DMAIC Projects: Lean Six Sigma in Healthcare Tutorial

8.1 Module 8 Putting it all Together

Hello and welcome to the eighth and final module of the Lean Six Sigma in Healthcare course offered by Simplilearn.   In this last module we will review the sample project that was used throughout the previous modules as it progressed through the entire Lean Six Sigma process.   Let us explore the objectives of this lesson in the next screen .

8.2 Objectives

After completing this module, you will be able to: Understand how all the Lean Six Sigma phases fit together; Recognize what tools can be used during the different phases; and Appreciate the importance of each phase of an improvement project. In the next screen, we will review the module overview.

8.3 Module Overview

In this module, first we’ll review the DMAIC steps by highlighting some broad features of each, and then, we’ll go through each step of the project and review what the team did to advance their project through the steps. Let us begin with the first topic of this lesson.

8.4 Topic 1 DMAIC Process

By now you will be familiar with the DMAIC process of Define, Measure, Analyze, Improve, and Control. However, we also introduced some pre-project activities that should be completed prior to the Define Phase that are necessary to start a project on the right foot.   The graphic on the next screen shows all the major points, considerations, and activities that were covered in this course for each of the DMAIC and the pro-project steps.

8.5 DMAIC Process

The major points, considerations, and activities of Lean Six Sigma projects are given in the following steps: pre-project activities, define, measure, analyze, improve and control. In the pre-project step, we saw how to recognize potential improvement opportunities and also check if they are good candidates for actual Lean Six Sigma projects. Then, we learned how to get the buy-in to commence that project. From there, we learned how to properly scope the project and set the stage to manage the improvement effort in the best way possible. In the Define phase, we covered the steps to build a SIPOC. Then, we looked at some factors to consider when putting together a project team. From there, we learned how to properly craft a powerful problem statement and understand its impact. Then we explored how to determine the vital few causes from the trivial many to investigate further. In the Measure phase we explained the different types of process maps and how to build one. Then, we discussed how value stream maps are different and what they can be used for in the measure phase. From there, we learned how to gather process data using a data collection sheet and then explored how to identify root causes using the Pareto principle and how to brainstorm effectively. In the Analyze phase, we discussed the relationship between causes and effect. Then, we looked at methods and the importance of validating the data from the measure phase. From there, we learned how to use process and data analysis to confirm the key process input variables. In the Improve phase, we explored how the project team can generate solutions to address the identified root cause of the problem.  We covered some techniques to help the project team come up with those ideas as well as reviewed some of the more common solutions used to address typical causes. Then, we discussed some methods to review and evaluate potential solutions so that the best ones are chosen for implementation.   We also covered some of the important risks of the Improve phase.  Finally, we learned how to develop and implement the chosen solution in such a manner as to ensure a successful improvement.    And in the Control phase, we covered the tasks the project team should undertake to ensure that the improved process performance is sustained after the team has disbanded and handed the process responsibility back to its owner. Then, we looked at some factors to consider to help standardize the process when documenting it. From there, we explored what it means to statistically control a process and why it’s so important to do this properly. Then we reviewed some key activities to implementing the solution and also what is required to finalize a project effectively and we summed up these topics with a control phase practical checklist.   In the next topic we’ll recap the Mercy West project and highlight some elements of this case study as it went through each of these phases.

8.6 Topic 2 Sample Project

The Board of Directors at Mercy West regional hospital had a problem with an overflowing ED. They had no more bed capacity. People were in the hallways on gurneys waiting for beds, the staff was overworked, there was high risk of infection and errors, and it wasn’t getting any better.   Recent data shows that the average wait time in the ED has steadily increased by at least 10% a month for the last 14 months and ED walk-outs have also increased.   The board decided to launch a lean Six Sigma project to try and find a way to improve the situation.   Let us look at how it was unfolded in the next screen.

8.7 Bed Capacity Problem at Mercy West Hospital

John started by doing a walkabout of the process. Since it wasn’t exactly clear what the problem was, or how to fix it, John decided to do some data gathering in order to properly identify the problem because the project scope was too large.   John created a high level Value Stream Map to represent the process flow of the patient from arrival at ED until the discharge.   From there, he identified the bottlenecks and decided to scope the first project to alleviate the bottleneck at the back end of the Value Stream first, i.e., discharge cycle time.   John decided to work on this part of the overall process first because if he made an improvement here, it may unblock the flow upstream as opposed to making admissions more effective and just increasing the backlog of patients waiting for space in the wards.   John then prepared his SIPOC for the discharge process, identified the stakeholders, determined the WIIFM, created his Project Charter sections including the Problem Description, Process and Project Scope & Boundaries, Project Goal & Benefits, Resource Requirements, and Timeline.   He then approached the process owner with his proposal and obtained his Sign-off to commence the project with his team.   Finally, John communicated the project to his team and to other stakeholders in the hospital by using the information contained in the project charter. He explained that he would be tracking progress of the project against the planned timeline. This is because it is important to stay on track so that the benefits can be realized and they can make further improvements to the value stream. The discharge process SIPOC revealed that there were many stakeholders in the discharge process ranging from the clinical departments to finance (depending on their involvement with the patient), and just about everything in between as well. Not to mention the external stakeholders like rehab, home care providers and long term care facilities.   The discharge process at Mercy West varied in complexity (and duration) depending on the state of the patient discharged and where they are discharged to. Despite this, the team agreed that the administrative and financial aspects of the discharge were probably a large cause of delays.    Looking at the brainstorm results of potential causes of delays in the discharge process, the team suspected that waiting for a vacancy in an outside facility was a major factor. Another factor was actually getting all the internal coordination done quickly enough so that a patient could leave without having to wait for all the administrative formalities to be completed. The team decided that this would be the factor that should be investigated in the Measure phase of the project.   Hence, the team crafted this problem statement:   “All discharges from Mercy West require administrative and financial transactions, which account for 30% of the process cycle time. The goal is to reduce this portion of the discharge cycle time by 50% by the end of the quarter.”   John didn’t have any additional data to help him for the Analyze phase so he had to devise a data collection strategy.   John decided to gather data over a 3-week period. He had to cover every day of the week and every shift of each day. So he decided to create a data collection sheet in the form of 2 travellers (the first would accompany the discharge order written by the doctor and the second would be with the discharge sheet). Once the patient was discharged, John would recover both travellers from the records department and then he would consolidate his data on a spreadsheet.   John’s travellers would include the actual date and time stamp in and out for each process contributor action as well as the duration of effort to complete the task.   With this information, John will be able to complete his VSM by calculating the Takt time, NVA time, and the overall process efficiency. The data collection effort at Mercy West hospital went swimmingly well. After a few hiccups in the beginning where people weren’t filling in the data travellers completely, a small information session in each department resolved the issue in a short order. The team was very glad that they physically followed the first few travellers and caught the errors before the damage was done.   After the 3-week data gathering effort was complete, all the results were transcribed and tallied in an Excel spreadsheet. Now it was time to validate the spreadsheet data against the data sheets to make sure there were no errors.   The first step was to simply create a scatterplot to see if there were any outliers in the data. They discovered a dozen data points that indicated cycles of several months, which really didn’t make sense. After a little verification in the excel sheet against the data traveller, they discovered that the data entry was done correctly, but for some reason, Excel formatted it wrong and inversed the month and the date for each of those data points. The team fixed the error but also decided to check all the possible inversions by sorting the data by date and checking if any data points were outside the sample date range.   Now that data was validated, the analysis could begin. John and his team started with a Pareto chart to determine which activities accounted for most of the cycle time. To do this, they calculated the mean duration of each activity in the process.   The next thing they did was to calculate the Value added time and NVA time for the process as well as the Takt time (or pace required). They discovered that in order to meet the pace, the slowest element would have to triple its productivity. That bottleneck was actually administrative clerk who was charged to gather all the “releases” prior to closing the discharge file. This made complete sense, so the team had to return to the data and view the cycle time for each of those release elements.   A boxplot was created for each of them and the two with the greatest variation were release logistics arrangements and continuing care.   Next, John had his team created a histogram for each of those two activities so they could have an idea if the long delays were a regular occurrence or an exception. In both cases, the histograms were skewed to the right, which indicates that the mean occurred fairly regularly but there were many instances of longer delays.   The team then decided to see if there was a correlation between the delays and the time and day the discharge order was commenced. To do this, they simply plotted the cycle time of the activity against the time of day the discharge was started. There seemed to be a causal relationship that suggested that any discharge orders after 10 am resulted in longer cycle time. Most interesting though, is the relationship between cycle time and the day of the week. It was found that discharges on Tuesdays and Wednesdays have the longest cycle times while Thursdays had the shortest.   The team now had some interesting insights on where to focus their improvement efforts. John and his team narrowed down the critical cause of delays to a bottleneck in the discharge process related to releases involving arrangements for continued care and/or logistics. The team also discovered that if they can avoid discharge orders being given after 10am and on Tuesdays or Wednesdays, they could reduce the overall cycle times.   Now it was time for the team to come up with potential solutions.   While several solutions were offered in the past by participants and employees and also during the measure phase of the project, the team remained very disciplined and recorded them on a Parking Lot as they continued to stay focused on their tasks. This parking lot served them well during the solution brainstorm as they were immediately able to see whether or not any of the parking lot items actually helped to address the now evident root cause.   One item in particular, seemed to be on target. It was from the administrative clerk who said that her workload was not steady, she always seemed to be bombarded with discharge orders midweek and she had a pile to get through when she came to work most mornings. She suggested that the discharges should somehow be scheduled evenly throughout the week.   This suggestion alone sparked a number of solution ideas during the brainstorm. In all, the team came up with 15 different ideas or combinations of ideas to help reduce discharge cycle times.   After reviewing each one and then using the multi-voting technique, the team reached a consensus that the solution they would implement was to try to align the discharge administrative process with the doctors’ patterns of initiating the discharge midweek.   Presently, most doctors were trying to get their patients discharged in time to be home for the weekend, so they would initiate most of their discharge orders on Tuesdays or Wednesdays thinking there would be ample time for the patient to be home by the weekend. This created a wave of discharge orders and a burden to the administrative staff who only worked during regular office hours.   In order to harmonize the administrative staff availability with this good (and customer centric) intention, they came ups with a solution. The administrative support work schedule would be modified slightly to be present at strategic times throughout the entire day as opposed to just during regular office hours and consequently eliminate the discharge orders from piling up overnight without being treated.   The team decided that a temporary employee in a clerk role could easily perform these preliminary and repetitive coordination tasks during off hours if they had adequate training.   The solution also required that some logistics arrangements and continuing care would have to be coordinated after hours. After a little discussion, the team realized that this would be rather difficult when it came to arranging for in-home care in particular. In order to address this limitation, they decided to create a risk abatement measure in the process. Accordingly, they thought of including a special note on the discharge form advising the treating doctor that if there is a possible in-home care that might be required, the discharge order should be submitted before 10 am weekdays if it is to be treated and coordinated the same day.   Now that the solution framework was established, the team validated their idea against the original project charter in order to confirm there was no scope creep and also to make sure that their solution was actually addressing the problem they set out to resolve. In addition, the idea of using temp clerks as opposed to changing the work schedule of the administrative clerk. This was was a way to pilot the solution without having to go through the long process of justifying and then hiring additional permanent staff and delaying the solution implementation.   The implementation plan was developed and included a detailed summary of what the solution was and how it would be introduced. A timeline and action plan was developed and it included activities such as modifying the discharge order form and process documentation, information sessions, also the creation of a detailed task sheet and training the temporary administrative clerk.   Upon the review of the stakeholder analysis, the team identified the key stakeholders and devised the strategies to get them on board with the proposed solution.   It was now time to get the approval to implement the solution.   The project team at Mercy West hospital had come up with an improvement plan and presented it to the Director of Administrative services.   To summarize, the solution entailed the initial assignment of a temporary administrative clerk to be available to perform discharge coordination tasks outside of regular office hours. This was to be done in addition to some minor process adjustments such as identifying discharges requiring in-home care and advising stakeholders to submit these by 10 am weekdays.   The director agreed with the plan and now it was time to put it into action.   Prior to implementing the solution, the project team ensured to document the process, change the release forms, and created a memorandum for circulation with the modified administrative procedure text and the implementation plan. This memorandum would be used for the initial change and then the text could easily be used to permanently modify the procedures afterward.   The team then held some training sessions for both the existing administrative staff and the new temporary clerk. This training covered the process, the documentation, a checklist, and an FAQ document. This FAQ covered what to do in certain likely scenarios so there would be no ambiguity in how to complete the tasks. The new release form had a highlighted note stipulating the 10 am submission requirement for same-day home care releases.   Once the fix went live, doctors who respected the 10 am deadline were personally called and thanked for their compliance.   I-MR control charts were created to monitor the release coordination cycle time and after 2 weeks the data was compared to the cycle time data from before the change. It was confirmed that the mean had shifted.   A control chart of the overall discharge cycle time also showed a shift in the mean for the same period. This confirmed that their improvement had made a difference.   The team created a control plan with some corrective actions in the event statistical process control signalled an out of control situation. The first was to verify the day’s’ releases submitted and the second was to check the time of releases.   The team also validated their stakeholder chart to make sure they had the proper level of support, scheduled a Q&A session a few days prior to implementation, and assigned a point of contact from the administrative staff who was a part of the solution design and who could answer any questions that may arise.   Finally, the sampling plan stipulated that a new sample of the cycle time would be taken after 4 weeks, after 6 months, and then after 12 months. John and the team included some suggestions to leverage this improvement in other areas of the hospital that also exhibited bottlenecks due to a lack of after-hours personnel. The project was handed back over to the director of administrative services and he organized a small pizza luncheon with the administrative staff and the project team to celebrate their success. Now the team was ready to move on to the next upstream bottleneck to resolve the bed capacity problem.  

8.8 Summary

In this module we reviewed some of the important elements of how to successfully conduct a Lean Six Sigma project.    First we reviewed the DMAIC steps by highlighting some broad features of each, and then, we’ll went through each step of the project and review what the team did to advance their project through the steps.   We also understood how all the Lean Six Sigma phases fit together, can recognize what tools to be used during the different phases

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