Lean Six Sigma and Change Management Missouri Department ...
45
Driving High Reliability Results with Robust Process Improvement Lean Six Sigma and Change Management Missouri Department of Mental Health
Transcript of Lean Six Sigma and Change Management Missouri Department ...
Driving High Reliability Results with Robust Process ImprovementLean Six Sigma and Change ManagementMissouri Department of Mental Health
The DMH Team
James Busalacki has been with the Division of Behavioral Health namely Fulton State Hospital since 2015 in different capacities with the most recent position being the Strategic Initiatives Coordinator Prior to working for Fulton State Hospital he spent almost 16 years in customer service and retail in various supervisory and managerial positions James received his Bachelor of Arts in PoliticalScience from the University of Missouri - Columbia and has taken Masterrsquos level courses in Education from Columbia College He is a trained RPI Black Belt and Certified RPI Green Belt His Black Belt project focused on Program Based Scheduling within Fulton State Hospital Green Belt project focused on Security Consolidation with the facility but more specifically on escorted medical and court trips off campus for clients
Lisa Franz has been with the Division of Behavioral Health since 2017 as the Chief Performance Improvement Officer for the Western Region focusing on the Center for Behavioral Medicine and Northwest Missouri Psychiatric Rehabilitation Center Prior to working for DBH she served over 30 years in healthcare focusing 20 of those years on process improvement Lisa holds a Master of Business Administration degree from the University of Missouri and is a Lean Six Sigma Master Black Belt a Certified Professional in Healthcare Qualityand a Certified Joint Commission Professional Lisa is a certified RPI Black Belt and RPI Change Leader Lisarsquos RPI Green Belt project focused on decreasing delays in visitor check-in at CBM In her free time Lisa enjoys travel and genealogy
Heather Osborne has been with the Division of Behavioral Health since 2011 She started out as a ward therapist and has also served as the Util ization Management Coordinator and most recently as the Director of Treatment Services for Southeast Missouri Mental Health Center-Adult Psychiatric Services Heather received a Masterrsquos degree in Clinical Counseling in 2011 and a graduate certificate in Gerontology in 2017 She is a trained RPI Black Belt and Certified RPI Green Belt Her Black Belt project focused on the tracking of employee sick leave usage and her Green Belt project focused on the turnaround time and tracking process of employee Adverse Action documentation In her spare time Heather volunteers for the Multiple Sclerosis Society and enjoys going to St Louis Cardinals baseball games
Bonnie Poole has been with the Division of Behavioral Health since 2014 as the Quality Assurance Specialist at Center for Behavioral Medicine Bonnie has been working in the field of healthcare QM since 2010 and before that spent some time as a Clinical Data Coordinator for Quintiles Bonnie received a Masterrsquos degree in Psychology in 2003 with a focus in Forensic Psychology She is a trained RPI Black Belt and Certified RPI Green Belt Her Black Belt project focused on the treatment efficacy of IST (Incompetent to Stand Trial) competency restoration Her Green Belt project focused on improving Human Resources hiring turnaround time In her spare time Bonnie is an amateur fiction writer and soap maker
Tara Yates has been with the Division of Behavioral Health since 2003 with the most recent position being Director of QualityManagement for the Eastern Region (St Louis Psychiatric Rehabilitation Center Metropolitan St Louis Psychiatric Center andHawthorn Children Psychiatric Hospital) Tara received her Bachelors of Science in Parks Recreation and Tourism with an Option in Therapeutic Recreation in 2001 and her Masters of Science in Healthcare Administration in 2020 She is a trained RPI Black Belt Certified RPI Green Belt Certified RPI Change Leader and Certified SOS Yellow Belt Her Black Belt project focused on RN overtime Green Belt project focused on increasing active treatment and Yellow Belt project focused on decreasing the amount of time for a client to retrieve funds for out trips In her spare time Tara enjoys attending the extracurricular activities of her daughter reading and baking
RPI
Vision
bull DBH leaders envision a high reliability culture of Robust Process Improvementreg (RPIreg) in which the Division achieves and sustains exemplary business clinical and safety outcomes
3
Presenter
Presentation Notes
Studies show that between 50 and 75 of improvement efforts fail due to a lack of focus on facilitating change 13
RPI
Clinical Active Treatment at SLPRC
4
Define Phase Goal- Voice Of The Customer
Which groups do clients attend
most
Diversion therapy groups
Phase II Work
Groups Clients identify as
required for discharge
How do you get clients to come
to groups
MoneyTokens
Snacks
Incentive towards discharge
What is Active Treatment
Anything on the schedule
Only PsychoEdgroups
Definitely out trips
What is the Goal for Active
Treatment
3 hours a day
It doesnrsquot matter
I have no idea
RPI 5
Presenter
Presentation Notes
A key principle of Lean Six Sigma is the customer improving the process to increase the value to the customer Reducing defects improves efficiency which improves the value to the customer For my project the customers were clients group leaders clinicians and members of the community We asked them these questions to understand what they valued from the process
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
ADLMorning
Treatment Block
Mid-Day Self Improvement
Afternoon Treatment
Block
Afternoon Self-
Improvement
Evening Activities
Time of Bed ADLs
Community Passes
Work
Work
11Therapy
No groups today
Room not available
Once a month
religious service
Meds
RPI 6
Presenter
Presentation Notes
After we understood the deliverables expected by the customer the next step was to gather the voice of the process The Core Team told us this was the process When we walked the process these were the challenges we encountered These variations are defects and waste which impacts the value to the customer Our task was to eliminate as much variation waste and defect from the process to develop a consistent product to the customers
Measure Phase Deliverables- Baseline Performance And Measurement
907560453015
LSL 6Target USL 9Sample Mean 52915Sample N 200Shape 942729Scale 0561296
Process DataPp 023PPL -017PPU 063Ppk -017
Overall Capability
lt LSL 6150 gt USL 050 Total 6200
Observed Performance
lt LSL 6921 gt USL 292 Total 7213
Exp Overall Performance
LSL USL
Process Capability Report for HoursCalculations Based on Gamma Distribution Model
RPI 7
Presenter
Presentation Notes
This is where the fun begins13If you enjoy statistics- The Process Capability report told us were 385 capable missing the target 615 of the time 13For those of you whose love language is not statistics- The Process Capability report tells us how the process is meeting the goal The vertical lines titled LSL (lower spec limit) and USL (upper spec limit) are the goals determined by the Sponsor 6-9 active treatment hours If we were meeting that goal the bell curve would be in between those lines but as you can see they are not 131313
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
The DMH Team
James Busalacki has been with the Division of Behavioral Health namely Fulton State Hospital since 2015 in different capacities with the most recent position being the Strategic Initiatives Coordinator Prior to working for Fulton State Hospital he spent almost 16 years in customer service and retail in various supervisory and managerial positions James received his Bachelor of Arts in PoliticalScience from the University of Missouri - Columbia and has taken Masterrsquos level courses in Education from Columbia College He is a trained RPI Black Belt and Certified RPI Green Belt His Black Belt project focused on Program Based Scheduling within Fulton State Hospital Green Belt project focused on Security Consolidation with the facility but more specifically on escorted medical and court trips off campus for clients
Lisa Franz has been with the Division of Behavioral Health since 2017 as the Chief Performance Improvement Officer for the Western Region focusing on the Center for Behavioral Medicine and Northwest Missouri Psychiatric Rehabilitation Center Prior to working for DBH she served over 30 years in healthcare focusing 20 of those years on process improvement Lisa holds a Master of Business Administration degree from the University of Missouri and is a Lean Six Sigma Master Black Belt a Certified Professional in Healthcare Qualityand a Certified Joint Commission Professional Lisa is a certified RPI Black Belt and RPI Change Leader Lisarsquos RPI Green Belt project focused on decreasing delays in visitor check-in at CBM In her free time Lisa enjoys travel and genealogy
Heather Osborne has been with the Division of Behavioral Health since 2011 She started out as a ward therapist and has also served as the Util ization Management Coordinator and most recently as the Director of Treatment Services for Southeast Missouri Mental Health Center-Adult Psychiatric Services Heather received a Masterrsquos degree in Clinical Counseling in 2011 and a graduate certificate in Gerontology in 2017 She is a trained RPI Black Belt and Certified RPI Green Belt Her Black Belt project focused on the tracking of employee sick leave usage and her Green Belt project focused on the turnaround time and tracking process of employee Adverse Action documentation In her spare time Heather volunteers for the Multiple Sclerosis Society and enjoys going to St Louis Cardinals baseball games
Bonnie Poole has been with the Division of Behavioral Health since 2014 as the Quality Assurance Specialist at Center for Behavioral Medicine Bonnie has been working in the field of healthcare QM since 2010 and before that spent some time as a Clinical Data Coordinator for Quintiles Bonnie received a Masterrsquos degree in Psychology in 2003 with a focus in Forensic Psychology She is a trained RPI Black Belt and Certified RPI Green Belt Her Black Belt project focused on the treatment efficacy of IST (Incompetent to Stand Trial) competency restoration Her Green Belt project focused on improving Human Resources hiring turnaround time In her spare time Bonnie is an amateur fiction writer and soap maker
Tara Yates has been with the Division of Behavioral Health since 2003 with the most recent position being Director of QualityManagement for the Eastern Region (St Louis Psychiatric Rehabilitation Center Metropolitan St Louis Psychiatric Center andHawthorn Children Psychiatric Hospital) Tara received her Bachelors of Science in Parks Recreation and Tourism with an Option in Therapeutic Recreation in 2001 and her Masters of Science in Healthcare Administration in 2020 She is a trained RPI Black Belt Certified RPI Green Belt Certified RPI Change Leader and Certified SOS Yellow Belt Her Black Belt project focused on RN overtime Green Belt project focused on increasing active treatment and Yellow Belt project focused on decreasing the amount of time for a client to retrieve funds for out trips In her spare time Tara enjoys attending the extracurricular activities of her daughter reading and baking
RPI
Vision
bull DBH leaders envision a high reliability culture of Robust Process Improvementreg (RPIreg) in which the Division achieves and sustains exemplary business clinical and safety outcomes
3
Presenter
Presentation Notes
Studies show that between 50 and 75 of improvement efforts fail due to a lack of focus on facilitating change 13
RPI
Clinical Active Treatment at SLPRC
4
Define Phase Goal- Voice Of The Customer
Which groups do clients attend
most
Diversion therapy groups
Phase II Work
Groups Clients identify as
required for discharge
How do you get clients to come
to groups
MoneyTokens
Snacks
Incentive towards discharge
What is Active Treatment
Anything on the schedule
Only PsychoEdgroups
Definitely out trips
What is the Goal for Active
Treatment
3 hours a day
It doesnrsquot matter
I have no idea
RPI 5
Presenter
Presentation Notes
A key principle of Lean Six Sigma is the customer improving the process to increase the value to the customer Reducing defects improves efficiency which improves the value to the customer For my project the customers were clients group leaders clinicians and members of the community We asked them these questions to understand what they valued from the process
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
ADLMorning
Treatment Block
Mid-Day Self Improvement
Afternoon Treatment
Block
Afternoon Self-
Improvement
Evening Activities
Time of Bed ADLs
Community Passes
Work
Work
11Therapy
No groups today
Room not available
Once a month
religious service
Meds
RPI 6
Presenter
Presentation Notes
After we understood the deliverables expected by the customer the next step was to gather the voice of the process The Core Team told us this was the process When we walked the process these were the challenges we encountered These variations are defects and waste which impacts the value to the customer Our task was to eliminate as much variation waste and defect from the process to develop a consistent product to the customers
Measure Phase Deliverables- Baseline Performance And Measurement
907560453015
LSL 6Target USL 9Sample Mean 52915Sample N 200Shape 942729Scale 0561296
Process DataPp 023PPL -017PPU 063Ppk -017
Overall Capability
lt LSL 6150 gt USL 050 Total 6200
Observed Performance
lt LSL 6921 gt USL 292 Total 7213
Exp Overall Performance
LSL USL
Process Capability Report for HoursCalculations Based on Gamma Distribution Model
RPI 7
Presenter
Presentation Notes
This is where the fun begins13If you enjoy statistics- The Process Capability report told us were 385 capable missing the target 615 of the time 13For those of you whose love language is not statistics- The Process Capability report tells us how the process is meeting the goal The vertical lines titled LSL (lower spec limit) and USL (upper spec limit) are the goals determined by the Sponsor 6-9 active treatment hours If we were meeting that goal the bell curve would be in between those lines but as you can see they are not 131313
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
RPI
Vision
bull DBH leaders envision a high reliability culture of Robust Process Improvementreg (RPIreg) in which the Division achieves and sustains exemplary business clinical and safety outcomes
3
Presenter
Presentation Notes
Studies show that between 50 and 75 of improvement efforts fail due to a lack of focus on facilitating change 13
RPI
Clinical Active Treatment at SLPRC
4
Define Phase Goal- Voice Of The Customer
Which groups do clients attend
most
Diversion therapy groups
Phase II Work
Groups Clients identify as
required for discharge
How do you get clients to come
to groups
MoneyTokens
Snacks
Incentive towards discharge
What is Active Treatment
Anything on the schedule
Only PsychoEdgroups
Definitely out trips
What is the Goal for Active
Treatment
3 hours a day
It doesnrsquot matter
I have no idea
RPI 5
Presenter
Presentation Notes
A key principle of Lean Six Sigma is the customer improving the process to increase the value to the customer Reducing defects improves efficiency which improves the value to the customer For my project the customers were clients group leaders clinicians and members of the community We asked them these questions to understand what they valued from the process
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
ADLMorning
Treatment Block
Mid-Day Self Improvement
Afternoon Treatment
Block
Afternoon Self-
Improvement
Evening Activities
Time of Bed ADLs
Community Passes
Work
Work
11Therapy
No groups today
Room not available
Once a month
religious service
Meds
RPI 6
Presenter
Presentation Notes
After we understood the deliverables expected by the customer the next step was to gather the voice of the process The Core Team told us this was the process When we walked the process these were the challenges we encountered These variations are defects and waste which impacts the value to the customer Our task was to eliminate as much variation waste and defect from the process to develop a consistent product to the customers
Measure Phase Deliverables- Baseline Performance And Measurement
907560453015
LSL 6Target USL 9Sample Mean 52915Sample N 200Shape 942729Scale 0561296
Process DataPp 023PPL -017PPU 063Ppk -017
Overall Capability
lt LSL 6150 gt USL 050 Total 6200
Observed Performance
lt LSL 6921 gt USL 292 Total 7213
Exp Overall Performance
LSL USL
Process Capability Report for HoursCalculations Based on Gamma Distribution Model
RPI 7
Presenter
Presentation Notes
This is where the fun begins13If you enjoy statistics- The Process Capability report told us were 385 capable missing the target 615 of the time 13For those of you whose love language is not statistics- The Process Capability report tells us how the process is meeting the goal The vertical lines titled LSL (lower spec limit) and USL (upper spec limit) are the goals determined by the Sponsor 6-9 active treatment hours If we were meeting that goal the bell curve would be in between those lines but as you can see they are not 131313
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
RPI
Clinical Active Treatment at SLPRC
4
Define Phase Goal- Voice Of The Customer
Which groups do clients attend
most
Diversion therapy groups
Phase II Work
Groups Clients identify as
required for discharge
How do you get clients to come
to groups
MoneyTokens
Snacks
Incentive towards discharge
What is Active Treatment
Anything on the schedule
Only PsychoEdgroups
Definitely out trips
What is the Goal for Active
Treatment
3 hours a day
It doesnrsquot matter
I have no idea
RPI 5
Presenter
Presentation Notes
A key principle of Lean Six Sigma is the customer improving the process to increase the value to the customer Reducing defects improves efficiency which improves the value to the customer For my project the customers were clients group leaders clinicians and members of the community We asked them these questions to understand what they valued from the process
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
ADLMorning
Treatment Block
Mid-Day Self Improvement
Afternoon Treatment
Block
Afternoon Self-
Improvement
Evening Activities
Time of Bed ADLs
Community Passes
Work
Work
11Therapy
No groups today
Room not available
Once a month
religious service
Meds
RPI 6
Presenter
Presentation Notes
After we understood the deliverables expected by the customer the next step was to gather the voice of the process The Core Team told us this was the process When we walked the process these were the challenges we encountered These variations are defects and waste which impacts the value to the customer Our task was to eliminate as much variation waste and defect from the process to develop a consistent product to the customers
Measure Phase Deliverables- Baseline Performance And Measurement
907560453015
LSL 6Target USL 9Sample Mean 52915Sample N 200Shape 942729Scale 0561296
Process DataPp 023PPL -017PPU 063Ppk -017
Overall Capability
lt LSL 6150 gt USL 050 Total 6200
Observed Performance
lt LSL 6921 gt USL 292 Total 7213
Exp Overall Performance
LSL USL
Process Capability Report for HoursCalculations Based on Gamma Distribution Model
RPI 7
Presenter
Presentation Notes
This is where the fun begins13If you enjoy statistics- The Process Capability report told us were 385 capable missing the target 615 of the time 13For those of you whose love language is not statistics- The Process Capability report tells us how the process is meeting the goal The vertical lines titled LSL (lower spec limit) and USL (upper spec limit) are the goals determined by the Sponsor 6-9 active treatment hours If we were meeting that goal the bell curve would be in between those lines but as you can see they are not 131313
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
Define Phase Goal- Voice Of The Customer
Which groups do clients attend
most
Diversion therapy groups
Phase II Work
Groups Clients identify as
required for discharge
How do you get clients to come
to groups
MoneyTokens
Snacks
Incentive towards discharge
What is Active Treatment
Anything on the schedule
Only PsychoEdgroups
Definitely out trips
What is the Goal for Active
Treatment
3 hours a day
It doesnrsquot matter
I have no idea
RPI 5
Presenter
Presentation Notes
A key principle of Lean Six Sigma is the customer improving the process to increase the value to the customer Reducing defects improves efficiency which improves the value to the customer For my project the customers were clients group leaders clinicians and members of the community We asked them these questions to understand what they valued from the process
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
ADLMorning
Treatment Block
Mid-Day Self Improvement
Afternoon Treatment
Block
Afternoon Self-
Improvement
Evening Activities
Time of Bed ADLs
Community Passes
Work
Work
11Therapy
No groups today
Room not available
Once a month
religious service
Meds
RPI 6
Presenter
Presentation Notes
After we understood the deliverables expected by the customer the next step was to gather the voice of the process The Core Team told us this was the process When we walked the process these were the challenges we encountered These variations are defects and waste which impacts the value to the customer Our task was to eliminate as much variation waste and defect from the process to develop a consistent product to the customers
Measure Phase Deliverables- Baseline Performance And Measurement
907560453015
LSL 6Target USL 9Sample Mean 52915Sample N 200Shape 942729Scale 0561296
Process DataPp 023PPL -017PPU 063Ppk -017
Overall Capability
lt LSL 6150 gt USL 050 Total 6200
Observed Performance
lt LSL 6921 gt USL 292 Total 7213
Exp Overall Performance
LSL USL
Process Capability Report for HoursCalculations Based on Gamma Distribution Model
RPI 7
Presenter
Presentation Notes
This is where the fun begins13If you enjoy statistics- The Process Capability report told us were 385 capable missing the target 615 of the time 13For those of you whose love language is not statistics- The Process Capability report tells us how the process is meeting the goal The vertical lines titled LSL (lower spec limit) and USL (upper spec limit) are the goals determined by the Sponsor 6-9 active treatment hours If we were meeting that goal the bell curve would be in between those lines but as you can see they are not 131313
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
ADLMorning
Treatment Block
Mid-Day Self Improvement
Afternoon Treatment
Block
Afternoon Self-
Improvement
Evening Activities
Time of Bed ADLs
Community Passes
Work
Work
11Therapy
No groups today
Room not available
Once a month
religious service
Meds
RPI 6
Presenter
Presentation Notes
After we understood the deliverables expected by the customer the next step was to gather the voice of the process The Core Team told us this was the process When we walked the process these were the challenges we encountered These variations are defects and waste which impacts the value to the customer Our task was to eliminate as much variation waste and defect from the process to develop a consistent product to the customers
Measure Phase Deliverables- Baseline Performance And Measurement
907560453015
LSL 6Target USL 9Sample Mean 52915Sample N 200Shape 942729Scale 0561296
Process DataPp 023PPL -017PPU 063Ppk -017
Overall Capability
lt LSL 6150 gt USL 050 Total 6200
Observed Performance
lt LSL 6921 gt USL 292 Total 7213
Exp Overall Performance
LSL USL
Process Capability Report for HoursCalculations Based on Gamma Distribution Model
RPI 7
Presenter
Presentation Notes
This is where the fun begins13If you enjoy statistics- The Process Capability report told us were 385 capable missing the target 615 of the time 13For those of you whose love language is not statistics- The Process Capability report tells us how the process is meeting the goal The vertical lines titled LSL (lower spec limit) and USL (upper spec limit) are the goals determined by the Sponsor 6-9 active treatment hours If we were meeting that goal the bell curve would be in between those lines but as you can see they are not 131313
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
Measure Phase Deliverables- Baseline Performance And Measurement
907560453015
LSL 6Target USL 9Sample Mean 52915Sample N 200Shape 942729Scale 0561296
Process DataPp 023PPL -017PPU 063Ppk -017
Overall Capability
lt LSL 6150 gt USL 050 Total 6200
Observed Performance
lt LSL 6921 gt USL 292 Total 7213
Exp Overall Performance
LSL USL
Process Capability Report for HoursCalculations Based on Gamma Distribution Model
RPI 7
Presenter
Presentation Notes
This is where the fun begins13If you enjoy statistics- The Process Capability report told us were 385 capable missing the target 615 of the time 13For those of you whose love language is not statistics- The Process Capability report tells us how the process is meeting the goal The vertical lines titled LSL (lower spec limit) and USL (upper spec limit) are the goals determined by the Sponsor 6-9 active treatment hours If we were meeting that goal the bell curve would be in between those lines but as you can see they are not 131313
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
Analyze Phase Deliverables- Validated Root Causes
Frida
yFri
day
Thursd
ay
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monda
y
10
8
6
4
2
0
Day
Indiv
idual
Value
(Hou
rs)
_X=513
UCL=959
LCL=068
Frida
yFri
day
Thur
sday
Thursd
ay
Wed
nesday
Wed
nesday
Tuesd
ay
Tuesd
ay
Monday
Monday
145
140
135
130
125
120
Day
Indiv
idual
Value
(Hou
rs)
_X=13883
UCL=14312
LCL=13455
6
66
5
2
2
2
5
1
2
66
665
5
6
2
2
6
55
5
5
1
11111111111111111111
1111
111
1
1
111111111111111111111
11
1111111
111111111111111111111
5
1
1
1
11111
111111111111111111111
1
111111
11
222222222222
1
11
111
1111
Actually Scheduled Active Treatment Hours Could of been Scheduled Active Treatment Hours
RPI 8
Presenter
Presentation Notes
Again if you are a stats person this slide is for you- We ran a comparison control chart on the active treatment scheduled vs the missed opportunities of active treatment the special cause variations told us to investigate the points more than 3 standard deviations there were nine points or more on the same side of the center line etc 13Non-stats people- The scheduled active treatment averaged around 513 hours for clients which was below the minimum goal of 6 hours our average for missed opportunities were 1383 hours a day Based off our goal the scheduled treatment hours should be higher than the missed opportunities1313When we analyzed the data further our root causes were validated ROOT CAUSE 1- a missing standardized definition of active treatment ROOT CAUSE 2- which included the goal ROOT CAUSE 3 There wasnrsquot a process owner who monitored the process to determine if clinicians were providing enough treatment for clients to attend enough treatment
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
Define active treatmentbull All groups were categorized as active treatment or diversional activitiesbull All clinicians and supervisors received education on the differences
Determined an active treatment goalbull All clinicians and supervisors received education on the expectation
Development of scheduling templatebull Clinicians and supervisors use the template to track the active treatment hours
Identification of the process ownerbull Process owner received education on the expectations of the role
RPI 9
Presenter
Presentation Notes
To address the root causes we facilitated conversations with the Core Team to identify action plans Clinicians were trained on the four changes noted above and implemented these changes into their into the process
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
Improve Phase Deliverables- Validated Improvements
1059075604530
LSL 6Target USL 9Sample Mean 672125Sample N 200StDev(Overall) 173898StDev(Within) 174168
Process Data
Pp 029PPL 014PPU 044Ppk 014Cpm
Cp 029CPL 014CPU 044Cpk 014
Potential (Within) Capability
Overall Capability
lt LSL 2250 3392 3394 gt USL 750 950 954 Total 3000 4342 4348
Observed Expected Overall Expected WithinPerformance
LSL USLOverallWithin
Process Capability Report for Hours
RPI
Presenter
Presentation Notes
The process was measured again and there was a relative improvement of 84213Stats people- The process was 70 capable After running a Two proportion test we determined the P-Value was 000 which told us there was a statistical difference in the data 13My love language people- The average of scheduled treatment improved to 672 hours (last time it was 529 hours) The process met the customer expectation 70 of the time (compared to 385 capable last time) We were above the customer expectation 75 of the time (compared to 50 last time) 1313
Control Phase Goals- Standardize And Sustain Improvement
0
20
40
60
80
100
120
NOP TRP SLP CBP
Increase in Active Treatment
Prior to Education After Education By Green Belts After education by Sponsor End of project
0
20
40
60
80
100
120
NOP TRP SLP CBP
Percent of Clients Meeting the Active Treatment Goal
Beginning of project End of project
RPI 11
Presenter
Presentation Notes
This project inspired another Green Belt project at SLPRC related to active treatment The current projectrsquos goal is to improve the active treatment measurement tool The projectrsquos success has inspired conversations across DBH facilities about data collection mechanisms and reporting platforms13Both projects demonstrate that Lean Six Sigma and Change Management have a place in healthcare There are numerous opportunities for projects in behavioral health to provide effective and efficient treatment to the citizens of Missouri
RPI
Clinical Results
bull The Challenge ndash Increase daily access to treatmentbull A minimum of 6 hours to a maximum of 9 hours of active treatment hours per
day for the client is not documented This appears to be occurring in most if not all of the facilitys programs
bull The Resultbull The average or mean of scheduled treatment was 655 hours (previously it
was 529 hours) bull The process was 665 capable (compared to 38 capable previously)
Capability means they met the expectations of 6-9 hours of active treatment 665 of the time
bull They were below the customerrsquos expectation of minimum of 6 treatment hours 265 of the time (compared to 615 previously)
12
Presenter
Presentation Notes
Use of scheduling template ndash not user friendly ndash hours arenrsquot tracked template not completed RPN 648 2Clinicians should be leading a minimum of 20 hours per week ndash lack of timeresources ndash perception of work duties RPN 729 3Process Owner was identified ndash project low priority ndash multiple tasks RPN 648
RPI
Robust Process Improvement
bull A systematic approach to problem solving proven in many other industries including healthcare
bull Equally effective when applied to health carersquos toughest safety and quality problems
bull Benefits patients stakeholders and employeesbull Appealing to physicians and other clinicians because it is data drivenbull Drives overall culture change in health care organizations bull Resulting in High Reliability Organization which consistently achieves positive
outcomes
13
Presenter
Presentation Notes
The Department of Mental Health Division of Behavioral Health (DBH) has implemented a program supported by The Joint Commission called Robust Process Improvement (RPI) DBH is the organization that provides forensic psychiatric services at 7 facilities across the state 1313RPI is a program that focuses on overall culture change in health care organizations and combines Lean Six Sigma with Change Management It relies on a collaborative team effort to improve performance Lean management is focused on eliminating waste also known as rdquomudardquo using a set of proven standardized tools and methodologies that target organizational efficiencies13The term six sigma comes from a statistical measure which evaluates process capability A six sigma process is one in which the organization is 9999966 successful in consistently producing a desired outcome13Organizational ldquochange managementrdquo employs a structured approach to ensure that changes are implemented smoothly and successfully to achieve lasting benefits13Using these approaches in combination an establishment may become a High Reliability Organization consistently achieving positive outcomes131313131313ldquo
Six Sigma
Lean Change Management
The Keys to Robust Process Improvement
RPI 14
Presenter
Presentation Notes
Six Sigma13Statistical measure which evaluates process capability139999966 successful in consistently producing a desired outcome13Lean 13Eliminate waste also known as rdquomudardquo 13Target organizational efficiencies13Organizational Change Management13Changes are implemented smoothly and successfully13Achieve lasting benefits13
Six Sigma Concept
15
CustomerSpecification
Every Human Activity Has Variability
defectsTarget
CustomerSpecification
defectsTarget
CustomerSpecification
RPI15
Six Sigma Concept
16
Parking Your Car in the GarageHas Variability
Target
defectsdefects
CustomerSpecification
CustomerSpecification
RPI16
RPI
DDefine
MMeasure
AAnalyze
CControl
IImprove
DMAIC Improvement Process
17
RPI
So What is Lean
bull The methodology of increasing the speed of production by eliminating process steps which do not add value
bull those which delay the product or servicebull those which deal with the waste and rework of defects along
the way
18
RPI
Synergy of Lean and Six Sigma
of Steps plusmn3σ plusmn4σ plusmn5σ plusmn6σ
1 9332 99379 99976 99999
7 6163 95733 98839 99997
10 5008 9396 99768 99996
20 2508 8829 99536 99993
40 629 7794 99074 99986
Lean reduces non-value-add steps
Six Sigma improves quality of value-add steps Source Motorola Six Sigma Institute
19
RPI
What is Change Management
bull A model for managing and facilitating changebull Makes change easierbull Creates buy-inbull Achieves more lasting resultsbull GE - The Effectiveness (E) of any initiative is equal to the product
of the Quality (Q) of the technical strategy and the Acceptance (A)of that strategy (E=QA)
20
Plan Your Project
Inspire People
Launch the Initiative
Support the Change
Facilitating Changetrade
Source The Joint Commissionrsquos Center for Transforming Healthcare 21
Presenter
Presentation Notes
Facilitating Change is the Change Management Approach to creating buy-in and support from people
RPI
GGreen
YYellow
BBlack
M
RPI Belt Progression
WWhite
22
Feb 2015 RPI Proposed
Nov 2015 RPI Forum
Jan 2016 RPI Steering
Committee
Sep 2016 Change Leader
Training
Jan 2017 Green Belt Training
Jan 2018 Black Belt Training
Jan 2019 Green Belt Training
Jan 2020 Green Belt Training
July 2020 Yellow Belt
Training
DBH Journey to RPI
RPI23
RPI
DBH Employees Trained in RPI
91
24
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1613Yellow Belt 26 13Green Belt 44 13Black Belt 5
RPI
Remaining DBH Employees Trained in RPI
85
25
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 1513Yellow Belt 26 13Green Belt 39 13Black Belt 5
RPI
Current DBH Employees Certified in RPI
51
26
Change Leaders Yellow Belt Green Belt Black Belt
Presenter
Presentation Notes
Change Leaders 4 13Yellow Belt 26 13Green Belt 20 13Black Belt 1
RPI
Financial Security Department Consolidation for Outside Trips at FSH
27
28
bull Problem Separate Security Departments create process redundancies and staffing conflicts that relate to inefficiencies with escorting and transporting clients
bull Primary Goalsbull Create operational definitions for trips bull Create a better tracking system for trips bull Utilize a program for scheduling trips bull Evaluate trips and eliminate redundancies in staffing resulting in
a reduction of the number of man hours used and a reduction of payroll spent
RPI
Define Phase Goal- Voice Of The Customer
28
Presenter
Presentation Notes
We followed the DMAIC Process as part of the Robust Process Improvement In the Define phase we worked with our Core Team members and key stakeholders in order to clearly define what our project would entail We stated our problem as clearly and concisely as possible narrowed our scope of the project by indicating what to include and exclude when the process begins and ends along with our goals and how we would measure success1313We performed ldquoGembardquo (The real or actual place) walks which we directly observed the key stakeholders performing the tasks within the process This was critical because if we had just trusted that the process was being followed as indicated by policy and operating procedure we never would have observed one of our key causes of failure and variation We took that information and with the help of our core team created a high level process map which captured the key process steps along with their inputs and outputs
29
Process Step Process Inputs (xs)Importance Total
FailuresSeverity
Occurrence
Failure
Score CommentsAction
Review Trip Schedule Assign Staff
Reviews schedule first and assigns drivers--4 to assign currently doesnt assign until Friday before week
144
assigning staff on F ridays doesnt allow
for resource allocation pre-notification on
training day svacation days 8 9 72
influences satisfaction of last minute changesreview schedule and assign staff
sooner scheduled training and v acation days posted
Schedule the Court Order or Medical Appointment
medical-Review tripsstaffing to determine if resched needed
144surgery priorities
follow ups postponed
v acationtraining day s 21 staffing
ratios 5 8 40
policy was not being followed changed practice reeducated on policy post trainingv acation schedule
do more planning in adv ance
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144If no FRS will work short in control room (more often than FRS going) 9 4 36
could increase security safety risks in
units additional PRN staff for trips
Review Trip Schedule Assign Staff
Unit Security assigns staff and when short looks for PRN and OT ppl that have signed up to assign at least the quick appts
144 Rotation schedule (BFC) v olunteers most of the time FRS get pulled
reschedule 9 3 27additional PRN staff for
trips
bull PFMEA Highest Failure scoresbull Last minute staffing assignments scored
highest on the failure scorebull Occurrence was every weekbull Severity of not having staff scheduled
meant moving staff schedules or trips getting volunteers for OT working short etc
bull The next highest score was on pre-planning of scheduling trips based on security availability
bull Another high failure score was related scheduling no backup for scheduling (call in on Friday resulted in a lot of juggling to make trips happen)RPI
Measure Phase Goal- Analyze Failure Modes
29
Presenter
Presentation Notes
In our Measure phase our team utilized several tools in order to understand the current process focusing on answering the questions1313What is our complete process flow13How is our process behaving13What areas do we need to focus on 1313Value Stream Mapping13Cause and Effect Matrix13PFMEA1313Here is a slide with a snapshot of our teamrsquos PFMEA which called out our highest failure modes and effects of those failures1313With DMAIC and RPI we just do not rely on a ldquogut feelingrdquo so we made sure to collect data We used an employee satisfaction survey to capture the voice of the stakeholders who lived and breathed the process everyday We used an existing excel spreadsheet that a subject matter expert had on their computer to capture some initial data and in some cases there was not already existing data to pull so our team had to create and develop a Trips Data Base which captured the metrics we were interested in This in turn meant we had to develop operational definitions educate staff and team members on how to collect the data to insure accuracy and precision 1313Employee Satisfaction Survey13Pareto13
bull30
Avg Hrs Per Trip HFCAvg Hrs Per Trip SORTSAvg Hrs Per Trip GFCAvg Hrs Per Trip Biggs
8
7
6
5
4
3
2
Hour
s
Average Secuirty Hours Per Trip By Unit
RPI
Analyze Phase Deliverables- Validated Root Causes
30
Presenter
Presentation Notes
13At first our team was moving along the reduction of Overtime path using Security OT as a primary indicator of our process was behaving but like many of you probably have we discovered there are a lot of variables that influence the number of OT hours and the $ spent paying OT We did not feel the data we were able to collect for OT was ldquocleanrdquo and accurately portrayed what was actually occurring within our escorted Medical and Court trips off campus Instead we decided to focus on the number of trips per unit and the number of security hours used by each unit per month This resulted in the boxplot you see here and like Tara mentioned before if statistics is not your love language you can visually see one unit stands out from the rest SORTS Which lead our team to ask the all important question of ldquoWhyrdquo1313To bring you back full circle if you recall earlier I mentioned the how critical the Gemba walk was to our project this data confirmed what we had observed during the GEMBA walk that SORTS was not following the escort ratio dictated by policy 13
Validated Root Cause Targeted SolutionTrip escorting policy not followed in allunits
Re-educate units to trip escorting policy
No back-ups for scheduling trips when call-insvacationretirement occur
Multi-skill training and increase access to appointments schedule
Numerous unknown cancellations rescheduled trips
Operational definitions to create accurate data of cancellations
No data source on trips happening Created trips data baseUnit to Unit involvement Progress has been made as a result of the
project more expected to continueAvailability of drivers unknown except what is scheduled from Campus Security
Moving drivers to units
Schedulers for appointments and driversdo not know in advance the pre-planned daystimes staff will be unavailable for drivingescorting
Put assignments and notifications of vacations training etc on appointments schedule
Drivers not scheduled with enough time to adjust work schedules to accommodate trips
Begin assigning staff before Friday
31RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
31
Presenter
Presentation Notes
Through our data collection we were able to identify and validate additional root causes of our failures in our process and thus we were able to brainstorm on targeted solutions to address those root causes
Average Security Hours Per SORTS Trip
This chart shows the comparison of Average Security Hours Used per SORTS Trip from our baseline of April of 2016 to March of 2017 to our improvement from April of 2017 to March of 2018
April of 2017 was the date in which the Escort Policy for outside trips was clarified and the unitsrsquo security and Specialty Clinic were re-educated
The greatest impact occurred in how the SORTS Program handled the number of staff needed to complete an outside trip
bull32
2181217101781761741721712161016816616416
9
8
7
6
5
4
3
2
1
NewDate
Indi
vidu
al V
alue
_X=3256
UCL=4820
LCL=1692
416 417
Avg Security Hours Per Trip
RPI
Improve Phase Goal- Stabilize The Process And Eliminate Or Reduce Waste Variation And Defects
32
2 Sample t Test for Total SORTS Security Hours
2 Sample t Test for Avg Security Hours Per Trip
33
Descriptive Statistics
Sample N Mean StDev SE
Mean
Security 416-0317 12 1880 351 10
Security 417-0318 12 1157 383 11 Estimation for Difference
Difference 95 CI for Difference
723 (411 1034) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
482 21 0000
Descriptive Statistics
Sample N Mean StDev SE Mean
Avg Sec HRS per Trip 416-317 12 5755 0959 028
Avg Sec HRS per Trip 417-318 12 3256 0611 018 Estimation for Difference
Difference 95 CI for Difference
2499 (1810 3189) Test
Null hypothesis H₀ μ₁ - micro₂ = 0
Alternative hypothesis H₁ μ₁ - micro₂ ne 0
T-Value DF P-Value
762 18 0000 RPI
Control Phase Goals- Standardize And Sustain Improvement
33
Presenter
Presentation Notes
Looking at two 12 month periods from April 2016 to March 2017 and April 2017 to March 2018 our project produced the following results with 45 additional trips13Relative Improvement based on Average Security Hours Per Trip ((567 ndash 313) 567) 100 = 448 13Reduced the cost incurred by Security Staff by $1300008 (86725 x 1499) 1499hr is the average wage of a FRS I13Reduction of the average cost per trip incurred by security staff by 448 (2016 to 2017 $8499 = 567 x 1499 versus 2017 to 2018 $4692 = 313 x 1499)13Finally if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499) 13
RPI
Financial Results
bull The Challenge - 1400 Offsite trips per yearbull Separate Security Departments create process redundancies and staffing conflicts
that relate to inefficiencies with escorting and transporting clientsbull The Result
bull $ 20000 Savings if SORTS would have operated with the additional security escort Security Staff would have spent an additional $2081362 in salary dollars (13885 x 1499)
bull Created operational definitions for tripsbull Created a better tracking system for tripsbull Utilized the MedConsprogram for scheduling trips bull Evaluated trips and eliminated redundancies in SORTS staffing resulting in a
reduction of the number of man hours used and a reduction of payroll spentbull Createdreclassified job positions in order to have multi skilled workers that can
perform schedulingdrivingescorting duties as well as work within the units
34
Presenter
Presentation Notes
All Units were re-educated in following the trip escorting policy13Adopted the MedCon System for scheduling Medical and Judicial Appointments13Granted Access to and trained multiple staff members on the use or view of the MedCon System13Created operational definitions to capture accurate data in relation to off-site trips13Created and Modified Microsoft Access Trips Database by Security Staff13Appointments less than 6 weeks out are put on the schedule in the MedCon System13Moved Security Driver positions to the Units13Convert Security Officer and Driver positions to SAI by attrition13Moved Clerical Position from Mainside Security to the Clinic13Modified Security SAIIrsquos schedule from 10hr4 days a week to 8hr5 days a week13Security meets weekly with Security Director13Established a more unified approach to staffing medical and judicial trips13
RPI
Operational Visitor Check-in at CBMGreeted to Seated
35
bull CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units
bull This causes delays at the front desk and creates safety concerns for patients staff visitors
RPI
Define Phase Goal- Voice Of The Customer
36
Presenter
Presentation Notes
The problem statement for this project is that CBMrsquos security staff does not have a standardized uniform process to screen visitors arriving for CBM and Truman Medical Center psychiatric units This causes delays at the front desk and creates safety concerns for patients staff visitors 13
Spaghetti Diagram prior to improvement
TMC
CBM
Seating
Kiosk Security Desk Security Desk
Metal detectorMetal detector
Entranceto
units
Lockers Front door
TMC Phone and
Computer
RPI
Measure Phase Goal- Identify All Steps And Inputs In The Value Stream
Presenter
Presentation Notes
The team participated in a Gemba Walk The spaghetti diagram illustrated how visitors proceeded through the lobby in an inefficient and unsafe manner
