1. Six-Sigma in Health Care
This presentation will:
Provide an overview to the 6-sigma and the DMAIC framework
Develop a practical appreciation of process variation (Based on an idea by Neil Westwood)
and outline progress made within the NW Wales NHS Trust in applying the methodology
Craig Barton (NHS Modernisation Director, NW Wales NHS Trust)
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2. What is 6-Sigma?
Six-Sigma is an integrated quality improvement framework, which aims at ensuring no more than 3.4 defects per million opportunities.
At the heart of the Six-Sigma methodology lies a process improvement framework known as DMAIC (Define, Measure, Analyse, Implement, Control).
It brings a rigour to process redesign, which takes into account the detailed, and dynamic complexity found in today’s health care systems.
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3. What is Six Sigma?
Six-Sigma is a data driven approach to service development, which provides a problem solving methodology, which allows you to get at the facts as the basis for informing decision-making.
“Facts are the bricks with which you will lay a path to your solution and build pillars to support it. Don't fear the facts.”
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4. DMIAC – An Overview Analyse
Pronounced (Duh-May-Ick). DMAIC refers to a data-driven quality strategy for improving processes, and is an integral part of the company's Six Sigma Quality Initiative. DMAIC is an acronym for five interconnected phases:
Define
Measure
Analyse
Improve
Control
Each step in the cyclical DMAIC Process is required to ensure the best possible results!!
Define
Measure
Analyse
Improve
Control
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5. Overview to the DEFINE Phase
Define the Customer, their Critical to Quality (CTQ) issues, and the Core Business Process involved.
Define who customers are, what their requirements are for products and services, and what their expectations are
Define project boundaries ­ the stop and start of the process
Define the process to be improved by mapping the process flow
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6. Overview to MEASURE
Measure the performance of the Core Business Process involved.
Develop a data collection plan for the process
Collect data from many sources to determine types of defects and metrics
Compare to customer requirements and/or Mandated targets to determine shortfall
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7. The ANALYSE Phase
Analyse the data collected and process map to determine root causes of defects and opportunities for improvement
Identify gaps between current performance and goal performance
Prioritise opportunities to improve
Identify sources of variation
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8. The IMPROVE Phase
Improve the target process by designing creative solutions to fix and prevent problems.
Create innovative solutions using technology and discipline
Develop and deploy implementation plan
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9. The CONTROL Phase
Control the improvements to keep the process on the new course.
Prevent reverting back to the "old way"
Require the development, documentation and implementation of an ongoing monitoring plan
Institutionalise the improvements through the modification of systems and structures (staffing, training, roles, procedures, policies, incentives)
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10. What do we mean by Sigma?
The chart below is a Histogram showing the time taken to get a GP appointment (all data is fictitious)! A basic understanding of statistics can help us understand the variation in the process.
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11. What do we mean by Sigma ()?
Sigma stands for the standard deviation, which represents the average variation from the mean (average) value
The smaller the standard deviation the smaller the amount of variation in the process.
MEAN
Average
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12. The Normal Distribution
The frequencies of events within a normal distribution have known probabilities.
Naturally occurring processes often approximate to a normal frequency distribution
The standard deviation about the mean of a normal distribution is given the Greek letter (lower case) Sigma, ()
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13. Sigma () from the Customer’s (Pts) Perspective
If the patient is prepared to wait between 1 and 7 days then we have..
A Six-Sigma (6 ) Process!!
Very Few Defects
Very Few Defects
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14. Sigma () from the Customer’s (Pts) ‘Changed’ Perspective…
No longer a Six-Sigma (6 ) Process!!
If the patient (or LHB) is now only prepared to wait between 1 and 3 days then we have..
Very High No of Defects on this side of the distribution!!
Very Few Defects
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15. Upper Service Specification Lower Service Specification
Improving Quality
6
Upper Service Specification
Lower Service Specification
We need to keep dong it so that the distribution curve gets tighter and tighter. And our customers (patients) get happier and happier
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16. From Decimals to Defects per Million Opportunities (DPM)
Probabilities are difficult to utilise eg % provides a confidence interval equivalent to  6 (Standard Deviations) about the mean.
Process Sigma
Defects Per Million Opportunities (DPMO) 6
3.4 5
233 4
6,210 3
66,810 2
308,537
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17. Process Yields and DPMO
These are Motorola’s adjusted Yields and DPMO, which are shifted 1.5 from the standard normal values to account for variation associated with repeated measures
Process Sigma
Yield %
Defects Per Million Opportunities (DPMO) 6
3.4 5
99.977
233 4
99.379
6,210 3
93.32
66,810 2
69.20
308,537
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18. ‘Six-Sigma’ in Practice ‘The Paper Aeroplane Metaphor’
Based on an Idea By Neil Westwood
Instructions:
Make an aeroplane using the materials on your tables (use only one type of material)
When you have made it, bring the plane to the front of the room
When instructed throw the plane
The planes go different distances – due to variation in deigns, materials and the people making them.
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19. Six-Sigma’ in Practice ‘The Paper Aeroplane Metaphor’
Understanding Variation…..
Note the distances flown by each design, what is the mean and standard deviation.
What are causing the aeroplanes to fly different distances?
Why are they not flying the same distance?
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20. Six-Sigma’ in Practice ‘The Paper Aeroplane Metaphor’
Define
Measure
Analyse
Improve
Control
Fishbone Diagrams are used to identify the root causes of variation
Causes
Some aeroplanes fly different distances
The different types of paper e.g. card, tracing paper,
No clear instructions provided
The people have different skills/ideas
Different throwing styles
Some Tables had scissors and rulers to help
Problem
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21. Six-Sigma’ in Practice ‘The Paper Aeroplane Metaphor’
Define
Measure
Analyse
Improve
Control
How can we reduce variation?
Train people [Improve]
Provide Instructions [Improve]
Provide the same materials [Improve]
Develop process measures and use to control process variance – apply SPC. [Control]
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22. Six-Sigma’ in Practice ‘The Paper Aeroplane Metaphor’
Towards a solution (ie to reduction in process variation)!!
Make another aeroplane – following the instructions. (Perhaps we have a master designer or Modernisation Director who is able to demonstrate)
Use the A4 white paper provided, 80g/m2 (everyone to use the same material.
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23. Six-Sigma’ in Practice ’The Paper Aeroplane Metaphor’ – INSTRUCTIONS (1 of 3)
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24. Six-Sigma’ in Practice ’The Paper Aeroplane Metaphor’ - INSTRUCTIONS (2 of 3)
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25. Six-Sigma’ in Practice ’The Paper Aeroplane Metaphor’ - INSTRUCTIONS (3 of 3)
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26. Six-Sigma’ in Practice ‘The Paper Aeroplane Metaphor’
Analysing the results of the experiment
Now note the mean and standard deviation of the distances flown
Do we have a more stable process?
Is it capable?
We need to know the upper and lower service specification!!
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27. Six Sigma Implementation in the NW Wales NHS Trust – Why are we doing it?
Engendering Service Improvement by providing the impetuous for sustainable Cultural Change!
Leading to …
The development of cost effective, patient (customer) centred & evidence based services derived form a rigours approach to systems analysis and redesign.
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28. What have we done? Initial Logistics – Developing the Infrastructure:-
Internal support
Appointment of Full time Senior Manager with strong background in training, leadership & org’ development
Trained as Green Belt, will be trained as Black Belt!
Agreed protocols for reinvesting savings
Agreed criteria for the selection of projects
External Support (Catalyst Ltd)
Consultancy
Project Surgeries
Toll-gate reviews
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29. What have we done? Awareness & Training:- Workshop for Executive Group
Executive Directors
Directorate Managers
Workshop for Project Sponsors
First phase roll out
Training for 14 to Green Belt standard
Participants from a variety of settings
Estates and Facilities
Human Resources
Clinical - Surgery, Medicine and Mental Health
Service Modernisation
Business Modernisation
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30. Surviving 1st Phase Projects:-
Reduction in inpatient length of stay (LOS) for stroke patients towards a target of <= 5 days [DMA - DOE Complete]
Reduction in the No of untouched patient meals within the Surgical Directorate [1.9 - 3.2]
Reduced cycle time for the recruitment & selection process within the Surgical Directorate [0.9 DMA - DOE Complete]
Reduce ‘trolley waits’ in A&E to ensure 100% compliance with the target of < 4 hours [3.0 - 3.3 (ENP Experiment)]
Improve processing of invoices from fuel cards to ensure 100% compliance with Financial Policy (F6b) [0.6  ]
Reduce occurrence of missing case notes at outpatient ENT & Dermatology O/Pt clinics to zero. [2.5 – 2.9 – 4.1  (Audit & Runner Experiment)]
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31. Surviving 1st Phase Projects:-
Reduction in do not attend rates (DNAs) for compulsory patient handling training to ensure 100% compliance with Trust Policy and HSE (Statutory) guidelines. [Root Cause Analysis – Undertaken]
Reduce cycle time in relation to lease care application process ensuring 100% compliance with Trust Policy F6(a)
Reduction in the No of Non BACs transactions to zero.
[2.5 – 3.2 ]
Improve contractor compliance with the audit requirements of the cleaning contract towards a target of 100% compliance with relevant clauses. [0.9 – 3.9 ]
Reduction in the time spent on pre & post payroll checks.
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32. What have been the benefits?
Development of a universal approach to solving problems which enforces:-
Business led approach to the selection of improvement projects, (Project charter incorporating an outline business case – facilitating strategic integration)
Customer/Patient centred (VOC)
Systemic perspective (SIPOC, Process Mapping/Redesign)
Focus on measurement (SPC)
Scientific approach to Root Cause Analysis – Fact NOT assumption! (Y = F(x1, x2, x3 … xn))
Rational DOE underpinning P-D-S-A (Fast prototyping)
Rational selection of solutions against a range of CTQs
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33. Benefits …/Ctd Empower managers & HCPs to solve problems
“I can make a difference”, “I have the tools to make a difference”, “It is my duty to make a difference”
“I understand the organisational consequences of my practice”!
Move away from ‘Assumptive/Solutionist’ thinking!!
Move from task to process management
Move from departmental to systems thinking
from detailed complexity to dynamic complexity
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34. Some Early Indicators:-
BACK
Utilisation of Audit & Runner to periodically chase missing Case Notes
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35. Some Early Indicators:-
Improve contractor compliance with the audit requirements of the cleaning contract towards a target of 100% compliance with relevant clauses.
Jan 05
Feb 05
Mar 05
Process Sigma
0.9
0.95
3.9
Process Yield
30%
31%
99%
BACK
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36. Some Early Indicators:-
Reduction in the No of Non electronic transactions (Cheques) to zero.
June 04
Feb 05
Mar 05
Process Sigma
2.5
2.8
3.2
Process Yield
84%
90%
95%
BACK
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37. Some Early Indicators:-
BACK
Utilisation of Trainee Emergency Nurse Practitioners
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38. What Have we Learnt from Phase I
The importance of developing a strong business case underpinning the improvement opportunity – strategic integration.
The critical importance of the project sponsors role – action not tokenism!
The importance of embedding black, green and yellow belt roles within job descriptions and other artefacts of culture – staff appraisal.
The importance of organising work to allow dedicated space and time for six-sigma practice.
Encouraging accountability for project outcomes by embedding the tollgate reviews within the directorate review process and local performance management arrangements.
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39. What Have we Learnt from Phase I
Importance of measurement (SPC) – identifying a range of upstream and downstream process measures.
Avoid the ‘McNamara Fallacy’
Recognising the need to balance hard systems modelling with soft-systems approaches
Balancing the What and Why with the How?
The importance of E = Q x A
The importance of V x D x S x C > R
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40. The Next Steps!!
Systematically select and train a further 14 project leaders from all clinical directorates and functional areas.
Ensure these are supported by sponsors & trained yellow belts
Identify and select projects (approx 2 per directorate/dept) which clearly impact on the achievement of KPIs & CIPs.
Develop accountability for project deliverables using existing organisational structures and processes.
Systematically exploit the learning of others whilst proactively sharing our experiences.
Develop the organisational capability wrt to the application of DMADV/DFSS.
Succession Plan for future black, green and yellow belts.
Have some fun!!
(Work shorter hours & take less work home, Quantity time with the kids)!!!
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