Creative Healthcare

What is Six Sigma?
A Specific Statistical Definition
A Problem-Solving Approach
A Management Philosophy
Ideal Six Sigma Implementation
Why do we use Six Sigma?
Isn't 99% Good Enough?
Where is Healthcare Today?
Healthcare's Challenge
Must We Change?
Six Sigma - Part of The Solution
The Promise of Six Sigma
Three Levels of Six Sigma Benefits
How do we use Six Sigma?
Six Sigma Problem Solving
The Six Sigma DMAIC Process
The Six Sigma Knowledge Funnel
Six Sigma: Before and After

Understanding and Using Control Charts
Process Variation Scenario
Introducing the Control Chart
Interpreting Control Charts
Special Cause: Process Shift
Special Cause: Process Trend
Is Every Picture Worth The Same 1,000 Words?
Process Stability
Control Charts for Making Decisions
Why Control Charts?
Control Charts: Special Cause = Process Information
Western Electric Rules
Common Cause Also Provides Information
Control Charts In Problem Solving
Control Charts for Leaders
Misinterpreting 3 Data Points
Control Charts: Leadership Imperative
Variation Management Paradox
Selecting and Creating Control Charts
Which Chart? Initial Answers
Generating an "Individuals" Control Chart
Generating "Individuals" Chart, Part 2
How Many Observations Are Enough?
How Many Observations Are Too Many?
Usage Example (Case Study)
Using a Control Chart

The Project Charter
Project Charter Template
Problem Statement
Project Scope
Performance Goals
Business Benefits
Team Members
Support Required
Issues / Risks / Constraints
Basic Meeting Management
Managing Meetings
Agendas and Minutes
Purpose / Process / Payoff
Team Roles
Seeking Consensus
The Parking Lot
Meeting Management = Meeting Productivity
Selecting Appropriate DMAIC Projects
Ideal DMAIC Projects
DMAIC Project Alarms
Project Selection Guidelines
DMAIC or DFSS
Managing Project Scope
A Word About First Projects
Project Complexity
DMAIC and Scope Reduction
Successful Project Launches
Project Launches
Preliminary Meeting
Team Kick-Off
Finalize Project
Adjust Team Roster

Customer Focus
Priorities In Six Sigma
Jack Welch Speaks
Outcomes vs. Measures
Why Use Data
Customer Needs Are Obvious
Who Says We Need Data?
Data Throughout DMAIC
Procedure: Developing Process Metrics
Developing Effective Process Metrics
A Word of Caution
Identify Process Outputs: Service As A Product
Introductory Concept: SIPOC
SIPOC In Context
Transactional Process Outputs
Service Products
Practice
Establish Customer Types
Describing Our Customers
How About Internal and External Customers?
Establish Customer Types Based On How They Use Service Products
Broker Customers: Special Challenges
Modifier Customers: Special Opportunities
Customer Types and SIPOC
Prioritize Requirements
Multiple Customers Equal Multiple Priorities
List Potential Requirements
Organize The List
Prioritize: Multi-Voting
Other Prioritizing Options
Process - Defined
Process Role Definition
Service-Profit Chain and Its Link to Customers
Customers - Needs and Requirements
Step #1 - Know What A Customer Is
Step #2 - Segment Customers
Step #3 - Determine Customer Needs and Requirements
Voice of Customer (VOC)
The (Noriaki) Kano VOC Model
Using The Kano Model: Must-Be
Using The Kano Model:1-Dimensional
Using The Kano Model: Delighters
Kano Model Migration
Kano's Model - Examples
Kano's Model - Example
Bringing It Together - The SIPOC Tool
Steps in Using the SIPOC
Questions To Help With SIPOC
Project Example
Convert Requirements To Metrics (CT Tree)
Critical To
CT Tree: From Outcomes to Measures
Benefits Of CT Trees
Deploy Operational Definitions
Examples of Operational Definitions
Example: Operational Definition
Never Assume that Everyone is Using the Same Definition
Data Collection Plan

Introduction
Probability - Independent Outcomes
The Basis of Probability Theory
Rolling A Single Die
Independent Events: Blackjack
Independent Outcomes On The Job
Probability - Dependent Outcomes
What Happens When We Roll A Pair Of Dice
Multiplying The Probabilities
Blood Types
Probability - Mixed Outcomes
What If We Mix Independent and Dependent Events?
Probability of Rolling A Seven?
Blood Types and Mixed Outcomes
Continuous vs. Attribute Data
Continuous and Attribute Data
How Many Samples?
Dealing With Attribute Data
np Chart (Simulated Data)
Introducing The Normal Distribution
The Normal Distribution
Introducing Normal Probabilities
Summarizing The Normal Distribution
A "Six Sigma" Process
Statistics - Descriptive vs. Inferential
Descriptive vs. Inferential Statistics
Statistics - Central Tendency (Mean and Median)
Example Data Set
Central Tendency
Median vs. Mean
When To Use the Median
Statistics - Dispersion (Standard Deviation and Variance)
Standard Deviation
Computing "s"
Variance and Standard Deviation
Practice #1
Statistics - Sampling Issues - Population vs. Sample
Population vs. Sample
Symbols: Population vs. Sample

Review: Normal Distribution
The Normal Distribution
Six Sigma Process
Process Capability Terminology
Normal Probabilities
Moving Forward
Continuous Data
Z Value Equations
Example #1: Time from arrival in ED until Treatment (aka "Door to Doc")
Applying the Normal Distribution
Example #1: Now We Use the Equations
Example #1: Interpreting ZU=12
Example #1: Z → Probability
Example #1: Summary Results
Practice
Practice Demonstration: Scenario #1
Terminology: Z and Cpk
Easier Still: SigmaXL
Attribute Data
Units or Opportunities?
Opportunity Counting: Beware!
Example #2: Collecting Health Histories
Example #2: Data and Equations
Short-term vs. Long-term Variation (ZST vs. ZLT)
Practice
Converting Between Z and PPM
Z ←→ PPM: 4 Options

Rules of Thumb: Z ←→ PPM
Z ←→ PPM Lookup Tables
Z ←→ PPM Graph
Z ←→ PPM Equations

Measurement: A Process With Variation
Outcome of DMAIC Projects
Measurement Is A Data-Producing Process
Even "High-Tech" Systems Experience Significant Measurement Variation
The Ideal Measurement System
Components of S² Measurement ("Measurement Variation")
It's a Matter of Integrity
Defining the perfect MandM®
Start with Operational Definitions
Next: Define the scope of your intended MSA
Repeatability in a Gage R&R Study
Reproducibility in a Gage R&R Study
Basic Terminology, Concept and Requirements
R&R Procedure
Generating R&R Template in SigmaXL
SigmaXL R&R Template
Entering R&R Data
Interpreting R&R Output
How Good Is Good Enough?
Dealing With Unacceptable R&R
R&R After Improve Phase
R&R's Moving Target
Data integrity has the final word

More Traditional View Of COPQ
"Traditional" COPQ Model
Containment Is Costly
Six Sigma View Towards COPQ
Pitfalls of Doing Inspection in Quality
American Society for Quality (ASQ) COPQ Categories
ASQ COPQ Categories
COPQ "Iceberg"
Applying COPQ
COPQ Worksheet
Approaches to Consider
Pitfalls to Avoid

By Way of Introduction
Formal vs. Informal Inspection
Formal Inspection
Not All Errors Make It to Formal Inspection
Informal Inspection and Hidden Rework
Informal Find-and-Fix Works, Right?
Quality And Rework
Terminology
Poisson Distribution and Throughput Yield
Rolled Throughput Yield
The Y_RT "Bucket Brigade" Concept
Let Us Try an Example
Y_RT Example: Step #1
Y_RT Example: Step #2
Y_RT Through the Entire Process
Y_RT: Computation Shortcut
Z-Values
Y_TP and Process Capability
Excel Formula: Using Yield to Estimate Z
Yield and Z in Non-Repetitive Processes
Hidden Factory
Resources for Rework
Rework and Resources
Higher DPU Processes and Rework
"Hidden Hospital" For High DPU

Getting Started: Analyze Strategies
Flow Charts Overview
Why Flow Charts?
Benefiting From Flow Charts
Flow Chart Case Study
Review: Flow Chart Basics
Getting More out of Flow Charts
The Mapping Challenge: How Much Detail?
Guidelines: Flow Chart Detail
Value-Added Analysis
Value / Non-Value Grid
Value / Non-Value Analysis
List Expansion
List Expansion and Reduction Opportunities
Expansion vs. Reduction
List Expansion: Traditional Brainstorming
List Expansion: Post-it Blitz
List Reduction
Right After List Expansion, Just Before List Reduction
The Fish-Bone Diagram
Fish-Bone Categories
Affinity Diagrams
Multi-Voting
Multi-Voting Silly Example: Prioritizing Beer Characteristics
Nominal Group Technique (NGT)
IPO Diagram / CN(X)
Input-Process-Output Terminology
Many Inputs, Few Outputs
The IPO Diagram
Basic Data Display Techniques
Benefits of Graphical Tools
Pareto Charts and Pivot Charts
Creating a Pareto Chart in SigmaXL
Resulting Pareto Chart
Histograms
Histograms - Pros and Cons
Creating Histograms in SigmaXL
SigmaXL Histogram Output
Grouping Histograms in SigmaXL
After Eliminating Bimodality
Box Plots
Grouped Histogram or Box Plot?
From Histogram to Box Plot
Box Plot Using Histogram Data
Box Plot Scenario
Creating Box Plots in SigmaXL
Box Plot Results

Standard Error of the Mean
Repeated Samples from a Process
Standard Error of the Mean and the Central Limit Theorem
Example - Central Limit Theorem in Use
Confidence Interval of the Mean
Recall: Normal Distribution
Normal Distribution Using the Standard Error of the Mean
Example #1a: Confidence Interval of Person-Hours
Example #1a: Using SigmaXL
Standard Error of the Mean and Confidence Intervals with Hypothesis Testing
The Process of Learning
Design of Experiments
Design of Experiments: How Do We Learn?
Design of Experiments - Methods
Trial and Error
Trial and Error Experiments
OFAT
OFAT (One Factor at a Time) Experiments
Full Factorial
Full Factorial Experiments
Fractional Factorial
Fractional Factorial Experiments
Basics of Hypothesis Tests SigmaXL P-Value
4 Ways X Impacts Y
How Sure Are We?
Process: The Hypothesis Test
The P-Value
Tests of Means: Single Data Set
Example #1b: Scenario
Example #1b: Hypothesis Test Process
Example #1c: Another Approach to the Same Hypothesis Test
Example #1c: Select t-Statistic and Compute t
Example #1c
How Many Tails on that Test?
1-Tail vs. 2-Tail Tests
A Non-Statistical Issue
2 Data Sets
Scenario: Comparing Two Data Sets
Example #2: Start with Descriptive Statistics
Example #2: Descriptive Stats Output
Example #2: 2 Sample t-Test (Part 1)
Example #2: 2 Sample t-Test (Part 2)
Example #2: Output SigmaXL 2 Sample t-Test
Test of Variances
Why the F-Test?
Example #3a: Manual F-Test Procedure
Example #3a: Manual F-Test Computations
Example #3b: SigmaXL F-Test and More (Part 1)
Example #3b: SigmaXL F-Test and More (Part 2)
Example #3b: SigmaXL "Comparison Tests" Output
Sequencing Hypothesis Tests

Summary: Transactional Six Sigma
Transactional Process Defined
10 Financial Six Sigma Projects
Process Summary: Transactional Six Sigma
Flow Chart Varieties
Interrelationship Diagraph
Relationship Maps
Relationship Map (RM) Example: Lemonade Stand
Developing the RM: The Relationship Table
Problem Solving Using Relationship Maps
RM Disconnects
Swim Charts
Swim Chart of a Sub-Process: Building the Lemonade Stand
Swim Chart Considerations
Why do Disconnects Exist?
Work Flow Layouts
Work Flow Layouts
Identifying Improvement Opportunities
Organizational Drivers
Scientific Basis of Consequence Analysis
Consequence Analysis Worksheet
Process: Consequence Analysis Worksheet
Consequence Analysis in the News: Accounting Scandals in Publicly Held
Companies
Process: Developing Should-Be

Selecting Hypothesis Tests
Basis for Selecting Hypothesis Tests
Selecting Hypothesis Tests
Analysis of Variance (ANOVA)
Overview of ANOVA
ANOVA Scenario
Example: ANOVA with SigmaXL
Interpreting SigmaXL ANOVA Output
Taking ANOVA Further
Tests of 2 Proportions
Overview: 2-Proportion Test
Proportion Test Scenario
Proportions Test Using SigmaXL
Taking it Further
Basic Linear Regression
Linear Regression Overview
Prediction Equation
Concept of R²
Example: Linear Regression
Linear Regression using SigmaXL
Linear Regression Output
Correlation = Causation?
Advanced Regression Topics
Hypothesis Testing Tradeoffs
Decision Errors
Hypothesis Tests and Sample Sizes
Determining Sample Sizes
Granularity Guidelines: t-test
When to Consider ( α = β) ≠ 0.05
Pivot Tables
More than One X
2 or More Factors: Excel Pivot Table and Pivot Chart
Building the Pivot Table
Pivot Table: Selecting the Fields
Pivot Table Output
Pivot Chart - After Editing
Other Uses for Pivot Tables
Multi-Vari Charts
Multi-Vari: Sources of Variation
Logging Multi-Vari Data
Creating a Multi-Vari in SigmaXL
Interpreting the Multi-Vari Chart
Criteria for Using Multi-Vari
Analyze This!

Open-Narrow-Close
Generating Solutions
Brainstorming
Modified Brainstorming
Best Practices
Organizing Solutions
Selecting Solutions
Multi-Voting (15 Items or Fewer)
Selecting Solutions: Multi-Voting Example
Selecting Solutions: Multi-Voting Example Results
Pay-Off Matrix
Selecting Solutions: Pay-Off Matrix Example
Musts/Wants Criteria
Selecting Solutions: Musts/Wants Example
Project Selection Matrix

Introduction to FMEA
The Concept Of Risk
Process and Product Risk
Producer and Customer Risk
FMEA: Dealing with Potential Failures
The FMEA Process
FMEA Template
Invoking SigmaXL FMEA Template
Overview: SigmaXL FMEA Template
Failure Modes vs. Effects
FMEA Terms
More Terms
Modes vs. Effects
Risk Priority Number (RPN)
RPN Elements
Rating RPN Elements
How to Use FMEA
The FMEA Process
Hints To Make FMEA Work
More Hints
Step 6: Develop Action Plans
Step 7: Follow-Up

Why People Resist Change
How Can We Help Reduce Uncertainty?
Uncertainty and Perceived Threats
Influencing Individuals' Behavior
Individuals We Want to Influence
Communicate to Motivate
Specifying the Desired Behaviors
Handling Performance Gaps: A 3-Step Process
Challenges of 3-Step Process
Step #1: Describe Performance Gap
Step #2: Explore How We Can Help
Step #3: Explain Consequences
Managing Organizational Change
Non-Delegable Roles of Leadership
10 Questions Leaders Should Answer
10 Questions Leaders Should Ask
Driving Cultural Change
Aligning the Reward System
Influencing Process Change
10 Ways To Sell Change
Confirming Project Stakeholders
Confirming Project Stakeholders: Example
Creating the Need for Your Solutions
Threat-Opportunity Matrix
Force Field Analysis
Force Field Example: New Public Hospital
Restraining Force Strategy
Resistance Strategies
Questioning Systems and Structures
Piloting
When to Pilot
Steps for Pilots
Tips for Pilots

Design for Six Sigma (DFSS)
What is DFSS
DFSS in Healthcare
DMAIC and DFSS Differences
DFSS = DMADV
Map of DFSS and DMAIC
Introduction to Lean Principals
What is Lean
Get Rid of the Waste
Examples of Muda
Five Principles of Lean Thinking
Value
Value Stream
Value-Added / Non-Value-Added
Rework
Other Non-Value-Added Activities
Flow
What Affects Flow?
Pull
Perfection
Linking Lean Thinking and Six Sigma

Process Improvement Monitoring
Monitoring Strategies
Example
Patient Evaluation Audit Scores
Run Chart
Central Tendency
Frequency Distribution
Statistical Process Control Methods
Statistical Process Control
Control Chart Review
Control Chart Selection
Selecting a Control Chart
Application for Control Phase in Six Sigma
Process: Launching SPC
SPC and Statistical Software
Recall: CNX
Revising Control Limits
Can Processes Change After DMAIC?
Criteria for Computing New Control Limits

Introduction
Why Control Plans
What is a Control Plan?
What to Include
Process Improvement Hand-Off: The Response Plan
Example - Completed Response Plan
Backup Documentation and Data
Backup Documentation Examples
Implementation
Selected Project Management Questions
Stakeholders and Resources
Milestone Examples
Resources: Planning the Rollout
Resources: Planning for Training
Risk Management: Issues to Anticipate
Sustaining Gains
Compliance Audits
Overview: Audit Process
Auditor Responsibilities
Corrective Action
Final Comments

Sources for External Reporting and Benchmarking
Joint Commission (JCAHO)
JCAHO Reviewable Sentinel Events
JCAHO National Sentinel Event Statistics
JCAHO National Sentinel Event Statistics - Root Causes
Research into Action - National Patient Safety Goals
National Patient Safety Goals for 2005
Center for Medicare and Medicaid Services (CMS)
CMS Initiative
Sample CMS Report
UHC
Solucient
Patient Satisfaction
Report Cards
Issues with Report Cards
Pay for Performance (P4P)
Issues with Pay for Performance

What Are Human Factors?
Why Human Factors in Healthcare?
Taking Human Factors Into Account
Donald Norman's Principles of Good Design
Other Things To Consider
Some Factors Affecting Performance
What Can Go Wrong?
Usability: ISO 9000 Standards
Usability
Usability: The 5 E's
Case Example: OR Suite Set-Up

The Baldrige Award
Healthcare Criteria
Core Values
Healthcare Criteria Expanded
Scoring
Scoring Matrix: Categories 1-6
Pursuing the Award
Baldrige-Based Assessments
Management and Resources
Example: Assessment Outcome
Example: Prioritizing the Opportunities
Example: Clustering of Opportunities
Example: Customized Six Sigma Rollout
Conclusions

Balanced Scorecard's Four Perspectives
Learning and Growth Perspective
Internal - Business Process Perspective
Customer Perspective
Financial Perspective
Additional Perspectives
Critical Requirements
Applying the Balanced Scorecard
Balanced Scorecard and Baldrige Criteria
Balanced Scorecard and Six Sigma

Six Sigma for Healthcare (Greenbelt course) - Table of Contents

Six Sigma Overview

Common Cause and Special Cause Variation

Project Selection, Scope and Kick-off

Customers and Metrics

Basic Probability and Statistics

Process Capability

Basic Measurement Systems

Cost of Poor Quality: COPQ

Yield and the "Hidden Hospital"

Basic Process Analysis

Basic Hypothesis Testing

Transactional Six Sigma

Data Analysis

Generating Solutions

Failure Modes and Effects Analysis: FMEA

Change Management

Design for Six Sigma and Lean

Statistical Process Control

Control Plans

External Benchmarking and National Patient Safety Goals

Human Factors and Usability

Malcolm Baldrige National Quality Award

The Balanced Scorecard