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Power in Numbers-Six Sigma in Healthcare

Premier’s 2006 Annual Breakthrough’s ConferenceJune 22, 2006

Presented by: Dr. Mark Vaaler

Vice President of Medical Affairs&

Michelle McCraySix Sigma Black Belt

BayCare is comprised of nine leading not-for-profit

hospitals in the Tampa Bay, Florida area and a host

of other health services. We have 17,000 employees -

we call them "team members" - who are

dedicated to our common Mission of improving the

health of all we serve. What that means is we are an

organization that feels very strongly about caring for

our community.

The simplest way to describe BayCare is this: we are an

organization of people taking care of people. Our core business

begins with the single relationship between our team member and you, the customer. Therefore,

BayCare’s Quality Model is built upon a foundational philosophy of Customer Needs, Process Focus, and Continuous Improvement.

Guided by these principles, we are able to establish a Quality Process, a series of actions that bring about

changes and results.

What is Six Sigma?

Six Sigma is a methodology that adds tools and infrastructure to our Quality Improvement process. Six Sigma enhances our ability to apply the BayCare Quality Philosophy and Process to problems team members face each day. To realize continuous improvement in our work processes, we must evolve our tools and methods for improving processes. Six Sigma is the next step in the development of BayCare's Quality Philosophy and Process.

Identify your biggest

problems

Assign these problems to your

best people

Provide full resources and

support

Guarantee uninterrupted focused time

Six Sigma is …

Voice of the Customer “What does the customer truly want and need?”

“How can we most efficiently meet that need?”

All Six Sigma Teams focus on…

Firefighting Mode

Six Sigma builds an infrastructure with lines of accountability running throughout the organization Stresses breakthrough improvement! Emphasis is placed on producing better, faster, and lower cost products and services than the competition Emphasis is placed on the use of valid data as a driver for process change and measurable bottom line results

What is different about Six Sigma from initiatives of the past?

Work-OutFast-paced, activity-driven workshop to solve problemsExamples:

Standardization of forms Call light response

LeanProjects that eliminate waste and increase efficiencyExamples:

Patient registration Emergency Room flow

DMAIC (Define, Measure, Analyze, Improve, Control)Led by Black Belts or Green BeltsTeam Members have the opportunity to earn Yellow Belt certificationA data driven in-depth project to eliminate errors or defectsExamples:

Reduce length of stay Reduce insurance denials

Types of Six Sigma Teams or Projects

What is D.M.A.I.C.?

DMAIC (Define, Measure, Analyze, Improve, Control) Led by Black Belts or Green Belts It is a structured, disciplined, rigorous approach to

process improvement consisting of the five phases mentioned, where each phase is linked logically to the previous phase as well as to the next phase.

A data driven in-depth project methodology to eliminate errors or defects

Examples: Reduce length of stay Reduce insurance denials

Tools Range from: SIPOC to complex statistical tools, such

as Chi Square hypothesis tests

Six Sigma… the D.M.A.I.C. Methodology

• Practical problem

• Statistical problem

• Statistical solution

• Practical solution

ICU ThroughputSt. Joseph’s Hospital

Tampa, FLProject Start: March 2005

Close of Project: December 2005

Problem StatementFor the last 3+ years, the availability of ICU beds in the Adult

Medical/Surgical ICU has become such a problem that patients wait

up to 72 hours for a critical care bed based on data reviewed from

ICU, PACU & ER reports..

Black Belt Project

Champion: Black Belt:Process Owner:Finance Rep:Team Members:

Roles & Responsibilities

Dr. Mark Vaaler, VP Medical AffairsMichelle McCrayMargie Butler, RN Director ICUJudy PaltooBarbara Pricher, RN Manager ICUVickie Miranda, RN Manager AdmittingAnne MacMillan, RN Manager PACULynn Dopp, RN Director NursingAdrienne Galluppo, RN ICUKelli Stephanko, RN Case ManagerToni Bush, Information SystemsShellia Keller, Environmental ServicesDr. Lee Kirkman, Medical Director ICU

Suppliers Inputs Process Customers

Printers PCs Telephone Housekeeping Invision Physicians Nursing Bed Briefing Unit ClerksBed Tracker

Step 1: Physician writes order

Outputs

Step 2: Bed requested

Step 3: Bed assigned

Step 4: Bed ready

See Below Transfer order Bed request Bed assignment Clean request Transported pt. Open ICU bed

Bed Control Nursing units Housekeeping EC PACU Physicians Direct Admits/

Transfers In Interventional

Radiology

Dietary

Step 5: Patient transferred

Transfer order

(Dr. Order) Bed

Request/Invision

info Bed Tracker infoPatients Clinical Info

SIPOC/Macro Map

Step 6: ICU room cleaned

Step 7: ICU bed is available

• Defect DefinitionTime from when ICU requests a bed to when the patient is

on the receiving units census is greater than 4 hours.

• Objective Statement*To improve the cycle time from when the ICU requests a

transfer bed to when a patient is on the receiving unit’s census from 9.52 to 4 hours in 6 months.

• Metrics– Business

• Avoidable days (hours), ICU LOS

– Primary• Turn-around-time of bed request to patient transferred

*S.M.A.R.T. – Specific-Measurable, Attainable, Relevant, & Timebound

Project Definition

Process Capability

403020100

USL

Process Data

Sample N 59Location 1.94088Scale 0.820107

LSL *Target *USL 4Sample Mean 9.51864

Overall CapabilityZ.Bench -0.68Z.LSL *Z.USL -0.12Ppk -0.04

Observed PerformancePPM < LSL *PPM > USL 762712PPM Total 762712

Exp. Overall PerformancePPM < LSL *PPM > USL 750553PPM Total 750553

Process Capability of Bed request to censusCalculations Based on Lognormal Distribution Model

Sampled 59 patients over 2 weeks with an average of 9.5 hours

Sigma Level

Defects per million

opportunities

Customer Need/Target:

4 hours

Translation = 75% defect rate!

Measure (all input variables)

Analyze

Improve

Control

Pour in all possible input variables• Process Mapping• Mind Mapping• Ishakawa diagrams• Survey design

Use soft tools to narrow the possibilities• C & E Matrix FMEA

•UUse quantitative tools to further narrow the field• ANOVA• Correlation• Multi-vari studies

Implement and validate solutions

•IImplement systems to ensure improvements are maintained

• SPC• Poka-Yoke

• Audits• Control Plans

• DOEs• Surveys

(Key input variables)

(Critical input variables)

•(Key leverage variables)

• Logistic Regression• Survey analysis

30 - 50

10 - 20

8 - 10

4 - 8

2-5

Data Collection Plan

Process Flow

Diagram

I/O Worksheet

Fishbone

Failure Modes and

Effects Analysis

C&E Matrix

Input Verification Matrix

Evaluate Flow for VA/NVA, Hidden Factorys and

Key Data Collection

Points

List Potential X's per

Process Step

Brainstorm List of

Potential X's

List of Potential Process

Failures or Errors

Measurement System

Analysis

Data Collection Plan

Details of completed deliverables available in Appendix A

Analyze Phase - Summary of Critical X’s

• Significant X’s*:– Delay in giving bed assignment (Bed request to bed assign)

– Patients moved at shift change and by shift

– Delays in transferring patients by certain units

– Delay in moving patient to receiving unit’s census

– Delay by day of week bed is requested

• Other: The lack of ability to properly measure the turn around time

*See Appendix B for details on hypothesis testing

What was driving the turn around time to be long? Y = f(x)

Improve Phase - Ideas

ICU Transfer

Time Reduction

Standardization

TMEducation and

Training

Process

Information Systems

Nursing

Create Prioritization Matrix for placing patients

Review Patient Placement Guidelines and review policy for transferring patients from room to room within same level of care.

Bed Request/Bed Assigned time captured in Invision to improve measurement system

Automate notification to ICU/PACU of Clean bed

Add Bed Tracker screens in key areas to improve communication

Streamline Invision process for transferring patient. Reduce # of screens, reeducate staff.

Change afternoon Bed Briefing meeting time from 4:00pm to 2:00 pm

Call ICU with Bed Assignment when be is "In Progress"

Anticipate next day transfers and the beds to be needed

Kanban system for isolation curtains

Transfer order set with Med List from Invision to ease transfer process

Train Housekeepers to clean entire room. Career ladder.

Create incentive program to improve room status accuracy

Improve - Recommendations

• Change afternoon Bed Briefing meeting time from 4:00pm to 2:00 pm

• Bed Request/Bed Assigned time captured in Invision to improve measurement system

• Streamline Invision process for transferring patient. Reduce # of screens, reeducate staff. • “Look alike” screen to print in ICU when bed assignment is

made to aid in transfer• Inform ICU that bed is ready when bed is “In Progress” instead

of waiting until “Clean” status.

• Transfer Order set

– Simplify process of rewriting physician’s orders prior to transfer.

– Transfer Med List will print from Invision

Short Term, Little to No Investment

• Create Prioritization Matrix for placing patients

• Review Patient Placement Guidelines and review policy for transferring patients from room to room within same level of care.

• Add Bed Tracker screens in key areas to improve communications.

• Anticipate next-day transfers from ICU and communicate bed needs to Patient Access.

• Create Kanban system for isolation room drapes

• Put ladders on every nursing unit for changing the isolation drapes

• Allow patients to be moved prior to curtains being re-hung



• Create incentive program for housekeepers to improve status accuracy of Bed Tracking system

• Train housekeepers to clean entire room. Look into educational ladder for housekeeping.

• Redeployed housekeepers to cover the hours of day when the discharge volumes are high (no change in FTEs)



• Process Control System*– Control Charts

• Daily monitoring of the critical inputs– Bed Request to Bed Assign

– Bed Assign to Transfer

• Daily monitoring of the key output– ICU Transfer time

– Accountability for process– Identify who is responsible for monitoring

*See Appendix C for completed tool

Control - Sustain the Gains

Project Transition

• Project Transition Action Plan (PTAP)

– Formal meeting to transition project from Black Belt to Process Owner

– Any open action items are noted

– Deployment Leader, Champion, & Finance representative must sign off on PTAP

• 12 Month Realization Phase

– Monitor data via the Process Control System

– Monitor financial impact

– Report the primary metric on a regular basis

Key Project Results

• Primary metric improvement– Transfer time reduction

• 9.52 to 4.6 hours (as of 6/7/06)

– Sigma Level & DMPO• 0.82 to 1.29 Sigma (ST)• 750,553 to 583,627 DPMO

• Financial Savings– $670,084 Net Contribution margin and Direct Variable

cost savings (8/15/05 through 4/30/06)

Key Project Results

• Effect on Secondary Metrics– Comparing Pre project to Post project data in

2005, PACU Holds for ICU beds have decreased by 36%

– ED holds continue to decrease (see next slide)

• Data Accuracy– Changes to measurement system in order to

capture accurate and timely data• Transfer request order• Bed request order

Key Project Results

Implemented Process Control System

Manual tracking during pilots

Key Project Results

Average Emergency Department hold time for ICU beds decreased significantly in 2005 (average 105 patients per month)

Month

Hours

121110987654321

5.5

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

DecemberNovember

October

September

August

July

June

May

April

March

February

January

Bed Request to Bed Assigned in ICU - 2005

Final Thoughts• Next Steps

– Continue to monitor via PCS and HOLD the GAINS!– Transfer knowledge throughout BayCare

• Lessons learned– Executive support for large scale projects is key to success– Validating improvement pilots with data is new to staff – ensure they understand that items my be “rejected” post-pilot.– Validate your data sources – Make sure everyone is measuring the same thing, the same way

• The Value of DMAIC– Focus improvements on what you know will fix the problem– Brings results that are sustainable for the long run

Questions?

For additional information or further information on this project or Six Sigma at the BayCare Health System:

Dr. Mark [email protected] [email protected]

mailto:[email protected]

mailto:[email protected]

Appendix A

Fishbone Diagram

Detailed Process Map

C & E Matrix

FMEA

Input Verification Matrix

FMEA

C & E Matrix

Tracking X's

Fishbone

Process Map

If you can not open these documents, you can contact Michelle McCray at [email protected]

Appendix B

Appendix B

Analyze Phase

Factor Reduction

Factor Reduction – Appendix B

• Findings– Variation of

median by Day of week bed requested (Moods-Median p=0.36)

– Wednesday (5.5), Thursday (4.95) & Sunday (7.15) have highest median TAT

Bed Request DOW

M2 -

Bed R

equest

to B

ed A

ssig

n

7654321

40

30

20

10

0

-10

Boxplot of M2 - Bed Request to Bed Assign vs Bed Request DOW

• Findings– Difference in

median by shift (Moods-Median p= 0.60)

– Median 2nd shift is 5.7, while 1st shift is 2.8

– Also, Time of day had similar results

BEDASGbySHIFT

M2 -

Bed R

equest

to B

ed A

ssig

n

321

40

30

20

10

0

Boxplot of M2 - Bed Request to Bed Assign vs BEDASGbySHIFT


• Findings– Bed Assigned

to Patient moved interval

– Difference in median by Transfer Unit (Moods-Median p= 0.159)*


• Findings– Patients moved

2 hours before or after shift change have a longer overall TAT

– 22 out of 59 patients in sample were moved in this 4 hr window

– Median 1 hour greater for these patients (p = 0.087)

Bwt17-21hr

M3 -

Bed A

ssig

n t

o P

atient

move

YN

14

12

10

8

6

4

2

0

Boxplot of M3 - Bed Assign to Patient move vs Bwt17-21hr


• Findings– While nurse staffing did

not seem to be an issue, approx ½ of the patients required telemetry to be transported, which requires an RNs support

– Over a quarter of the patients request/need private rooms

– Housekeeping delays are an issue, but the extent of the problem can not truly be known until the Bed Tracker system utilization is under control

Would this be higher/lower if

tracker was being utilized

correctly?


Appendix C – Process Control System

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