what it means to be a six sigma organization
TRANSCRIPT
What it means to be…
A Six Sigma Organization
Decatur Memorial Decatur Memorial HospitalHospital
Decatur Memorial HospitalBrief Overview
• Located in Decatur, IL• Founded January 1st, 1916• Community based, Not-for-profit• Capture over 65% of market share in our area• 30+ satellite facilities reaching all of Macon
County as well as Dewitt and Moultrie counties• 43 owned physician practices
Annual Operating Statistics2005
• Licensed Beds = 356• Inpatient Stays = 12,463• Outpatient Visits = 302,054• Emergency Center Visits = 48,913• Average Daily Census = 155.3• Average Length of Stay = 4.4 days• Number of Employees = 2492
Where have we been...— Facilitator Training (CAP/WorkOut)
— Executive Training
— Deployment Partner Training - Black/Green Belts
— Incorporate Six Sigma Awareness - New Hire Orientation
— Complete Initial Belt Training (2 projects)
— Master Black Belt Training
— Begin In house Training Waves – Black/Green Belts
— Corporate Project Tracking
— Integration of I21
— Begin In house Yellow Belt training
— Decentralization of belts
— Decentralization of project accountability
Oct ‘01
Oct ‘01
Nov ‘01
Feb ‘02
Nov ’02
Oct/Nov ‘02
Jan ‘03
Jun ‘04
Aug ’04
Jan ’05
Jul ’05
Jan ‘06
1
234
5
Imagine 21
• Fifth Discipline – Personal Mastery
• Emotional Tension vs Creative Tension
• The need for a vision
• Beliefs about Reality vs the Truth
• If you dwell in the past, then tomorrow looks like today
• Commitment to the Truth
Vision
CR
Learnings from our Deployment
1. Deployment champions (Executive Staff) need to be “Kool Aid” drinkers.
2. Seek middle management buy-in and understanding.
3. Never conduct a training session without a meaningful project attached, otherwise is an exercise in futility.
4. Teach the most meaningful tools.
5. Results are the goal, not the training.
6. Realize Six Sigma is not for a select group of belts, it is an organization approach to improvement – stick with it.
7. Incorporate Six Sigma training into employee development plans.
8. Give Six Sigma care and feeding.
Nosocomial Infection StrategiesA Six Sigma Approach
IT’S A CULTURE!!!
What is the compelling need to change?
An honest assessment of Current State!
How many black dots are there?
1. Zero Nosocomial Infections is impossible.2. I always wash my hands.
… We see things not as they are, but as we believe them to be …
Nosocomial Infection StrategiesA Six Sigma Approach
Are these your finger tips?
Unit by Unit Assessment
Every place and Every one is in play
OR Evaluations
Every place and Everyone is in play1. Right solutions2. Right duration3. Right procedures
Nosocomial Infection StrategiesA Six Sigma Approach
Surgical Wounds
Primary Blood Stream
UTI
• Appropriate antibiotic within 60 mins of surgery start• Appropriately discontinued prophylactic antibiotic within 24hrs• Staff enter/exit OR during case• Surgical Scrub Techniques, attire, gloving• Hand Hygiene
• Use and disposal of needles and other sharps, • Instrument decontamination, cleaning, sterilization, disinfection and storage,• Housekeeping and waste disposal.
• Central Line Dressings / Insertion – Maximal Barrier Precautions (handwashing, wearing a cap, mask, sterile gown and gloves )
• Glucose Control• Hand Hygiene
• Monitoring catheter days by patient• Ongoing monitoring of flow• Hand Hygiene
NI – Current State, trend analysis
2003 = 142
2004 = 128
2005 = 109
43% 24%
21%
A first project… ICU/CVU focus
Nosocomial Infections
documentation
dressing changes
pre-op bath
clippers
dressing changes
insertion technique
catheter type
catheter days
closed system
catheter type
sputum cultures
Mouthwash
Evac ETT
HOB > 30
isolation procedure
clean equipment
isolation compliance
hand hygiene complia
staff training
staff awareness
People
Env ironment
Pneumonia
UTI
Blood stream inf ection
Surgical Site
Cause-and-Effect Diagram
Low hanging fruitClippers for shaving all CABG patientsImproved isolation processMore specific isolation signage Easy to access references on isolation
typesImproved signage re hand hygieneImproved location of hand cleaning
foamStaff education re isolation and hand
hygiene
Six Sigma team and tools…
What are the X’s?
• Compliance with Hand Hygiene Policy
• Head of Bed of Ventilator Patients
• Central Line Dressing Intact and <72 hours
Project Successes:
1. Sustained awareness of Nosocomial Infections at
all levels
2. Creation of improved tracking mechanisms
3. Surgical Site Infections Project – Pre SCIP
4. Timeliness of Antibiotics in Pneumonia
Local Success = Organization Need
Surgical Wound Infection
Antibiotics delivered within 1 hour of Surgery Start time
Baseline DPMO: 209,677Project Close: 22,700 90% Reduction in DPMOLatest Month: 85,000 60% Sustained reduction
Antibiotics delivered within 1 hour of Surgery Start time
Baseline DPMO: 209,677Project Close: 22,700 90% Reduction in DPMOLatest Month: 85,000 60% Sustained reduction
Traffic Flow in/out of OR
Nosocomial Infection StrategiesA Six Sigma Approach
Hand Hygiene Compliance• What get’s measured, gets done.
Patient Safety Oversight Committee• All Six Sigma project progress is reviewed
• All Nosocomial infections are reviewed and Root
Cause Analysis done data analyzed for trends
IT’S A CULTURE!!!
Root Cause - Structure
Note: Minimize variability in investigation process
Redesign Medication Delivery System
$ 0.8157 per dose savings
x 883,000 doses per year
$720,000
Med Ordered
Critical Process Factors
1. “Complete Order”
2. Patient Information
3. Successful Transmission
Med Delivered
Critical Process Factors
1. Types / Numbers of Meds
2. Delivery Locations
3. Delivery Times
4. Tech Availability
Order Verified
Critical Process Factors
1. Pharmacist
2. “Packaged Meds”
Med Administered
Critical Process Factors
1. Meds Due Prompt
2. Medications
3. Patient / Nurse
4. “Correct” Med Administration Process
Order Filled
Critical Process Factors
1. “Complete Order”
2. Meds Available
3. Personnel to Prepare
4. “Label”
Critical Process Factors
Pharmacy
Scan not readable - Call floor
to re-scan
Order scanned with no patient name - Call
floor to re-scan
Incomplete Med Orders - (No Route,
strength)Call MD to Clarify
MD Handwriting Illegible
- Clarify with MD
Medication Ordered
Order Scanned to Pharmacy
Order Faxed to Pharmacy
Order Phone Call - received per pharmacy -
MD only
Enter Order in HBOC
Pharmacy System
Pharmacy Personnel Scan Order into Pyxis
Connect for order entry
Incomplete Med Orders - (No Route,
strength)Call MD to Clarify
Order faxed with no patient name - Call
floor to re-fax
MD Handwriting Illegible
- Clarify with MD
Fax not readable - Call floor
to re-fax
Nurse must write as
"telephone order" from
MD
Nurse phoning in
order
Write Order on Physician Order Sheet
Scan in PyxisFile in
appropriate folder
Send copy to floor
Order re-written by R.Ph. on
Physician Order Sheet
Order placed on cart by
Pharmacist
Order re-written by R.Ph. on
Physician Order Sheet
Order placed on cart by
Pharmacist
Order placed on cart by
Pharmacist
Order re-written by R.Ph. on
Physician Order Sheet
Order placed on cart by
Pharmacist
Order re-written by R.Ph. on
Physician Order Sheet
Non-Formulary Drug Med
Order
Contact MD for Formulary Substitution if no P&T auto-sub in place
Sub OK
R.Ph. Writes Order in Chart
Yes
Call floor to see if family can bring in
Send MD formulary
request form & obtain the
item
No
Label Generated for filling if not floor
stock
IV Label generated for filling
Med Label generated
for unit dose filling
Order filled by tech - placed
in baggie - label
affixed & signed - to be checked by
R.Ph.
Bag contents verified by R.Ph. and
R.Ph. sign off
Tech places in appropriate bin for next
delivery round
Medication in Pharmacy
Bins -Ready for Delivery
Stat
No
Tech delivers or tubes
Yes
Printer jam/off-line
No techs to fill unit does
meds
Med not available from manufacturer
Non-formulary Out-of-Stock
Filled incorrectly by tech (wrong dose, wrong
drug)
R.Ph. checking discovers
order entry error
IV Label sent to IV Room for
Preparation
Conventional IV Product - Iv technician to
obtain components
and compound
Pharmacist Checks
IV - Initials Label Correct
CRRT Solutions and TPN Products Pharmacist Enter Order into Abbott
Compounding Computer
Draws up IV components -
Leaves for Pharmacist to
Check
IV Technician completes IV - takes to Unit
Bins for Delivery
Stat
Tubes to Floor
Order Entered - Required
2nd Pharmacist
Check
TPN Label generated
from Abbott Compounder
Components drawn up for
Compounding by Technician
Components Checked by
one Pharmacist
Components Checked by
second Pharmacist
TPN Compounded by Technician
Placed in refrigerator
for 5PM Delivery for 6PM Start
Chemotherapy - Oncology Pharmacist
enters Chemo Order
Oncology Order 2nds Checked by
Another Pharmacist
Oncology Pharmacist Compounds
under horizontal
hood
Oncology Product Completed -
Oncology Pharmacist delivers to Oncology Nurse
No
Yes
Technician on duty not
trained for IV Compounding
Delay in Label being sent to
IV Room - Tech not available
Omnicell Restock
Medication
IV's Large Volume Not Refrigerated
IV's Large Volume
Refrigerated
IVPB Syringes / Bags
Refrigerated
IVPB Syringes / Bags Not
Refrigerated
Unit Dose Oral Meds
Unit Dose Meds
Refrigerated
Locked Drawer
Not Enough Room in Drawer
Pt in Isolation Put IV on
Unlocked Cart Outside Room - ICU/IMC/CVU
Pt getting Bath or
Procedure
Early AM - Unable
to see in Room - ICU/I
MC/CVU
Demand IV Already in
Drawer
Refrig on Omni Refrig
STAT - NOW to Nurse
Which Nurse? Where is Nurse?
Demanded Med Already
in Refrig
Calls - Unable to find
Med - Don't Look in Refrig
Locked Draw
STAT - NOW to Nurse
Which Nurse? Where is Nurse?
Early AM - Unable
to see in Room - ICU/I
MC/CVU
Pt in Isolation Put IV on
Unlocked Cart Outside Room - ICU/IMC/CVU
Not Enough Room in Drawer
Demand IV Already in
Drawer
Pt getting Bath or
Procedure
Meds Delivered to Refrig in Omnicell Nursing Units
- IMB-ICU-OB
To Refrig on Nursing Units - Peds-4100-5100-6400
STAT - NOW to Nurse
Which Nurse? Where is Nurse?
Meds Delivered to Refrig in Omnicell Nursing Units
-IMC-ICU-OB
To Refrig on Nursing Units - Peds-4100-5100-6400
STAT - NOW to Nurse
Which Nurse? Where is Nurse?
Locked Drawer
STAT - NOWShould be
delivered to specific nurse
within 15 minutes
Not Enough Room in Drawer
Demand Med Already in Drawer
Which Nurse? Where is Nurse?
Fill Order Corrected
Tech places follow-up
phone call if tubed
Family did not bring in, call family again to bring in
med
Notify MD med not
given, family did not bring
in
Enter Order HBOC Floor
Stock in Omnicell
Med Available in Omnicell for
Administration
Pharmacy
Scan not readable - Call floor
to re-scan
Order scanned with no patient name - Call
floor to re-scan
Incomplete Med Orders - (No Route,
strength)Call MD to Clarify
MD Handwriting Illegible
- Clarify with MD
Medication
Ordered
Order Scanned to
Pharmacy
Order Faxed
to Pharmacy
Order Phone
Call - received per pharmacy -
MD only
Enter Order in HBOC
Pharmacy System
Pharmacy Personnel Scan Order into Pyxis
Connect for order entry
Incomplete Med Orders - (No Route,
strength)Call MD to Clarify
Order faxed with no patient name - Call
floor to re-fax
MD Handwriting Illegible
- Clarify with MD
Fax not readable - Call floor
to re-fax
Nurse must write as
"telephone order" from
MD
Nurse phoning in
order
Write Order on Physician Order Sheet
Scan in PyxisFile in
appropriate folder
Send copy to floor
Order re-written by R.Ph. on
Physician Order Sheet
Order placed on cart by
Pharmacist
Order re-written by R.Ph. on
Physician Order Sheet
Order placed on cart by
Pharmacist
Order placed on cart by
Pharmacist
Order re-written by R.Ph. on
Physician Order Sheet
Order placed on cart by
Pharmacist
Order re-written by R.Ph. on
Physician Order Sheet
Non-Formulary Drug Med
Order
Contact MD for Formulary Substitution if no P&T auto-sub in place
Sub OK
R.Ph. Writes Order in Chart
Yes
Call floor to see if family can bring in
Send MD formulary
request form & obtain the
item
No
Label Generated for filling if not floor
stock
IV Label
generated
for filling
IV Label sent to IV Room for
Preparation
Conventional IV Product - Iv technician to
obtain components
and compound
Pharmacist Checks
IV - Initials Label Correct
CRRT Solutions and TPN Products Pharmacist Enter Order into Abbott
Compounding Computer
Draws up IV components -
Leaves for Pharmacist to
Check
IV Technician completes IV - takes to Unit
Bins for Delivery
Stat
Tubes to Floor
Order Entered - Required
2nd Pharmacist
Check
TPN Label generated
from Abbott Compounder
Components drawn up for
Compounding by Technician
Components Checked by
one Pharmacist
Components Checked by
second Pharmacist
TPN Compounded by Technician
Placed in refrigerator
for 5PM Delivery for 6PM Start
Chemotherapy - Oncology Pharmacist
enters Chemo Order
Oncology Order 2nds Checked by
Another Pharmacist
Oncology Pharmacist Compounds
under horizontal
hood
Oncology Product Completed -
Oncology Pharmacist delivers to Oncology Nurse
Yes
Technician on duty not
trained for IV Compounding
Delay in Label being sent to
IV Room - Tech not available
IV's Large Volume Not Refrigerated
IV's Large Volume
Refrigerated
IVPB Syringes / Bags
Refrigerated
IVPB Syringes / Bags Not
Refrigerated
Locked Drawer
Not Enough Room in Drawer
Pt in Isolation Put IV on
Unlocked Cart Outside Room - ICU/IMC/CVU
Pt getting Bath or
Procedure
Early AM - Unable
to see in Room - ICU/I
MC/CVU
Demand IV Already in
Drawer
Meds Delivered to Refrig in Omnicell Nursing Units
- IMB-ICU-OB
To Refrig on Nursing Units - Peds-4100-5100-6400
STAT - NOW to Nurse
Which Nurse? Where is Nurse?
Meds Delivered to Refrig in Omnicell Nursing Units
-IMC-ICU-OB
To Refrig on Nursing Units - Peds-4100-5100-6400
STAT - NOW to Nurse
Which Nurse? Where is Nurse?
Locked Drawer
STAT - NOWShould be
delivered to specific nurse
within 15 minutes
Not Enough Room in Drawer
Which Nurse? Where is Nurse?
Family did not bring in, call family again to bring in
med
Notify MD med not
given, family did not bring
in
Enter Order
HBOC Floor
Stock in
Omnicell
Med Available in Omnicell for
Administration
EliminatedEliminated
Most
Eliminated
Major Changes…
Pharmacy:• Med Labeling for Unit dosing• Medication verification and floor delivery• IV Bag handling • Communication processes
Nursing• Workflow (Where do I get my meds?)• Communication processes
Medication Errors (Total C and Above)January 2004 thru December 2005
55 6
1
50 5
6
41
17
49
48
56
35
65 67 7
2
67
45 5
1
43 46
43 4
8
31
38
25
0
10
20
30
40
50
60
70
80
Jan
-04
Feb
-04
Mar-
04
Ap
r-04
May-0
4
Ju
n-0
4
Ju
l-04
Au
g-0
4
Sep
-04
Oct-
04
No
v-0
4
Dec-0
4
Jan
-05
Feb
-05
Mar-
05
Ap
r-05
May-0
5
Ju
n-0
5
Ju
l-05
Au
g-0
5
Sep
-05
Oct-
05
No
v-0
5
Dec-0
5
Medication Errors CJanuary 2004 thru December 2005
49 5
4
41 4
6
39
13
46
39
51
33
60
60
60
59
39
46
39
39 40 42
26
33
22
0
10
20
30
40
50
60
70
Jan
-04
Feb
-04
Mar-
04
Ap
r-04
May-0
4
Ju
n-0
4
Ju
l-04
Au
g-0
4
Sep
-04
Oct-
04
No
v-0
4
Dec-0
4
Jan
-05
Feb
-05
Mar-
05
Ap
r-05
May-0
5
Ju
n-0
5
Ju
l-05
Au
g-0
5
Sep
-05
Oct-
05
No
v-0
5
Dec-0
5
Medication Errors DJanuary 2004 thru December 2005
6
7
9
10
2
4
2
9
5
2
3
6
9
8
5
2
3
6
2
5
4
5
3
0
2
4
6
8
10
12
Jan
-04
Feb
-04
Mar-
04
Ap
r-04
May-0
4
Ju
n-0
4
Ju
l-04
Au
g-0
4
Sep
-04
Oct-
04
No
v-0
4
Dec-0
4
Jan
-05
Feb
-05
Mar-
05
Ap
r-05
May-0
5
Ju
n-0
5
Ju
l-05
Au
g-0
5
Sep
-05
Oct-
05
No
v-0
5
Dec-0
5
Medication Errors EJanuary 2004 thru December 2005
0
0.5
1
1.5
2
2.5
3
3.5
Jan
-04
Feb
-04
Mar-
04
Ap
r-04
May-0
4
Ju
n-0
4
Ju
l-04
Au
g-0
4
Sep
-04
Oct-
04
No
v-0
4
Dec-0
4
Jan
-05
Feb
-05
Mar-
05
Ap
r-05
May-0
5
Ju
n-0
5
Ju
l-05
Au
g-0
5
Sep
-05
Oct-
05
No
v-0
5
Dec-0
5
The Quality Side
A Circumstances or events that have the capacity to cause errorB An error occurred; medication did not reach the patientC An error occurred that reached the patient but did not cause patient harmD An error occurred that resulted in the need for increased patient monitoring but no patient harmE An error occurred that results in the need for treatment or intervention and caused temporary patient harmF An error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harmG An error occurred that results in permanent patient harmH An error occurred that results in a near-death eventI An error occurred that resulted in patient death
What percentage of the time is the medication entered into Care Manager for administration in a timely manner?
Mean - 65.8% 82.7%
What percentage of the time are the routine medications available for administration when due?
Mean - 74.9% 85.4%
What percentage of the time are stat medications available when needed?
Mean - 59.6% 78.6%
How many times per shift are you engaged in conversations with pharmacy about medication questions / issues?
Mean - 4.3 / Shift 1.4 / Shift
Note:
All questions show statistical significant difference at 95% confidence
Voice of the CustomerNursing Personnel
Project Successes
• Patient Safety improved as demonstrated in reduction of
Medication Errors
• Increased personnel efficiency – Nursing - Reduced Medication Collection Time
• Before: 2.14 mins per patient
• After: 0.72 mins per patient
– Pharmacy - Reduced Pharmacy Technicians
• 2 technicians because of change in medication delivery process
• Before: Ordered to Floor time= 109 mins (overall)
• After: Ordered to Floor time = 21 mins (Omni), 44 mins
(non Omni)
• Increased satisfaction patient / nrsg / phrm / MD
Enabling Technology
Floor Units Type• 6400 2 2-Cell (400 Meds)• 5400 W 1 2-Cell• 5400 S 1 2-Cell• 5100 3 3-Cell (730 Meds)• 4100 3 3-Cell• ICU 1 2-Cell• IMC 1 2-Cell• OB 1 2-Cell• Peds 1 1-Cell (230 Meds)• Ortho 2 3-Cell• Pharmacy 2 Carousels
• 1 RX 2500 Meds • 1 IV 800 Meds
• Ospak-400 Automated U/D
Note: All savings reflect deductions of depreciation and leases.
Acute Myocardial Infarction
AMI Core Measures
What is a Defect? What are the process specifications?1. No Pre or Post arrival EKG2. No ASA w/in 24 hrs before or after arrival (with no Contraindication documented)
3. No Beta blocker w/in 24 hrs before or after arrival (with no Contraindication documented)
4. No ASA prescribed at discharge (with no Contraindication documented)
5. No Beta blocker prescribed at discharge (with no Contraindication documented)
6. No LVSD documented7. If LVSD documented @ <40% , No Ace Inhibitor prescribed at discharge
Defect:Any one of these 7 questions answered “NO”
Before:DPMO = 117,381Zst = 2.69
Oct, Nov, Dec combined)
AMI Core Measure
On admission: what did we learn?
• No set Lab protocol for verifying MI
• No standard order set (ECC/CVU/House wide)
On discharge: what did we learn?
• No process for prompting core measures accounted for on discharge.
• Standard Operating Procedures should be project focus.
AMI Core Measure
Key Findings / Actions Taken
• ECC using new treatment protocol for people who are
diagnosed with MI
• Establish Panic Troponin Level in Lab
• Create Daily “Troponin” report
• Cardiology nurses follow-up on Troponin report daily
• Create Physician prompts to be placed on chart by
Cardiology nurses
• Create and implement new discharge instructions-Care
Manager
AMI Core Measure
Implementation CompletePercentage of all measures met by month
Medicare “High Quality Performer”
• Health Services Advisory Group Inc. (HSAG), the Medicare Quality Improvement Organization (QIO) of Arizona, identified Decatur Memorial Hospital as a “High Performer” in a study initiated in October 2003 focusing on care given within the core measures.
• The study, “Identification and Synthesis of Components Essential to Achieving ‘High Performer’ Status in Various Provider Types”, had as its objective: to identify high performer hospitals and analyze their distinguishing characteristics to help the QIO program transform and accelerate healthcare quality improvement.
• Six Sigma is one of the distinguishing characteristics.
Inserting a video clip here…
This is why…We do Six Sigma…
Impact on our CommunityImpact on Quality
Impact on FinancialsImpact on our People