lean six sigma and process improvement in healthcare summit

© Pittsburgh Regional Health Initiative 2011 1

View from the Top: “It’s not about tools to achieve success in Lean Six Sigma. It’s about how to get leaders to believe in and EMBRASE quality!”

Karen Wolk Feinstein,PhDPres ident & Chief Execut ive Off icer Lean S i x S i gma and Proces s Improvement i n Hea l thca re Summi t , New Or leans , LA

May 11 , 2011Spreading Quality, Containing Costs.


Who We Are and

How We Approach Transformation


Who Are We?

Pittsburgh Regional Health Initiative (PRHI) A not‐for‐profit, regional, multi‐stakeholder coalition formed in 1997

An initiative of a business group, the Allegheny Conference on Community Development

PRHI’s messageDramatic quality improvement (approaching zero deficiencies) is the best cost‐containment strategy for health care


Regional Health Improvement Collaboratives: The Infrastructure for Transformation

Unique to U.S.

Multi Stakeholder Focus

PRHI = oneof the first

NeutralRegional

Measurement/Transparency

40+

A Decade of Growth

1995‐2005

PayersProvidersPurchasersEmployersPatients

Quality Improvement

Disease Management

THE GOAL: Quality ImprovementCost Containment


Pittsburgh Regional Health Initiative

Founders:

Karen Wolk Feinstein, PhDPresident and CEO since founding

Paul O’NeillAlcoa Chairman 1987‐1999

U.S. Secretary of Treasury 2001‐2002


PRHI’s Prescription for Transformation

Services That Add Value All Services Add Value

Preventable Complications

Unnecessary Treatments

Inefficiencies

Errors

100% Value

60% Value

40% Waste

NOW FUTURE


The Problem Was Worse Than We Thought

How Does the U.S. Measure Up Globally?

Source: Commonwealth Fund Commission on a High Performance Health

Australia Canada Germany NetherlandsNew

ZealandUnited Kingdom

United States

OVERALL RANKING (2010)

Quality Care

Effective Care

Safe Care

Coordinated Care

Patient‐Centered Care

Access

Cost‐Related Problem

Timeliness of Care

Efficiency

Equity

Long, Healthy, Productive Lives

Health Expenditures/ Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290

Country Rankings Excellent Fair Poor

© Pittsburgh Regional Health Initiative 2011


“Bringing state‐of‐the‐art care to all will require a fundamental, sweeping redesign of the entire health system … merely making incremental improvements in current systems of care will not suffice.”

‐ The Institute of MedicineMarch 2001

The Bottom Line: Transformation of Organizations and Systems


Moving Beyond Repair to Transformation

PPC for Systems Transformation

PPC for Organizational Transformation

PPC for Repairs

An Early Vision for Perfecting Care

A Method for Perfecting Patient CareSM (PPC)

PPC in New Technologies and New Models


The Original Vision


Where Value Derives

THE PATIENT

• Outcomes of Care

• Efficiency of Care

• Zero Defects

Value begins at the frontline


Toyota Lean Production Thinking: The Basics

Problems identified and solved

Rapid root cause analysis

Organized work areas

Concise communication

Active involvement of managers

“Go and see”

On the floor

Intense respect for the employee:

Every employee has what they need, when they need it to succeed

Career development

Team problem solving to meet customer need


What We Observed in Health Care

W. Edwards Deming, PhD: “Where Art Thou?”

ChaosUncertaintyRandom BehaviorsWork‐AroundsConfusionDisorderErrorsHigh TurnoverSecrecy


Where We Beganon the Journey to Transformation


Our Method:What We Value in Perfecting Patient CareSM (PPC)

One universal improvement method

Meeting patient need is the focus of all work

Frontline clinical teams apply daily problem‐solving methods and work process improvement techniques

Research occurs and is performed at the frontline

Focus is clinical care improvement


What We Value About PPC (cont’d)

Coaches and Core Champions are “embedded” professionals

Knowledge and learning are elicited and shared across organization

Ultimate goal is perfection— 100% error reduction and best clinical practices

Leadership engagement reaches to highest levels


“The job of CEOs, COOs, CMOs, CNOs, Presidents, chairs, and chiefs must include dynamically discovering ever better approaches for performances.

What they don’t do is get into the nitty gritty of mastering the skills necessary for discovering greatness–starting with small, safe, skill‐incubating pilots and then expanding to more comprehensive, complex, and sophisticated applications.”

‐ Steven J. SpearAuthor of “Decoding the DNA of the Toyota Production System” and “Fixing Healthcare from the Inside, Today”

Role of Leadership


The Executive Role in Transformation

Paul O’Neill ‐ Alcoa Chairman, 1987‐1999

Corporate commitment to reduce workplace injury rate to zero

Imported Toyota Production System, manager accountability, real‐time data reporting to Alcoa; reduced workplace injuries by 90% over 12 years

Alcoa became the safest company in the world


The Champion Role in Transformation

PPC empowers frontline staff…and more

Nurse Navigators

Nurse Managers

Team LeadersSalk Fellows

Patient Safety Fellows

Physician Champions

Clinical Pharmacists

Long‐term Care Workers

Librarians

Hospital Trustees

Emergency Medical Technicians

Caregivers


PPC University: Preparing Champions

Four‐day, in‐depth course dealing with actual, on‐the‐floor problems – at the point of patient care

Examine PPC principles, using hands‐on exercises

Learn the Rules of Work Redesignand tools

Observe actual clinical problems and solve them!


Perfecting Patient CareSM (PPC) Training


Demonstrating the Value of PPC


STEP ONE: Reducing Hospital‐Acquired Infections

30+ hospitals participating in PRHI’s community‐wide infection control project reported an average 68 percent reduction in CLABs over four yearsResults varied among institutions

The Power of Perfecting Patient CareSM: one hospital virtually eradicated CLABs from its main intensive care units


PPC Eliminates CLABs in One ICU

After the standardization and additional training, the hospital essentially eliminated CLABs in its CCU

Coronary Care Unit

Pre Improvement

Post Improvement

4%

3%

2%

1%

0%


68% Dropin CLABs in 34 regional hospitals

50% FewerReadmissionsw/ COPD focus

86% Reductionin medication errors

180 to Zero!Lost patient hours per month due to ambulance diversions

Efficiency Increased 100%

in pathology lab

17% Dropin pediatric clinic

wait times

100% Reductionin nurse turnover

50% Reductionin pap smear

sampling defects

>20% DeclineNosocomialC. difficileinfections

35 to Zero!defective charts

100% Compliancew/guidelines & aspirinuse in a diabetes clinic

PRHI Stories of Success in Acute Care


Our Methods and Successes Have Attracted Attention


But, success didn’t spread

beyond individual units — and

sustainability was uncertain.


Global Vision

Culture of Quality and Safety

Quality Improvement Strategy

Targets and Measurement

Designated Champions and Teams

Training, Education and Coaching

Interdisciplinary/Transitional Collaborations

Research/Experimentation/Registries

Consumer and Purchaser Engagement

Information Technology

Public Reporting

Incentives for High Performance

Transforming Healthcare Organizations: Hit all the notes on the xylophone or no music


What Does Organizational Transformation Look Like?



System‐Wide Transformation:Veterans Affairs (VA) Hospital Attacks HAIs

When Perfection is the Goal

Pittsburgh VA targets elimination of methicillin‐resistant Staphylococcus aureus (MRSA)

Identified lack of standardization for hand hygiene and use of personal protective equipment

Used red tape as visual cue for when to gown and glove


Hand Hygiene


What Workers Need – Where They Need It


Equipment Room Disorganization

Keeping the equipment room clean and organized eliminates time wasted searching for supplies and reduces opportunities for contamination

BEFORE AFTER


(Orderly?) Supply Room

AFTER


Unexpected Issue: Poor Transport at the VA

Problem: Wheelchairs weren’t available (or clean) when needed

Solution:Colored labels to identify which unit a wheelchair belongedLocations identified for convenient wheelchair courtesy pointsWheelchairs regularly cleaned and maintained

Outcome:Patients were on time more often for appointments (from ~40% to 90% on‐time rate)Wheelchairs returned to the VA after patient transfers (otherwise would have been lost)


VA MRSA Intervention Results

85% reduction in MRSA rate

Sustained compliance with hand hygiene, gowning, and gloving

Team continues to identify opportunities to reduce MRSA rates

For more information, go to www.prhi.org to watch a Teachable Moment about this project

0

0.5

1

1.5

2

MR

SA

Infe

ctio

ns

per 1

000

BD

OC

Start of Intervention

2000 2001 2002 2003 2004


Systemwide Improvement


PPC: The Transformed Organization

Leadership engagement reaches to highest levels

One universal improvement method

Meeting patient need is the focus of all work

Frontline clinical teams apply daily problem‐solving methods and work process improvement techniques

Research occurs and is performed at the frontline

Focus is clinical care improvement

Coaches and Core Champions are “embedded” professionals

Knowledge and learning are elicited and shared across organization

Ultimate goal is perfection— 100% error reduction and best clinical practices


PRHI is about VALUE

Spreading Quality

and

Containing CostSpreading Quality,Containing Costs.


Perfecting Care in Systems


Treating Chronic Illness Accounts for 75% of Expenditures

Major chronic interventional

34%

Chronic illness management

35%

Major acute/ interventional

23%

Minor acute8%

Preventive use only<1%

Percent of costs associated with medical needs

Source: Luft, Harold. Total Cure. Cambridge, 2008: Harvard University Press. pg. 66


22.9%

49.5%

65.2%74.6%

81.2%

97.0%

3.0%0%

20%

40%

60%

80%

100%

Top 1% Top 5% Top 10% Top 15% Top 20% Top 50% Bottom 50%

Percent of Population, Ranked by Health Care Spending

Focus on Spending Leads to Complex PatientsP

erce

nt o

f Tot

al

Hea

lth C

are

Spe

ndin

g

The 5% of the U.S. population with highest health care expenses was responsible for nearly half of total health care spending

Concentration of Health Care Spending in the U.S. Population, 2007


Currently: Where do the $$$ go? Hospital Care

Hospital Care31%

Physician and clinical services21%

Retail sales of prescription durges

10%

Program administration and net cost of private

insurance7%

Investment in research, structures and equipment

7%

Nursing home care6%

Other professional serives and personal care

6%

Dental services4%

Government public health activities

3%

Home health care3%

Retail sales of durable medical equipment

1%

% of Healthcare Spending, U.S., 2008

Source: Modern HealthcareJanuary 11, 2010, pg. 7


Hospital Errors Lead to More Hospitalizations

Infections Lead to Readmissions

• 1.2% of PA hospital patients contract a hospital‐acquire infection

• 30% of all infected patients are re‐admitted within 30 days of initial discharge due to infection

• 60% of patients who contract surgical site infections are readmitted within 30 days

Source: Pennsylvania Health Care Cost Containment Council, “The Impact of Healthcare‐Associated Infections in Pennsylvania,” 2009


Transforming Transformation into Two Targets

1• Preventing hospitalizations of complex patients

2• Preventing infection

Ø Target Burnout


The Readmissions Cycle

Incomplete Primary Care

Emergency RoomInfection

Hospitalizations

$ $


PRHI’s researchers perform analyses on hospital discharge data

PRHI found that approximately 20% of discharges are readmitted within 30 days

Data Source


The Complex Patient

Who is frequently hospitalized?

Do you know your customer?

Are you meeting their need?


Let the Data Guide Our Work

The Complex Patient

HIV/AIDS End of Life

Skilled Nursing

Chronic Disease

Behavioral Health and Substance Abuse


Why So Many Readmissions?

“Nobody integrates care for the medical condition as a whole and across the full cycle of care, including early detection, treatment, rehabilitation, and long-term management.”

‐Michael E. Porter &

Elizabeth Olmstead Teisberg, PhD


The Second Systems Vision: Transforming the Care of Complex Patients

Across Ca

re Settings

Essential Services System Requirements

Care Mgt

Clinical Pharmacy

Patient Engagement

Health IT

QI Training

Financial Incentives

Collaboration and

Integration

Medication Reconciliation

Informed Activated Discerning Consumers

Data to Treat,

Measure,Evaluate

Perfect PatientCare

RewardsFor Quality

Hospice/Palliative

Long Term Care

Rehab

Hospital

Emergency Services

Specialty Care

Primary Care

Screening and Tx

Behavioral Health


What is essential to ourvision for reducingreadmissions?

Care Management

ClinicalPharmacy

Patient Engagement

Behavioral Health

HIT QI Training

Isn’t reimbursed


Testing our Model:Reducing Preventable Hospitalizations — COPD

Our data mining identified chronic obstructive pulmonary disease (COPD) as prominent cause of hospital admissions (4th highest) and readmissions (3rd highest)

Readmissions in Western PA, 2005-06

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

CHF Pneumonia Depression COPD KidneyFailure

AbnormalHeartbeat

Diabetes Asthma

Diagnosis at Initial Admission

# R

eadm

itted

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

% R

eadm

itted

# ReadmitsReadmit Rate


Kaizen Uncovers Current Condition

Patient discharged without training on inhaler use

MD gives patient prescription for inhaler, but no training

Patient gets inhaler from pharmacy, but training

Patient fails to use inhaler properly, leading to hospitalization

Patient is treated with nebulizer during hospital stay

DANGEROUS CYCLE


Breaking the Cycle of COPD Readmissions

MD gives patient prescription for inhaler, but no training

Patient fails to use inhaler properly, leading

to hospitalization

Patient is treated with nebulizer during hospital stay

Patient is discharged without training in use of inhaler

Patient gets inhaler from pharmacy, but no training


Kaizen Team Breaks Cycle

Team determines two keys:

Hospital – Patient education to address causes of admission

Community – Improved patient education and support in the community


The Solution Coordinates Transition Between Hospital and Community

Improvedpatient

educationand

support*in the

community

Patienteducationto addresscauses of admission

COMMUNITYHOSPITAL

Patient uses inhaler properly, leading to improved functioning

Patient is discharged WITH training in use of inhaler

MD gives patient prescription for inhaler, but no

training

Patient gets inhaler from pharmacy, but no training

Patient fails to use inhaler properly, leading to

hospitalization

Patient is treated with nebulizer

during hospital stay

Patient is discharged without

training in use of inhaler

+ + +*CareMgt

ClinicalPharmacy

PatientEngagement

BehavioralHealth


With the goal of reducing readmissions of patients with COPD, learn how a team from UPMC St. Margaret redesigned the way they delivered care.

Teachable Moments

www.prhi.org/ppc_teachablemoments.php

http://www.prhi.org/TeachableMoments/2010/COPD.html

http://www.prhi.org/ppc_teachablemoments.php


COPD Readmissions Reduction Results

By focusing on the transitions between care settings:30 readmissions prevented

$160,000+ saved

Net savings of $80,000+ after cost of Care Manager

0%1%2%3%4%5%6%7%8%9%

10%11%12%13%14%15%

Jan-Dec 2008 Jan-Dec 2009

% of Patients Admitted for COPD Exacerbation and Readmitted within

30 Days for COPD or Pneumonia

44% Reduction


Reducing Preventable Hospitalizations: Behavioral Health Comorbidities

Patients with co‐morbid depression are more likely to be readmitted

% Readmitted with No Secondary

Depression

% Readmitted with Secondary Depression

Asthma 29% 42%COPD 43% 51%

Pneumonia 34% 42%All Other 29% 37%

Source: PRHI Analysis of PHC4 Data 2005‐2006, SW PA

Patients with depression and co‐morbid substance use disorders are more likely to be hospitalized for four days or longer


A Solution: Integrating Behavioral Health Into Primary Care

Consulting Pharmacist

Performs med. rev. and consults with PCP, PRN

Consulting Psychiatrist

Consults weekly with the

CS/BHCM on all cases

Clinical Specialist (or BHCM)

Brief interventions and self‐

management support

Informed, Activated Patient, Primary Care Physician, and Office Staff

SBIRT IMPACT

All patients are screened for behavioral

health and/or substance abuse issues

http://images.google.com/imgres?imgurl=http://www.glamour.com/images/sexmen/2006/07/10/Seqa01_hutcherson.jpg&imgrefurl=http://www.glamour.com/sexmen/sextips/articles/2006/08/28/hutcherson06oct&h=164&w=150&sz=10&hl=en&start=29&tbnid=lguVE2wu8GeeUM:&tbnh=98&tbnw=90&prev=/images?q=primary+care+doctor&start=20&gbv=2&ndsp=20&hl=en&sa=N


Results of Integrating Behavioral Health into Primary Care

Of patients screened; 24% positive

49% achieved at least 50% reduction in depression symptoms at six months

24% reported ER visit at baseline versus 14% through six months in ITPC

Led to $3.5 Million partnership among Minnesota, Wisconsin and Pennsylvania


“High‐utilizer work is about building relationships with people who are in crisis. The ones you build a relationship with, you can change behavior…”

‐ Jeffrey Brenner, M.D.Camden Coalition of Healthcare Providers


New Models of Care:Leading with Behavioral Health

Behavioral Health Specialists

The Nuka Model

http://www.facebook.com/album.php?profile=1&id=92232120943


Reducing Preventable Hospitalizations:PPC in Skilled Nursing Facilities (SNFs)

6% of seniors in SNFs = 17+% of healthcare costs

20% of hospital patients discharged to a SNF were readmitted

51% of residents have one or more ER visits

38% have a hospitalizations: 41% are readmitted


PPC in Skilled Nursing Facility Reduces Unplanned Hospital Admissions

60% decrease in pressure ulcers

25% improved pain management

40% improvement in risk assessment compliance

Unplanned hospital admissions among residents with chronic conditions reduced to zero over a 12‐month period


Preventing Hospitalizations:New Rules for End of Life

Discussing advance planning with patients before a health crisis

Respecting the patient’s end of life plans

Communicating a realistic prognosis to the patient

Referring patient for palliative care and/or hospice in a timely manner

Estimates show that about 27% of Medicare's annual budget goes to care for patients in their

final year of life

Source: http://www.usatoday.com/money/industries/health/2006‐10‐18‐end‐of‐life‐costs_x.htm


Disruptive Innovations


“The challenge we face is not unique to health care. The transformational force that has brought value to other industries is disruptive innovation. The healthcare industry screams for disruption.”

‐ Clayton M. ChristensenThe Innovator’s Prescription: A Disruptive Solution for Health Care

Disruptive Innovations: System Transformations


Disruptive Innovations

1. Simple, less expensive, “upstream” innovations

2. Serve more with fewer features

Do not overshoot customer need

Show better understanding of customer need


“Training dosage had most important effect on measures of success. A combination of PPC training, additional training, and coaching were associated with improved outcomes. Social networking or on‐line technology can foster a virtual PPC community.”

‐ Donna O. Farley, PhDRAND: Results from the Retrospective Evaluation Effects of PPC University Training

The Technology Innovation


The Web‐based Solution: Tomorrow’s HealthCare™


Perfecting Patient CareSM OnlineDemonstrations & toolsCertification & accredited educationCase studies & examples

Lean tools & techniquesAssessment templatesRegistries Sample interventionsImplementation & planning guides

Individual, team & institute projectsEducational credit & project trackingProject progress assessment tools

Communities of interestBest practice sharingOpen source content developmentDiscussion boards

Process & Quality Improvement

Customized ePortfolio

Professional NetworkingLearning

Tomorrow’s HealthCareTM at a Glance


“Put everybody in the company to work to accomplish the transformation.”

‐W. Edwards Deming, PhD


Team Leaders & Managers

Champions

Frontline Staff

PhysiciansHealthcare Executives

Tomorrow’sHealthCare™

• Test• Prove• Collaborate

• Learn• Experiment• Document

• Educate• Motivate• Incentivize• Reward

Tomorrow’s HealthCare™ Participants

• Team up• Improve• Capture

• Manage• Communicate• Measure• Reward• Spread


Interactive Animated Learning


You Can’t Reward What You Don’t Measure

Pay for Performance

Hospital Admissions Data

Patient Registries

Electronic Health Records

Tomorrow’s HealthCareTM can be customized to measure what you want to reward


Lessons From the Field

The combination of PPC and Tomorrow’s HealthCareTM is being tested in many healthcare settings

Hospitals

Skilled Nursing

Behavioral Health

Community Health Centers


Lean Philosophy is a Way of Life

Not spot repair

Enterprise thinking

Maximization of resources

Adaption for survival and

competitive positioning Vitruvian Man


What We Teach

Systems thinking

Work derives from customer pull/need

Critical performance pathways extend to and from the organization

Teamwork

Automation and Precision

Efficiency and “work leveling”

Rapid Frequent Problem Solving

Work Redesign begins at the Frontline

Circuit Board Exercise


Lean Organizations are Adaptive

Change is a constant, Now Accelerating

Policy (payment, regulations, accountability)

Demand

Workforce

Patients

Quality Expectations

Technology


Chronic Disease Care

Coordination

Pharmacist Consults

Behavioral Health

Screening

Anticoagulation Clinic

Support Reaching “Meaningful Use” EHR Targets

Nurse Care Managers

PCP Refers Patient for PCRC

Management

PRIMARY CARE RESOURCE

CENTER

Self-ManagementSmoking

Cessation

Spirometry

New Models of Care: Hospital‐based Primary Care Resource Center

Supports team‐based care coordination of chronic medical conditions

Provides added‐value primary care support services beyond the means of small practices

Can utilize excess hospital space


New Models of Care: Secondary Care Centers

United States Care Model

Israeli Care Model Cost‐effective, ambulatory care:operates between primary and hospital care with multi‐disciplinary post‐discharge follow up, team‐based specialty clinics.

United States hospitals have 40% more

acute beds per 1000

population than Israel

Urgi‐CareCenters

Specialists Offices

Ambulatory Surgi‐Centers

Same Day Surgery

Outpatient Imaging

23 Hour OBS Units

Hospitals

HOSPITALS IN THE UNITED STATES

SECONDARY CARE CENTERS IN ISRAEL

Lin Medical Center

Zvulun


Secondary Care Centers (cont’d)

Asthma

Breast Cancer

Pelvic Floor

COPD Parkinson’s Disease

PPC for Systems Transformation


PPC for Repairs

An Early Vision for Perfecting Care

A Method for Perfecting Patient CareSM (PPC)

PPC in New Technologies and New Models

Moving Beyond Repair to Transformation

lean six sigma and process improvement in healthcare summit

Documents

manager accountability

neutral measurement

containing costs

theinfrastructurefortran