Methodology

Methodologies: Lean / Six Sigma / PDSA

Create Flow

Improve Quality*

Eliminate Waste

Lean

6s

D M A I C

PDSA PLAN

DO

ACT

STUDY

Lean: The Toyota Production System Decoded

Each of these can be achieved alone or in conjunction with the other two. *poor quality is a form of waste.

Create Flow

Improve Quality

Eliminate Waste “It’s not the big that eat the

small. It’s the fast that eats the slow.”

– Jennings and Haughton

• Map your Value Streams• Identify Value vs. Waste• Value is defined by our patient

Lean Value Principles

Value = Quality + ServiceCost

Healthcare Quality Cost Curve

As HC Quality Increases Costs Decrease

Cost

Qua

lity

A

B

• Spending too much on healthcare doesn’t just waste money. It lowers quality.

• GOOD NEWS: When we focus on quality, costs come down.

Optimal Value

US Healthcare Today

Focus on Value

Value Stream: Every activity required to deliver your product or service, from very first to very last.

DIRT $$

FIRST CONTACT $$

Value Stream:

Applying Lean to healthcare value streams means making it easier for patients and their information to move between our silos.

Patients come to us for two reasons: 1. Information about their health2. Care provision

Identify Value & Eliminate Waste

Manufacturing Value-Added:An activity which changes the form, fit, or function of the product. Everything else is non-value added (NVA).

Healthcare Value-Added: An activity that builds on a patient's information or is directly involved in care provision. Everything else is non-value added (NVA).

“Okay, but where is all this waste? I don’t see it.”

Non Value Added: The 7 Wastes

NVA ≠ “UNNECESSARY”

A taxonomy for seeing NVA1.Defects / Mistakes 2.Waiting3.Over-processing4.Over-production5.Transportation 6. Inventory7.Motion

-Taiichi Ohno

“Eliminating waste is easy. Seeing waste is hard.”

How much waste is in our system?

Old Adage Lean Adage

Create Flow

Improve Quality

Eliminate waste Before Lean:

• You can have it fast. • You can have it high quality. • You can have it low cost.

Pick 2.

Lean says, “Pick 3.”

• Map your Value Streams• Identify Value vs. Waste• Value is defined by our patient• Eliminate delays• Create Standard Work• Design Error-Proof Systems• Use pull to avoid over-production• Design Out the Complexity you can…• Use Visual Controls to manage the

remaining complexity• Track process performance

Lean Principles

6sDefine

MeasureAnalyze

ImproveControl

TaguchiShewhartDeming

Juran

Ishikawa

Six Sigma in Nothing New

• Variation is the Enemy• The answers are in your data• Listen to the Voice of the Process• For consistent output, control your inputs• Listen to the Voice of the Customer• Your problems are in your processes,

NOT your people

Six Sigma Principles

Mean

Process Improvement with Six Sigma

Step 1: Control Step 2: Shift

Before

TargetLower Spec

Upper Spec

Target,Lower Spec

Upper Spec

TargetMeanLower Spec

Upper Spec Mean

Six Sigma follows a methodology called DMAIC (“duh-MAY-ick”).

Define • Define the project with a chartering document. • Map the process in low-detail, maybe with SIPOC. • Gather VOC (Voice Of the Customer) data.

Measure • Quantitatively describe the current situation. • Identify the appropriate process metrics and establish a baseline.

You will compare these against post-implementation metrics. • Map the process in greater detail.

Analyze • Determine the root causes with a variety of methods.• Most of your statistical analysis happens here. • Tie the root causes to the problems you are solving.

Improve • Design improvements • Model improvements • Pilot improvements• Estimate post-implementation process metrics

Control • Design control systems to ensure gains are sustained.• Establish metrics collection systems.• Design elements that reduce the cognitive load while ensuring the

new process is followed: visual cues, electronic cues, etc.• Transfer ownership back to original process owner.

DMAIC is sometimes shown as a cycle, sometimes as a linear project progression.

Improve

Control

Define Measure

Analyze

Six Sigma Project Plan (aka “best intentions”)

DefineMeasure

AnalyzeImprove

ControlX weeks

What actually happens.

DefiMeas

AnalyImp

Control

DefineMeasure

Analysis

Re-Define

Improve

X + 50% weeks

Plan-Do-Study-Act

When a change is deemed worthy of implementing:• The team turns toward spreading and adapting the

change to all appropriate places in the organization.

• Continued monitoring.

• The scientific method applied to process improvement

• What are we trying to improve?• What are the baseline measures?• What are the goals?• Who are the right people to evaluate

the improvement?

PLAN

DO

ACT

STUDY

• Orderly• Controlled• Time-consuming • Expensive • Rapid implementation,

multiple iteration• In this sense, you are

experimenting, but… • If you shortchange the

methodology, you’re NOT engaged in continuous quality improvement; you’re chasing hunches.

• Throw things against the wall to see what sticks

• Go with your gut • Rely on common sense (a myth)

PDSA:

Clinical Research

Shotgun Approach

P

D

A

S

• Needs to be tolerance for not getting it perfect on the first try

• This is how innovation works• But remember that “change fatigue”

is a threat.• This image does not

mean constant tinkering.

Potential Issues with PDSA

PLAN

DO

ACT

STUDYContinuous Improvement PLAN

DO

ACT

STUDY

PLAN

DO

ACT

STUDY

PLAN

DO

ACT

STUDY

Value improvement methodology at UUHC

1. Project Definition2. Baseline Analysis 3. Investigation4. Improvement Design5. Improvement Implementation6. Monitoring

Lean 6s PDSA

Project Life Cycles

Project Progress

Res

ourc

es R

equi

red

&

Bus

ines

s D

isru

ptio

n

Project Def.

Baseline Analysis

Investigation

Improvement Design

Improvement Implementation

Monitoring

Define MeasureAnalyze Improve

Control

6s

PDSA MonitoringPLAN DO STUDY ACT

• A process of incremental resource allocation. • At the end of every phase progress is reviewed. • A stop/redirect/continue business decision is made.

Project Gating: Incremental Project ApprovalR

esou

rces

Req

uire

d &

B

usin

ess

Dis

rupt

ion

Project Def.

Baseline Analysis

Investigation

Improvement Design

Improvement Implementation

Monitoring

Draw in the gates

Bottom Line Benefit

Effo

rt an

d C

ompl

exity

Project Selection: Align with strategic priorities and go for the green.