Basic Process Improvement Methods in Health Care€œBasic 7 Tools” • Check sheets • Pareto...

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James C. Benneyan, PhD, Director Healthcare Systems Engineering Institute CMS Innovation Healthcare Systems Engineering Center NSF Center for Health Organization Transformation Northeastern University, Boston MA www.HSyE.org Basic Process Improvement Methods in Health Care Summer Intern Orientation, May 2015
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Transcript of Basic Process Improvement Methods in Health Care€œBasic 7 Tools” • Check sheets • Pareto...

  • James C. Benneyan, PhD, DirectorHealthcare Systems Engineering InstituteCMS Innovation Healthcare Systems Engineering Center NSF Center for Health Organization TransformationNortheastern University, Boston MAwww.HSyE.org

    Basic Process Improvement Methods in Health CareSummer Intern Orientation, May 2015

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Outline

    1. Thebig3:i. Sixsigma(Motorola,GE)ii. Lean(Toyotaproductionsystem)iii. PDSA(PlanDoStudyAct)

    2. Othersi. Theoryofconstraintsii. others

    3. InstituteforHealthcareImprovement(IHI)i. ModelforImprovementii. Collaborativeimprovement

    2

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Healthcare Systems Engineering Institute

    3

    Partnerships ProjectTypes Criteria PrimaryMechanism

    NSFResearchCenter

    CMSApplicationCenter

    Capstone,Coops SummerInterns

    Research

    Discover

    Applied

    Impact

    Experiential

    Education

    1 2years

    3 9months

    Developingwhatwe

    dontknow

    Doing whatweknow

    2 6months

    Teachingothersbydoing

    Mission:Broadmeasureableimpactonhealthcare,nationally,throughresearch,education,andapplicationofindustrialandsystemsengineering

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Recall (70-20-10 rule)

    4

    SimpleComplex

    IndustrialandSystemsEngineering

    1.Methodsbased Modelbased

    PDSA

    Lean

    SixSigma2.Computersimulation

    4.Mathematicaloptimization

    3.Probabilityandstochasticmodelsetc etc

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    1.Basic Improvement Methods

    (70% of it)

    10

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Process improvement methods

    11

    Approach

    Totalqualitymgmt(TQM)

    Continuousqualityimprovement

    PDCA /ModelforImprovement

    SixSigma

    LeanToyotaProductionSystem

    Varietyofapproaches

    80%+ problems

    Slightlydifferenttool kitsandapproaches

    Commonconcepts: Understand currentprocess

    Drawpictureofprocesslogic

    Usedata(before/after) Test improvementideas

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Similar/differentfocus

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Total quality management (TQM)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    TQM overview

    PopularizedinU.S.industryin197080s Gurus:Deming,Juran,Feigenbaum,Crosby,

    Appreciationofthesystemasawhole

    Focusonprocessquality

    85%problemsduetoprocess(notpeople)

    Useofstatisticalmethodstounderstand,monitor,andimprovequality

    Adaptedintohealthcare,1990s

    Quality is Job 1

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Common approach & philosophy

    Managementsjobistocreateasystemtoimprovequalityandremovebarrierstoimprovement

    Thereisnoquickfix,noinstantpudding,nomagicbulletcontinuousimprovementofprocessrequired

    Longtermfocusoncontinuousneverendingoftenincrementalimprovements

    EmployeeinvolvementinQIasvaluableresource Engagementoffrontlineworkersinimprovementaskey

    processexperts(qualityimprovementcircles)

    Useofdataandstatisticalmethodstoimprovequality,not tomeasure/reward/punishworkers

    Studyofvariation(naturalvs.specialcause)(SPC)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Continuous quality improvement (CQI)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Common QI/6tools

    23

    Basic7Tools

    Checksheets Paretocharts Causeandeffect

    fishbonediagrams

    Processflowcharts Histograms Scatterdiagrams Runandcontrolcharts

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Examples

    Monthly Volume

    Temps hired dueto high volume

    (r = 0.23)

    Billin

    g co

    ding

    erro

    r rat

    e

    0

    200

    400

    600

    800

    1000

    Posi

    t

    Dar

    k

    Ligh

    t

    Mot

    ion

    Oth

    er

    Cho

    ice

    Equi

    p

    Art

    if.

    DB

    L EX

    J R

    eas

    K R

    eas

    L R

    eas

    Trivial/vital many (can add up to a lot)

    Critical few

    Reasons for Poor Mammogram Image

    Freq

    uenc

    y

    The 5 Ms and 5 Whys

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Process flow examples

    25

    Graphicaldepictionofprocesslogic Severalcommonformats(noneright

    orwrong) Usefultounderstandhowprocesscould

    beimproved Sharedconsensusandstandardization

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    How do you make tea?

    26

    Making Tea

  • Healthcare Systems Engineering | www.coe.neu.edu/healthcare | Northeastern University 2010

    Qualitycontrolchartexamples

    0

    5

    10

    15

    20

    25

    30

    35

    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

    Month

    VAP

    rate

    per

    100

    0 ve

    ntila

    tor d

    ays

    UCL

    UWL

    LWL

    LCL

    Subgroup Num

    2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

    SurgicalSiteInfections

    Subgroup (Month) Number

    -200

    -100

    0

    100

    200

    300

    4/93

    5/93

    6/93

    7/93

    8/93

    9/93

    10/9

    311

    /93

    12/9

    31/

    942/

    943/

    944/

    945/

    946/

    947/

    94

    8/94

    9/94

    10/9

    411

    /94

    12/9

    41/

    952/

    953/

    954/

    95

    5/95

    6/95

    7/95

    8/95

    9/95

    UCL

    CL

    LCL

    Trial X-bar Control ChartPerioperativeAntibioticTiming

    XbarChart

    VentilatorAssociatedPneumonia(VAP)

    ScotlandSurveillanceforRegionalMRSA Morelater

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Six sigma(a CQI implementation approach)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Six Sigma DMAIC basics

    30

    Focus:Qualityimprovement Structuredapproaches,integratedmeasuring

    DMAIC: Improveexistingprocess DFSS: DesignforSixSigma DMADV: Define,Measure,Analyze,DesignVerify

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    DMAIC example

    31

    Define: ProcessmapsforEBMdelivery(AMI,SSI,CHF)

    Measure: Baselineelementandcompositemeasures

    Analyze: Weeklyreviewof10randompatientchartsbychangeagentsandcasecoordinators.Rootcauseanalysis

    Improve:Staffeducation,ordersets,Protocols,checklists

    Control: StandardizeprocessesCompliancemonitoring

    http://www.commonwealthfund.org/Content/Innovations/Case-Studies/2007/Nov/Case-Study--Improving-Performance-at-Charleston-Area-Medical-Center.aspx

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Why Six Sigma?Upper

    SpecificationLimit

    Lower Specification

    Limit6

    Sigma Defectspermillion Yield

    1 690,000 30.9%

    2 308,000 62.9%

    3 66,800 93.3%

    4 6,210 99.4%

    5 230 99.98%

    6 3.4 99.9997%

    7 0.019 99.99998%

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    LeanToyota production system (TPS)

  • Healthcare Systems Engineering | www.coe.neu.edu/healthcare | Northeastern University 2010

    Leanprimer

    7TypesofWaste

    Transportation

    Motion

    Waiting

    Inventory

    Overproduction

    Overprocessing

    Defects

    (Variation)

    LeanTools

    Valuestreammapping

    5S(sort,simplify,standardize)

    Nonvalueaddedtime

    Singlepieceflow

    Quickchangeover(SMED)

    Wasteelimination

    Errorproofing

    Visualcontrols

    Focus:Flow,simplification,reducewaste Idea:Simplerprocessesworkbetter,lesserror,lowercost,highersafety

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Examples of non-value added activities

    Approving

    Batching

    Searching

    Walking

    Waiting

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    5 S

    38

    SortStandardizeSimplifySetinorderSustain(Safety)

    SeiriSeitonSeisoSeiketsushitsuke

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Healthcare examples

    39

    5S

  • Healthcare Systems Engineering | www.coe.neu.edu/healthcare | Northeastern University 2010

    VisualcontrolsToyota

    Wristbands

    BarbAveryt,programdirectorofpatientsafetyatArizonaHospitalandHealthcareAssociation3 Cup System

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Cross functional maps(aka swimming lane charts)

    43

    Time

    Func

    tion

    / Per

    son

    / Loc

    atio

    n

    Sequential Scheduling Example

  • Healthcare Systems Engineering | www.coe.neu.edu/healthcare | Northeastern University 2010

    Swimminglaneexample

    14handoffs!

    Delays Errors incompletecare

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Non-value added work (NVA)

    Nonvalueadd,waste

    Person Nonvalueadd,waste

    Swimminglanediagram currentstatemap

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Value stream maps

    46

    Current State Future State

    VAT = 110 seconds / 9.5 days= .01% (0.0001)

    VAT = 128 seconds / 3.2 days= .04% (0.0004)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    VSM Appointment scheduling example

    4732days

    26days

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    48

    Valueaddvs.Nonvalueaddtimes

  • Healthcare Systems Engineering | www.coe.neu.edu/healthcare | Northeastern University 2010

    Waste - Travel as a form of wasteBefore

    CQI / Lean projects

    New layout

    375 ft travel distance14.9 minutes70 85% reduction!

    3,215 ft travel distance98 minutes

  • Healthcare Systems Engineering | www.coe.neu.edu/healthcare | Northeastern University 2010

    Waste NVA and travel time (50% NVA)

    Documentation: 35% Non-nursing practice: 25% Foraging, Travel time, Patient escorting

    IHI TCAB Study

    ~50%!

  • Healthcare Systems Engineering | www.coe.neu.edu/healthcare | Northeastern University 2010

    Waste Spaghetti diagram

    Lean: 7 types of waste Travel = waste Visual data

    Relocate workstations 75% travel reduction Loss cross-over

    congestion

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Waste - Shingos bolt metaphor

    53

    Bolt attachments requires 32 complete turns for each bolt or screw to fasten die to a machine.

    Single minute exchange of die Quick changeover and set-up Race pit / tire change metaphor

    Only last turn has value

    No-value add> 80% time

    Split thread bolts

    Underusedconceptinhealthcare.HowcouldweimplementSMED?

    OR/clinicroomturnover? Sterileequipmentreprocessing Labdiagnostics Other?

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Kaizen event

    aka,Rapidprocessimprovementworkshop(RPIW)orRapidImprovementEvent(RIE)

    Awaytorapidlydolean

    56

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    What it really looks like

    57

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    A3 storyboard example

    58

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    PDSAInstitute for Healthcare

    Improvement(A way to implement PDSA)

    Act Plan

    Study Do

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    IHI growth & impact: 1986 - present

    Active in over 50 countries and 14,000 organizations worldwide Modern Healthcare: 3rd (2nd) most important person in health care E.F. Hutton of health care

    1986

    15,000organizations.50countries

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Plan Do Check (Study) Act

    62

    Act What changes

    are to be made?

    Next cycle?

    Plan Goal Questions and

    predictions (why) Plan to carry out

    the cycle (who,what, where, when)

    Study Analyze the data

    Compare data topredictions

    Summarize what was

    learned

    Do Carry out the plan Document problems

    and unexpectedobservations

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Basic idea

    Plan(who,when,etc)

    Executetest(do)

    Measures(study)

    Refine,retest(act)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Planning deliberate tests

    64

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    CABG Example

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Our PDSA planning form

    66

    PDSA#1 PDSA#2

    Planpreparation

    Baselines:

    Materials:

    Schedules:

    Planpreparation

    Baselines:

    Materials:

    Schedules:

    Doexecution

    Who:

    When:

    Duration:

    Doexecution

    Who:

    When:

    Duration:

    Studyanalysis

    DataQualitative:

    Quantitative:

    Studyanalysis

    DataQualitative:

    Quantitative:

    Actbasedonresults

    Ifsuccessful:

    Ifnot:Act

    basedonresultsIfsuccessful:

    Ifnot:

    ChecklistAchievable7daysNotpossibleonsmallerscale

    ChecklistAchievable14daysNotpossibleonsmallerscale

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    IHI Improvement Model

    3motivatingquestions RepeatedPDSAlearningcycles Rapidcycletesting/learning Poormansscientificmethod

    69

    Aim

    Measures

    Changes

    (aka,ImprovementScience)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    3 motivating questions

    70

    Question Explanation Example

    1. What are we trying to accomplish?

    - Guides and focuses improvement effort.- Includes a specific measurable goal and timeline.

    Reduce surgical site infection rate in OR to .05 (10-1) in the next 6 months

    2. How will we know a design change is an improvement?

    - Measures used to test design changes- Outcome, process, & balancing measures

    - SSI rate- Percent receiving appropriate prophylaxis- Time / effort required

    3. What deliberate designs can we test that may result in improvement?

    Use 3-tier model to develop specific ideasTest using PDSA model

    - Antibiotic guidelines (standardization)- Reminder system- Etc

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Measuring improvement - Run charts

    Visualdisplayofdataovertime,annotated Testif/notchangesresultinimprovement

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Annotated run chart - Example

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Secondexample

    Providence

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Putting it into practice

    Startingsmall(smallest1st testaspossible) Linkedtestsovertime Highlyiterative.(Numbertests=PImeasure) Buildingknowledge,culture,comfort,degreeofbelief,support,learning

    Testingacrosscontexts,settings,days Improvementadvisor(IA)coachingrole

    74

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Small multiple tests - why

    75

    Rapidsmalltestsacceleratelearningandimprovement

    Startwithsmallestpossibletest one afternoon,one doc,one typeofpatient,etc

    Learnwhatworksandwhatdoesnot Learnhowtomakeprocessrobust

    Testinmultipleenvironments 2nd doc,2nd shift,2nd department,weekends,etc

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Time

    Multiple testing context

    Hunches Theories

    Ideas

    Designs That Result in

    Improvement

    A PS D

    A PS D

    Short and long term process measures

    OutcomeMeasures

    Knowledgeand

    Reliability

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Example (appointment access)

    77

    Hypothesis:Reductionofappointmenttypeswillincreaseappointmentavailability

    Improvedappointmentaccess

    /satisfaction

    A PS D

    A PS D

    Cycle1:Testasmallnumberofappttypesin1dept/doc

    Cycle2:Reviseappttypes/lengthsbasedonlearning

    Cycle3:Testwithmultipledocs/days

    Cycle4:Refine,testdeptwide

    Cycle5:Testrobustnessinotherdepts,refine

    Approach:Multiple(rapidcycle)testsandrefinementsofchangeacrossavarietyofoperatingconditions

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Useful quotes / ideas

    Allprocessesareoptimallydesignedtogetexactlytheresultstheyproduce

    Thedefinitionofinsanityisdoingthesamethingandexpectingdifferentoutcomes

    Allimprovementrequireschange,notallchangeleadstoimprovement

    WhatcanyoutestbynextTuesday? Allfailedtestsaresuccesses(learning) Goodenoughdataforlearningandimprovement Improvementsoonvsslowperfection

    78

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    (WHY REPEATED TESTS)

    Allimprovementrequireschange,Butnotallchangesresultinimprovement

    Allimprovementislocal79

    Onemonth

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Balanced PDSAs = Actual tests

    Pitfalls PDCA Pleasedontchangeanything Killersyndromesandepidemics:Perpetualmeeting

    syndrome,perpetualanalysissyndrome,andperpetualmodelingsyndrome

    80

    Act

    Check

    Plan

    Do

    Too Much Planning

    Plan

    DoCheck

    Act

    Too Much Doing

    Act Plan

    DoCheck

    Proper Balance

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Size and duration of tests

    81

    Size: Small Medium LargePurpose: Learning Evidence Impact

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    Degree of belief

    D e g re e o fb e l ie f

    th a t th ec h a n g e

    w i l l re s u l tin

    im p ro v e m e n t

    H ig h

    D e v e lo p in g a c h a n g e

    T e s tin g a c h a n g ec y c le 1 , c y c le 2 , . . .

    Im p le m e n t in ga c h a n g e

    A s u c c e s s fu l c h a n g e

    C h a n g e s t il ln e e d s fu r th e rte s tin g

    U n s u c c e s s fu lp ro p o s e d c h a n g e

    L o w

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Collaborative improvement approach

    86

    Selecttopic

    Expertmeeting

    Developframework,changeideas

    Participants(10100teams)

    Prework

    P

    S

    A

    P

    S

    A

    SupportEmail Visits

    Phone Assessments

    SeniorLeaderReports Analysis

    LS1

    D D

    LS3LS2

    Disseminate

    Guides

    Publications

    etc.Planninggroup

    P

    S

    A D

    8 14months

    Act Plan

    Study Do

    Discovernewknowledge Implementlocally

    Act Plan

    Study Do

    Act Plan

    Study Do

    Repeatedtestsacross2040settings Underexploited Learning,DOE,robustopportunities

    (aka,BreakThroughSeries,BTS)

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    General collaborative approach

    87

    Prework

    MaterialdevelopmentEarlytestingParticipantenrollment

    Kickoffmeeting

    BaselinesGeneral

    knowledgeTools

    6monthcycles(phase1,phase2,phase3) Actionoriented

    Fall2014 Jan2015

    GeneralknowledgePreliminarychangepackage

    Preliminaryexperiences

    LocalimplementationBuildongeneralknowledge

    Broadimpact/spread

    Winter&Spring2015

    Actionperiod

    TestingchangesandQImethodsSharingresults,learning,trainingMonthlycycles

    Monthlyvirtualmtg

    WebExcalls

    Impactspread

    Continue

    Disseminateresults&tools

    SemiannualF2Fsharing

    NeoQIC mtg

    Fall15

    Allimprovementrequireschangetestingtesting testing

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Examples

    Patientsafety,Readmissions() Flowanddelays Specialtycareaccess Painmanagement Dozensothers

    88

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    100,000 Lives Campaign

    Campaign sense of urgency

    Save 100,000 lives by 6/14/06 (9 am EST)

    Focus on six areas: Adverse drug events (2k) Surgical site infection (8k) Myocardial infarction (10k) Ventilator pneumonia (10k) Central line infection (10k) Rapid response teams (60k)

    Over 3,200 U.S. hospitals participating

    90% of acute care beds

    Accomplish via bundles of proven interventions

  • Northeastern University 2012www.coe.neu.edu/healthcareHealthcare Systems Engineering Institute

    recapPutting it all together

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Recap - putting it all together

    91

    Specificaims

    Runandcontrolcharts

    Driverdiagram

    Repeatedtesting,sharing,andcolearning

    S specificM measurableA actionorientedR realisticT timeline

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Zen of Improvement Science

    1. Rapidcycletestingisrapid(1perweek)

    2. QIprojectsslowelectronicdata Goodenough>slowperfectdata

    5. LinkedPDSAs(6in3months)92

  • Northeastern University 2012www.HSyE.orgHealthcare Systems Engineering Institute

    Discussionwww.hsye.org

    93

    Contact information:James Benneyan, PhD, DirectorHealthcare Systems Engineering Institute334 Snell Engineering CenterNortheastern UniversityBoston MA [email protected]