Morrow, Richard 　著

目次

Overview of Process Improvement and the 3MsOutcomes Are the Result of ProcessesPerformance Excellence3Ms for Process Improvement     Measure     Manage to the Measure     Make It EasierWe Need All Three Ms to Sustain the ImprovementsThe Science of Process ImprovementQuality Foundational Process Improvement ToolsProductivity Process Improvement ToolsChange LeadershipCase Study in Process Improvement     Utilizing the 3Ms for Process Improvement3Ms, Scientific Methodology, Change LeadershipKey PointsNotes Change LeadershipWhat Is Change Leadership? Change Management? How Do They Differ?The Need for Leadership in Change: A Case Study in HealthcareToo Many Examples of Not Leading Change WellManagement and Leadership: "Scientific ManagementPerfect Example of Scientific Management"Definition of Manager and LeaderWhat 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 AmericaHealthcare’s Change LeadersWalking the TalkDefinition of Common Terms across MethodologiesKey PointsNotes Resistance to Change and Process ImprovementForces against Change: Resistance, Time, Natural LawsA Quick Win against ResistanceRole of the Change LeaderA Policy of Change and Continuous ImprovementPiloting ChangesWhat Can Happen if Change Is Not Piloted FirstBalancing Change and ContinuityThe Emancipation ProclamationWhat 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 ImprovementForcing Does Not Always WorkThe Force of ResistanceBen Franklin, Electricity, and Change LeadershipPrinciples of Electricity Explain Resistance to ChangeWhat You Cannot See Can Hurt YouUsing Resistance to Help Lead ChangeElectricity and Forcing Change Can Be DangerousGetting Change to FlowThe Resistance to Change Can Vary within the Same PersonResistance between Two BodiesResistance at HomeKey Points Process Improvement MethodologiesOverview of the Most Popular MethodologiesYou Need at Least One Recipe and Do Not Forget a "Heaping Tablespoon" of Change LeadershipWhich Recipe Delivers the Culture and Change Leadership Skills?Work with Toyota and for MotorolaMotorola and Toyota Use Lean and Six Sigma Tools and ConceptsPDSA and PDCA Compared to Six SigmaAll Good Methods Analyze for Root Causes before SolutionsCase Study of Sterilized Instrument Processing     A "Milk Run"Cross Reference of PDSA, Six Sigma, Lean, Change LeadershipHuman Factors and Ergonomics in Process ImprovementCase Study: Human Factors Added to Lean Six Sigma?Hand Hygiene Change Leadership IssueFailure to Engage Others with the MeasureBaseball and Managing to the MeasureMeasures for Research PurposesMeasures for Process Improvement PurposesCedars-Sinai Using Measure and Manage to the MeasureKey PointsNotes Roadmap for Process ImprovementIntroductionStart the Journey on Main StreetLet Us Start on Our JourneyPossible ShortcutPrepare for ChangeTrainEnvision     Articulating a Vision     Elements in a Vision Statement     Try Out Your Vision Statement     How Does One Communicate the Vision?Abraham Lincoln’s VisionAdvocate a Vision and Continually Reaffirm It     For Whom the Bell TollsEngageEnable     Quality Circles          Enabling during the Recession of the Early 1980s     Assumptions and DecisionsEmpowerKey PointsNotes Chartering the Process Improvement WorkThe CharterNo Charter? Big Problem     Sharing Findings before Departing     Clear Definition of the Issue and What Was to Be Measured Are Key     The Final Report and SurpriseThe Charter Template     The Issue Statement     The Measures or Metrics     Outcome and Process Measures     GoalsProgressive Goals and Successive Successful ApproximationsMeasures and Goals to Build a Safer CultureHold Off on Financial Metrics Until      Scope the WorkCharter "Signatories"     SponsorChartering Is IterativeSign the CharterKey PointsPracticing Skills: CharteringNotes Stakeholder AnalysisPurpose of Stakeholder AnalysisCase Study in Stakeholder AnalysisMission and Values of the OrganizationStakeholdersOverview of the SHAMeasuring the Gap: The Level of ResistanceThree Stakeholder Analysis Scenarios to Know Up Front for Your StrategyDesigning the "Circuit" to Achieve Flow and Manage ResistanceDifficult to Be PerfectThem Is Us EventuallyStarting a New ClinicTime to Assess Each Stakeholder’s Buy-inKey PointsNotes Finding the Root Causes, Improving, and ControllingExplore TogetherDoctor Livingstone, I Presume?Explore Together with Empathy and PatienceBuilding the TeamCase 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 ImprovementTrain, 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 AccountableTimes Not to Speak Up? Key PointsNotes Utilizing the 3Ms: Measure, Manage to the Measure, and Make It EasierIntroductionMeasurePracticing MeasureManage to the MeasureMake It EasierVisual ManagementMeasuring ExampleManaging to the Measure ExampleMake It Easier ExampleTakt Time: A Measure of the Pace Needed to Meet Customer DemandMeasuring: The Most Important MApplying 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 ExperimentThe Hawthorne EffectDesire to Increase ProductivityUtilizing the 3Ms by Changing the Measure     Incentive Piecework as a Measure     More on the Perverse Incentive MeasureFrench Restaurant DiningThe Hawthorne Effect RevisitedCase Study in Timeliness in Sharing the MeasureKey PointsNotes What to MeasureIntroductionHidden Factory of Rework and Swiss CheeseGetting 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 SurgeryMeasuring the Quality of a DecisionPracticing Measuring     SetupA Change in One Area May Affect Other Areas     Inventory ManagementBalancing Metrics, Be Careful What You Measure!Measure What the Customer MeasuresBase the Measure on Correlation with the OutcomeHigh-Reliability Organizations: What Do They Measure?A Safety Culture and How to MeasureMeasuring the Inputs versus Just the OutcomesMeasuring the CultureKey PointsNotes Measure Risk to Achieve High ReliabilityIntroductionThe FMEA Form     The Process Step or Design Function     Input, Failure Modes, Effects, Causes, and Scoring of Risk     Existing Controls     Risk Priority NumberOne FMEA Every Eighteen Months Sends the Wrong MessageFMEA for Information Technology     Data Can Be a Component in Today’s High-Tech Equipment     But There Never Has Been an FMEA on Data ComponentsFMEAs Do Not Always Prevent Catastrophic FailureLesson of 3Ms: Must Manage to the Measure, Not Just MeasureFacilitating an FMEAKey PointsNotes Measurement as a SystemOverviewMeasurement as a SystemMeasuring the Quality of a Measurement System (Measurement System Analysis)Qualities of an Acceptable Measurement SystemMeasuring the Quality of a Measurement System: A Measurement System Analysis     Accuracy and Precision          Accuracy          Precision     Repeatability     ReproducibilityDesigning a Measurement SystemPerforming a Measurement System AnalysisMSA Can Be Really EasyMSAs Are Critical in Utilizing the 3MsInaccurate Measurement Systems Can Lose You CustomersA Measurement System Using Actual Data by Surgeon and by ProcedureDrawdownMeasurement Systems that Add No Value to the ClientCalibrating a Measurement SystemCategories and Types of DataChecklists as Measurement SystemsGranularityDiscriminationOverview of Performing a Gauge R&R StudyMSA for Blood Pressure ReadingMSA for Attribute DataAttribute Agreement Analysis     The Soft Drink Challenge with AAAStabilityLinearityOverview 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 ContributionSampling     Should I Measure 100% or Sample?Sampling QualityKey PointsNotes How to Share and Communicate MeasurementsChartingPareto ChartsPareto Analysis to Reduce ResistanceAsk Why Five TimesStatistical Process Control (SPC) Charts     May 1924     High-Reliability Organizations and SPC     The "Swiss Army Knife" for Process Improvement     Components of the Control ChartControl and Out of ControlCase Study: Ambulatory Surgical Center Wait TimesInterpreting SPC ChartsReliability and SPCSPC Is Often Preferred in Managing to the MeasureProve Change Really OccurredChange Management without SPC?Frontline Workers Have Been Using SPC Since the 1920sRun ChartsMeasuring Common Healthcare MeasuresKey PointsNotes 3Ms: Manage to the MeasureThe ScoreboardVisual ManagementWhat to Expect Short and Long Term from MeasuringInstructing and CoachingTraining within Industry     Job Instructions     Job Methods     Job Relations     Program DevelopmentStandard Work to Manage to the MeasureCoaching Is Key in Managing to the MeasureCoach’s PlaybookKey PointsNotes 3Ms: Make It EasierPerformance Improvement Makes It Easier to Change     The "Laws" in Change Leadership     Case Study: Nurses Spending Time with Patients          Job SatisfactionMaking Change Easier Is What We Need to DoSatisfaction and Loyalty Measurement     Explain     Experiment, Explore, Build ConsensusChoosing the Best Countermeasures     Piloting and Choosing the Best Countermeasures     Piloting to See if the Measure MovesTrain, Enable, Empower, and Hold AccountableMindfulness and ControlMindfulnessCommitment to ResilienceCase Study: Penn Medicine Utilizing the 3MsSPC Making It EasierKey PointsNotes High ReliabilityIntroductionCase 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 GreaseChange Is Not Always Easy, Except Stakeholder Analysis Revisited for Making It EasierDesigning an Experiment Should Start with the People Doing the WorkKey PointsNote SummaryUtilizing the 3Ms Is the AnswerMistake-Proofing?Mistake-Proofing Promotes Defect Prevention versus DetectionTypes and Levels of Mistake-Proofing DevicesStart with Failure Modes and Effects Analysis, Then Mistake-Proof the High Risks     Errors Cause Defects     Human Error Drives the Need for Mistake-ProofingMistake-Proof ApproachesTrain, Engage, Enable, and Empower the People Doing the WorkControl PlansLast and Definitely Not Least: Reinforcing Continuous Process ImprovementKey PointsNotes Appendices:Roadmap for Performance ExcellenceProcess Improvement Foundational ToolsThe Emancipation ProclamationCharter TemplateStakeholder Analysis TemplateHand Hygiene Data Collection SheetHand Hygiene Compliance Chart for PostingMeasure Data Collection ToolFMEA Severity, Occurrence, Detection TablesThe Soda Drink Challenge to Learn Attribute Agreement Analysis Index