Six Sigma ApproachSix Sigma Approachtoto

Reduction of InfectionsReduction of Infections

Lois Yingling, RNC, MSN, CPHQ, Black Belt Lois Yingling, RNC, MSN, CPHQ, Black Belt Florida HospitalFlorida HospitalOrlando, FloridaOrlando, FloridaLois.Yingling@flhosp.orgLois.Yingling@flhosp.org

ObjectivesObjectives

At the conclusion of the At the conclusion of the presentation participants will:presentation participants will:

List the 5 steps of Six SigmaList the 5 steps of Six SigmaIdentify components of the IHI Identify components of the IHI central line bundlecentral line bundleAppreciate the value of a Appreciate the value of a systematic approach to process systematic approach to process improvementimprovement

OverviewOverview

Who is Florida HospitalWho is Florida HospitalBloodstream infectionsBloodstream infections

Five steps of Six Sigma Five steps of Six Sigma DefineDefineMeasureMeasureAnalyzeAnalyzeImproveImproveControlControl

Lessons learned with CDTLessons learned with CDT

Who is Florida Hospital?Who is Florida Hospital?

Founded in 1908 by Adventist ChurchFounded in 1908 by Adventist ChurchOldest & largest healthcare system in Oldest & largest healthcare system in Central FloridaCentral FloridaSeven campuses in 3 countiesSeven campuses in 3 countiesLicensed for over 1800 bedsLicensed for over 1800 bedsThird largest employer in Central FloridaThird largest employer in Central FloridaLargest Medicare population in the nationLargest Medicare population in the nationRecognized as one of America’s Best Recognized as one of America’s Best Hospitals in U.S. News & World Report for Hospitals in U.S. News & World Report for the seventh year in a rowthe seventh year in a rowHealthGrades 2005 Award for Excellence in HealthGrades 2005 Award for Excellence in Patient SafetyPatient Safety

DDMAICMAIC

DefineDefine

Why Bloodstream Why Bloodstream Infection (BSI)Infection (BSI)

Published mortality rates as high as Published mortality rates as high as 35%35%

Baseline CVC related BSI: 13%Baseline CVC related BSI: 13%Additional therapy costs $56,000Additional therapy costs $56,000

Baseline CVC related BSI: $16,699 Baseline CVC related BSI: $16,699 variable costvariable cost

Increased length of stayIncreased length of stayBaseline CVC related BSI: 20.6 Baseline CVC related BSI: 20.6 additional days per caseadditional days per case

National InterestNational InterestInstitute for Healthcare Quality Institute for Healthcare Quality (IHI)(IHI)

Central line bundleCentral line bundleHand hygieneHand hygieneMaximal barrier precautionsMaximal barrier precautionsChlorhexadine skin antisepsisChlorhexadine skin antisepsisAppropriate care of site and line Appropriate care of site and line systemsystemNo routine replacementNo routine replacement

Center for Disease Control (CDC)Center for Disease Control (CDC)GuidelinesGuidelines

DDMMAICAIC

MeasureMeasure

ScopeScopeIn Scope:In Scope:

Inpatients systemInpatients system--wide >17 y/owide >17 y/oPositive blood culture within 48 Positive blood culture within 48 hours of admission (2 weeks rehours of admission (2 weeks re--admission)admission)Confirmed based on CDC definitionConfirmed based on CDC definitionCVCCVC

Out of ScopeOut of ScopePICC linesPICC linesTunneled, port, dialysis, peripheralsTunneled, port, dialysis, peripherals

Project Description/ Project Description/ Problem StatementProblem Statement

Based on 2003 & annualized 2004 data:Based on 2003 & annualized 2004 data:43% of BSIs were secondary to CVCs43% of BSIs were secondary to CVCsLOS is increased by 20.6 days per LOS is increased by 20.6 days per casecaseVariable treatment cost is increased Variable treatment cost is increased by $16,699 per caseby $16,699 per case

Goal:Goal:Decrease the number of CVC related Decrease the number of CVC related cases by 10%, a decrease of 16 cases cases by 10%, a decrease of 16 cases per yearper year

SIPOCHigh Level Process Map

Supplier Input Process Output Customer

Physician Referral

Line

ProtectiveGarb

Tray

Start = line Insertion

Selectdevice

Select site

Don fullbarrier garb

Prep site

Insert line

Care for line& dressing

End = line removal

No BSI

BSI

Patient

Family

BaselineBaseline

Process in control, no special cause variation

Gauge RepeatabilityGauge Repeatability ICP Initial

Surveillance Determination

ICP Second Surveillance Determination

Agree Disagree

Patient Surveillance result

Surveillance result

BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired Total 10 0 100% One person repeatedly measures same unit

Gauge ReproducibilityGauge Reproducibility ICP #1 ICP#2 Agree Disagree Patient Surveillance

result Surveillance result

BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Not Hospital

Acquired

CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired Total 9 1 90% Two or more persons measure the same unit

DMDMAAICIC

AnalyzeAnalyze

Process CapabilityProcess Capability

Y1 All BSI Overall Z.USL -1.39 Sigma 0

Vital XsVital Xs

BSI

Education

Patient/Visitor

Catheter Care

Equipment

Site

Technique

Contamination

Prep

Skill level

Sterile barrier

Hand hygiene

PICC Candidate

Femoral

Subclavien

Jugular

Stabilizer

Cost

Non-antimicrobialcatheter

A ntimicrobialcatheter

ContaminationHub care

Dressing

A septic techniue

Line maintenance

Hand hygiene

Handling drsg

Handling catheter

Hand hygiene

Visitors

Patient

Physician

Staff

CVC related blood stream infections cause & effect fishbone

DMADMAIICC

ImproveImprove

Nail P&PChloraprep

Staff BSI Education

Began conversion to antimicrobial catheters in custom trays with sterile garb in all trays except Anesthesia Trays

Hand Hygiene Campaign

Interventions & ResultsInterventions & Results

Statistical SignificanceStatistical Significance

Two-Sample T-Test and CI: Historical VS New Mean

Two-sample T for Rate

C7 N Mean StDev SE Mean1 11 0.658 0.154 0.047 (Jan 2003 - November 2003)2 14 0.355 0.131 0.035 (Nov 2003 - January 2005)

Difference = mu (1) - mu (2)Estimate for difference: 0.30318295% CI for difference: (0.181309, 0.425054)T-Test of difference = 0 (vs not =): T-Value = 5.21 P-Value = 0.000 DF = 19

Difference between historical & new mean

is statistically significant

Error Proofing TraysError Proofing Trays

Custom Trays:Custom Trays:Anesthesia Trays Anesthesia Trays -- no sterile no sterile garbgarbED & Unit Trays ED & Unit Trays –– sterile garbsterile garb

Issue:Issue:Anesthesia trays without Anesthesia trays without sterile garb distributed to unitssterile garb distributed to units

Error Proof:Error Proof:All custom trays include sterile All custom trays include sterile garb and antimicrobial cathetergarb and antimicrobial catheter

DMAIDMAICC

ControlControl

Reliable MeasurementsReliable Measurements

What How X1 X What Where When HowMany

Total Blood Stream Infections Y=BSI Rate

Continuous Data

Positive Blood culture after 48 hours od admission or readmission within 7 days for S&S if BSI

Query Medmined for positive blood cultures

Line Type: CVC Swan Ganz, PICC, tunneled

Infection Control Survelance Criteria for Center for disease Control Definition BSI

System-wide Monthly !00%

X=number of infections secondary to CVC

Discrete data Same as above

Same as above

Extarpolate CVC lines

Confirmed BSI secondary to CVC line

Review records for accuracy

System-wide Monthly !00%

Gage R&R for all new emplyees after 90 days & for all staff annually. Gage R&R may be done more frequently if indicated.

Procedure &Data Form

Sampling Plan What toMeasure Type of

Measure Type of

Data

Clarify Data Collection Goals

Develop Operational Definitionsand Procedures

Operational Definition

Other Conditions to Record

Collecting and Recording

BSI Rate is based on CDC definition.

CVC related BSI extrapolated from total BSI cases.

Current StatusCurrent Status

Ja nua r y 2003 t hr o ugh Ju ly 2005

Per

1000

Pat

ient

Day

s

Jun e

Ma rch

De cembe

r

Sep te

mb erJu

n eMar

c h

De cembe

r

Sept

e mber

J une

M arc h

1 .2

1 .0

0 .8

0 .6

0 .4

0 .2

0 .0

_X =0 .383

UC L=0 .733

LC L=0.033

1 2

I C ha r t o f C V C B S I R a te H is tor ica l V S N e w M e a nDa ta S ource : A IC E

Process is in Control

Target: 5 or Less/MonthTarget: 5 or Less/Month

Process CapabilityProcess Capability

0 .70 .60 .50 .40 .30 .20 .1

U S LP ro ce ss D a ta

S a m p le N 18S tD e v (W ith in ) 0 .1 2359S tD e v (O v e ra ll) 0 .1 3445

LS L *T a rge t *U S L 0 .4 2000S a m p le M e a n 0 .3 8000

P o te n tia l (W ith in ) C a pa b ility

C C pk 0 .1 1

O v e ra ll C a pa b ility

Z .B e nch 0 .3 0Z .LS L *Z .U S L 0 .3 0P pk

Z .B e nch

0 .1 0C pm *

0 .32Z .LS L *Z .U S L 0 .3 2C pk 0 .1 1

O bse rv e d P e rfo rm a nceP P M < LS L *P P M > U S L 388888 .8 9P P M T o ta l 3 88888 .8 9

E xp . W ith in P e rfo rm a nceP P M < LS L *P P M > U S L 373103 .1 9P P M T o ta l 3 73103 .1 9

E xp . O v e ra ll P e rfo rm a nceP P M < LS L *P P M > U S L 383038 .4 7P P M T o ta l 3 83038 .4 7

W ith inO v er all

P r oce s s C a pa bi l i ty o f R a te

Y1 All BSI overall Z.USL 0.30 current Sigma 1.8

Owner AccountabilityOwner Accountability

What Who When Data collection Process Confirmed with IC Director & Manager

Director

Monthly beginning June 2005

Monthly report of CVC BSI Cases & LOS by Campus to Esmond Chan

Director Monthly beginning June 2005

Variable cost/capacity adjustment

Financial Analyst January 2005 & monthly

ResultsResults

Capacity YTD AprilCapacity YTD AprilActual 296 DaysActual 296 DaysTarget 110 DaysTarget 110 DaysVariance 186 Days Variance 186 Days

Dollar Savings YTD April Dollar Savings YTD April Actual $207,196Actual $207,196Target $77,233Target $77,233Variance $129,963Variance $129,963

CDT: Lessons CDT: Lessons LearnedLearned

Scope: ContainmentScope: Containment

In Scope:In Scope:Inpatients systemInpatients system--wide >17 y/owide >17 y/oDiarrhea with confirmed assay Diarrhea with confirmed assay diagnosis of CDTdiagnosis of CDT

Out of ScopeOut of ScopeOutpatientsOutpatientsInpatients without diarrhea & Inpatients without diarrhea & confirmed assay diagnosis of CDTconfirmed assay diagnosis of CDT

Scope: PreventionScope: PreventionIn Scope:In Scope:

Inpatients systemInpatients system--wide, except wide, except Campus 3, >17 y/o with a history of a Campus 3, >17 y/o with a history of a surgical procedure on the SIP listsurgical procedure on the SIP listDiarrhea with confirmed assay Diarrhea with confirmed assay diagnosis CDTdiagnosis CDT

Out of ScopeOut of ScopeAll patients admitted to Campus 3All patients admitted to Campus 3All medical patients and all surgical All medical patients and all surgical patients not on SIP listpatients not on SIP list

CDT Baseline Out of CDT Baseline Out of ControlControl

M ont h

Indi

vidu

al V

alue

June

Ma rc h

Decem be r

Septem be rJu

neMa r ch

Dec embe r

S eptem be rJu

neMa rch

5 .5

5 .0

4 .5

4 .0

3 .5

3 .0

2 .5

2 .0

_X =3.564

UC L=4.530

LC L=2.597

11

1

1

1

1

I C har t of C D T R a te

Baseline 2003 through June 2004

CDT RateCDT Rate

Ja n u a r y 2 0 03 t hr o ug h M a y 2 0 0 4

Per

1000

Pat

ient

Day

s

June

M a rc h

De cem be r

Se p tem be rJu

neM a r ch

De c embe r

S e p tem be rJu

neM a rch

5 .5

5 .0

4 .5

4 .0

3 .5

3 .0

2 .5

2 .0

_X =4 .195

UC L=5 .117

LC L=3 .273

1 21

11

I C ha r t o f C D T R a te P r e -A s s a y V S P os t A s s a yDa ta S ource : A IC E

June 2 0 0 4 t hr o u g h Jun e 2 0 05

100% Assay Testing increased Case Finding

ContainmentContainmentApril 2005April 2005

Terminal Cleans with Terminal Cleans with bleach for rooms of CDT bleach for rooms of CDT patientspatients

May 2005May 2005Error ProofingError ProofingTerminal Cleans for all Terminal Cleans for all roomsrooms

July Pilot Campus 6July Pilot Campus 6New nonNew non--bleach product bleach product

Kills sporesKills sporesNo damage to furnitureNo damage to furniture

Bleach

CDT RateCDT Rate

CDT Cases/Month CDT Cases/Month

Terminal bleach clean CDT rooms

Terminal bleach clean all Rooms

2004 - June 2005: Target 152 or less/month

PreventionPrevention

Right AntibioticRight AntibioticRight timeRight time

Within one hour of incisionWithin one hour of incisionRight durationRight duration

Discontinue within 24 hours for Discontinue within 24 hours for prophylaxisprophylaxisDocument if treating infectionDocument if treating infection

Business CaseBusiness Case

Improved clinical quality Improved clinical quality (absence of infection)(absence of infection)Capacity opportunity of 1639 Capacity opportunity of 1639 daysdaysFinancial opportunity of Financial opportunity of $1,298,484$1,298,484

SummarySummary

Six Sigma:Six Sigma:Well defined methodologyWell defined methodologySystematic approachSystematic approachRobustRobustData drivenData drivenDirectionalDirectionalStatistical application for other Statistical application for other initiativesinitiatives

““Alice came to a fork in the Alice came to a fork in the road. ‘Which road do I road. ‘Which road do I take?’ she asked. ‘Where take?’ she asked. ‘Where do you want to go?’ do you want to go?’ responded the Cheshire responded the Cheshire cat? ‘I don’t know.’ Alice cat? ‘I don’t know.’ Alice answered. ‘Then’ said the answered. ‘Then’ said the cat, ‘it doesn’t matter.’”cat, ‘it doesn’t matter.’”

From “Alice in Wonderland” From “Alice in Wonderland” by Lewis Carrollby Lewis Carroll