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Lean Six Sigma Processes

H:\1 Ongoing Projects & Programs\Magnet\Redesignation 2012\Redesignation-2012\2012 Redesignation

Team Folder\Transformational Leadership\TL 4\Database Projectsv20doc.docx

Project Project Description Project Sponsors Team Leaders DMAIC * Phase Committee

1 Patient Safety Indicator # 11 : Post Op Respiratory Failure

Dr. Kain, Associate Dean Clinical Operations

Mohsen Davoudi, MD Diane Rigger, RN

Closed: Now in Control Phase Diane McPherson to monitor and continue publishing results

2 Patient Safety Indicator # 3 : Pressure Ulcer

Dr. Kain, Associate Dean Clinical Operations Karen Grimley , Chief Nursing Officer

Sonia Lane Mo Espinoza

Analyze MBB Call today with review of Skin Defects findings. Have data on casual factors

Clinical Excellence

3 Eliminate delays in getting patients into Radiology, both inpatient and outpatient.

Alice Issai, Chief Operating Officer

Pat Bird Mike Schneider

Improve Met with new MBB on next steps

4 Improve discharges by Noon for elective surgeries


Susan Christensen RN

Control

Clinical Excellence

5 ED Door to Doc with an evaluation of ED Nurse Interventions prior to MD evaluation

Karen Grimley, Chief Nursing Officer

Dr. Jennifer Oman Darlene Bradley

Improve/Control Presented at Clinical Excellence

Clinical Excellence

6 Patient Safety Indicator # 15 Accidental Punctures / Lacerations

Dr. Kain, Associate Dean Clinical Operations Karen Grimley, Chief Nursing Officer

Marianne Lovejoy, RN Ninh Nguyen, MD

Improve Met with MBB to get input for improve phase and next steps.

Clinical Excellence

7 Infusion Center Streamlining: Throughput, cost savings, and chemo prep.


Raja Zeitany Luanne Sims RN

Analyze/ Improve

Team has completed staff workflow analysis and Order Set analysis

8 Patient Referral Process scope to focus on Oncology Outpatient Referrals.

Teresa Conk , Chief Strategy Officer

Gay Serway Erwin Altamira Nancy Eagan, Dr. Ed Nelson, Dr. Stamos, Dr. Ken Chang

Analyze Ongoing meeting with MBB and actively analyzing data.

9 OR room turnaround time ( measure ,may be median time, and objective to be defined by team; )

Alice Issai, Chief Operating Officer Dr. Kain( already a Black Belt)

Laura Bruzzone Dr. Scott Engwall

Improve Meeting held with MBB’s on project 10/5. Team is experiencing some change mgmt issues

OR Committee

10 Priority Project Related to ROI : Transfers in “phone to floor”

Morris Frieling, CFO

Jean Teetor Mary Owen, RN

Improve phase 80%

complete; Presented project to Cohort #3 Measure: 6 quick fixes

TL4g,Lean Six Sigma Teams.pdf

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already showing improvements

11. Safe Discharges Alice Issai, Chief Operating Officer Karen Grimley, Chief Nursing Officer

Israel De Alba , MD Margaret O’Brien, RN

Analyze. Presented to clinical excellence on 10/4. Deciding which interventions and prioritizing given QUEST impacts and other confounding variables occurring in parallel.

Clinical Excellence

12 **Door to Needle tPA to reduce Stroke mortality and morbidity

Dr. Kain( already trained Black Belt)

Haley Rudzwick ( July 2 Day)

Dr. Oman (Cohort #1)

Analyze Met with MBB to discussion analyze findings. Schedule Champion session to discuss improvement suggestions for process streamlining

Clinical Excellence

13 AHRQ Quality Indicator : PSI 02 Death in low mortality DRG Surgical

Dr. Kain

Dr. Vakharia (Cohort #2) Diane McPherson ( train in January) on LOA

Measure Meeting with MBB to get feedback on Data collection/analysis Scheduled for MBB Minitab support session

Clinical Excellence

14 PSI 18 OB Trauma vaginal with instrument; PSI 19 OB Trauma vaginal without instrument

Dr. Porto Dr. Kain

Diane Rigger Dr. Hameed (train in September 5 day)

Define

Met with MBB to get input for Charter refinement

Clinical Excellence

15 Compliance in mandatory required data on blood transfusion tagging.

Dr. Kain Dr. Minh-Tran Chris Sandoval

Define Meeting with MBB to get input for Charter.

16 Pain Management

Dr. Kain, Associate Dean Clinical Operations Karen Grimley , Chief Nursing Officer

Donna Grochow, RN

Define Met with MBB for project charter input, need schedule follow up

Clinical Excellence

17 Physician Credentialing Dr. Heydt Dr. Barron

Natalie Maton Rose Jacobs ***

Define Class 9/12-9/16 Meeting with MBB to get input for charter refinement


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18 Heart Failure readmissions improvement

Dr. Kain Nathalie De Michelis Dr. Lombardo (Oct 2 day)


19 DSRIP : Sepsis Improvement ( Severe sepsis detection and management)

Dr. Barron Karen Grimley

Mary Owen Kristie Hare

Define Need to schedule meeting with MBB

20 DSRIP: CLABSI Dr. Barron Karen Grimley

Linda Dickey Susan Huang, MD

Define Meeting held with MBB for project charter. Team launch 10/5/11

21 DSRIP: Redesign clinic processes to improve patient experience.( Focus Plaza Ophthalmology, Plaza Primary Care, Cancer Cntr)

Kurt Stauder Julie Limfueco Erwin Altamira

Define Meeting held with MBB. Team launch 10/5/11

22 Priority Project Related to ROI : Safe handoff between ED and inpatient team to allow right patient in the right ( acuity) setting and to reduce 1 day stays

Morris Frieling Jim Murry

Pam Findley Scott Rudkin, MD


23 IS Project Management Process Improvement

Jim Murry Alexandra Celano


24 Improve/streamline IR intake process

Alice Issai Lisa Cuccarese ( aka Lisa Brown) Laura Findeiss, MD

Define Need to Meet with MBB to get input for charter refinement

25 Improve Turnaround time for clinical engineering equipment repair.

Alice Issai Shereen Johnson Greg Eikam***

Define Team launch 10/7/11 with clinical side

26 Streamline SOM process for hiring faculty and staff

Dr. Clayman Ralph Clayman, MD Rebecca Brusuelas

Define Need to meet with MBB for charter refinement (MBB to reach out)


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27 Streamline the patient safety event management system process.

Dr. Barron Mary Owen, RN Define Need to meet with MBB to get input for charter refinement

28 Green Lean OR Dr. Kain Kate Tobin, MD Define/Measure Analysis of Medisorb consumption data


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