The purpose of this book is to introduce the concepts embedded in quality function
deployment (QFD) and Lean-Six Sigma to help Public Health professionals implement quality improvement within their agencies. The tools and techniques of QFD and Lean-Six Sigma are designed to augment a robust PDCA or PDSA problem-solving process, not replace it.
The tools and techniques of QFD and Lean-Six Sigma can help problemsolving teams by providing insight into customer needs and wants, design and development of customer-centric processes, and mapping value streams. Both QFD and Lean-Six Sigma focus on doing the most with the resources we have.
Each of these megatools supports efforts to expand our community support programs
and to increase the effectiveness of internal capacities. This dual external/ internal focus offers an excellent partnership of quality improvement tools for
Public Health.
The tools and techniques of QFD and Lean-Six Sigma can help a problemsolving team make breakthrough improvements by building in customer requirements early in the problem-solving process as well as setting the stage for future improvements. You will fi nd that the QFD process ensures that the voice of the customer (VOC) drives all activities associated with designing or redesigning a product or service for internal or external customers. Lean-Six Sigma uses the same VOC inputs to align every activity within the Public Health department (PHD) directly with stated needs of the community and its stakeholders. These two methodologies will help improve quality, costs, and timeliness of products and services, which in for-profi t businesses translates into increased profi tability.
In Public Health, having lower costs can mean more can be done with existing budget dollars.
The objectives of QFD and Lean-Six Sigma are as follows:
• Provide higher-quality products and services to customers.
• Achieve customer-driven design of these products and services by
converting user needs into design parameters.
• Provide documentation and tracking system for future design endeavors
• Develop delivery processes that are effi cient and effective
• Involve suppliers early in the process
• Require data-driven decision making and incorporate a comprehensive set of quality tools under a powerful framework for effective problemsolving
• Provide tools for analyzing process fl ow and delay times at each activity in a process
The early results of the use of QFD in the United States included a reduction in the cycle time for design work, a defi ning of quality early in the design stage, a decrease in quality problems during manufacturing, a way to objectively benchmark
against the competition on improvements, reduced warranty claims, and an improvement in cross-functional team work.
In this book we will modify the QFD process and Lean-Six Sigma methodology so they are aligned with the needs and differences in Public Health design and delivery of products and services. When we make modifi cations we will point this out so readers will understand the change from what might be seen in an industrial or healthcare application of the same concepts.
As the Public Health community expands its use of quality improvement (QI), there is often confusion about how all the tools, techniques, methodologies, models, and approaches fi t together.1 Available techniques include basic and advanced tools of quality improvement as well as several QI models including quality function deployment, Lean-Six Sigma, daily management, mobilizing for action through planning and partnerships (MAPP),2 turning point,3 Baldrige,4 and state quality award models. At times, these models are introduced as competing techniques and processes. The models are not tied together into a system by which they complement one another. This chapter provides an overview showing how various QI techniques and improvement models are related to one another and can be used in compatible ways. The Public Health community would benefit from an overall approach that completely integrates QI into its management practices. Continuous improvement is one component of an integrated system of performance management by which an organization meets and exceeds the needs and expectations of its multiple customer, client, and stakeholder communities.
Some of the ways in which performance management can positively influence a Public Health agency are:
• Better return on dollars invested in health
• Greater accountability for funding and increases in the public’s trust
• Reduced duplication of efforts
• Better understanding of Public Health accomplishments and priorities among employees, partners, and the public
• Increased sense of cooperation and teamwork
• Increased emphasis on quality, rather than quantity
• Improved problem solving5
Autores:The Public Health Quality Improvement Handbook,
by Ron Bialek, Grace L. Duffy, and John W. Moran
terça-feira, 1 de junho de 2010
5 whys and 5 hows
What It Is
•The five whys and five hows constitute a questioning process designed to drill down into the details of a problem or a solution and peel away the layers of symptoms.
•The technique was originally developed by Sakichi Toyoda. He states “that by repeating why five times, the nature of the problem as well as its solution becomes clear.”
•The five whys are used for drilling down into a problem and the five hows are used to develop the details of a solution to a problem.
•Both are designed to bring clarity and refinement to a problem statement or a potential solution and get to the root cause or root solution.
•Edward Hodnet, a British poet, observed, “If you don’t ask the right questions, you don’t get the right answers. A question asked in the right way often points to its own answer. Asking questions is the ABC of diagnosis. Only the inquiring mind solves problems.”
When to Use It
•When we want to push a team investigating a problem to delve into more details of the root causes, the five whys can be used with brainstorming or the cause-and-effect diagram.
•The five hows can be used with brainstorming and the solution-and-effect diagram to develop more details of a solution to a problem under consideration.
•Both methods are techniques to expand the horizon of a team searching for answers. These two techniques force a team to develop a better and more detailed understanding of a problem or solution.
How to Use It
•Draw a box at the top of a piece of flip chart paper and clearly write down the problem or solution to be explored.
•Below the statement box draw five lines in descending order.
•Ask the “Why” or “How” question five times and write the answers on the lines drawn from number one to five.
•It may take less or more than five times to reach the root cause or solution.
Examples of five whys and five hows are below.
Five whys of less vigorous exercise:
Too much TV and video games
Why?
Few community-sponsored recreation programs
Why?
No family recreational activities
Why?
No safe play area
Why?
Lack of resources
Why?
Five hows of more vigorous exercise:
Less TV and video games
How?
More community-sponsored recreation programs
How?
More family recreational activities
How?
Safe play areas
How?
Additional resources
How?
Excerpted from Ron Bialek, Grace L. Duffy, and John W. Moran, The Public Health Quality Improvement Handbook (Milwaukee, WI: ASQ Quality Press, 2009), pages 168–170.
•The five whys and five hows constitute a questioning process designed to drill down into the details of a problem or a solution and peel away the layers of symptoms.
•The technique was originally developed by Sakichi Toyoda. He states “that by repeating why five times, the nature of the problem as well as its solution becomes clear.”
•The five whys are used for drilling down into a problem and the five hows are used to develop the details of a solution to a problem.
•Both are designed to bring clarity and refinement to a problem statement or a potential solution and get to the root cause or root solution.
•Edward Hodnet, a British poet, observed, “If you don’t ask the right questions, you don’t get the right answers. A question asked in the right way often points to its own answer. Asking questions is the ABC of diagnosis. Only the inquiring mind solves problems.”
When to Use It
•When we want to push a team investigating a problem to delve into more details of the root causes, the five whys can be used with brainstorming or the cause-and-effect diagram.
•The five hows can be used with brainstorming and the solution-and-effect diagram to develop more details of a solution to a problem under consideration.
•Both methods are techniques to expand the horizon of a team searching for answers. These two techniques force a team to develop a better and more detailed understanding of a problem or solution.
How to Use It
•Draw a box at the top of a piece of flip chart paper and clearly write down the problem or solution to be explored.
•Below the statement box draw five lines in descending order.
•Ask the “Why” or “How” question five times and write the answers on the lines drawn from number one to five.
•It may take less or more than five times to reach the root cause or solution.
Examples of five whys and five hows are below.
Five whys of less vigorous exercise:
Too much TV and video games
Why?
Few community-sponsored recreation programs
Why?
No family recreational activities
Why?
No safe play area
Why?
Lack of resources
Why?
Five hows of more vigorous exercise:
Less TV and video games
How?
More community-sponsored recreation programs
How?
More family recreational activities
How?
Safe play areas
How?
Additional resources
How?
Excerpted from Ron Bialek, Grace L. Duffy, and John W. Moran, The Public Health Quality Improvement Handbook (Milwaukee, WI: ASQ Quality Press, 2009), pages 168–170.
6 steps for implement lean
This practical, how-to book clearly and succinctly takes the reader through six proven “success steps” for implementing lean in any healthcare environment:
1. Create physician flow
2. Support physician value-added time
3. Visually communicate patient status
4. Standardize everyone’s work
5. Lay out the clinic for minimal motion
6. Change the care delivery model
Why go through such a transformation? Because it works. Tell a doctor that he can see the same number of patients, offering the same high quality and personal care, and have an extra 90 minutes at the end of his clinic day – and that means something. Tell the staff that they can look forward to actually ending on time, with satisfied patients, no backlog, and having focused their attention completely on quality patient care – and they will listen.
These Lean principles and success steps work in clinics ranging from orthopedics to neurology to cardiac care—the specialty doesn’t matter. They work in small practices and large hospital settings. Lean methodology provides the tools to address the frustrations patients and doctors alike experience in the clinic process.
Included throughout the book is a case study showing the lean transformation undertaken at the Orthopedic Center at Children’s Hospital of Wisconsin, with numerous quotes and insights from those actually involved. This transformation resulted in patient wait times being reduced by more than 70 percent, the clinic being able to see 25 percent more patients in less space, patient satisfaction scores sometimes reaching 100 percent, and staff satisfaction scores improving by more than 25 percent.
1. Create physician flow: This centers on the idea of the physician as a “shared resource”—a pacemaker in the process—who should never have down time due to missing information or lack of clear priorities. Everything except the physician’s consultation with the patient is essentially changeover and should be done as
efficiently as possible to set the doctor up for the best possible patient interaction.
2. Support physician value-added time: In order for the physician to maintain a state of flow and not experience undue downtime, she needs a high level of coordination of clinic processes. This step calls for the creation of a team leader position, whose primary responsibility is to make sure the doctor’s time is used effectively.
The team leader is usually a nurse who has leadership potential; the duties include tracking the status of each patient and “driving the bus” to direct the clinic.
3. Visually communicate patient status: Visual communication is the Lean concept of using visible markers, signals, and signs to communicate the status of a given process so that anyone walking into the work
environment can tell what’s in process, what’s working, and where the problems are. With this step, I describe a seemingly simple, powerful tool in the clinic setting: the Patient Status Whiteboard.
4. Standardize everyone’s work: Standard work is a tool of Lean that provides process stability and a mechanism for formal process improvement. In this step the care team creates standard work for their processes to find immediate improvement opportunities, achieve predictable outcomes, and clarify their roles in the care process. Creating standard work also formalizes changes made so far and helps the Lean system become an integral part of the practice’s culture.
5. Lay out the clinic for minimal motion: This step focuses on examining how to change the physical layout of a clinic or other healthcare environment to improve patient flow and staff communication. It uses the tools of spaghetti mapping and 5S to look at individual workstations, and discusses the flow of care and communication throughout the clinic. Some of the Lean improvements discussed here are simple ones: creating supply and material carts, moving commonly used forms and supplies inside the exam rooms, organizing paperwork at the front desk, and establishing “pull” by creating a kanban card system. Architectural improvements, such as U-shaped cell designs, help develop an enhanced team space to improve patient safety, staff communication, and patient handoffs.
6. Change the care delivery model: This means rethinking the clinic processes to focus relentlessly on patient flow. The idea of focusing on flow is central to Lean, because organizing work in departments simply does not work. Support departments—such as radiology, casting, physical therapy, labs, echo, and pharmacy—should be rethought and broken into decentralized mini-departments, where feasible. The previous steps—managing the physician’s time, visually controlling patient status, standardizing the individual tasks in the care process—lay a stable foundation so that larger process changes do not create chaos.
Autores: Aneesh Suneja with Carolyn Suneja
Lean Doctors A Bold and Practical Guide to Using Lean Principles to Transform Healthcare Systems,One Doctor at a Time , ASQ Quality Press Milwaukee, Wisconsin
1. Create physician flow
2. Support physician value-added time
3. Visually communicate patient status
4. Standardize everyone’s work
5. Lay out the clinic for minimal motion
6. Change the care delivery model
Why go through such a transformation? Because it works. Tell a doctor that he can see the same number of patients, offering the same high quality and personal care, and have an extra 90 minutes at the end of his clinic day – and that means something. Tell the staff that they can look forward to actually ending on time, with satisfied patients, no backlog, and having focused their attention completely on quality patient care – and they will listen.
These Lean principles and success steps work in clinics ranging from orthopedics to neurology to cardiac care—the specialty doesn’t matter. They work in small practices and large hospital settings. Lean methodology provides the tools to address the frustrations patients and doctors alike experience in the clinic process.
Included throughout the book is a case study showing the lean transformation undertaken at the Orthopedic Center at Children’s Hospital of Wisconsin, with numerous quotes and insights from those actually involved. This transformation resulted in patient wait times being reduced by more than 70 percent, the clinic being able to see 25 percent more patients in less space, patient satisfaction scores sometimes reaching 100 percent, and staff satisfaction scores improving by more than 25 percent.
1. Create physician flow: This centers on the idea of the physician as a “shared resource”—a pacemaker in the process—who should never have down time due to missing information or lack of clear priorities. Everything except the physician’s consultation with the patient is essentially changeover and should be done as
efficiently as possible to set the doctor up for the best possible patient interaction.
2. Support physician value-added time: In order for the physician to maintain a state of flow and not experience undue downtime, she needs a high level of coordination of clinic processes. This step calls for the creation of a team leader position, whose primary responsibility is to make sure the doctor’s time is used effectively.
The team leader is usually a nurse who has leadership potential; the duties include tracking the status of each patient and “driving the bus” to direct the clinic.
3. Visually communicate patient status: Visual communication is the Lean concept of using visible markers, signals, and signs to communicate the status of a given process so that anyone walking into the work
environment can tell what’s in process, what’s working, and where the problems are. With this step, I describe a seemingly simple, powerful tool in the clinic setting: the Patient Status Whiteboard.
4. Standardize everyone’s work: Standard work is a tool of Lean that provides process stability and a mechanism for formal process improvement. In this step the care team creates standard work for their processes to find immediate improvement opportunities, achieve predictable outcomes, and clarify their roles in the care process. Creating standard work also formalizes changes made so far and helps the Lean system become an integral part of the practice’s culture.
5. Lay out the clinic for minimal motion: This step focuses on examining how to change the physical layout of a clinic or other healthcare environment to improve patient flow and staff communication. It uses the tools of spaghetti mapping and 5S to look at individual workstations, and discusses the flow of care and communication throughout the clinic. Some of the Lean improvements discussed here are simple ones: creating supply and material carts, moving commonly used forms and supplies inside the exam rooms, organizing paperwork at the front desk, and establishing “pull” by creating a kanban card system. Architectural improvements, such as U-shaped cell designs, help develop an enhanced team space to improve patient safety, staff communication, and patient handoffs.
6. Change the care delivery model: This means rethinking the clinic processes to focus relentlessly on patient flow. The idea of focusing on flow is central to Lean, because organizing work in departments simply does not work. Support departments—such as radiology, casting, physical therapy, labs, echo, and pharmacy—should be rethought and broken into decentralized mini-departments, where feasible. The previous steps—managing the physician’s time, visually controlling patient status, standardizing the individual tasks in the care process—lay a stable foundation so that larger process changes do not create chaos.
Autores: Aneesh Suneja with Carolyn Suneja
Lean Doctors A Bold and Practical Guide to Using Lean Principles to Transform Healthcare Systems,One Doctor at a Time , ASQ Quality Press Milwaukee, Wisconsin
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