Lean Six Sigma & A3 Thinking method and concept.pdf

A3 Thinking

1. Evelyn A. Catt, 2015
Lean Six Sigma & A3 Thinking
Workbook
06-01-15 v21
Evelyn A. Catt, MHA, BSPH, CSSBB
Principal, TTAC Consulting, LLC
Adjunct Professor, Indiana University
Fairbanks School of Public Health
A Review of Basic Concepts
with Exercises, Checklists, and Learning Guides

2. Evelyn A. Catt, 2015
2.
SUBJECT SLIDE SUBJECT SLIDE SUBJECT SLIDE
Title Page 1 Safe Hand-offs 31 Lean Six Sigma Methodology 61
Index pg. 1-90 2 Evidence-Based Standard Work 32 Lean Six Sigma Roadmap 62
Index pg. 91-180 3 Standard Work -Value Added 33 Understanding Variation 63
Index pg. 181-270 4 Continuous Improvement 34 Variation & Reliability 64
Value Stream View of Patient Journey 5 Summary 35 Types of Variation 65
Lean Focus 6 Safe Passage 36 Variation in Healthcare Processes66
Pursuit of Perfection 7 Systems Thinking Section 37 Concept of a Function 67
Identify and Eliminate Waste 8 Origin of Systems Thinking 38 Concept of a Function Example 68
Types of Waste 9 A3 Thinking 39 Reducing Variation in Healthcare69
Create Flow 10 Plan –Do –Study –Act (PDSA) 40 Y = f (x) EXERCISE 70
Establish Pull 11 Lean, Six Sigma, and A3 Thinking 41 Kaizen Continuous Improvements 71
Specify Value 12 Lean, Six Sigma, and A3 Thinking 42 Kaizen -Continuous Improvements 72
Value Added 13 Lean, Six Sigma, and A3 Thinking 43 KaizenEvent Agenda 73
Non-Value Added 14 A3 Thinking 44 KaizenEvent Agenda 74
Impact of Non-Value Added Steps 15 A3 Structured Problem Solving Format45 A3 Structured Problem Solving Steps75
Value Streams Section 16 Lean Principles Section 46 A3 Exercise: Define Phase 76
Value Stream 17 Origin of Lean 47 A3 Exercise: Measure/Analyze Phases77
Value Stream Levels 18 Lean Focus 48 A3 Exercise: Improve/Control Phases 78
Lean Goals 19 Lean Thinking 49 Action Plan Template 79
Value Stream Analysis 20 Lean Rules 50 Communication Plan Template 80
Value Steam Mapping 21 Reflections 51 Control Plan Template 81
Patient Journey 22 Lean Key Concepts Section 52 Control Plan Checklist 82
Navigating the Value Stream 23 Key Concepts 53 Reflections 83
What will happen during my journey?24 Value Added Process 54 Lean 5-S Section 84
Patient Expectations 25 Waste 55 What is Lean 5-S? 85
What The Patient Expected 26 The Cost of Quality 56 Lean 5-S 86
What The Patient Experienced 27 Six Sigma Principles Section 57 Lean 5-S Examples 87
Safe Passage ThroughValue Stream 28 Origin of Six Sigma 58 Visual Control Examples 88
Silos 29 Six Sigma Focus 59 Lean 5-S Achievement Levels 89
Risk Mitigation 30 Lean Six Sigma Model 60 Lean 5-S Benefits 90

3. Evelyn A. Catt, 2015
3.
SUBJECT SLIDE SUBJECT SLIDE SUBJECT SLIDE
Keys To Lean 5-S Success 91 First: Go to “Gemba” 121 Patient Flow & Accountable Care 151
Lean 5-S EXERCISE 92 “Gemba” is Everywhere! 122 What happens when the flow stops? 152
Standard Work Section 93 Foundation for Success 123 Lack of Flow Creates Waste 153
Standard Work 94 Brainstorming 124 Tools to Improve Flow Section 154
Why Standard Work? 95 Affinity Diagram 125 Identifying Bottlenecks 155
Standard Work Goals 96 Reflections 126 Reflections 156
Standard Work Components 97 Voice of the Customer/Stakeholder 127 Spaghetti Diagram 157
Creating Standard Work 98 SWOT EXERCISE 128 Spaghetti Diagram EXERCISE 158
Standard Work Example 99 Customer Requirements EXERCISE 129 Simplify Process Flows 159
Viewing Your Facility as a System100 Customer Requirements Tree 130 The 7 Flows 160
System-wide Goals 101 Customer Requirements Tree EXERCISE131 Checklist for Improving Flow 161
System-wide Benefits 102 Kano Model Section 132 Checklist for Improving Flow 162
Core Process Map 103 Characteristics of Products & Services133 Checklist for Improving Flow 163
Hospital Core Process Map 104 Kano Model 134 Checklist for Improving Flow 164
Department Core Process Map 105 Kano Model Elements 135 Root Cause Analysis Section 165
Core Process Map EXERCISE 106 Kano Model Uses & Strengths 136 Root Cause Analysis 166
Defining the Process Section 107 Value Stream Mapping Section 137 Root Cause Analysis (5 Whys) 167
High Level Process Map 108 Value Stream Map (VSM) 138 Root Cause Analysis EXERCISE 168
High Level Process Map EXERCISE 109 Value Stream Mapping –Current State139 Fishbone Diagram 169
Reflections 110 Design the Ideal “Future State” 140 Fishbone Diagram Example 170
Process Flow Chart 111 Value Stream Mapping –Future State141 Fishbone Diagram EXERCISE 171
Process Flow Chart Symbols 112 Value Stream Mapping EXERCISE 142 Mistake Proofing (Poka Yoke) 172
SIPOCS Diagram 113 Value Stream Measurements EXERCISE143 Mistake Proofing (Poka Yoke) Examples173
SIPOCS EXERCISE 114 Identifying Waste Section 144 Project Selection Section 174
X-Y Chart (C&E Matrix) 115 Waste in the Emergency Department145 Project Selection & Prioritization175
Murphy’s Analysis 116 Types of Waste 146 Project List EXERCISE 176
Murphy’s Analysis EXERCSE 117 Waste Walk Worksheet EXERCISE 147 Project Goal EXERCISE 177
Reflections 118 Checklist for Removing Waste 148 Project Impact vs. Effort Grid 178
Customer Requirements Section 119 Flow Section 149 Project Prioritization Matrix 179
Customer Requirements 120 Flow 150 Goals Grid 180

4. Evelyn A. Catt, 2015
4.
SUBJECT SLIDE SUBJECT SLIDE SUBJECT SLIDE
Goals Grid EXERCISE 181 Measurement Systems 211 Impact of Outliers 241
Project Charter Section 182 Primary & Secondary Data 212 Process CapabilitySection 242
Project Charter 183 Data Integrity 213 Tools 243
Project Team Roles 184 Data Audits & Validation 214 Process Capability 244
Project Team Worksheet 185 Sampling Bias 215 Process Capability 245
Problem Statement 186 Tips to Avoid Data Disaster 216 Specification Limits 246
Problem Statement Worksheet 187 Measurement System Analysis (MSA)217 Specification Limits Example 247
Aim Statement 188 Data Types & Display Section 218 Accuracy vs. Precision 248
Aim Statement Worksheet 189 Process, Outcome, Balancing Metrics219 Improving Process Performance 249
Project Scope 190 Process Measures 220 The Normal Distribution 250
Project Scope Worksheet 191 Outcome Measures 221 The Normal Distribution 251
Project Timeline & Milestones 192 Balancing Measures 222 The Normal Distribution 252
Project Metrics Section 193 Quantitative Data 223 What Lies Beneath 253
Project Metrics –Definitions 194 Qualitative Data 224 Sub-Populations 254
Project Metrics –Initial/Target State195 Categorical Data 225 Reflections 255
Project Metrics Worksheet 196 Interval Data 226 Learning Guides& Deliverables 256
Stakeholder Analysis Section 197 Parametric and Non-Parametric Data 227 Define Phase Deliverables 257
Stakeholder Analysis 198 Measuring Data Consistency 228 Define Phase –Learning Guide 258
Force Field Analysis 199 Measures of Central Tendency 229 Measure Phase Deliverables 259
Force Field Analysis Worksheet 200 Meaningful Uses of Data 230 Measure Phase –Learning Guide 260
Data Collection Plan Section 201 Value of Data Display 231 Analyze Phase Deliverables 261
Data Collection Plan –5 Steps 202 Questions to Guide Data Display 232 Analyze Phase –Learning Guide 262
Data Collection Plan 203 Charts for Measuring Variation Section233 Improve Phase Deliverables 263
Operational Definitions 204 Using Run Charts for Data Display234 Improve Phase –Learning Guide 264
Data Collection Methods 205 Benefits of Run Charts 235 Control Phase Deliverables 265
Check Sheet 206 Control Chart 236 Control Phase –Learning Guide 266
Check Sheet Example 207 Pareto Chart 237 Project Hand-off 267
Check Sheet Template 208 Pareto Chart Example 238 Recognition & Celebration 268
Measurement Systems Section 209 Frequency Plot 239 References 269
Measurement Checklist 210 Interpreting Frequency Plot Data 240 References 270

5. Evelyn A. Catt, 2015
A Value Stream View
of the Patient Journey
5.

6. Evelyn A. Catt, 2015
Lean Focus
•Lean is focused on the constant
pursuit of perfection
•By eliminating wasteand non-value
added activities
•To improve the flow of valueto the
patient
Perfection
Waste
Flow
Value
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
6.

7. Evelyn A. Catt, 2015
Pursuit of Perfection
•Lean is focused on the constant pursuit of
perfection using:
–Evidence based practices/standard work
–Continuous Improvement (PDSA cycle)
–Monitoring quality & performance metrics
–Rapid Improvement Events (RIEs), Kaizen Events
–Value Stream Mapping & Value Analysis
–Lean 5-S (sort, store, shine, standardize, sustain, + safety)
–Visual Management (color coding, visual cues)
Perfection
Waste
Flow
Value
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
7.

8. Evelyn A. Catt, 2015
Identify and Eliminate Waste (Muda)
•Waste is any activity that consumes
time, resources, or space but does
not add value to the product or
service in the eyes of the patient.
Perfection
Waste
Flow
Value
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
8.

9. Evelyn A. Catt, 2015
Types of Waste (Muda)
Perfection
Waste
Flow
Value
Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.
Source URL: http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples
Defects
Errors, poor quality, failure to meet
customer requirements
Overproduction
Providing unnecessary products,
services, or features.
Waiting
Delays, periods of inactivity,
bottlenecks, or patient wait time.
Non-Utilized Potential
Failure to fully utilize human potential
(time and talents of people).
Transportation
Unnecessary movement of supplies,
equipment, or people.
Inventory
Excess inventory/supplies, batch
processing, queues, or backlogs of work.
Motion
Extra steps taken by employees because
of inefficient layout, searching, hunting
and gathering.
Excess Processing
Excess activity and processing steps
caused by poor process design.
9.

10. Evelyn A. Catt, 2015
Create Flow
Perfection
Waste
Flow
Value
•Flow is the continuous movement of
people, materials and supplies through a
process.
•Flow ensures that patients have what they
need exactly when they need it.
–No delays or waiting
–One piece flow (instead of batching)
–Well organized supplies and work space
–Alignment of work volume and resources
–Replenishment of only what is needed
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
10.

11. Evelyn A. Catt, 2015
Establish Pull
Perfection
Waste
Pull
Value
•Pull is the timely transition of work from
one process step to the next.
•Pull means performing work as it is
requested or needed by a step in the value
stream so that demand triggers action.
•When a downstream process is ready for
more supplies, patients, etc., a signal is
made to pull more into the process “just in
time” (JIT).
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
11.

12. Evelyn A. Catt, 2015
Specify Value
•Value is defined by the patient.
•Value may be tangible or intangible.
•Every process should be designed
to deliver what the patient values
and would be willing to pay for in the
service/care that is being provided.
Perfection
Waste
Flow
Value
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
12.

13. Evelyn A. Catt, 2015
Value Added
•Example: Medication Administration
•The “value added” elements in this
process include:
Value Added
Non-Value Added
13.
AccuracyTimelinessComfortDignitySafety Knowledge

14. Evelyn A. Catt, 2015
Non-Value Added
•Example: Medication Administration
•“Non-value added” elements and waste
(muda) may also occur in this process.
Value Added
Non-Value Added
AnxietyErrors Delays Pain
14.

15. Evelyn A. Catt, 2015
Impact of Non-Value Added Steps
•Non-value added steps and waste
may result in:
–Decreased value to the patient
–Decreased satisfaction
–Decreased quality
–Decreased productivity
–Increased risk
–Increased cost
Value Added
Non-Value Added
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
15.

16. Evelyn A. Catt, 2015
Value Streams
16.

17. Evelyn A. Catt, 2015
Value Stream
•A value stream includes all of the steps and
activities required to provide services and care
for a patient.
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
17.
Admission Care Delivery Discharge
High Level

18. Evelyn A. Catt, 2015
Value Stream Levels
Admission Care Delivery Discharge
•Pre-certification
•Registration
•Scheduling
•Room assignment
•Assessments
•Interventions
•Medication Admin.
•Diagnostic Testing
•Transition Planning
•Referrals
•Prescriptions
•Home Care
High Level
Detailed
•Registration
oStep 1
oStep 2
oStep 3
•Assessments
oStep 1
oStep 2
oStep 3
•Transition Planning
oStep 1
oStep 2
oStep 3
Step by Step
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
18.

19. Evelyn A. Catt, 2015
Lean Goals
•The goal of using Lean is to eliminate the “non-value
added” elements (waste) in each value stream and
retain only the “value added” components.
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
19.
AccuracyTimelinessComfortDignitySafety Knowledge

20. Evelyn A. Catt, 2015
Value Stream Analysis
•Value stream analysis is used to identify & eliminate
“non-value added” elements (waste) in a process.
Overproduction Waiting Non-Utilized
Potential
Defects
Transportation Inventory Motion Excess
Processing
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
20.

21. Evelyn A. Catt, 2015
Value Steam Mapping
Scope
Current State
Future State
Action Plan
Diagram Source URL:
http://www.bing.com/images/search?q=lean+value+stream&FORM=HDRSC2#view=detail&id=2E7FAF5B08108784A719AFBEC3F50DA5E24C0902&selectedIndex=30
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22. Evelyn A. Catt, 2015
•In a value stream view of the patient journey:
–The patient is an active participantin their
own care.
–The patient makes informed choices
regarding their healthcare options and goals.
–In partnership with the patient, the care team
helps the patient safely navigate through their
journey to achieve their goals.
Patient Journey
References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patient’s Voice. J Amer Board of Fam Med.
2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008.
Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
22.

23. Evelyn A. Catt, 2015
Navigating the Value Stream
•What is the plan for my journey
through the value stream?
–Patients value being well informed about
their plan of care, knowing their schedule,
and having options and choices.
Plan of Care
Schedule
Choices
Cost
References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patient’s Voice. J Amer Board of Fam Med.
2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008.
Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
23.

24. Evelyn A. Catt, 2015
What will happen during my journey?
Goals
Risks
Outcomes
•What are the treatment goals?
•What are the potential risks?
•What outcomes will be achieved?
•How will this journey end?
–Patients value clear and timely
information, respect, compassion,
and reassurance.
References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patient’s Voice. J Amer Board of Fam Med.
2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008.
Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
24.

25. Evelyn A. Catt, 2015
Patient Expectations
•Does the patient have realistic
expectations for their journey?
•Have they been given clear
information to make well informed
choices?
•Do they understand their treatment
options and the associated costs?
Plan of Care
Schedule
Choices
Cost
References: Van Berckelaer A, DiRocco D, Ferguson M, Gray P, et al. Building A Patient-Centered Medical Home: Obtaining The Patient’s Voice. J Amer Board of Fam Med.
2012;25(2):192-198. Source URL: http://www.jabfm.org/content/25/2/192.full.pdf
Patient-Centered Care Improvement Guide, Planetree & Picker Institute. 2008.
Source URL: http://planetree.org/wp-content/uploads/2012/01/Patient-Centered-Care-Improvement-Guide-10-28-09-Final.pdf
25.

26. Evelyn A. Catt, 2015
What The Patient Expected
26.
Timeliness
Dignity
Safety
Comfort
Accuracy
Knowledge

27. Evelyn A. Catt, 2015
What The Patient Experienced
S.S. Healthcare
Errors Pain
Delays
27.

28. Evelyn A. Catt, 2015
Safe Passage Through
the Value Stream
S.S. Safe Passage
28.

29. Evelyn A. Catt, 2015
Silos
•Instead of working together as a value stream we often
function as silos that work in isolation from each other.
•Pre-certification
•Registration
•Scheduling
•Pre-Admit Testing
•Room Assignment
•Assessments
•Interventions
•Medication Admin.
•Diagnostic Testing
•Surgery/Recovery
•Transition Planning
•Referrals
•Prescriptions
•Home Care
•Transportation
Admission Care Delivery Discharge
Reference: Hajek AM. Crushing the Silos: A Leadership Imperative to Ensuring Healthcare Safety in the Era of Healthcare Reform. 2010 Clarity Group, Inc. Source
URL: http://www.claritygrp.com/media/1346/crushing-the-silos-white-paper.pdf
29.

30. Evelyn A. Catt, 2015
Risk Mitigation
•The potential risk of silos in the value stream must
be mitigated, especially during patient hand-offs.
Reference: Hajek AM. Crushing the Silos: A Leadership Imperative to Ensuring Healthcare Safety in the Era of Healthcare Reform. 2010 Clarity Group, Inc. Source
URL: http://www.claritygrp.com/media/1346/crushing-the-silos-white-paper.pdf
30.

31. Evelyn A. Catt, 2015
Safe Hand-offs
•Implementing tools such as SBAR (situation,
background, assessment, recommendation) helps
ensure consistent hand-off communications are
completed.
•Value added = increased patient safety.
Reference: SBAR Technique for Communication: A Situational Briefing Model. Institute for Healthcare Improvement.
Source URL: http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx
31.

32. Evelyn A. Catt, 2015
Evidence-Based Standard Work
•Standard work is the best known way of
performing a process today.
•Standard work is based on creative
problem solving and continuous
improvement.
•Standard work evolves over timeas new
evidence-based practices are identified
and implemented.
References: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15,2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
Best Known Way
Creative Problem
Solving
Continuous
Improvement
Evidence Based
Practices
32.

33. Evelyn A. Catt, 2015
Standard Work -Value Added
•Reduces variation in performance
•Creates balanced work load
•Promotes consistency of outcomes
•Exposes waste in the process
•Reveals opportunities for improvement
Best Known Way
Creative Problem
Solving
Continuous
Improvement
Evidence Based
Practices
References: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://clinicalmicrosystem.org/assets/toolkits/getting_started/decoding_dna.pdf
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15,2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
33.

34. Evelyn A. Catt, 2015
Continuous Improvement
•Lean is a journey of continuous improvement in
pursuit of perfection using:
–Evidence based practices/standard work
–Continuous Improvement (PDSA cycle)
–Monitoring quality & performance metrics
–Rapid Improvement Events (RIEs), Kaizen Events
–Value Stream Mapping & Value Analysis
–Lean 5-S (sort, store, shine, standardize, sustain,+ safety)
–Visual Management (color coding, visual cues)
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
34.

35. Evelyn A. Catt, 2015
Summary
•Lean is focused on the constant pursuit of
perfectionby eliminating wasteand non-
value added activities to improve the flowof
valueto the patient.
•Value is defined by the patient.
•Every process in the value stream should be
designed to deliver what the patient values
in the service/care that is being provided.
Perfection
Waste
Flow
Value
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
35.

36. Evelyn A. Catt, 2015
Safe Passage
•Our shared goal is the safe passage of all
patients through the healthcare value streams!
36.
S.S. Safe Passage

37. Evelyn A. Catt, 2015
Systems Thinking
37.

38. Evelyn A. Catt, 2015
Origin of Systems Thinking
“A fault in the interpretation of observations, seen everywhere, is to suppose
that every event is attributable to someone (usually the one closest at hand),
or is related to some special event.
The fact is that most troubles……. lie in the systemand not the people”.
Dr. W. Edwards Deming, The New Economics
Image Source: http://www.pixshock.net/pic_b/6f9e0c8cb7c046a59b86ff4d7fccfee0.jpg
38.

39. Evelyn A. Catt, 2015
A3 Thinking
•A3 Thinking is a structured, collaborative problem solving process.
•The A3 process uses the PDSA (plan-do-study-act) model as the
foundation of an iterative cycle of continuous improvement.
•This cycle promotes “systems thinking” and the development of
people as “problem solvers”.
39.

40. Evelyn A. Catt, 2015
Plan –Do –Study –Act (PDSA)
•The PDSA “Model for Improvement” serves as the foundation of A3
Thinking and the pursuit of continuous improvement.
•The PDSA model guides rapid improvement cycles using small tests
of change driven by empowered employees.
•The PDSA cycle starts by asking three questions:
–What are we trying to accomplish?
–How will we know that a change is an improvement?
–What changes can we make that will result in improvement?
Reference: Institute for Healthcare Improvement (IHI), 2011. Diagram Source: http://www.saferpak.com/images/pdsa.gif
40.

41. Evelyn A. Catt, 2015
•The PDSA Cycle uses the following steps in an iterative cycle of
continuous improvement.
41.
Plan –Do –Study –Act (PDSA)
STEP ACTIVITY
PLAN
Identify the opportunity and plan the
improvements.
DO Carry out the plan.
STUDY
Compare actual results to predicted
results and summarize what has
been learned.
ACT
Identify any changes that are
required and/or develop a plan to
spread improvements.
Reference: Institute for Healthcare Improvement (IHI), 2011.
Diagram Source: http://www.advancingrecovery.net/Images/Misc/RollingPDSA.jpg

42. Evelyn A. Catt, 2015
Lean, Six Sigma, and A3 Thinking
42.
Lean
Six Sigma
Tools, Analysis,
and Solution
Development
A3
Problem
Solving
PDSA
Model
Reference: A3 Thinking
Source URL: http://a3thinking.com/
•Lean and Six Sigma provide the methods and tools to facilitate the
appropriate level of analysis and solution development based on the
complexity of the problem being addressed with the A3 process.

43. Evelyn A. Catt, 2015
Lean, Six Sigma, and A3 Thinking
•The appropriate Lean and Six Sigma methods and tools are selected
based on the scope, complexity, and directional flow of each problem.
–Horizontal flows (value stream mapping)
–Vertical depth (root cause analysis)
–Highly complex issues (statistical analysis)
–Rapid cycle improvements (Kaizen)
–Safety issues (mistake proofing, root cause analysis)
–Supplies and equipment (Kanban, Lean 5-S, visual controls)
–Throughput (standard work, value stream mapping)
–Work flow and environment (Lean 5-S, flow, pull, cellular layout)
43.
Reference: A3 Thinking
Source URL: http://a3thinking.com/

44. Evelyn A. Catt, 2015
A3 Thinking
•Why is it called “A3” Thinking?
•The term “A3” refers to the 11x17 size of paper used for the A3 report.
•The A3 report format is used for simplicity, consistency, and also serves
as a rapid communication toolto promote organizational learning.
44.Reference: A3 Thinking Source URL: http://a3thinking.com/

45. Evelyn A. Catt, 2015
A3 Structured Problem Solving Format
45.
Reference: A3 Thinking . Source URL: http://a3thinking.com/
*Countermeasures are proposed solutions to address the root cause of the problem and move the process closer to the “target state”.

46. Evelyn A. Catt, 2015
LEAN Principles
46.
SUSTAIN
OPTIMIZE
SIMPLIFY &
STANDARDIZE
CUSTOMER FOCUSED

47. Evelyn A. Catt, 2015
Origin of Lean
•Lean principles are based on a management philosophy derived
from the Toyota Production System (TPS).
•TPS is focused on the identification and steady elimination of
wasteto preserve value with less work.
•This is achieved by getting the right things to the right place at the
right time in the right quantity to achieve perfect work flow, while
minimizing waste.
•When applied in the daily workplace, “Lean thinking” is used to
continually improve all functions by people at all levels in the
organization.
47.
Reference: Source URL http://en.wikipedia.org/wiki/Kaizen,
http://www.strategosinc.com/kaizen.htmhttp://en.wikipedia.org/wiki/Lean_manufacturing

48. Evelyn A. Catt, 2015
Lean Focus
Lean is focused on the
constant pursuit of perfection
by eliminating waste and
non-value added activities to
improve the flow of value to the customer.
48.

49. Evelyn A. Catt, 2015
Lean Thinking
“Lean Thinking”
creates a culture and practices
that continually improve
all functions by all people
at all levels in the organization.
49.

50. Evelyn A. Catt, 2015
Lean Rules
RULE 1: Clearly specify all activities.
Mindful standardization of work.
•Content: What is being done?
•Sequence: In what order?
•Timing: How long should it take?
•Outcomes: What clearly defined
measurable results are expected?
RULE 3: Clearly define all pathways.
Organize for uninterrupted flow.
•Simple (with as few steps and people
as possible).
•Direct steps to deliver the requested
product or service.
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999
Source URL: http://www.systems2win.com/solutions/5s.htm
RULE 2: Clearly define all connections to
every customer and supplier.
No ambiguity.
•Direct (no intermediary between)
•Yes or No answers (no maybes)
RULE 4: Continuously Improve.
Develop leaders who can apply the
scientific method to improve anything.
•Direct response to any problem that arises.
•By those doing the work -as close to the
problem as possible.
•If feasible, start as an experiment.
•Supported by a coach.
50.

51. Evelyn A. Catt, 2015
51.
Reflections
•What type of benefits and competitive advantage could Lean create for
your facility?
•How will you communicate and prepare your staff for a Lean culture and
the new practices and expectations?
•What tools or support will you need to make this a successful transition?

52. Evelyn A. Catt, 2015
Lean
Key Concepts
52.

53. Evelyn A. Catt, 2015
Key Concepts
•All work is a process and even the smallest change can
impact the entire organization.
•Every process should be designed with the patient in
mind, to deliver what the patient values in the process.
•Lean organizations are continually improving and
looking for new opportunities to:
–Eliminate waste
–Increase valueto the patient
–Achieve efficient work flow
Reference: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication
No. 08-0022, April 2008. Source URL: http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf
53.

54. Evelyn A. Catt, 2015
Value Added Process
A value-added process:
•Creates value for the patient/customer.
•Produces a good result every time.
•Does not cause delays.
•Is satisfying:
–for people to perform
–for managers to manage
–for patients to experience
54.
Reference: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication
No. 08-0022, April 2008. Source URL: http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf

55. Evelyn A. Catt, 2015
Waste
•Waste is any activity that consumes time, resources,
or space but does not add value to the product or
service in the eyes of the patient.
•And waste consumes resources!
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
Image Source URL: http://www.13dots.com/reddragon/trashcan/4.gif
55.

56. Evelyn A. Catt, 2015
The Cost of Quality
56.
•The Cost of Quality is the sum of four cumulative types of costs:
–Appraisal, Detection, Internal Failure, External Failure
•The Cost of Poor Quality is the cost associated with producing defects,
which includes internal failure costs and external failure costs.
Diagram Source URL: iSixSigma http://www.isixsigma.com/implementation/financial-analysis/cost-quality-not-only-failure-costs/

57. Evelyn A. Catt, 2015
Six Sigma Principles
57.

58. Evelyn A. Catt, 2015
Origin of Six Sigma
•Six Sigma was originally developed by Motorola in 1986.
•Motorola set a goal of "six sigma" (99.99966% perfect) for all of its
manufacturing operations, and this goal became a byword for the
methods used to achieve it.
•Six Sigma seeks to improve the quality of process outputs by
identifying and removing the causes of defects (errors) and
minimizing variation.
•Reducing variation in a process is the key to reducing errors and
waste, which increases reliability.
•Increased reliability results in safe, high quality care.
Reference: http://en.wikipedia.org/wiki/Six_sigma
58.

59. Evelyn A. Catt, 2015
Six Sigma Focus
Six Sigma is focused on
identifying and correcting errors (defects)
to minimize variation
and increase accuracy.
59.

60. Evelyn A. Catt, 2015
Lean Six Sigma Model
60.
SUSTAIN
OPTIMIZE
SIMPLIFY &
STANDARDIZE
VALUE
ACCURACY
WASTE
VARIATION
LEAN
Eliminate waste and non-value
added activities in a process.
SIX SIGMA
Correct errors and defects to
minimize variation in a process.
CUSTOMER FOCUSED

61. Evelyn A. Catt, 2015
Lean Six Sigma Methodology
Define the process &
determine customer
requirements
DEFINE MEASURE ANALYZE IMPROVE CONTROL
Map and measure
the process to
understand current
performance
Identify amounts &
types of waste and
determine the
root causes
Design the future
state; select and test
improvements
Create a process control
strategy to sustain and
spread improvements
Reference: Source URL http://business901.com/wp-content/uploads/2009/10/DMAIC.JPG
•Lean Six Sigma is a data-drivenproblem solving
methodology with a structured Roadmap (D-M-A-I-C).
61.

62. Evelyn A. Catt, 2015
Lean Six Sigma Roadmap
Confidential/proprietary document
PHASE STEPS TOOLS DELIVERABLES
DEFINE
Initiate the project, define the
process, and determine
customer requirements.
•Project Charter
•SIPOCS, I&O, High Level Process Map
•Murphy’s Analysis/Affinity Diagram
•Voice of the Customer/Go to Gemba
•Customer Requirements Tree (CTQ)
•Project charter created
•Project team formed
•Project goals defined
•Customer requirements
•Project metrics identified
MEASURE
Map and measure the process
to understand current
performance.
•Detailed Value Stream Map
•Swim Lane Map
•Spaghetti Diagram
•Histograms/Frequency Plot
•Control Charts/Process Capability
•Current state map created
•Data collected & validated
•Baseline performance
measured and process
capability evaluated
ANALYZE
Identify amounts/types of waste
and determine the root causes.
•Fishbone (Ishikawa) Diagram
•Pareto Chart, Statistical Analysis
•Hypothesis & Relationship Testing
•Capacity Analysis, Flow Analysis
•Root Cause Analysis (5 Whys), FMEA
•Waste & issues identified
•Additional data collected
& critical factors identified
•Root causes of errors,
waste & variation analyzed
IMPROVE
Design the future state and
select and test improvements.
•Future State Value Stream Map
•5S, LEAN Tools, Kaizen Events
•Visual Controls/Mistake Proofing
•Plan-Do-Study-Act (PDSA)
•Pilot Implementation Plan
•Future state designed
•Solutions selected, tested,
and validated
•Action plans created
•Pilot conducted
CONTROL
Create a process control strategy
to sustain and spread the
improvements.
•Standard Work Instructions
•Control Charts & Control Plan
•Communication Plan
•Full Scale Implementation Plan
•Control system in place
•Communication plan
implemented
•Project celebration
NOTE: All projects
do not require the
use of every tool.
62.

63. Evelyn A. Catt, 2015
Understanding Variation
63.
Lean Six Sigma uses data:
•To understand the sourcesof variation
•To target factors that have the most influenceon performance
•To design evidence-basedimprovements
•To monitor and sustain resultsover time
•To conduct proactive analysisof potential failure modes to:
oReduce risks
oReduce errors
oIncrease safety

64. Evelyn A. Catt, 2015
Variation & Reliability
•Variation: A measure of change or difference.
•Reliability: Consistently giving the same result.
64.

65. Evelyn A. Catt, 2015
Types of Variation
•Common Cause Variation: Natural variation within a process
(expected or acceptable variation).
•Special Cause Variation: Unpredictable or extreme variation
(unexpected or unacceptable variation).
65.

66. Evelyn A. Catt, 2015
Variation in Healthcare Processes
Examples of variation in healthcare processes:
•Quality
–Accuracy of labeling blood tubes
–Completeness of pre-op testing for surgery patients
–High readmission rates for patients with diabetes
•Timeliness
–Turnaround time for test results
–Length of time to get a clinic appointment
–Waiting time in the Emergency Department
•Cost
–Variation in the cost of treating patients with the same diagnosis
–Differences in the cost of supplies from multiple vendors
–Fluctuations in employee turnover rates and the associated costs
66.

67. Evelyn A. Catt, 2015
Concept of a Function
67.
•Six Sigma changes the problem solving approach from trial and
error to Y = f (x).
•A process is described by identifying the measurable output (Y)
and all known inputs (x).
•The Six Sigma roadmap and tools are used to analyze the
relationship between the measurable output (Y) and the process
inputs (x).
Y = f (x)
The value of Yis a function of the value of x
Y(measurable output)= function of x(process inputs)
Y(measurable output)is sometimes referred to as the “Big Y”

68. Evelyn A. Catt, 2015
Concept of a Function Example
68.
Y(% of surgery on-time starts) = function of (x
1, x
2, x
3, x
4, x
5,…….)
x
1= Patient shows up on time
x
2= Admitting office registers patient quickly
x
3= History and physical form (H&P) form received
x
4= Signed, current consent form received
x
5= Required professionals present (RN, surgeon,
anesthesiologist, etc.)

69. Evelyn A. Catt, 2015
Reducing Variation in Healthcare
To reduce variation in healthcare processes:
•Identify the measurable output(Y) of the process.
•Identify the inputs(x’s) of the process.
•Use LEAN Six Sigma tools to identify the few critical inputsthat have
the greatest influence on the output.
•Identify and correct the defects, errors, and variationassociated with
these critical inputs.
All possible inputs (x’s)
Few critical inputs (x’s)
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
69.

70. Evelyn A. Catt, 2015
Y = f (x) Exercise
•Select a process from your facility for this exercise.
•Identify the measurable output(Y) of the process.
•Identify the inputs(x’s) of the process.
70.

71. Evelyn A. Catt, 2015
Kaizen -
Continuous Improvements
71.

72. Evelyn A. Catt, 2015
Kaizen –Continuous Improvements
•Kaizenis Japanese for "improvement" or "change for the better“. It refers to a
culture and practices that focus on continuous process improvements.
•When applied in the daily workplace, Kaizen refers to activities that continually
improve all functions by people at all levels in the organization.
•Individual Kaizen improvements can be implemented quickly by one person.
•A Kaizen Event is an intense, rapid improvement event (RIE) with a team that
is focused on a specific process with a well defined scope.
Reference: Source URL http://en.wikipedia.org/wiki/Kaizen, http://www.strategosinc.com/kaizen.htm 72.
Individual
Kaizen
Kaizen Event
with a Team

73. Evelyn A. Catt, 2015
Kaizen Agenda (Rapid Improvement Event)
DAY 1: Define the Current State
•Set goals and expectations for the event
•Review Lean, Six Sigma, and A3 Thinking concepts
•Review reason for action (problem statement) and AIM statement
•Review data for current performance levels (initial state)
•Define customer requirements & critical to quality standards(CTQs)
DAY 2: Map/Measure the Process, Conduct Root Cause Analysis
•Go to Gemba to map and measure the current process
•Identify amounts and types of waste and quantify their impact
•Analyze issues and barriers to determine their root cause
•Implement “Just Do It” and Lean 5-S improvements
73.

74. Evelyn A. Catt, 2015
Kaizen Agenda (Rapid Improvement Event)
DAY 3: Develop Solutions, Conduct Experiments, Develop Action Plans
•Develop counter measures to address the root cause of the issues
•Conduct rapid experiments to test the results of proposed solutions
•Finalize solutions to implement; create 30-60-90 day action plans
•Create a “future state” value stream map for the new process flow
•Finalize improvement goals (target state) for each performance measure
DAY 4/5: Create Standard Work, Complete the A3 Project Summary
•Document standard work and accountability standards
•Develop policies and procedures to support the new process
•Complete the A3 project summary
•Communicate results and celebrate project success
74.

75. Evelyn A. Catt, 2015
75.
DEFINE1.PROBLEMSTATEMENT MEASURE 4. INITIAL STATE METRICSIMPROVE 7. COUNTERMEASURES
Describe the background of the
current problem or opportunity.
What business problem are we
trying to solve?
Why is this issue important now?
*How will weknow a change is an
improvement?
•Mapand measure the current process
performance.
•What metrics are used to evaluate this
process? (initialstate)
*What changes can we make that will result in
improvement?
Develop proposed solutions andcounter measures.
Conductrapid experimentstotest/validate solutions.
Create a future state valuestream mapfor the new
process.
Create standard work anddevelop policiesand
proceduresto support the new processwith clearly
defined accountability.
DEFINE 2.AIMSTATEMENT MEASURE 5. TARGET STATE METRICS IMPROVE 8. ACTION PLAN
*What are wetrying to accomplish?
State your goals in measurable terms.
What are the boundaries for this
project?
oIncluded/excludedfrom scope:
oProcessstart point & end point:
•What are the improvement goals for each
metric? (target state)
•How are these metrics aligned with the
organization’s strategic goals?
•How will these metrics be monitored?
Develop anaction plan to fully implement the
solutions, including details of who, what, and when.
oIdentify “Just-DoIts” tobe implemented immediately.
oImplement Lean 5-Sand visual controls, as needed.
oCreate and implement a communication plan.
DEFINE3. CURRENT CONDITIONS ANALYZE 6. GAP ANALYSIS CONTROL 9.FOLLOW-UP
•Describe thecurrent conditions of this
process using visual diagrams & charts.
•Determinethe customer requirements
for this process.
•Identify themeasurableCritical to
Quality (CTQ) elements of this process
that are essential for customer
satisfaction.
•Identify waste within the current process:
oGemba walk,waste worksheet, value
added/non-value added analysis
•Analyze mainissues,quantify theirimpact:
oPareto charts, control charts, statistical
analysis, capability analysis
•Identify the root cause ofissues and gaps:
oFishbone diagram, Five Whys, Root Cause
Analysis, Failure Modes Analysis (FMEA)
•Confirm that actual results match the expectedand
desiredresults.
•Identify any issues or barriers that still need to be
addressed.
•Create aplan tomonitor, sustain,and spread the
new process.
•Summarize and share the insights gained from this
project.
*Reference: Institute for Healthcare Improvement (IHI), 2011.
A3 Structured Problem Solving Steps

76. Evelyn A. Catt, 2015
76.
DEFINE 1.PROBLEMSTATEMENT
Describe the background of the current problem
or opportunity.
What business problem are we trying to solve?
Why is this issue important now?
DEFINE 2.AIMSTATEMENT
*What are wetrying to accomplish?
State your goals in measurable terms.
What are the boundaries for this project?
oIncluded/excludedfrom scope:
oProcessstart point & end point:
DEFINE 3. CURRENT CONDITIONS
•Describe thecurrent conditions of this process
using visual diagrams & charts.
•Determinethe customer requirements for this
process.
•Identify the measurableCritical to Quality (CTQ)
elements of this processthat are essential for
customer satisfaction.
*Reference: Institute for Healthcare Improvement (IHI), 2011.
Exercise: Define Phase

77. Evelyn A. Catt, 2015
77.
MEASURE 4. INITIAL STATE METRICS
*How will weknow a change is an improvement?
•Mapand measure the current process
performance.
•What metrics are used to evaluate this process?
(initialstate)
MEASURE 5. TARGET STATE METRICS
•What are the improvement goals for each metric?
(target state)
•How are these metrics aligned with the
organization’s strategic goals?
•How will these metrics be monitored?
ANALYZE 6. GAP ANALYSIS
•Identify waste within the current process:
oGemba walk,waste worksheet, value
added/non-value added analysis
•Analyze mainissues,quantify theirimpact:
oPareto charts, control charts, statistical analysis,
capability analysis
•Identify the root cause ofissues and gaps:
oFishbone diagram, Five whys, Root Cause
Analysis, Failure Modes Analysis (FMEA)
*Reference: Institute for Healthcare Improvement (IHI), 2011.
Exercise: Measure & Analyze Phases

78. Evelyn A. Catt, 2015 78.
IMPROVE 7. COUNTERMEASURES
*What changes can we make that will result in improvement?
Develop proposed solutions andcounter measures.
Conductrapid experimentstotest/validate solutions.
Create a future state valuestream mapfor the new process.
Create standard work anddevelop policiesand proceduresto
support the new processwith clearly defined accountability.
IMPROVE 8. ACTION PLAN
Develop anaction plan to fully implement the solutions, including
details of who, what, and when.
oIdentify “Just-DoIts” tobe implemented immediately
oImplement Lean 5-Sand visual controls, as needed.
oCreate and implement a communication plan.
CONTROL 9.FOLLOW-UP
•Confirm that actual results match the expectedand desiredresults.
•Identify any issues or barriers that still need to be addressed.
•Create aplan tomonitor, sustain,and spread thenew process.
•Summarize and share the insights gained from this project.
*Reference: Institute for Healthcare Improvement (IHI), 2011.
Exercise: Improve & Control Phases

79. Evelyn A. Catt, 2015
Action Plan Template
•An Action Plan is used to document the deliverables, task ownership,
and timeline for the implementation of process improvements.
79.
ITEM # ACTIONITEM OWNER DUE DATE STATUS

80. Evelyn A. Catt, 2015
Communication Plan Template
•A Communication Plan ensures that all stakeholders will be well
informed regarding the plan for implementing the new process.
TYPEOF INFORMATION & PURPOSE PREPARED BY DUE DATE DISTRIBUTION LIST STATUS
80.

81. Evelyn A. Catt, 2015
Control Plan Template
•A Control Plan is a tool for tracking the on-going performance of a process to
monitor and sustain the improvements that have been implemented.
PROCESS NAME: PROCESSOWNER:
PROCESSSTEP MEASUREMENT FREQWHOMEASURESCORRECTIVE ACTION
81.

82. Evelyn A. Catt, 2015
Control Plan Checklist
•A Control Plan is a tool for tracking the on-going performance of a process to
monitor and sustain the improvements that have been implemented and
respond to “out of control” measures. It includes the following elements:
Define the parameters to measure (key performance metrics).
Measure current performance as a baseline = “initial state”
Define goals for key performance metrics = “target state”
Compare future performance to the baseline and goals.
Assign task ownership and time intervals for tracking metrics.
Adjust tracking frequency based on process performance.
Establish feedback loop and response plan for out-of-control measures.
Develop and document standard work and related policies & procedures.
Assign accountability for achieving goals.
82.

83. Evelyn A. Catt, 2015
Reflections
•Have you ever participated in rapid improvement event?
•Do you anticipate that your staff will be excited about being empowered
to make rapid cycle improvements?
83.

84. Evelyn A. Catt, 2015
Lean 5-S
84.

85. Evelyn A. Catt, 2015
What is Lean 5-S?
•5-S is a workplace organization tool used to eliminate waste and
improve flow
–Eliminates the need for searching
–Reduces probability of error
–Increases quality
–Improves productivity
–Expedites response time
–Improves staff morale
–Enhances professional image of an area
–Increases efficiency of the supply replenishment process by using
visual cues such as a Kanban system
•Kanban aligns inventory and consumption levels; a signal is sent to
deliver additional inventory when current supplies are consumed.
85.

86. Evelyn A. Catt, 2015
Lean 5-S
86.
•5-S produces a workplace that is clean, uncluttered, and safe.
•5-S environments have “a place for everything & everything in its place”.
•5-S uses visual controls to make every item easy to locate and return.
SORT
Identify needed items
and remove the rest.
STORE
Organize (set in order)
the remaining items
SHINE
Clean the area and create a
specific place for each item.
STANDARDIZE
Simplify/standardize procedures
and monitor compliance.
SUSTAIN
Create a 5-S culture and
practices to sustain it.
S
A
F
E
T
Y

87. Evelyn A. Catt, 2015
Lean 5-S Examples
Examples provided courtesy of Deb McCarter, Director of Nursing Practice & Quality, IU Health, University Hospital.
87.
BEFORE
AFTER
BEFORE BEFORE
AFTER AFTER

88. Evelyn A. Catt, 2015
•Key Principle: Make it easy to see, use, and return.
•Equipment, supplies/information should be available within 30 seconds.
Visual Control Examples (simple signals)
88.
AFTER
BEFORE BEFORE AFTER
Examples courtesy of IU Health
Small Rural Hospitals

89. Evelyn A. Catt, 2015
Lean 5-S Achievement Levels
LEVEL
5
Continuous
Improvement
LEVEL
4
Focus On
Reliability
LEVEL
3
Make It
Visual
LEVEL
2
Focus On
Basics
LEVEL
1
Just
Beginning
Sort Store Shine Standardize Sustain
Cleanliness problem
areas are identified
and mess prevention
actions are in place.
Cleaning schedules
and responsibilities
are documented
and followed.
Initial cleaning is
done and mess
sources are known
and corrected.
Necessary and un-
necessary items are
identified; those not
needed are gone.
Needed and not
needed items are
mixed throughout
the area.
Items are randomly
placed throughout
the workplace.
Needed items are
safely stored and
organized according
to usage frequency.
Needed items are
outlined, dedicated
locations are labeled
in planned quantities.
Minimal needed
items arranged in
manner based on
retrieval frequency.
Needed items can
be retrieved in 30
seconds with
minimum steps.
Potential problems
are identified and
countermeasures
documented.
Work area cleaning,
inspection, and
supply restocking
done daily.
Visual controls and
indicators are set
and marked for
work area.
Key area items
are marked to check
and required level of
performance noted.
Key area items
checked are not
identified and are
unmarked.
Proven methods for
area arrangement
and practices are
shared and used.
Proven methods for
area arrangement
and practices are
used in the area.
Agreements on
labeling, quantities,
and controls are
documented.
Work group has
documented area
arrangement and
controls.
Work area methods
are not always
followed and are
not documented.
Root causes are
eliminated and
improvement actions
include prevention.
Sources, frequency
of problems are
noted w/ root cause
& corrective action.
Work group is
routinely checking
area to maintain
5-S agreements.
Initial 5-S level
is established and
and is posted in
the area.
Work area checks
are randomly done
and there is no
5-S measurement.
Reference: Uptime Magazine Source URL: http://www.uptimemagazine.com/uptime/AugSept09/augsep09precmaint03.jpg
89.

90. Evelyn A. Catt, 2015
Lean 5-S Benefits
•Pride in the workplace and supports team development.
•Sorting means removing unnecessary items that congest the work
area.
•Clean equipment allows everyone to notice problems.
•Sorting retains only the needed items. This allows for a smaller work
area resulting in reduced effort (walking, reaching, etc.) to do the
work.
•Reduced changeover times result from being organized and
minimizing search time.
•Items have a definitive home location that is labeled and easily found.
90.

91. Evelyn A. Catt, 2015
Keys To Lean 5-S Success
•Get everyoneinvolved.
•Integrate 5-S principles into daily work requirements.
•Communicate need for 5-S, roles of all participants, how it is
implemented.
•Be consistent in following 5-S principles in all areas.
•Periodic senior management involvement is absolutely required.
•Follow through and finish what is started, 5-S takes effort and
persistence.
•Link 5-S activities with all other improvement initiatives.
•Commitment to the process, a few individuals cannot undermine the
efforts of the entire team.
91.

92. Evelyn A. Catt, 2015
Lean 5-S Exercise
•We often have to search for (equipment, supplies, information, people):
•We often have to transport (equipment, supplies, etc.):
•We often have to walk/travel a long way (or frequent short trips) to obtain:
•Some areas are cluttered, unorganized, and/or need a good cleaning:
92.

93. Evelyn A. Catt, 2015
Standard Work
93.

94. Evelyn A. Catt, 2015
•Standard work is the best known wayof performing a
process today.
•Standard work is based on creative problem solving
and continual improvement.
•Standard work evolves over timeas new evidence-
based practices are identified and implemented.
Standard Work
94.
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://www.systems2win.com/solutions/5s.htm
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148

95. Evelyn A. Catt, 2015
•Reduces variation in performance
•Creates balanced work load
•Promotes consistency of outcomes
•Exposes waste & opportunities for improvement
Why Standard Work?
95.
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://www.systems2win.com/solutions/5s.htm
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148

96. Evelyn A. Catt, 2015
Standard Work Goals
96.
•The goal of standard work is to
develop the most reliable methods
to consistently achieve the best
outcomesfor each process.
•This is accomplished by defining
the best known way to perform the
process today.
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://www.systems2win.com/solutions/5s.htm
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
Steps
Sequence
Task Ownership
Methods
Materials
Outcomes

97. Evelyn A. Catt, 2015
Standard Work Components
97.
•Steps: What is being done?
•Sequence: In what order? How long should it take?
•Task Ownership: Who is responsible for each step
in the process?
•Methods: What instructions are required?
•Materials: What equipment & supplies are needed?
•Outcomes: What clearly defined measurable results
are expected?
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://www.systems2win.com/solutions/5s.htm
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148
Steps
Sequence
Task Ownership
Methods
Materials
Outcomes

98. Evelyn A. Catt, 2015
Creating Standard Work
•Keep it simple
•Include all info on one, easy-
to-read document
•Include key points to optimize
technique
•Make it accessible
•Always look for ways to
improve the process
•Make it overly complicated
•Put it away in a binder or in a
desk drawer
•Allow people to make one-off
changes on a whim
•Make it too rigid or difficult to
change
DO: DON’T:
98.
Reference: Spear, S. and Brown, H.K. Decoding the DNA of the Toyota Production System, Harvard Business Review, 1999.
Source URL: http://www.systems2win.com/solutions/5s.htm
Toussaint, J.S. ThedaCare Center for Healthcare Value. Organization Transformation Blog # 7 Process: Standard Work. March 15, 2010.
Source URL: http://www.createvalue.org/blog/post/?bid=148

99. Evelyn A. Catt, 2015
Standard Work Example
Reference: Lean Healthcare: Implementing the Standard Work. Dave Munch, MD. August 9, 2012.
Source URL http://www.leanhealthcareexchange.com/wp-content/uploads/2012/08/JIT.jpg 99.

100. Evelyn A. Catt, 2015
Viewing Your Facility
as a System
Diagram Source URL: http://www.hah-emergency.net/Puzzle%20-%20full%20hospital.JPG
100.

101. Evelyn A. Catt, 2015
System-wide Goals (example)
Quality &
Safety
Improve quality
outcomes and
promote clinical
systemness
Service &
People
Improve patient,
physician, and
employee
satisfaction
Education &
Research
Promote and
facilitate education
and clinical
research
Finance &
Growth
Increase system
efficiency and
reduce total cost of
care per person
101.

102. Evelyn A. Catt, 2015
System-wide Benefits
102.
•Leadership development using
common language and tools for
making process improvements
•Working smarter vs. harder
•Time savings for caregivers
•Evidence based improvements
•Mindful standardization of work
•Reduced variation in key processes
•Improved quality & safety outcomes
•Increased capacity & throughput
•Increased productivity & profitability
Empowered
Employees
Constant
Pursuit of
Perfection
Patient
Centered
Design
Data
Driven
Decisions

103. Evelyn A. Catt, 2015
Core Process Map
•A Core Process Map helps an organization to:
–Promote an understanding of your facility as a systemrather than “silos”.
–Learn to understand work as inter-related processeswithin a system.
–Prioritize projects by identifying the “pain points” across the system that have
the greatest impact on organizational performance.
–Identify key performance measures related to each area’s primary function.
103.
The Core
Process Map
contents can be
tailored for each
facility and
department

104. Evelyn A. Catt, 2015
Hospital Core Process Map
INPATIENT CARE TRANSITIONS (example)
104.

105. Evelyn A. Catt, 2015
Department Core Process Map -Surgery
105.
© I.U. Health Operational Improvement Group 2012, 2013
PATIENT INTAKE OPERATING ROOM RECOVERY/EXIT
O.R. RESOURCE PROCESSPT DISCHARGE
PRE-OP
TESTING
ADMIT
DAY OF
SURGERY
PT. PREP
SAME DAY
SERVICES
RECOVER
IN
PACU
RECOVER
IN
ICU
FAMILY MEMBER
TRANSPORT
EMS
TRANSPORT
POLICE
TRANSPORT
OBTAIN
PHYSICIAN
ORDERS
OBTAIN
PATIENT
INFO.
OBTAIN
MEDICAL
RECORDS
ASSEMBLE PATIENT CHART
CREATE
PRE-OP STAFF
SCHEDULE
CREATE
REG. STAFF
SCHEDULE
CREATE
SDS STAFF
SCHEDULE
CONFIRM
SURGEON
AVAILABLE
CONFIRM
PATIENT
AVAILABLE
CONFIRM
O.R. ROOM
AVAILABLE
SCHEDULING PROCESS
IDENTIFY REQUIRED RESOURCES
(ROOM, STAFF, EQUIPMENT,
INSTRUMENTS, SUPPLIES)
CREATE
O.R. ROOM
SCHEDULE
CREATE
O.R. STAFF
SCHEDULE
OBTAIN
SUPPLIES
& MEDS
ASSEMBLE
CASE
CARTS
CHART ASSEMBLY
STAFF
TRANSPORT
CLINICS
HX/PHYSICAL
FORM
CONSENT
FORM
PRE-OP
ORDERS
COORDINATE SCHEDULING WITH CLINICS
SURGERY
DATE
PT. PRE-OP
PREP INSTR.
MEDICATION
RECONCIL.
INSURANCE
PRE-CERT
SURGICAL
PROCED.
DETAILS
HRC
TRANSPORT
INSTRUMENT
PROCESSING
& REPAIRS
SURGICAL CARE TRANSITIONS (example)
BLOCK
TIME
SCHEDULE
TURNOVER
TRANSFER
TO IP UNIT
DISCHARGED
HOME
STAFF SCHEDULES
ROOM
READY
PATIENT
IN
ANESTH
IN
SURGEON
IN
TIME
OUT
CUT -
CLOSE
PT
OUT
POSITION/PREP PT PROCEDURE
SET UP
INSTRUMENT
ORDERING &
PURCHASING
SELECT
PREFERENCE
LIST
MD
DECISION
TO
OPERATE
105.

106. Evelyn A. Catt, 2015
Core Process Map Exercise
106.
Exercise: What would your Core Process Map look like?
•What are the main functions or areas in your facility?
•How does work flow from one area to the next?
•Which issues create the greatest impact in each area?
•What measures are used to evaluate performance?

107. Evelyn A. Catt, 2015
Defining the Process
107.

108. Evelyn A. Catt, 2015
STEP 1:
Get the
bread
STEP 2:
Plug in
the toaster
STEP 3:
Put bread
In the toaster
STEP 4:
Set the dial
and press
down lever
STEP 5:
Take toast
out when it
pops up
STEP 6:
Put butter
on the toast
High Level Process Map
In order to understand the process being evaluated, the first step is to
create a High Level Process Map with 4-6 high level actions required to
complete the process. More detailed mapping will be completed later.
108.
Example: Making toast
Note: The steps in the High Level Process Map are used as the center
column in the SIPOCS Diagram, which is covered later in this section.

109. Evelyn A. Catt, 2015
STEP 1: STEP 2: STEP 3: STEP 4: STEP 5: STEP 6:
High Level Process Map Exercise
109.
Your process name:
Exercise: Select a process from your work area and list the 4-6 high
level actions required to complete this process.

110. Evelyn A. Catt, 2015
110.
Reflections
•Did it take very long to complete the High Level Process Map?
•Do your colleagues agree on the sequence of these 4-6 process steps?

111. Evelyn A. Catt, 2015
Process Flow Chart
•A process flow chart is a graphic representation of the steps in a
process in sequential order. It uses standardized symbols to reflect
the different steps in the process.
Image Source: http://www.bpminstitute.org/images/contributors/Sweet_November10_Image1.jpg
111.

112. Evelyn A. Catt, 2015
Process Flow Chart Symbols
Reference:http://www.breezetree.com/articles/what-is-a-flow-chart.htm
Symbol Name Description
TerminatorIndicates the start and stop points in a process.
ProcessIndicates a process or action step.
Decision
Indicates a decision or branch in the process flow when
there are 2 options (Yes/No, etc.)
DelayDepicts any waiting period that is part of a process.
ConnectorLine connector shows the direction the process flows.
DocumentIndicates a process step that produces a document.
Data I/OIndicates data inputs to and outputs from a process.
112.

113. Evelyn A. Catt, 2015
SIPOCS Diagram
•A SIPOCS Diagram is a tool used at the beginning of a project to capture all the
relevant information about the process being studied.
•The SIPOCS Diagram defines the high level process steps, required resources
and suppliers, and clearly identifies the outputs and customers of the process.
Reference: http://www.valuestreamguru.com/?p=131
Diagram Source: http://www.projectbuild.org.uk/images/sipoc.jpg
INPUTS PROCESS OUTPUTS
CUSTOMERS
STAKEHOLDERS
SUPPLIERS
Resourcesrequired to
complete the process.
Activitybeing
completed. (verb)
Deliverable/Outcome
created by the process.
Personwho receives or
benefits from outputs.
Providersof the
required resources.
113.

114. Evelyn A. Catt, 2015
SIPOCS Exercise
INPUTS PROCESS OUTPUTS
CUSTOMERS
STAKEHOLDERSSUPPLIERS
I P O CS
Resourcesrequired to
complete the process.
Activitybeing completed.
(verb)
Deliverables or outcomes
created by the process.
Person/entitywho receives
or benefits from an output.
Providersof the required
resources.
FIRST: Fill in process START
THIRD: Fill in MIDDLE steps
Dept: Process: Project Leader: Date:Hospital:
SECOND: Fill in process END
Complete Inputs column Complete Process column Complete Outputs columnComplete Suppliers column
1 324
Complete Customers column
5
114.

115. Evelyn A. Catt, 2015
115.
X-Y Chart
•The X-Y Chart helps to identify and prioritize the relationship between multiple
inputs and the resulting outcomes. All process outcomes (Y’s) are achieved
based on the interaction of multiple inputs (X’s), which is often referred to as a
“cause and effect” relationship. Therefore, the X-Y Chart is also known as a
C&E Matrix. The most traditional use of an X-Y Chart is to help narrow down a
large number of inputs (X’s) to a manageable list for further evaluation. Steps:
–Identify & rank customer “critical to quality” (CTQ) requirements across the top of the matrix.
–List all of the inputs to the process down the left side of the matrix.
–Rank the impact of each input on each CTQ requirement (1 = weak, 3 = moderate, 9 = strong) to
determine the correlation between each input and CTQ.
–Cross multiply the input ranking with the CTQ value then add across each line for a total score.
–Sort the total scores from highest to lowest to identify the inputs with the greatest impact.
–Select a breaking point for items with scores that are too low to warrant further investigation.
Diagram Source URL:
http://www.bing.com/images/search?q=CE+Matrix+Templates&FORM=HDRSC2#view=detail&id=4517A5CB24A308023435F67DB409264C36CFAD55&selectedIndex=2

116. Evelyn A. Catt, 2015
Murphy’s Analysis
•Murphy’s Analysis is a brainstorming tool that helps to identify problem
areas and common ways that the current process breaks down or fails.
116.
Example
Process: Accurate Lab Tube Labeling
WHAT COULD GO WRONG
WITH THIS PROCESS?
Tube system
Down/lack of
supplies
Printer not
working
Order of draw/
Too little blood
Inconsistent
Patient ID process
Wrong supplies/
Lack of supplies
Wrong
Label
Placement/
Info
Labeling at
Bedside
Order details
incorrect

117. Evelyn A. Catt, 2015
Murphy’s Analysis Exercise
Your Process:
WHAT COULD GO WRONG
WITH THIS PROCESS?
117.
Note: Additional circles may be added, as needed.

118. Evelyn A. Catt, 2015
Reflections
•SIPOCS
–What new insights did the SIPOCS exercise provide regarding the inputs,
outputs, suppliers, and customers associated with your process?
–Were any issues identified related to the suppliers and inputs for this
process?
•Murphy’s Analysis
–Was as the Murphy’s Analysis an easy exercise to complete?
–Were you already aware of all the issues documented during this
exercise?
118.

119. Evelyn A. Catt, 2015
Customer Requirements
119.

120. Evelyn A. Catt, 2015
Customer Requirements
•Customer requirements refers to the qualities and features of products
and services that are needed to achieve customer satisfaction.
•It’s important to obtain direct “Voice of the Customer/Stakeholder”
inputfrom patients, physicians, staff, and visitors to define customer
requirements and determine if the current process meets their needs.
•Several methods can be used to obtain the “Voice of the Customer”:
–Conduct interviews
–Establish a focus group
–Develop a questionnaire
–Conduct research
Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html
120.

121. Evelyn A. Catt, 2015
First: Go to “Gemba”
•Gemba in Japanese means “the actual place” or “the real place”.
•Go to “Gemba” to observe the current process in action.
•Talk to the people who actually perform the process.
•Identify gaps between the current process and customer defined
requirements and develop a strategy to address unmet needs.
•Identify opportunities to eliminate waste and improve flow.
Reference: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University 121.

122. Evelyn A. Catt, 2015
“Gemba” is Everywhere!
•Gemba is every location where work is being done!
–Administrative Offices
–Clinical Areas
–Non-clinical Areas
–Environmental Services
–Facilities
–Financial Counseling
–Food Services
–Health Information Services
–Human Resources
–I.T. Systems
–Marketing
–Patient Billing
–Payroll
–Quality & Risk Management
–Security
–Supply Chain Management
–Other Areas………………..
122.

123. Evelyn A. Catt, 2015
Foundation for Success
•Observe the work in action.
•Honor everyone’s contribution.
•Establish relationships based on trust and transparency.
•Design every process with the patient in mind!
123.

124. Evelyn A. Catt, 2015
Brainstorming
•Brainstorming is used to rapidly
generate ideas from multiple people
simultaneously regarding customer
requirements:
–Write the name of your process on a
flipchart or whiteboard.
–Without discussion, each person works
independently and writes their ideas on
sticky notes regarding potential
customer requirements.
–Each person posts their sticky notes on
a flipchart or white board.
–No comments, censoring, or criticism is
allowed during this process.
Diagram Source: http://jwsokol.files.wordpress.com/2010/07/brainstorming.jpg
124.

125. Evelyn A. Catt, 2015
Affinity Diagram
Diagram Source: http://www.six-sigma-material.com/images/AffinityDiagram.GIF
•An Affinity Diagram is a group decision-making technique designed to sort a large
number of ideas/concepts/opinions into naturally related groups. Affinity
Diagrams are often used to sort customer requirements into logical categories.
125.
Nominal Voting Technique
Each person is then given a
limited number of colored dots
(usually 5-8) and votes by
placing a dot on the items they
consider the highest priority.

126. Evelyn A. Catt, 2015
Reflections
•What type of leadership style will be required to create a culture that
honors everyone’s contribution?
•Are relationships based on trust and transparency in your current work
environment?
•How will the practice of “going to Gemba” be received by the areas
being observed?
126.

127. Evelyn A. Catt, 2015
Voice of the Customer/Stakeholder
Goals
•Obtain direct “Voice of the Customer/Stakeholder” feedback from
patients, physicians, staff, and visitors about the current process.
•Identify gaps between the current process and customer defined
requirements. Develop strategies to address any unmet needs.
Questions To Ask (SWOT Analysis)
•What do you like about our services? (Strengths)
•What do you think needs improvement? (Weaknesses)
•What Opportunitiesdo you feel we could take advantage of?
•What could potentially Threatenour success?
References: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University.
Woodward-Haag, H. and Woodbridge, P.A. Rapid Process Improvement Workshops. Veterans Administration Systems Redesign, 2008.
127.

128. Evelyn A. Catt, 2015
Exercise: Create a SWOT Analysis for your area:
SWOT Exercise
STRENGTHS WEAKNESSES OPPORTUNITIES THREATS
128.

129. Evelyn A. Catt, 2015
Customer Requirements Exercise
QUALITY TIMELINESS COST
•Response time,
procedure time,
test turnaround
time,
appointment
availability, etc.
•Quality and
excellence
standards that are
required
•Cost issues or
barriers that
impact patient
access, choice,
and satisfaction
OTHER
•Other services or
features that are
desired or
required
Exercise: Create a list of customer requirements for your area.
129.

130. Evelyn A. Catt, 2015
Customer Requirements Tree
CUSTOMER WANTS/NEEDS DRIVERS
CRITICAL TO QUALITY (CTQ)
(measurable requirement)
Accurate Charges 100% of the time
Invoices that are on time
and correct
Bill received within 3 days
Timely Processing
Insurance filed within 5 days
•A Customer Requirements Tree defines the key measurable
characteristics of a process that must be met to satisfy the customer.
•It converts customer wants and needs into Critical to Quality (CTQ)
measurable requirements for the business to implement.
INCREASED SPECIFICITY
130.

131. Evelyn A. Catt, 2015
Customer Requirements Exercise
CUSTOMER WANTS/NEEDS DRIVER
CRITICAL TO QUALITY (CTQ)
(measurable requirement)
INCREASED SPECIFICITY
131.

132. Evelyn A. Catt, 2015
Kano Model
132.

133. Evelyn A. Catt, 2015
Characteristics of Products & Services
•The characteristics of products and services can be defined as:
–Dissatisfying: annoying features -avoided characteristics
–Mandatory expectations: basics -must have characteristics
–Customer needs: reasonable expectations -performing features
–Delighters: surprise -innovators -unexpected features
•To find out which characteristics deliver on which level of
satisfaction it is necessary to develop a questionnaire, interview,
or focus group; or conduct research to find the customer defined
characteristics and the associated level of satisfaction.
Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html
133.

134. Evelyn A. Catt, 2015
•The Kano Model is used to visually depict the customer defined
characteristics (for products and services) versus the level of satisfaction
each characteristic delivers.
•The Kano Model can be used to organize and prioritize activities to design
and/or improve products and services to meet or exceed customer
requirements.
Kano Model
Reference: Six Sigma, Kano Model: Source URL: http://www.six-sigma-material.com/Kano.html 134.
DISSATISFIED
CUSTOMERS
Achievement Axis
Satisfaction Axis
Not necessarily expressed
Happy surprises, unexpected features!
Expressed needs
Strong source of satisfaction.
Usually unexpressed
“Must haves”, basic requirements.

135. Evelyn A. Catt, 2015
Must Haves ( “Basic Needs”)
These basic requirements are not always expressedbut they are obvious to the
customer and must be met. These requirements are not a source of satisfaction
but can cause major disappointment if they are not met.
Examples: brakes of a car; bed in a hotel room.
Performance Needs (”Linear”)
The need is expressedand customer satisfaction is proportional to the level of
performance (and quality) of what is implemented.It is a strong source of
customer satisfactionand a priority for development. Customer feedback on these
products and services is crucial.
Delighters ( “Exciters “)
These requirements are not necessarily expressed.Sometimes they’re unconscious.
This is the happy surprisethat can make a difference, and an important source of
satisfaction. If not there, no dissatisfaction, no frustration: they’re not expected.
Exciters are the keys to innovation!
Kano Model Elements
Reference URL: http://www.agile-ux.com/tag/kano-model/
135.

136. Evelyn A. Catt, 2015
Kano Model Uses & Strengths
•Kano Model Uses:
-To understand customer needs
-To benchmark services
-To prioritize product/service development
-To drive your vision and strategy
•Kano Model Strengths:
-Simplicity
-Direct user feedback
-User-centered design tool
-Valuable decision-making tool
Reference URL: http://www.agile-ux.com/tag/kano-model/
136.

137. Evelyn A. Catt, 2015
Value Stream Mapping
137.

138. Evelyn A. Catt, 2015
Value Stream Map (VSM)
•A Value Stream Map (VSM) is a graphic representation of the process being
studied. It’s used to identify value and lead time. It shows the sequence of
the major tasks performed during the process as it currently functions.
•The VSM uses color coding to designate whether each step is value added,
non-value added, or a business requirement.
138.
VALUE
ADDED
(VA)
NON-VALUE
ADDED
(NVA)
BUSINESS
REQUIREMENT
•Delays
•Errors
•Extra steps
•Waste
•Good results
•No mistakes
•Safe and timely
•Valued by patient
•Accreditation
•Legal compliance
•Regulatory req.
•Safety standards
GREEN
RED
YELLOW

139. Evelyn A. Catt, 2015
Value Stream Mapping –Current State
•Map the current work flowto identify the “value stream” within the
process and to measure the lead timefor each process step.
Reference: Source URL http://www.archfield.com/how_to_increase_profit_using_lean_enterprise.htm
139.
FLOW
STOPPER
FLOW
STOPPER
FLOW
STOPPER
VALUE
ADDED
(VA)
NON-VALUE
ADDED
(NVA)
BUSINESS
REQUIREMENT
GREEN
RED
YELLOW

140. Evelyn A. Catt, 2015
Design the Ideal “Future State”
•Analyze the “current state” value stream map.
•Measure the timefor each step and between steps.
•Identify value added steps.
•Eliminate waste and non-value added steps.
•Design the ideal “future state”.
Reference: Woodward-Haag, H. and Woodbridge, P.A. Rapid Process Improvement Workshops. Veterans Administration Systems Redesign, 2008.
VALUE
ADDED
(VA)
NON-VALUE
ADDED
(NVA)
BUSINESS
REQUIREMENT
TIME
TIME
TIME
TIME TIME
140.

141. Evelyn A. Catt, 2015
•The waste (waiting time) has been removed from the ideal “future
state” of the E.D. patient registration, triage, and placement process.
VALUE
ADDED
(VA)
NON-VALUE
ADDED
(NVA)
BUSINESS
REQUIREMENT
FLOW
STOPPER
Value Stream Mapping –Future State
141.

142. Evelyn A. Catt, 2015
Exercise: Select a process from your work area and list the major steps in this
process. Does every step provide value? How much lead time is required? Where
does the waste occur? At what points do you see “flow stoppers” in this process?
Value Stream Mapping Exercise
STEP 1: STEP 2: STEP 3: STEP 4: STEP 5:
STEP 6: STEP 7: STEP 8: STEP 9: STEP 10:
VALUE
ADDED (VA)
?
NON-VALUE
ADDED (NVA)
?
BUSINESS
REQUIREMENT
?
Are each of these steps:
FLOW
STOPPER
142.

143. Evelyn A. Catt, 2015
Measurements in the Value Stream
Reference: Six Sigma for Dummies. 2005, Wiley Publishing, Inc., Hoboken, NJ. 143.
METRIC METRICDEFINITION
Defects per Unit(DPU)
Total Number of Defects
Total Number of Product Units
Total Opportunities(TO) Total Number of Product Units x Opportunities per Unit
Defects per Opportunity
(DPO)
Total Number of Defects
Total Opportunities
Defects per Million
Opportunities(DPMO)
DPO x 1,000,000
Percent Defective
Total Number of Defective Unitsx 100
Total Number of Units
Rolled Throughput Yield
(RTY)
The number of good units produced divided bythe number of total units going
into the process. Calculate the yield (number coming out of each step/number
going into each step).This is the First Pass Yield.Rolled Throughput Yield is
created by multiplying all First Pass Yields together.
Takt Time
Defined as the rate of customer demand,often called “the heartbeat” of the
process.It is how often a product or service needs to be completed to meet
customer demand.
•Formula = Effective Working Time / Average Customer Demand (for that time period).
•Effective Working Time = Hours Worked minus non-productive periods(lunch, etc.).

144. Evelyn A. Catt, 2015
Identifying Waste
144.

145. Evelyn A. Catt, 2015
Waste in the Emergency Department
Waiting for
a room
Travel to
Radiology
Waiting to
return to E.D.
Waiting to be
transported
Unnecessary
forms
Redundant
questions
Travel time
to O.R.
WASTE
WASTE
WASTE
WASTE
WASTE
WASTE
WASTE
Delayed
test results
WASTE
Wrong test
ordered
WASTE
145.

146. Evelyn A. Catt, 2015
Types of Waste (Muda)
Errors, poor quality, failure to meet customer requirements.
Providing unnecessary products, services, or features.
Delays, periods of inactivity, bottlenecks, or patient wait
time.
Failure to fully utilize human potential (time and talents of
people).
Unnecessary movement of supplies, equipment, or people.
Excess inventory/supplies, batch processing, queues, or
backlogs of work.
Extra steps taken by employees because of inefficient
layout, searching, hunting and gathering.
Excess activity and processing steps caused by poor process
design.
146.
Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.
Source URL:http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples
Defects
Over Production
Waiting
Non-utilized Potential
Travel/Transportation
Inventory/Scrap
Motion (search time)
Excess Processing

147. Evelyn A. Catt, 2015
Waste Walk Worksheet Exercise
Errors, poor quality, failure to meet customer requirements.
Example:
Providing unnecessary products, services, or features.
Example:
Delays, periods of inactivity, bottlenecks, or wait time.
Example:
Failure to fully utilize human potential (time and talents of
people). Example:
Unnecessary movement of supplies, equipment, or people.
Example:
Excess inventory/supplies, batch processing, queues, or
backlogs of work. Example:
Extra steps taken by employees because of inefficient
layout, searching. Example:
Excess activity and processing steps caused by poor process
design. Example:
Reference: Healthcare Performance Partners, 8 Wastes with Healthcare Examples.
Source URL:http://leanhealthcareperformance.com/page.php?page=8%20Wastes%20with%20Healthcare%20Examples
Defects
Over Production
Waiting
Non-utilized Potential
Travel/Transportation
Inventory/Scrap
Motion (search time)
Excess Processing
147.

148. Evelyn A. Catt, 2015
Simplifythe process to remove unnecessary or redundant steps.
Standardizeequipment, supply locations, and stocking procedures.
Optimizeeach step by designing the work area to create uninterrupted flow.
Developand document standard work and provide appropriate education.
Modifythe sequence of activities to increase efficiency.
Identifyand remove bottlenecks and constraints.
Clarifyroles and responsibilities for each process step.
Introducenew deliverables and/or accountability standards.
Verifythat clear expectations have been communicated to everyone who plays
a role in the process, including external areas.
Checklist for Removing Waste
148.

149. Evelyn A. Catt, 2015
Flow
149.

150. Evelyn A. Catt, 2015
Flow
•Flow is the continuous movement of people, materials and supplies
through a process.
•Flow ensures that patients have what they need exactly when they
need it.
–No delays or waiting
–One piece flow(instead of batching)
–Well organized supplies and work space
–Alignment of work volume and resources to meet customer demand
•Takt time = available working time / customer demand
•Takt time is often called “the heartbeat” of a Lean organization
–Allows replenishment of only what is needed
References: Joosten T, Bongers I, Jansen R. Application of Lean Thinking to Health Care: Issues and Observations. Int J Qual Health Care 2009; Volume 21, Number 5:
pp. 341-347. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742394/
Womack JP, Byrne AP, Flume OJ, Kaplan GS, Toussaint J. Going Lean In Health Care. Cambridge. Institute for Healthcare Improvement; 2005.
150.

151. Evelyn A. Catt, 2015
Patient Flow & Accountable Care
SAFE –EFFECTIVE –TIMELY –PATIENT CENTERED –EQUITABLE –EVIDENCE BASED CARE
Patient flow –the movement of patients through all levels and sites
of care –is a critical component of accountable care.
Reference: Institute for Healthcare Improvement (IHI), 2011 151.

152. Evelyn A. Catt, 2015
What happens when the flow stops?
It slows down or stops the process!
152.

153. Evelyn A. Catt, 2015
Lack of Flow Creates Waste
153.

154. Evelyn A. Catt, 2015
Tools to Improve Flow
154.

155. Evelyn A. Catt, 2015
Identifying Bottlenecks
•A bottleneck occurs when the performance or capacity of an entire
process is constrained by a single step or limited number of resources.
•Bottlenecks must be removed to improve flow and utilize the full
capacity of the system.
Reference: http://en.wikipedia.org/wiki/Bottleneck
Image Source: http://www.labcentrix.com/images/bottleneck_diagram.jpg 155.

156. Evelyn A. Catt, 2015
Reflections
•What bottlenecks or constraints exist in your facility that affect
performance or limit capacity?
156.

157. Evelyn A. Catt, 2015
Spaghetti Diagram
•A Spaghetti Diagram is a map showing the movement of people, equipment,
materials, and total distance traveled. In order to decrease this type of waste:
oRedesign the work flow to reduce movement and search/travel time.
oRelocate frequently used supplies in closer proximity to work stations.
157.

158. Evelyn A. Catt, 2015
Spaghetti Diagram Exercise
Exercise: Draw the layout of your work area.
•Do people, equipment, and materials flow smoothly through this area?
•How could the layout be improved?
158.

159. Evelyn A. Catt, 2015
Simplify Process Flows
by untangling process complexity
Public Domain Image
159.

160. Evelyn A. Catt, 2015
The 7 Flows
1.Patients & Family
2.Providers*
3.Information
4.Medications
5.Supplies
6.Equipment/Instruments
7.Process Steps
*Everyone working in the process is
considered a provider
All 7 Flows and their relationship to
one another must be clear and
understood in order to make
improvements in processes.
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
160.

161. Evelyn A. Catt, 2015
Checklist for Improving Flow
1. Flow of Patients and Family/Relationships
Bring services to the patient whenever possible
Minimize patient walking if services can’t be delivered to them
Respect the patient’s wishes for family involvement
Eliminate unnecessary movement or separation from the family
2. Flow of Providers
Ensure there is standard work for all tasks
Remove all wasted motion
Correlate supply locations to frequency of use
Do not isolate people in work “silos”
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
161.

162. Evelyn A. Catt, 2015
3. Flow of Information
Include information flow in designing new processes
Information should flow with the patient
Convey information in simple visual or auditory signals
Avoid data overload; minimize to only necessary information
4. Flow of Medications
Bring services to the patient
Medications should arrive just-in-time
Get as close to the point of use as possible
Make smaller “satellite” pharmacies where possible
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
Checklist for Improving Flow
162.

163. Evelyn A. Catt, 2015
5. Flow of Supplies
Make the flow simple and visual
Only needed materials should be on-hand
Supplies should arrive exactly when needed
Consider using two-bin strategies for point of use supplies
6. Flow of Equipment & Instruments
Arrange equipment in a sequence that facilitates flow
All equipment should be on wheels, if possible
Use mistake-proofing to avoid waste and errors
Buy only what you need, avoid unnecessary features
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
Checklist for Improving Flow
163.

164. Evelyn A. Catt, 2015
7.Flow of Process Steps
Maintain simplicity of the work process
Include standard work
Include mistake-proofing principles
Evaluate process size, scope, speed, and quality
Reference: Virginia Mason Institute, 2013. Methods for Optimizing the VMPS Flows of Medicine.
Checklist for Improving Flow
164.

165. Evelyn A. Catt, 2015
Root Cause Analysis
165.

166. Evelyn A. Catt, 2015
Root Cause Analysis
http://www.thinkreliability.com/graphics/CauseMaps/PPT%20graphic%20-%20Root.gif
166.

167. Evelyn A. Catt, 2015
Root Cause Analysis (5 Whys)
•A Root Cause Analysis is a standardized method used to identify the real
cause of a problem, rather than the superficial, easily identified cause.
•To use this technique, ask “why” 5 timesto drill down to the underlying root
cause of the issue (next slide).
•Brainstorm solutions and corrective actions.
•Discuss the analysis and pros & cons of each potential solution.
•Additional questions to consider afteryou complete the “5 whys” exercise.
–Why wasn’t the error prevented by our current system?
–Why do our tools, rules, or procedures allow the problem to occur?
–Why didn’t our system immediately catch the problem?
–Why wasn’t it obvious how to fix the problem?
Reference: Ries, E. How to Conduct a Five Whys Root Cause Analysis. July 2, 2009. Source URL:
http://www.startuplessonslearned.com/2009/07/how-to-conduct-five-whys-root-cause.html
167.

168. Evelyn A. Catt, 2015
Root Cause Analysis Exercise
Enter example here:
1
st
Question Why:
Answer:
2
nd
Question Why:
Answer:
3
rd
Question Why:
Answer:
4
th
Question Why:
Answer:
5
th
Question Why:
Answer:
Exercise: Describe an error or issue that has occurred in your work area.
168.

169. Evelyn A. Catt, 2015
Fishbone Diagram
•A Fishbone Diagram (Ishikawa Diagram) is used to identify, explore,
and display the potential causes of a problem and the resulting effects.
Diagram source: http://www.juliasilvers.com/embok/Risk/RiskAssessmentMgmt/CauseEffect.gif
169.

170. Evelyn A. Catt, 2015
Fishbone Diagram Example
Medication Not
Administered
Per Guidelines
170.
Example provided courtesy of Kourtney Kouns, Clinical Informatics Coordinator, IUH Methodist Hospital

171. Evelyn A. Catt, 2015
Fishbone Diagram Exercise
EFFECT
Measurements
Cause
Cause
Cause
Materials
EnvironmentPolicies/ProceduresPeople (Man)
Methods
Cause
Cause
Cause Cause
Cause
Cause
Cause CauseCause
Cause
Cause Cause
Cause
Cause
Cause
Machines
Cause
Cause
Cause
Physical Plant
Cause
Cause
Cause
171.

172. Evelyn A. Catt, 2015
Mistake Proofing
•Mistake Proofing is about adding controls to preventerrors,
reducetheir severity, and detectthem if they can occur. These
mistake proofing mechanisms are called “Poka Yokes”.
•Replacing inspection and correction with true quality is known as
“Quality at the Source”.
GOOD: Detect errors/defects beforeproceeding to the next step.
BETTER: Detect errors/defects duringthe actual process.
BEST: Preventerrors/defects from occurring at all.
Reference: http://www.six-sigma-material.com/Mistake-Proofing.html
Image Source: http://www.exegens.com/media/incoming/0328.jpg
172.

173. Evelyn A. Catt, 2015
Mistake Proofing (Poka Yoke) Examples
Image Source: http://www.leanblog.org/2010/04/quaid-patient-safety-documentary-airs-saturday-morning/
173.

174. Evelyn A. Catt, 2015
Project Selection
174.

175. Evelyn A. Catt, 2015
Project Selection & Prioritization
•Identify and prioritize projects that:
–Are aligned with the organization’s strategic goals.
–Have the most significant enterprise-wide benefits.
–Provide the greatest value to patients.
•Ensure that projects have a manageable scope
•Identify project metrics
–Define key performance metrics.
–Measure current “initial state” performance for each process being studied.
–Establish well defined “target state” process improvement goals and return
on investment (ROI) goals. The percent Return on Investment (ROI) =
Gain from Investment –Cost of Investment x 100
Cost of Investment
References: Quality Improvement Tools & Tips, Carol Birk, M.S., R.Ph., Purdue University
Nemana, K. Six Critical Success Factors for a Six Sigma Deployment.Source URL:
http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111 175.

176. Evelyn A. Catt, 2015
Project List Exercise
•What are the “pain points” in your facility that have a significant impact on
quality, cost, efficiency, and satisfaction? Create a list of potential projects to
address these issues. How would you rank/prioritize these projects?
Rank ProjectName
Quality
Goal
Cost
Goal
Efficiency
Goal
Satisfaction
Goal
176.

177. Evelyn A. Catt, 2015
Exercise: Define the goal for your project in measureable terms:
We want to improve ____________________________________
from ______________________________________ (initial state)
to ________________________________________ (target state)
by ________________________________________ (target date).
•Example: We want to improve surgery on-time starts from 20%
(initial state) to 50% (target state) by June 2016 (target date).
•Clarify Definitions: How would you define an “on-time start”?
Project Goal Exercise
177.

178. Evelyn A. Catt, 2015
Easy
to Do
Hard
to Do
Low
Impact
High
Impact
Do
Over Time
Do
Now
Do
As Time
Permits
Never
Do
178.
Place each potential project in
the appropriate quadrant of
the impact/effort grid.
Project Impact vs. Effort Grid

179. Evelyn A. Catt, 2015
Project Prioritization Matrix
•A Project Prioritization Matrix aligns project selection decisions with value
based criteria and weighted scores. Each organization should develop a
prioritization matrix based on organizational pillars and strategic priorities.
179.
PROJECT PRIORITIZATION MATRIX
Project # Project Description
Finance/
Growth
Weighted Score
Quality/
Safety
Weighted Score
Service/
People
Weighted Score
Resources
Available
Weighted Score
Strategic
Imperative
Weighted Score
TOTAL
Weighted
Score
Project
Priority
Ranking
Weight Factors (EXAMPLES) Score 30 Score 10 Score 20 Score 15 Score 25
1. Example Project #1 6 180 6 60 3 60 6 90 9 225 615
2. 0 0 0 0 0 0
3. 0 0 0 0 0 0
4. 0 0 0 0 0 0
5. 0 0 0 0 0 0
6. 0 0 0 0 0 0
7. 0 0 0 0 0 0
8. 0 0 0 0 0 0
9. 0 0 0 0 0 0
10. 0 0 0 0 0 0
11. 0 0 0 0 0 0
12. 0 0 0 0 0 0
13. 0 0 0 0 0 0
14. 0 0 0 0 0 0
15. 0 0 0 0 0 0
Scoring: No Impact = 0, Low Impact = 3, Medium Impact = 6, High Impact = 9

180. Evelyn A. Catt, 2015
Goals Grid
A Goals Grid is a helpful tool to clarify strategic priorities for each area and
to create a shared vision for alignment with organizational strategic goals:
180
Diagram Source:http://home.att.net/~nickols/goals_grid.htm
ACHIEVE PRESERVE
ELIMINATE
AVOID
What do you want
that you don’t have?
What don’t you have that you don’t want?
What do you have now that you don’t want?
What do you want to keep
that you already have?
Reference URL:http://home.att.net/~nickols/goals_grid.htm
180.

181. Evelyn A. Catt, 2015
Exercise: Create a Goals Grid together as a team. Discuss how each
item on the completed grid aligns with organizational strategic priorities.
Goals Grid Exercise
Reference URL:http://home.att.net/~nickols/goals_grid.htm
181.
ACHIEVE PRESERVE
ELIMINATE
AVOID

182. Evelyn A. Catt, 2015
Project Charter
182.

183. Evelyn A. Catt, 2015
Project Charter
•The project charter is a contract between the organization’s
leadership and the project team. It is created at the beginning of
the project to clarify what is expected of the team.
•Project charter elements include:
–Project Team
–Project Roles
–Problem Statement
–Aim Statement
–Project Scope
–Project Timeline
–Project Milestones
–Project Metrics
183.

184. Evelyn A. Catt, 2015
Project Team Roles
Reference: Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL:
http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111
184.
PROJECT ROLES DESCRIPTION OF DUTIES
Executive Sponsor
Senior management/leaderwho sponsors the project, authorizes resources, and reviews and approves project
deliverables. Holds the team accountable for meeting project goals and achieving measurable results.
Process Owner
Department based leader ultimately responsible for the process being improved and for monitoring and
sustaining the process improvements over time.
Project Leader
Leader who drives project execution by developing plans, timelines, and assigning tasks; educates and leads the
team in the use of standardized tools and data analysis; maintains project documentation and ensures
completion of project deliverables; coordinates effective communication with the team, stakeholders, and
leaders; and promotes collaboration, transparency, and trust.
Team Members
Cross functional, high performing employees familiar with the process who participate in the project and
complete assigned tasks using standardized tools.
Team Facilitator
Individual who facilitates effective team meetings and helps with issues related to communication and problem
solving, but does not contribute to the management of the project or completion of tasks and deliverables.
ProjectCoach/
Mentor
An experienced and highly skilled professional coach who provides expert knowledge, strategic guidance, and
mentoring for projects using Lean Six Sigma concepts and tools.
Key Stakeholders
Stakeholders are persons or groups with an interest in a project. Their interest may be based on the impact a
project may have on their area’s processes, or because they have to supply resources to support the project. A
rule of thumb for identifying key stakeholders is to question whose support or lack of it may significantly
influence the success of the project.

185. Evelyn A. Catt, 2015
Project Team Worksheet
ProjectName Charter Date:
Location Version:
Timeline Start Date: Target End Date:
TEAMMEMBERS Name/Title Name/Title
Executive Sponsor(s)
Process Owner(s)
Project Leader
Team Members
Key Stakeholders
Project Mentor/Coach
185.

186. Evelyn A. Catt, 2015
•The problem statement is the reason for action. It is a basic
description of the process to be worked on and the background of
the current problem or opportunity. Examples:
–Only 20% of surgery patients are seen in the pre-admission
testing area, which results in delays on the day of surgery due to
additional testing that needs to be performed before the patient
goes to the O.R.
–The Emergency Department average length of stay exceeds
benchmark standards and the Left Without Being Seen rate is
escalating due to the long waiting times in the E.D.
–5% of laboratory specimens are submitted without a label, which
results in additional work to redraw the specimens, unnecessary
discomfort to patients, and delayed test results.
Problem Statement
186.

187. Evelyn A. Catt, 2015
Describe the background of the current problem/opportunity.
What business problem are you trying to solve?
Why is this issue important now?
Problem Statement Worksheet
187.

188. Evelyn A. Catt, 2015
Aim Statement
•The Aim statement defines what the project is trying to accomplish.
•A sound Aim statement is phrased using measurable terms.
•The goals in the Aim statement should follow the SMART acronym:
ELEMENT DEFINITION
Specific:Clearand focused to avoid misinterpretation.
Measurable:Can be quantified and compared to other data.
Attainable:Achievable, reasonable,and credible under current conditions.
Realistic:Fits into the organization’s constraints and is cost effective.
Timely: Can be accomplished within the time frame given.
Reference : Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL:
http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/
188.

189. Evelyn A. Catt, 2015
Aim Statement Worksheet
•What are you trying to accomplish?
•State your goals in measurable terms:
189.

190. Evelyn A. Catt, 2015
Project Scope
•The project scope statement defines which part of the process will
be investigated (process start and end points) and clearly specifies
the scope of what will be included and excluded in the project:
–Process start & end points: The “bookends” for the part or
segment of the process that will be investigated
–Included in scope (areas that will be addressed)
–Excluded from scope (areas that will notbe addressed)
oAspects of the problem that are intentionally excluded
oAreas of the business that will not be included
oRelated issues that will be addressed at a later time
190.

191. Evelyn A. Catt, 2015
•What part or segment of the process will be investigated in this
project?
–Process starting point:
–Process ending point:
•What are the boundaries for the areas that will be addressed in this
project?
–Included in the scope:
–Excluded from the scope:
Project Scope Worksheet
191.

192. Evelyn A. Catt, 2015
•A detailed schedule should be maintained by the Project Leader for
the key milestones of the project and the associated timelines.
Project Timeline & Milestones
Key Milestones Target Date Status
INITIATEthe project, form the team, develop the charter
DEFINE the processandcustomer requirements
MEASURE and map the current process
ANALYZE main issues and identify root causes
IMPROVE the process and test solutions
CONTROL plan to sustain/spread the new process
RAPIDIMPROVEMENT EVENT (2-5days)
5-S EVENT (sort/store/shine/standardize/sustain/safety)
IMPLEMENTATION DATE
192.

193. Evelyn A. Catt, 2015
Project Metrics
193.

194. Evelyn A. Catt, 2015
Project Metric Definition Use in Improvement Project
Primary Metric
Defines the project goal: “improve
(primary metric) from (baseline) to
(target) by (date)”
Measure baseline “initial state” and
improvement level when the project ends
Secondary Metric
Captures, validates and tracks
welcome side effects of the project
Measure baseline and impacts of project
after improvements. Monitor during and
after project if linked to financial metric.
Financial Metric
Links progress in the primary and
secondary metrics to financial
advantage. Most often this metric is
tailor-made for the specific project
Evaluate at project milestonesand at
regular intervals for one year after the
project endsto calculate project ROI.
Consequential
Metric
Captures, validates and tracks
unwelcome side effects of the project
Collect data before, during and after the
project to confirmthat no collateral
damage was caused by the project.
Project Metrics -Definitions
Source: Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL:
http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/
194.

195. Evelyn A. Catt, 2015
•How will we know a change is an improvement?
–Define key performance metrics for each process being evaluated.
–Indicate which strategic area is aligned with each metric (quality/safety,
finance/growth, service, people, education, etc.)
–Select one primary metricfor the project team to focus on for each
improvement project.
oUse the primary metricto formulate the main project goal.
–Brainstorm for possible secondaryand consequentialmetrics.
oConstruct a financial metricbased on the primary & secondary metrics.
–Confirm that all metrics meet the criteria to create a data collection plan.
oMeasure current performance = “initial state”
oEstablish well defined process improvement goals = “target state”
Project Metrics –Initial & Target State
Source: Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL:
http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/
195.

196. Evelyn A. Catt, 2015
•Define key performance metrics for each process being evaluated.
–Measure current performance = “initial state”
–Establish well defined process improvement goals = “target state”
–Indicate which strategic area is aligned with each metric (quality/safety,
finance/growth, service, people, education, etc.)
Project Metrics Worksheet
Source: Ohler, M. Be Consistent in Six Sigma Project Metric Selection, 2010. Source URL:
http://www.isixsigma.com/methodology/metrics/be-consistent-six-sigma-project-metric-selection/
Strategic
Alignment
Metric Name
CurrentValue
(initial state)
Goal
(target state)
Quality/Safety Value: Time period:
Finance/Growth Value: Time period:
Service Value: Time period:
People Value: Time period:
Education Value: Time period:
196.

197. Evelyn A. Catt, 2015
Stakeholder
Analysis
197.

198. Evelyn A. Catt, 2015
Stakeholder Analysis
•Stakeholders are persons or groups with an interest in a project. Their
interest may be based on the impact a project may have on their area’s
processes, or because they have to supply resources to support the project.
•A rule of thumb for identifying key stakeholders is to question whose
support or lack of it may significantly influence the success of the project.
•Stakeholder participation:
–Gives people the opportunity to provide input regarding how projects or policies
may affect their areas
–Generates a sense of ownership if initiated early in the development of the
project
–Provides opportunities for learning and gaining a new perspective on the process
–Enhances responsibility and accountability for achieving project milestones
–Can reduce or reverse the threats to solutions that are developed by the team
–Is essential for sustaining improvements that are implemented during the project
198.

199. Evelyn A. Catt, 2015
Force Field Analysis
•A Force Field Analysis can be used to depict the driving/helping forces that
support movement toward a goal, and the restraining/hindering forces that are
blocking movement toward a goal. This tool is helpful in evaluating key
stakeholders and their interests (positive or negative) in the project.
Diagram Source: http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif
199.

200. Evelyn A. Catt, 2015
Force Field Analysis Worksheet
Diagram Source: http://www.relationship-economy.com/wp-content/uploads/2007/10/force_field_analysis1.gif
200.
•List stakeholders with
a positiveinterest in
your project:
__________________
__________________
__________________
__________________
__________________
•List stakeholders who
could have a negative
impact on your project:
__________________
__________________
__________________
__________________
__________________
•After assessing the importance of each stakeholder and their positive or negative
level of influence or impact on the project, a strategy should be developed to
effectively communicate and collaborate with each stakeholder.
Evaluate key stakeholders and their +/-impact on your project.

201. Evelyn A. Catt, 2015
Data Collection Plan
201.

202. Evelyn A. Catt, 2015
Data Collection Plan –5 Steps
STEP 1
DEFINE
Clear goals
CLARIFY
Definitions
DEVELOP
Methods
COLLECT
Data
COMPILE
Data
STEP 2 STEP 3 STEP 4 STEP 5
Reference: Building a Sound Data Collection Plan. Source URL: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-
sound-data-collection-plan&Itemid=217
202.

203. Evelyn A. Catt, 2015
Data Collection Plan
•Step 1:Define clear goals and objectives for collecting the data.
•Step 2:Clarify operational definitions (examples: procedure starting point,
procedure ending point, time segments during the procedure).
•Step 3:Develop methods to ensure accurate measurements (examples:
synchronized clocks, calibrated instruments, ranking scales, codes for
responses, abbreviations, naming conventions).
•Step 4:Collect data using a standardized format and unique identifier for
each observation (survey, questionnaire, incident report, etc.).
•Step 5:Compile and enter data into a secure electronic database using pre-
defined codes for responses, ranking scales, etc. (immediate entry into an
electronic database is ideal, but not always possible).
Reference: Building a Sound Data Collection Plan. Source URL:
http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1265:building-a-sound-data-collection-plan&Itemid=217
203.

204. Evelyn A. Catt, 2015
Operational Definitions
•A clear, precise definition of each factor being measured must be
documented and confirmed with the process owner and key stakeholders.
•Example of challenges with operational definitions: Measuring time
segments in the Operating Room.
OPERATING ROOM
ROOM READY
SET UP
PROCESS
CUT TO
CLOSE
PATIENT
OUT
CLEAN
UP
PATIENT IN ANESTHESIA IN
TURN
OVER
SURGEON IN TIME OUT
SET UP PROCESS
204.

205. Evelyn A. Catt, 2015
Data Collection Methods
•Direct Observation in the “Gemba” using Check Sheets
•Data Mining (from data previously collected)
•Electronic Data Extraction and Interfaces
•Interviews
•Questionnaires
•Surveys
•Web Based Tools (“Survey Monkey”)
205.

206. Evelyn A. Catt, 2015
Check Sheet
•The Check Sheet is a simple document that is used for collecting data in real-
time at the location where the data is generated “in the Gemba”.
•The document is typically a simple form that is designed for the quick, easy, and
efficient recording of quantitative or qualitative information.
•5 Basic types of Check Sheets:
―Classification(defect/error or failure mode, classified by category)
―Location(physical location of a trait indicated on a picture of a part or item)
―Frequency(the presence or absence of a trait or combination of traits)
―Measurement Scale(measures indicated on a scale divided into intervals)
―Check List(items to be performed for a task are listed in sequence)
Reference: http://en.wikipedia.org/wiki/Check_sheet
206.

207. Evelyn A. Catt, 2015
Check Sheet Example
Reference & Diagram Source: http://quality-management-tools.com/check_sheet-template.png
•“The simplest form of check sheet is a table of categories where users add a
check as they collect the data. After the first data collection you may analyze
the data and modify the check sheet to better reflect and analyze the data.”
207.

208. Evelyn A. Catt, 2015
Check Sheet Template
Check Sheet
Department: Date:
Employee Name: Phone:
PROBLEM FREQUENCY NOTES
List the categories you want to measure such as
problems, errors, number of calls, etc.
Add a check mark in the
appropriate category.
Add more information to clarify the
details for each type of problem.
Problem 1
Problem 2
Problem 3
Problem 4
Problem 5
Problem 6
Problem 7
Problem 8
Problem 9
Problem 10
208.

209. Evelyn A. Catt, 2015
Measurement Systems
& Data Integrity
209.

210. Evelyn A. Catt, 2015
Measurement Checklist
“Initial state” measurements should include the following steps:
Identify key process or outcome measures
Obtain agreement from key stakeholders on key measures
Confirm the operational definition of each key measure
Conduct a Measurement System Analysis to validate measurement accuracy
Create and implement a data collection plan
Calculate high level performance metrics and compare to benchmarks
Identify measures that require additional data or drill-down
Display process variation data using appropriate charts and graphs
Identify high frequency and high impact errors (defects) and variation
Communicate findings to key stakeholders
210.

211. Evelyn A. Catt, 2015
Measurement Systems
•“If measurements are used to guide decisions, then it follows logically
that the more error there is in the measurements, the more error there
will be in the decisions based on those measurements.”
Errors in measurements = Errors in decisions
Reference: Measurement Systems http://www.moresteam.com/toolbox/t403.cfm
Bad Data = Bad Decisions
Garbage In Garbage Out
211.

212. Evelyn A. Catt, 2015
Primary & Secondary Data
•Primary Data
–Primary data is original datathat has been collected for the first
timefor a specific study.
•Secondary Data
–Secondary data is data that was previously collectedfor another
purpose.
•Statistical Analysis
–When you perform statistical analysis on primary datathen the
results become known as secondary data.
Reference: http://en.wikibooks.org/wiki/Statistics/Different_Types_of_Data/PS
212.

213. Evelyn A. Catt, 2015
Data Integrity
•In order to assess data integrity, the following questions should be
answered:
–Where did the data come from?
–Who has been accessing or manipulating the data?
–Has the data been edited or modified in any way?
–Is there a unique identifier for each entry?
–Are the naming conventions, codes, etc. consistent?
–Are the scoring and ranking tools consistent and valid?
–Has the accuracy of the measurement process been validated?
–Who developed the benchmarking standards?
213.

214. Evelyn A. Catt, 2015
Data Audits & Validation
•Data must be validated to ensure that it is accurate and to identify
and confirm or remove data that may be suspect.
•Tools for the data audit and validation include (but are not limited to):
–Manual Review
–Frequency Plot (histogram)
–Evaluation of Outliers & Standard Deviations
–Control Charts & Pareto Charts
–Drilling Down by Subpopulations
–Measurement System Analysis (MSA) to validate measurement accuracy
–Common Sense! Does the data appear reasonable?
214.

215. Evelyn A. Catt, 2015
Sampling Bias
•Bias can occur in multiple ways, resulting in a sample that does not
represent the attributes of the population being studied. Care
should be taken to avoid or mitigate these types of bias:
─Over coverage: Inclusion of data from outside the population.
─Under coverage: Some members of the population are not
adequately represented in the sample.
─Non-response bias: Individuals chosen for the sample may be
unwilling or unable to participate in the study.
─Measurement systems: Variation in the measurement process
or tools.
─Processing errors: Mistakes in coding or entering data.
Reference: http://stattrek.com/AP-Statistics-2/Data-Collection-Methods.aspx
215.

216. Evelyn A. Catt, 2015
Tips to Avoid Data Disaster
•Save a copy of the original database before you make any changes
so you can restore it, if necessary.
•Assign a unique identifier to each observation to:
–Audit for duplicates
–Link de-identified data back to source documents
–Sort data back to the original state
•Limit access to the database, to keep the data secure and avoid the
potential for data corruption or file deletion.
•Use version control methods, such as adding a date to the file name
and initials of the person updating the file.
216.

217. Evelyn A. Catt, 2015
217.
Measurement System Analysis (MSA)
•A measurement system analysis (MSA) is used to identify the components of variation
that exist in a measurement system. It is designed to test the measurements used to
collect data for a Lean Six Sigma project to ensure the accuracy of the data.
•Total observed variation is made up of two parts: the actual variation that exists in an
item or process and the variation that is created by the measurement system itself.
•An ANOVA Gauge R&R (repeatability & reproducibility) test is used to determine the
variability that comes from the measurement system and compares it to the total
observed variation to determine what portion of the variation can be attributed to the
measurement system itself. There are two essential components of a Gauge R&R test:
–Repeatability:The variation in repeat measurementstaken by one personor
instrument on the same itemand under the same conditions.
–Reproducibility:The variation in measurements that occurs when different
peoplemeasure the same item.
•A Gauge R&R value of <0.1 reflects a good measurement system; 0.1 to <0.3 is
considered marginal; and >0.3 is an unacceptable measurement system.
Reference: Six Sigma for Dummies. 2005, Wiley Publishing, Inc., Hoboken, NJ. pp. 156-61.

218. Evelyn A. Catt, 2015
Data Types & Display
218.

219. Evelyn A. Catt, 2015
Process, Outcome, Balancing Metrics
•Improvement efforts should include process, outcome,
and balancing measures:
–Process
•Are the steps in the process being performed correctly and in
the right sequence?
–Outcome
•How does the system performance impact the health and well
being of patients and the things they value?
–Balancing
•Are changes designed to improve one part of the system
causing new problemsin another area of the system?
Source URL: Institute for Healthcare Improvement (IHI)
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
219.

220. Evelyn A. Catt, 2015
Process Measures
•Little Dots
–Are the steps in the process being performed correctly
and in the right sequence?
•Monitor performance
•Understand variation
•Initiate process improvements
Source URL: Institute for Healthcare Improvement (IHI)
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
220.

221. Evelyn A. Catt, 2015
Outcome Measures
•BIG DOTS
–How does the system performance impact the health
and well being of patients and the things they value?
•Total system or population measures
•Tracking overall performance or impact
•Publicly reported measures (mortality, pressure ulcers, etc.)
•Examples of “Big Dots”:
Source URL: Institute for Healthcare Improvement (IHI)
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
Average
Length
of Stay
Nursing
Hrs. per
Pt. Day
Falls per
1,000 Pt.
Days
221.

222. Evelyn A. Catt, 2015
Balancing Measures
•Are changes designed to improve one part of the system
causing new problems in another area of the system?
Source URL: Institute for Healthcare Improvement (IHI)
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
Image URL: http://healthinformatics.wikispaces.com/Whack-a-mole+healthcare+delivery
222.

223. Evelyn A. Catt, 2015
Quantitative Data
•Quantitative = Quantity
–Deals with numbers.
–Data can be measuredand iscontinuous.
–Length, cost, weight, height.
–Not all numbers are continuous and measurable
(ex: social security number).
Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
223.

224. Evelyn A. Catt, 2015
Qualitative Data
•Qualitative = Quality
–Deals with descriptions.
–Data can be observed, but not measured.
–Colors, textures, tastes.
Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
224.

225. Evelyn A. Catt, 2015
Categorical Data
Reference: http://regentsprep.org/REgents/math/ALGEBRA/AD1/qualquant.htm
NOMINAL
Nonatural ordering of the
categories.
•Gender
•Race
•Religion
•Sports
ORDINAL
The categories can beordered.
•Small, medium, large
•Strongly agree, agree, neutral,
disagree, strongly disagree
•May not know which value is best
•Distance between categories
cannot be measured
225.

226. Evelyn A. Catt, 2015
Interval Data
•Intervals = equally spaced
–Numeric values
–Increments are known, consistent and measurable
–No absolute zero (time, Celsius thermometer)
–Cannot calculate ratios
226.

227. Evelyn A. Catt, 2015
Parametric and Non-Parametric Data
Source URL: http://www.six-sigma-material.com/images/DataMeasurements.GIF
Non-parametric:
This type of data
can be analyzed
without the mean
(average), standard
deviation, or other
related parameters.
Parametric:
The analysis of this
type of data is based
on assumptions about
probability distributions
using the mean
(average) and
standard deviation.
227.

228. Evelyn A. Catt, 2015
Measuring Data Consistency
•A simple way of measuring the level of consistency in a data set is by
calculating the Minimum, Maximum, and Range.
Reference: Measures of Central Tendency http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm
Minimum: The smallestvalue in a data set.
Maximum: The largestvalue in a data set.
Range:
The differencebetween the Maximum and the
Minimum.
228.

229. Evelyn A. Catt, 2015
Measures of Central Tendency
•Measures of central tendency include the mean, median, and mode.
Reference: Measures of Central Tendency http://regentsprep.org/REgents/math/ALGEBRA/AD2/measure.htm
Mean:
The mean (average) is a measure of central tendency,
that is the “center” of the data. The mean is the sum of a
set of data divided by thenumber (count) of the data. It is
often referred to as “x-bar” using the symbol
Median:
The median is the middlevalue (or the mean of the
middle two values, when the data is arranged in numerical
order). The median is calculated by listing the data in
ascending order and then finding the value in the middle of
the list. Think of the median as the middle of a highway.
Mode:
The modeis the value (number) that appears the most.
It is possible to have more than one mode,and it is
possible to have no mode.
229.

230. Evelyn A. Catt, 2015
Meaningful Uses of Data
•Identify trends and patterns.
•Measure the impact of process changes.
•Monitor and sustain improvements.
•Compare organizational performance to industry
benchmarks and government mandated standards.
•Increase understanding and take action!
Reference: Baker, N. Top 10 Critical Success Factors for Six Sigma-Part 3.Bright Hub. Dec. 18, 2009.
Source URL: http://www.brighthub.com/office/project-management/articles/7620.aspxRetrieved 3/30/10.
230.

231. Evelyn A. Catt, 2015
Value of Data Display
•Graphs can be used to visually summarize relationshipsbetween
variables, especially if the data set is large.
•They can be used in reports to enhance readabilityor underscore a
particular statement about a data set.
•Graphs can appeal to visual memoryin ways that plain summary
tables cannot.
•Graphs can misrepresent relationships between variables or promote
inaccurate conclusionsif not used correctly.
Source URL: http://www.preciousheart.net/chaplaincy/Auditor_Manual/11grphd.pdf
231.

232. Evelyn A. Catt, 2015
Questions to Guide Data Display
•What is the target problem?
•What are the target measures?
–Process (Little dots) focused on process steps
–Outcome (BIG dots) system or population measures
–Balancing (new problems caused by process changes)
–Are the measures quantitative or qualitative?
•Who is the target audience?
•What are the key points to be illustrated?
232.

233. Evelyn A. Catt, 2015
Charts for Measuring
Variation & Change*
*Not inclusive of all chart types
233.

234. Evelyn A. Catt, 2015
Using Run Charts for Data Display
•“Improvement takes place over time. Determining if
improvement has really happened and if it is lasting
requires observing patterns over time.
•Run charts are graphs of data over time and are one of
the most important tools for assessing the effectiveness of
change.”
Source URLs: http://www.ihi.org/resources/Pages/Tools/RunChart.aspx
http://app.ihi.org/Workspace/tracker/
234.

235. Evelyn A. Catt, 2015
Benefits of Run Charts
•They help improvement teams formulate aimsby depicting
how well (or poorly) a process is performing.
•They help in determining when changes are truly
improvements by displaying a pattern of data that you can
observe as you make changes.
•They give direction as you work on improvement and
information about the value of particular changes.
Source URLs: http://www.ihi.org/resources/Pages/Tools/RunChart.aspx
http://app.ihi.org/Workspace/tracker/
235.

236. Evelyn A. Catt, 2015
Control Chart
•A Control Chart is used to monitor performance and draw conclusions
about whether the process is in control (common cause variation only)
or is out of control(affected by special cause variation, unpredictable).
•An X-Bar control chart is used to monitor variable data.
•A P-Chart control chart is used to monitor attribute data and error rates.
References: http://www.asq.org/learn-about-quality/data-collection-analysis-tools/overview/control-chart.html
http://www.six-sigma-material.com/SPC-Charts.html
Diagram Source: http://sixsigmaindonesia.com/blog/wp-content/uploads/2008/11/contchart1.gif
236.
(LCL)

237. Evelyn A. Catt, 2015
Pareto Chart
•The purpose of a Pareto Chartis to assess the most frequently occurring
errors/defects by category. It is used to highlight the most significant issues
among a large set of factors (often referred to as the “80/20” rule).
•The Pareto Chart contains both a bar and a line graph.
–Individual values are represented in descending order by bars.
–The cumulative total is represented by the line.
Reference & Diagram Source: http://en.wikipedia.org/wiki/Pareto_chart 237.

238. Evelyn A. Catt, 2015
Pareto Chart Example
•A Pareto Chart showing reasons for arriving late at work.
Reference & Diagram Source: http://en.wikipedia.org/wiki/Pareto_chart 238.

239. Evelyn A. Catt, 2015
Frequency Plot (Histogram)
•A Frequency Plot (histogram) depicts the frequency of
observations occurring in a certain range of values.
•An important way of summarizing data is by measuring the average
“spread” or variation between each data point and the mean.
•A commonly used term in statistics for measuring this variation is
the standard deviation.
Spread
Peak
Distribution
Y axis
X axis
239.

240. Evelyn A. Catt, 2015
Interpreting Frequency Plot Data
Common Cause Variation Special Cause –BimodalSpecial Cause –Outlier
Outlier
•Frequency Plots help us to understand if the variation that is present in a
process is the result of:
–Common Cause Variation (natural variation within a process)
–Special Cause Variation (unpredictable or extreme variation)
–Special Cause -Bimodal Variation (one system is using 2 different processes)
240.

241. Evelyn A. Catt, 2015
Impact of Outliers
•Understanding the impact of outliers is important because just one
extreme outlier in either direction can distort the mean and give a
very erroneous impression of performance (positive or negative).
•A high standard deviation (sigma) value is an indication there may
be extreme outliers that warrant further investigation and validation.
LOWoutlier pulls the
mean value DOWN
HIGHoutlier pulls
the mean valueUP
Always investigate extreme
outliers to validate the data
Special Cause –Outlier
OutlierOutlier
241.

242. Evelyn A. Catt, 2015
Process Capability &
Specifications
242.

243. Evelyn A. Catt, 2015
Tools
“If you only have a hammer, you tend to see every problem as a nail.”
~ Abraham Maslow
243.

244. Evelyn A. Catt, 2015
Process Capability
Reference: http://en.wikipedia.org/wiki/Process_capability_index
Diagram Source: http://www.qualitytrainingportal.com/resources/problem_solving/images/process_capability.gif
•Process capability measures the ability of a process to produce output
within certain specifications.
–Centering:Put the process on target (accuracy)
–Spread:Reduce variation in the process (precision)
244.

245. Evelyn A. Catt, 2015
Process Capability
•As the process capability improves, the error rate (DPMO = defects per
million opportunities) will decreaseand the Sigma level will increase:
6 Sigma = 3.4 DPMO
5 Sigma = 233 DPMO
4 Sigma = 6,210 DPMO
3 Sigma = 66,800 DPMO
2 Sigma = 308,540 DPMO
Diagram Source: http://picsdigger.com/image/53a16da4/
245.
CAPABLE
NOT
CAPABLE
METRIC METRICDEFINITION
Defects per Unit(DPU)
Total Number of Defects
Total Number of Product Units
Total Opportunities(TO) Total Number of Product Units x Opportunities per Unit
Defects per Opportunity(DPO)
Total Number of Defects
Total Opportunities
Defects per Million Opportunities(DPMO) DPO x 1,000,000
Sigma Calculator http://www.isixsigma.com/process-sigma-calculator/

246. Evelyn A. Catt, 2015
Specification Limits
Reference: http://www.six-sigma-material.com/SPC-Charts.html
Diagram Source: http://www.competitivexpert.com/files/Image/processvariationa.jpg
•Specification Limits are defined by the customer. They are one element
of the “Voice of the Customer”and may be modified over time.
•LSL= Lower Specification Limit USL= Upper Specification Limit
246.
Cp = Process Capability
•Note the Cp value listed under each
diagram, which is a simple measure
of process capability.
•A process is capable if almost all of
the measurements fall within the
upper and lower specification limits.

247. Evelyn A. Catt, 2015
Specification Limits Example
7:00am6:55am 7:05am
Employee Arrival Time
6:56 6:57 6:58 6:597:01 7:02 7:03 7:04
Outliers
7:06 7:07 7:08
Outliers
6:52 6:53 6:54
247.

248. Evelyn A. Catt, 2015
Accuracy vs. Precision
•Accuracy:Is a measure of the average distance from the target.
•Precision: Is a measure of the average distance from each other.
Image Source: http://www.cmg.org/measureit/issues/mit70/m_70_4_2.jpg
248.

249. Evelyn A. Catt, 2015
Improving Process Performance
•There are two aspects of improving process performance:
–Align the process to a target value (centering) = increased accuracy
–Reduce variation (spread) = increased precision
•Achieving one without the other is of limited value.Desired
Current
USLLSL
Desired
Current
USLLSL
LSL= Lower Specification Limit USL= Upper Specification Limit
249.

250. Evelyn A. Catt, 2015
The Normal Distribution
•Over time, most processes tend to follow a Normal Distribution or bell
shaped curve.
•The Normal Distribution is important in statistics because of the relationship
between the shape of the curve and the standard deviation.
Y = ƒ(x)
Variation
Average
Y axis
X axis
250.

251. Evelyn A. Catt, 2015
The Normal Distribution
•One way of demonstrating the relationship between the standard deviation
(sigma) and the shape of the curve is to use sigma as a “measuring rod” to
describe how far we are away from the mean (average).
-3s -2s -1s +1s +2s +3s
+/-3s=99.73%
+/-2s=95.45%
+/-1s=68.27%
251.

252. Evelyn A. Catt, 2015
The Normal Distribution
•Another property of the normal distribution is the area under the curve gives us
the probability of a data point being drawn from this portion of the distribution.
–This allows us to predicthow a process will perform over time.
•Almost all of the area (99.73%) of the normal distribution is contained between -
3 sigma and +3 sigma from the mean. Only 0.27% of the data falls outside 3
standard deviations from the mean:
-3s -2s -1s +1s +2s +3s
+/-3s=99.7%
252.

253. Evelyn A. Catt, 2015
What Lies Beneath
•Although the average (mean) is commonly used for reporting key
performance metrics, it is imperative to understand the range of data
points that contribute to the mean value. This is essential to:
–Understand the degree of variationin a process.
–Recognize the impact of outlierson the mean.
–Detect potential errorsin the data.
Diagram Source: http://aviationhumor.net/wp-content/uploads/2010/11/shark-fin.jpg
253.

254. Evelyn A. Catt, 2015
Sub-Populations
•Many performance metrics are a combined average for multiple sub-
populations. It is important to review the data for each sub-population,
to understand the level of performance and sources of variation in
each area (example: patient satisfaction scores by nursing unit).
Diagram Source: http://ophinions.com/images/columns/bellcurveex02.jpg
Nursing Unit A
Nursing Unit B
Nursing Unit C
Nursing Unit D
Nursing Unit E
254.

255. Evelyn A. Catt, 2015
255.
Reflections
•What type of data do you use most often to inform your decisions?
•What resources or training will be needed to use data more effectively?

256. Evelyn A. Catt, 2015
APPENDIX
Learning Guides for Review &
Deliverables by Project Phase
256.

257. Evelyn A. Catt, 2015
Define Phase Deliverables
INITIATE THE PROJECT
Project charter created
Project team formed
Project metrics and performance goals defined
Stakeholder analysis completed
DEFINE THE PROCESS
High level process map created
SIPOCS diagram completed
Murphy’s analysis completed
Affinity diagram developed
DETERMINE CUSTOMER REQUIREMENTS
Voice of the Customer obtained (interviews, surveys, focus groups)
Customer Requirements Tree created with critical to quality requirements (CTQ)
Process observed in action (Go to Gemba)
257.

258. Evelyn A. Catt, 2015
Define Phase –Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
•Lean & Six Sigma (DMAIC)
•A3 Thinking
•8 Types of Waste (Muda)
•Specify Value
•Value Added/Non-Value Added
•Flow, Pull, Takt Time
•Going to “Gemba”
•Voice of the Customer/Stakeholder
•SIPOCS Diagram
•Project Charter & Roles
258.

259. Evelyn A. Catt, 2015
Measure Phase Deliverables
MAP THE PROCESS
“Current state” Value Stream Map created
Swim Lane map created (if appropriate)
Spaghetti Diagram created (if appropriate)
MEASURE THE PROCESS
Key performance measures identified
Data collection plan created
Data collected and validated
Data compiled and summarized (descriptive statistics, graphs, control charts)
EVALUATE CURRENT PERFORMACE
Current “initial state” performance measured (baseline)
Process capability evaluated (desired performance vs. actual performance)
Baseline compared to industry standards and benchmarks (if available)
259.

260. Evelyn A. Catt, 2015
Measure Phase –Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
•Value Stream Map
•Process Flow Chart
•Spaghetti Diagram
•Data Collection Plan
•Check Sheet
•Operational Definitions
•Measurement System Analysis (MSA)
•Process Capability
•Sigma Levels
•Histogram (Frequency Plot)
260.

261. Evelyn A. Catt, 2015
Analyze Phase Deliverables
IDENTIFY AMOUNTS & TYPES OF WASTE
Gemba walk, waste worksheet,
and value analysis (VA/NVA) completed
Issues and waste identified and categorized
•Affinity Diagram
Critical factors quantified and prioritized
•Pareto Chart
•Control Charts
•Statistical Analysis
DETERMINE ROOT CAUSE OF ERRORS, WASTE & VARIATION
Fishbone Diagram
Root Cause Analysis (“5 Whys”)
Failure Modes & Effects Analysis (FMEA), if appropriate
261.

262. Evelyn A. Catt, 2015
Analyze Phase –Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
•Accuracy & Precision
•Reliability
•Variation
•Frequency Plot (Histogram)
•Pareto Chart (80/20 rule)
•Process Specifications
•Control Chart & Control Limits
•Root Cause Analysis & Five Whys
262.

263. Evelyn A. Catt, 2015
Improve Phase Deliverables
263.
DESIGN THE FUTURE STATE
Develop proposed solutions and key interventions.
Create a “future state” value stream map to illustrate the new flow.
Identify “quick hits” that can be implemented immediately.
Implement Lean 5-S, visual controls, and error proofing (poka yoke)
CONDUCT RAPID EXPERIMENTS
Conduct rapid experiments to test the proposed solutions (PDSA cycles).
Evaluate results of experiments and select the final solutions.
DOCUMENT STANDARD WORK
Create standard work and accountability standards.
Develop policies and procedures to support the new process.
DEVELOP ACTION PLAN
Develop a detailed action plan to fully implement the solutions:
•Actions/deliverables, owner, due date (30-60-90-days)
Create and implement a communication plan.

264. Evelyn A. Catt, 2015
Improve Phase –Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
•Current State, Future State
•Lean 5-S (Sort, Store, Shine, Standardize, Sustain, + Safety)
•Rapid Improvement Event (Kaizen)
•Visual Controls
•Mistake Proofing (Poka Yoke)
•Plan-Do-Study-Act (PDSA)
•Gemba Walk
•Waste Worksheet
•Action Plan
264.

265. Evelyn A. Catt, 2015
Control Phase Deliverables
DEVELOP STANDARD WORK
Document and implement standardized process steps and update
related policies and procedures
DEVELOP PROCESS CONTROL STRATEGY
Utilize graphs and charts to track key performance metrics
Determine Process Capability and Sigma Level (if applicable)
Establish a Control Plan to monitor on-going process performance
PROJECT CLOSURE
Quantify project benefits and cost savings (or cost avoidance)
Transfer ownership/hand-off to process owner
Close project and complete final documentation
Communicate results to stakeholders
Celebrate project success!
NOTE: All projects
do not require the
use of every tool.
265.

266. Evelyn A. Catt, 2015
Control Phase –Learning Guide
The learner should understand and be able to describe the meaning of
the following terms and tools:
•Control Plan
•Key Performance Metrics
•Initial State
•Target State
•Standard Work
•Process Owner
•Project Closure
266.

267. Evelyn A. Catt, 2015
Project Hand-off
•An important aspect of project closure involves the Project Leader
transferring ownership of the project back to the Process Owner.
•This hand-off should be authorized by the Project Champion after all
project deliverables have been reviewed and approved, a Control Plan
is in place, and the final project documentation has been completed.
267.

268. Evelyn A. Catt, 2015
Recognition & Celebration
•Timely recognition of project teams
•Communication of project results
•Celebration of successful projects
Reference: Nemana, K. Six Critical Success Factors for a Six Sigma Deployment. Source URL:
http://www.isixsigma.com/index.php?option=com_k2&view=item&id=804:&Itemid=111.
268
268.

269. Evelyn A. Catt, 2015
References
Hajek AM. Crushing the Silos: A Leadership Imperative to Ensuring Healthcare Safety in the Era of Healthcare Reform. 2010
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Acknowledgments
The following individuals have generously shared their time, knowledge, and
resources, which greatly enriched the contents of this document:
―Glenn Bingle, MD, PhD, Chairman (retired), Indianapolis Coalition for Patient Safety
―Carol Birk, RPh, MS, President (retired), Indianapolis Coalition for Patient Safety
―LEAN Work Group Members, Indianapolis Coalition for Patient Safety
―Patricia Ebright, PhD, RN, FAAN, Associate Professor &Associate Dean for
Graduate Programs, Indiana University School of Nursing
―Matthew Horn, Systems Redesign Coordinator, V.A. Hospital, Indianapolis
―Betsy Lee, BSN, MSPH, Director, Indiana Patient Safety Center
―Aadron Rausch, Administrative Director, IU Health Arnett
―Gretchen Shook, Employee Education, IU Health Arnett
―Mary Sitterding, PhD, RN, CNS, Executive Director, Nursing Research and
Professional Practice, Indiana University Health
―Tim Tarnowski, VP, CIO, Indiana University Health
―Ian Wedgwood,PhD,Co-Founder & Principal, Haelan Group, LLC
―Heather Woodward-Hagg, Chief –V.A. Systems Redesign Service and Director

272. Evelyn A. Catt, 2015
272.
Evelyn Catt, MHA, BSPH, CSSBB
Principal, TTAC Consulting, LLC
Adjunct Professor, Indiana University
Fairbanks School of Public Health
[email protected]
Cell: 317.442.2837
Permission from the author is required to reproduce or distribute any part of this document.
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