Adrienne's Presentation

Adrienne ElberfeldSix Sigma Master Black Belt

Virtua HealthMarlton, NJ

Six Sigma...Getting Real about

Results in Healthcare

Virtua Facilities

Virtua Locations

Virtua Health

Four hospital system in Southern New Jersey Two Long Term Care Facilities Two Home Health Agencies Two Free Standing Surgical Centers Ambulatory Care - Camden Fitness Center 7000 employees + 1700 physicians 7,000 deliveries $600 million in revenues STAR Culture

Dramatically improve patient satisfaction scores. Advance Virtua’s POE development. Continue implementation of medical staff development

plan. Continue to improve and sustain global clinical quality

and patient safety metrics. Continue rigor in cost expense management, revenue

enhancement and reduced length of stay. Recognize and continuously develop best people and

monitor employee satisfaction. Begin facilities planning and development of ambulatory

sites and regional medical centers.

Virtua Imperatives 2005

The “STAR”…PERFORMANCEEXCELLENCE

Clinical Quality & Safety

Caring Culture

Best People

Excellent Service

Resource Stewardship

Outstanding Patient

Experience

Achieve Vision and Receive Recognition

MISSION ANDVALUES

STRATEGICINITIATIVES

The STAR InitiativeAn organization wide cultural transformation initiative that will assure that Virtua fulfills its

covenant with the community, achieves its vision, and is highly successful over the

long-term.Three Objectives:1) Focus the work on creating an outstanding experience for patients

2) Become a high performing organization

3) Be recognized for our excellenceWe Know Where We Want to Go, How

Are We Going to Get There?

Current State: STAR

Commitment

Desired State: STAR

Performance

It’s Great to Have a Philosophy

. . . But We Need a Strategy !!

Six Sigma is our strategy on our journey through the mazeSix Sigma is our strategy on our journey through the maze

The Tool Chest

Paths to Change•Strategic Decision

•Operational issue Requiring a Decision

•“Wisdom of the Group” Problem

•Analytical Problem

Change Acceleration

WorkOut

Six Sigma

VIRTUA’S QUALITY JOURNEYVIRTUA’S QUALITY JOURNEY

WJ: Quality Circles: early - late 1980sMH: Morbidity and Mortality Reviews, Quality Audits

WJ: Quality Assurance: mid 1980’s

MH: Quality Assurance: mid 1970’s to mid 1980’s

WJ: Quality Assessment: late 1980’sMH: Quality Assessment mid to late 80’s (Leadership explores Total Quality Management Concepts with VHA 1988 - 1990)

WJ: Total Quality Management: early 1990s

MH: Total Quality Management 1990 - 1995

WJ: Re-engineering / Patient Centered Care: mid 1990’sMH: Metric Focused Quality Improvement (AQP) / Patient Focused Care: mid 1990’s

Virtua Health: Quality Management, Six Sigma, Workout: 2000 and beyond

April 2001

What is Six Sigma?…

Methodology for achieving goals and objectives

Quantitative technique for problem solving

Comprehensive improvement process

Tools For Driving Sustainable Change

Solid tools but….

Quality toolVague goalsNo standard metricsOpen-ended, unstructuredDepartment-basedFocus on product quality

Real results that matter to customers….

Business toolClear goals/deliverablesClear, consistent metricsRigorous timelineBusiness-basedFocus on customer

Six Sigma builds on Lessons Learned from prior approaches

TQM Six Sigma

What Makes Six Sigma Different?Adapted with permission from Hamadi Said, US Mint Philadelphia, PA

The Nature of Variation

. . . So how does this principletranslate into the real world?

Mean is Centered ( it is On Target), but

there is Large Variation (Big Sigma!)

Mean is Centered ( it is On Target), but

there is Large Variation (Big Sigma!)

Accurate but not Precise

Mean is not Centered ( it is Off Target);

the Variation is Small

Mean is not Centered ( it is Off Target);

the Variation is Small

Precise but not Accurate

Six Sigma is… A Quantitative Methodology

Sigma = Standard Deviation

Goal: Eliminate Defects

“Move the Mean…Reduce Variability”

1

2

3

TargetCustomer

Spec

36.6% Defects

Today

1

36

Target

No Defects!

Desired State

6

2 308,537

3 66,807

4 6,210

5 233

6 3.4

DPMO

Y= f(X1+X2+X3+…..Xn)

Why Six Sigma as a Tool?…

A Health System The Size of Virtua Fills ~400,000 New In-Patient Medication Orders Per Year…

Six Sigma Can Make a Difference in Healthcare

Error Rates atError Rates at2to 6 2 123,415 69.1%

3 26,723 93.3%

4 2,484 99.4%

5 93 99.98%

6 1.4 99.99966%

Script Errors / Yr % Correct

…Six Sigma Means 1-2 Incorrect Orders Per Year

Overall Approach

Practical ProblemPractical Problem Statistical ProblemStatistical Problem

Statistical SolutionStatistical SolutionPractical SolutionPractical Solution

y f x x x k ( , , . . . , )1 2

What is Six Sigma?

DMAIC: To improve any existing product or process

Six Sigma Methodologies

DefineDefine MeasureMeasure AnalyzeAnalyze ImproveImprove ControlControl

Who are the customers and what are their priorities?

How is the process performing and how is it measured?

What are the most important causes of the defects?

How do we remove the causes of the defects?

How can we maintain the improvements?

What is Six Sigma?

What measurements will the process owner use to confirm sustained

improvements? What system and structure changes support sustained

gains?

Define

Project Scoping

Operations Plan

Strategic Plan

Control

ImproveAnalyze

Measure

What is the right operational area for a project?

What is the right process result to address? What does the customer

expect?How is the current process

performing?

What are the most important factors driving the process results? What changes will deliver the desired process

result?

How well did the changes improve the process?

Project Conclusion

The DMAIC Process

DEFINE PHASE: Focus on the Y Y = f (x)“How do my customers look at me?”

Define

Define Phase: Focus on the Y Y = f (x)

Measure Phase: Focus on the Y

“What do I want to improve?”“What’s the best way to measure?”“Can I trust the output data?”

Measure

X1 X2 X3 X4

X5 X6 X7 X8 X9 X10

X11 X12 X13 X14 Define Phase: Focus on the Y

X1 X2 X3 X4 X5 X6

X7 X8 X9 X10 X11

X12 X13

X14

Y = f

Measure Phase: Focus on the Y

Analyze Phase: List & prioritize X’s

“How good am I today?”“How good do I need to be?”“What factors make a difference?”

Analyze

Define Phase: Focus on the Y

Measure Phase: Focus on the Y

Analyze Phase: Identify vital X’s

Y = f +

X1 X2 X3 X4 X5 X6

X7 X8 X9 X10 X11

X12 X13

X14

X2 X 7

“How good am I today?”“How good do I need to be?”“What factors make a difference?”

Analyze

Define Phase: Focus on the Y

Measure Phase: Focus on the Y

Analyze Phase: Identify vital X’s

Improve Phase: Focus on vital X’s

+X2 X 7X2 + X7Y = f“What’s at the root of the problem?”

“How can I predict the output?”

Improve

24

10

5

0

6

5

4

3

2

1

0

Y

X7

Define Phase: Focus on the Y

Measure Phase: Focus on the Y

Improve Phase: Focus on vital X’s

Control Phase: Sustain improvements

Analyze Phase: Identify vital X’s

“Have I reached my goal?”“How can I sustain the improvement?”

Control

DMAIC Training & Project Management Plan

Define Project

Measure

TRAINING

REVIEWS

R0R0

The Fundamentals

Define & CAP

Application

R1R1 ApplicationAnalyze

ImproveR2R2 Application

R3R3 ApplicationControl & CAP

R4R4

4 weeks

4 weeks

6 weeks

6 weeks

6 weeks

Project Management

Master Black Belt role Driven by the “R” document cycleTracking software

– Formal Project Management software - (November 2004 implementation of e-project)

– “Good Enough for Now” software

The Work-OutTM Process - An Enabling Technology

A 1-2 day session that involves employees to fix the problem

Concentrated, empowered decision making Leadership responds with

immediate decision or alternative direction

Follow up ensures completion of action plans

Work-OutWork-OutTMTM Is… Is… Key OutcomesKey Outcomes

Tool That Drives Decisions and Actions for Employees

Process to drive improvement

Opportunity to engage and empower people

Results-based:DecisionsAccountabilityFollow up

What’s a Work-Out?

Addresses an important process Facilitated by a STAR coach (130 trained) Gives immediate feedback to staff Examples:

Create a new process for Root Cause AnalysisCreate a process to deliver patient satisfaction data

to leaders and managersFix night call schedule for residentsFix transport process for LTC patients

Total: 161 so far

The Change Acceleration Process

Leading Change

Changing Systems and Structures

CurrentState

TransitionState

ImprovedState

Creating A Shared NeedCreating A Shared Need

Shaping A VisionShaping A Vision

Mobilizing CommitmentMobilizing Commitment

Making Change LastMaking Change Last

Monitoring ProgressMonitoring Progress

Simple, Yet Powerful Model to Assure that Change Happens

Summary: Six Sigma Methodologies

Six Sigma Six Sigma Six Sigma Six Sigma Change Change Acceleration Acceleration

ProcessProcess

Change Change Acceleration Acceleration

ProcessProcess

Effective Effective ResultsResults

Effective Effective ResultsResults

Work-OutWork-Out™™Work-OutWork-Out™™

Q x A = E

The Effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea.

A Proven Formula For Results

How they work together:

Six Sigma

project

Decisions

Implementation

Implementation

Development

WorkOut

Detailed

Analysis

Six Sigma

project

What’s Different About Six Sigma?

Quantitative: Where is the bang for your buck?

Accelerates and sustains change

Applicable to all parts of the system

Reduce defects----Increase dollars

More Than Just Another Flavor of the Month

Six Sigma Personnel Master Black Belt: Full time; advanced training in Six Sigma;

leads initiative, consults, teaches, and leads projects. Black Belt: Full time; trained in Six Sigma; leads projects and

assists green belts. Six Sigma Analyst: Full time; trained in Six Sigma and

reports directly to campus COO Green Belt: Part time; trained in Six Sigma; undertakes one

project every nine months. STAR Coach: Part time; trained in CAP and Work-Out; leads

two projects a year.

Accepted Nomenclature Adapted to Virtua

Virtua Health: The Initial Investment

Commitment of leadership: CEO and Board Executive sponsor Project manager Training from GE Six full time blackbelts 60 STAR coaches Leadership Coalition Resources for internal communications

$1.4 Million!

Six Sigma: Why partner with GE? Need for tools to improve performance and

to initiate and sustain change

Proven track record at GE

Tell you what you need to hear, not what you want to hear

Clear commitment to our success and independence

Complete package

The Right Company and Capabilities

What Makes a Good Target for a Six Sigma Project?

Addresses an important business objective Data driven Process Map and Measurable Output Foundation team (key staff) is the driver of the

project Black Belt leads the team as a consultant Average time to completion ~6 months

Large and Complex Undertaking

Driving the Project …..

Black Belt and

Project Team

Process Owner

and Project Team

Define Measure Analyze Improve Control

Evolution of Six Sigma at Virtua

2001 Present Central Control Deployed to Operations

Physician Six Sigma Champion Six Blackbelts Two MBB, Six BB, Forty GB

Just another thing to do Method to hit the metrics

Just do it MBB are consultants

World hunger type projects Well scoped projects

Emphasis on Work-Out Emphasis on CAP

Commitment and Flexibility

Cardiac Meds: A PRO/CMS Quality Indicators Project

What the Cardiac Meds Team Did … Why They Did It …

Project started in 7/02. All PRO indicators were achieved for Q4 ‘02. Project closed out in July ’03; continued success sustained!

• Gaged current data collection system

Project requested by physician leadership

Documentation was more of a problem than the actual delivery of care

Major progress in achieving physician support for process improvement (including physicians firmly addressing physician outliers!)

• Improve quality and consistency of data

• Created a cardiac discharge instruction sheet

• “Contained” defects immediately while implementing more sustainable systems and structures to support improvements

• To obtain immediate results to achieve aggressive system targets

• Increase compliance from docs and support accurate data collection

>90%CHF ACE at DC

ResultsIndicator

>95%AMI Beta Blocker at DC

>95%AMI Beta Blocker < 24 hrs

>95%AMI ASA at Discharge

>95%AMA ASA < 24 hrs

Project Results …

Home Care HHRG Case Weight Mix and Coding

What the Team Did … Why They Did It …

Total Project Benefit Estimate $1,200,000

Medicare Length of Stay

• Established standards in completion of initial OASIS form

• Enhanced Care Manager role in team

• Implementation of standard operating procedures for both agencies, two bargaining units through use of WorkOuts

• Weekly review of lock days for concurrent review by manager

• Substantial ROI to purchase new computerized system

• On-going sustainable changes in place during training and implementation of new system

• Increase in initial HHRG case weight mix & broader knowledge base of MO questions

Overall Case Weight Mix Average = 1.34

Agency OASIS Lock Within 7 Days = 92%

Percentage of Agency LUPA’s = 15%

• Decreased percentage of LUPA’s to 15%

• Surpassed the Medicare threshold for OASIS lock within 7 days

• Decrease in adjustments (refunds) to government

• Decrease in technical denials and increase in cash flow

Project Results …

Advantages to Virtua Health

Results measured in dollars, quality and service Common language Breaks down silos Physicians like it Faster decisions and implementation A method to accelerate and sustain change Creates clarity and objective measures of

success

All in all, a Great Return on Investment

Key Success Factors

Six Sigma should be undertaken with a clear vision of where you want to be

Introduce Six Sigma as a tool, not a philosophy CEO must own it Make Six Sigma a system wide effort….Focus on $$$,

productivity and patient issues Measure, measure measure…Deal with information issues Hold people accountable for using Six Sigma to achieve

outcomes that are important to the organization Invest in resources and make a long term commitment Change the systems and structures to support the effort

It Has to Become the Way You Do Your Work

Lessons Learned Clear objectives, measurable outcomes and ‘doable’

projects are a must----scope the projects It is about the process There is plenty of ‘fat’ in healthcare Hold people accountable to use the tools to get

results----Resistance to change and accountability is high and in high places

Teach management how to use the tools Hit the areas that are ready and fertile--Finance! Over communicate by a factor of 1000

Q X A = E!

Lessons Learned

Be flexible and patient Deal with the problem of bad data Use CAP Sponsor Education is critical-teach them how to ask good

questions-implementation of Yellow Belt training It is all about the customer It is a process that shines the light, there is nowhere to hide Can help identify future leaders Massive staff empowerment Common language This is constantly evolving…there is always something to

improve

Six Sigma: Leadership Development

Emerging leadersTime limited position“Rotating Internship”Developing business rigor and results

orientation“Infecting” the organization with

excellence and competence

Leadership Developmentsome success stories

Director Patient Billing Services Black Belt AVP Home Care VP Operations

Director Quality Master Black Belt VP Quality Nurse Manager Med Surg Black Belt Quality

Director Home Care Home Care Director of Nursing HR IS Black Belt Cardiology Product Line at

Marlton Nurse Manager Emergency Department Master

Black Belt Virtua Enterprise Manager AVP Community Services Black Belt VP Nursing

Services AVP Operations Black Belt Director of Finance

Director Patient Billing Services Black Belt AVP Home Care VP Operations

Director Quality Master Black Belt VP Quality Nurse Manager Med Surg Black Belt Quality

Director Home Care Home Care Director of Nursing HR IS Black Belt Cardiology Product Line at

Marlton Nurse Manager Emergency Department Master

Black Belt Virtua Enterprise Manager AVP Community Services Black Belt VP Nursing

Services AVP Operations Black Belt Director of Finance

Should You Use Six Sigma?

Purpose?– Vision– Motivation

Commitment?– CEO– At least 3 years– Investment

Capacity?– Culture– Accountability– Skills of the managers

Are You Willing to Destroy the Good to Get Better?