2. Introduction to Six Sigma

3. Conceptual Framework Critical to Quality (CTQ):Critical to Quality (CTQ): Attributes most important to the customer Defect:Defect: Failing to deliver what the customer wants Process Capability:Process Capability: What your process can deliver Stable Operations:Stable Operations: Ensuring consistent, predictable processes to improve what the customer perceives

4. History “Six Sigma” coined at Motorola in the 1980s Adopted by Allied Signal (Honeywell) with great success Later adopted by Jack Welch (GE) and further developed into a true management system

5. What is Six Sigma? measurement 1.The term “Sigma” is a measurement of how far a given process deviates from perfection – a measure of number of “defects”. “Six Sigma” implies near zero defects. 2.“A quality improvement methodology that applies statistics to measure and reduce variation in processes.” management system 3. A management system that is “comprehensive and flexible for achieving, sustaining, and maximizing business success.”

6. Measurement: Measurement: Six Sigma as a Quality Goal The higher the sigma, the fewer the defects. A increase from 3 to 6 Sigma represents a 20,000 fold improvement in quality. 3 99% “Good” (3.8 Sigma) No electricity for 7 hours per month 5,000 incorrect operations per week 20,000 wrong prescriptions per year 99.99966% “Good” (6 Sigma) No electricity for 1 hour every 34 years 1.7 incorrect operations per week 68 wrong prescriptions per year

7. Measurement: Measurement: Variation is the Enemy Time Intervals Mean W I D E Variation Slim Variation Example: TAT Project Time (Min.). Target Customer Upper Limit Customer Upper Limit DEFECTS ZERO DEFECTS Time (Min.).

8. Improvement Methodology: Improvement Methodology: DMAIC “Backbone” D Define …the problem in a measurable way M Measure …the data A Analyze …and validate root cause(s) I Improve Devise solution(s) and implement C Control Sustain improvement

9. Improvement Methodology: Improvement Methodology: Key Players Team Members: Individuals who receive specific Six Sigma training and who support projects in their areas Champions/Sponsors: Trained business leaders who lead the deployment of Six Sigma in a significant business area Black Belts: Fully-trained Six Sigma experts who lead improvement teams, work projects across the business and mentor Green Belts Green Belts: Fully-trained individuals who apply Six Sigma skills to projects in their job areas Master Black Belts: Fully-trained quality leaders responsible for Six Sigma strategy, training, mentoring, deployment and results

10. Management System: Management System: Themes Customer Focus Data- and Fact-Driven Management Process is Key Proactive Management “Boundaryless” Collaboration Drive for Perfection; Tolerate Failure Source: Adopted from “The Six Sigma Way” by P. Pande, R. Neuman, and R. Cavanagh

11. Scalable Implementation Problem Solving Strategic Improvement Full-Scale Business Transformation Source: Adopted from “The Six Sigma Way” by P. Pande, R. Neuman, and R. Cavanagh

12. How is Six Sigma Different? Six Sigma Driven by the customer Targets variation Focuses on processes Prospective; prevents defects Focuses on quality & ROI Attentive to total business Training is integral to management system Other Quality Programs Driven internally Looks at averages Focuses on outcomes Retrospective; fixes defects Focuses on quality Attentive to production Training is separate from management system

13. Success in Industry - Financial savings as a percentage of revenue were observed to vary between 1.2% and 4.5%. In a study of Motorola, Allied Signal, GE, and Honeywell -- companies with mature Six Sigma deployments and associated culture changes -- savings as a percentage of revenue were observed to vary between 1.2% and 4.5%. -- Charles Waxer (2003), “Six Sigma Costs And Savings”

14. Success in Industry - Non-FinancialGE 98% -Reduced invoice defects and disputes with a key customer by 98% 76% to 99% -Improved a key call center performance measure from 76% to 99% 300% -Reduced vibrations in Power System rotors by 300% 30 seconds from 3 minutes -Developed breakthrough technology that reduced medical scan times to 30 seconds from 3 minutes Allied Signal (Honeywell) 68% in 4 months -Reduced defects by 68% in 4 months Texas Instruments 84.3% to 99.8% -Improved yield from 84.3% to 99.8% since 1998

15. Industry Pursuing Six Sigma  FedEx  Sony  Toshiba  Nokia  American Express  Oracle  Amazon.com  Texas Instruments  Hitachi  Honda  Raytheon  Lockheed Martin  Siemens  Honeywell  Kodak  Dupont  Conseco  IBM  Bombardier  Maytag  Canon

16. The Application of Six Sigma in Healthcare Delivery Carolyn Pexton Director of Communications, GE Healthcare Performance Solutions

17. Dissatisfaction with being “average” Physicians not engaged with prior approaches Insufficient tools to execute vision Need for structure and discipline in decision-making processes What is driving healthcare to adopt new models? Need for higher level analysis Need to “shine a light” on processes Need for a new platform/bar for leadership skills Market positioning Current quality programs need resuscitation

18. 44,000 to 98,000 Preventable Hospital Deaths (IOM study, 1999) In-Hospital Deaths from Medical Errors at 195,000 per Year. Patient Safety Incidents In Hospitals Account for $6 Billion per Year in Extra Costs (HealthGrades - July, 2004) How Safe is Healthcare? Defects in healthcare are costly -- unlike manufacturing, you can’t simply shut down the line until you find and fix the problem.

19. Pioneering effort gets underway Is Healthcare Ready for Six Sigma? (Mark Chassin, MD – 1998) From a few early adopters…to a variety of project-focused and enterprise-wide implementations in healthcare. But still just the tip of the iceberg in terms of spread.

20. Reduction in Blood Stream Infections in ICU Stroke Patient Length of Stay Reduced Number of Inpatient Transfers Emergency Department Patient Wait Time Improved Patient Throughput in Radiology Reduction in Lost Films MR Exam Scheduling Improvement Staff Recruitment and Retention Operating Room Case Cart Accuracy Physician (Professional Fee) Billing Accuracy Appointment Backlog for Hospital-Based Orthopedic Clinic Quality of Care and Satisfaction of Families in Newborn ICU Examples of Projects Across a Health System

21. Prioritizing Patient Safety Projects Topic Wrong side/Wrong site surgery Instrumentation left in patient Failure to triage high risk patients Medication error-wrong dose Metal in magnet during scan (MRI) Restraint use resulting in injury Patient injury Falls Burns from faulty equipment Inaccurate lab results reported resulting in wrong therapy Number of Annual Occurrences 2 5 4 43 1 6 12 8 2 15

22. Facility TypeImprovement OpportunityResult Regional Medical Center in the Southeast Patient LOS in ED and admit bed delay, reducing diverts  $1 million in documented gains Healthcare Delivery System in California Increase throughput and generate incremental revenue opportunities  $8.4m in documented gains Large Metropolitan Hospital System Reduce number of inpatient transfers (defect — any patient transferred more than once) 75% reduction in inpatient transfers; $2m annual cost savings Health System in Midwest Bed availability (3 projects)  $1.86 million in documented gains Renowned Academic Medical Center in California Improved throughput and workflow for PACS, MR, CT, CR/Ortho  $4 million dollars in documented gains Six Sigma and the Bottom Line It takes a strong margin to support a noble mission Even non-clinical projects can potentially support quality and patient safety efforts by freeing capital that can be used to hire additional nurses, acquire new lifesaving technologies, invest in CPOE etc.

23. Key Success Factors CEO must own it and must have a clear vision for the initiative Invest in resources and make a long term commitment Dedicate “best and brightest” Measure and hold people accountable Change the systems and structures to support the effort Establish early, ongoing and clear communications Be flexible and patient Select and scope projects carefully: Focus on critical issues tied to business priorities, with measurable and manageable parameters Use change management tools to identify cultural barriers, gain acceptance and build momentum Establish shared need, values and vision Recognize, reward and celebrate successes

24.  Customer Service/Satisfaction Reduced Wait Times Consistent Service  Delivered Quality of Care Reduced Medical Errors Use of Appropriate Technology  Cost Management Increased Productivity and Throughput Decreased Cost through Reduced Variation  Compliance requirements Align opportunities with organizational objectives Addressing key issues in healthcare:

25. This is a journey – not a destination Six Sigma is a solid approach, but not a “magic bullet” -- Transforming healthcare will also likely require changes in technology, legislation/regulation, transparency and culture. Over 60% of quality efforts fail. To be among the successful 40%, pay attention to the people side of change. The Effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea.

26. "Evidenced-based medicine tells us what is needed to improve clinical outcomes, but Six Sigma provides a road map of how to get there." David Keefe, MD Women & Infants Hospital of Rhode Island Voices of Experience "The Six Sigma projects are sort of a means to the end -- the end is cultural change, the notion of constantly improving, raising that bar, driving change through the organization, making those sustained changes and improvements for our patients." Jim Springfield President and CEO Valley Baptist Health System, Harlingen, TX " Six Sigma has become the capstone to the pyramid of quality we’ve built over the years. It brings everything to a whole new level. " John Desmarais, President and CEO Commonwealth Health Corporation, Bowling Green, KY "Virtua's Six Sigma and change management initiatives have delivered tangible, measurable results having a positive impact on patient care, employee morale and the organization's bottom line." Susan McGann, MBB Virtua Health, New Jersey