Reducing Avoidable Days on Your Telemetry Unit

SIX SIGMAOperational Excellence

Reducing Avoidable Days on Your Telemetry Unit

Todd SperlSix Sigma Master Black BeltSt. John HealthDetroit, MI

Sue CarterDirector of Nursing InformationSix Sigma Green BeltProvidence HospitalSouthfield, MI

Vicki KamalSupervisor Care and Resource ManagementSix Sigma Green BeltProvidence HospitalSouthfield, MI

SIX SIGMAOperational ExcellenceSt. John Health Overview

• Member of Ascension Health• Comprised of 8 hospitals and over 100 medical

facilities in southeast Michigan• Guided by our Mission; Shaped by our Values

• Committed to providing spiritually centered, holistic care

• Sustain and improve the health of individuals in the communities we serve, with special attention to the poor and vulnerable

• $146 million in uncompensated care FY’05

• Vision for the Future• To provide the highest quality patient care

experience in all that we do

• Launched Six Sigma Oct 31st, 2003


How Six Sigma Is Organized at SJH

• System COO directs deployment of Six Sigma

• System MBB’s directly report to the System COO

• Steering Committee made up of COO, CMO, CFO, EVP-HR, EVP-OE, System VP of Quality, and MBBs

• Each hospital has an Executive Sponsor (Champion) with a reporting relationship to the System COO in addition to the Hospital CEO

• Hospital BB’s directly report to Executive Sponsors with dotted lines to System MBB’s

System COO

SteeringCommittee

MBBs Executive Sponsor

Hospital BBs


• Service Excellence

• Patient/Family safety concerns

• Physicians seeking the best care for patients

• Costly technology • Labor Shortage

Challenges We Face

• Our competition isn’t sitting still

SIX SIGMAOperational ExcellencePerformance Improvement

at SJH

+

6

5

4

3

2

1

0

-

As scope and complexity increases, the tactic shifts to Six Sigma (DMAIC)

As scope and complexity increases, the tactic shifts to Six Sigma (DMAIC)

DMAIC

Lean DMAIC

Lean

CAP & WorkOut

Leadership Decisions


Economic Impact of Performance Improvement

PERFORMANCE IMPROVES

Profit Improves

Market share increases

Revenues go up

Productivity improves

Customers sing our praises

Costs go down

Processes improve

Outcomes

Perceptio

ns

(Fred Lee – If Disney Ran Your Hospital)


Right Place, Right Time

Reducing Avoidable Days in Providence

Hospital’s Telemetry Unit


Original Problem Statement

• 10 to 20% of monitored beds are being used inappropriately.

• Our project is to reduce inappropriate use of monitored beds to improve patient safety, customer service and patient though put.

Problem Statement…Why do this project?


Project Goal

• To reduce the number of patients not meeting clinical criteria in monitored beds. These avoidable days cause delays in placing patients into monitored beds from the Emergency Department/ Operating Room and potentially other medical floors.


Telemetry Process Map

Process Map Before


• Created Universal Criteria to stay on Telemetry Unit.

• Created a standard process for identifying when a patient should be transferred or discharged.

Solutions Implemented


Discharge Criteria1. All - inclusive of Endocrine, Pulmonology, Infectious Disease, Nephrology.Per Established Discharge Criteria: 12-24 hours stable:• Vital signs have not generated need for intervention (BP, RR, HR), or interventions

can be performed on med-surg floor. • Pain management can be accomplished on med-surg floor. • Arrhythmia controlled on oral medications (No acute arrhythmia requiring active

treatment, Persistent acceptable stable tachycardia). • Hemodynamically stable off intravenous medications requiring telemetry monitoring

(Stable on oral medications). • Metabolic abnormality that can lead to deterioration corrected or can be managed

effectively on med-surg floor. • Urine output stabilized/appropriate for patient condition. Fluid management/diuresis

can be managed on med-surg floor. • ABG's and/or oximetry at optimal level for patient x 24 hours. • Laboratory data trending toward normal or at level safe for transfer (Hgb, K+, BS,

Pulse Ox > 92, Coags, etc. as related to diagnosis or procedure). • DNR – does it need to be on the step-down? No step-down treatment, no palliation

requiring step-down. Futile care• Bipap/Cpap – New Bipap/Cpap patients and patients who use Bipap/Cpap at home

should be monitored on Intermediate Care to establish respiratory stability for 24 hours on admission. After 24hrs, if necessary he/she may be transferred to a non-monitored unit if able to apply and remove the Bipap/Cpap without assistance.

• Placement in skilled ECF or LTAC• Hospice transfer


Discharge Criteria

2. Cardiac – Cardiac Surgery• Stable patient 3 days post-MI without clinically important complications (CHF,

arrhythmia, silent ischemia, post-infarct angina, conduction defects, or shock).• Myocardial infarction has been ruled out using enzyme criteria. • AICD or PPM after 24 hours post-insertion.• Heart rate and rhythm stable with device functioning appropriately. 3. Surgery – Vascular – Trauma• Exam of wounds and exam of pulses distal to operative sites are without

change for 12-24 hours and have not required active intervention such as unplanned anticoagulation or bedside drainage during this timeframe.

• Frequency and extent of wound care can be handled on med-surg floor. • Chest tube or other drainage outputs do not require active fluid or blood

produce replacement. 4. Neurology – Neurological surgery• Frequency of neurological checks reduce to every four hours or less frequently,

with no worsening of neurological status over 12-24 hours. • Patient has not required active adjustment of seizure medications due to

breakthrough seizure activity over 12-24 hours. • Stable neurological status x 24 hours.


Discharge Criteria

Note: Patients not meeting the above

criteria are eligible for transfer to medical floor

Physicians are required to justify the patient requiring stepdown care by noon daily in the daily progress notes.


NP/RN/CM assess patient

during morning analysis.

Patient meets

established criteria, transfer

to Med/Surg Floor?

Continue Stepdow n Care

No

Yes

Is Patient ready for

transfer to Med/Surg?

Move patientto Med/Surg. Yes

RN/CM consult with NP for

transfer.

Patient meets

established criteria to D/C

home?

NP/RN/CM calls Attending Physician

to discuss D/C status.

Yes

D/C patient home?

Patient is D/C home.

Yes

No

No

No

NP/RN/CM review Physician progress notes.

*Patients meeting established posted transfer/discharge criteria are eligible for transfer to medical floor.

Current Process MapIntermediate Care Transfer/Discharge Process*

Six Sigma Pilot – Seton IntermediatePreliminary Pilot Data Shows Avoidable Stepdown Days Now at 14%!


Pre-Pilot

Analyze

Pilot

4 weeks

9/19 to 10/16

Control

4 weeks

10/17 to 11/13

N= N= N=

308 137 26

Stepdown LOS - Average 3.79 2.68 3.23

Avoidable Day Average 2.41 1.09 0.35

Avoidable Day SD 1.76 0.30 0.85

% of Avoidable Days 32.90% 19.42% 10.71%

% of Charts w/Avoidable Days 52% 38% 14%

Z-Score (Avoidable Days) 1.9 2.4 2.4

Project Results


Sample

Sam

ple

Count

Per

Unit

4321

0.5

0.4

0.3

0.2

0.1

0.0

_U=0.1059

UCL=0.4748

LCL=0

U Chart of Days Avoidable

Tests performed with unequal sample sizes

Control Chart


Project Benefits

• More collaborative work environment between Nursing and Physician

• Empowered Nursing to “transfer” patients to Med/Surg floors in order to free up Telemetry beds

• Changed Physician Behavior

• Improved patient safety, e.g., right patient in the right bed at the right time.

• Realized financial benefits, e.g., correct staffing expense to the correct patient, improved reimbursement.


Lessons Learned

• Team Leadership

• Project Scope – Need to be flexible

• Nursing, Nursing and Nursing

• Physician Involvement and Buy-in is Key

• Have Fun!


Extended Team Members

• Dr. Ernie Yoder• Dr. John Fath• Sue Markowitz, Nursing• Sandra Deering, Nursing• Monique Ulman, Nursing• Wendy Cole, Nursing• Denise Mclean, Project Sponsor

Thank You!


Questions?

Reducing Avoidable Days on Your Telemetry Unit

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