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The Quality Colloquium
Leadership for Reliable Systems
August 21, 2006
Stephen R. Mayfield
Senior Vice President
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Visualize Success:
We Don’t all SEE the Same Thing
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Seeing Differently
• De Kalb, Illinois
• DeKalb, Georgia
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“Would you tell me please which way I ought to go from here?”
asked Alice.
“That depends a good deal on where you want
to get to,” said the cat.
“I don’t much care,” said Alice.
“Then it doesn’t matter which way you go,” said the
cat.
Leaders Create the Vision and Set Direction
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Leaders Create Expectations
• Leaders ->
Values ->
Behaviors ->
Culture ->
Performance
Courtesy of Ann Rhoades
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Leaders Must
• Eliminate Preventable Harm
• Develop Highly Reliable Systems
• Improve Outcomes Year-to-Year
• Reduce Costs of Care Year-to-Year
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Unceasing Efforts to :
• Remove Waste
• Eliminate Defects
• Reduce Variability
“All work is a system, every system has processes and every process has waste
and variability.”
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Relentless Pursuit of Waste
• Public perception, the Camry Effect and Community Contribution
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2000 20062002
Change in Cost of Insurance Premiums and Co-Pays
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The Camry Effect
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Other Approaches Exist
• Juran: “There is 30% waste in most healthcare processes”
• Dartmouth study: “Providers in Salt Lake are number one, if all providers emulated their efficiency CMS could save 30% in expenditures”.
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Reliability and the Four Components of Care Delivery
Patient Information
Clinical Decision
Care Process
Patient Flow
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Visualize Success:
We Need to SEE our Processes
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Our Approach to Date is not Yielding Desired Rate of Change
• We have believed that –
• If we have enough of the right data –
• Analysis will indicate compelling need to change –
• Change will therefore occur
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We need to Learn to see our processes in a different light
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Reliability and the Four Components of Care Delivery
Patient Information
Clinical Decision
Care Process
Patient Flow
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Systems of Care and Simple MetricsInformation -> Clinical Decisions -> Care Processes -> Patient Flow
Clinical Information SystemFinancial System
Patient Patient Patient Patient
Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….
CD CD CD
Evidenced Based
Medicine
Clinical Best
Practices
Outcome
Indicators
(LOS, Mortality, Infection, Readmits)
Patient Flow
Process Measures(Waste, SMR,
Cycle Time Variances, etc.)
Charges
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Innovation in Reliable Care
Clinical Information SystemFinancial System
Patient Patient Patient Patient
Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….Cp1 + Cp2 + Cp3….
CD CD CD
Evidenced Based
Medicine
Clinical Best
Practices
Outcome
Indicators
(LOS, Mortality, Infection, Readmits)
Patient Flow
Process Measures
(SMR, Cycle Time Variances, etc.)
Charges
I.D. and Match
CPOE
Accurate Labs
RFID
Sponges
RFID Location
Timely Resulting
Safe Meds
EMR & Orders Free of Preventable Harm
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Lean + Six Sigma = More Value
1 93.32% 99.379% 99.9767% 99.99997%
7 61.63% 95.733% 99.839% 99.9976%
10 50.08% 93.96% 99.768% 99.9966%
20 25.08% 88.29% 99.536% 99.9932%
40 6.29% 77.94% 99.074% 99.9864%
# Steps + 3σ + 4σ + 5σ + 6σ
Six Sigma improves quality of value-add stepsLean
Red
uces
non
-val
ue a
dd s
teps
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Leaders Must
• Eliminate Preventable Harm
• Develop Highly Reliable Systems
• Improve Outcomes Year-to-Year
• Reduce Costs of Care Year-to-Year
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Unceasing Efforts to :
• Remove Waste
• Eliminate Defects
• Reduce Variability
“All work is a system, every system has processes and every process has waste
and variability.”
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Cost of Poor Quality and Defects
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The 8 Deadly Wastes
• Overproduction• Waits/Delays• Transport• Process• Movement• Inventory• Defects• Underutilization
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Laboratory Improvements: Six Sigma Methods
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Suppliers Inputs Process Customers Requirements
Phys ic ians
Order in O.C.LISLabel Generated
Outputs
Phlebotomist travels to patient
Match Pat ient Draw Sample
See Below Specimen Delivered Physic ians
Patients
Lab Personnel
Tim eliness
Accuracy
Matching
Convenient
Matching
Matched Specimens
Tim ely Delivery
Transport Specimen toLaboratory
Orders
Patient Specimen
Phlebotomist
Test ing Personnel
Laboratory
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High Level Phlebotomy Flow
MQC
Retrieve Order
Print Label
Travel to Patient
Collect Specimen
Deliver Specimen
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Detailed Phlebotomy Flow
MQC
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Data Collection
• Design instrument
• Develop plan
• Collect Information
• Found 3 Problems: Matching, Batching Attaching
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Over 40 specific defects identified in 6 classes:
• Label defects (unlabeled, misplaced, wrong patient labels, misaligned, etc.)
• Patient ID band defects ( improper matching, no label, wrong label, etc.)
• Unsuccessful draw (not first stick, second phlebotomist required)
• Unacceptable specimen/recollect (wrong tube, clotted, hemolyzed, insufficient quantity, contaminated, overfilled, etc.)
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Surounded by Defects !
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Prevention – Appraisal – Failure:
Visible Defects and
Direct Costs are
The Tip of the Iceberg!
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Error Incidence for Patient Identification and Lab Draws
0
1
2
3
1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05
CY Quarter
Inco
rrec
t D
raw
Co
un
t
Defect Rate Driven to Zero!
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Improving Interventional Flow with Lean Six Sigma
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Suppliers Inputs Process Customers Requirements
Physicians
Receive call from Physician for Interventional test
Outputs
Approve Test Contact ordering Physician, Schedule test
Patient enters our “system” (“Orders, Labs, H&P)
See Below Completed Procedure
Specimen Obtained
Results in System
Physician
Patient
Radiologist
Pathology/Lab
Nursing/ I.P.
Registration
Convenient
Accurate Results
Timely On Demand
Convenient
Clear expectations
Timely Results
Results
Previous Exam
Good History
Convenient Schedule
H&P
Accurate Scheduling
Completed record
Demographic info
Payer info
ICD 9
Administer and complete test
Orders
Patient Information
Schedule Information
Capacity
Staffing
SIPOC Interventional Scheduling
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Detailed Flow Chart
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Data Collection
• Data Collection
bserving the Processbserving the Process
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Analysis
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CurrentProcess
vs.Delay
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Effect of Inpatient inserted in Schedule
Y=Arrival to ARMC to depart procedure room, below table wrt those patients that had inpatient interjected prior to their time period (Y In) versus those who did not have inpatient interjected (Y Out).
Y In Y Out Anova: Single Factor 298 224 Of data where complete from Arrival Time to Finish Time which defines Y 194 181 SUMMARY 350 186 Groups Count Sum Average Variance 274 127 Y In interjected 9 2441 271.2222 5324.944444 204 219 Y Out interjected 8 1609 201.125 1662.410714 200 230 294 260 ANOVA 403 182 Source of Variation SS df MS F P-value F crit 224 Between Groups 20810.628 1 20810.63 5.7555 0.0299 4.5431
Within Groups 54236.431 15 3615.762 Total 75047.059 16 F stat is greater than F crit so reject that means could be same
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Sometimes the System Just Gets You
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MinMax
62 Min
234 Min
609 Min
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Costs of Poor Quality
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Visible Defects and Hidden Costs
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The 8 Deadly Wastes
• Overproduction• Waits/Delays• Transport• Process• Movement• Inventory• Defects• Underutilization
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One Hospital’s Approach:
Latent CostsIdentified Opportunities
Realized Gains
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One Example of Latent Costs
4Q04 Targets WeightMortality 1 20Length of Stay 1 10CVC infections 3.6 5VAP infections 6 5Med Safety Rate 1 20*Readmit Rate 4.55 10*Safety (falls) 0.37 10*Returns to OR 1.19 10Continuous Readiness Index 90 10
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It Can Be done – One Example
Growth Pillar:Latent Costs, Identified and Realized Gains
-$6,000,000
-$4,000,000
-$2,000,000
$0
$2,000,000
$4,000,000
$6,000,000
$8,000,000
$10,000,000
$12,000,000
$14,000,000
$16,000,000
Late
nt
Ind
ent
ifie
d
Re
aliz
ed
Late
nt
Ind
ent
ifie
d
Re
aliz
ed
Lat
en
t
Inde
ntif
ied
Re
aliz
ed
Lat
en
t
Inde
ntif
ied
Re
aliz
ed
La
ten
t
Inde
ntif
ied
Rea
lized
1Q04 2Q04 3Q04 4Q04 YTD
Mill
ion
s o
f d
olla
rs
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Visualize Success:
We Need to SEE our Processes
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Pursuing Excellence by Improving Care and Increasing Affordability
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Our Mission
• The AHA Quality Center™ is a resource of the AHA designed to help providers accelerate their quality improvement processes to achieve better outcomes for patients and improve organizational performance.
• In collaboration with leading quality improvement stakeholders, it provides access to leading practices, tools and resources that support providers to achieve better patient outcomes, improved operational performance, enhanced safety and increased satisfaction.
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Increasing Pressure on Hospitals & Providers
• Need for accurate patient I.D. and Matching.
• Increasing numbers of older and more acute patients.
• Increased volumes through the E.D.
• Increasing incidence of HAI.• Pay for Performance
initiatives.• Reduced reimbursements.• Pressure for public reporting.
• Medication errors and harm.• Patient falls.• Poor handoffs.• Delays, queues, bottlenecks.• Incomplete information for
decisions.• Rework.• Staffing and resources.• Pressure to define and assess
“Quality.”
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The Quality Center will support the continuum of care:
• Improve throughput and reduce LOS.• Reduce readmissions.• Improve patient identification and matching.• Reduce Healthcare associated infections (HAI).• Improve medication safety.• Reduce incidence of falls.• Improve top clinical processes.• Reduce mortality.• Improve financial performance (C/Adj/DC).
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Unceasing Efforts to :
• Remove Waste
• Eliminate Defects
• Reduce Variability
“All work is a system, every system has processes and every process has waste
and variability.”
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Some Wicked Questions• What are we trying to accomplish with respect to
our performance?• What level of quality and safety are we
pursuing?• How do we measure it?• How is our performance changing?• What are we doing to improve it?• What are our latent costs?• What are our Costs of Poor Quality?• How is the CFO involved?
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Leaders Must
• Eliminate Preventable Harm
• Develop Highly Reliable Systems
• Improve Outcomes Year-to-Year
• Reduce Costs of Care Year-to-Year
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We need to Learn to see our processes in a different light
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The Quality Colloquium
Leadership for Reliable Systems
August 21, 2006
Stephen R. Mayfield
Senior Vice President