Project Management

Improvement is not something to fear. It is something to embrace and enjoy.

A high school teacher was teaching a unit on problem solving and asked his class what a good leader should do first when a business problem is identified. Several hands went up, and the teacher called on one of the students. The student confidently replied, “Find out who is to blame and fire them.” At first the instructor thought the student was joking, but quickly realized by the nodding of heads in the room that he was not. Pointing fingers at someone else has been modeled over and over in our society by leaders in all types of arenas. The last thing any organization needs is a group of employees who think finding fault and blaming others supersedes root cause analysis.

For close to 20 years, I have been successfully solving problems for organizations, resulting in substantial cost savings and increased customer satisfaction. The credit goes to the leaders in the organizations I worked with who realized the value of training employees how to be more efficient and effective by incorporating the this mindset and technique into their organizations.

Although quality improvement is now my full-time occupation, I didn’t learn these things just to perform my current role of quality leader/trainer. I learned these things to perform all the roles I have held prior to this job. In other words, I was not trained so the organization could be in the business of quality: I was trained to improve the quality of the business.

According to Institute of Medicine (IOM) in a report titled: To Err is Human: Building a Safer Health System, the majority of medical errors are not the result of individual recklessness. Instead, the report finds, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.

Fixing systems, processes, and conditions requires employees to have a toolbox within reach. If you have a toolbox at home, I suspect that it is filled with many different types of tools that may fit different situations. Sometimes we need a hammer, other times a wrench or a screwdriver will do the job. The same holds true for the type of toolbox we need at work. Many of the quality improvement tools have been tried and tested over a handful of decades. We know they work. You just need to equip the organization with problem solvers that know how to use them.

Improvement is not something to fear. It is something to embrace and enjoy. Below are two of my favorite techniques and tools to identify risks, defects, variation (the enemy of quality), and waste.

Risk Identification

Failure Mode and Effect Analysis: This technique was developed in the late 1950s to study problems that might arise from military system or process malfunctions. It is a simple to use yet powerful way to identify risk (uncertainty). The technique starts with a cross-functional group of individuals — it is important that you have the right people participating. While data is useful in quantification of failure modes, it can be collected before or after the FMEA workout. All the information collected is housed in a matrix (see Example 1), and the facilitator walks the team through the topics. We have made significant progress in identifying risks just through the dialogue that occurs when following this technique.

• Failure Mode — Way in which a process/system could fail if not detected and either corrected or removed, resulting in an effect
• Failure Effects — Impact on customers — internal and external — including downstream processes or regulatory impact due to the failure mode
• Severity (SEV) — Significance of impact of effect to internal or external customers, expressed as a number between 1 (best) and 10 (worst) to signify severity
• Cause(s) — Underlying phenomena that instigate or create failure modes
• Occurrence (OCC) — Likelihood of the cause of the failure mode to occur, expressed as a number between 1 (rare) and 10 (certain) to signify occurrence
• Detection (DET) — Ability of current system to detect the cause or failure mode, expressed as a number between 1 (best) to 10 (worst) to signify detectability
• Risk Priority Number (RPN) — A numerical calculation of the relative risk of a particular failure mode
• RPN = SEVxOCCxDET
• This number is then used to place priority on items needing additional investigation.

Once the team identifies the highest risks, the appropriate problem-solving methodology is used to reduce, if not eliminate, the negative risks.

Problem-Solving Structure

DMAIC (Define, Measure, Analyze, Improve, and Control): This structure comes to us from Motorola (the founders of the Six Sigma methodology) and is now used by hundreds of healthcare organizations (including hospitals, pharmaceutical companies, insurance companies, and bio-tech labs) to lead a cross-functional team to the root cause(s) of variation, defects, and non-value-added costs. This method is commonly used in a project structure that can take 3-6 months. Organizations have realized millions of dollars in savings using this technique.

If the cause is glaringly obvious or just requires a change in the process flow, other structures, such as a Kaizen Event Workshop, might be used. Select the structure that aligns to the problem. You don’t need a cannonball to kill a flea, but you also don’t want to slay a dragon with a pea shooter. When in doubt, use the DMAIC structure.

The Define phase of the DMAIC structure starts with problem definition. A problem is defined as a question or situation that calls for a solution. The first step is to clearly define the problem by quantifying the frequency of occurrence and the impact when it occurs. This is harder than it sounds. Most people want to solve the problem before it is even defined. Some even write their theories as to the cause in the problem definition. For example, I once had a Green Belt in healthcare write the below problem statement.

• Problem Statement: Because workers are allowed to work 12-hour shifts, 15% of patients are given the wrong medications, leaving the patient and organization at risk.

The team assumed that the cause of the problem was exhausted workers and said so right in the problem statement. This is not uncommon; we all have our theories as to the cause and we want to solve the problem as quickly as possible. I have learned that it is best to approach the problem with as little bias as possible and let the DMAIC structure lead you to the best solution. More often than not our theories are symptoms but not the root cause.

The Measure and Analyze phases of the DMAIC structure involve baselining a key performance metric of the problem so there is something to measure the improvement against. In the previous example the key metric might be the number of errors in the dose or the method of administering medications. The goal will be to reduce or eliminate those errors.

Additionally, this is the phase where the focus shifts from the effects of the problem to the possible causes. These are called factors, and the best way to find the most likely factor(s) is to facilitate root cause analysis. It is so much easier to fix a problem when you truly know the root cause(s). So many leaders still opt for the trial-and-error method of problem solving, which often results in fixing just a symptom. Symptoms are like weeds: not getting them out at the root means the problem will reoccur.

I once had a leader tell a conference room full of managers that “done is better than right.” He truly believed that we needed to prioritize speed of solution over accuracy and circle back to fix whatever didn’t work. Really? If we don’t have time to do it right, when will we ever find the time to do it again? This mindset only works if you have lots of time and money to waste and the risk is minimal. I’ve never worked in that type of environment.

When you reach the Improve phase of DMAIC, you are ready to generate solutions to the problem. Albert Einstein once said, “The significant problems we have cannot be solved at the same level of thinking with which we created them.” This is where critical thinking techniques come in.

We need to shift our thinking with variations of brainstorming, such as Random Word, Morphological Box, or Reverse Thinking. These are all techniques designed to see a problem through a fresh perspective. One of my favorites is Reverse Thinking. This is where a team of individuals spends a set amount of time (usually 10 minutes) discussing how the problem could get worse before allowing their minds to identify solutions. This technique creates a shift in thinking away from those top-of-mind solutions that Einstein speaks about. You’ll be surprised at how this opens your mind to new thinking and generates better, more thorough solutions.

The last phase of DMAIC is the Control phase, and it primarily deals with change management. As it turns out, we humans aren’t too good with change. We might want it in theory, but our habits get in the way. This phase deals with some necessary steps to sustain the gains made by solving a problem. Without this phase, many of the problems return, thanks to the tendency of those who need to sustain the solution reverting to what they have done before.

A wise man named Theodore Roosevelt once said, “In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.” Problem solvers need the confidence that comes with a mindset and toolset that helps identify the right thing to do. Organizations need problem solvers that know how to find that right thing and implement it. Improvement opportunities are everywhere in healthcare. You just need to train employees how to find them without ever pointing a finger at anyone.

Resources

Barry, Robert, Amy C. Murcko, and Clifford E. Brubaker. The Six Sigma Book for Healthcare: Improving Outcomes by Reducing Errors. Chicago: Health Administration, 2002. Print.

Breyfogle, Forrest W., et al. Managing Six Sigma: a Practical Guide to Understanding, Assessing, and Implementing the Strategy That Yields Bottom-Line Success. Wiley, 2001.

Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. 2000.

About the Author

Anne Foley, PMP, MBB, CSSBB is an author, speaker and training consultant with Corporate Education Group (CEG). Anne has spent 25 years of her career using data to identify root causes of defects and non-value added activities in processes. She incorporates data collection and analysis to decisions ranging from routine to complex. An energetic and interactive trainer, Anne has been leading virtual and traditional training classes, workshops and conferences for 18 years.