Potential of Six Sigma in Clinical Settings

1. August 20, 2007 Recognizing the Potential of Six Sigma in a Clinical Setting Matiana Gonzalez Vela, Ed.D., R.D., Master Black Belt Cary Montalvo, B.S., Black Belt Valley Baptist Health System

2. and the Six Sigma

3. Six Sigma and the Institute for Healthcare Improvement • 100,000 Lives Campaign • 5 Million Lives Campaign • Unveiled in December 2004 • Reduce unnecessary hospital deaths by 100,000 • Focused on 6 Interventions shown to have major impact on reducing mortality • Unveiled on December 12, 2006 • Focus is to protect patients from five million incidents of medical harm over the next two years • Builds upon the success of the 100,000 Lives Campaign • Additional 6 Interventions

4. The six interventions from the 100,000 Lives Campaign • Deploy Rapid Response Teams…at the first sign of patient decline • Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack  • Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation • Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps • Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time • Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps

5. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack  Our Criteria y1 = Aspirin on arrival y2 = Aspirin at discharge y3 = ACE/ARB for LVSD y4 = Smoking cessation counseling y5 = Beta blocker on arrival y6 = Beta blocker at discharge y7 = Timely reperfusion (<90 minutes) IHI Criteria • Early administration of aspirin • Aspirin at discharge • ACE-inhibitor or angiotensin blockers (ARB) at discharge for patients with systolic dysfunction • Smoking cessation counseling • Early administration of beta-blocker • Beta-blocker at discharge • Timely initiation of reperfusion (thrombolysis or percutaneous intervention)

6. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack  Brownsville Y = % compliance with Centers for Medicaid & Medicare Services Acute Myocardial Infarction Core Measures (All or None Strategy)

7. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack  Brownsville Source: www.solucient.com

8. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack  Harlingen Y = % compliance with Centers for Medicaid & Medicare Services Acute Myocardial Infarction Core Measures (All or None Strategy)

9. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack  Harlingen Source: Premier, Inc.

10. Foundations of Success Reward Performance Respect People Recognize Effort ACCOUNTABILITY

11. 1 2 3 4 5 6 BROWNSVILLE Nurse Name

12. Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps Our Criteria • y1 = Head of bed (HOB) elevated 30 - 45 degrees (unless contraindicated) • y2 = Deep Venous Thrombosis (DVT) prophylaxis (unless contraindicated) • y3 = Peptic Ulcer Disease (PUD) prophylaxis • y4 = Daily sedation vacation and assess readiness to extubate (unless contraindicated) • y5 = Oral care twice a shift IHI Criteria • y1 = Head of bed (HOB) elevated 30 - 45 degrees (unless contraindicated) • y2 = Deep Venous Thrombosis (DVT) prophylaxis (unless contraindicated) • y3 = Peptic Ulcer Disease (PUD) prophylaxis • y4 = Daily sedation vacation and assess readiness to extubate (unless contraindicated) 12

13. Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps Harlingen 13

14. Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps 14 Source: Premier, Inc.

15. New interventions targeted at harm • Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin • Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention • Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions • Reduce Methicillin-Resistant Staphylococcus Aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices • Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (www.medqic.org/scip) • Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care

16. Deliver Reliable, Evidence-Based Care forCongestive Heart Failure... to avoid readmissions Our Criteria y1 = Measurement of Left Ventricular Function documented y2 = On ACEI/ARB or contraindication documented y3 = Smoking cessation counseling documented y4 = Complete discharge instructions documented IHI Criteria • Left ventricular systolic function assessment • ACEI/ARB at discharge for CHF patients with systolic dysfunction • Anticoagulant at discharge for CHF patients with chronic or recurrent atrial fibrillation (AF) • Smoking cessation advice and counseling • Discharge instructions that address: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen • Influenza immunization* (seasonal) • Pneumococcal immunization*

17. Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions Brownsville

18. Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions Brownsville Source: www.solucient.com

19. Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions Harlingen

20. Deliver Reliable, Evidence-Based Care for Congestive Heart Failure...to avoid readmissions Harlingen Ranked #1 in the Nation for Heart Failure Management by the Premier/Center for Medicare and Medicaid Services Hospital Quality Incentive Demonstration (HQID) project. Source: Premier, Inc.

21. Prevent Pressure Ulcers...by reliably using science-based guidelines for their prevention IHI Criteria Pressure Ulcer Prevention • Conduct a Pressure Ulcer Admission Assessment for All Patients • Reassess Risk for All Patients Daily • Inspect Skin Daily • Manage Moisture:  Keep the Patient Dry and Moisturize Skin • Optimize Nutrition and Hydration • Minimize Pressure Our Pressure Ulcer Criteria Prevention y1 – Braden on Admission y2 – POC documented for wound care y3 – Heels offloaded y4 – Complete wound assessment y5 – Referral for wound necrosis y6 – Ancillary Screens completed y7 – Turning every 2 hours y8 – Skin protectant for incontinence y9 – Specialty bed for high risk Management y1 - Proper assessment to include location, dimension and staging y2 - Braden scale completed y3 - Nurse notifies physician of pressure ulcer y4 - Pain assessment documented to include pre and post wound care y5 - Time of initial assessment documented y6 - Time of wound care performed and documented y7 - Physical Therapy screen completed y8 - Dietary screen completed

22. Prevent Pressure Ulcers...by reliably using science-based guidelines for their prevention

23. Prevent Pressure Ulcers...by reliably using science-based guidelines for their prevention

24. Prevent Pressure Ulcers...by reliably using science-based guidelines for their prevention Brownsville Pressure Ulcer Prevention and Management Source: KCI

25. Lessons Learned!!! • President / CEO Champion is a must! • Physician Champion / Leader is a must! • Clean your house before you ask Physicians to clean theirs! • Have a formal mechanism to choose initiatives (projects) • Once an initiative is selected, scope it to a manageable rangeand ensure it fits the DMAIC model! • Greenbelts during training should have vested interest in initiative (Green Belt / Owner combination works best) • Training classes should be kept to a manageable size

26. Lessons Learned!!! • Allow enough time between the Improve and Control Phase to ensure the best possible solutions can be implemented and sufficient data collected • Thoroughly educate Owners on responsibility for sustaining improvements in Post-Control period • Strive for electronic data collection for Post-Control – Manual data collection is a bear!!! (leverage Information Technology department) • Data collection for Post-Control should NEVER be a “self-report” process • Develop “owners manual” to ensure continuity when unexpected change in owner occurs • ACCOUNTABILITY goes hand-in-hand with TRANSPARENCY

27. Discussion