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Power in Numbers-Six Sigma in Healthcare
Premier’s 2006 Annual Breakthrough’s ConferenceJune 22, 2006
Presented by: Dr. Mark Vaaler
Vice President of Medical Affairs&
Michelle McCraySix Sigma Black Belt
BayCare is comprised of nine leading not-for-profit
hospitals in the Tampa Bay, Florida area and a host
of other health services. We have 17,000 employees -
we call them "team members" - who are
dedicated to our common Mission of improving the
health of all we serve. What that means is we are an
organization that feels very strongly about caring for
our community.
The simplest way to describe BayCare is this: we are an
organization of people taking care of people. Our core business
begins with the single relationship between our team member and you, the customer. Therefore,
BayCare’s Quality Model is built upon a foundational philosophy of Customer Needs, Process Focus, and Continuous Improvement.
Guided by these principles, we are able to establish a Quality Process, a series of actions that bring about
changes and results.
What is Six Sigma?
Six Sigma is a methodology that adds tools and infrastructure to our Quality Improvement process. Six Sigma enhances our ability to apply the BayCare Quality Philosophy and Process to problems team members face each day. To realize continuous improvement in our work processes, we must evolve our tools and methods for improving processes. Six Sigma is the next step in the development of BayCare's Quality Philosophy and Process.
Identify your biggest
problems
Assign these problems to your
best people
Provide full resources and
support
Guarantee uninterrupted focused time
Six Sigma is …
Voice of the Customer “What does the customer truly want and need?”
“How can we most efficiently meet that need?”
All Six Sigma Teams focus on…
Firefighting Mode
Six Sigma builds an infrastructure with lines of accountability running throughout the organization Stresses breakthrough improvement! Emphasis is placed on producing better, faster, and lower cost products and services than the competition Emphasis is placed on the use of valid data as a driver for process change and measurable bottom line results
What is different about Six Sigma from initiatives of the past?
Work-OutFast-paced, activity-driven workshop to solve problemsExamples:
Standardization of forms Call light response
LeanProjects that eliminate waste and increase efficiencyExamples:
Patient registration Emergency Room flow
DMAIC (Define, Measure, Analyze, Improve, Control)Led by Black Belts or Green BeltsTeam Members have the opportunity to earn Yellow Belt certificationA data driven in-depth project to eliminate errors or defectsExamples:
Reduce length of stay Reduce insurance denials
Types of Six Sigma Teams or Projects
What is D.M.A.I.C.?
DMAIC (Define, Measure, Analyze, Improve, Control) Led by Black Belts or Green Belts It is a structured, disciplined, rigorous approach to
process improvement consisting of the five phases mentioned, where each phase is linked logically to the previous phase as well as to the next phase.
A data driven in-depth project methodology to eliminate errors or defects
Examples: Reduce length of stay Reduce insurance denials
Tools Range from: SIPOC to complex statistical tools, such
as Chi Square hypothesis tests
Six Sigma… the D.M.A.I.C. Methodology
• Practical problem
• Statistical problem
• Statistical solution
• Practical solution
ICU ThroughputSt. Joseph’s Hospital
Tampa, FLProject Start: March 2005
Close of Project: December 2005
Problem StatementFor the last 3+ years, the availability of ICU beds in the Adult
Medical/Surgical ICU has become such a problem that patients wait
up to 72 hours for a critical care bed based on data reviewed from
ICU, PACU & ER reports..
Black Belt Project
Champion: Black Belt:Process Owner:Finance Rep:Team Members:
Roles & Responsibilities
Dr. Mark Vaaler, VP Medical AffairsMichelle McCrayMargie Butler, RN Director ICUJudy PaltooBarbara Pricher, RN Manager ICUVickie Miranda, RN Manager AdmittingAnne MacMillan, RN Manager PACULynn Dopp, RN Director NursingAdrienne Galluppo, RN ICUKelli Stephanko, RN Case ManagerToni Bush, Information SystemsShellia Keller, Environmental ServicesDr. Lee Kirkman, Medical Director ICU
Suppliers Inputs Process Customers
Printers PCs Telephone Housekeeping Invision Physicians Nursing Bed Briefing Unit ClerksBed Tracker
Step 1: Physician writes order
Outputs
Step 2: Bed requested
Step 3: Bed assigned
Step 4: Bed ready
See Below Transfer order Bed request Bed assignment Clean request Transported pt. Open ICU bed
Bed Control Nursing units Housekeeping EC PACU Physicians Direct Admits/
Transfers In Interventional
Radiology
Dietary
Step 5: Patient transferred
Transfer order
(Dr. Order) Bed
Request/Invision
info Bed Tracker infoPatients Clinical Info
SIPOC/Macro Map
Step 6: ICU room cleaned
Step 7: ICU bed is available
• Defect DefinitionTime from when ICU requests a bed to when the patient is
on the receiving units census is greater than 4 hours.
• Objective Statement*To improve the cycle time from when the ICU requests a
transfer bed to when a patient is on the receiving unit’s census from 9.52 to 4 hours in 6 months.
• Metrics– Business
• Avoidable days (hours), ICU LOS
– Primary• Turn-around-time of bed request to patient transferred
*S.M.A.R.T. – Specific-Measurable, Attainable, Relevant, & Timebound
Project Definition
Process Capability
403020100
USL
Process Data
Sample N 59Location 1.94088Scale 0.820107
LSL *Target *USL 4Sample Mean 9.51864
Overall CapabilityZ.Bench -0.68Z.LSL *Z.USL -0.12Ppk -0.04
Observed PerformancePPM < LSL *PPM > USL 762712PPM Total 762712
Exp. Overall PerformancePPM < LSL *PPM > USL 750553PPM Total 750553
Process Capability of Bed request to censusCalculations Based on Lognormal Distribution Model
Sampled 59 patients over 2 weeks with an average of 9.5 hours
Sigma Level
Defects per million
opportunities
Customer Need/Target:
4 hours
Translation = 75% defect rate!
Measure (all input variables)
Analyze
Improve
Control
Pour in all possible input variables• Process Mapping• Mind Mapping• Ishakawa diagrams• Survey design
Use soft tools to narrow the possibilities• C & E Matrix FMEA
•UUse quantitative tools to further narrow the field• ANOVA• Correlation• Multi-vari studies
Implement and validate solutions
•IImplement systems to ensure improvements are maintained
• SPC• Poka-Yoke
• Audits• Control Plans
• DOEs• Surveys
(Key input variables)
(Critical input variables)
•(Key leverage variables)
• Logistic Regression• Survey analysis
30 - 50
10 - 20
8 - 10
4 - 8
2-5
Data Collection Plan
Process Flow
Diagram
I/O Worksheet
Fishbone
Failure Modes and
Effects Analysis
C&E Matrix
Input Verification Matrix
Evaluate Flow for VA/NVA, Hidden Factorys and
Key Data Collection
Points
List Potential X's per
Process Step
Brainstorm List of
Potential X's
List of Potential Process
Failures or Errors
Measurement System
Analysis
Data Collection Plan
Details of completed deliverables available in Appendix A
Analyze Phase - Summary of Critical X’s
• Significant X’s*:– Delay in giving bed assignment (Bed request to bed assign)
– Patients moved at shift change and by shift
– Delays in transferring patients by certain units
– Delay in moving patient to receiving unit’s census
– Delay by day of week bed is requested
• Other: The lack of ability to properly measure the turn around time
*See Appendix B for details on hypothesis testing
What was driving the turn around time to be long? Y = f(x)
Improve Phase - Ideas
ICU Transfer
Time Reduction
Standardization
TMEducation and
Training
Process
Information Systems
Nursing
Create Prioritization Matrix for placing patients
Review Patient Placement Guidelines and review policy for transferring patients from room to room within same level of care.
Bed Request/Bed Assigned time captured in Invision to improve measurement system
Automate notification to ICU/PACU of Clean bed
Add Bed Tracker screens in key areas to improve communication
Streamline Invision process for transferring patient. Reduce # of screens, reeducate staff.
Change afternoon Bed Briefing meeting time from 4:00pm to 2:00 pm
Call ICU with Bed Assignment when be is "In Progress"
Anticipate next day transfers and the beds to be needed
Kanban system for isolation curtains
Transfer order set with Med List from Invision to ease transfer process
Train Housekeepers to clean entire room. Career ladder.
Create incentive program to improve room status accuracy
Improve - Recommendations
• Change afternoon Bed Briefing meeting time from 4:00pm to 2:00 pm
• Bed Request/Bed Assigned time captured in Invision to improve measurement system
• Streamline Invision process for transferring patient. Reduce # of screens, reeducate staff. • “Look alike” screen to print in ICU when bed assignment is
made to aid in transfer• Inform ICU that bed is ready when bed is “In Progress” instead
of waiting until “Clean” status.
• Transfer Order set
– Simplify process of rewriting physician’s orders prior to transfer.
– Transfer Med List will print from Invision
Short Term, Little to No Investment
• Create Prioritization Matrix for placing patients
• Review Patient Placement Guidelines and review policy for transferring patients from room to room within same level of care.
• Add Bed Tracker screens in key areas to improve communications.
• Anticipate next-day transfers from ICU and communicate bed needs to Patient Access.
• Create Kanban system for isolation room drapes
• Put ladders on every nursing unit for changing the isolation drapes
• Allow patients to be moved prior to curtains being re-hung
Short Term, Little to No Investment
Improve - Recommendations
• Create incentive program for housekeepers to improve status accuracy of Bed Tracking system
• Train housekeepers to clean entire room. Look into educational ladder for housekeeping.
• Redeployed housekeepers to cover the hours of day when the discharge volumes are high (no change in FTEs)
Short Term, Little to No Investment
Improve - Recommendations
• Process Control System*– Control Charts
• Daily monitoring of the critical inputs– Bed Request to Bed Assign
– Bed Assign to Transfer
• Daily monitoring of the key output– ICU Transfer time
– Accountability for process– Identify who is responsible for monitoring
*See Appendix C for completed tool
Control - Sustain the Gains
Project Transition
• Project Transition Action Plan (PTAP)
– Formal meeting to transition project from Black Belt to Process Owner
– Any open action items are noted
– Deployment Leader, Champion, & Finance representative must sign off on PTAP
• 12 Month Realization Phase
– Monitor data via the Process Control System
– Monitor financial impact
– Report the primary metric on a regular basis
Key Project Results
• Primary metric improvement– Transfer time reduction
• 9.52 to 4.6 hours (as of 6/7/06)
– Sigma Level & DMPO• 0.82 to 1.29 Sigma (ST)• 750,553 to 583,627 DPMO
• Financial Savings– $670,084 Net Contribution margin and Direct Variable
cost savings (8/15/05 through 4/30/06)
Key Project Results
• Effect on Secondary Metrics– Comparing Pre project to Post project data in
2005, PACU Holds for ICU beds have decreased by 36%
– ED holds continue to decrease (see next slide)
• Data Accuracy– Changes to measurement system in order to
capture accurate and timely data• Transfer request order• Bed request order
Key Project Results
Implemented Process Control System
Manual tracking during pilots
Key Project Results
Average Emergency Department hold time for ICU beds decreased significantly in 2005 (average 105 patients per month)
Month
Hours
121110987654321
5.5
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
DecemberNovember
October
September
August
July
June
May
April
March
February
January
Bed Request to Bed Assigned in ICU - 2005
Final Thoughts• Next Steps
– Continue to monitor via PCS and HOLD the GAINS!– Transfer knowledge throughout BayCare
• Lessons learned– Executive support for large scale projects is key to success– Validating improvement pilots with data is new to staff – ensure they understand that items my be “rejected” post-pilot.– Validate your data sources – Make sure everyone is measuring the same thing, the same way
• The Value of DMAIC– Focus improvements on what you know will fix the problem– Brings results that are sustainable for the long run
Questions?
For additional information or further information on this project or Six Sigma at the BayCare Health System:
Dr. Mark Vaalermark.vaaler@baycare.org813.870.4000Michelle McCraymichelle.mccray@baycare.org727.519.1794
Appendix A
Fishbone Diagram
Detailed Process Map
C & E Matrix
FMEA
Input Verification Matrix
FMEA
C & E Matrix
Tracking X's
Fishbone
Process Map
If you can not open these documents, you can contact Michelle McCray at michelle.mccray@baycare.org
Appendix B
Appendix B
Analyze Phase
Factor Reduction
Factor Reduction – Appendix B
• Findings– Variation of
median by Day of week bed requested (Moods-Median p=0.36)
– Wednesday (5.5), Thursday (4.95) & Sunday (7.15) have highest median TAT
Bed Request DOW
M2 -
Bed R
equest
to B
ed A
ssig
n
7654321
40
30
20
10
0
-10
Boxplot of M2 - Bed Request to Bed Assign vs Bed Request DOW
• Findings– Difference in
median by shift (Moods-Median p= 0.60)
– Median 2nd shift is 5.7, while 1st shift is 2.8
– Also, Time of day had similar results
BEDASGbySHIFT
M2 -
Bed R
equest
to B
ed A
ssig
n
321
40
30
20
10
0
Boxplot of M2 - Bed Request to Bed Assign vs BEDASGbySHIFT
Factor Reduction – Appendix B
• Findings– Bed Assigned
to Patient moved interval
– Difference in median by Transfer Unit (Moods-Median p= 0.159)*
Factor Reduction – Appendix B
• Findings– Patients moved
2 hours before or after shift change have a longer overall TAT
– 22 out of 59 patients in sample were moved in this 4 hr window
– Median 1 hour greater for these patients (p = 0.087)
Bwt17-21hr
M3 -
Bed A
ssig
n t
o P
atient
move
YN
14
12
10
8
6
4
2
0
Boxplot of M3 - Bed Assign to Patient move vs Bwt17-21hr
Factor Reduction – Appendix B
• Findings– While nurse staffing did
not seem to be an issue, approx ½ of the patients required telemetry to be transported, which requires an RNs support
– Over a quarter of the patients request/need private rooms
– Housekeeping delays are an issue, but the extent of the problem can not truly be known until the Bed Tracker system utilization is under control
Would this be higher/lower if
tracker was being utilized
correctly?
Factor Reduction – Appendix B
Appendix C – Process Control System
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