Transcript montalvo_1b

August 20, 2007
Recognizing the Potential of
Six Sigma in a Clinical Setting
Matiana Gonzalez Vela, Ed.D., R.D., Master Black Belt
Cary Montalvo, B.S., Black Belt
Valley Baptist Health System
Six Sigma
and the
Six Sigma and the Institute for
Healthcare Improvement
• 100,000 Lives Campaign
– Unveiled in December 2004
– Reduce unnecessary hospital deaths by 100,000
– Focused on 6 Interventions shown to have major impact on
reducing mortality
• 5 Million Lives Campaign
– Unveiled on December 12, 2006
– Focus is to protect patients from five million incidents of
medical harm over the next two years
– Builds upon the success of the 100,000 Lives Campaign
– Additional 6 Interventions
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The six interventions
from the 100,000
Lives Campaign
• Deploy Rapid Response Teams…at the first sign of patient decline
• Deliver Reliable, Evidence-Based Care for Acute Myocardial
Infarction…to prevent deaths from heart attack
• Prevent Adverse Drug Events (ADEs)…by implementing
medication reconciliation
• Prevent Central Line Infections…by implementing a series of
interdependent, scientifically grounded steps
• Prevent Surgical Site Infections…by reliably delivering the correct
perioperative antibiotics at the proper time
• Prevent Ventilator-Associated Pneumonia…by implementing a
series of interdependent, scientifically grounded steps
4
Deliver Reliable, Evidence-Based Care for
Acute Myocardial Infarction…
to prevent deaths from heart attack
Our Criteria
IHI Criteria
y1 = Aspirin on arrival
•
Early administration of aspirin
y2 = Aspirin at discharge
•
Aspirin at discharge
y3 = ACE/ARB for LVSD
•
ACE-inhibitor or angiotensin
blockers (ARB) at discharge for
patients with systolic dysfunction
•
Smoking cessation counseling
•
Early administration of betablocker
•
Beta-blocker at discharge
•
Timely initiation of reperfusion
(thrombolysis or percutaneous
intervention)
y4 = Smoking cessation counseling
y5 = Beta blocker on arrival
y6 = Beta blocker at discharge
y7 = Timely reperfusion (<90 minutes)
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Deliver Reliable, Evidence-Based Care for
Acute Myocardial Infarction…
to prevent deaths from heart attack
AcuteBrownsville
Myocardial Infarction
6+ Sigma
100.0%
100.0%
100.0% 100.0%100.0% 100.0%
100.0%
100.0%
96.0%
100.0%
100.0%
100.0%
87.5%
94.1%
93.7%
94.7%
100.0%
100.0%
90.0%
80.0%
70.0%
97.0%
81.4%
86.0%
83.3%
86.2%
75.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Six Sigma Accountability
SOP Implemented with
Scorecard Dispersed
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Y = % compliance with Centers for Medicaid & Medicare Services Acute Myocardial
Infarction Core Measures (All or None Strategy)
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Deliver Reliable, Evidence-Based Care for
Acute Myocardial Infarction…
to prevent deaths from heart attack
Brownsville
By APR DRG 190
Baseline:
January 2002 March 2005
Post Control:
Rate Percent
April 2005 Improvement
December 2006
# of Discharges
459
268
# of Deaths
74
23
Mortality Rate
0.161
0.087
45.96%
ALOS
7.30
6.70
8.22%
Source: www.solucient.com
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Deliver Reliable, Evidence-Based Care for
Acute Myocardial Infarction…
to prevent deaths from heart attack
AcuteHarlingen
Myocardial Infarction
100.0%
6+ Sigma
100.0% 100.0% 100.0% 100.0% 100.0%100.0%100.0% 96.2%
100.0%100.0% 100.0% 100.0%
90.0%
95.7%
94.6%
89.5%
80.0%
96.2% 96.8%
100.0%
95.5%
94.3% 96.2%
100.0%
85.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Six Sigma Accountability
SOP Implemented with
Scorecard Distributed
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Y = % compliance with Centers for Medicaid & Medicare Services Acute Myocardial
Infarction Core Measures (All or None Strategy)
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Deliver Reliable, Evidence-Based Care for
Acute Myocardial Infarction…
to prevent deaths from heart attack
Harlingen
By APR DRG 190
Baseline:
January 2002 June 2004
Post Control:
Rate Percent
October 2004 Improvement
January 2007
# of Discharges
508
494
# of Deaths
86
50
Mortality Rate
0.169
0.134
20.61%
ALOS
6.20
5.55
10.48%
Source: Premier, Inc.
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Foundations of Success
ACCOUNTABILITY
Reward
Performance
Recognize
Effort
Respect
People
BROWNSVILLE
Valley
Baptist - Brownsville
1
2
Acute Myocardial Infarction Core Measures
Sigma:
3
Y = % Compliance to all CMS AMI Core measures
Yield:
Target = 100%
Defect < 100%
N:
Job Title Ranked:
Discharge RN
May 2007
6.0 +
100.0%
15
4
April Discharges reported on May Dashboard
Discharge RN
5
Santos, Dolorine
Dominguez, Nova
Oliviera, Kathy
Valenzuela, Ludy
Discharge RN Subtotal *
Nurse Name
Patient a non-smoker
TOTAL **
ID
Unit
Tele
Tele
3T
3T
N
Defect
Yield
Rank
2
1
1
1
5
0
0
0
0
0
100.0%
100.0%
100.0%
100.0%
100.0%
5
5
5
5
10
15
0
100.0%
Note:
*Discharge Nurse is being ranked for providing information on smoking cessation
**includes compliance with all
6
AMI Core Measures
Aspirin on arrival
Aspirin at discharge
ACEI or LVSD
Smoking cessation counseling*
Beta Blocker on arrival
Beta Blocker at discharge
Timely reperfusion
Inpatient mortality rate
Sponsor: Lorenzo Pelly, MD
Owner: Andrea Hayes
Master Black Belt: Matiana Vela, EdD
Black Belt: Cary Montalvo
Key:
Yield
Rank
5
99% - 100 % yield
4
95% - 98.9% yield
3
80% - 94.9% yield
0
0% - 79.9% yield
Prevent Ventilator-Associated Pneumonia…
by implementing a series of interdependent,
scientifically grounded steps
Our Criteria
IHI Criteria
•
y1 = Head of bed (HOB) elevated
30 - 45 degrees (unless
contraindicated)
•
y1 = Head of bed (HOB) elevated
30 - 45 degrees (unless
contraindicated)
•
y2 = Deep Venous Thrombosis (DVT)
prophylaxis (unless contraindicated)
•
y2 = Deep Venous Thrombosis (DVT)
prophylaxis (unless contraindicated)
•
y3 = Peptic Ulcer Disease (PUD)
prophylaxis
•
y3 = Peptic Ulcer Disease (PUD)
prophylaxis
•
y4 = Daily sedation vacation and
assess readiness to extubate (unless
contraindicated)
•
y4 = Daily sedation vacation and
assess readiness to extubate (unless
contraindicated)
•
y5 = Oral care twice a shift
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Prevent Ventilator-Associated Pneumonia…
by implementing a series of interdependent,
scientifically grounded steps
Ventilator Associated Pneumonia
Harlingen
100.0%
97.9%
100.0%
96.4%
90.0%
100.0%
93.6%
81.6%
70.0%
95.2%
89.8%
80.0%
71.8%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
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Prevent Ventilator-Associated Pneumonia…
by implementing a series of interdependent,
scientifically grounded steps
Baseline:
Pilot & Control:
Post Control:
January 2006 July 2006
August 21,2006 October 12, 2006
October 13,2006 March 28, 2007
n = 268
N = 59
N = 246
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1
0
Ventilator Associated Pneumonia Rate
0.034
0.017
0.000
100.0%
Mortality Rate (Patients in the ICU acquiring
Ventilator Associated Pneumonia)
0.111
0.000
0.000
100.0%
Average Ventilator Days (non-VAP patients)
4.4
2.7
1.8
59.1%
13.2
11.2
11.4
13.6%
ICU LOS
5.8
5.8
3.8
34.5%
ICU Mortality
59
6
38
0.184
0.102
0.137
Measure
# of Ventilator Patients
# of Ventilator Patients Acquiring Pneumonia
ALOS
Percent
Improvement
25.6%
ICU Mortality Rate
Source: Premier, Inc.
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New interventions
targeted at harm
•
Prevent Harm from High-Alert Medications... starting with a focus on
anticoagulants, sedatives, narcotics, and insulin
•
Prevent Pressure Ulcers... by reliably using science-based guidelines for
their prevention
•
Deliver Reliable, Evidence-Based Care for Congestive Heart Failure...
to avoid readmissions
•
Reduce Methicillin-Resistant Staphylococcus Aureus (MRSA)
infection…by reliably implementing scientifically proven infection control
practices
•
Reduce Surgical Complications... by reliably implementing all of the
changes in care recommended by SCIP, the Surgical Care Improvement
Project (www.medqic.org/scip)
•
Get Boards on Board … by defining and spreading the best-known
leveraged processes for hospital Boards of Directors, so that they can
become far more effective in accelerating organizational progress toward
safe care
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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Our Criteria
IHI Criteria
•
y1 = Measurement of Left Ventricular
Function documented
•
y2 = On ACEI/ARB or contraindication
documented
•
y3 = Smoking cessation counseling
documented
•
•
y4 = Complete discharge instructions
documented
•
•
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Left ventricular systolic function
assessment
ACEI/ARB at discharge for CHF
patients with systolic dysfunction
Anticoagulant at discharge for CHF
patients with chronic or recurrent
atrial fibrillation (AF)
Smoking cessation advice and
counseling
Discharge instructions that address:
activity level, diet, discharge
medications, follow-up appointment,
weight monitoring, and what to do if
symptoms worsen
Influenza immunization* (seasonal)
Pneumococcal immunization*
Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Heart
Failure Management
Brownsville
6+ Sigma
100.0%100.0% 100.0%100.0% 100.0%
95.2%
100.0%
97.5%
95.8% 95.2%
90.5%
100.0%
100.0%
90.0%
80.0%
86.0%
85.0%
85.1%
100.0%
97.7% 96.9%
92.1%
94.9%
90.5%
77.8%
70.0%
60.0%
50.0%
52.5%
40.0%
30.0%
20.0%
10.0%
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Six Sigma Accountability
SOP Implemented with
Scorecard Dispersed
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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Congestive HeartBrownsville
Failure (VBMC-Brownsville)
By APR DRG 194
# of Discharges
Baseline:
January 2002 March 2005
Post Control:
Rate Percent
April 2005 Improvement
December 2006
1,115
800
# of Complications
21
11
Complication Rate
0.019
0.014
# of Readmissions (1-30 days)
297
186
Readmission Rate (1-30 days)
0.266
0.233
55
39
0.049
0.049
0.00%
7.3
5.60
23.29%
# of Deaths
Mortality Rate
ALOS
Source: www.solucient.com
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26.32%
12.59%
Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Heart Failure Management
Harlingen
6+ Sigma
100.0%
100.0% 100.0% 100.0% 100.0% 100.0%100.0% 100.0%
100.0%100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0%100.0%100.0% 100.0%100.0% 100.0% 98.4%100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
58.0%
40.0%
30.0%
20.0%
10.0%
Six Sigma Accountability
SOP Implemented with
Scorecard Distributed
0.0%
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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure...
to avoid readmissions
Harlingen
Baseline:
January 2002 March 2005
Post Control:
April 2005 January 2007
1,711
1,221
# of Complications
22
15
Complication Rate
0.013
0.012
# of Readmissions (1-30 days)
418
331
# of Deaths
80
37
Mortality Rate
0.047
0.030
35.19%
ALOS
5.05
4.47
11.49%
By APR DRG 194
# of Discharges
Rate Percent
Improvement
4.46%
Ranked #1 in the Nation for Heart Failure
Management by the Premier/Center for Medicare
and Medicaid Services Hospital Quality Incentive
Demonstration (HQID) project.
Source: Premier, Inc.
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Prevent Pressure Ulcers...
by reliably using science-based
guidelines for their prevention
Our Pressure Ulcer Criteria
Prevention
•
y1 – Braden on Admission
y2 – POC documented for wound care
y3 – Heels offloaded
y4 – Complete wound assessment
y5 – Referral for wound necrosis
y6 – Ancillary Screens completed
y7 – Turning every 2 hours
y8 – Skin protectant for incontinence
y9 – Specialty bed for high risk
•
•
•
•
•
IHI Criteria
Pressure Ulcer Prevention
Conduct a Pressure Ulcer Admission
Assessment for All Patients
Reassess Risk for All Patients Daily
Inspect Skin Daily
Manage Moisture: Keep the Patient Dry
and Moisturize Skin
Optimize Nutrition and Hydration
Minimize Pressure
Management
y1 - Proper assessment to include location, dimension and staging
y2 - Braden scale completed
y3 - Nurse notifies physician of pressure ulcer
y4 - Pain assessment documented to include pre and post wound care
y5 - Time of initial assessment documented
y6 - Time of wound care performed and documented
y7 - Physical Therapy screen completed
y8 - Dietary screen completed
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Prevent Pressure Ulcers...
by reliably using science-based
guidelines for their prevention
Pressure Ulcer Prevention
100.0%
90.0%
71.8%
80.0%
82.4% 87.1%
75.8%
50.0%
59.5%
57.6%
55.6%
65.4%
81.8% 82.7%
86%
66.7%
70.0%
60.0%
80.0%
72.4%
64.4%
58.8%
40.0%
30.0%
20.0%
10.0%
0.0%
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Prevent Pressure Ulcers...
by reliably using science-based
guidelines for their prevention
Pressure Ulcer Management
94.0%
100.0%
86.7%
90.0%
76.1%
80.0%
80.0%
91%
86%
84.6%
73.9% 76.5%
70.0%
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Prevent Pressure Ulcers...
by reliably using science-based guidelines
for their prevention
Brownsville
Pressure Ulcer Prevention and Management
Pressure Ulcer Prevention and Management (VBMC-Brownsville)
Before
Improvements:
March 2005
# surveyed
Prevalence Rate
Post PUP* : Post PUP & PUM**: Post PUP & PUM :
February 2006
October 2006
May 2007
117
97
98
110
0.320
0.196
0.200
0.163
% Diabetic
Incidence Rate
49.1%
72.2%
0.190
0.110
0.090
% Diabetic
National Standard: 16% - Prevalence
7% Incidence
Source: KCI
Rate Percent
Improvement
0.024
100.0%
*PUP: Pressure Ulcer Prevention Initiative
**PUM: Pressure Ulcer Management Initiative
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87.4%
Lessons Learned!!!
•
President / CEO Champion is a must!
•
Physician Champion / Leader is a must!
•
Clean your house before you ask Physicians to clean theirs!
•
Have a formal mechanism to choose initiatives (projects)
•
Once an initiative is selected, scope it to a manageable range and
ensure it fits the DMAIC model!
•
Greenbelts during training should have vested interest in initiative
(Green Belt / Owner combination works best)
•
Training classes should be kept to a manageable size
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Lessons Learned!!!
•
Allow enough time between the Improve and Control Phase to ensure the best
possible solutions can be implemented and sufficient data collected
•
Thoroughly educate Owners on responsibility for sustaining improvements
in Post-Control period
•
Strive for electronic data collection for Post-Control – Manual data collection
is a bear!!! (leverage Information Technology department)
•
Data collection for Post-Control should NEVER be a “self-report” process
•
Develop “owners manual” to ensure continuity when unexpected change in
owner occurs
•
ACCOUNTABILITY goes hand-in-hand with TRANSPARENCY
26
Discussion
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