Using Six Sigma to Improve Cardiac Medication Administration and CAT Scan Capacity

1. Using Six Sigma to Improve Cardiac Medication Administration and CAT Scan Capacity Harvard Quality Colloquium August 22, 2005 Susan McGann RN, BSN Adrienne Elberfeld

2. Virtua Health….Today • Four hospital system in Southern New Jersey • Two Long Term Care Facilities • Two Home Health Agencies • Two Free Standing Surgical Centers • Ambulatory Care - Camden • Fitness Center • 8000 employees + 2000 physicians • 7,000 deliveries • $650 million in revenues • STAR Culture

3. Virtua Facilities

4. ExcellentService ResourceStewardship Clinical Quality & Safety Outstanding Patient Experience CaringCulture BestPeople The Virtua STAR

5. Virtua Health…. The Future • Change in HR Structure and Process • Focus on Programs of Excellence • Building a Greenfield site • Potential consolidation of multiple sites • Ambulatory Strategy • Growth in the North • Additional Strategic Partnerships

6. Define R0 Cardiac Medication Indicators Project Description: Increase quality of patient care by use/non-use and appropriate documentation of aspirin, beta-blockers, and ACE inhibitors in CHF or AMI patients to achieve or exceed Virtua benchmark goals. Project Title: Cardiac Medication: Indicators Six Sigma Project Sponsors: Jim Dwyer, Ann Campbell, Ellen Guarnieri, Adrienne Kirby, Mike Kotzen Champions: Pat Orchard & Jane Slaterbeck Master BB: Mark Van Kooy Black Belt: Adrienne Elberfeld Green Belt: Ted Gall Finance Approver: Gerry Lowe Project Start Date: July 22, 2002 Project Scope: To have all four acute care facilities, within all medical disciplines, meet the standards of Core/JCAHO guidelines Potential Benefits: To achieve improved outcomes for patients with AMI/CHF diagnosis by adhering to evidence based practice through education, documentation, and compliance while meeting regulatory standards and enhancing quality of patient care at Virtua. Team Members: Jay Brewin, Darlene Euler, Christine Gerber, Val Torres, Kathy Halstead, Kathy Plumb, Cindy D’Esterre, Lori Edell, Heather Scheckner, Angie Smolskis, Pat Quackenbush, Ronald Kieft, Michelle Weaks, Robert Singer, Vince Spagnuolo, Steve Fox Alignment with Strategic Plan:IIA-Cardiology; Global MICP Goals for Virtua.

7. Measure QRA Chart Review Gage R&R • During this gage, it was determined that there was variation between the QRA’s review of charts • A Workout was held on September 18th with the QRA’s and Case Management Directors to develop SOP’s in reviewing of all CHF and AMI patients for core indicators Percentage of time QRA’s agreed on assessment

8. Analyze Root Cause Analysis Identified through Containment Issue Concurrent reviews of AMI & CHF patients Ongoing information needed for medical staff and nursing staff of the core indicators Cardiac POE needs real time access to Clinical Care Advisor to review data Solution Met with CCM’s, Case Management & Quality to educate on core indicators Identified key areas, (physician lounges, Cardiac specific units, nursing specific areas), and posted storyboards that are the same throughout the system Cardiac POE Director, AVP, and Black Belt access to system; able to review ongoing and provide feedback to Case Management Conclusion Between Case Management, Quality & Nursing charts needed to coordinate efforts in reviewing charts Have team members develop a storyboard template with pathways and indicators to be available at key areas throughout the facility Coordinate with IS accessibility to system Who Team members specific to campus, J. Slaterbeck, A.Elberfeld Team members specific to campus C. Mullin, J. Slaterbeck, B. Rodin

9. Analyze Root Cause Analysis Identified through Containment (continued) Who Case Mtg Directors, Quality Directors, CCM’s Case Mgt, QRA’s, B. Singer, V. Spagnuolo, S. Fox Case Mgt, QRA’s, C. Mullin, A. Elberfeld Solution Case Management to take the lead on chart reviews for patients with AMI, CHF & related diagnosis. Support from quality & nursing If nursing and/or case mgt has direct contact with physician, they give necessary feedback. Next step is the facility QRA and physician champion Case Management to coordinate with nursing & quality; all paperwork forwarded to Black Belt & VP Quality Conclusion Nursing, case management and quality are all reviewing charts; need to coordinate efforts in regard to the indicators Need one point person to communicate directly with physicians in a timely manner Need to appoint point people within the facility to ensure that activities are being completed and coordinated Issue Who is going to perform the task of daily chart reviews concurrent with care? Communication with physicians per need for documentation Coordination of ongoing chart reviews, documentation completion, and data information

10. Improve Root Cause Analysis

11. Control Realized Results of Implemented Solutions Improvement Y Benefit Quality Benefit

12. Control P Chart

13. Define R0 CT Scan Capacity Project Description: Increase capacity by reducing in and out of room times for the CT Scan to adhere to GE industry benchmarks of 15 minutes without contrast and 25 minutes of with contrast. Project Title: CT Scan Six Sigma Project Sponsors: Ellen Master BB: Adrienne Elberfeld Black Belt: Kathy Eichlin Green Belt: John Graydon, Wendy Seiler Finance Approver: Rex Rueblinger Project Start Date: July 28, 2004 Project Scope: Marlton CT Scan department Potential Benefits: A more efficient process will lead to increased capacity thereby increasing opportunities for increased volumes. Team Members: Beverly Crawford, Melody DeLaurentis, JoAnn Domingo, Audrey Fley, Darryl Fussell, Cynthia Koller, Jo Nast, Heather Pierce, Donna Rapp, Elizabeth Zadsielski Alignment with Strategic Plan:Resource Stewardship Patient Satisfaction

14. Measure Descriptive Statistics • Y1 • Mean = 13.6333 • Standard Deviation = 6.6993 • Z Score = 2.78 • Mode = 9 • Percent of Defects = 11.1% • Y2 • Mean = 23.4688 • Standard Deviation = 6.9884 • Z Score = 1.90 • Mode = 20, 21 and 24 • Percent of Defects = 34.4%

15. Measure Descriptive Statistics • Y3 • Mean = 11.3671 • Standard Deviation = 4.2972 • Z Score = 2.58 • Mode = 7 • Percent of Defects = 13.98% The problem is too much standard deviation/ variation in the process!!

16. Analyze T Test for Equal Variances Levene’s test –Test for equal variances for continuous data that is not normally distributed. There is a statistical difference in the variance!

17. Analyze Pareto Chart A Pareto Chart shows where within the process the greatest opportunity exists for improvement. Here we see opportunities for the need for improvement with interruptions caused by the phone, door interruptions and assistance needed to move a patient resulting in 59 % of CAT Scan Delays.Use LEAN opportunities to streamline process.

18. Improve 2 Sample T Test & ANOVA Y1 Y1-Abdomen-Pelvis Without Contrast One-way ANOVA: Before-Avg. Time, After-Avg. Time Analysis of Variance Source DF SS MS F P Factor 1 426.2 426.2 8.04 0.005 Error 166 8794.9 53.0 Total 167 9221.1 Individual 95% CIs For Mean Based on Pooled StDev Level N Mean StDev ---------+---------+---------+------- Before-A 62 14.952 9.869 (--------*--------) After-Av 106 11.651 5.214 (------*------) ---------+---------+---------+------- Pooled StDev = 7.279 12.0 14.0 16.0 Two-sample T for Before-Avg. Time vs After-Avg. Time N Mean StDev SE Mean Before-A 62 14.95 9.87 1.3 After-Av 106 11.65 5.21 0.51 Difference = mu Before-Avg. Time - mu After-Avg. Time Estimate for difference: 3.30 95% CI for difference: (0.61, 5.99) T-Test of difference = 0 (vs not =): T-Value = 2.44 P-Value = 0.017 DF = 81 P-value was less than .05, therefore, there is a statistical difference!

19. Improve 2 Sample T Test & ANOVA Y1 Y2-Abdomen-Pelvis With Contrast One-way ANOVA: Before-Avg. Time, After-Avg. Time Analysis of Variance Source DF SS MS F P Factor 1 361.4 361.4 9.15 0.004 Error 50 1974.9 39.5 Total 51 2336.3 Individual 95% CIs For Mean Based on Pooled StDev Level N Mean StDev ----------+---------+---------+------ Before-A 32 23.469 6.988 (------*-------) After-Av 20 18.050 4.925 (--------*---------) ----------+---------+---------+------ Pooled StDev = 6.285 18.0 21.0 24.0 Two-sample T for Before-Avg. Time vs After-Avg. Time N Mean StDev SE Mean Before-A 32 23.47 6.99 1.2 After-Av 20 18.05 4.93 1.1 Difference = mu Before-Avg. Time - mu After-Avg. Time Estimate for difference: 5.42 95% CI for difference: (2.09, 8.74) T-Test of difference = 0 (vs not =): T-Value = 3.27 P-Value = 0.002 DF = 49 P-value was less than .05, therefore, there is a statistical difference!

20. Improve Mood’s Median/Non-Normal Data P-value was less than .05, therefore, there is a statistical difference!

21. Control Can we see the improvement on the chart post SOP implementation? I & MR Control Chart Take away: Process is capable and in control.

22. Control Can we see the improvement on the chart post SOP implementation? I & MR Control Chart Take away: Process is capable and in control.

23. Control Can we see the improvement on the chart post SOP implementation? I & MR Control Chart Take away: Process is capable and in control.

24. The “other results” • Ahead of the ‘hospital’ curve • Data driven organization • The dots are connected: • Strategy, Operations, Quality, Finance, People • Financial up-spin • Leadership Development The Results Go Well Beyond the Project!

25. Questions