Tomas A. Gonzalez, M.D., M.B.A.Tomas A. Gonzalez, M.D., M.B.A.Vice President of Six SigmaVice President of Six Sigma

WCBF's Lean Six Sigma ConferenceWCBF's Lean Six Sigma ConferenceNovember 16-18, 2005November 16-18, 2005

• Valley Baptist Medical Center - Harlingen– 611 Licensed Beds– Lead Level 3 Trauma Center– State of the Art Children’s Center– # 1 Rated Orthopedics Service– Heart & Vascular Institute– Teaching facility for the Regional

Academic Health Center of The University of Texas Health Science Center at San Antonio

• Valley Baptist Medical Center – Brownsville– 243 Licensed Beds– Level 3 Trauma Center– State of the Art Imaging Center– Center of Diabetes Management

• Other Entities– Golden Palms Retirement and Healthcare

Center– Valley Baptist Health Plans– Advanced Medical Supply (DME)– Valley Baptist Ambulatory Surgery Center– Clinical Pastoral Education Center– Licensed Vocational Nurse School– Family Practice Residency Program– Internal Medicine Residency Program– Home Health & Hospice– Rehabilitation & Wellness– Behavioral Health Services

Valley Baptist Health SystemValley Baptist Health System

• Strategic Initiatives– Integration– Simplicity– Six Sigma Quality– Relentless Service– Expansion of Services & Regionalization

• Values– Disciplined– Accountable– Entrepreneurial– Performance Oriented

Valley Baptist Health SystemValley Baptist Health System

September

October

December

January

February

May

AprilMarch

July

August

June

November

1st Quarter 2nd Quarter

3rd Quarter4th Quarter

Execute Initiatives:Mgmt. Mtg. Marching Orders

Performance Reviews

Board Retreat

QOR

Aug. Board

Meeting (Present budget)

QOR

QOR

Valley Baptist Health System Valley Baptist Health System Operating CalendarOperating Calendar

QOR

Talent Review / Succession, HR

Planning

Initiatives Dev. & Review +

Sr. Mgmt. & Review and

Key Mgmt. Retreat

Performance Stds. Set

Budget

= Work product req.= Processes link

Sr. Mgmt. Mtg

Key Mgmt. Retreat

Guidance

VBHS Confidential & Proprietary Information

VBHS ValuesVB

Survey II

Strategic Planning

Integration

Simplicity

Service Expansion & Regionalization

Relentless Service

Six Sigma Quality

VBSurvey I

• A comprehensive and flexible program for achieving, sustaining and maximizing business success that:

– Is uniquely driven by a clear focus on the “Voice of the Customer”

– Is founded in a rigorous use of facts, data and statistical analysis

– Provides for diligent attention on managing, improving and reinventing business processes.

– Is a management methodology with three perspectives:• A Measure of Quality• A Process for Continuous Improvement• An Enabler for Cultural Change

What is Six Sigma?What is Six Sigma?

What is Six Sigma?What is Six Sigma?

• Integrated part of management system• Fact & data based decision making• Knowledge transfer, learning process• Value added focus on defect removal• Utilization of technology tools• A lasting infrastructure

Six Sigma Advantage, Inc.

What Six Sigma is not:What Six Sigma is not:

• Not a quick fix• Not a cost reduction program• Not a training program• Not a statistics program• Not a quality program• Not a publicity stunt

Six Sigma Advantage, Inc.

A Few Basic Terms:A Few Basic Terms:

• Black Belt – 6 Sigma Trained Specialist who works on a 6 Sigma improvement project, usually on a full time basis

• Green Belt – 6 Sigma Trained Specialist who uses the Six Sigma methodology to solve problems as a function of their normal work

• Yellow Belt – An individual contributor, trained in basic 6 Sigma methods, to assist on a problem solving task or solution implementation.

• Sponsor – Usually a member of management with responsibility to identify 6 Sigma projects, assign resources and remove barriers.

• DPMO – Defects per Million Opportunities, a common measure of process defects which can be converted to Sigma.

• Sigma (σ) – A Greek letter, symbol for a measure of variation in any process, where 6 Sigma represents only 3.4 defects per million opportunities.

• Six Sigma is a statistical measure that expresses how close a service process comes to its quality goal

• Six Sigma refers to a process that produces only 3.4 defects per million opportunities

Sigma DPMO Yield

2 308,537 69.1463%

3 66,807 93.3193%

4 6,210 99.3790%

5 233 99.9767%

6 3.4 99.9997%

A Measure of Quality:A Measure of Quality:

DMAIC MethodologyDMAIC Methodology

How did we begin implementing How did we begin implementing Six Sigma?Six Sigma?

• CEO Commitment!– Vision– Leadership– Resources (time, money, people, etc.)

• Partnership with General Electric Medical Systems– Guidance– Expert Knowledge– Training – Six Sigma, CAP, Work-Out™– Project Mentoring– Transition Assistance

VBHS TimelineVBHS Timeline

• May 2002– Engagement with GEMS– Wave 1: 6 initiatives– 11 Green Belts trained

• March 2003– Wave 2: 6 initiatives– 3 Full Time Black Belts appointed

• April 2003– 3 Full Time Master Black Belts appointed and trained

• June 2003– Wave 3: 8 initiatives underway– 2 Master Change Agents trained– 6 Green Belts trained

• March 2004– Wave 4: 16 initiatives underway– 14 Green Belts trained

• August 2004– Wave 4 completed

• July 2005– Wave 5 initiatives completed

• September 2005– Wave 6 initiatives begin at VBMC-H, Wave 2 at VBMC-B

Completed InitiativesCompleted Initiatives

• Wave 1– ED Wait Times– Diabetes Management– Pharmacy Order Verification– OR Turnaround Time– Staff Scheduling– Nursing Order Activation

• Wave 2– ED Wait Times– Laboratory Turnaround– Admissions Process– OR Turnaround Time– Radiology Turnaround – Discharge Process

• Wave 3– ED Wait Times– Surgery Patient Preparation &

PATT– DRG Assurance of Accuracy– RN Admissions Assessment– Patient Registration Accuracy– Outpatient Service Redesign– Performance Management– RN New Hire Process

Wave 4 InitiativesWave 4 Initiatives

• Timely Utilization of Ancillary Services in the ED

• Inpatient Floor to Floor Transfers

• Event Response• Golden Palms MDS Coding

Accuracy• CHF• Stroke Care• AMI

• Forms Management• Pain Management• STO Turnaround Time• Patient Identification• Outpatient Services Integration• Timely & Safe Medication

Turnaround• Abbreviations• Pathology Process Flow

Improvement

VBMC-HarlingenWave 5

• ED Registration & Accuracy• Pneumonia Core Measures• Interdisciplinary Communication• VBMC-H Accessibility• Ancillary Departments Results

Availability• Physician Pay for Performance• ED Charges

VBMC-BrownsvilleWave 1

• Emergency Department Hold Time• MeMedical Records / Transcription

Turnaround Process• ICU Care Management Process• Outpatient Registration Turnaround

Time• Length of Stay Planning & Mgmt

Process• Radiology Turnaround Time

Wave 5, Wave 1 Initiatives:Wave 5, Wave 1 Initiatives:

Six Sigma Practitioners October 31, 2005

• Master Black Belts (5)– 3 Certified– 2 Seeking Certification

• Black Belts (4)– 3 Harlingen– 1 Brownsville

• Green Belts (61)– 31 Certified – 30 Seeking Certification

• Yellow Belts (34)– 15 Executives– 19 Physicians

• Master Change Agents (2)• Change Agents (237)

– 190 Harlingen– 47 Brownsville

• Future– All Executives will be trained to Yellow Belt level– All Directors and Managers to Green Belt certification

Physician Yellow BeltsPhysician Yellow Belts

• Jose Ayala, DPM• Maria T. Camacho, MD• Miguel Cintron, MD• Chandler E. Deal, MD• Luis Gaitan, MD• Alfredo Garcia, MD• Giovanna Ghafoori, MD• Khadim Hussain, MD• Garner Klein, MD• Robert A. Lozano, MD

• Raul Maldonado, DPM• Juan Mancillas, MD• Carlos Medina, MD• John A. Partin, MD• Eric Six, MD• Adela S. Valdez, MD• Daniel F. Villarreal, MD• Gerald Witson, DDS• Robert T. Wright, DO

Six Sigma Six Sigma Physician Council MembersPhysician Council Members

• Miguel Cintron, MD• Lisa Dix-Emperador, MD• Luis Gaitan, MD• Giovanna Ghafoori, MD• Tomas A. Gonzalez, MD• Christopher Hansen, MD• Khadim Hussain, MD• Garner Klein, MD

• Bruce Leibert, MD• Juan J. Mancillas, MD• Clay W. Ross, MD • Michael Simpson, MD• Eric Six, MD• Adela S. Valdez, MD• Gerald Whitson, MD• Robert Wright, MD

VBHS Application of VBHS Application of Six SigmaSix Sigma

Operating RoomOperating Room

• The amount of time it takes to turnaround surgical suites from one case to the next has been decreased 34% from

61 minutes on average in 2002, to

40 minutes in 2005.

Emergency DepartmentEmergency Department

• The amount of time it takes a patient to see a doctor after walking into the ED has been decreased 21% from 105 minutes on average in 2002, to 83 minutes in 2005.

• The amount of time it takes to discharge a patient after the doctor has determined the discharge disposition has been decreased 30% from 33 minutes on average in 2003, to 23 minutes in 2005.

• The amount of time it takes to admit a patient after the doctor has determined the admission disposition has been decreased 46% from 226 minutes on average in 2004, to 122 minutes in 2005.

NursingNursing

• The amount of time it takes to complete the Nursing Assessment on inpatients at VBMC – H has been improved 68% from 102 minutes on average in 2003, to 33 minutes in 2005.

• Pain Management assessment and follow up has been improved 16% from a compliance rate of 73% in 2004, to 84% in 2005.

• The amount of time it takes the nursing department to activate physician orders has been improved 76% from 88 minutes on average in 2002, to 21 minutes in 2005.

• The amount of time it takes to discharge a patient after the physician has determined that the patient’s discharge from the hospital is appropriate has been improved 73% from 185 minutes on average in 2003, to 50 minutes in 2005.

PharmacyPharmacy

• The amount of time it takes the pharmacy to verify a physician order has been improved 79% from 110 minutes on average in 2002, to 23 minutes in 2005.

Diagnostic Related Group Diagnostic Related Group

• Assignment on 12 DRGs has improved 31% from an accuracy rate of

75% in 2003, to Six Sigma performance in 2005.

Stroke CareStroke Care

Letter dated September 27, 2005 from Joint Commission’s Executive Vice President, Russell P. Massaro, MD, FACPE:

The Joint Commission is pleased to award Disease – Specific Certification to your organization’s primary stroke center as a result of the September 2, 2005 review at Valley Baptist Medical Center

This certification is effective for two years from September 3, 2005, and is indicative of your program’s compliance with consensus-based national standards; effective use of established clinical practice guidelines to manage and optimize care; and performance measurement and improvement activities.

Patient Identification Patient Identification

• Proper patient identification prior to medical procedures has been improved from a compliance rate of 96.8% to 100%

Evidenced Based MedicineEvidenced Based Medicine

• The compliance with the Joint Commission on Accreditation of Healthcare Organization’s core measures for Acute Myocardial Infarction has been improved from 94.6% in 2004, to 100% in 2005.

• The compliance with the Joint Commission on Accreditation of Healthcare Organization’s core measures for Heart Failure Management has been improved from 58% in 2004, to 100% in 2005.

Wave 5

Six Sigma Improvement Initiatives:Initiative:Initiative: Baseline Baseline

Yield:Yield:Baseline Baseline Sigma:Sigma:

Pilot Pilot Yield:Yield:

Pilot Pilot Sigma:Sigma:

Control Control Yield:Yield:

Control Control Sigma :Sigma :

VBMC-H Accessibility 78% 2.27 82.6% 2.44 85.8% 2.57

Interdisciplinary Communication

1.9% 0 100% 6+ 100% 6+

Ancillary Departments Results Availability

64.3% 1.87 75.8% 2.2 87.5% 2.65

Community Acquired Pneumonia

5% 0 86.7% 2.61 84.6% 2.52

ED Registration Process (accuracy and cycle time)

89.3% 2.74 93.3% 3 95.5% 3.24

45.2% 0 89.1% 2.7 95.5% 3.24

ED Charges 80.3% 2.35 92.2% 2.92 92% 2.9

Wave 1 Theme: Patient Flow/Throughput

Six Sigma Improvement Initiatives:

Initiative:Initiative: Baseline Baseline Yield:Yield:

Baseline Baseline Sigma:Sigma:

Pilot Pilot Yield:Yield:

Pilot Pilot Sigma:Sigma:

Control Control Yield:Yield:

Control Control Sigma:Sigma:

ICU Care Management 58% 1.70 80% 2.34 83% 2.46

Length of Stay Planning and Management Process

57% 1.68 86% 2.60 86% 2.21b

OP Registration Turnaround Time

58% 1.70 88% 2.68 90% 2.81c

Radiology Turnaround Time

29% 0.00 91% 2.82 90% 2.80c

Medical Records/Transcription Turnaround Process

12% 0.00 85% 2.60 92% 2.90c

Emergency Department Hold Time

54% 1.61 98% 3.67 96% 3.28c

a. Yield = percent of opportunities with specification limit (customer requirements)

b. Translated to additional medical-surgical unit

c. Translated hospital wide

Translation Theme–IntegrationTheme–Integration

Initiative:Initiative: Baseline Baseline Yield:Yield:

Baseline Baseline Sigma:Sigma:

Control Control Yield:Yield:

Control Control Sigma:Sigma:

Patient ID

–Labor & Delivery 99% 3.75 100% 6+

–Ancillary Departments

100% 6 100% 6+

AMI Core Measures 81% 2.39 100% 6+

CHF Core Measures 53% 1.56 96% 3.27

Surgical Preparation 73% 2.12 - -

a. Yield = percent of opportunities with specification limit (customer requirements)

Six Sigma Translation Initiatives:

VBMC – Harlingen• Surgical Preparation – Day Surgery• DRG Assurance of Accuracy• Inpatient Identification Process – Mother Baby Unit• Inpatient Identification Process – Ancillary Departments• Forms Management• Acute Myocardial Infarction• Heart Failure Management• MDS Accuracy – Golden Palms

VBMC-Brownsville• Patient Identification (IP/OP) – Ancillary Departments• Acute Myocardial Infarction

Initiatives Reaching Initiatives Reaching Six Sigma PerformanceSix Sigma Performance

Start: 01/05 End: 06/05Interdisciplinary Communication

Start: 01/05 End: 06/05Interdisciplinary Communication

Initiative Description: Ensure interdisciplinary collaboration and communication in patient care

Initiative Description: Ensure interdisciplinary collaboration and communication in patient care

Interdisciplinary CommunicationInterdisciplinary CommunicationJanuary 12, 2005 – Present

Interdisciplinary CommunicationInterdisciplinary CommunicationJanuary 12, 2005 – Present

Initiative Title: Interdisciplinary Communication

Champion: Shane Spees, CEOSponsor: Chris Hansen, MD

VP, Medical AffairsOwner: Joanne WetchMaster BB: Art Rangel, CHEBlack Belts: Patrick Ybarra Terri Teinert

Initiative Title: Interdisciplinary Communication

Champion: Shane Spees, CEOSponsor: Chris Hansen, MD

VP, Medical AffairsOwner: Joanne WetchMaster BB: Art Rangel, CHEBlack Belts: Patrick Ybarra Terri Teinert

Team Members:

Rosemary Perkins David MannNicole Ballenger Candy Woodin Shelley Eyzaguirre Eddie UribeJeannie Dodson-Brown Rita VillarrealShirley Fisher Cindi BrentSue Griffin Henrietta PeynadoRosie Arredondo Sylvia Garza

Team Members:

Rosemary Perkins David MannNicole Ballenger Candy Woodin Shelley Eyzaguirre Eddie UribeJeannie Dodson-Brown Rita VillarrealShirley Fisher Cindi BrentSue Griffin Henrietta PeynadoRosie Arredondo Sylvia Garza

Alignment with Strategic Plan: Disciplined Offering of Services, Six Sigma Quality, Relentless Customer Service, Employee Partnership

Alignment with Strategic Plan: Disciplined Offering of Services, Six Sigma Quality, Relentless Customer Service, Employee Partnership

Initiative Scope:In: 6 South Tower, Inpatients, Interdisciplinary Team Members, Care Paths, Discharge Planning Rounds

Initiative Scope:In: 6 South Tower, Inpatients, Interdisciplinary Team Members, Care Paths, Discharge Planning Rounds

Problem Statement:

There is no standardized process for interdisciplinary communication in patient care. Currently there are multiple forms (Kardex, Care Path, Care Plan) for communication.

Problem Statement:

There is no standardized process for interdisciplinary communication in patient care. Currently there are multiple forms (Kardex, Care Path, Care Plan) for communication.

METRICS   BASELINE  

       

Dates  Oct. 2004 –Jan. 2005 

 

n   315   

DPMO    980,952  

Yield    1.9%  

Z Score    0  

Baseline Metrics/Process CapabilityBaseline Metrics/Process Capability

1.90%

0.0 20.0 40.0 60.0 80.0 100.0

1

% Compliance

Improvement efforts:- Developed an electronic Interdisciplinary Communication Record (ICR) to include documentation from:

Nursing, Care Management, Pastoral Services, Respiratory, Rehabilitation Services, Nutrition, Cardiac Rehab,

Enterostomal Therapy, Diabetes Educators

- Developed a SOP , “Interdisciplinary Communication Record”

- Numerous Change Acceleration Process activities

Improvement efforts:- Developed an electronic Interdisciplinary Communication Record (ICR) to include documentation from:

Nursing, Care Management, Pastoral Services, Respiratory, Rehabilitation Services, Nutrition, Cardiac Rehab,

Enterostomal Therapy, Diabetes Educators

- Developed a SOP , “Interdisciplinary Communication Record”

- Numerous Change Acceleration Process activities

What did you change/improve?- Interfaced discipline specific documentation in IDX (clinical documentation

software) to the electronic ICR

- Nutrition Services adopted 100% electronic documentation

- Rehabilitation Services created an IDX documentation screen for the ICR (Goal – 100% electronic documentation by August 31, 2005)

- Respiratory created an IDX documentation screen for the ICR; requires discipline to document per shift to assist with compliance ( Goal – to utilize IDX for all documentation with the next upgrade)

What did you change/improve?- Interfaced discipline specific documentation in IDX (clinical documentation

software) to the electronic ICR

- Nutrition Services adopted 100% electronic documentation

- Rehabilitation Services created an IDX documentation screen for the ICR (Goal – 100% electronic documentation by August 31, 2005)

- Respiratory created an IDX documentation screen for the ICR; requires discipline to document per shift to assist with compliance ( Goal – to utilize IDX for all documentation with the next upgrade)

How do you know your changes made a difference?Statistical significant difference between baseline and pilot data (Chi-Square Test P-value = 0.00)

How do you know your changes made a difference?Statistical significant difference between baseline and pilot data (Chi-Square Test P-value = 0.00)

Respiratory NursingPastoral Services

Nutrition

Care Management

Rehab Services

Cardiac Rehab

Enterstomal Therapy

ICR View

Diabetes

1.9%

100%

100%

0 20 40 60 80 100

Control

Pilot

Baseline

Interdisciplinary Communication Compliance Rate

Questions?