Lean, Six Sigma and Emotional Intelligence

The shortest distance between You and Improved
Lean, Six Sigma & Emotional Intelligence
Medical Staff Presentation
April 15, 2015

Program Overview
• Introduction to Lean & Six Sigma
• Case Study
• What we’ve learned from 16 years
in supporting health systems

We believe that healthcare leaders should have
all the tools they need to excel in their mission.
Segment Leadership:
• Founded 1998
• ACHE, ASQ, & UM solutions
• Prolific publishing activity
• Average tenure per staff > 12 years
• Full suite of PI technologies
• Pure production in healthcare space
• 3 Baldrige Award winning clients

Insert your own horror story here
The time I was abandoned by Air China in Beijing
The time(s) Delta lost my luggage in Italy
The time United changed my flight without telling me
The time I was stuck on the tarmac in Denver for hours…
The time I was stuck on the tarmac in Phoenix for hours..
The time I was stuck on the tarmac in Boston for hours….
The time I was…….

Why improve processes
when you can simply apologize nonstop?

Why improve processes
when you can simply apologize nonstop?
Is this an
option for
your
Organization
?

Better idea: “Learn to Lean”
Accelerate the speed and reduce the cost of any
process by removing non-value-added activities
“Re-examine the way you think about waste, as it is often difficult to recognize.
Start by making waste obvious to everyone.”
Taiichi Ohno, Founder
Toyota Production System

Cost of Quality
© All Rights Reserved.
Up to 40%
Productive
Quality
Adding
Features
• Preventing
problems
• Detecting and
correcting
problems before
the customer
sees them
• Dealing with
problems after
they occur

The shortest distance between You and Improved9
Cost of Poor Quality
• 20% to 50% = not always valued by the
customer
• Up to 40% of the expense budgets in an
organization are associated with COPQ
(it may be even higher in health care)
• Every 4% reduction in waste increases
operating margin by 1%
• - Murphy Leadership Institute

Why is it difficult to
eradicate waste?
Patient
Asks for
Information
Patient
Gets
Answer
PERCEIVED WAIT TIME
Patients over estimate their wait
time by 50% or more;
PERCEPTION IS REALITY
A B C D
ACTUAL WAIT TIME
Determined by the process to
retrieve information

Bottlenecks
Flow of work = process time + delay time = cycle time!

Hand-offs
“Lessons from DMV”

PULL
PERFECTION
Principles of Lean Thinking
VALUE1.
VALUE STREAM2.
FLOW3.
4.
5.

“The Hidden Hospital”
Rework
Hidden Hospital
NOT OK
OperationInputs First Time
Yield
OK
98%
Customer
Quality
Described below is any process that meets a customer need
98% Yield After
Inspection or Test
65%
35%
Inspect
Exposing waste made more difficult by the way we map, and the way we measure
This classic approach
does not account for the
“Hidden Hospital”
Rework:
20-30%

VALUE-ADDED
• Alters the work
• Meets customer
wants or needs
• Is done right the first
time
NON-VALUE ADDED
• Eliminate it
• Consolidate it
• Automate it
Protocol to Eradicate Waste

Mastectomy Mistake: 'You Don't Have Cancer‘ Woman Told She Has Breast Cancer,
but Learns After Operation Her Biopsy Slide Was Mixed Up
Darrie Eason talked to "Good Morning America" about undergoing a
double mastectomy after a lab mix-up. (ABC News) Oct. 4, 2007
A state report blames Eason's mix-up on a
former technician at CBLPath lab who
mislabeled her biopsy results. The report said
the technician "cut corners."
“The technician was batching the specimens”
They could not confirm that the other person,
who did have breast cancer was ever notified.
Stakes are High in Healthcare

Two Six Sigma “blackbelts” sitting at a bar...

Six Sigma is Process Improvement
Process
X1
X2
Y
X3
Process Input
Variables
Process Output
Variable
Customer
Requirements
In-Process
Variables
X1 X2 X3
X…n
Six Sigma focuses on the “critical X” that drives process
performance more than any other variable.
The aim of Six Sigma is to fix the problem “for the last time”

Six Sigma is Project Management
Who is the customer?
What do they want?
Is the data clean or dirty?
What is the baseline performance?
What is the project objective?
What are the various x’s?
What are the critical x’s?
What solutions will control the x’s?
What are the specs for the x’s?
What is the data integrity of x’s?
What is the capability of the x’s?
Can the improvement stand the test of time?
Y
x
Define
Measure
Analyze
Improve
Control
Describe
The customer
experience
Optimize
The customer
experience

Six Sigma is a Metric
s s s s s s
LSL m
A six-sigma (6s) process
The distance between the
mean (m) and the inflection
point is the standard
deviation (s).

A Six Sigma Project
“Home Run”
 Identify and eliminate NVA activity
 Identify and reduce variation

System Performance
0
100
200
300
400
500
600
700
800
900
50.00% 60.00% 70.00% 80.00% 90.00%
(Utilization (Throughput / Max. Theoretical Throughput)
CycleTimeORWorkinProcess
What’s Going On Here?
Understanding The Role Of Variation In Process Performance

System Performance
0
100
200
300
400
500
600
700
800
900
50.00% 60.00% 70.00% 80.00% 90.00%
(Utilization (Throughput / Max. Theoretical Throughput)
CycleTimeORWorkinProcess
Impact
of variation
What’s Going On Here?
Understanding The Role Of Variation In Process Performance

Linking Lean and Six Sigma
• While Six Sigma will focus on the “critical few,” Lean
focuses on the “trivial many”
• Lean focuses on speed, efficiency, and waste
• Six Sigma focuses, defects, variation and quality of
products and processes
LEAN Six Sigma
Six SigmaLEAN
Either method provides a prescriptive approach
to performance improvement
24

USLLSL
Center
Process
Reduce
spread
USLLSL
Off-Center
USLLSL
Unpredictable
Centered
A BTarget
Remember... customers experience our variation,
not our averages
Lean/Six Sigma Improvement Strategy

Case Study:
Lean Project in Hospital Lab

Problem Statement: Survey data from the American College of Pathologists shows that
physicians think troponin TAT should be 45 mins or less, while laboratories strive for 60 mins or less.
Currently, the hospital is incapable of meeting its goal consistently, failing over 50% of the time.
Failure can frustrate physicians, threaten patient safety and erode the hospital’s commitment to
quality care.
Who Are The Customers? COPQ: Treatment delays, physician and patient
disatisfaction, potential impact on morbidity
ED physician and patients & mortality
What is Critical To their Satisfaction (CTS): Defect Definition: TAT > 60 minutes
Consistent and timely delivery of results (CTD)
Baseline Sigma: - 0.48
Project Scope
Test ordered Result delivered
0
10
20
30
40
50
60
70
80
OD DR RV Total
Hema
Panel
Troponin
Project Charter: Lab Cycle Time

• Phlebotomist not available (28)
• Locating patient (26)
• Patient refusal/not available (26)
• Phone interruptions (19)
• Staff attitudes (17)
• Accuracy of labeling (16)
• Multiple draws (15)
• Poor communication (13)
• Poor workflow (10)
Only 17%
of the total
TAT is
impacted by
these obstacles…
Q. What are the obstacles to improved TAT in delivering
Lab results to ED?
What they said first, and next

• Phlebotomist not available (28)
• Locating patient (26)
• Patient refusal/not available (26)
• Phone interruptions (19)
• Staff attitudes (17)
• Accuracy of labeling (16)
• Multiple draws (15)
• Poor communication (13)
• Poor workflow (10)
Only 17%
of the total
TAT is
impacted by
these obstacles…
…but observations
and data reinforce
the impact of these issues
Q. What are the obstacles to improved TAT in delivering
Lab results to ED?
What they said first, and next

Measure Phase
Determining Stability of Process
Establishing Baseline Performance
Ensuring Data Integrity
Establishing Capability
Integrating Subjective Input

Whether Lean or Six Sigma,
it all begins with Current State

Process Flow Diagram - Troponin
ED
Lab1
Lab 2
ED
Start
Physician
Writes Order
Order Given To
Unit Clerk
Input Sent
Order
Arrives In
Outpt. Lab
Order Has
Correct
Information?
Phl. Goes To
Outpt. Or ED
Computer For
Another Patient
Phl. Draws
Specimen
Phl. Tries
To See
Another
Patient?
Phl. Makes
Multiple
Draws?
Specimen
Arrives In Lab
Specimen
To
Hematology
Blood RolledBlood Spun
Specimen
Processed
Specimen To
Instrument
Specimen To
Instrument
Specimen
To
Chemistry
Results
Verified And
Sent To ED
Results Sent
To Chart
Physician
Reviews
Results
End
Unit Clerk
Immediately
Inputs
Order?
Draw Complete
Results
Arrive In ED
Results Reviewed
Immediately?
No
Specimen To
Instrument
Specimen Sent
For Troponin
Analysis
Yes
Pt. in
room?
Yes
Yes No
No
Phl. Tubes
Specimen
To Lab?
No
No
Yes
Specimen
Logged In?
Yes
Input Delay
No
Yes
Specimen
Walked To Lab
Specimen
Delayed
Getting To Lab
Yes
Specimen
Movement
Delayed
No
Delay in
reviewing
results
NO
Yes
What’s wrong
with this picture?

30 90 150 210 270 330 390
95% Confidence Interval for Mu
66 71 76 81
95% Confidence Interval for Median
TAT Troponin First Qtr 2003
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
76.037
38.863
67.000
74.078
0.000
78.7104
40.6673
1653.83
4.03449
22.2818
891
36.000
57.000
68.000
86.000
419.000
81.384
42.649
70.000
Anderson-Darling Normality Test
95% Confidence Interval for Sigma
Descriptive Statistics
Turnaround Time: Troponin

Analysis Phase
“Rounding up the usual suspects”
Hypothesis testing
Identification of Critical X’s

In search of “X”
Analysis of Troponin Process
• Ho: No significant delay due to multiple draws
• Ho: No impact from use of pneumatic tube
• Ho: No significant time loss from end of
instrument processing to delivery of results

Does a multiple draw cause cycle time to increase or
decrease, or is it unrelated to cycle time?
60 160 260 360 460 560
95% Confidence Interval forMu
35 36 37 38 39 40 41 42 43 44
95% Confidence Interval forMedian
Variable: TAT - Phlebotomist
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
41.335
23.945
35.000
73.588
0.000
42.5212
24.7560
612.861
3.55094
26.7708
1675
10.000
27.000
36.000
51.000
334.000
43.708
25.624
38.000
MDraw: Single Draw
95% Confidence Interval forSigma
60 160 260 360 460 560
95% ConfidenceInterval forMu
41 46 51
95% ConfidenceInterval forMedian
Variable: TAT-Phlebotomist
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rdQuartile
Maximum
45.173
29.554
41.000
50.475
0.000
47.5972
31.1758
971.933
10.4494
171.578
638
11.000
33.000
43.000
54.000
608.000
50.021
32.987
44.000
MDraw: Mult. Draw
Anderson-DarlingNormality Test
95% ConfidenceInterval forSigma

Mood Median Test: TAT for Multiple vs Single Draw
Chi-Square = 37.60 DF = 1 P = 0.000
Individual 95.0% CIs
M Draw N<= N> Median Q3-Q1 ----------+---------+---------+------
Mult. Draw 256 382 43.00 21.00 (-------+---)
Single Draw 911 764 36.00 24.00 (---+-------)
----------+---------+---------+------
37.5 40.0 42.5
Overall median = 38.00
A 95.0% CI for median(Mult. Dr) - median(Single D): (4.00,8.00)
Does a multiple draw cause cycle time to increase or
decrease, or is it unrelated to cycle time?

Does it make a difference if Phlebotomist utilizes
Tube System or drops sample direct at the Lab?
6454443424144
151311
Troponin "Draw to Receive"
11.0000
8.7175
13.5792
Maximum
3rdQuartile
Median
1st Quartile
Minimum
N
Kurtosis
Skewness
Variance
StDev
Mean
P-Value:
A-Squared:
13.0000
10.0532
15.4629
66.0000
18.0000
12.0000
8.0000
0.0000
380
4.92349
1.79371
87.1895
9.3375
14.5211
0.000
11.930
Check inby Accessioning
6454443424144
11.810.89.88.87.8
Troponin "Draw to Receive"
8.0000
7.3894
10.0289
Maximum
3rdQuartile
Median
1st Quartile
Minimum
N
Kurtosis
Skewness
Variance
StDev
Mean
P-Value:
A-Squared:
9.0000
8.4410
11.5124
50.0000
15.0000
9.0000
5.0000
0.0000
436
2.61618
1.38520
62.0944
7.8800
10.7706
0.000
11.184
Check inby Phlebotomist

Does it take a significant amount
of time for the Technician to inspect and
release results?
0 40 80 120 160 200 240
3 4 5 6 7 8 9 10 11 12
Perform to Verify -
Positive Results Only
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
4.263
19.493
3.000
30.710
0.000
7.8732
21.7640
473.672
8.69490
86.5909
142
0.000
2.000
3.000
7.250
235.000
11.484
24.638
5.000
95% Confidence Interval for Sigma

Improve Phase
FMEA Initiation
Brainstorming solutions
Fundamentally changing the Process

Easy Hard
Ensure draw for
Troponin 100%
of the time
Leverage
Nurse-initiated
orders for Trop
Implement
best practices
in Phlebotomy
Ensure room
or location ID
on ED orders
Eliminate
Multiple Draws
Drop off
at Lab for
Troponin Expedite attention
to instrument
4 Quadrant Analysis - A Brainstorming Tool
Effort

Trial Summary: Overall Performance
(new draws only)
• Troponin Before
– Order to Draw
• μ = 13.1
• σ = 14
– Draw to Receive
• μ = 12.4
• σ = 9.2
– Receive to Verify
• μ = 51.4
• σ = 40
– Total TAT
• μ = 76.9
• σ = 40.7
• Troponin Trial Only
– Order to Draw
• μ = 11.0
• σ = 8.3
– Draw to Receive
• μ = 7.9
• σ = 6.7
– Receive to Verify
• μ = 40.1
• σ = 11.4
– Total TAT
• μ = 59.0
• σ = 17.6

30 60 90 120 150 180 210
55 59 63
Troponin TAT: June 1 - 20
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
58.418
19.792
54.000
15.916
0.000
60.6562
21.2614
452.048
2.49118
11.0310
349
24.000
48.000
56.000
67.500
219.000
62.895
22.968
57.000
Conducting the trial
enabled the organization
to anticipate impact of
expansion

6305805304804303803302802301801308030
51.550.549.548.547.546.545.544.543.5
TAT ALL TESTS - 2002
44.000
29.520
49.605
Maximum
3rdQuartile
Median
1st Quartile
Minimum
N
Kurtosis
Skewness
Variance
StDev
Mean
P-Value:
A-Squared:
45.000
30.508
51.002
656.000
60.000
44.000
33.000
8.000
7085
58.9612
5.06223
900.358
30.0060
50.3035
0.000
308.720
30 80 130 180 230 280 330
37 38 39 40 41 42 43 44 45
TAT ALL TESTS: JUNE 1 - 20
A-Squared:
P-Value:
Mean
StDev
Variance
Skewness
Kurtosis
N
Minimum
1st Quartile
Median
3rd Quartile
Maximum
42.342
25.256
37.000
91.965
0.000
43.4421
26.0115
676.600
4.81157
44.4322
2149
7.000
28.000
38.000
52.000
365.000
44.542
26.813
39.000
Were improvements at the expense
of other tests?
Turnaround Time:
All Tests Pre-Project
Turnaround Time:
All Tests Post-Project

Control Phase
Celebrating Success
Holding the Gains
Looking Ahead

Process Step
What's
Controlled?
Spec. Limits /
Requirements
Measurement Method Sample Size Frequency
Who/What
Measures
Decision Rule/
Corrective Action
SOP
Order to Draw Patient Room ID In Process In Process In Process In Process In Process
I
n
P
In Process
Order to Draw Multiple Draws
No mult draw when
one or more Trop
ordered
Compare check in time for
different samples by
Phlebotomist
500-1000 Monthly Cerner* TAT > 13.0 min
Draw to Receive
Check in to
Chemistry
Check in to Chem
when Trop is ordered
Compare Draw ID to
Receive ID for Trop
500-1000 Monthly Cerner TAT > 10 min
Draw to Receive
Check in to
Chemistry
Phlebotomist logs on
to PC
Compare Draw ID to
Receive ID for Trop
500-1000 Monthly Cerner Compliance < 75%
Receive to Verify In Process
I
n
In Process In Process In Process In Process In Process TAT > 50
Perform to Verify
Attention to
Instrument
Use alarm to indicate
instrument completion
Monitor Peform to Verify
from instrument
500-1000 Monthly Cerner TAT > 5
Troponin TAT TAT 60 mins or less
Cerner stats, adjusted for
drawn before ordered
500-1000 Monthly Cerner TAT > 65
*Need to identify staff person to process Cerner data Approved by:
Approved by:
Control Plan

How we’ve evolved as an
organization, and
what we’ve learned

Performance
Improvement
Training
&
Credentialing
How we’ve evolved as an organization,
and what we’ve learned

“Culture Eats Lunch”
Q x A = E
Business
Results
Quality of solution times its Acceptance = Effectiveness
See “The Missing Link to Improvement Capability,”
Becker’s Hospital Review, February 2013

The ”burning platform” approach to
change management

• A man working on an oil platform in the North Sea
awakened one night by an explosion. Amidst the
chaos, he made his way to the edge of the
platform. As a plume of fire billowed behind him,
he decided to jump from the burning platform
even though jumping is a risky option for the
following reasons:
o It was a 150 – foot drop to the water.
o There was burning oil on the surface of the
water.
o If jumping into 40°F water did not kill him, he
would die of exposure within 15 minutes.
• Luckily, the man survived the jump and was
hauled aboard a rescue boat shortly thereafter.
When asked why he jumped, he replied, “Better
probable death than certain death.”
The ”burning platform” approach to
change management

The Golden Rule has Limits!

EQ Leadership
• EQ leaders create resonance
(connection) among their
followers
• EQ leadership creates trust
• EQ leaders can empathize with
their followers
• Ineffective leadership creates
dissonance (disconnect) and
mistrust among followers

Why EQ Leadership?

EQ Leadership
• How to recognize the behavioral
styles of peers and subordinates
• How to recognize the needs of
each behavioral style
• How to adapt behavior to give
staff “what they need”
• How to create more harmonious
and productive relationships

Champion
Training
&
Candidate
Selection
Performance
Improvement
Training
&
Credentialing
Portfolio
Management
System
(“COMPASS”)
How we’ve evolved as an organization,
and what we’ve learned

• Number of CHC Clients = 10
• Number of Projects = 150
• Average Cost per Project = $45,000
• Average Return per Project = $327,058
• Median Project Return = $160,675
• Range of Returns from $60 to $3.75M
• Average ROI = 7:1
Does our approach work?

$-
$20,000,000
$40,000,000
$60,000,000
$80,000,000
$100,000,000
$120,000,000
$140,000,000
$160,000,000
$180,000,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
CAMC Financial Impact
2001 - 2013
Cumulative Total Annual Improvements
CHC
Online
Training

What Success Looks Like
A statistically significant improvement in “Corporate Culture”
Performance Improvement Scores
3.75
3.43
3.18
2.65
2.73
3.12
2.5
3.0
3.5
4.0
1998 1999 2000 2001 2002 2003 2004 2005
Year
Average

Thank you for the opportunity to be with you today!
Ian R. Lazarus
irl@creative-healthcare.com
www.creative-healthcare.com

Lean, Six Sigma and Emotional Intelligence

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