSFSSLLEANEAN
CChangehange AAccelerationcceleration
PProcessrocess
CChangehange AAccelerationcceleration
PProcessrocess
Effective Effective ResultsResults
Effective Effective ResultsResults
WWork-ork-OOutut™™WWork-ork-OOutut™™
The Effective Result (E) of a change effort is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea.
A Proven Formula For Results
Q x A = EQ x A = E
Performance Excellence
DDefineefineDDefineefine MMeasureeasureMMeasureeasure AAnalyzenalyzeAAnalyzenalyze CControlontrolCControlontrol
Who are the customers and what are their priorities?
How is the process performing and how
is it measured?
What are the most important causes of
the defects?
How do we mitigate the
causes of the defects?
How can we maintain the
improvements?
IInnovannovatete
IImprovmprovee
Six Sigma
DFSS
• Why Is This Different?
• Is This the “Flavor of the Day”?
• How Do We Know the Change Will Last?
• How Much Does it Cost and What is the ROI?
Performance Excellence
• Driven Internally
• Focuses on Outcomes
• Fixes Defects
• Improves Quality
• Looks Backward
• Concentrates on Product
• High on Theory and People
• Driven By the Customer
• Focuses on Processes
• Prevents Defects
• Improves Entire System
• Looks Forward
• Concentrates on CTQs
• High on Methodology and Data
Traditional Quality ProgramTraditional Quality Program Performance ExcellencePerformance Excellence
Performance Excellence: The DifferencePerformance Excellence: The Difference
Implementation Objectives:
• Knowledge Transfer
• Transformative Cultural Change
• Accountability
• Management Discipline
• No One Left Behind
• All Levels, All Disciplines
Hospital Wide AdoptionHospital Wide Adoption
TRAINING DESIGN
• Training Curriculum: Incorporates DMAIC, LEAN, DFSS and CAP/Work-Out
• 17 Days over 6 Months
• Training Team Composition: Black Belt with 3 – 4 Green Belts; Extended Team Created Later
• Actual Projects Used as Training Projects
• Abbreviated Training Delivered to Medical Staff, to Management Staff, and to Line Employees
Training DesignTraining Design
Organizational CommitmentOrganizational Commitment
Class 1 Class 2
Class 1 Class 2
MBB Class
MBB Class
Q1 Q2 Q3Q3 & Q4 Q4
2003 2004
GE Mentoring
Q1 Q2 Q3 Q4
2005 2006
Class 3Class 4
Class 3Class 4
GE Mentoring
Class 5 Class 6
Class 5 Class 6
GE Mentoring
Class 7Class 8
Class 7Class 8
GE Mentoring
Self Sustaining Performance Excellence Culture
Class 9
Class 10
Class 9
Class 10
GE Mentoring
Q1 Q2 Q3
Where we are today!
5
30
15
35
15
LEANLEAN
DFSSDFSS
CAP/CAP/WORKOUWORKOUTT
JUST JUST DO IT!DO IT!
SIX SIX SIGMASIGMA
Performance Excellence at NYPHPerformance Excellence at NYPH
ResultsResults
ProgramProgram• 10 Performance Excellence Classes
• 50 Full Time Black Belts; 26 Active, 20 Returned to
Operations
• 4 Full Time Master Black Belts• 200+ Green Belts
• 140+ Projects
OutcomesOutcomes• Length of Stay: 3500 Additional Inpatient Admissions (2005);
1000 Additional Admissions (ytd 2006)
• Revenue/Cost Avoidance: $68M (2004 – 2006)
KEY SUCCESS FACTORS
• Lead Projects Using DMAIC, DFSS, LEAN and/or CAP Methodology
• Mentor Others Doing Projects• Introduce Methodology and Tools to Team Members and
Broader Audiences• Act as Both Technical and Cultural Change Agent• Reduce Defects and/or Process Variation With Successful
Project Management• Help Deploy Six Performance Excellence Thinking Into the
Organization• Three Year Commitment
Role:
Black Belt RoleBlack Belt Role
• Demonstrated Leadership and Project Management Skills
• Strong Business and Technical Foundation With Proven Analytical and Statistical Problem Solving Skills
• Excellent Communication Skills• Strong Track Record of High Performance With Strong
Upward Potential• Performance and Promotibility to Top First or Second
Level• Strong Sense Of Organization’s Values• High Degree Of Customer Sensitivity• Long Term Commitment To Organization
Selection Criteria:
Black Belt Selection CriteriaBlack Belt Selection Criteria
103
49
1710
0
25
50
75
100
125
ResumesReceived
InitialInterviews
MBB/VPPanel
OffersExtended
Black Belt RecruitmentBlack Belt Recruitment20062006
Executive Vice PresidentChief Operating Officer
Vice President, Clinical Practice EvaluationChief Quality Officer
Quality and Performance Improvement
Innovation Strategies
Performance Excellence
Quality Table Of OrganizationQuality Table Of Organization
Quality Informatics
Quality Research
Performance Excellence Performance Excellence Table Of OrganizationTable Of Organization
Performance Excellence
Master Black BeltFinancial Improvement
Master Black BeltQuality & Patient Safety
Master Black BeltOperational Excellence
Black Belts(12)
Black Belts(12)
Black Belts(2)
Master Black BeltNursing Quality
COOMS/CHONY
COONYP/CU
COONYP/WC
Chief Quality Officer
• Directly Aligned With Strategic Initiatives
• Active Senior Leadership Sponsors
• Significant, Tangible Benefit – Financial or Otherwise
• Cross-Campus Design
• Engagement Of CEO And Senior Leadership
• Ongoing Management Metrics
Successful Project CharacteristicsSuccessful Project Characteristics
• Projects Must Continue to Advance Strategic Initiatives and Exhibit Visible Senior Management Sponsorship
• Outcomes Must Continue to Be Systematically Measured
Must Leverage Best Practice
Must Continue to Be Systematically Communicated
SustainabilitySustainability
Media
• Official Hospital Memoranda
• NYPress ArticlesIntranet
• Executive Portal
• Performance Improvement Team WebMeetings
• Monthly Clinical Dept. Heads & Physician Groups
• Annual Management Kick-Offs & New Employee Orientation
• Monthly Department Head and Key Personnel Meetings
CommunicationCommunication
LESSONS LEARNED
Use Any/All Performance Improvement Tools – as Indicated by the Specific Project
Ensure Ongoing Green Belt Involvement
Leverage Best Practices Across Campuses
Enhance Awareness of Performance Excellence Programs
Course CorrectionsCourse Corrections
• Senior Leadership Support and Involvement
• Project Selection Aligned With Strategic Initiatives
• Right Projects, Right Performance Excellence Tools
• Ongoing, Relentless Measurement
• Resource Commitment; During and Post Projects
• Communication, Communication, Communication!
So, In Order to Succeed……So, In Order to Succeed……
Case StudyCase Study
Managing Medical /Surgical Managing Medical /Surgical Supplies with Expiration DatingSupplies with Expiration Dating
Why Focus on the Supply Chain?Why Focus on the Supply Chain?
Non-Labor Expenses Rising Faster Than Labor
Expenses
Issues Identified with Expired Meds and Supplies
Prior Project Improvements Not Sustained
Bedside Care Not Affected
Up/Down Organizational Buy-In
Physician Led, Physician Driven
Why DFSS?Why DFSS?
Transformation Required; Not Sufficient to Transformation Required; Not Sufficient to
Tweak Existing ProcessesTweak Existing Processes
Quality Must Be “Designed In”, Rather than Quality Must Be “Designed In”, Rather than
“Tested In”“Tested In”
Scientific Appeal to CliniciansScientific Appeal to Clinicians
Robust DeRobust Design Approachsign Approach
Why Not Six Sigma?Why Not Six Sigma?
Small Slices of Improvement Not EnoughSmall Slices of Improvement Not Enough
Lengthy And Rigorous ProcessLengthy And Rigorous Process
ExpensiveExpensive
Problem:Problem:
The Current Method of Managing Expired Products With The Current Method of Managing Expired Products With Manual Intervention and Audit Activity Is Ineffective and Manual Intervention and Audit Activity Is Ineffective and Unsustainable Over Time. An Entirely New Process is Unsustainable Over Time. An Entirely New Process is Required.Required.
Desired OutcomesDesired Outcomes::
Ensure Effective Inventory Management Procedures Ensure Effective Inventory Management Procedures Are Practiced and Controlled Are Practiced and Controlled
Eliminate the Potential of Receiving, Housing and Eliminate the Potential of Receiving, Housing and Distributing Expired ProductDistributing Expired Product
OpportunityOpportunity
Baseline Data
Inpatient Units Audited: 81
No Expired Products Found: 18%18%
Expired Products Found: 72%72%
Quantity of Expired Products:
Med/Surg Supplies 1053
Medications 155
Nutrition 19
Mean Quantity of Expired Product / Location: 22
Med/Surg Supplies Management Med/Surg Supplies Management
Loading DocksLoading DocksGeneral StoresGeneral StoresSupply RoomsSupply RoomsOther Storage AreasOther Storage AreasFood and NutritionFood and NutritionEmergency Emergency DepartmentsDepartments
Perioperative ServicesPerioperative ServicesCardiac Cath/EPS LabsCardiac Cath/EPS LabsAmbulatory CareAmbulatory CarePharmaciesPharmaciesInterventional RadiologyInterventional RadiologyLaboratoriesLaboratories
Receiving andDistribution
Inventory Managemen
tOrdering
Project Scope: Project Scope: Medications, Medical & Surgical Supplies,Medications, Medical & Surgical Supplies,Specialty InventorySpecialty Inventory
Define & Measurement ActivitiesDefine & Measurement Activities
Conducted Assessment Of Current Status; Identified Fragmentation And Lack Of Consistency Throughout
Developed Tools For Initial Sweeps And Designed & Implemented Ongoing Audits
Identified “Specialty” Inventory Areas, Locations, and Responsible Parties
Required All Areas to Complete and Document a “Sweep” of All Inventory Locations - Baseline Data
Conducted Daily Checks of Inbound Shipments for General Stores Inventory
Potential Critical FactorsPotential Critical Factors
Ordering Ordering Practices
Stock RotationStock Rotation
Par and Inventory LevelsPar and Inventory Levels
Inventory Management PracticesInventory Management Practices
Knowledge and Use of TechnologyKnowledge and Use of Technology
Communication With Practice AreasCommunication With Practice Areas
Vendor ManagementVendor Management
DesignDesign
Detailed Policies Developed Inventory Locations Limited to Only Authorized
Areas Par Level Reviews Conducted Regularly Products May Only Be Returned to Designated
Areas; Shaded Shelf Labels and Product Lists No Punitive Action For Finding And Destroying
Outdated Products Management Systems Customized for Specialty
Areas Continuous Education Programs
Education and Policy ChangesEducation and Policy Changes
Global Training Materials and Product Packs Developed
Specific Instruction and Training Provided to PSS Staff And Pharmacy Staff
Separate Scripts Provided for Nursing Education
Laminated Cards With Symbols and Examples Developed and Distributed
Policy ExcerptsPolicy Excerpts
…When Using Medical/Surgical Supplies and Medications, All Staff Must Identify the Expiration Date Prior to Use
…Products Without Expiration Dates May Be Used Indefinitely Provided That the Package Is Intact
…Distinguish Between Expiration Dates and Manufacturing Dates
PRODUCT EXPIRATION DATING PRODUCT EXPIRATION DATING A USERS GUIDE A USERS GUIDE
02/08/05 Use By 02/08/07
Expiration Date Symbols Vary from Product to Product
MANUFACTURING DATE SYMBOL EXPIRATION DATE SYMBOL
DON’T CONFUSE SYMBOLS
Checking Checking forfor Expiration Dates Expiration Dates
The Words “Manufactured On” In Front of an The Words “Manufactured On” In Front of an Expiration Date May Be Substituted With a Drawing of Expiration Date May Be Substituted With a Drawing of Factory or A Saw Toothed Symbol:Factory or A Saw Toothed Symbol:
02/08/01
Checking for Expiration Dates Checking for Expiration Dates
The Words “Expires On” or the Abbreviation “EXP” In Front of an Expiration Date May Be Substituted With a Drawing of an Hourglass, or a Similar Symbol:
ValidateValidate
Third Party Audits Conducted In Inpatient And Specialty Areas
Monthly Self- Audits; Each Area Samples 25% of Items in 100% of Locations
In-bound Inspections Continue
Weekly Conference Calls With Specialty Areas Continue
Report Cards Distributed Monthly
ResultsResults
72%
47%
12%
0%
20%
40%
60%
80%
NYPH
Oct. '05 Pilot Period June '06
Results - Hospital-Wide ImprovementResults - Hospital-Wide Improvement
Pe
rce
nt
De
fec
tiv
e
Key MessagesKey Messages Management of Expiration Dating Is a Shared
Responsibility – No One Group or Department Can Ensure Success
Not A One Time “Fire Drill” – Requires Ongoing Commitment
One Failure Is One Too Many!
Significant Improvement Opportunities Remain
Mary O. CramerMary O. Cramer
[email protected]@nyp.org
212-746-5939212-746-5939
Mary O. CramerMary O. Cramer
[email protected]@nyp.org
212-746-5939212-746-5939
Thank YouThank You