Six Sigma Case Study: Surgical Site infections in Bowel cases

Six Sigma in Healthcare - March 3-4, 2005 - New Orleans, LA

Six Sigma Case Study:

Surgical Site infections in Bowel cases

Nick Nauman, MBB

Commonwealth Health Corporation


Three hospital campuses

Full range acute & tertiary Open heart surgery Cancer treatment Neonatal Intensive Care Psychiatric Services Home Health EMS Managed Care Primary care walk-in clinics OP Rehab Center Physician Practices Free Clinic Long Term Acute Care Hospital

437 acute care beds

105 long-term care

$350M Revenue annually


Six Sigma: The Basics

“Sigma” is another word for standard deviation.

“Six” refers to the level of defects per million opportunities. The higher the number, the fewer the defects.

Most companies operate around a Three to Four Sigma.

σ Defects Per Million

Opportunities

123456

697,672.15308,770.2166,810.636,209.70232.673.40

From 3σ to 6σ represents a 20,000 times improvement in

quality.


Evolution of Healthcare Quality Initiatives

Inte

nsi

ty

Time

Six Sigma:Statistical Analysis/Data Driven

Outcomes Measurements:Benchmarking; Care Plans/Critical Paths

Continuous Quality Improvement:Team Based Charters; Soft Skills

Quality Assurance Programs:Retrospective measurements

GE, MotorolaAllied Signal

Managed Care;Payors

Accreditation, Licensure,

Regulations, Risk & Liability

Deming & Juran


Pursuing Perfection

The Effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea.

Work-OutTM

Six SigmaMethodology

Change Acceleration

ProcessEffectiveResults

62% of quality initiatives fail from lack of attention to the cultural and people

side of change – the “A.”

Q x A = E


Organizational Dashboard for Success

Customer Satisfaction: Press Ganey

Quality of Care: Timeliness of Service within Core processes and CMS projects for Improved Quality

Cost Efficiency: Six Sigma Cost savings


Six Sigma Functional Structure

Jean CherryCorporate

Sponsor

Connie SmithCorporateSponsor

Ron SowellCorporateSponsor

Press Ganey Score & Target

Timeliness Z Score & Target

Cost Efficiency & Target

ProjectSponsorsProject

Sponsors

MasterBlack Belts

(3)

MasterBlack Belts

(3)

Bro

wn

Belt

s(1

7)

Bro

wn

Belt

s(1

7)

ChangeAgents

(9)

ChangeAgents

(9)

Green Belts(70)

Green Belts(70)

Joh

n C

. D

esm

ara

is


WORLD CLASS CARE

QUALITYPRACTICE

QUALITYPROCESS

EFFECTIVE & EFFICIENTUSE OF RESOURCES


Project completed by Infection Control Practitioner

Case Study:Surgical Site infections in Bowel cases

Problem: A higher than expected number of post-op infections in bowel cases has been identified.

Customer(s) identified: Patient, Physician, Payer

Specification: Using a CDC standard, any post-op infection or wound integrity problem occurring within 30 days.

Data collected for 60 patients over a 6 month period.

The higher than expected rate adversely affects quality of care, patient days and cost.

Multi-disciplinary Team formed to assist on the project.


Current process performance:

DPPM = 333,333

Z Short Term = 1.931

Characteristic

1

Total

Defs

20

20

Units

60

Opps

1

TotOpps

60

60

DPU

0.333

DPO

0.333333

0.333333

PPM

333333

333333

ZShift

1.500

1.500

ZBench

1.931

1.931

Report 7: Product Perf ormance

Performance Level


Trivial Many Variables

Sex Age Discharge instructions Day of week Time of day Flashed instruments

used Prophylactic antibiotics Bowel Prep Surgeon & others on

case Shave prep Surgical prep Pt. risk factors Reason for surgery Type of drape used Skin closure used

Drains used Irrigant How much Dressing Post-op unit Complications When out of bed Discharge status Powdered gloves used Oxygen use Home w

staples/suture in Type procedure # of procedures Hibiclens bath pre-op Length of stay Length of case ASA & NNIS risk index

With the Team’s help, we were able to develop a lengthy list of factors that influence infections in patients.


Vital Few Variables

Using Chi Square, we determined these variables impact the process the most.

Type dressing applied post-op (dry dressing vs. betadine vs. bacitracin/bactroban)

Betadine dressing vs. bacitracin/bactroban

O2 use on post-op unit (none, liter flow, concentration)

O2 use on post-op unit (<40% vs. >40%) Hibiclens bath pre-op Discharge to self care vs. HC vs. other

facility Discharge to self care vs. other # procedures performed


Pilot

For the most part, the surgeons were receptive to the recommendations. Anesthesia was very willing to implement the suggested oxygen delivery.

Hibiclens shower within 48 hours pre-op. Dry sterile dressing or only Bactroban or

Bacitracin ointment. > 40% oxygen in the OR. > 40% oxygen during the immediate 2

hour post-op period. These specific recommendations were

presented to general surgeons and anesthesia via a letter from the hospital Epidemiologist and Infection Control Nurse. Additionally, several meetings were held with the Chief Anesthesiologist regarding oxygen utilization in the OR and in PACU.


Chi Square

There is a statistically different (lower) rate of post-op infections after the improvements were implemented.

Chi-Square Test: CombFail, CombPass

Expected counts are printed below observed counts

CombFail CombPassTotal

Original 20 40 60

13.73 46.27

Improved 7 51 58

13.27 44.73

Total 27 91 118

Chi-Sq = 2.865 + 0.850 +

2.963 + 0.879 = 7.557

DF = 1, P-Value = 0.006


Sample size

Since there are very few bowel cases performed, data collection will be on-going.

Sample Size Required To Statistically Confirm PPM Reduction

DPPM p(d) ZST

Process performance (Before change) --> 333,333 33.3% 1.9

Process performance (After change) --> 120,690 12.1% 2.7

Opportunities on each unit: --> 1

Confidence --> 95.0%

TOP's UnitsSample size required to distinguish between processes --> 77 77


Characteristic

Historical

New (May-Nov 02)

Total

Defs

20

7

27

Units

60

58

Opps

1

1

TotOpps

60

58

118

DPU

0.333

0.121

DPO

0.333333

0.120690

0.228814

PPM

333333

120690

228814

ZShift

1.500

1.500

1.500

ZBench

1.931

2.672

2.243

Report 7: Product Performance

Improved Performance Level

The defect rate dropped from 33% to 12% based on the improvements piloted.


Control Mechanism

0 1 2 3 4 5 6 7 8 9

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Sample Number

Pro

por

tion

P-chart for Post-Op Bowel Infections

P=0.1688

UCL=0.4590

LCL=0

Improvements Implemented

To be updated monthly as part of an ongoing infection control effort.


Final Steps

Update/Report findings to the Team on the outcome of the pilot.

Continue to monitor the outcomes and update the control chart on a monthly basis.

Report any indications that the process is out of control to the Infection Control Team. We will take appropriate action as necessary.


Questions and Answers

Email: [email protected]

Phone: (270) 745-1520

Six Sigma Case Study: Surgical Site infections in Bowel cases

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