Lean Six Sigma - Chapters 1-3

Marketing Strategy

development of a response in the marketplace

The Four P’s

1. product

2. price

3. place

4. promotion

Goal of lean six sigma

1. cut errors

2. costs

3. delivery time

4. space requirements

5. employee turnover

Example of lowering errors and costs great gains can be made

• nonreaction of physicians to deaths of patients from anesthesia during medical education

• he rejected that mortality should be accepted as normal

• set performance standards to reduce deaths

Lean six sigma

framework to improve products by aligning them with customer needs and expectations and to reduce costs by increasing efficiency of processes

Challenges of lean six sigma

1. Time - identifying issues to work on instead of spending more time collecting than using data

2. change - convincing works to change

3. implementation - analyzing and applying data

4. control - maintaining the change

Lean concept in healthcare - STEEEP

S - safe

T -timely

E- effective

E - efficient

E- equitable

P - patient satisfying

Safe healthcare

making sure the treatment does not injure the patient

Monitor Adverse events

Adverse event is anything that results in death or injury of patients

Adverse events

1. infection

2. medication error

3. wrong - site surgery

Monitor no-harm events and near misses

The frequency predict injury-causing events → Heinrich (1959) examinedindustrial accidents and documented that for every major injury there were 29 minor injuries and 300 no- injury events

Heinrich

avoid major injuries we should focus on reducing the number of unsafe practices and conditions that give rise to injury

Healthcare conditions

Timeliness – reduce waiting times and harmful delays

• Long patient waits (patients die in ER waiting area)

• Obtaining appointments

• Emotional harm

• Physical harm

Effective care

1. treatments that restore patients health and reduce pain

2. measured in health care by mortality rates and readmission rates

3. evidence based medicine

4. better system to ensure healthcare advances

Efficiency

Cost per output - coal of minimizing the cost per output and maximizing output from a set of resources

many people believe that effectiveness and efficiency can not coexist

Equity

seeks to ensure that care does not vary in quality based on a persons gender, ethnicity, place of residence, and ro socioeconomic status

Patient centered

• treatment should be patient centered based on individual patient preferences, needs, and values

Six STEEEP Goals Pursue

1. technical excellences (safe, effective)

2. economic stewardship (efficiency)

3. patient satisfaction

4. equal care for all

What kind of healthcare system do we have

• Not the type of health care system desired

Recurring questions of quality, cost, and access cry out for more effect means to

achieve desired goals

Lean

visua; examination of processes seeking to eliminate waste and increase efficiency

Six sigma

• primarily a statistical approach centered on output attempting to minimize variation and error

• designed to reduce defects per million opportunity

• simplest provides a set of tools to improve performance

• every process is an opportunity to do things better

Five ideas of how to change how people think

1. value - encompasses the total product experience (what customers want, product features)

• value adding work - work the customer is willing and able to pay for and changes to a good or service

2. value stream - every action taken to design, produce, and deliver a product

pull -Is the idea that nothing should be produced until it is needed by a

customer

perfection - Pursues minimum defects by doing it right the first time, with no errors

or at least no repeated errors

House of toyota

• Foundation base of load leveling – making sure everyone has the right amount of work

• Standardize inputs and process to make sure all outputs are the same

• Root cause analyzes – to make sure we know the real cause

• People are the center of the house

Eight Wastes

1. overproduction

2. idleness

3. overprocessing

4. defects

5. excess inventory

6. unnecassary transport

7. unnecassary motion

8. underutilized talent

Kaizen

continuous improvement

Eli Whitney

demonstrated how standardized parts facilitated production - hospitals continue to stock multiple competing supplies that service the same purpose

Frank Gilbreth

used systematic and purposeful observation to identify inefficient motion and redesign work to achieve large productivity gains

Henry Ford

understood what workers were doing and questioned the most efficient way of

doing it.

Walter Shewhart

demonstrated the need for continual monitoring to ensure processes are fulfilling the goal for which they were undertaken.

Problem w/ healthcare

is a physician-centric industry in which other members of the healthcare team often feel their contributions are undervalued.

Healthcare value formula

Countries with higher capita income typically have higher life

expectancy.

quality / cost

Quality

Patient satisfaction, health outcomes like complications, functional

status, and return to work.

Cost

all costs are calculated and everyone has an opportunity to decrease cost

Porter (2010)

defines values as health outcome for a medical conception divided by total dollars spent

problem w/ this:

• coordinating care

• payment across organizational lines

• accounting for patient behaviors that produce poor outcomes

Rewards

should be based on outcomes and that outcomes depend on the cooperation of

multiple providers

Porter three levels of outcomes

Tier 1 – measure of survival (mortality rates) and degree of health or recovery

(morbidity)

Tier 2 – measures recovery including time to recovery and disutility of care measured as errors, ineffective treatment, discomfort, and adverse effect.

Tier 3 – looks at the sustainability of health including the recurrence and long-term

consequence of treatment

Kano Model - customer satisfaction

using delights - move the bar more because the care goes beyond

normal. (they work you in or the doctor makes a house call).

must haves - Normal expected care, so patient doesn’t move the

bar much on satisfaction

Customer intimacy

Healthcare is viewed as a “people” industry – but many workers are

impersonal.

How to create sustainability

1. product leadership - requires innovation

2. operational excellence - focuses on product pricing, quality, selection, and delivery

House of quality

recognize customers’ highest priorities and tie their priorities to activities

the organization must perform to satisfy their expectations

Nine Elements of the House of Quality

Customer requirements (wants and needs)

• Technical requirements (what are we good at)

• Interrelationships – between customers and technical (which customer

needs are met)

• Interrelationships between technical requirements (departments working

together?)

• Competitor analysis (how does the competition perform to our customer

needs)

• Competitor technical assessment (do we have the same abilities as our

competition)

• Targets (what is our desired performance level)

• Regulatory requirements (minimum standards)

• Priorities (reassessing customer needs)

Natural and special cause variation

Shewhart (1930) measured how much tolerance would a patient give in treatment variation

How much can a drug vary before it is lethal or ineffective.

Challenge:

• no two patients are alike

• variability of delivery of care

Causes:

• human beings

• machines

• processes

Pareto or 80/20 rule

80% of events arise from 20% of causes

One way to reduce errors and improve health outcomes

1. standardize treatment

2. reduce over utilization of services

3. increase underused tests and procedures

4. ensure treatments are delivered appropriately

Role of statistics

understand how the world operates by organizing data and identifying relationships

between variables

Epidemiology

Data are used to determine the frequency of disease, its distribution, and potential causes.

seek to increase the effectiveness of healthcare resources by answering the following questions about healthcare practice:

Which treatments are more effective for particular conditions and patients?

Which providers are more effective, and why are they more effective?

Which treatment plans and providers are more efficient?

Which treatment plans and providers deliver more timely care?

Which providers produce the highest patient satisfaction, and why?

Which employees have the highest morale, and why?

Statistics

Statistics is a field of study concerned with data collection, organization, summarization, and analysis, often using a small sample to make inference to a population

Data analysis - isaac newton

• Observation

• Hypothesis

• Prediction

• Testing

Causation

Means cause and effect – a change in X causes Y to change.

Increase in Price / Decrease in Demand

Correlation

When X increases, Y increases (or decreases)

Types of statistics

1. descriptive - summarize data

2. inferential - draw conclusions beyond data set

Types of Measure of Central Tendency and Dispersion

1. mean - sum of value / number of observations

2. median - number that divided a data set into two equal parts

3. mode - most frequently occurring value

Sampling

The amount of data points we decide to draw from.

• Populations – All entities of interest

• Sample – a subset of the population

• Elements of observation – a single or individual

member of the population

• Parameter – a characteristic of the population

• Statistic – a characteristic of the subset (sample)

Types of samples

cluster - divide the group by geographical area

systematic - build sample base on desires characteristics

stratified - divides the population into groups

Four types of collecting data

• Categorical - ex: race

• Ordinal

• Interval

• Ratio

Variables

• Interval variables – provide distance and scale

• Numeric variables – measure rank or the distance between

observations

• Ordinal variable – ranks observations from highest to lowest,

best to worst, or vice versa

• Ration variable – provides equality of ratios as well as equality of

intervals

Probability

Means of dealing with chance

event - something happens and we want to know the probabilities of all the possible results of the event

outcomes - results of an event

sample space - provides all possible outcomes

independence - relationship between events

Priori Probability vs Empirical

• Priori – based on theory (coin flip heads/tails)

• Empirical – is based on experience or history

Types of probability

1. marginal - likelihood of single event occurring - The probability of surviving small cell lung cancer is about 13%

2. conditional - probability of an event when another occurred

3. additional - probability of either two events occurring