1. An Introduction to Lean Six Sigma What gets measured gets done…… But not always in the way we want

2. Process Improvement Initial problem perception Clarify problem Locate point of cause Root cause analysis Design solutions Test to see if worked Standardize

3. Lean Six Sigma Process Improvement Lean Six Sigma Seeks to improve the quality of manufacturing and business process by: – identifying and removing the causes of defects (errors) and variation. – Identifying and removing sources of waste within the process – Focusing on outputs that are critical to customers DefineMeasureAnalyzeImproveControl

4. 193019501900 Ford Assembly Line Guinness Brewery Shewhart Introduces SPC Gilbreth, Inc. Management Theory Industrial Engineering Deming 14 Points 7 Deadly Diseases Toyota Production System Lean Six Sigma Timeline

5. 199020001980 Motorola Introduces Six Sigma Just – in–Time SPC Lean Mfg. TQM AlliedSIgnal GE Adapt LSS to Business Processes Lean Six Sigma Timeline

6. 20152000 Lean Six Sigma Timeline

7. Lean vs. Six Sigma Lean tends to be used for shorter, less complex problems. Often time driven. Focus is on eliminating wasteful steps and practices. Continuous/ongoing Six Sigma is a bigger more analytical approach – often quality driven – it tends to have a statistical approach. – reduce defects. Special project Some argue Lean moves the mean, SixSigma moves the variance. – Waste elimination eliminates an opportunity to make a defect – Less rework means faster cycle times Six Sigma training might be specialized to the “quality” department, but everyone in the organization should be trained in Lean

8. VOC vs. VOP Voice of Customer Voice of Process The Voice of the Process is independent of the Voice of the Customer Sigma Capability Defects per Million Opportunities % Yield 2308,53769.15% 366,80793.32% 46,21099.38% 523399.98% 63.4 99.99966%

9. Background on Lean Lean comes out of the industrial engineering world Taiichi Ohno – Toyota Production System. – 1940s-1950s company was on verge of bankruptcy – Dynamics of industry were changing – moving from mass production to more flexible, shorter, varied batch runs (people wanted more colors, different features, more models, etc). Ohno was inspired by 3 observations on a trip to America – Henry Ford’s assembly line inspired the principle of flow (keep products moving because no value is added while it is sitting still) – The Indy 500 – Rapid Changeover – The American Grocery Store – led to the Pull system – material use signals when and how stock needs to be replenished

10. What is Lean? Taiichi Ohno: – “all we are doing is looking at the timeline from the moment a customer gives us an order to the point when we collect the cash. And we are reducing that timeline by removing the non-value- added wastes” – It is about eliminating waste and showing respect for people

11. Lean Thinking Lean is about making the right work easier to do Work is designed as a series of ongoing experiments that immediately reveal problems Problems are addressed immediately through rapid experimentation Solutions are disseminated adaptively through collaborative experimentation People at all levels of the organization are taught to become experimentalists

12. Path To Lean TheoryWaste is Deadly Application1.Define Value – act on what is important to the customer 2.Identify Value Stream – understand what steps in the process add value and which don’t 3.Make it flow – keep the work moving at all times and eliminate waste that creates delay 4.Let customer pull -- Avoid making more or ordering more inputs for customer demand you don’t have 5.Pursue perfection -- there is no optimum level of performance FocusFlow Focused AssumptionsNon-Value added steps exist ResultsReduced cycle time

13. Waste Defined WastesHealthcare Examples Transport 1.Moving patients from room to room 2.Poor workplace layouts, for patient services 3.Moving equipment in and out of procedure room or operating room Inventory 1.Overstocked medications on units/floors or in pharmacy 2.Physician orders building up to be entered 3.Unnecessary instruments contained in operating kits Motion 1.Leaving patient rooms to: Get supplies or record Documents care provided 2.Large reach/walk distance to complete a process step Waiting 1.Idle equipment/people 2.Early admissions for procedures later in the day 3.Waiting for internal transport between departments Over-Production 1.Multiple signature requirements 2.Extra copies of forms 3.Multiple information systems entries 4.Printing hard copy of report when digital is sufficient Over-Processing 1.Asking the patient the same questions multiple times 2.Unnecessary carbon copying 3.Batch printing patient labels Defects 1.Hospital-acquired illness 2.Wrong-site surgeries 3.Medication errors 4.Dealing with service complaints 5.Illegible, handwritten information 6.Collection of incorrect patient information Skills 1.Not using people’s mental, creative, and physical abilities 2.Staff not involved in redesigning processes in their workplace 3.Nurses and Doctors spending time locating equipment and supplies 4.Staff rework due to system failures

14. Applying Lean in Real Life Toast Kaizan 3:28 – Current Condition 20:10 – Target Condition

15. The Lean House Goals: Safety, Quality, Time, Cost, Morale Heijunka Standardized Work Kaizen (level loading (employee empowerment) (Continuous Improvement) Prevent Delays Value Stream Focus Pull Systems Right care, right place, right time Identify root Cause Prevent errors at the source Involve employees Avoid blame Developing People FlowQuality

16. Lean Foundations Standardized Work – people should analyze their work and define the way that best meets the needs of all stakeholders. – “The current one best way to safely complete an activity with the proper outcome and the highest quality, using the fewest possible resources” – Standardized not Identical – mindless conformity and the thoughtful setting of standards should not be confused – Written by those who do the work.

17. Lean Foundations Heijunka -- Level loading – smoothing the workflow and patient flow throughout the hospital. Kaizen – continuous improvement Employee Empowerment – Andon Cord Jidoka – problems are fixed at the source instead of being passed along and fixed at the source – “Suggestion Box”

18. Lead Time and Value Added

19. Types of Work Value Added Work – Activities that transform materials or information into something that the customer cares about Non-Valued Added Work – Necessary Room changeover Testing Administration? – Unnecessary (pure waste) Re-testing Waiting for a test Walking

20. Value Stream Mapping A value stream map is a type of process map – But shows how long each step takes – As well as the wait time between each step Current State VSM – Helps identify waste and opportunity for improvement Future State Map – Target for where we want to be

21. Compile Folder with Docs Receiving: Open & Array Docs Verify Claim Calculate Amount & Address Print, Stuff & Mail Check Policy Holder’s Family Insurance Co. FIFO 2Min5 10Min1 1 P/T = L/T = # inputs = Reliability = P/T = L/T = %C&A = # ops = P/T = L/T = % rejects = Reliability = P/T = L/T = % rework = # ops = P/T = L/T = Reliability = % errors = 7Days7 7 7 FIFO 28Days 19Min email mail manual finan Process Box Process Data Box Technology Used Work PrioritySystem Metric Insurance Claim Processing

23. Swim Lane Processes and decisions are grouped visually by placing them in lanes. Parallel lines divide the chart into lanes, with one lane for each person, group or subprocess. Arrows between the lanes represent how information or material is passed between the subprocesses.

25. Spaghetti Diagram A spaghetti diagram is a visual representation using a continuous flow line tracing the path of an item or activity through a process. Decide what you are going to observe eg product, staff or patient flow. Draw the layout of the area and then draw lines on the diagram to represent the main flows of the staff member or patient. By analyzing the lines, you can identify any areas with unnecessary movement. This helps staff decide whether to bring two points closer together and optimizes the flow.

28. Lean Methods Kaizen Events (or SCORE events) – Planned and structured process that enables a small group of people to improve some aspect of their business in a quick, focused manner. Select Clarify Organize Run Evaluate 5S – this methodology reduces waste through improved workplace organization and visual management – Sort, Store, Shine, Standardize and Sustain Kanban – a Japanese term that can be translated as “signal,” “card,” or “sign.” – Most often a physical signal (paper card of plastic bin), that indicates when it is time to order more, from whom, and in what quantity.

29. 5S and the Visual Healthcare Workplace Sort – Get rid of unneeded items Straighten – Organize and label the location for items that are needed in the area Shine – Clean the workspace – Equipment clean and prepped for use Standardize – Develop cleaning methods and cleanliness standards to maintain the first 3 S’s Sustain – Review the workplace regularly. Make it a habit

31. Lean Daily Management The LDM process promotes employee ownership of their operational performance Creates a no-fault culture Reinforces continual improvement efforts. Physicians often respond well to its transparent, data-oriented nature.

32. Lean Daily Management Each day, a team (composed of all operational stakeholders) gathers for a 5-minute discussion to review a dashboard four categories: safety, quality, cost, and efficiency. To help focus and prioritize its improvement efforts, the team should place only one metric in each category.

33. The Glass Wall

36. Departmental Boards

40. Six Sigma Overview Diligent attention to managing, improving, and reinventing business processes Disciplined use of facts, data, and statistical analysis A close understanding of both internal and external customer needs Standard deviation (σ) is used to measure the amount of process variation As sigma gets larger, process variation increases Variation is the enemy

41. Six Sigma is a Quality Measure and a Goal

42. Six Sigma as a Methodology Underlying methodology called DMAIC Empowerment of trained professionals Formal project charters set the scope and objectives Various basic quality tools and statistical tools applied during project Project champion/sponsor both approve project tollgates

43. Lean & Six Sigma are Synergistic Lean Goal: Improve process performance through waste elimination & cycle time reduction Focus: Bias for action Method: Implement Lean tools such as Kaizen events, Value Stream Mapping, 5S, TPM etc. Deployment: Implicit infrastructure Speed, Flow, Cost Six Sigma Goal: Improve process performance in relation to what is critical to the customer Focus: Bias for analysis Method: Uses the DMAIC method and quality tools Deployment: Explicit Infrastructure Customer Satisfaction Lean Focus on Waste Elimination supports Six Sigma Quality (waste elimination eliminates an opportunity to make a defect) Six Sigma Quality supports Lean Speed (less rework means faster cycle times)

44. What Tool do I use? Complexity of toolComplexity of tool Complexity of IssueComplexity of Issue Variation Reductio n Waste and Flow Issues Simple Problems 6σ6σ LeanLean

45. What Makes a Good Six Sigma Project? There is no known solution The root cause is not known The problem is complex and needs statistical analysis The problem is part of a process The process is repeatable A defect can be defined Project will take 3-6 months There are data available

46. The DMAIC Methodology Define – describe the problem quantifiably and the underlying process to determine how performance will be measured. Measure – use measures or metrics to understand performance and the improvement opportunity. Analyze – identify the true root cause(s) of the underlying problem. Improve – identify and test the best improvements that address the root causes. Control – identify sustainment strategies that ensure process performance maintains the improved state.

47. Define Define Scope of the Problem – Document the Process – Collect and Translate the Voice of the Customer Determine Project Objective and Benefits – Define Metrics and Defects – Establish Preliminary Baseline – Develop Problem & Objective Statements – Estimate Financial Benefit

48. Define (continued) Create Project Charter – Confirm Improvement Methodology – Define Project Roles and Responsibilities – Identify Risks – Establish Timeline – Managerial Buy-in Focus here is on the problem

49. Measure Measure what is measurable, and make measurable what is not so” – Galileo Define “As Is” process – Value stream map/process flow diagram Validate Measurement System for Outputs – Don’t assume your measurements are accurate – measuring system must accurately tell what is happening Quantify Process Performance – Collect data (Y’s) – Examine process stability/capability analysis

50. “Before”

52. Analyze Identify Potential Causes (X’s) Investigate Significance of X’s – Collect data on x’s – Graphical/Quantitative analysis Pareto Chart Fishbone Diagram (cause and effect) Chi Square Test Regression Analysis Failure Mode Effects Analysis Identify Significant Causes to focus on y=f(X) – Evaluate the impact of x’s on y Here you identify the critical factors of a “good” output and the root causes of defects or “bad” output.

53. Pareto Diagram According to the “Pareto Principle,” in any group of things that contribute to a common effect, a relatively few contributors account for the majority of the effect. Error TypeFrequencyPercentCumulative % Wrong Supplier6746.5 Excess Count2416.763.2 Too Few Count1711.875 Wrong Size106.981.9 Wrong Sterile Instrument Set 106.988.8 Missing Item85.694.4 Damaged Item64.298.6 Other21.4100 TOTAL144100 Types of Errors Discovered During Surgical Setup

54. Pareto Diagram Important Few

55. Fishbone (Cause and Effect) Diagram

56. Cause and Effect Matrix (Root Cause Analysis)

57. Improve Generate Potential Solutions Select & Test Solution Develop Implementation Plan

58. Control Create Control & Monitoring Plan – Mistake proof the process – Determine the x’s to control and methods – Determine Y’s to monitor Implement Full Scale Solution – Revise/develop process – Implement and evaluate solution Finalize Transition – Develop transition plan – Handoff process to owner

59. “After”