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Engaging the Leadership Triad in Accelerating Change Using Lean Six Sigma

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Title: Engaging the Leadership Triad in Accelerating Change Using Lean Six Sigma


1
Engaging the Leadership Triad in
Accelerating Change Using Lean Six Sigma
  • Stephen Mayfield, Dr. H.A., MBA, MBB
  • Senior Vice President
  • American Hospital Association
  • smayfield_at_aha.org

2
Several Themes from High Performing Organizations
  • Seeing differently especially using variation
    and error as welcome feedback.
  • Engaging two levels of leadership for
    collaboration which means
  • embracing system thinking which cultivates
    process excellence in which the human factors
    tendencies within the system are attended.
  • Use of tools that facilitate the dialogue between
    levels of leadership.
  • Establishing the value proposition, or the
    Business Case for Quality
  • Using Lean / Six Sigma as methods to Reduce Waste
    and Eliminate Defects

3
It All Starts With
  • Create awareness for transformative change that
    focuses on the Patients Experience
  • Grow capacity for Robust Performance Improvement
  • Executive Leadership owns Common Cause Variation

4
Aspects of the Situation
  • Humans are fallible
  • Healthcare is a high-risk environment
  • Faulty communication and hierarchal barriers are
    common root causes of medical error
  • Healthcare providers do not receive adequate
    training in communication, teamwork, and
    assertiveness skills
  • Errors can be reduced through a definable set of
    teamwork concepts and skills

From Check Six Training
5
Observations from High Performing Organizations
  • Learning to SEE differently its not about more
    data, its how you look at existing information.
  • DeKalb, Illinois
  • DeKalb, Georgia

6
How Did Healthcare Become So Unsafe?
Disease
  • Number
  • Of Deaths
  • Years

Treatment
From P. Gluck
7
  • Medicine used to be simple, ineffective and
    relatively safe.
  • Now it is complex, effective and potentially
    dangerous.
  • Cyril Chantler
  • Lancet, 1999

8
Lessons from Other Fields
9
PI Hospitals in Pursuit of Excellence
  • Its About Leadership
  • Executive Leaders Administrators, Trustees
    Physician Leaders
  • Patient Care Leaders those close to the
    delivery of care to the patient
  • Executives have to own common cause variation
    !

10
PI Hospitals in Pursuit of
Excellence
  • Core Principles
  • Focus on the Patients Experience - Care must be
    respectful of, and responsive to, individual
    preferences, needs and values
  • Create a Culture of Reliability - Culture
    defines the values and behaviors of
    organizations. Highly reliable cultures are
    known to be the safest organizations in the world
  • Manage Organizational Variability - Achieve
    consistency wherever possible in what you do and
    how you do it

11
PI Hospitals in Pursuit of
Excellence
  • Core Principles
  • Remove Inefficiency and Waste - Removing waste,
    including in the form of unnecessary steps, has a
    direct, positive impact on clinical and financial
    performance
  • Eliminate Harm and Defects - Finding and
    resolving problem points will result in greater
    efficiency and better health outcomes
  • Reduce Process Variation - Using quality tools
    and frameworks can increase consistency in
    processes of care and administration, thus
    reducing the risk of errors

12
More Important than ever The New Realities
  • Moodys has a negative outlook for the US
    not-for-profit hospital sector, as virtually all
    rated healthcare credits are facing some degree
    of credit stress due to a combination of impaired
    access to the capital markets, soaring credit
    spreads, counterparty downgrades, and a slowdown
    in the global economy.
  • Moodys Investors Service
  • Dec. 2008

13
The New Realities
-

Margin
COSTS
REVENUES
Non payment adverse events
Waste Inefficiency
Medicare pressures
Non payment readmissions
20 to 50 of all health care efforts are
attributable to waste and inefficiency. Rework,
work arounds, defects, errors, unnecessary harm,
delays, misuse, overuse, underuse.
14
A Physician CEO Sees Differently
15
Seeing
Differently 1847
  • See

Dr. Ignaz Semmelweiz
General Hospital of Vienna
First Ward
Second Ward
16
Outward Visible Signals of Culture
17
Outward Visible Signals of Culture
18
Jump From 1847 to 2009
  • Number One National Patient Safety Goal of the
    Joint Commission for reducing Healthcare
    Associated Infection

19
Seeing
Differently 1986

Challenger Disaster resulted from decisions made
in 1972
Individual competence in a poorly designed system
20

Seeing Differently 2003

Jesica Santillan
  • Successful transplant surgery (twice)
  • No verification system for matching blood type

Individual competence in a poorly designed system
21
Optimizing the System Context and Content
  • Premise
  • All patient care is a system, every system has
    processes and every process has waste and
    variability.
  • Corollary
  • Separating all the processes and optimizing each
    one and then combining them DOES NOT optimize
    system performance

22
Four Major Components of Care Delivery
23
Systems of Care and Simple Metrics At the
Operational Level Information -gt Clinical
Decisions -gt Care Processes -gt Patient Flow
Evidenced Based Medicine
Clinical Information System
Outcome Indicators (LOS, Mortality, Infection,
Readmits)
Financial System
Clinical Best Practices
Charges
Cp1 Cp2 Cp3….
Cp1 Cp2 Cp3….
Cp1 Cp2 Cp3….
Process Measures (Waste, SMR, Cycle Time
Variances, etc.)
Patient
Patient
Patient
Patient
Patient Flow
24
On a Cruise who has the most impact on your
safety?
25
What is Human Factors Science?
  • …..Concerned primarily with the performance of
    one or more persons in a task-oriented
    environment interacting with equipment, other
    people, or both.
  • National Academy of Sciences

26
The Study of factors that contribute to errors
including
  • Human Vulnerabilities related to memory
  • Situational or environmental aspects
  • Cognitive Lapses

27
  • Perception and Communication
  • An Example

28
Perception and Communication How Many Squares Do
You Count? Silently count, and write down your
total
Image One
29
Say the Color of the word
30
Say the Color of the word
31
Mistake Proofing
32
  • Perception and Communication
  • An Example of How Technologies Impact System
    Performance

33
  • In Short Performance is affected by Human
    Tendencies related to cognitive processing
    attributes and limitations and the effects of
    system variability and interactions, ESPECIALLY
    those associated with decisions and communication.

34
PI Hospitals in Pursuit of
Excellence
  • Core Principles
  • Focus on the Patients Experience - Care must be
    respectful of, and responsive to, individual
    preferences, needs and values
  • If it starts with the Patients Experience, what
    does the system deliver?

35
Consumerism Book
36
New Book Im Working On
  • If a Hospital Ran Your McDonalds

37
Are we getting the message?
  • American industry has become very accustomed to
    running their businesses by watching each other.
    In fact many of them are still focusing on the
    competition, only this time it is Japan. In a
    few years it will be Korea, then China, then some
    other country. If you just try to meet the
    competition, you will not survive in this new
    economic age. You must try to meet the customer,
    not just the competition.
  • And it is you who must change, not the
    competition.
  • -- William Scherkenbach, 1986, excerpted from
    a presentation to General Motors

38
Healthcare Excellence Requires Collaborative
Leadership System Thinking that Supports Process
Excellence
Context Leaders (executive, trustee, physician
leaders)
  • Systemness
  • Culture
  • Structure
  • Strategy
  • Process Field

Engage Leaders
Content Leaders (clinical and non-clinical)
  • Process Excellence
  • Competencies
  • Team
  • Training
  • Process Improvement

39
Leadership Creates the Framework for a System
that Supports Process Excellence
Strategy
Process Excellence
Structure
Process
Culture
40
Performance Improvement is a function of
standardizing the methods, stabilizing the
performance, reducing variation until the next
innovation moves performance to a new level
41
Iceberg of Ignorance What of the
Organizations Problems are known to….
Top Management
4
Middle Managers
9
Problems hidden from management
74
Supervisors
Front-line Employees
100
Adopted from Sydney Toshida
42
Five Important Questions for Trustees
  • What are we trying to accomplish with respect to
    our performance?
  • What level of quality and safety are we pursuing?
  • How do we measure it?
  • How is our performance changing?
  • Is what were doing making a difference?

43
Trustees have a Right and a Responsibility to
ask
  • How do we know if care in our hospital is
  • Safe?
  • Timely?
  • Efficient?
  • Effective?
  • Equitable?
  • Patient-Centered
  • (The Six Institute of Medicine Aims STEEP )

44
Five Important Questions for Physicians
  • How do we know if our care processes are
    reliable?
  • How do we embrace and promote evidence-based
    practices?
  • Are we eliminating preventable harm?
  • Am I managing the care of my patients and their
    flow through the system, or have I assigned that
    to others?
  • Are we actively engaged in peer review learning?

45
Seven Important Questions for Executive Leaders
  • Are we developing Systems of Care?
  • Are we providing efficient processes?
  • What indicators of quality and safety are we
    bringing to our Board and Physicians?
  • How are we engaging our Physicians?
  • What are our Costs of Poor Quality?
  • How is the CFO involved?
  • How are we continually reducing variation?

46
Hierarchy of Activities for High
Performers Engage the Triad
  • Has the organization clearly established what is
    important?
  • Has the organization determined expected
    performance levels for
  • (a) Clinical outcomes
  • (b) Operational performance
  • (c) Safety
  • (d) Satisfaction?
  • Has the organization developed a Balanced
    Measurement System?
  • Has the existing performance been assessed?

47
Hierarchy of Activities for High Performers
  • Has the Business Case for Quality been
    established clearly?
  • Are departments/functional areas aligned with the
    organizations performance expectations?
  • Are priorities for process improvement
    identified?
  • Are appropriate tools and methods used to bring
    about successful change and improved performance?

48
Outpatient Surgery
49
Process Oriented Results Driven
  • The Toyota mind develops brilliant processes in
    which average employees may excel. (Taiichi
    Ohno)

50
Process Oriented Results Driven
  • The Toyota mind develops brilliant processes in
    which average employees may excel. (Taiichi
    Ohno)
  • Healthcare Analogue -
  • Healthcare systems have discontinuous processes
    in which brilliant staff struggle to produce
    average results.

51
Six Sigma Example High Level Phlebotomy Flow
  • MQC

52
Detailed Phlebotomy Flow
  • MQC

53
Over 40 specific defects identified in 5 classes
  • Label defects (unlabeled, misplaced, wrong
    patient labels, misaligned, etc.)
  • Patient ID band defects ( improper matching, no
    label, wrong label, etc.)
  • Unsuccessful draw (not first stick, second
    phlebotomist required)
  • Unacceptable specimen/recollect (wrong tube,
    clotted, hemolyzed, insufficient quantity,
    contaminated, overfilled, etc.)
  • Order entry defects (time, test, patient)

54
Surrounded by Defects !
55
The System will get you if you Choose
Sub-Optimal Solutions !
56
Cost of Poor Quality and Defects
  • For Error that can lead to harm - What is the
  • Possibility?
  • Availability?
  • Probability?
  • Liability?
  • Opportunity Cost?

57
(No Transcript)
58
PI Hospitals in Pursuit of Excellence
  • Its About Leadership
  • Executive Leaders Administrators, Trustees
    Physician Leaders
  • Patient Care Leaders those close to the
    delivery of care to the patient

59
Leaders must ask
  • How do we know if care in our hospital is
  • Safe?
  • Timely?
  • Efficient?
  • Effective?
  • Equitable?
  • Patient-Centered
  • (The Six Institute of Medicine Aims STEEP )

60
Several Themes from High Performing Organizations
  • Seeing differently especially using variation
    and error as welcome feedback.
  • Engaging two levels of leadership for
    collaboration
  • embracing system thinking which cultivates
    process excellence in which the human factors
    tendencies within the system are attended.
  • Use of tools that facilitate the dialogue between
    levels of leadership.
  • Establishing the value proposition, or the
    Business Case for Quality
  • Becoming a Learning Organization
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