PI Boot Camp 2015.06 Participant Packet

Performance Improvement
Boot Camp
Michael E. Rudolf
June 9, 2015

Are You In The Right Place This Morning?
The answer is ‘YES’ if:
• Do you ever waste time waiting?
• Do you ever redo your work?
• Do the procedures you use waste steps, duplicate efforts, or
frustrate you?
• Is information that you need ever lost?
• Does communication ever fail?

Our Mindset Today (& Everyday) Should Be Looking Outside The Box . . .

Ice-Breaker Exercise:
Jefferson Memorial Example
• In Thomas Jefferson’s time patriots defended our nation’s
capital from the invading British. More recently, the Park
Service had to defend the Jefferson Memorial from
invaders of another sort.
• The stone in the Jefferson Memorial was crumbling.
• In small groups, take one puzzle piece that contains one
real question asked and attempt to diagnose the problem
and solution needed.

Jefferson Memorial Questions
• How do you define “the root cause of a problem?”
• Why don’t we spend the time necessary to uncover
the root cause of a problem?
• Reward those who are decisive and make fast decisions.
• Recognize and reward quick decision-makers through promotions,
recognition, and pay increases.
• This bias for action can fly in the face of a systematic approach to
identifying the root cause.
• What happens when we apply solutions to the problems before
identifying the root cause?
• What is an e.g. of a problem you encountered that persisted because no
one identified the root cause?
• Can you think of another recent problem that benefited because you
identified the root cause?

Deming: Three Percent “KNOWABLE”
• Only THREE PERCENT of data is “KNOWABLE” in any
organization - thus, NINETY-SEVEN PERCENT is
“UNKNOWABLE.”
• Do You Agree?
• What if it was 20% like what the puzzle piece represented
or two puzzle pieces – 40%
• How does this affect your Unit, Area, Service Line,
Department and this Hospital?

Process Improvement (PI) Methodology
• Focus is on having a ‘toolbox’ of various problem solving tools and
to match the right tool to the right situation AND being flexible on
how to solve a problem following the basic steps of:
• Define problem / team Identification (Define)
• Determining current process information (Measure)
• Identifying the largest cause of the problem (Analyze)
• Identifying / implementing solutions (Improve)
• Implementing systems to sustain Improvements
(Control)
• Evaluate problem solving process / recognize team
(Share)
• The process will have the advantage of having both the structure in
a 6-step problem solving method and the flexibility in having a
variety of tools that are used in Lean, Six Sigma, and PDCA from
which to choose

What is DMAICS? It is an acronym
• DMAICS (Duh-May-Icks) is a methodical process that
incorporates six structured phases to focus on quality
improvement while maintaining critical customer elements.
• Define
• Measure
• Analyze
• Improve
• Control
• Share
• It is a process
• It is a set of tools
• It is a roadmap
I

DEFINE
• Key Steps:
• Validate problem statement and goal
• Define primary metric
• Identify process owners / stakeholders
• Determine financial measures
• Map major process steps
• Key Tools:
• PROJECT CHARTER & SIPOC; Voice of the Customer;
Process Map

Project Charter
(AHRQ Example)
• PLAN
• Project Description / Scope
• Case for Change (Potential ROI)
• Performance Measures (Baseline and Goal)
• Milestones – Evaluation Date
• Potential Barriers to Success
• TEAM / RESOURCES
• Stakeholders
• Team Members
• Additional Resources Needed
• Signatures

SIPOC: Feeding The Dog Example
Suppliers Inputs Process Outputs Customers
• Wal-Mart • Go shopping • Open
cupboard
• Dog eats • Dog
• Buy dog food • Get bowl • Dog fertilizes
garden
• Family
• Return home • Fill bowl • Garden
• Put groceries
away in
cupboard
• Call dog

MEASURE
• Key Steps:
• Develop Process Map
• Identify all relative information for the process
• Identify key inputs and outputs of the process
• Assess measurement systems
• Establish baseline capability of outputs
• Key Tools:
• Process Mapping (Flow Charting); Data Collection
• Failure Modes and Effects Analysis (FMEA)

ANALYZE
• Key Steps / Goals:
• Identify potential issues (causes)
• Prioritize issues to find root cause
• Estimate impact of root cause
• Explore relationships between inputs and outputs
• Key Tools:
• Brainstorming; Affinity Diagram
• Process Flow Charts (Mapping);
Graphical Quality Tools

IMPROVE / IMPLEMENT
• Develop list of solutions
• Evaluate, select, and prioritize optimal solutions
• Develop / Implement pilot solution
• Develop full implementation plan
• Identify training opportunities
• Determine “handover” between personnel
• Identify control plans
• Key Tools:
• Brainstorming; XY Matrix; FMEA; Process Mapping
• Training Plan; Implementation Plan

IMPROVE / IMPLEMENT
(Continued)
• Implementation Plan:
• Timelines established; who is responsible
• Decision for testing period
• Identify potential roadblocks
• Resources required to implement
• Communication/Training plan
• Transition plan (anticipate resistance)
• Execute & roll out
• Validate improvement

CONTROL
• Institutionalize changes
• Develop SOP’s and process controls
• Transfer ownership
• Key Tools:
• Statistical Process Control (SPC): Run / Control Charts etc.
• Control Plan
• SOP’s/Audits

SHARE
• Celebrate success of the team
• Write up results of the project
• Develop Lessons Learned from
the PI Process
• Key Tools:
• One page ‘Highlight’
• Project Tracking Matrix

DMAICS Approach
• Understand who are your key stakeholders / customers
• Understand what you provide for those key stakeholders / customers
• Use statistics as a tool for interpreting & clarifying data
• Requires change in culture; changes in the way we approach
performance improvement and projects
• Requires questioning the way we provide services to our key
stakeholders / customers and questioning the traditional way “things
are done or have always been done”
• Requires communication among various service lines,
departments/units, managers and staff

Questions For Everyone To Answer
1. What do you make?
2. How do we make what we make?
3. Why do we make what we make?
4. How do we improve what we make?

Performance Metric / Quality Indicator
• A quality indicator is a measurable characteristic or
occurrence that demonstrates a degree of compliance to a
customer’s expectation or standard.
• Examples may include: Complaints; Lost Business; Credit
Adjustments; On-Time Service; Missed Deadlines (internal
& external); Exception/Variance Reports; Overtime
Worked; Cycle Time; Inaccurate Billing; Rework;
Laboratory: TAT, Errors, Productivity; Nutritional Services:
Timeliness, Food (Hot / Cold / Fresh), Correct Order, etc.
• Your Department /Unit / Service Area?
Now It’s Your Turn!

Group Exercise: Questions For Everyone To Answer
1. What do you make?
2. How do we make what we make?
3. Why do we make what we make?
4. How do we improve what we make?
• Group Activity: Working within your group, identify 1–2
internal suppliers (those depts./units/service lines you receive
information/materials from). List 2–4 specific needs &
expectations that you expect to receive from them to meet
your needs to “make what you make”. If possible, list how
you measure each of these needs / expectations.

Why Examine A Process?
• NO ONE individual knows the TOTAL process (example,
Calvin’s father in Calvin & Hobbes comic)
• A need to expose rework and complexity
• Problems cut across the organization resulting in different
points of view of the problem, causes and solutions

Complexity Produces RE-WORK
• REAL WORK – What we would do if everything in the
process was perfect. It is the minimal steps.
• RE-WORK (Non-Real Work) – The additional steps we do
because everything in the process is not perfect. It is the
additional steps.

Complexity / RE-WORK
A Training Session Example
• Reserve conference room.
• Resolve meeting room conflict due to a mistake in
scheduling.
• Leading a group discussion.
• Having a discussion about why handouts can not be
read due to copier problems.
• Watching a video taped lecture.
• Waiting for all participants to arrive so the meeting can
start.

Generic Elements of a Process
• PEOPLE - Customers, co-workers, . . .
• EQUIPMENT - Test equipment, production equipment,
data bases, . . .
• MATERIALS - Supplies, input information
• METHODS - Procedures, protocols, techniques, . . .
• ENVIRONMENT - Physical conditions, bias or inaccurate
data, . . .

Common Causes
• Those causes that are inherently part of the system (or
process) hour after hour, day after day, and affect every
occurrence of the process, including everyone working in
the system, and affect all outcomes.
• Normal drive to work: On average, it takes – minutes?

Special Causes
• Those causes that are NOT part of the system (or process)
all of the time or do not affect everyone, but arise because
of specific circumstances.
• Accident, flat tire or traffic jam/major road repair occurs on
your drive to work – it takes same time or longer?

Probability of Performing “Perfectly”
• 95%: If only 1 - 24 steps in the process
• 28%: If 25 - 49 steps
• 8%: If 50 - 99 steps
• .6%: If 100 or more steps (that is, 6 chances in 1000 of
getting through process without an error)
• How many steps are there in your _______ process?

Lean / Six Sigma Challenge
99% Good (3.8 Sigma)
• 16,000 articles of LOST mail
per hour
• NO electricity for almost
seven hours each month
• 200,000 WRONG drug
prescriptions per year
• 5,000 INCORRECT surgical
operations per week
99.99966% Good (6 Sigma)
• Seven articles lost
per hour
• One hour without electricity
every 34 years
• 68 wrong prescriptions
per year
• 1.7 incorrect operations
per week

“99.9% is a really high percentage, why isn’t it good enough?”
• For those undergoing surgery in the U.S., a 99.9% quality
level would yield 70,000 patients annually with surgery
performed on the wrong part of their body.
•
• Approximately 4 million babies are born in the U.S. annually.
If the probability of taking home the correct baby was only
99.9%, then 4,000 families would leave with the wrong
baby each year.

To create significant,
lasting improvement we must erase:
• Anecdotal data (“most likely”, “in all likelihood”, “many”,
“slim chance”)
• “Shoot from the hip” or “instant answers”
• Guesswork without data
• Any debate that leads directly to “known” solutions
• Arbitrary numerical goals

Common Errors in Selecting Projects
• Selecting a problem that NO one is really interested in
• Selecting a solution to implement rather than a problem
to investigate
• Selecting a process in transition
• Selecting a system to study, NOT a process

Three Diseases of
Data Collection
• Collect “Everything”
• Paralysis - paralyzed by magnitude and complexity
• Initial decisions about what data to collect has NEVER been
clearly defined

Tips About Using Data
• The goal of data based problem solving is to collect
meaningful data, not more data
• Proper use of data eliminates much of the interpersonal
and/or interdepartmental conflicts
• Data is used to understand the actual situation and to
regulate or change a process
• BAD data is worse than NO data

5 Questions for your
Workplace Data
1. What is the objective of these data?
2. Is there an operational definition? Is it appropriate for the
objective?
3. How is data collected? Is collection appropriate for the
objective?
4. How is data analyzed and displayed?
5. What action is being taken?
• Given the objective and action, is anything “wrong” with the
current number?

Data Collection Questions
• WHY collect the data?
• WHAT data will be collected?
• WHAT methods will be used for the analysis?
• WHEN will the data be collected?
• WHERE will the data be collected?
• WHO will collect the data?
• WHAT training is needed for the data collectors?
• HOW will the data be measured?

Three Topics Critical to Effective and
Efficient Data Collection
1. Operational Definitions: Clearly defines what you want to
measure. Three components are:
1. Measure (length, weight, temperature, etc.)
2. Instrument
3. Procedure
2. Stratification: Process of gathering and analyzing data by
breaking into categories.
3. Sampling: Methods to ensure reliable, efficient data
collection. Three types are:
1. Block
2. Systematic
3. Random

Three Types of Data
1. VARIABLE - Data which is measured (length, weight,
temperature, etc...).
2. ATTRIBUTE - data that is counted (turnover, errors,
accidents, falls, complaints).
3. SUBJECTIVE - experience, gut feel, not based upon specific
data.

“It’s All in How You Ask”
• DESCRIPTIVE: “What can be said about this patient?”
• ENUMERATIVE: “What can be said about this group of
patients?”
• ANALYTIC: “What can be said about the process that
produced this group of patients?”

The Analytic Process Asks:
“What can be said about the process that produced this group of patients?”
• Data - Is this a typical snapshot?
• How does snapshot relate to previous ones?
Is process still the same?
• Any significant sources of variation?
• Is there agreement on how these numbers should be
measured?
• What can be predicted from the data?

Examples of Some Management PI Tools
• Flow Chart: What goes on in the activity?
• Pareto Analysis: What are the big problems?
• Cause & Effect Diagram: What causes the big problems?
• Control Chart: What does current data show about the current
activity?
• Histogram: What does a look at past data show?
• Scatter Plot: What are the statistical relationships?

Sampling of Tools used for Analysis
Flow Chart Fishbone Diagram Pareto Chart
Histogram 5 Why’s Run Chart
Scatter Plot Control Chart Pictograph
Problem
Problem
Root Cause
Why
Why
Why
Why
Why

The Flow Chart
‘What goes on in the activity’
• Definition: A picture of how a process
works or how we would like it to work,
showing all of the steps of a process
and how they relate to each other. Use
flow charts when you need to identify
the actual and ideal path that any
product or service follows in order to
identify deviations and opportunities
for improvement.

The Flow Chart Process Steps
‘Picturing the Process’
1. Decide on the process to flow chart.
2. Define the beginning and ending steps of
the process (boundaries).
3. Write beginning step in an oval.
4. Asking “what happens next?”, write each
subsequent step in a rectangle.
5. When a decision step is reached, write a
Yes/No question in a diamond and develop
each path.
6. Write ending step in an oval.

Analyzing a Flow Chart:
Examine Each Rework Loop
• Would these activities be necessary if
we had NO failures? How long is this loop
(steps, time lost, people / machine,
resources consumed, etc..?) Does this
rework loop prevent the problem from reoccurring?
• Examine each Decision Point:
• Is this checking activity? Is this a complete check, or do some errors
go undetected? Is this a redundant check?
• Examine each Activity:
• Is this a redundant activity? What is the value of this activity
relative to its cost? How have we prevented errors in this activity?

Deployment Flow Chart
• Definition: Shows the people
or departments responsible
and the flow of the process
steps or tasks they are
assigned. It is useful to clarify
roles and track accountability
as well as to indicate
dependencies
(interrelationships) in the
sequence of events.

Basic Flow Chart Team Exercise: “Turning on Light Switch or
Computer” or Hospital-specific
1. Get the “right” people in the room
2. Decide on which type of flow chart
3. Define first and last steps
4. Begin defining steps in sequence
5. At decision points, choose ideal or most natural branch and continue to
end
6. Use “clouds” or notes for unfamiliar steps and continue to end
7. When you reach last step, go back to branches
8. Read through flow chart to check for accuracy
9. Assign action steps to fill in unfamiliar steps and verify accuracy
10. When complete and accurate analyze it

Not Just When Flow-Charting
(Creative Thinking: Approaches to Developing New Ideas)
• Challenge the boundaries
• Rearrange the order of the steps
• Look for ways to smooth the flow of activities
• Evaluate the purpose
• Visualize the ideal
• Remove “the current way of doing things”

The Pareto Diagram
‘Focusing on Big Problems’
• A Pareto diagram is a bar graph which displays the priority
of factors or characteristics of a process. It helps to
separate the vital few from the useful many.
• 80% of the observed variation is caused by 20% of the
process inputs (80/20 Rule).

Pareto Diagram Process Steps (‘Focusing on Big Problems’)
1. Decide which problems you want to know more about.
2. Choose the problems that will be monitored, compared, and rank ordered by
brainstorming or with data.
3. Calculate most meaningful unit of measurement such as frequency or cost.
4. Choose the time period for the study.
5. Gather data on each problem category (starting now or historically).
6. Compare the relative frequency or cost of each problem category.
7. List problem categories on horizontal line & frequencies on vertical line.
8. Draw cumulative percentage line showing the portion of the total that each
problem category represents.
9. Interpret the results.
• Variations: Major cause breakdowns; Before and after;
Change the source of data; and Change measurement scale.

Pareto Data Collection Guidelines
• # of Categories
• 4 – 6
• 7 – 10
• 11 or more
• # of Data Points
• 30
• 60
• 100

Pareto Needle Stick Example
• CY 2014 = 54 total needle sticks occurred in Hospital XYZ
• Data was collected and stratified into the following six
categories:
1. Surgery = 4 needle sticks occurred in 2014
2. Trash = 6
3. Starting IV = 22
4. Bed Linen = 3
5. Piggyback IV = 17
6. Other = 2
• Complete pareto data form
CATEGORY FREQUENCY % CUMULATIVE

CATEGORY FREQUENCY % CUMULATIVE
Complete a Pareto Data Form: Needle Stick Example
• CY 2014 = 54 total needle sticks occurred in Hospital XYZ
• Data was collected and stratified into the following six categories:
1. Surgery = 4 needle sticks occurred in 2014
2. Trash = 6
3. Starting IV = 22
4. Bed Linen = 3
5. Piggyback IV = 17
6. Other = 2

Cause and Effect / Fishbone Diagram
‘What causes the Big Problems?’
• Definition: A cause and effect (or fishbone) diagram is a
picture of the relationship between causes and effects.

Advantages of Cause & Effect/Fishbone Diagram
• Organize and display.
• Allows use of anecdotal evidence.
• Encourage divergent thinking & balanced view of possible
causes.
• Indicates where team’s knowledge is sparse.
• Demonstrates complexity of the problem.
• Encourage scientific analysis.

Cause and Effect Diagram Process Steps:
‘What causes the Big Problems?’
1. Write an effect in a box on the right-hand side of the page.
2. Draw a horizontal line to the left of the effect.
3. Decide on categories of causes for the effect.
4. Draw diagonal lines above and below the horizontal line and label
with categories.
5. Generate a list of causes for each category.
6. Organize the causes on each bone, drawing branch bones to show
relationships among the causes.
7. Develop the causes by asking “WHY?” until a useful level of detail is
reached.
8. Optional: Survey key stakeholders on top 3 causes.

Generic Categories for Cause & Effect /
Fishbone Diagram
• PEOPLE - Customers, co-workers, . . .
• EQUIPMENT - Test equipment, production equipment,
data bases, . . .
• MATERIALS - Supplies, input information
• METHODS - Procedures, protocols, techniques, . . .
• ENVIRONMENT - Physical conditions, bias or inaccurate
data, . . .

Cause and Effect / Fishbone Diagram Exercise:
Bed Assignment Delay

Cause and Effect / Fishbone Diagram Exercise:
Bed Assignment Delay or Other
• Cause = Patient Waits for Bed
• Possible Categories:
• Resources
• Timing
• Machine (Computer / Phone / IT System / Pyxis)
• MD Procedures
• Hospital Procedures
• Communication

PI Methodology: LEAN
• Focus is on having a ‘toolbox’ of various problem solving tools and to
match the right tool to the right situation AND being flexible on how to
solve a problem following the basic steps of:
• Define problem / team Identification (Define)
• Determining current process information (Measure)
• Identifying the largest cause of the problem (Analyze)
• Identifying / implementing solutions (Improve)
• Implementing systems to sustain Improvements (Control)
• Evaluate problem solving process / recognize team (Share)
• The process will have the advantage of having both the structure in a 6-
step problem solving method and the flexibility in having a variety of tools
that are used in LEAN, Six Sigma, and PDCA from which to choose

Defining “LEAN”
A systematic approach to the identification and elimination of
waste and non-value-added activities through continuous
improvement in all products and services.

Pull SystemsStandardized
Work
Process
Capability
Level
Scheduling
Small Lots
Supplier
Development
Error-Proofing
Lead-time
Reduction
Planned
Maintenance
LEAN
Containerization
Workplace
Organization &
Visual Controls
Process
Control
Quick
Set-up
Facility Layout
Transportation
Reduction
of
Variation

Defining WASTE
Webster: loss of something valuable that occurs because too much
of it is being used or because it is being used in a way that is not
necessary or effective; an action or use that results in the
unnecessary loss of something valuable; a situation in which
something valuable is not being used or is being used in a way that
is not appropriate or effective

Defining WASTE
• Anything that doesn’t add value to the process.
• Anything that doesn’t help create conformance to the
stakeholders expectations (patients, families, community,
co-workers, etc..).
• Anything your stakeholders would be unwilling to pay you
to do!

Understanding WASTE
• Identification and elimination of WASTE is the central focus of
a lean system.
• It is dependent on the understanding and involvement of all
employees.
• Successful implementation requires all employees to be
trained to identify & eliminate WASTE from their work areas.

Understanding WASTE
Waste is anything other than the minimum resources:
• Equipment
• Direct & indirect labor
• Material
• Floor space
• Energy
absolutely necessary to add value to the product or service
for your key stakeholders.

Why We Want To
Reduce Inventory
1. The greater the inventory, the greater the handling:
• Carts, bins, file cabinets, containers, indirect labor to
move/store
• Administrative effort and cost to control the inventory
(losses, locating and counting)
2. Inventory deteriorates, causing more scrap & rework:
• Forms become obsolete
• Medications become outdated
• Sterile equipment/supplies become outdated
• Materials accumulate dirt

Why We Want To
Reduce Inventory
3. Inventory takes up space:
• Adds cost to heat, light, and insurance
• Facilities should be used for Value Added activities (i.e.,
production rather than warehousing)
4. Guiding principles of “lean” manufacturing:
• Elimination of buffers makes problems surface and
forces an organization to address and resolve those
problems.
5. Reduce waste and rework:
• When defect is detected, the entire inventory has to be
scrapped, reworked or returned.

Identification of WASTE – 7 Types + 3
1. Correction
2. Overproduction
3. Material & Information Movement
4. Motion
5. Waiting
6. Inventory
7. Processing
8. Confusing Goals & Metrics – misinformation
9. Underutilized Human Potential — skills, talents & creativity
10. Unsafe or Unergonomic Work Conditions

WASTE of Correction
(“rework & inspection”)
Definition: Inspection and / or repair of a
product or service
Symptoms to Look For:
• Adverse drug events
• High infection rates
• High incidence of patient bill rejections
• Frequent rescheduling of office appointments
• Multiple quality control checks
• Loss of patient/family confidence
• Missed shipment and deliveries

WASTE of Overproduction
(“too much, too fast”)
Definition:
Producing more than needed
Producing faster than needed
• Too many meal trays delivered
• Asking pt. the same questions multiple times
• Un-level scheduling
• Multiple years’ supply of forms, handouts, etc...
• Extra floor space utilized
• Unbalanced material flow
• Back-ups between departments

WASTE of Material &
Information Movement
(“too much, to far”)
Definition: Any material or
information movement
• Medical Records pick-up & delivery
• Multiple Information Systems
• Prolonged pre-operative testing times & convoluted
layouts
• Inappropriate bed assignments on admission
• Over-staffing
• Extra hand-offs
• Reduced quality

Spaghetti Diagram Example
Source: iSixSigma “Roadblocks into Results: Lean Benefits Surgical
Center” by Maryanne Kuchler and Michele Hoover

WASTE of Motion
(“inefficient movement”)
Definition: Any movement of people or
machines
• Locations of computer/fax/copy machines
• Poor workplace lay-out for pt. services
• Assignments of care-givers
• Inconsistent work methods
• Reduced productivity
• Large reach / walk distances
• Longer lead-times

WASTE of Waiting (“idle time”)
Definition: Idle time created when
people wait for machines,
people wait for people, and
machines wait for people
• Unbalanced scheduling/workload
• Idle machines / people
• Large waiting rooms
• Access to care problems
• Unnecessary testing

WASTE of Inventory
(“excess stock banks”)
Definition: Any supply in excess of customer requirements
necessary to produce goods or services just-in-time
• Multiple forms, multiple copies & multiple years’ supply
• No standardization of supplies
• Unused appointment slots
• Empty beds
• Complex tracking systems
• Storage & handling
• Extra rework/hidden problems

WASTE of Processing (“adds no value”)
Definition: Effort which adds no value to the
product or service from the customer’s perspective
• Multiple signature requirements
• Extra copies of forms
• Multiple information systems entries
• Distribution of reports
• Longer lead-time
• Sorting, testing & inspection

+ (PLUS) / (DELTA)
WHY?
After a plan, process, idea, project has been implemented, this tool
enables you to identify:
What elements are working well
and
Where you need to focus your energy to ensure success

+ (PLUS) / (DELTA) Process Steps
• Brainstorm all of the positive aspects of the project, topic
or subject** (PLUS)
• Brainstorm those issues that are not going well or could be
“done better” (DELTA)
• ** Always begin with the things that are going well. This changes any
negative focus of the group to looking at the entire situation in a more
positive frame of mind, which then facilitates problem solving.

PI Boot Camp 2015.06 Participant Packet

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