Why 85% of Decisions Made in Your Organization are Wrong and How to Fix It!

Why are 85% of your
decisions wrong and
how to fix it?
John Bachman
Bachman.john@mayo.edu

Strategies
► Run up the hill
► Something different-The foreman stopped
set fire to an area and jumped into the
burnt out area (escape fire) Beckoned his
men to joint him
► Men died…. All of them had their packs on
and were carrying their axes or shovels

Points of the Story
1. Danger happens and change is needed
2. Escape Fires are present along the way
3. Cling to our past and hold on to the
familiar
1. Knowledge is learning something new.
Wisdom is letting go of something old.

Outrageous
► Escape Fire
► Let go of things that are holding you back
and are a part of your every day life!

That’s a lot of nerve
► Edwards Deming
► He felt over 90% of
decisions designed to
make things better
were wrong
► Father of Quality
improvement

Quality Improvement
► We have quality improvement!
► Six Sigma Lean and all sorts of tools!
► Organizations have improved!
► Point to an area and see what we have
done
► We reorganized things and it is better
► We have data to support it

Deming would smile at us
► Language-overuse reduces meaning
► Finding a better way to scrape burnt toast
► Flavor of the month…. Of course you can improve
things for a little while and then if you watch
things it regresses
► Reorganizations 25% successful at 4 years
► Victims of a constantly changing environment and
controlled by outside forces
► We lead and get what we want and that is the
problem

Deming would then say “Let us
learn a new philosophy”

What is the Aim of a System?
► Person?
► Office?
► Health Care System?
► Fastest way to get to the heart of an issue
 Example Joan
 Example Group Please the top
► Better
than that
► How do we measure it?????

How do we manage a
system?

Management by Results
► Peter Drucker
► “People on a balance
sheet are recorded as
liabilities”
► 1950s
► Extremely common
method
► Deming’s view
 Neighbors
 One of 14 points not to
use it

Top Rung
► Leadership sets up
goals and objectives
for the system
► Give it to the rung
below them
► Give it to the rung
below them
► Give to the rung below
them

Makes sense
► Give Responsibility to
other so they have
freedom to act
► Performance reviews
► Control of resources
► Logical and organized

► “Command and
Control”

Problems with Management of
Results
► Please the people above you-Give the results they
need to see (Management gets what it wants)
► Silos-nurses, secretaries, medical, financial
► We have accountability of individuals? How much
do we control?

Problems with Management of
Results
► Communication
► Knowledge of processes
 Top management 4%
 Middle management 9%
 Supervisors 74%
 Frontline 100%
► Implementation is success
► Compliance vs Commitment
► Numbers-Fear-Fudging-short term thinking

► Elite
group design future for the many (design
team)
 6-12 people supervisors professionals and workers
 Analysis
 Redesign
 One best design
► Shortcomings
 Resistance
 Misses subtleties
 Long time
 70% failure rate at 4 years

Management by Results
► Summary: Better to do things right then to
do the right thing.

Different Approach-Profound
Knowledge
1. System
2. Variation-Take a group next
3. Knowledge
4. Psychology

What is the difference between
Data, Information, and
Knowledge?

LOOK AROUND YOU
DATA DATA EVERYWHERE AND NOT A BIT
TO THINK

We can explain data Numbers have power

Déjà vu? How many meetings?

We make decisions by reacting to observed
variations in data or information???

Davis Balestracci
www.davisdatasanity.com

Board Member #1: “Find out
what happened!”

“Why are we having more bacteremias?”

Davis Balestracci

Information
1. Describes the present
or past
2. Data organized in
patterns
1. Prejudice
2. Percentages
3. Comparisons to other
groups
(benchmarking and
rankings)
4. Experiments or Pilots

Experiments (Implementation is
Success)

0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Annualised Attrition rate

Davis Balestracci
Oct-08

But do we?
Nov-08
progress”

Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
“We have a trend of steady

Jul-09
Aug-09

What is the trend?
Nursing Attrition Rate (Monthly)

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%
May-08

May-09
Apr-08
Aug-07

Nov-07

Mar-08

Aug-08

Nov-08

Mar-09

Apr-09
Oct-07

Oct-08
Sep-07

Dec-07

Feb-09
Jul-07

Jan-08

Feb-08

Jun-08

Sep-08

Dec-08
Jul-08

Jan-09

Jun-09
Adults Hospital Private Hospitals Childrens Hospitals Mother's Hospitals Combined Hospitals

Davis Balestracci

Profound truth: Given two
different numbers…

Something
Important

Yesterday Today

…one will be larger!
Davis Balestracci

“Account for your performance!”
“Upward Trend”

“Downturn”

“Rebound” This month…
vs. last month…
vs. the month before
“Setback”

“Turnaround”
How much time is wasted
explaining random variation?

“Downward Trend”
Davis Balestracci
Time

A=AA B=TB and C=LC L=BB Q=BE
F=ML H=IY M=DC

“Let’s set some stretch goals”
► The bottom 10% of the group will improve
to the 50th percent
► We will be in the top 80% of all quality
markers

Example
► Teachers
 Your child has a test and is below average
 Your child has now had two tests and is below
average

How do we know what we are
doing?

Knowledge
► Rooster
► Knowledge implies
theory
 Means it can be revised
 Predictive
► Future related

Trend

► Variation All processes vary Is it just
background noise (common cause)
► Variation Is this related to something new
(special cause )

People Need to Solve their Problems!!!!

Tampering
► Tampering: Treating common cause as
special cause
 Human tendency is to account for ALL
variation as special
 Looking for an explanation and finding one
- positive or negative
 Wastes time and resources
► Deming: “The losses caused by
tampering are incalculable.”
Davis Balestracci

A statistical definition of “trend”
"Sweat" Index Upward Trend Downward Trend

Time Time

Special Cause –
A sequence of SIX successive increases
or decreases

Usually indicates a process “in transition”

Davis Balestracci

“I can’t wait for five or
six increases!”

►You don’t have to in the context of
variation
►Increase the frequency of
measurement (quarterlyweekly)
►Use other methods

Davis Balestracci

If We Talk Improvement:
Knowledge=Plot the Dots
►Eliminate tampering
►Meaningful Interventions
►Improved Conversations
►Eliminate 75-85% of data and
information
 “Your current processes are
perfectly designed to get the
results you are already getting.”
Davis Balestracci

Bread-and-butter tool: Run Chart

Time ordered plot with the MEDIAN as reference
Median=Middle Value
Davis Balestracci

Special Cause: A consecutive sequence of
8 or more points on one side of the
median

Indicates a probable shift in the
process during this time period
Davis Balestracci

What would you do now? - Plot
the dots!

Have things
changed?

Davis Balestracci

“What is happening with NICU
Infections?”
16 1400

14 1200
12
1000
10
800 # Infections
8
600 #Patients
6
400
4

2 200

0 0
1 2 3 4 5 6 7 8 9 101112131415161718

Infection Rate

2.5

2

Plot the rate
Infecction Rate

1.5

1

(Infections/Patients) 0.5

0

-0.5
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18
Month

Davis Balestracci

West
93.6% Do you do “Percent Compliance?”
90.8%
90.2% Red…Yellow…Green…
90.1%
91.8%
90.7%
90.1%
91.7%
89.7%
89.8%
88.5%
91.0%
89.7%
91.1%
90.1%
90.1%
91.1% IF you plot the dots …
90.8%
91.4% Davis Balestracci
91.9% www.davisdatasanity.com

With a stable process, we can construct a
CONTROL CHART

93.6%

93.2%

90.6%

87.9%

Week-to-week EXPECTED variation:  3.5%
Davis Balestracci

0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Annualised Attrition rate

Davis Balestracci
Oct-08

Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Remember this?…

Apr-09
May-09
Jun-09
Jul-09
Aug-09

Is there as steady trend?

Annualized Attrition Rate
Special Cause Flag

25.00%

20.00%
Individual Value

15.00%

10.00%

5.00%

0.00%
Oct-07

Dec-07

Oct-08

Dec-08
Aug-07

Feb-08

Apr-08

Apr-09
Jun-08

Aug-08

Feb-09

Jun-09
Davis Balestracci Period

Did we improve the
A1c?

What about the LDL?

Constructing Run and Control
Charts
► Quality Academy templates
http://mayoweb.mayo.edu/quality-learning/qa-
templates.html
 Select C-chart 5e
 Copy 50 cells to paste
 View control chart
 Relabel chart title and axes
► Copy and paste chart into document
► Get Software
► http://asq.org/learn-about-quality/data-collection-
analysis-tools/overview/control-chart.html

Amundsen-Exploring
► Preparation
 Dolphin was
eaten
 Expeditions
 Read original
work-Thinking

Scott
► Tradition of Britain
“We can do it” “We
are English”
► Scientific background

Scott used Ponies and Motorized
Sleds (Manly thing to push)

Ponies died and motorized sleds stopped working in a week
4500 calories given 7000 used for hauling

Amundsen

Amundsen used dogs…. Excessive use of animals
Abundance of materials carried redundancy

Concept of the 20 mile March
► Amundsen used the 20 mile march
► Good days or bad would try to go 15-20
Miles.
► Scott would on fair weather go long
Distances and then not be ready if bad
Weather came

► Point was constancy of purpose!

What did they do to be successful
► Preparation-know what status of
environment is-(Stable System)
► Used proven methods (control and run
charts)
► Constancy of purpose (PDSA cycles)

Lets Take an Example
► Our office
 We were having issues with “open access”
 All the slots would fill up and we would call an
access alert
 Patients not happy
 Clinicians not happy because mess-hours
►Add more slots that would be open-lose continuity
►Add more slots in general
►Decrease panel Size

Unfilled Slots and Sames
► We could go to the computer and get this
information
► It has been around for years

It would lead you completely astray!

Step 1 Get together and discuss
what things mean!
► Same=a slot that is open and kept open for
people who call in on that day
► Actually at 3 PM the preceding day it starts
► Actually a doctor can put a person in if no
space
► Actually we will put a person in who is a
bleeding heart

Deming

►“Thereis no meaning to
anything!!!”

Raw Data
► Kept track of it on a graph (Put the numbers
in the template) We used Mayo You can
use ASQI (google calculate control chart)

Step 2
► We plotted people who needed to be seen
that day and from the previous day
► We plotted unfilled slots

We Looked at a Stable System
► We shared it with everyone
► This is the PowerPoint We Used

Access Can be Broken Down
► Availability On a given day can a patient be
seen
► Access (Continuity) Can the patient see
own doctor
► Affordability Can a patient afford it
► Acceptability Can a patient come in at a
time of choosing

We are Going to Look at
Availability
If I am Sick Can I be Seen
at Baldwin today
It is really nice to see a
doctor when I am sick!!!

We want a balance between
supply of patients and openings

Patients Patients in
Taken Care
of

No alerts, cramming, or compromise in care

How Many Slots Do We Need to
Serve Each Day Who Call in and
are Seen That Day?
► 40 per day
► 60 per day
► 80 per day
► 100 per day
► 150 per day

The answer
► About 60!
If you look at the next graph you can learn a few things

TOTAL DAY

MORNING AFTERNOON
Average is 25 Average is 42

Spikes INDICATE MONDAYS
MONDAYS ARE ALWAYS BUSIEST DAYS OF THE WEEK FOLLOWING!!!
MORINGS 25, AFTERNOONS 42 AND TOTAL 67

VARIATION
► Averages of 65 are nice but not practical
► You can have one foot in ice water and
another in boiling water and on average you
are fine
► We need 0-140 slots a day!
► No wonder we have problems!!!

Deming said “The Key to
Process Improvement is
Decrease Variation

We can….

Look at next graph…

This is the Next Step
► Decreasevariation
► Implement a new system

Eliminate Mondays

Look at this less variation if we just eliminate Mondays!!!!!!

Mondays has more activity by almost 50%

TOTAL

AM on consecutive Mondays PMs

Interesting
► Ifwe eliminate Mondays=Variation reduced
by 40
► Mondays average 100 slots
► We use as many slots on Monday PM as we
do for whole days Tues to Thurs
► Two days (Biggest Numbers are Tuesdays
after Busy Mondays)

► So our first step would be

We are Kidding
► However We Need to Have Mondays
Handled Differently then Tues-Friday
► We have on average 40 people scheduled
the day before On Monday we average 25
from the weekend
► There are some other add ons ER and
Hospital Visits are higher

So Step 1 in Improving
Availability
► Treat Monday as Something Different
► We can expect more patients and more
complex patients.
► If we handle Monday better will Tuesday be
better??
► We have set up a PDSA group to work on
Monday

So that is where we are
1. We know that we have a stable system
but with a great deal of variability
2. By using Data a group will help with
making Monday better for handling
increased demand

It makes sense
► Yes, This is not revolutionary but we have
data to support it so when we make
changes we can see impact
► This is going to take awhile but we are
moving in a direction of continuous
improvement!

What did we come up with
► Monday Afternoon was total blocked
 Monday PM First 30 minutes used for Hospital
Recheck, ER Recheck, Newborns
 Doctor could override system and see patient
(no one else)
 We will have excess access and expect some
afternoons will be quiet but what ever happens
Monday will be taken care of!!!

Family Medicine Baldwin
Weekly Fill Rates
• Fill rates in Q4 2011 mainly between 90% and 95%
• Overall daily and weekly fill rates declined early in 2012
• Fill rates stabilized from Feb 2012 through July 2012
• Ranged between 85 and 90% – more acceptable/manageable

Baldwin -- Monday PM Fill Rates

Filled in Last 2 Days
• Pre-Pilot: 7%
• During Pilot: 24%

During Day Fill Rate
• Pre-Pilot: 32%

End of Day Unfilled Rate
• Pre-Pilot: 6%

Baldwin – Mondays
PM Slots Filled Same Day - Monday Only (Or 1st Day of Week)
Same Day Slots Filled
140
• The counts of PM slots filled 120
Pre-Pilot Pilot Phase
UCL=136.0

during the day has ranged

Slots Filled Same Day
100 _
from 70 to 115 over the past 80
X=90

six months, significantly 60

higher than in 2011 40
LCL=44.0

20

0
Sept-2011 . . . . . . . . . July-2012
Date

Overall Slots Filled
• Average counts of filled slots Monday Filled Slots

has slightly decreased 400
UCL=392.0
during the pilot phase (one
350
of the goals)
Filled Slots

_
• Variability of filled slots is 300 X=299.7

similar during both phases
250

LCL=207.4
200
Sept-2011 . . . . . . . . . July-2012
Date

Baldwin – Tuesday / Wednesday
Tuesday Filled Slots Tuesday Filled Slots

• Average number of filled 450

slots is slightly higher during 400 UCL=396.7

pilot phase with significantly 350

Filled Slots
_
less variability X=329.3

300

LCL=261.9
250

200
Sept-2011 . . . . . . . . . July-2012
Date

Wednesday Filled Slots
Wednesday Filled Slots
400
• Average number of filled Pre-Pilot Pilot Phase

slots is slightly higher during 350 UCL=352.3

pilot phase with significantly 300
Filled Slots

_
less variability X=276.3

250

200 LCL=200.3

150
Sept-2011 . . . . . . . . . July-2012
Date

Baldwin – Thursday / Friday Slots
Thursday Filled Slots
Thursday Filled Slots
400
• Average number of filled
1

Pre-Pilot Pilot Phase UCL=376.0

slots is higher during pilot 350

phase with significantly less _

Filled Slots
300
X=291.1
variability
250

LCL=206.2
200

Sept-2011 . . . . . . . . . July-2012
Date

Friday Filled Slots
Friday Filled Slots
400
• The average number of filled Pre-Pilot Pilot Phase UCL=383.3

slots is higher during the 350

pilot phase with less _
Filled Slots

300 X=300.2
variability
250

LCL=217.1
200

Sept-2011 . . . . . . . . . July-2012
Date

Other Items
► Stopped churning on Mondays
 Phone calls
 Triage
 Complex patients now seen by own clinician
► Decreased testing
► Decreased coming back

► Providers very happy Patients very happy
► No access alerts
 Providers being ill not an issue
 Monday AM Team meetings
► Further PDSA Thursday for complex pts
► More likely to have add ons

Constancy of Purpose
► Weekly to monthly graphs
► PDSA Thursday PM for Complex patients
from hospital, ER, or Newborn
► Monday AM team meetings
► Not an issue…
 Moving on to appt times

How do we make continual
improvement
► Don Berwick
 Outsiders Management can make judgments on
improvement
 Insiders are the ones who can make
improvement

 Constancy of Purpose

Resources
► Web Site:
http://www.qualityandtraining.com
 This has short films for teams about this
 IHI Open School
►www.ihi.org/offerings/ihiopenschool/Pages/default
.aspx

Books
► Fundamentals of Health Care Improvement
 www.ihi.org/.../ihiopenschool/.../Fundamenta
lsofHealthCareImprovement.aspx
► Deep Change
► www.amazon.com/Deep-Change-
Discovering...Bass.../0787902446
► Great by Choice
 www.amazon.com/Great-Choice-Uncertainty-
Luck.../0062120999

Best All Around
► DATA SANITY
► davisdatasanity.com/
 Weekly newsletter
 Book

Variation
John Bachman MD
Saunders of Primary Care
Mayo Foundation
Bachman.john@mayo.edu

Different Approach-Profound
Knowledge
1. System
2. Variation
3. Knowledge
4. Psychology

Variation
► All Processes Vary
► Reacting to individual fluctuations is
tampering
► Not understanding a special cause leads to
tampering
► Tampering is successful initially and then
over times falls apart because of the 8
influences on processes

Response to Variation

“If I had to reduce my message for management
to just a few words, I’d say that it all had to do
with reducing variation”

W.E.DEMING

Control Chart Template (free)
► http://asq.org/learn-about-quality/data-
collection-analysis-tools/overview/control-
chart.html

Funnel Experiment
If you aim at the target and drop the ball 50
times

Imagine
► You are leading a parade…….

People cause variation

Now you are pushing
a wheelbarrow

Machines may alter
variation

You Come to a Building
Where Someone Gives
you instructions

Methods Cause
Variation

Someone Dumps
Cement into Your
Wheelbarrow

Materials
Alter Variation

Materials go to a Certain
Line

Measurement
Varies

Go Out in the Sun where
it is Hot

Environment
causes variation

Causes of Variation
OUTSIDE INSIDE
1. People 1. Materials
2. Machines 2. Measurement
3. Methods 3. Environment

MONEY AND MAINTENANCE

How to use????
► My car will not start

► Fish Bone Diagram

Instructions
► Draw a line
► Draw 6-8 bones of causes of variation
► Use sticky notes to put on the sides of
causes
► Keep drilling deeper 5 Whys?
► Brainstorming Not to think

Funnel Rule 1
Variation
► Management or people look at the pattern
and think they can just improve it

Rule 2
Messed up by people
► Drop a ball on the target
► Measure the distance from the ball and go
180 degrees in the opposite direction
► You will now be dropping a ball on the
target again.
► Now….. Measure the distance between the
impact of two balls and go 180 degrees
opposite from the second impact
► Keep using last ball as your marker

Rule 2 Tweaking!
Simply put, your reference point for
adjustment is the last event.

We base our decision on last result
and tweak it
By chance it may improve
“Confirming Evidence Trap”

Examples

► Adjusting a process when a part is out of specifications
 Complaint from a patient
► Operator adjustments without the aid of control charts
► Changing company policy based on the latest attitude
survey
► Recalibrating instruments to a standard
 Gun firing in the morning
► Adjusting the quota to reflect current output
► Stock market reaction to last month's deficit

Rule 3
► Drop the ball and measure distance from
the target. Measure the distance from the
target and go 180 degrees opposite

► Firea gun…. Adjust in the opposite and fire
again

Simply put, your reference point for
adjustment is a standard.

More Variation in Different
Quadrants

Rule 3 Compensation for Errors
► Illicit
drugs. Enforcement improves so drugs
become scarcer. The price goes up which
stimulates the import of more drugs. The
cycle repeats.
► Gambler increases his bet to cover losses
► Farmers doing supply and demand
► Unfilled Slots in appt schedule

Rule 4 There we go to the Milky
Way
► Drop the Ball
► Aim at the Last landing place

Examples
► History passed down from generation to generation.
► Worker training replacements in succession
► Adjustment of time of meeting based on last actual starting
time.
► Use of last board cut as a pattern for the next board.
► Sitting in a circle with a number of people. One person
whispers a secret to the next person who in turns whispers
it to the next person and so on.
► Train the trainer

Examples
► Normal Variation
► Tweaking
► Compensating
► Going to the Milky Way

Reorganizations
► 1-4 success after 3-4 years
► Start out great and then run out of steam

Why?

Process
► If I implement a change…Does it make a
difference…..

Quality templates have
information

Gathering Data-IHI Open School
► Students from College or Medical Schoo
► Faculty from school and clinic
► Students learn 18 courses and receive
certification
► Develop projects
► Free

Get Then Together and Do a
Project

Where to get materials for
projects?

Lets look at it
► Workbook on out patient

Started a Study
► Shadowing and Interviewing Patients by IHI
students
► Initially free
► Purpose 1 Measure Times and Get
Impressions of Patients
► Purpose 2 See about Hand Hygiene

Look at what we learned!

Average time waiting 15 minutes Median is 12 minutes

Average time waiting 10 minutes Median in 9

Waiting in Room 12 minutes Median is 9 minutes

Time spent with clinician 19 minutes Median 16.5 minutes

61 minutes is average Median is 62 minutes

Look what we have
► 15 30 45 minute appts
► 50% of the time patients are waiting
► Stable system

► Intervention

Another Project
Participation by Design
► This is what is happening with diabetes

What we have done
► Variation….
 Bead test
 Funnel test
► Examples
 IHI open school
 Appointments
 Diabetes-Participation by design

► His response was very quick
► “Go back to your work”
► “ Teach”
► “ Be patient”
► “Share your knowledge
► He most likely would have loved the next
painting……

What is the Title of This
Painting??

On display at the Getty Center

Crazy parade? Health Care
Systems? Chaos?? No….


Christ Entry Into Brussels 1989!
Where is Christ????


Christ Entry Into Brussels 1989!
► First painting to put Christ in background
► Point is in the crazy parade one person
influence only those around him

Who knows maybe you will
Help change the parade!
Deming thought you could


Homework
► Find a partner
► Select an area of improvement you wish to
see implemented and how you might plot
the dots!!!!

► http://intqhc.oxfordjournals.org/content/10/
1/69.full.pdf

► http://www.statit.com/services/CQIOvervie
w.pdf

Why 85% of Decisions Made in Your Organization are Wrong and How to Fix It!

Recomendados

Recomendados

Mais conteúdo relacionado

Semelhante a Why 85% of Decisions Made in Your Organization are Wrong and How to Fix It!

Semelhante a Why 85% of Decisions Made in Your Organization are Wrong and How to Fix It! (10)

Mais de MPCA

Mais de MPCA (20)

Último

Último (20)

Why 85% of Decisions Made in Your Organization are Wrong and How to Fix It!