Lean Six Sigma in Healthcare Improving Healthcare at Presbyterian Healthcare Services Using Lean Six Sigma
Learning Objectives Why we need to improve our processes What is Lean Six Sigma Why do we need to have Lean Six Sigma Presbyterian Process for Improvement Case Studies
What you will gain Introduction to Lean Six Sigma What it takes to implement successful Lean Six Sigma How to sustain the gains from the improvement
THE BURNING PLATFORM
Costs and Spending Health Care Cost in the United States 1980 1990 2008 $2.3 Trillion $253 Billion $714 Billion Health Care Spending KaiserEDU.org : Health Policy Explained US Health Care Cost http://www.kaiseredu.org/issue-modules/us-health-care-costs/background-brief.aspx
What s driving Healthcare Reform? Technology & Prescription Drugs Chronic Disease Aging of the Population Administrative Cost
What are the Major Proposals to Contain Cost? Investment in information technology Improving Quality and Efficiency Adjusting Provider Compensation Government Regulation Prevention Increasing Consumer Involvement in purchasing Altering the Tax Preference for Employersponsored insurance
What do we all see as Customers of Healthcare? Clinical Issues Long waits in ED Wrong Surgeries Prescribing wrong medicine and dosage Financial Issues Incorrect Billing of charges Timely filing issues; denials from payers Inaccurate charges for procedures Poorly developed and inefficient processes Multiple handoffs and rework adding increasing cost
What s really driving cost in Healthcare Inefficient processes Lack of communication Processes developed over time Band-Aid approach to fixing problems Complex processes built around silos
WHAT IS LEAN SIX SIGMA
DMAIC Methodology Define Control Improvement Measure Improve Analyze Used to reduce defects or improve a current process
LEAN Methodology Define Value Control Process Improvement Measure Value Improve Process-Flow Analyze Process-Flow Used to reduce waste or shorten cycle times
DMADV Methodology Goal: Developing a process that provides the Customer the products and services that best meets their expectations. h b h i Verify Define Design Measure Design Analyze Used to create a new process
Lean Six Sigma Methodology LEAN DMAIC Define Control Process Improve Process- Flow Define Vl Value Lean Improvement Analyze Process- Flow Measure Value DMADV Define Control Improvement Measure Verify Design Measure Improve Analyze Design Analyze
Define: Scoping the Project Finding the Scope Charter SIPOC Process Mapping Capturing the Voice of the Customer (VOC) External view of our process and issues Talk to our customers to understand their pain points
Define: Right Players on the Project Oversight Boards and Committees Leadership Champions Ownership Process Owners Work Team Members Facilitators Black Belts
Define: Capturing the Voice of the Customer Who is the Customer? What drives the Customers to have difficulties with our products/processes? Where are the pain points in the process? How inefficiencies causes customer complaints? lit? Translation of Key Issues to Critical to Quality Understanding of what we should be measuring
Measure: Understanding Baseline Data Using Data to make Decisions Stop using gut feel and anecdotes to make decisions Review the numbers to help truly identify problem areas Understand baseline to determine if changes make a difference Capture current performance levels
Measure: Understanding the Basic Formula Y = f(x) Process Input x 4 Step 1 In-Proce ess x 1 In-Proce ess x 2 In-Proce ess x 3 Input x 5 Step 2 Step 3 Step 4 Output Y Input x 6 Input x 7 Input x 8 Input x 9 Y = f(x 1 ) + f(x 2 ) + f(x 3 ) + + f(x n )
Measure: Using Root Cause Analysis Tools Use basic tools that have been around since for over 100 years Process Mapping pp g Cause and Effect Diagram Pareto Analysis y FMEA
Other Tools in the Toolbox Lean Toolbox Ohno Circle 8 Waste Reduction 6S Group Huddle Value Stream Map (VSM) Product Process Flow (PPF) Full Work Analysis (FWA) Group Technology Mistake Proofing Changeover Capacity and Labor Review Line Balancing Standard Work Kanban & Point of Use Video Analysis Visual Controls Six Sigma Toolbox Charter SIPOC Process Map Pareto Analysis Cause and Effect (Ishikawa hk Diagram) FMEA Histogram Barrier Analysis Brainstorm/Affinitize Measurement System Analysis (MSA) Box Plots Basic Statistical Graphs Process Capability Hypothesis Testing Design of Experiments (DOE) Pugh Selection Matrix + Others Quality Function Deployment
Analyze: What Xs will make a difference to the Y Understand the affects of each root cause (X) on the output (Y) Use basic data analysis tools Use statistics to test hypothesis Drive decision making using analysis tools Eliminate the Xs that don t make a difference
Analyze: Understanding the Cause for Poor Performance f(x2) f(x4) f(x6) f(x8) f(x3) Y = f(x1) f(x7) f(x5 ) f( (x9) Y = f(x 1 ) + f(x 5 ) + f(x 7 ) + f(x 9 )
Analyze: Identifying the Critical Xs Understand the current problems Define What s the problem? What s the customer telling us? What s Critical for Quality? Identify Potential (Xs) in all areas that may affect the Outcome (Y) Measure Where s the breakdown? Why s the process failing? How well are we doing? Validated Xs that attribute for the majority of the problems. What are the few areas that drive the poor performance. Analyze Which Xs presents the biggest issues? Which Xs really causing a problem?
Improve: Develop Solutions to Eliminate Failures for Xs Innovate through out of the box thinking Shift your paradigm Status quo changes must be stopped Work with stakeholders to help develop ideas for improvement
Improve: Working with Teams Help spread process understanding Improve understanding of each other s work Promote team approach to problem solving Break down silos across the system Use the team s collective understanding di
Change Management Help with change Provide the need for change Constant communication from Sr. Leadership and through Project Team Provide upfront changes to help eliminate problems Work with key staff in each area to promote test of change
Improve: Developing Solutions Use the Front Line Staff to identify solutions Conduct pilot testing to test effectiveness ect ess of change Develop improvements throughout testing process Implement multiple solutions to fix single problem
Control: Sustaining the Gains Monitor and Show Performance Elicit improvements from all staff members Develop control plans to help determine actions Setup the front line staff to self monitor
Change Management Communicate throughout the system from start to finish Change the culture through changing how we manage System thinking identify process that best suits the organization Work as a team to eliminate system problems Break down barriers Resource and support
Why the Methodology Works Organization Level Systematic and structured approach to problem solving and improvement Oversight at various levelsl Senior management supported Operational Level Meeting deliverables for tollgates Operation owned improvements Official handoff and transition improvements into Operations 1 Internal and External Customers
Presbyterian s Quality Infrastructure for Sustained Improvements HOW DO WE IMPROVE?
What is Quality At Presbyterian Quality Means Having Excellent Services Free of Deficiencies What customers and stakeholders tkh want How they expect it delivered dli d
The Value of Quality Quality of a System Impacts the Bottom Line Excellent Services Customers Expect Free from Deficiencies Market Leader Fair Price Faster Cycle Times Lower Costs Less Rework Higher Vl Volume Improved Margins Lower Total Cost
Quality at Presbyterian Our quality initiatives allow us to deliver: Improved patient safety Improved patient satisfaction Improved patient access Improved outcomes Improved financial returns Decreased length of stay Lowered supply costs
Process Excellence Through different types of projects Process Excellence helps drive quality improvements at Presbyterian Different Tools for Different Goals Lean Six Sigma (DMAIC) Design for Six Sigma (DMADV) Successful projects require involved leaders and engaged front-line staff
Project Identification Prioritization &
Financial Acceleration Committee FACT Process
FACT Responsibilities Finance Process Excellence Business Unit Verify logic, data, Coach and guide Submit requests assumptions are Business Unit on for data from valid which systems they systems Identify specific need to use to pull Calculate resource for specific data business case follow-up tasks Assist Business Present logic and Provide training / Unit on defining calculations to education Project Y FACT Update PE / BU on Guide BU through PHS financial decision tree practices Standardize forms and business case validation Review calculations, provide suggestions
PEP Oversight
Physician Engagement
Physician CMEs
Post-Deployment Three meetings after close of PEP: Business Acceptance Audit Business Acceptance Meeting 2nd Business Audit Goal of Post-Deployment t activity: it Ensure process changes are being sustained Verify measures are still meeting expectations Confirm continued management attention and executive oversight
Post-Deployment
Project Oversight
Engage Leadership and Teams Champion Perspective Senior Leaders that fully support projects and teams continue to drive for perfection and out of the box thinking Process Owners Empowered to take on initiative and make decisions based on sound evidence Has full stake in the process and results Front Line Staff Developing front line staff for continual improvements
Case Study DOOR TO BALLOON CYCLE TIME
Restoring Blood Flow in a Coronary Artery 100% Blockage in a Blood Flow is Restored with Coronary Artery a Balloon and Stent
Improve State Performance Evaluation
An Individual Case Control Chart (I Chart) 350 I Chart of Door-to-Balloon Times (through 9-30-08) Pre-Improve Phase Improve Phase 1 Blue Line = 90 minute Upper Spec Limit -Balloon Tim me Door-to 300 250 200 150 100 50 0 1 2 2 2 1 6 UCL=117.1 _ X=62.8 LCL=8.6 90 After the Improve Phase Median Time went from 63.0 to 62.8 min 01/01/07 02/27/07 05/28/07 07/07/07 10/18/07 12/29/07 03/04/08 04/25/08 07/09/08 08/28/08 Percent within 90 minutes went from 94.6% to 86.5%
Case Study PHYSICIAN BILLING
Goal Statement Y1: Decrease the Billing WIP AR by 50% from average of $2,983,350 to $625,000 by 12/31/2009 Y2: Increase clean claim rate for both Primary and Secondary Billing by 10% from 86.75% to 95% by 12/31/2009 Data as of 7/17/2009
Billing Value Stream (Before) Mainframe Manual Processes (Blue) Eliminated Claims in Mainframe System Migrate VSM Current State to MedAssets Eliminated Manual Rework Cycles Manual Process (Orange) Improved Automated Processes Automated Process (Green) Reduced Manual Processing
Billing Value Stream (New State) VSM Future State Automated Process (Green) Improved Automation for more payers Improved internal process for non- electronic payers Manual Process (Orange) Further work with MedAssets to reduce manual processes Improve Productivity it and Accuracy Reduce variation through continued standardization
Results: Billing WIP Good $6,000,000 $5,000,000 AR EPIC Billing Work In Progress (WIP) Baseline 1 1 Total Unbilled EPIC Billing AR 1 1 Measure Analyze Improve Control Step wise drop in AR Billing WIP Dollars $4,000,000 $3,000,000 Total $2,000,000 1 January 1, 2009 at $5.8M $1,000,000 $0 4/25/2008 6/27/2008 1 8/29/2008 10/31/2008 1/2/2009 3/6/2009 5/8/2009 7/10/2009 1 9/11/2009 11/13/2009 _ UC L=$1,054,290 X=$739,826 LCL=$425,362 Sustained Control Phase Last updated on 1/12/2010 Date
Results Claims Aging Claims Aging by Dates of Service Physician (EPIC) Billing Process of Days Number 110 100 90 80 70 60 50 Measure Analyze Improve Control Before: Average 95 Days _ UCL=65.17 X=58.43 LCL=51.69 Good 40 30 5/25/2009 6/17/2009 7/9/2009 7/31/2009 8/24/2009 9/16/2009 10/9/2009 11/2/2009 11/24/2009 12/16/2009 1/7/2010 After: Average 58 Days Date Last updated 1/12/2010
$uperior Outcome$ Project Start January 1, 2009 Project Completion December 31, 2009 Project Sustainment May 31, 2010 Goal Unbilled AR WIP $5.8M $566K $285K $600K Total Days Billing WIP (Number of Days Revenue on Hold for Billing WIP) 5.9 Days 0.6 Days 0.4 Days 0 Days % Clean Claims (Claims with no edits) 87.6% 89.0% 93.0% 90% % ECT Claims (Claims with an edit, fixed manually and submitted ECT) Total Claim Inventory (Primary/Secondary/Tertiary) 81.7% 97.9% 98.24% 95% 21,586 Claims 3,012 claims 1500 Claims 0 Claims
What Have we Learned? Mythology with Tools and Deliverables Senior Management Support and Drive for Improvement pove et Systematic processes across organization for oversight Willing staff to make things happen Follow through h with managing change Celebrate successes
Learn More About Lean Six Sigma Books The Six Sigma handbook: a complete guide for green belts, black belts, and managers at all levels by Thomas Pyzdek, Paul A. Keller The Toyota way: 14 management principles from the world's greatest manufacturer by Jeffrey K. Liker What is Lean Six Sigma? by Michael L. George, Dave Rowlands, Bill Kastle Websites www.isixsigma.com Stanley Lei s Email slei@phs.org