integrating six sigma into your existing clinical performance improvement activites
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Integrating Six Sigma into your ExistingClinical Performance Improvement Activities
Dr. James LaMorgeseChief Medical Officer
Sherrie JusticeDirector, Performance Improvement
Objectives
• Interpreting Six Sigma under the umbrella of the Baldridge Criteria for process excellence
• Complementing the models of organizational excellence with quality improvement
• Clinical practice project for improving and reducing variation in door to therapy time – “Door to Dilatation”
• Involving multiple departments
St. Luke’s Hospital
• 120 year old Non-Profit Community Hospital in Cedar Rapids, Iowa
• 240 - Average daily census• 39,000 ED visits/year• 2500 Births/year• 25+ year Cardio Thoracic Heart Program
– 2004 Solucient Top 100 Cardiovascular Hospital
• 25+ year CARF accredited Rehab Program• Surgical Services – 75% Outpatient, 25% Inpatient • Behavioral Health – Adult/Geriatric, Child/Adolescent• Home Care/Hospice
Iowa Health System• 1995 Formed: St. Luke’s and Central Iowa, Des Moines
charter members
• Hospital Affiliated/Not full mergers
• Retain Local Boards
• Economies of Scale – purchasing supplies, physician contract negotiation, information technology support.
Waterloo
Cedar Rapids
Dubuque
Des Moines
Sioux CityFort Dodge
Quad Cities
Opportunity
“Opportunity is missed by most people because it is dressed in overalls and looks like work”
Thomas Edison
St. Luke’s Approach to Achieving the Strategic Framework
The Home Front• St. Luke’s Hospital had new leadership team –
CEO, COO, CFO• Strategic Plan – Deliver Demonstrably Better
Quality• People critical to this strategy • Added 2 additional roles
– Director, Center for Quality Management and Clinical Effectiveness
– VP, Organizational Effectiveness
• Resources devoted to physician and staff development
Elements of the Strategic Plan
• Demonstrably better quality
• Physician workshop of choice
• Partnership with associates
• Strengthen the core
• Regional provider of choice
Breaking Out of the Pack
• Balanced Scorecard Team• Baldridge Organization Profile Team• Clinical Quality Steering Committee• Communication Team• Patient Satisfaction Team• Physician Efficiency Team• Staff Alignment Team• Staff Efficiency Team
Performance ImprovementStructure Highlights
B aldridge O rganiza tional P rofile T eam
C linical Q ua lity S teering C ommittee
P res ident's C ouncil M edical E xecutive C ommittee
Q uality o f C are C ommittee
B oard of D irectors
Interpreting Six Sigma under the umbrella of the Baldrige Criteria for
process excellence
St. Luke’s Strategic Planwith the Baldridge Criteria
St. Luke’s Strategic Framework
Partnership with Associates Partnership with
Associates
High Middle Ground
Top 100
Better Outcomes
Strengthen the Core
Better Outcomes Workshop of Choice
Strengthen the Core Regional Resource
Conclusions
• The Baldridge values embedded in the criteria provide an ideal set of performance and quality criteria
• Six Sigma provides an ideal deployment vehicle for leveraging quality and process improvement
• Together, the Baldridge Criteria and robust statistical and analytical tools of Six Sigma can result in quantum improvements in organizations willing to invest
Complementing the models of organizational excellence with
quality improvement
St. Luke’s Journey• 1970 – 1980’s: Internal Focus
– Emphasis on individual competence. Internal trends.
• 1990’s: Shift toward process improvement– Began external benchmarking in key services.
• 2000: Benchmarking across the system– Best practice sharing
– Evidence based practice to decrease variation: resulted in receiving the JCAHO Codman Excellence Award for statewide care of Diabetes.
– IHI strategic partner for the IHS - sets stretch goal, reached through small tests of change
Six sigma as just one of the tools for clinical improvement to patient care
and Involving multiple departments
at multiple levels
See Handout
Tool Function Who We Educated Examples
PDSA Basic improvement methodology forconfined processes and/or outcomes
Everyone Department specific indicators,for example Documentation compliance Hand washing compliance
Six Sigma Eliminate variation for complex,resource intensive processes
VP, Medical AffairsDirector, Performance ImprovementProgram Mgr., Risk Mgmt/Patient SafetyProgram Mgr., Infection ControlCardiac Outcomes Manager
Door to Dilatation for theacute ST Elevated MI patient
Lean Eliminate unnecessary processes, orsteps within a process
VP, Operational EffectivenessDirectors, Performance Improvement,
Lab, and RadiologyProgram Mgr., Risk Mgmt/Patient SafetyIntegrated Services
Patient Transport
IHIBreakthrough Series
Small incremental improvementsSet of proven ideas (change package),
the challenge is to learn how toimplement in your organization
Nursing staff at various levels (Directors,Managers, and direct care givers)
Supervisor, PharmacyPerioperative Staff EducatorMedical Director, ICUProgram Mgr., Risk Mgmt/Patient Safety
Ventilator PneumoniaPerioperative Safety
IHIInnovative Community
Small incremental improvementsDiscovery of new knowledge, testing
of new ideas. Specific changesand exact measures are unknown
Director, Performance ImprovementDirector, Nursing OperationsPerioperative Staff EducatorTotal Joint Coordinator
Key Clinical Areas – TotalJoint Replacement
Root Cause Analysis Determine why something happened Program Mgr., Risk Mgmt/Patient SafetyQuality Review NursesStaff involved in the occurrence
Sentinel EventsNear Misses
FMEA Determine where the risk lies, anddirects you where to make changes
Director, Performance ImprovementProgram Mgr., Risk Mgmt/Patient SafetyStaff involved in the process
Medication AdministrationProcess
Peer Review Determine if care is outside of thenorm or acceptable standard
VP, Medical AffairsMedical Staff CoordinatorPerformance Improvement staff
Quality of care concerns forlicensed independentpractitioners and nursing staff
Who Decides?
• Administration– Vice President– Director– Manager
• Clinical Quality Steering Committee
How to choose?
• Impact to the hospital
• Impact to the strategic plan
• Breadth of the project
• Resources needed
• Time required
Clinical Quality Steering Committee
Functions:• Recommends to the Board of Directors a hospitalwide
approach to performance improvement and how all levels of the hospital address improvement issues.
• Charters direct care performance improvement action teams
• Ensures the ongoing development and implementation of the clinical processes within the Baldridge strategy.
Clinical practice project for improving and reducing variation in door-to-therapy
time - “Door to Dilatation”
Door to Dilatation (D2D) Charter
• Decrease the variation in the door to dilatation time range for an ST elevated MI patient (STEMI).
• Increase the number/percent of patients whose culprit lesion is dilated within the 90 minute time frame.
• Baseline sigma 2.2
Measure
• 41% of STEMI patients have their culprit lesion dilated within 90 minutes
• St. Luke’s average time is 103 minutes (April 2003-March 2004)
Measure/Analyze
• Voice of the customer– EDP, cardiologists views
• NRMI data
• Concurrent case review
• Literature review - Advisory Board case example(s)
40
60
80
100
120
140
1st Qtr'03
2nd Qtr'03
3rd Qtr'03
4th Qtr'03
1st Qtr'04
2nd Qtr'04
St Lukes
National
Upper Limit Target
Average Door to Dilatation Time (minutes) for STEMI Patients
From NRMI
Sept ‘04
Percentage of Defects by Process Slices
Door to EKG
Target =10 min
Door to Cath
Target =60 min
Cath to Dilatation Target =30 min
Door to Dilatation Target =90 min
Days 43 34 71 43 Evenings 73 64 73 82
Nights 25 38 67 54
Weekdays 41 36 66 50
Weekends 42 58 83 75
*Defect- anything that does not meet customer requirement. The lower the number the better.
11.7 13.2 9.3
20.426.4
40.8
21.3
23.9
25.818.7
18.1
20.918.7
18.1
20.9
0
20
40
60
80
100
120
140
Days (n=22) Eves Nocs
min
ute
s
Culprit ID to DilationCath lab to culprit IDCardiologist to Cath LabEKG to cardiologistDoor to EKG
STEMI Process Times by Shifts Identified from Six Sigma Chart Review (n=44)
Analyze
Correlation Relationship0.32 Weak0.51 Modest0.83 Strong0.30 Weak0.87 Strong0.94 Very Strong0.43 Modest
Door to Dilatation Pearson Correlations
Door to EKG/Card ArrivalDoor to EKG/Total D2DEKG to Card/Total D2DDoor to Card/Card to Cath LabDoor to Card/Total D2DDoor to Cath Lab/Total D2DCath Lab to Culprit Lesion ID/Total D2D
Rank Order of Solutions to Decrease the ED Time
Cost Benefits
Ease of Implement-ation
Potential Problems Buy-in Score
Value 1.8 2.0 1.1 1.1 1.0
Registration 21 26 25 24 24 167.7
Concurrent Monitoring 19 26 24 22 24 160.8
Protocol/Order Set/Algorithm 22 25 23 20 21 157.9
Activation of Cath Lab 18 25 21 19 20 146.4
ED Logistics 17 22 16.5 15 20 129.3
Point of Care Testing 12 27 11 12 13 113.9
Lessons Learned
• Team leadership
• Project scope
• Completion of education– External assistance
• Influence over the project
Thank You
James R. LaMorgese, M.D.
319-369-7391
Sherrie L. Justice, R.N., M.A.
319-369-8367
St. Luke’s Hospital
1026 A Avenue NE
Cedar Rapids, Iowa 52406-3026