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Making AFSO21 Work in Your Laboratory

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1 Making AFSO21 Work in Your Laboratory
TSgt Brent Whitby NCOIC, Quality Assurance 375 Medical Group, Scott AFB, IL

2 Ice Breaker Let’s Draw a Pig Question 1
- How many of you have variance or deviation reporting system Question 2 How many of the same variances do you see If you are seeing repeated variances you may want to look deeper at the root cause, you will probably find that your process lacks standardization Standardization is the back bone of AFS021. This exercise hopefully demonstrated that more clear and concise you make a process the more standard or consistent a process will become. Good morning this morning I want to walk you through some of the foundational principles of AFSO21 and help you be more successful in implementing AFSO21 into your workcenters

3 Agenda/Topics To Be Covered
AFSO21 Implementation Linking AFSO21 to Organizational Goals OODA Loop process of AFSO21 We will begin by examining the AFSO21 implementation. Identifying obstacles Show you how to link it to your Org The second hour I will go throught he OODA Loop process of AFSO21 Transition: Let’s begin by discussing what brought about the onset of the AFSO21 model of the QMF.

4 AFSO21 Implementation Launched in 2005 Obstacles to deployment
Quality Air Force Conundrum Senior Leadership buy-in AFSO21 vs. QAF Value stream mapping vs. process mapping Results - AFSO21 was implemented in 2005 with the thought of the AF being static by 2009 (meaning fully functional) however, it has met many road blocks. The first being the QAF cunnundrum—many commanders were releasing personnel for PAT and never saw there results Although QAF often ID’d root causes of problems – solutions to those problems were never implemented Senior leadership buy-in How is AFSO21 different though – why should senior leadership buy-in Value stream mapping vs. process mapping – AFSO21 targets ineffeciencies not just problems as we move forward this morning we are going to discuss how you can get not only senior leadership buy-in but get buy-in up and down the org chart.

5 Linking AFSO21 to Organizational Goals
Time: 2 min Assess outlook/future path Current state map Future state map Evaluate current organizational performance Review system change/improvement capacity Implementing AFSO21 begins with vision. You have to link AFSO21 to your organizational goals. If you don’t you are doomed to fail. The way you link it to your org goals is to simply figure out where you are and where your going. This requires you to assess your path, evaluate your current performance, and review your improvement capacity Assess – Is strategy course clear – does everyone in your organization from top to bottom know where your headed? Can we meet our financial/compliance goals Do we respond well to new circumstances Evaluate org performance Instill a “Go & See” mindset to thoroughly understand problems at their source Are we meeting our company needs (look at the SDA report) How effectively are we operating System change /improvement How well do we manage change control Cross-functional process management Is our process improvement model clear

6 Key AFSO21 Questions Which process needs the most attention
Time: 2 min Which process needs the most attention Where can biggest cost savings occur How can quality be improved (to what degree?) Look at your metrics – if you are not currently tracking metrics I strongly recommend you do that. What areas seem to fall short ( for us at Scott we recognized a problem with our preanalytical error rates) With the domestic agenda/budget in congress growing daily, the defense budget is going to take hit. We are going to have to find ways to save money. Look around your work center and figure out how you generate savings. This may mean spending money up front to save money in the long run. One thing we are looking at right now is creating a corelab, because we realize how inefficient compartmentalized laboratory medicine is. It will cost some money up front but in the long run we work more effeciently and require less manpower. How many of you are QA coordinators in the room. Ask yourself before you implement AFSO21 will it improve the overall quality of care that we render. LSS in the healthcare industry is gaining a lot of momentum in the civilian sector in fact ASQ is looking into a QA certification for healthcare workers right now.

7 Key Themes of AFSO21 Customers are important
Speed, quality, low cost are linked Variation/defects minimized Time trap elimination Data driven improvements Teamwork One variable that never changes is that our patients are important. We have all been to customer services classes that tell us the customer is always right. Just because we are in the military doesn’t mean that our patients don’t pay our wages. Therefore if we can find ways to process patients faster, better, and cheaper then we will keep these patients coming back…if can’t do that then dependents and retirees will seek care elsewhere. There was a big push about 5 years ago to incorporate 6 Sigma into our daily operations, problem they ran into was that 6 Sigma in the lab field was virtually impossible to achieve due to the amount of variation. At best most labs could run at 4 Sigma simply due to non-automated processes associated with our jobs. Therefore, there is a push to minimize variations.

8 Benefit/Effort Matrix
Time: 3 min Q1 - Immediate attention Q2 - Hardest decision Q3 - Sometimes beneficial Q4 - Avoid High 1 2 Benefit 3 4 Low Effort Low High - As we continue looking at implementing AFSO21 into our work processes, it is advantageous for you to perform benefit/effort matrix.

9 Project Selection Process elements Stakeholder analysis Customer data
Quality function deployment Benchmarking

10 Process Elements (SIPOC)
Supplier (provide inputs) Input (services provided) Process (value added steps) Output (final product) Customer (internal/external) Suppliers Inputs Process Output Customer MLTs Perform Test Verify Patient Acceptable Specimen to analyze Patient Patients Provide Specimens Accession Test Accurate Results Physician Phlebotomist Collect specimens Collect Sample Timely treatment Technical Supervisor Report Results Process Sample Put on Analyzer SIPOC model creates, monitors and improves process management, process improvement, and process design/redesign Displays cross-functional activities (flow charts) Framework for all processes Big picture perspective Although we focus on the SIPOC the order in which we address these issues is critical. 1. Name the process (keep it simple but direct) 2. Start/stop points this will control the scope Output. The largest problem here is often qualifying/quantifying ID Customers both primary/secondary ID Suppliers of the of the process ID inputs of the process (Data) ID 5-7 highest level as they exist today – what is the culture (Ready Fire Aim???)

11 Stakeholder Analysis Control resistance (reduce or remove)
Provide alternatives Remove pitfalls Ensure buy-in Perceived value drives feedback Positive Negative

12 Customer Data Use Service Delivery Assessment data (customers define quality/expectation) Listen to external/internal customers WoW Forms Internal customer surveys CQFA Cost Quality Features Availability

13 Quality Function Deployment
Often referred as “Voice of Customer” House of Quality Customer needs Design features/technical requirements Customer priorities Benchmarking (targeted values) Inter-relationship between design features Creates customer driven environment Reduces cycle times Uses concurrent engineering methods Reduces design costs (fewer changes) Increases communication Creates data Establishes priority requirements

14 Benchmarking Types Sequence Process Performance Project Strategic
Determine current practices ID best practices Analyze best practices Model best practices Repeat Process – Find the most effective operating practices from other orgs who have similar work functions Performance – Price, technical quality, speed reliability Project – Planning, scheduling, and controlling specific projects Strategic – examines how companies compete (not industry focued) Determine current practice Find problem areas ID key performance factors Understand your own/other processes Analyze performance vs. needs/priorities ID best practices Compare performance w/I org Determine leaders w/I criteria areas Find internal/external org to model Analyze best practices Visit w/partner Collect data Evaluate Note improvement areas Model Focus on improved performance Extend breakthroughs w/I org Share

15 BREAK

16

17 OODA Loop Originated by Col John Boyd (USAF)
Also known as Decision Cycle Four Overlapping and Interacting Processes Observe Unfolding Circumstances and Information Orient Analysis and Synthesis Decide Act (and Test) Decision making occurs in an OODA cycle Processing OODA quickly gets inside opponent’s decision cycle Military or Business Competitive Advantage Orient Phase most important Observed information must be processed to orient Data must be Filtered via various factors Complexity grows as OODA processed by team Many teams therefore stutter “OO-OO-OO” Winning requires team to Orient faster than opponents Often compared to Toyota’s PDCA Cycle

18 Problem Solving Process
Plan Act Check Do 1. Clarify The Problem Observe 2. Break Down The Problem/ Identify Performance Gaps 3. Set Improvement Target Orient 4. Determine Root Causes 5. Develop Countermeasures Decide 6. See Countermeasures Through 7. Confirm Results & Process Act 8.Standardize Successful Processes

19 Elements of the 8 Step Problem Solving and A3 Approach
Time: 1 min Logical Thinking Process Objectivity Focus on Results and Processes Synthesis, distillation, and visualization Alignment Coherence & Consistency Systems Viewpoint Thinking generated by using the A3 is more important than the report itself The mind-set behind the A3 system is distilled into these seven elements These interact and reinforce each other. Ask them to think about the way their units work—do they exhibit any of these characteristics?

20 Logical Thinking Process
Time: 2 min Strong emphasis on cause and effect Focuses organization to maximize resources by focusing on the “critical few” Minimizes wasted time by management by using a robust problem solving process Toyota wants its people to be able to think and then act rationally in decision making and problem solving Great emphasis in factually discerning the difference between “cause” and “effect” Infinite number of problems but finite amount of resources Toyota develops people to recognize the most important problems and instill in the employee the obligation and capability to solve the problems expeditiously Creates consistent, socially constructed approaches to key classes of problems Logical thought processes are thorough, address important details, consider numerous potential avenues, take into account the effects of implementation, anticipate possible stumbling blocks, and incorporate contingencies The process applies to goal setting, policymaking, and daily decision making just as much as business, organizational, and engineering problem solving Emphasize here getting to the “critical few” problems—prioritization is critical.

21 Objectivity Time: 2 min Process drives employees to think with quantitative data as opposed to emotion and opinions Fosters a collaborative process as opposed to a “silo mentality” THIS IS EXTREMELY HARD --- Setting aside your biases and preconceived notions, but it is ESSENTIAL Human observation is inherently subjective; every person sees the world a little bit differently His or her representation is the “right” one Ops maintenance down time as example: ops blames mx, mx blames supply, etc Natural reaction, if one feels their representation is “right”, is to view other’s as “wrong” Quickly devolve into the blame game A3 thinking attempts to resolve those multiple viewpoints Objectivity is a central component to A3 thinking Effective problem solvers continually test their understanding of a situation for assumptions, biases, and misconceptions Begins by framing the problem with relevant facts and details, as objectively as possible Promotes organizational good rather than personal agendas Very little room for qualitative opinion or wishful thinking Ask them if we are all inherently subjective due to our experiences, training, world view etc: of course we are Here is a good place for personal example, i.e. When I was a commander, I did the “Ready, Fire, Aim” approach based on “I have seen this before, etc” where I don’t think I truly understood the REAL problem, and the better approach would have been start with a clean slate, get out of the office and go and see and reset or adjust your perception of the problem.

22 Focus on Results and Processes
Time: 2 min Example: Insurance company is losing business due to 5 day turnaround on quotes. Possible Solutions: Hire more people to reduce time Incentivize employees to work harder Find the root cause for lengthy turnaround and implement permanent corrective action Results and process are important, neither favored over the other. Both are necessary and critical to effective organizational improvement and personnel development. As much about personal development as it is about achieving results, so the process used becomes paramount. The ultimate goal is not just a problem resolved in the immediate term, but also that: the problem is less likely to occur in the future because the overall system is improved the problem-solver has enhanced his or her problem-solving skills and is prepared to tackle even more challenging tasks The results truly are the result of one’s understanding of the problem or opportunity Insurance problem example: Toyota would want to know the REASON for the 5 day turn time. Missing information? Poor flow in processing the quote? Approval process too lengthy? Employees properly trained? A process that quickly jumps to a solution (hiring more) without good grasp of the root causes may achieve desired results but not viewed as successful, must go through the process

23 Synthesis, Distillation, and Visualization
Time: 2 min Minimizes “Death by PowerPoint” Forces brevity and clarity Only most vital points used for proper understanding Utilizes graphs, pictures, and sketches to promote understanding (visualization) A3 is brief by design, hits main point directly Brevity for brevity’s sake is not the point (but attractive side benefit) Brevity Forces synthesis of the learning acquired and interaction with others during the process Not all info is equally salient, therefore must distill the synthesized picture to only the most vital points needed A picture is worth a thousand words Emphasize here that once alignment is achieved and inputs are considered, you will have a very broad picture of the situation, but the key is to distill down to most critical info. THIS IS HARD. This is where visualization is invaluable. Takes out subjectivity when data is used, and visual representation through graphs, pictures, etc helps you do that.

24 Alignment 3D Communication Heavy emphasis on consensus decision making
Time: 2 min 3D Communication Up and down the hierarchy Horizontally across the organization Back and forth in time Heavy emphasis on consensus decision making Develop agreement around decisions 3D communication: horizontally across the organization, up and down the hierarchy, and back and forth in time Consensus is actually Practical consensus: 100% buy in not always possible, so when someone’s concern is not incorporated, the problem solver returns to that person to explain (a courtesy and tangible act to show the concerns were taken seriously). This is also an implicit request of the individual to sacrifice some of his or her interests for the greater good Ask them what consensus it? (May not agree with the point, but I can live with it). Inform them this is proper buy-in or coordination as they may know it.

25 Coherence & Consistency
Time: 2 min Avoids: Tackling problems that are not important to organizational goals Solutions that do not address root cause(s) Incomplete implementation plans Omission of follow up plans and standard work Coherence within & Consistency Across the organization What it does do: Establishes a logical flow from one section of the A3 to the next—flows like a storyline Promotes coherency within the problem solving approach A3 makes the coherency of one’s approach (or lack of it) visible Theme or issue should be consistent with the organization’s goals and values Promotes consistency across organizational units Here point out that some folks a few days or weeks into a major problem could stray and for example, have countermeasures that don’t address any of the root causes. The A3 approach helps prevent that.

26 Systems Viewpoint Time: 2 min The impact of the proposed solution must not adversely impact other parts of the organization (i.e. transferring a problem from one department to another) The good of the whole organization takes clear precedence over the individual departments Simply saying “Let’s take a systems viewpoint” is insufficient Activities and conversations that occur are paramount importance Toyota individuals mentored to develop deep understanding of: The purpose of the course of action How the course of action further the organizations goals, needs or priorities How it fits into the larger picture and affects other parts of the organization The good of the overall organization takes full precedence over any individual or unit. Ask what behavior is generated at the end of FY money wise? Spend or lose correct. Whose money is it really (Taxpayers, and the AF is trusted with those resources for mission performance). Should we not give that back to big AF for the overall good? Or to DoD? The problem is the process generates behavior that gets rewarded that is very counter to a systems viewpoint.

27 Cell Design / Variation Reduction Error Proofing Quick Changeover TPM
Time: 5 min SA&D SWOT Voice of Customer VSM Go & See Brainstorming Pareto Affinity Fishbone Control Charts 6S & Visual Mgt Standard Work Cell Design / Variation Reduction Error Proofing Quick Changeover TPM RIE KPIs/Metrics Performance Mgt SA&D Standard Work Audit KPI/Metrics Performance Gap Analysis Bottleneck Analysis A3 Action Plans Timelines Financial Reporting Template So here is how an AF A3 would flow using OODA (PDCA) methodology and some of the tools available to the problem solver at each step We will go into each of these steps in great detail throughout the rest of the course Emphasize here that the tools are not exclusive to the steps where they are listed. They can and are used wherever needed. Also a good place to emphasize that this is not a cookbook, so use the tools where they help you. Ideal State Future State Mapping B-SMART Checkpoints / Standardization Tbl Report Out Theme Story Broad Implementation CPI Mgt Tool 27 27

28 Observe Phase Clarify the Problem Strategic Alignment and Deployment
OODA Clarify the Problem Strategic Alignment and Deployment Voice of Customer Value Stream Mapping Go & See Break Down the Problem and Identify Performance Gaps Key Process Indicators / Metrics SWOT Performance Gap Analysis Bottleneck Analysis

29 Step 1 – Clarify the Problem
OODA Strategic Alignment & Deployment (SA&D) Ensuring that activities are linked to the key strategies and directives of the organization Strengths, Weaknesses, Opportunities & Threats (SWOT) Analysis Assessing the organization from a SWOT perspective to identify areas of need Needs to be rolled into SA&D at appropriate levels Voice of Customer (VOC) Understanding who the customer is and what they need from the process or problem area Value Stream Mapping (VSM) Overview of Process to determine areas of needed focus Go & See Determine issues by actually walking the process or problem area (Gemba or Genchi Genbutsu)

30 Step 1 – Key Questions Does this problem, when solved, help meet needs identified by the organization? Is it linked to the SA&D of organization? Does it help satisfy customer needs (VOC)? Does this problem, when solved, address key issues identified during SWOT analysis? Has this problem been identified and directed by a Value Stream Map at the appropriate level? What does the “Future State” need? What resources have been identified to address this issue? What opportunities were identified or observed by the process or problem area “walk”? Will addressing or improving these issues deliver results that relate to #1 or #2? Will addressing or improving this problem deliver the desired future state from #3?16 OODA

31 Step 2 – Break Down Problem & I.D. Performance Gaps
OODA Gather and Review Key Process Indicators and Metrics Problem Solving and Process Improvement begin with Data Understanding what data is necessary and what the data means is critical to true “root cause” problem solving Performance Gap Analysis Once data has been gathered, analyzing the gap between the current state and the desired state directs efforts Bottleneck Analysis Bottlenecks are inhibitors to the flow of the process Understanding bottlenecks (TOC) is critical to flow

32 Step 2 – Key Questions Is this simply a leadership directive?
Does the problem require more analysis or does leadership have enough information to execute a solution? Is this simply a leadership directive? If more data is needed, how do we measure performance now? What are the Key Performance Indicators (KPI)? What is the performance gap? Does other “non-existent” data need to be gathered? What does the data indicate are the potential root causes? Does the data review indicate a bottleneck or constraint? OODA

33 Step 3 - Set Improvement Target
OODA Ideal State Map Brainstorming “Could-Be” without constraints Future State Mapping “Vision” of Future for Process B - SMART Action Plan Balanced Specific Measurable Action Oriented Results Oriented Time-based

34 Step 3 - Set Improvement Target
Target characteristics Must be measurable, concrete, challenging and achievable Statement of a Target Do what: (examples include “decrease ____?”, “increase ____?”, eliminate ____?, reduce ____?) By how much: (measured in the same terms as the standard) By when: (specific date) Must be output oriented Things to be achieved, not things to do OODA

35 Step 3 – Key Questions Is the Improvement Target measurable?
Is it Concrete? Is it Challenging? Is the Target “Output Oriented”? What is the desired output? Should be “things to achieve” Should avoid “things to do” Will be addressed by Action Plans in “Develop Countermeasure” The desired target should: Do What? By How Much? By When? If it is a Process Problem, what is the future state? How will it be realized? OODA

36 Step 4 – Determine Root Cause
OODA Root Cause Characteristics The root cause is the most likely source of the discrepancy or greatest possible improvement target The root cause can be dealt with directly and a countermeasure can be planned to address it If root cause is addressed, it will address the performance gap The root cause must be verified by “go and see” Determining the Root Cause is easier with Data

37 Step 4 – Determine Root Cause
Tools for Step 4 5 Whys Brainstorming Pareto Analysis Affinity Diagrams Fishbone Diagrams (also called Cause & Effect) Control Charts Additional Data Gathering Tools Check Sheets, Chonbo Charts, Scatter Diagrams OODA

38 Step 4 – Key Questions 10 heads are better than one
What root cause analysis tools are necessary? Why are these tools necessary? What benefit will be gained by using them? Who will need to be involved in the root cause analysis? 10 heads are better than one Remember “cultural” issues related to problem What is (are) the root cause(s) according to the tools? How will the root cause be addressed? Will addressing these address the performance gap? Can the problem be turned on or off by addressing the root cause? Does the root cause make sense if the problem solving 5 Whys are worked in reverse? Working in reverse, say “therefore” between each of the “whys” OODA

39 Step 5 – Develop Countermeasure
Decide Stage – Develop Countermeasures A3 Problem Solving and Reporting Format Common Structure and Concise Reporting Action Plans SMART Action Items Timelines & Project Management Managing complex Problem Solving in a project fashion FM Tool Understanding the impact of the improvements OODA

40 Step 5 – Key Actions Develop potential countermeasures Tools and philosophies from Lean, TOC, 6 Sigma and BPR as appropriate Select the most practical and effective countermeasures Build consensus with others by involving all stakeholders appropriately Communicate, communicate, communicate Create clear and detailed action plan SMART Actions Reference Facilitation Techniques as appropriate OODA

41 Step 6 – See Countermeasures Through
Process Improvement Philosophies Lean, TOC, 6 Sigma, BPR Lean and Process Improvement Tools 6-S & Visual Management Standard Work Cell Design Variation Reduction Error Proofing Quick Changeover Total Productive Maintenance (TPM) Rapid Improvement Events (RIE) OODA

42 Step 6 – Key Questions Which philosophy best prescribes tools that address root cause(s)? Which tools best address root cause(s)? Which method for implementation fits the tool and improvement need? Rapid Improvement Event? Improvement Project? Point Improvement or “Just Do It”? If RIE or Project, create “Charter” and communicate What training or education is needed? By Whom? OODA

43 Step 7 – Key Questions How are we performing relative to the Observe phase (Steps 1 & 2)? How are we performing relative to Step 3? How are we performing relative to FM Tool projections? If we are not meeting targets, do we need to return to OODA Step #4? Most problem solving “breakdowns” occur relative to improper root cause identification OODA

44 Step 8 – Standardize Successful Processes
Checkpoints and Standardization Tables Report-out Storyboards Board Implementation Capture Results in Powersteering Sharing of Results Communication of Best Practices Restart OODA Loop OODA

45 Step 8 – Key Questions What is needed to Standardize Improvements?
Tech Order changes? Air Force Instruction changes? Official Instruction changes? How should improvements and lessons learned be communicated? Powersteering Key meetings? Were other opportunities or problems identified by the Problem Solving Process? Restart OODA Loop OODA

46 Step 8 – Standardize Successful Processes
Checkpoints and Standardization Tables Report-out Storyboards Board Implementation Capture Results in Powersteering Sharing of Results Communication of Best Practices Restart OODA Loop OODA

47 Step 8 – Key Questions What is needed to Standardize Improvements?
Tech Order changes? Air Force Instruction changes? Official Instruction changes? How should improvements and lessons learned be communicated? Powersteering Key meetings? Were other opportunities or problems identified by the Problem Solving Process? Restart OODA Loop OODA

48 Clarify the Problem Problem Solving Process & Related Toolsets SA&D
SWOT Voice of Customer Value Stream Mapping Go & See

49 Break Down the Problem/Identify Performance Gaps
KPI/Metrics Performance Gap Analysis Bottleneck Analysis

50 Set Improvement Target
Ideal State Future State Mapping B-SMART

51 Determine Root Cause 5 Whys Brainstorming Pareto Affinity Fishbone
Control Charts

52 Develop Countermeasure
6S & Visual Management Standard Work Cell Design Variation Reduction Error Proofing Quick Changeover TPM RIE

53 Confirm Results & Process
KPIs & Metrics Performance Management SA&D Standard Work

54 Standardize Successful Processes
Checkpoints & Standardization Table Report Out theme Story Board Implementation Powersteering Start OODA

55 OODA Loop Summary Effective Problem Solving must follow the Observe, Orient, Decide and Act process Following OODA ensures actions will result in desired results Following OODA ensures results will meet the needs of the organization Meeting the needs of the organization will lead to a stronger Air Force (Culturally as well) A stronger Air Force leads to a Safer Country!


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