Transcript Document

Healthcare Operations
Management
An Integrated Approach to
Improving Quality and Efficiency
Chapter 8. Quality Management: Focus
on Six Sigma
Daniel B. McLaughlin
Julie M. Hays
Chapter 8. Quality Management:
Focus on Six Sigma
•
•
•
•
Defining Quality
Cost of Quality
Quality Programs
Six Sigma
- DMAIC Process
- Seven Basic Quality Tools
- Statistical Process Control (SPC)
•
•
•
•
Benchmarking
Quality Function Deployment (QFD)
Taguchi Methods
Mistake Proofing (Poka-Yoke)
Copyright 2008 Health Administration Press. All rights reserved.
6
8-2
Defining Quality
• Organization’s perspective
- Performance (design) quality
- Conformance (design) quality
• Customer perspective
- Garvin’s eight dimensions
- Parasuraman, Zeithaml, and Berry’s five
dimensions
- Institute of Medicine
- Quality assurance program
Copyright 2008 Health Administration Press. All rights reserved.
8-3
Cost of (Poor) Quality
• External failure—costs associated with failure
after the customer receives the product or service
• Internal failure—costs associated with failure
before the customer receives the product or
service
• Appraisal—costs associated with inspecting and
evaluating the quality of supplies and/or final
product/service
• Prevention—costs incurred to eliminate or
minimize appraisal and failure costs
Copyright 2008 Health Administration Press. All rights reserved.
8-4
Quality Programs
• Total Quality Management (TQM) or
Continuous Quality Improvement (CQI)
• ISO 9000
• Baldrige Criteria
• Six Sigma
Copyright 2008 Health Administration Press. All rights reserved.
8-5
Total Quality Management (TQM)
•
•
•
•
•
•
Focus on the customer
Top-management leadership and support
Employee involvement
Systems thinking
Continuous improvement
Data-based decision making
Copyright 2008 Health Administration Press. All rights reserved.
8-6
ISO 9000
• International standards concerned with
ensuring that organizations maintain
consistently high levels of quality
• Five sections:
-
Quality management system
Management responsibility
Resource management
Measurement, analysis, and improvement
Product realization
Copyright 2008 Health Administration Press. All rights reserved.
8-7
Baldrige Criteria
• Award established to recognize organizations for
their achievements in quality and to raise
awareness about the importance of quality
• Seven categories:
- Leadership
- Strategic planning
- Customer and market
focus
- Measurement, analysis,
and knowledge
management
- Human resource focus
- Process management
- Results
Copyright 2008 Health Administration Press. All rights reserved.
8-8
Six Sigma
• Philosophy
6
- Eliminate defects through prevention and process
improvement
• Methodology
- Team-based approach to process improvement using
the DMAIC cycle
• Set of tools
- Quantitative and qualitative statistically based tools
• Goal
- 3.4 defects per million opportunities (DPMO)
Copyright 2008 Health Administration Press. All rights reserved.
8-9
Successful Six Sigma
•
•
•
•
•
•
Top-management support
Extensive training
DMAIC approach
Use of quantitative measures
Team-based projects
Impact on organization’s financials
Copyright 2008 Health Administration Press. All rights reserved.
6
8-10
Six Sigma
Culture
• Leadership
• Training
- Green belt
- Black belt
- Master black belt
Copyright 2008 Health Administration Press. All rights reserved.
8-11
DMAIC Process
•
•
•
•
•
Define
Measure
Analyze
Improve
Control
Control
Improve
Define
Act
Plan
Check
Do
Measure
Analyze
Copyright 2008 Health Administration Press. All rights reserved.
8-12
DMAIC Process
Define
• Project team chooses a project on the basis
of strategic objectives of the business and
the needs or requirements of the customers
of the process
• Characteristics of “good” projects:
-
Save or make money for the organization
Produce measurable process outcomes
Relate clearly to organizational strategy
Are supported by the organization
Copyright 2008 Health Administration Press. All rights reserved.
8-13
DMAIC Process
Measure
INPUT
Key
Process
Input
Variables
(KPIV)
PROCESS
OUTPUT
Key
Process
Output
Variables
(KPOV)
Copyright 2008 Health Administration Press. All rights reserved.
CUSTOMERS
Critical
to
Quality
(CTQ)
8-14
DMAIC Process
• Analyze
- Analyze collected data to determine the root
causes
• Improve
- Identify, evaluate, and implement the
improvement solutions
• Control
- Put controls in place to ensure process
improvement gains are maintained
Copyright 2008 Health Administration Press. All rights reserved.
8-15
Seven Basic Quality Tools
Check Sheet
Fishbone
Diagram
Run Chart
Histogram
Pareto Chart
Flow Chart
Copyright 2008 Health Administration Press. All rights reserved.
Scatter
Diagram
8-16
Statistical Process Control (SPC)
• SPC is a statistics-based methodology for
determining when a process is moving “out of
control.”
• All processes have variation in output.
• Some of the variation is inherent in the process
(common).
• Some of the variation is due to assignable
(special) causes.
• SPC is aimed at discovering variation due to
assignable causes and correcting those causes.
Copyright 2008 Health Administration Press. All rights reserved.
8-17
Statistical Process Control (SPC)
Out of
Control
Sample
Mean Wait Time (minutes)
40
35
+/- 1
30
+/- 2
+/- 3 
25
20
0
5
10
15
20
25
30
Day
Copyright 2008 Health Administration Press. All rights reserved.
8-18
SPC
Out-of-Control Situations
Sample More
Than +/-Than
3 Standard
Errors
Mean
One One
Sample
More
+/3 from
Standard
Errors from Mean
14 or More
Samples Oscillating
14 or More
Samples
Oscillating
UCL=3
UCL=3
_
X=0
_
X=0
LCL=-3
LCL=-3
Observation
Observation
8 or More
Samples
Above
8 or More
Samples Above
(or Below)(or
Mean Below)
Mean
6 or More
Increasing
(or
6 or More Samples
Samples Increasing
(or Decreasing)
Decreasing)
UCL=3
UCL=3
_
X=0
_
X=0
LCL=-3
LCL=-3
Observation
Copyright 2008 Health Administration Press. All rights reserved.
Observation
8-19
Statistical Process Control (SPC)
Current Wait Time
Wait Time Goal
50% of
patients
wait
more
than 30
minutes
15
20
25
30
35
40
45
10% of
patients
wait
more
than 30
minutes
15
Wait Time (minutes)
Copyright 2008 Health Administration Press. All rights reserved.
20
25
30
35
40
45
Wait Time (minutes)
8-20
Process Capability
• A measure of how well the process can
produce output that meets desired
standards or specifications
• Compares process specifications (set by
the customer or management) to control
limits (the natural or common variability in
the process)
Copyright 2008 Health Administration Press. All rights reserved.
8-21
Process Capability
Cp and Cpk
USL  LSL
Cp 
and is estimated by
6
USL  LSL
ˆ
Cp 
6s
 x  LSL USL  x 
C pk  min 
or
and is estimated by

3 
 3
 x  LSL USL  x 
ˆ
C pk  min 
or

3
s
3
s


Copyright 2008 Health Administration Press. All rights reserved.
8-22
Process Capability
Cp and Cpk
USL  LSL
Cp 
and is estimated by
6
USL  LSL
ˆ
Cp 
6s
 x  LSL USL  x 
C pk  min 
or
and is estimated by

3 
 3
 x  LSL USL  x 
ˆ
C pk  min 
or

3
s
3
s


Copyright 2008 Health Administration Press. All rights reserved.
8-23
Process Capability
Cp and Cpk
1.5  shift
USL
LSL
3.4
DPM
O
-7
-6
-5
-4
-3
-2
-1
0
1
Copyright 2008 Health Administration Press. All rights reserved.
2
3
4
5
6
7
8-24
Rolled Throughput Yield
Proportions
Step 1
Step 2
Step 3
Step 4
95/100
error-free
products
95/100
error-free
products
95/100
error-free
products
95/100
error-free
products
Step 2
Step 3
Step 4
95 in
90 errorfree
“products”
out
90 in
86 errorfree
“products”
out
86 in
81 errorfree
“products”
out
Actual
Step 1
100 in
95 errorfree
“products”
out
Copyright 2008 Health Administration Press. All rights reserved.
8-25
Quality Function Deployment (QFD)
House of Quality
Correlation
matrix
Customer
requirements
Importance
Design
requirements
Relationship
matrix
Competitive
assessment
Importance weight
Specifications
or
target values
Copyright 2008 Health Administration Press. All rights reserved.
8-26
QFD Example
Customer
needs
Goal: Develop a system to
ensure that diabetes patients
receive preventive exams
Knowledge that it is time for an office visit
Knowledge of why follow-up is needed
Convenient to schedule
Known appointment length
Appointment on time
Copyright 2008 Health Administration Press. All rights reserved.
8-27
On-time
appointment
Appointment
length range
Time to
schedule
Information on
need
Subsequent
notification
Technical
responses
Initial
notification
QFD Example
Time knowledge
Why knowledge
Convenient
Appointment length
Appointment time
Copyright 2008 Health Administration Press. All rights reserved.
8-28
Time knowledge
5
Why knowledge
3
Convenient
4
Appointment length
3
Appointment time
4
Copyright 2008 Health Administration Press. All rights reserved.
On-time
appointment
Appointment
length range
Time to
schedule
Information
on need
Initial
notification
Importance:
Patient desire
Cost
Competitive
advantage
Subsequent
notification
QFD Example
8-29
Time knowledge
5
Why knowledge
3
Convenient
4
Appointment length
3
Appointment time
4
On-time
appointment
Appointment
length range
Time to
schedule
Information
on need
Initial
notification
Relationships:
 Strong = 5
 Medium = 3
 Weak = 1
Subsequent
notification
QFD Example
 
Copyright 2008 Health Administration Press. All rights reserved.


 
 
8-30
Convenient
Appointment length
Appointment time
Copyright 2008 Health Administration Press. All rights reserved.
Time to
schedule
3
Information
on need
5
On-time
appointment
Why knowledge
5
3
4
3
4
Subsequent
notification
Time knowledge
Initial
notification
Replace icons with numbers
Relationships:
 Strong = 5
 Medium = 3
 Weak = 1
Appointment
length range
QFD Example
5
3
3
5
5
3
8-31
QFD Example
Time knowledge
Why knowledge
Convenient
Appointment length
Appointment time
5
3
5
On-time
appointment
Appointment
length range
Time to
schedule
Information
on need
Subsequent
notification
Initial
notification
Multiply by importance and sum
3
5
4
3
4
5
25
15
Copyright 2008 Health Administration Press. All rights reserved.
15
20
5
3
3
5
27
29
8-32
QFD Example
Technical
correlations
Relationships:
+ = Strong positive
− = Strong negative
+
On-time
appointment
3
Convenient
4
Appointment length
3
5
3
Appointment time
4
3
5
27
29
Time to
schedule
Why knowledge
5
Information
on need
5
Subsequent
notification
Time knowledge
Initial
notification
Appointment
length range
+
3
5
5
25
15
15
Copyright 2008 Health Administration Press. All rights reserved.
20
8-33
QFD Example
Target:
100
diabetics/month;
85% compliance

On-time
appointment
3
Convenient
4
Appointment length
3
5
3
Appointment time
4
3
5
27
29
Time to
schedule
Why knowledge
5
Information
on need
5
Subsequent
notification
Time knowledge
Initial
notification
Appointment
length range

3
5
5
25
15
15
Copyright 2008 Health Administration Press. All rights reserved.
20
8-34
QFD Example
Outcome
To: Dan McLaughlin
From: Southview Clinic
Dear Dan,
You had an appointment with Dr. Adams about six months ago, and it
is now time for another visit. We need to check your blood pressure,
do some blood tests, and adjust your prescriptions if needed. We
would like to review these preventive procedures in advance, so
please see www.southview.com/prev22.
We have two openings available next week, on Tuesday at 8:30 am
and Thursday at 2:30, to see Dr. Adams. Click on one of these days to
make the appointment, or e-mail us with dates and times that work
for you.
We appreciate you continuing your care with us, and Dr. Adams looks
forward to seeing you.
Copyright 2008 Health Administration Press. All rights reserved.
8-35
Taguchi Methods
• Taguchi loss function
- A quality product is a
product that causes a
minimal loss
(expressed in $) to
society during its entire
life.
Taguchi Loss Function

Loss  k  2  Y  T 
• Design of Experiments
(DOE)
• Design for Six Sigma
(DFSS)
Copyright 2008 Health Administration Press. All rights reserved.
2
Loss
 where k  $ 
2
Y ($)

LSL
Target
USL
8-36
Design of Experiments (DOE)
• A structured approach to the investigation of
a system or process that determines the
level of each input variable for each trial and
does not require all possible levels of every
input variable
• Requires fewer trials because it eliminates
the need to change one variable at a time
• Can “find” effects of combinations of input
variables
Copyright 2008 Health Administration Press. All rights reserved.
8-37
Benchmarking
• Process of identifying, understanding, and
adapting outstanding practices and
processes to improve organizational
performance
• Steps in benchmarking:
Best
Your
organization
-
Determine what to benchmark
Determine how to measure it
Gather information and data
Implement the best practice within the
organization
Copyright 2008 Health Administration Press. All rights reserved.
Range
of
values
Worst
8-38
Mistake Proofing (Poka-Yoke)
• A mechanism that either:
- Prevents a mistake from being made
- Makes the mistake immediately obvious
• Eliminates errors
Copyright 2008 Health Administration Press. All rights reserved.
8-39
Riverview Generic Drug Project
Riverview Drug Prescription Process
Information
on drugs
Drug doesn’t work
Patient
needs
drug
Clinician
prescribes
drug
Type of
drug
Generic
Drug
efficacy
Drug
works
End
Drug
works
End
Non-Generic
Drug
doesn’t
work
Drug
efficacy
Copyright 2008 Health Administration Press. All rights reserved.
8-40
Riverview Generic Drug Project
Drug Type and Availability
Generic
20%
65%
35%
15%
Non-Generic,
Generic
Available
Non-Generic,
Generic Not
Available
Microsoft Excel® screen shots reprinted with permission from Microsoft Corporation.
Copyright 2008 Health Administration Press. All rights reserved.
8-41
Non-generic prescriptions
where a generic is
available/month
Riverview Generic Drug Project
Clinician Prescriptions
20
15
10
5
0
Davis
Jones
Smith
Swanson
Anderson
Clinician
Prescriptions/month
Non-Generic Prescriptions Where There Is a Generic Available
20
15
10
5
0
O
W
J
V
B
H
M
A
C
I
G
D
K
L
T
U
N
P
Q
R
Drug
Microsoft Excel® screen shots reprinted with permission from Microsoft Corporation.
Copyright 2008 Health Administration Press. All rights reserved.
8-42
Cause-and-Effect Diagram
Run Chart
Check Sheet
Histogram
Pareto Chart
Scatter Diagram
Flowchart
x
x
x
x
Copyright 2008 Health Administration Press. All rights reserved.
pr
ov
e
C
on
tr
ol
Im
na
ly
ze
re
A
ea
M
D
ef
in
Tools and Techniques
su
e
DMAIC Process
Seven Quality Control Tools
x
x
x
x
x
x
x
x
8-43
DMAIC Process
Other Tools
Tools and Techniques
Bar Graph
Line Graph
Pie Chart
5 Whys/ Root Cause
FMEA
Hypothesis Testing
Regression Analysis
DOE
Control Chart
Process Capability
Simulation
Copyright 2008 Health Administration Press. All rights reserved.
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
8-44
DMAIC Process
Other Tools
Tools and Techniques
Quality Function Deployment
Poka-Yoke
Brainstorming
Benchmarking
Project Planning
Charters
Gantt Chart
Tree Diagram
Force Field Analysis
Activity-Based Costing
Balanced Scorecard
Cost and Benefit Analysis
x
x
x
x
Copyright 2008 Health Administration Press. All rights reserved.
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
8-45