1st Edition
Utilizing the 3Ms of Process Improvement in Healthcare A Roadmap to High Reliability Using Lean, Six Sigma, and Change Leadership
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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 DesignWith 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 CompanyAs 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 InternationalThe 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 YorkI 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