1st Edition

Utilizing the 3Ms of Process Improvement in Healthcare A Roadmap to High Reliability Using Lean, Six Sigma, and Change Leadership

By Richard Morrow Copyright 2012
    320 Pages 60 B/W Illustrations
    by Productivity Press

    320 Pages
    by Productivity Press

    Utilizing the 3Ms of Process Improvement in Healthcare supplies step-by-step guidance on how to use the 3Ms of change leadership to improve healthcare processes. Complete with forms, templates, and healthcare case studies, it illustrates the proper application of the 3Ms. It weaves stories throughout the book of role models who have succeeded, as well as some who have failed. It identifies the specific elements that were missing or defective in the failed attempts to teach readers about how the three elements work together.

    Arming you with a culture change method that is based on changing behaviors, it provides a leadership and management guide to achieving your objectives. The 3Ms have worked for Ben Franklin, Abraham Lincoln, and the author’s teams across the globe. Now, with this book, you can put the power of the 3Ms to work for you in your quest towards improving processes, providing better care, and reducing costly errors.

    The author encourages reader interaction and feedback on his website: www.rpmexec.com. He also provides you with access to the forms and templates described in the book.

    Overview of Process Improvement and the 3Ms
    Outcomes Are the Result of Processes
    Performance Excellence
    3Ms for Process Improvement
         Measure
         Manage to the Measure
         Make It Easier
    We Need All Three Ms to Sustain the Improvements
    The Science of Process Improvement
    Quality Foundational Process Improvement Tools
    Productivity Process Improvement Tools
    Change Leadership
    Case Study in Process Improvement
         Utilizing the 3Ms for Process Improvement
    3Ms, Scientific Methodology, Change Leadership
    Key Points
    Notes

    Change Leadership
    What Is Change Leadership? Change Management? How Do They Differ?
    The Need for Leadership in Change: A Case Study in Healthcare
    Too Many Examples of Not Leading Change Well
    Management and Leadership: "Scientific Management
    Perfect Example of Scientific Management"
    Definition of Manager and Leader
    What Happens When There Is No Leader?
    Leadership Principles
         Abraham Lincoln on Leading Change
              Abraham Lincoln’s Principles of Leadership
              Leading Change to a Slave-Free America
    Healthcare’s Change Leaders
    Walking the Talk
    Definition of Common Terms across Methodologies
    Key Points
    Notes

    Resistance to Change and Process Improvement
    Forces against Change: Resistance, Time, Natural Laws
    A Quick Win against Resistance
    Role of the Change Leader
    A Policy of Change and Continuous Improvement
    Piloting Changes
    What Can Happen if Change Is Not Piloted First
    Balancing Change and Continuity
    The Emancipation Proclamation
    What Happens When One or More of the Ms Is Missing?
         Dr. Semmelweis and Washing Hands: The Right Change, but ...
         Why Is Change Needed in Healthcare?
         Semmelweis Dies and So Did His Improvement
    Forcing Does Not Always Work
    The Force of Resistance
    Ben Franklin, Electricity, and Change Leadership
    Principles of Electricity Explain Resistance to Change
    What You Cannot See Can Hurt You
    Using Resistance to Help Lead Change
    Electricity and Forcing Change Can Be Dangerous
    Getting Change to Flow
    The Resistance to Change Can Vary within the Same Person
    Resistance between Two Bodies
    Resistance at Home
    Key Points

    Process Improvement Methodologies
    Overview of the Most Popular Methodologies
    You Need at Least One Recipe and Do Not Forget a "Heaping Tablespoon" of Change Leadership
    Which Recipe Delivers the Culture and Change Leadership Skills?
    Work with Toyota and for Motorola
    Motorola and Toyota Use Lean and Six Sigma Tools and Concepts
    PDSA and PDCA Compared to Six Sigma
    All Good Methods Analyze for Root Causes before Solutions
    Case Study of Sterilized Instrument Processing
         A "Milk Run"
    Cross Reference of PDSA, Six Sigma, Lean, Change Leadership
    Human Factors and Ergonomics in Process Improvement
    Case Study: Human Factors Added to Lean Six Sigma?
    Hand Hygiene Change Leadership Issue
    Failure to Engage Others with the Measure
    Baseball and Managing to the Measure
    Measures for Research Purposes
    Measures for Process Improvement Purposes
    Cedars-Sinai Using Measure and Manage to the Measure
    Key Points
    Notes

    Roadmap for Process Improvement
    Introduction
    Start the Journey on Main Street
    Let Us Start on Our Journey
    Possible Shortcut
    Prepare for Change
    Train
    Envision
         Articulating a Vision
         Elements in a Vision Statement
         Try Out Your Vision Statement
         How Does One Communicate the Vision?Abraham Lincoln’s Vision
    Advocate a Vision and Continually Reaffirm It
         For Whom the Bell Tolls
    Engage
    Enable
         Quality Circles
              Enabling during the Recession of the Early 1980s
         Assumptions and Decisions
    Empower
    Key Points
    Notes

    Chartering the Process Improvement Work
    The Charter
    No Charter? Big Problem
         Sharing Findings before Departing
         Clear Definition of the Issue and What Was to Be Measured Are Key
         The Final Report and Surprise
    The Charter Template
         The Issue Statement
         The Measures or Metrics
         Outcome and Process Measures
         Goals
    Progressive Goals and Successive Successful Approximations
    Measures and Goals to Build a Safer Culture
    Hold Off on Financial Metrics Until 
         Scope the Work
    Charter "Signatories"
         Sponsor
    Chartering Is Iterative
    Sign the Charter
    Key Points
    Practicing Skills: Chartering
    Notes

    Stakeholder Analysis
    Purpose of Stakeholder Analysis
    Case Study in Stakeholder Analysis
    Mission and Values of the Organization
    Stakeholders
    Overview of the SHA
    Measuring the Gap: The Level of Resistance
    Three Stakeholder Analysis Scenarios to Know Up Front for Your Strategy
    Designing the "Circuit" to Achieve Flow and Manage Resistance
    Difficult to Be Perfect
    Them Is Us Eventually
    Starting a New Clinic
    Time to Assess Each Stakeholder’s Buy-in
    Key Points
    Notes

    Finding the Root Causes, Improving, and Controlling
    Explore Together
    Doctor Livingstone, I Presume?
    Explore Together with Empathy and Patience
    Building the Team
    Case Study: Patient Feeds Go Missing
         Work-Arounds in the "Factory of Hidden Defects"
         Exploring Using the "Five Whys"
    Explain
         Experiment
         Explore
         Brainstorming for Solutions
         Building Consensus
         Resistance
         Additional Benefits from the Process Improvement
    Train, Enable, Empower, Hold Accountable
         Training in the Improvements
         Case Study: Enabling and Engaging the Customer in the Process
              There Are Good Times, and There Are Bad Times
         Enable
         Empower
         Hold Accountable
    Times Not to Speak Up?
    Key Points
    Notes

    Utilizing the 3Ms: Measure, Manage to the Measure, and Make It Easier
    Introduction
    Measure
    Practicing Measure
    Manage to the Measure
    Make It Easier
    Visual Management
    Measuring Example
    Managing to the Measure Example
    Make It Easier Example
    Takt Time: A Measure of the Pace Needed to Meet Customer Demand
    Measuring: The Most Important M
    Applying the First of the Three Ms and Seeing the Value
         Setting Up Your Experiment
         Measuring the Baseline
         Statistical Process Control Charting: Turning Data into Information
         Sample Size
         Hand Hygiene and the 3Ms
         Ready to Observe
         Alternative Experiment
    The Hawthorne Effect
    Desire to Increase Productivity
    Utilizing the 3Ms by Changing the Measure
         Incentive Piecework as a Measure
         More on the Perverse Incentive Measure
    French Restaurant Dining
    The Hawthorne Effect Revisited
    Case Study in Timeliness in Sharing the Measure
    Key Points
    Notes

    What to Measure
    Introduction
    Hidden Factory of Rework and Swiss Cheese
    Getting Started: Preparing for Change, Chartering, and Stakeholder Analysis
         Case Study: 3Ms Improving Surgical Safety
         The Measure Is Invented
         Measuring the Errors to Reduce the Risk of Wrong-Site Surgery
    Measuring the Quality of a Decision
    Practicing Measuring
         Setup
    A Change in One Area May Affect Other Areas
         Inventory Management
    Balancing Metrics, Be Careful What You Measure!
    Measure What the Customer Measures
    Base the Measure on Correlation with the Outcome
    High-Reliability Organizations: What Do They Measure?
    A Safety Culture and How to Measure
    Measuring the Inputs versus Just the Outcomes
    Measuring the Culture
    Key Points
    Notes

    Measure Risk to Achieve High Reliability
    Introduction
    The FMEA Form
         The Process Step or Design Function
         Input, Failure Modes, Effects, Causes, and Scoring of Risk
         Existing Controls
         Risk Priority Number
    One FMEA Every Eighteen Months Sends the Wrong Message
    FMEA for Information Technology
         Data Can Be a Component in Today’s High-Tech Equipment
         But There Never Has Been an FMEA on Data Components
    FMEAs Do Not Always Prevent Catastrophic Failure
    Lesson of 3Ms: Must Manage to the Measure, Not Just Measure
    Facilitating an FMEA
    Key Points
    Notes

    Measurement as a System
    Overview
    Measurement as a System
    Measuring the Quality of a Measurement System (Measurement System Analysis)
    Qualities of an Acceptable Measurement System
    Measuring the Quality of a Measurement System: A Measurement System Analysis
         Accuracy and Precision
              Accuracy
              Precision
         Repeatability
         Reproducibility
    Designing a Measurement System
    Performing a Measurement System Analysis
    MSA Can Be Really Easy
    MSAs Are Critical in Utilizing the 3Ms
    Inaccurate Measurement Systems Can Lose You Customers
    A Measurement System Using Actual Data by Surgeon and by Procedure
    Drawdown
    Measurement Systems that Add No Value to the Client
    Calibrating a Measurement System
    Categories and Types of Data
    Checklists as Measurement Systems
    Granularity
    Discrimination
    Overview of Performing a Gauge R&R Study
    MSA for Blood Pressure Reading
    MSA for Attribute Data
    Attribute Agreement Analysis
         The Soft Drink Challenge with AAA
    Stability
    Linearity
    Overview of MSA for Continuous Data and High Granularity
         Gauge Repeatability and Reproducibility
              Example of a MSA and Steps
         Precision to Tolerance (%P/T)
              Knowing Good from Bad
         Percentage Precision to Total Variation (%P/TV)
         Percentage Contribution
    Sampling
         Should I Measure 100% or Sample?
    Sampling Quality
    Key Points
    Notes

    How to Share and Communicate Measurements
    Charting
    Pareto Charts
    Pareto Analysis to Reduce Resistance
    Ask Why Five Times
    Statistical Process Control (SPC) Charts
         May 1924
         High-Reliability Organizations and SPC
         The "Swiss Army Knife" for Process Improvement
         Components of the Control Chart
    Control and Out of Control
    Case Study: Ambulatory Surgical Center Wait Times
    Interpreting SPC Charts
    Reliability and SPC
    SPC Is Often Preferred in Managing to the Measure
    Prove Change Really Occurred
    Change Management without SPC?
    Frontline Workers Have Been Using SPC Since the 1920s
    Run Charts
    Measuring Common Healthcare Measures
    Key Points
    Notes

    3Ms: Manage to the Measure
    The Scoreboard
    Visual Management
    What to Expect Short and Long Term from Measuring
    Instructing and Coaching
    Training within Industry
         Job Instructions
         Job Methods
         Job Relations
         Program Development
    Standard Work to Manage to the Measure
    Coaching Is Key in Managing to the Measure
    Coach’s Playbook
    Key Points
    Notes

    3Ms: Make It Easier
    Performance Improvement Makes It Easier to Change
         The "Laws" in Change Leadership
         Case Study: Nurses Spending Time with Patients
              Job Satisfaction
    Making Change Easier Is What We Need to Do
    Satisfaction and Loyalty Measurement
         Explain
         Experiment, Explore, Build Consensus
    Choosing the Best Countermeasures
         Piloting and Choosing the Best Countermeasures
         Piloting to See if the Measure Moves
    Train, Enable, Empower, and Hold Accountable
    Mindfulness and Control
    Mindfulness
    Commitment to Resilience
    Case Study: Penn Medicine Utilizing the 3Ms
    SPC Making It Easier
    Key Points
    Notes

    High Reliability
    Introduction
    Case Study: SKF
         High-Reliability Program Number 1
         High-Reliability Program Number 2
         The Products Surrounding the Variation
         Scrapping versus Inspecting
         Utilizing the 3Ms in Zero Defects and SWOC
         Program 3: Building a Safety Culture2
         A Story of a Seal and Its Grease
    Change Is Not Always Easy, Except
    Stakeholder Analysis Revisited for Making It Easier
    Designing an Experiment Should Start with the People Doing the Work
    Key Points
    Note

    Summary
    Utilizing the 3Ms Is the Answer
    Mistake-Proofing?
    Mistake-Proofing Promotes Defect Prevention versus Detection
    Types and Levels of Mistake-Proofing Devices
    Start with Failure Modes and Effects Analysis, Then Mistake-Proof the High Risks
         Errors Cause Defects
         Human Error Drives the Need for Mistake-Proofing
    Mistake-Proof Approaches
    Train, Engage, Enable, and Empower the People Doing the Work
    Control Plans
    Last and Definitely Not Least: Reinforcing Continuous Process Improvement
    Key Points
    Notes

    Appendices:
    Roadmap for Performance Excellence
    Process Improvement Foundational Tools
    The Emancipation Proclamation
    Charter Template
    Stakeholder Analysis Template
    Hand Hygiene Data Collection Sheet
    Hand Hygiene Compliance Chart for Posting
    Measure Data Collection Tool
    FMEA Severity, Occurrence, Detection Tables
    The Soda Drink Challenge to Learn Attribute Agreement Analysis

    Index

    Biography

    Rick Morrow is a consultant with more than 25 years of senior leadership experience in healthcare, aviation, construction, automotive, and high tech. Morrow leads the automotive industry Healthcare Performance Partners’ Quality, Safety, and High Reliability unit, a MedAssets company. He has authored Lean Six Sigma performance excellence courses and taught and deployed programs internationally for Eaton Corporation, SKF, Motorola, United Airlines, The Joint Commission, and Healthcare Performance Partners.Morrow is the author and leader of HPP’s Six Sigma consulting and wrote and leads the Belmont University Lean Healthcare Certification Program for Supply Chain Professionals, which is a blend of The Toyota Production System, Six Sigma, and Change Leadership. Morrow also wrote and taught The University of Penn’s Penn Medicine Leadership and Performance Improvement courses. He authored the Lean Six Sigma Program at The Joint Commission and led its Center for Transforming Healthcare, where he and his team led collaborations improving patient care and safety with major academic medical centers including Cedars-Sinai, Johns Hopkins, Mayo Clinic, Intermountain Healthcare, North Shore Long Island Jewish, and Stanford University.Morrow earned his MBA from the University of Illinois’ Executive Program and has a B.S. in business from Illinois State University. His certifications include Motorola Master Black Belt and Lean Enterprise from the University of Tennessee. He is an international speaker on Lean Six Sigma, Quality, and Safety at conferences including NPSF, ASC, and ASQ.Morrow is also the author of the companion book, Utilizing the 3Ms in Process Improvement, and is a contributing editor on performance improvement, quality, and safety publications.He is as proud of his work coaching his son and daughter in baseball and soccer as he is of leading as president of the Holy Family Commission of Education.

    In this book, Rick Morrow provides a clear, structured, and disciplined approach to improving processes and systems in healthcare, an industry in great need of improvement. He gives readers great insight into how all the tools of improvement can indeed be used in an integrated approach to improve reliability of care, clinical utilization, quality, patient safety, and efficiency. He wraps this around straightforward steps and the management systems required to sustain improvements. A must read for all looking to improve a complex organization and delivery system.
    —Charles Hagood, President & Founder, Healthcare Performance Partners, Inc & Co-Author of Lean Led Hospital Design

    With Rick Morrow’s help, we were able to reduce hospital acquired infections by over 50% using the tenets described in this book. Those improvements have been sustained. Rick provides a simple and elegant description of improvement methods and how to apply them. Those serious about performance could benefit from this book.
    —David Munch, MD, Senior VP, Chief Consulting and Clinical Officer, Healthcare Performance Partners, Inc. (HPP), A MedAssets Company

    As an international expert in quality and safety, Utilizing the 3Ms of Process Improvement for Healthcare is my go-to-guide for practical applications in process improvement. This is a must read for all healthcare professionals looking to create sustainable processes and improve outcomes.
    —David Jaimovich, MD, President of Quality Resources International

    The stories that Rick shares in this book, I think, everyone can relate to. His ability to translate difficult lessons into easy, memorable stories will engage even the most skeptical readers. … This book includes a step-by-step approach to change that begins with proven techniques. … includes templates that guide teams in driving change and utilization of the 3Ms for process improvement. This book is a great place to start your journey in process improvement. The key to longevity and success in process improvement is the utilization of the 3Ms. I can’t imagine succeeding without the concepts shared in this book.
    —Erin DuPree, MD, Deputy Chief Medical Officer, Vice President Patient Safety, Mount Sinai Medical Center, New York

    I have made it a habit to listen more carefully to those who have actually been successful doing what they teach. Rick Morrow has the track record to back up the methodology suggested in his book. To the degree that it is theory, it is theory tested and proven on the front lines. He is a veteran in the ongoing ware to improve the patient experience, reduce waste and enhance quality of the care we provide. As such, he is worth listening to. Take the time to read his book. It will be time well invested.
    —Terry Howell, Ed.D., Chief Quality Officer, Hennepin County Medical Center