Transcript PI46b PI Concepts Methodologies and Tools

Maintaining the Gain
Process Ownership & Accountability
Teresa Pinter, RN, Managing Master Black Belt
Performance Improvement Division
OSF Saint Francis Medical Center, Peoria, Illinois
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PROCESS MANAGEMENT
•An effective measurement system
•Performance analysis
• Performance to target (gap analysis)
• Variation (special cause or routine)
• Mean performance and range of performance
•Enrolling staff and key stakeholders in performance
improvement efforts and goals
•Education, training, communication
•Developing, implementing, and monitoring action plans for
improvement
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ESSENTIAL ELEMENTS OF
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PROCESS MANAGEMENT PLAN
•A measurement plan to
assist the Process Owner to
implement change and to
manage performance of key
processes
• Process Steps
• Key performance
indicators
• Measurement Plan
• Targets
• Corrective actions
to be taken when
performance fails
to meet
expectations
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•Provides process owners
with all the information
needed to evaluate how well
the process is meeting the
requirements of Those We
Serve
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KEY COMPONENTS…..
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•It is how we know that improvement solutions have
been implemented and are effective.
•It is how we know that implementations have
achieved projected benefits.
•It is how we sustain the gains over time.
•It is how we identify when our
environment is changing and
additional improvement is needed.
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WHY IS PROCESS MANAGEMENT
IMPORTANT?
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• Process Management is a critical competency
that managers need to develop in order to
achieve the organization’s strategic goals
• Process Management requires measurement
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To identify performance gaps
To focus our improvement efforts
To communicate performance objectives
To demonstrate ongoing performance
improvement outcomes
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PROCESS MANAGEMENT IS NOT JUST ABOUT
PERFORMANCE IMPROVEMENT PROJECTS
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WITH PROCESS MANAGEMENT?
• Control charts are tools used to monitor performance over time
• The control chart will allow us to view variation in the process
• Variation means that a process does not produce exactly the
same result every time the product or service is delivered.
• Variation exists in all processes.
• Has the ability to determine the presence of routine causes vs.
special causes that upset our processes
• Help us to detect, diagnose, and correct problems in a timely
fashion
• Provide an easy to understand visual indicator of process
performance
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WHY USE A CONTROL CHART
• Trending vs. Dashboard (red/yellow/green)
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Project Team
Process Owner
Implemented Solution
Y = f (x)
Good
Process Mgmt
Time
Y = f (x)
Financial Benefit
($)
Process Errors
# of Failures
Improvement Methods
Good
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SUSTAINING THE GAINS…OBSERVING
PERFORMANCE OVER TIME
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Hardwire process management into our daily work
• Review measures
• Focus on closing your largest performance gaps
• First, reduce routine variation by finding and
eliminating root causes
• Next, work on improving the mean
Process Management may start with:
• The control phase of a performance improvement
project
• Key indicators that you need to improve for your
area
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THE GOAL OF PROCESS MANAGEMENT
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• Provides the “Voice of the Process”
• Method to detect process “signal” vs. “noise”
• Method to focus process improvement efforts
• Simple method for displaying and interpreting process
performance over time and in context
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CONTROL CHARTS
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Time series data
Central line for detecting shifts and trends
Control Limits computed from the data
Distance of the limits from the center line =
3σ
Statistically there is <1% probability of
data point falling outside of Limits
Inpatient Satisfaction Score
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Raw Mean Score
87
UCL=86.87
86
Mean=85.16
85
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Filters out the process noise so that
real signals can be detected
Control Limits help us understand
what needs to change by
demonstrating the type of
variation
• Special Cause variation
makes the process
unpredictable and must be
eliminated (dots outside of
the control limits)
• Common Cause variation
can not be eliminated
without making fundamental
process change (dots within
the control limits)
LCL=83.45
83
0
5
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CONTROL CHARTS FUNDAMENTALS
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Helps us understand when to react…and when not to
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Allows us to focus on the important questions:
• Is the process stable and predictable?
• Is the amount of common process variation
acceptable?
• If not, what is the root cause of variation?
• Is the average process performance acceptable?
• If not, work on eliminating variation. That will usually be
sufficient to move the mean.
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WHY USE CONTROL CHARTS?
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• All work occurs in a system of interconnected
processes
• Variation exists in all processes
• Understanding and reducing variation are
keys to process and performance
improvement
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PROCESS VARIATION
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• There are always inherent chance causes
responsible for natural variation in all processes due
to “normal” variation in materials, environments,
methods, people etc. (common cause)
• Variation within a stable process is inevitable
• Do not react to this type of variation (process
tweaking)
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COMMON CAUSE VARIATION
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• Once we have an indication of a shift outside what
seems to be normal in a previously stable process,
we must discover the reason for the shift (special
cause)
• We want to remove the influence of a special cause if
it is adversely affecting the process
• If the special cause influence is improving the
process, we want to permanently capture its effect
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SPECIAL CAUSE VARIATION
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Special Cause
Special Cause Variation
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UCL
Mean
LCL
Commuting Time (mins)
Commuting Time (mins)
Common Cause
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UCL
Mean
LCL
M T W Th F M T W Th F M T W Th F M T W Th F M
M T W Th F M T W Th F M T W Th F M T W Th F M
Days
Days
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IDENTIFYING SPECIAL CAUSES
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• Now that we have reviewed tools monitor our
processes…
• Lets discuss maintaining our gains.
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MAINTAINING THE GAINS
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The goal is to hardwire process management into our daily
work
• Review measures
• Focus on closing your largest performance gaps
• First, reduce routine variation by finding and
eliminating root causes
• Next, work on improving the mean
Process Management may start with:
• The control phase of a Performance Improvement
project
• Key indicators that you need to improve for your area
Sustain the gains, pursue perfection
• Show me the data
• Action plans
• Specific Recommendations for action based
on analysis
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HOW CAN I INTEGRATE PROCESS
MANAGEMENT INTO MY WORK?
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Leadership Questions to ask…
Q:
What progress has the team made
in implementation of solutions and
achieving performance targets?
Q: What are the lessons learned?
Q: What milestones have been
reached? Not reached?
Q: What obstacles have been
identified? Are anticipated?
Q: What is the action plan to
overcome the obstacles and place
the team back on schedule or to
improve the process?
Q: What support or resources do you
need?
Q: What actions needs to be taken
and by when?
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Reviewing process performance…
Q: Is the new process being
followed?
Q: Have the key leading and lagging
indicators for your process been
identified?
Q: Is the process stable?
(free of special cause variation)
Q: Is the process capable?
(able to meet requirements)
Q: Is your process stability and
capability being
monitored on an
ongoing, regular basis?
Q: Is there a mechanism to monitor
feedback from Those We Serve for
changes in expectations?
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PROCESS VARIATION QUESTIONS FOR
LEADERSHIP
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“Confusion between common causes and special causes leads to
frustration of everyone, and leads to greater variability and to higher
costs, exactly contrary to what is needed.”
“I should estimate that in my experience, most troubles and most
possibilities for improvement add up to proportions something like
this: 94% belong to the system (responsibility of management), 6%
special.”
– W. Edwards Deming
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QUOTES:
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Communicating the performance and action plans locally
 Unit/Department/Division/Regional meetings
– Standing agenda item
• “Takeaway” information
 Performance Improvement Display Boards:
• Include: What was the baseline data, current performance and
the target?
 Utilize existing structures:
• Professional Committees or Councils
• Local communication pathways
• Portals
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SUSTAINING GAINS THROUGH COMMUNICATION
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• Leverage all current processes, vehicles, and resources
• Management structure & processes
• Employee newsletters
• Internal communication boards etc
• Provide consistent key messages that are easy to remember
• Use a variety of methods & media
• Tailor messages to meet the needs of the specific audience
• Uses appropriate language and detail
• Addresses audience specific concerns (What’s in it for them or
WIFM)
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COMMUNICATION TACTICS
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•
All key elements of process management must be in place to sustain
gains
• Control charts show performance trends over time and focus analysis
efforts
•
Leadership engagement and involvement is essential to success.
•
Effective communication is a critical function for successful
implementation and sustaining change
Process management is the first step in process maturity
Remember - a mature process is:
owned and managed,
documented, known,
standardized,
produces consistent quality outputs,
is measured and evaluated’
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TAKEAWAYS
and is improved in a disciplined way
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PMCS: PROCESS MANAGEMENT
CONTROL SYSTEM
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Business Leaders
Directors/Project Sponsors
Managers/Supervisors
Process Owners
PI Coach/MBB
PI Facilitator/BB
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WHO IS PART OF THE PROCESS MANAGEMENT
TEAM?
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A measurement plan to assist the Process Owner to
implement change and to manage performance of key
processes
• Illustrates the relationship between process
performance and outcomes
• Focuses on the key process variables that have
significant impact on the quality of the process
outputs
Defines process priorities
Establishes performance targets and accountabilities
necessary to drive change and continuously improving
performance
Provides process owners with all the information needed
to evaluate how well the process is meeting its
customer’s requirements
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PROCESS MANAGEMENT CONTROL SYSTEM
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PMCS EXAMPLE
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PMCS Process Description
Process Description:
• Reflects a key process, job, or group of
work tasks
• Uses simple and general terms
• Must be understandable for owners,
customers, and users
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CCRs of “Those we serve”:
• Identified measurable expectations in
regard to service product or experience
• Includes the “Voice of the Business”
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PMCS CCRs of Those We Serve
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Outcome Indicator (Y):
• Measures how well the requirements
of “Those we serve” are being met”
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PMCS Outcome Indicators
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PMCS: Key Process Steps
Process Map or Process Steps:
• The set of sequential and parallel activities
that must be completed to ensure the
Customer requirement is met
• Shows individual as well as cross-functional
accountability
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Outcome Indicators (Ys):
• A set of indicators identified during the project
which measure key elements of performance
•Based on critical relationship between process
variables and outcomes Y = f(x)
•Tied to the specific process activities
•Approved by Business Leader Team
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PMCS Outcome Indictors
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Upstream Indicators (Xs):
• The description of the data type and operational
definitions to be monitored based on CCRs
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PMCS Upstream Indicators
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Capturing Data:
• Defines the measurement plan the
Process Owner will implement
• Defines the frequency at which they
should be checked
• Defines the individual accountable
for checking
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PMCS Capturing Data
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Recovery Action:
• Defines the actions the Process
Owner will take in response to
certain identified events
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PMCS Recovery Action
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Next Steps
Develop the turnover agreement
Compile the turnover documents
Sign the turnover documents
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Standard documentation for project turnover
includes all of the following:
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Charter
MGPP
CCRs/CBRs
Root Cause Validation
Matrix
• Communication Plan
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•FMEA
•Implementation Plan
•PMCS
•Turnover Agreement
•Education & Materials
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TURNOVER DOCUMENTS
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Purpose: to formally transfer the project implementation
responsibility and management to the process owner.
• Elements of a turnover agreement
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Define Roles and Responsibilities
Agreed upon project success metrics
Agreed upon time frame for Leadership Reviews
Signatures of those taking ownership
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TURNOVER AGREEMENT
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We are presenting to you on August 24, 2012 a detailed Solution Implementation
Plan for the Respiratory Protection Program for Employees Project that was
approved on July 5, 2012. This document contains process design, process control
management, communication/ education plan, and implementation plan. Upon
review of this plan, it is agreed this project team’s work is complete and the process
owner will complete the detail as written in the implementation work plan.
Roles & Responsibilities
Black Belt:
Patty McMahill
Provide detailed implementation plan to process owner.
Coordinate quarterly leadership review.
Global Process Owners:
Director of Business and Community Health, Jo Garrison
Occupational Health Manager, Peggy Grace
Serve as Chair of the Environment of Care Safety Sub-Committee
See EOC Safety Committee Charter in Turnover documents
Track completion of employee medical evaluations.
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TURNOVER AGREEMENT DOCUMENT
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Success Metrics & Review
The solutions for this project were implemented on July 5, 2012. The
following metrics and success criteria will be used to evaluate the
success of this project starting July 1, 2012.
Operational definitions and collection plans are documented in the
Process Management Control plan provided at this meeting.
Leadership review of performance will be scheduled as listed below.
Measure
Current
Success
Target
Respiratory Protection Program Compliance
90%
Hazard Assessment Completion Rate
100%
Respiratory Protection Education Module Completion
90%
PAPR Education Module Completion
90%
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TURNOVER AGREEMENT METRICS
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Leadership Reviews
Review Dates
Coordinated by
January, 2013
Patty McMahill
April, 2013
Patty McMahill
July, 2013
Patty McMahill
October, 2013
Patty McMahill
Leadership Sign Off
We, agree with the above, assume the process owner(s) responsibilities and will complete the
activities assigned to ensure successful implementation and process control.
____________________________________
Director of Business and Community Health, Jo G
Process Owner Signature
__________________
Date
____________________________________
Occupational Health Manager, Peggy G
Process Owner Signature
__________________
Date
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TURNOVER AGREEMENT TEMPLATE
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• All key elements of process management must be in
place to sustain.
• Key elements include clear responsibilities,
measurement plan with targets, communication plan
• Clear recovery action if not meeting target.
• Clear line of sight of accountability.
• Provides process owners with all the information
needed to evaluate how well the process is meeting its
customer’s requirements
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TAKEAWAYS
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Thank you!
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QUESTIONS?
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