1. What is Lean Six Sigma?
How does it apply in
Healthcare?
InAHQ Conference
May 1, 2008

2. Lean Six Sigma Presentation
Introduction
What is Lean and Six Sigma?
‘Toast Kaizen’ video
Examples of LSS in SSFHS
Lean Six Sigma in Healthcare

3. Your Presenter
Brian W. Hudson
Lean Six Sigma Coordinator
St. Elizabeth Regional Health
brian.hudson@ssfhs.org
765-449-3102
16 years industrial experience as a Manufacturing Engineer
8 years experience with Lean and Six Sigma

4. Corporate Office
Mishawaka
Insert map of all of
our locations
Franciscan
Physicians
Hospital
Munster

5. St. Elizabeth Regional Health
St. Elizabeth Medical Center
Opened in 1876
183 Beds
Facility includes comprehensive patient care
facilities and the only hospital-based nursing
school in the state
Home Hospital
Opened in 1869
365 Beds
Facilities include education, rehabilitation,
ambulatory surgery and patient care centers
St. Elizabeth and Home Hospital merged in 1998 to form St.
Elizabeth Regional Health (2,600 employees)
Currently building a new 150 bed facility to open in Fall 2009

6. What the organization wants
What that leads to:
• Available and prompt care
• Smooth operations • Better patient outcomes
• Ensure patient safety • Increased patient satisfaction
• Improved financial viability
• Provide quality care • Improved patient throughput
• Effective patient treatment • Improved publicly reported
information
• Utilized staff and resources• Higher employee involvement
and satisfaction
• Reduced LOS

7. What do our Patients need?
Favorable patient outcomes
Patient safety
Implement new procedures and capabilities
Slow rising healthcare costs

8. The pressure on Healthcare
Improving patient care
Controlling costs
Government regulations
Increasing competition
Implement new procedures and capabilities
Treatment reimbursement rates are capped based on diagnosis
Number of uninsured
Growth in the number of people age 65 and older
Healthcare costs continue to rise.
New technologies are “Expensive” and adoption in question.
Staff shortages in some areas continue to drive up costs.
“Report Cards” on providers – quality, cost, number of procedures

9. What is Lean?
What is Six Sigma?

10. Lean Six Sigma Basics
The Hospital as a System:
feedback
information information
Hospital
Suppliers Patients
Processes
feedback
All work is a process . . .
this is true of a hospital too!

11. What is Lean?
Originated within Toyota in 1950’s
Its use focuses on elimination of Waste
Enhancing ‘Value-Added’ operations
A method to reduce complexity and
improve process flow

12. LSS in Healthcare
Includes a variety of improvement tools:
7 kinds of waste
Flowcharting or process mapping
5S
Changeover reduction
Constraint Management
Rapid Improvement Events
Quick and Easy Kaizen
Gemba or Genchi Genbutsu
Value
Value Flow Pull Perfection
Stream

13. What is Six Sigma?
Motorola is credited developing Six Sigma
around 1985
Use focuses on reducing process variation
Step One
Lean Step Two Six Sigma
Material and information Value added
flow between process Step Three transformations
steps occur within the
process steps

14. Sources of Variation
Y= f(X , X2, X3, …)
1
= + + Yeast + + +…

15. Why Six Sigma level performance?
Why 99% isn’t good enough
Example 99% Good 99.99966% Good
(3.8 Sigma) (6 Sigma)
Unsafe drinking water per day 14.4 minutes 0.3 seconds
Electricity power failure per month (30 days) 7.2 hours 8.8 seconds
Severe turbulence on a 6 hour flight 3.6 minutes 0.1 second
Impurities in a kg of raw material 10 grams 0.0034 grams
Losses per $1,000,000 worth of business $10,000 $3.40
Man days lost per 10,000 employees 100 man days 480 minutes
99% just isn’t good enough

16. How do we do it?
By applying Six Sigma tools:
CTQ Tree
Hypothesis testing Regression
VOC
Design of Experiments
To reduce variation

17. Systems Analysis Framework…
Six Sigma
Daily Control Plan
Statistical Process SIPOC
Control Recognize Define Project Charter
Simulation the problem Voice of the Customer
Techniques exists Process Map
Form Quality
Continuous Improvement
Improvement Teams
Control
Define the
Ensure
Problem
Permanence
Measure
PDCA Develop
Performance Measurement Plan
Evaluate
Measures FMEA
Solution
Ishikawa Diagram
Statistical Process Control
Select and Analyze
Capacity Analysis
Improve Implement problem/
Pareto Analysis
Solution process
Lean Process Design Determine
FMEA Root Cause Correlation of KP variables
Correlation Studies Analyze Confidence intervals
Statistical Process Control Hypothesis testing
Design of Experiments Regression analysis
Simulation Techniques ANOVA

18. Outline Step 1: DEFINE
Goal
Cha ect
rter
Define the project’s
j
Pr o
purpose and scope and
get background on the
process and customer
5 1
Output CONTROL DEFINE
A clear statement of the
intended improvement
and how it is to be 4 2
measured IMPROVE MEASURE
A high level process map
A list of what is important 3
to customer ANALYZE

19. Outline Step 2: MEASURE
Goal
Focus the improvement
effort by gathering
information on the 5 1
current situation CONTROL DEFINE
Output 4 2
Baseline data on IMPROVE MEASURE
current process
performance
3
Data that pinpoints
ANALYZE
problem location or
occurrence
A more focused
problem statement

20. Outline Step 3: ANALYZE
Ask
What vital few process and 1
input variables affect CTQ 5
CONTROL DEFINE
process performance or
output measures?
Goal 4 2
Develop theories of root IMPROVE MEASURE
causes
Confirm them with data 3
ANALYZE
Output DO
A theory that has been
Dat
E
aA
tested and confirmed
nal
ysis

21. Outline Step 4: IMPROVE
Goal
Develop, try out,
and implement
5 1
solutions that address CONTROL DEFINE
root causes
Soluti
ons
Output FMEA
4 2
IMPROVE MEASURE
Planned, tested
actions that should t
eliminate or reduce Pilo 3
the impact of the tio
n ANALYZE
ta
en
identified root causes plem
Im

22. Outline Step 5: CONTROL
Stan
Control
Goal
Do
dard
cum
Use data to evaluate both
ize
M
ent
the solutions and the plans
on
Ev
i to
a lua
r
Maintain the gains by
standardizing processes te
Clos 5 1
ure
Outline next steps for on- CONTROL DEFINE
going improvement including
opportunities for replication
Output 4 2
IMPROVE MEASURE
Before and After analysis
Monitoring system
3
Completed documentation of
ANALYZE
results, learning's, and
recommendations

23. Lean Six Sigma in Healthcare
Combining the
Stan
Control
Do
dard
Cha ect
rter
cu
Quality of Six
j
Pro
me
ize
OC
M
SIP
nt
on
Ev
ito
a lua
r
Sigma with the te C
VO
Clos 5
ure 1
CONTROL DEFINE
Process Speed of S o lu tio
ns
2
4
Lean to drive FMEA
t
IMPROVE MEASURE
Pilo 3
improvement and em
en
ta
tio
n
ANALYZE
pl
achieve the best
DO
Im
Da t
E
aA
n al
competitive position
y s is

24. LSS Challenges
This is not industry, we’re not Toyota,
and we’re not making parts
We’re too busy to do this
Healthcare is very much silo driven

25. Toast Kaizen Video
Bruce Hamilton
GMBP

26. 7 Kinds of waste
Inventory - unneeded stock or supplies
Motion - movement of staff and information
Overproduction - unnecessary tests
Overprocessing - filling out extra paperwork
Transportation -movement of patients or equipment
Rework/Correction - paperwork, med errors
Waiting - delays in diagnosis and treatment

27. Lean Six Sigma
Project Examples

28. CT and 7 Kinds of Waste
Inventory Overprocessing
Set up tray for unneeded Paperwork
procedures Films vs. disk
Expired IR stock Multiple systems - RIS, PACS,etc
Wasted contrast
Transportation
Motion Patients
Transporting patients Ordering syringes and having extra boxes to
Walking between procedure room store
and control room Taking oral contrast to the floor
Getting onto computer IV lock
Overproduction Rework/Correction
Supplies/tray Duplicate work
Protocols Phone calls to communicate with
Making contrast and Patient departments or units
consumption of contrast
Waiting
On Toshiba scanner
Waiting on ED patients to be ready
On oral contrast

29. 5S Workplace Organization
Before 5S Needed
Not Needed
Create Visual Workplace
- S2: Set In Order (Seiton)
- S3: Shine (Seiso)
S1: Sort - S4: Simplify & standardize
(Red Tagged) (Seiri) (Sieketsu)
After 5S
Remove from
Workplace
Discard after
a defined time
-S5: Sustain (Shitsuke)
A place for everything and everything in its place

30. 3PCW Nurses station before 5S

31. Sort and Set in Order

32. Shine (Clean)

33. After - Sustain

34. Storeroom before & after color coding
Before After

35. Rehab Standard Room Layout
Standardized room layout will
aid staff as they care for
patients and reduce room
turnaround time

36. Door to Balloon RIE

37. Project Example – Door to Balloon
Define
Project goals:
Achieve Door to TIMI 3 perfusion time of
less than 90 minutes for all patients
Project scope:
Start – Patient arrival at St. Elizabeth
Stop – Establishment of TIMI 3 Flow
Includes – ST elevated, non-transferred, primary PCI
Excludes – All other cases

38. Project Example – Door to Balloon
Measure
Door to Balloon Time - St. Elizabeth Campus
3rd Qtr. 2006 - 1st Qtr. 2007 Door to Balloon time
250 Goal of 90 min.
Average time of 112 min
200
AMI Process Flowchart
150 Patient EMS Emergency Cardiology or Cath Lab
Minutes
Patient seeks medical attention Department Interventional
Recognition patient having MI
100 2125 1713
Get 12-lead, IV, O2
Not utilizing
2300 Call MD and notify pre-hospital EKG
Transport patient to ED
Obtaining ECC EKG
50 Report-off to RN and MD and
contact Registration
Additional IV’s, get 15-lead EKG 1722 2125
9 0
Who gets the pt.
Start Chart
Who calls the
info to registration Interventionalist
Start meds & Call Cardiologist Who gets the labs
on-call
drawn and to Lab
0 Additional meds awaiting direction
from Cardiologist
7/1/2006 8/1/2006 9/1/2006 10/1/2006 11/1/2006 12/1/2006 1/1/2007 2/1/2007 3/1/2007 4/1/2007 Variation of Cardiologist See patient in ECC or Cath Lab
Date meds and x-ray Informed consent by Card. or
sign/consented by RN
Consent Give consent to get
Cath Lab called Supervisor or Cath Lab called
Who calls the
Cath Lab Cath Lab confirms receiving the
page/call
Cath Lab calls when arrives
RN gets patient ready for Standardization in
transport Cath Lab supplies Cath Lab sets up
and setup
Cath Lab calls when ready - 2158 Cath Lab calls when ready &
transport 33 talks to RN
Patient arrives in Cath Lab Take patient stickers 1828 2202
to the Cath Lab 75 0014 38
Patient arrives in Cath Lab
Pt. transported to bed and prepped
74
for procedure Pt. transported to bed and prepped
Interventionalist meets with patient 0034 for procedure
94
Cath placed by MD 2215
50
Pictures taken
Stent/balloon placed 2236 0911
MR# MR# MR# 0149
285366 060228 725868 72 118
169

39. Door to Balloon Project
Analyze Phase
Door to Balloon Time
by Day of Week
250
225 222 224
200
175
150
Minutes
125 104
105
100 Goal 90 minutes Door to Balloon Time
by Time of Day
75
56 55 250
50
225 222 224
25 215
200
0
Fri-Sat-Sun Mon-Thu 175
Day of Week
150
Minutes
95
125
112
Day of Week Friday-Sunday
100 92.5 Goal 90 minutes
95
250 75 72
55
50
225 222
25
200
0
Midnight-0700 0700-1600 1600-Midnight
175 178
172 Time of Day
Minutes
150
139
125 123
105
100 Goal 90 minutes
82
75 72
56
50
Midnight-0700 0700-1600 1600-Midnight
Time of Day

40. Project Example – Door to Balloon
Analyze
The D2B Alliance has developed six strategies to reduce
door-to-balloon times:
1. Have attending Interventional Cardiologist always on-site
2. Have ED and Cath Lab staff use real-time data feedback
3. Have ED activate the Cath Lab while the patient is still en route to
the hospital
4. Cath Lab team arrive and be ready to start procedure in 20 minutes
5. ER medicine Physician activates the Cath Lab
6. A single call to a central page operator activates the Cath Lab and
Interventional Cardiologist

41. Strategy 2:
Have ED and Cath Lab staff use real-time data feedback
Benefit
8.6 minutes faster door-to-balloon time
What it will take to implement
Modify Chest pain and Quality records
Copy of the completed form to the Cath Lab Director
Barriers to implementation
Staff education
Compliance
Trust and teamwork between all staff
Legibility of information on the form

42. Project Example – Door to Balloon
STEMI Flowchart
Improve
12-lead from Ambulance
i-Stat test
Paging system
Revised P & P
Staff training
ED treatment plan

43. Project Example – Door to Balloon
Control
Door to Balloon Time - St. Elizabeth Campus
July 2006 - February 2008
150 Door to Balloon time
Goal of 90 min.
132
125 125 123
119 118
110 110
Minutes
109 108
100 102 101 103
97 96
84 87
75 75 78 78
73
50
RIE
Conducted
25
0
November
November
September
September
December
December
February
February
January
January
August
August
October
October
March
June
July
July
May
April
(7) (8) (9) (7) (3) (5) (5) (1) (8) (3) (3) (7) (7) (4) (4) (6) (5) (8) (3) (5)
2006 2007 2008
Month
* number in brackets indicates the number of cases for that month

44. Surgery room changeover reduction

45. Home Hospital ED Patient Triage & Registration

46. Lean Six Sigma-Lab Specimen Labeling
Process Flowchart Failure Mode and Effects Analysis
Process Step Potential Effect(s) Recommended Responsibility &
SEV
OCC
DET
RPN
SEV
OCC
DET
RPN
Patient arrives via Patient arrives via other
Ambulance method
Solution(s) Target Date
Start Start Potential Failure Modes
N. Collect specimen
A Start IV with cath Assess patient M
N.1Missing Specimen Delay in testing 3 3 1 9 0
Redraw specimen 6 3 1 18 0
Pt. dissatisfaction 8 3 1 24 0
Use syringe to No test results 8 3 1 24 0
B Collect specimen N
draw blood
N.2 Submitted unlabeled Delay in testing 3 6 1 18 0
Redraw specimen 6 6 1 36 0
Put needle on Manually label
C
syringe specimen on bag
O No test results 8 6 3 144 0
Consuming resources/lab 6 6 1 36 0
Put specimen in
Pt. dissatisfaction 8 3 1 24 0
D Blood in tubes P N.3 Submitted mislabeled Delay in testing 6 6 8 288 0
basket
Redraw specimen 8 6 8 384 0
Receive Doctors Consuming resources/lab 8 6 8 384 0
E Put tubes in bag Q
order Pt. dissatisfaction 8 3 1 24 0
Wrong results on wrong pt. 10 6 8 480 0
Write pt name, WS enter order
R
O. Manually label specimen on bag/specimen
F date, & time, and into computer
initial on the bag S
O.1 Wrong name Results would be wrong for 8 3 6 144 0
T
that patient
Labels printed or
Put blood with L100 used
Collect specimen Confused with another patient 8 3 6 144 0
G
patient
Delay in testing 8 3 1 24 0
WS places labels
U O.2 Misspelled name Delay in testing 8 3 1 24 0
H Take patient to ER on chart
0 0 0 0 0
Nurse places label O.3 Step omitted Wrong patient name 8 3 6 144 0
Transfer patient to V
I on specimen Patient having to be redrawn 3 3 1 9 0
bed
Sample sent to lab unlabeled 8 3 1 24 0
Specimen goes
If unidentified into bag with extra W
Delay in testing 8 3 1 24 0
J patient - write bed labels O.4 Illegible handwriting Patient having to be redrawn 3 3 1 9 0
number on bag Wrong patient name 8 3 6 144 0
Nurse/Tech tubes Delay in testing 8 3 1 24 0
X
(SE) (HH) Put blood in specimen to lab
K Put blood into central L collection basket
O.5 Missing some information Patient having to be redrawn 3 3 1 9 0
blood basket with bed like name, time, etc.
End Wrong patient name 8 3 6 144 0
Delay in testing 8 3 1 24 0

47. Lean Six Sigma in Healthcare

48. What is a Lean Hospital?
Housekeeping
ED Lab
Physicians Food Service
Pharmacy
Surgery
Cath Lab
Radiology
Nursing Units
L&D
Staff
It all works together without waste
HIM
Materials Management

49. Lean Hospital – More specifically
Working to eliminate waste through:
Goals and measures leading to accountability and
driving improvement
Areas organized and arranged
Trained and empowered staff
Smooth and consistent processes working in unison
Problem solving and proactive failure mode analysis
Working to promote the value stream (service line)
instead of silos
Getting everyone involved

50. Application of Lean Six Sigma
Can be used with:
Dashboard or Scorecard metrics
Quality measures
Departmental operation
Financial measures
Leading to:
Improved patient care, safety, and satisfaction
Improved quality
Increased revenue and reimbursement
Better employee satisfaction
Improved capacity for patient flow

51. Additional Information on LSS
www.isixsigma.com
American Society for Quality (www.asq.org)
Books:
What is Lean Six Sigma? George, Rowlands, and Kastle
The Six Sigma Way Fieldbook Pande, Newman, & Cavanagh
Lean Six Sigma hospital systems:
Virginia Mason – Seattle, WA
ThedaCare – Appleton, WI
IUPUI – Laboratory for Enterprise Excellence
Toast Kaizen video, Bruce Hamilton, GBMP