Six Sigma in Healthcare: A prescription for change? Carolyn Pexton October 24, 2007 CAHPMM Annual Conference.

Six Sigma in Healthcare: A prescription for change?

Carolyn PextonOctober 24, 2007CAHPMM Annual Conference

Objectives

2

• Articulate the case for organizational transformation in healthcare

• Acquire high-level understanding of Six Sigma and related change management methods

• Learn from case study examples

• Know the keys to a successful deployment

The Need for Change in

Healthcare

A Perfect Storm

•Patient safety and quality concerns

•Demographic changes•Rapidly changing

technologies and treatment •Digital transition•Workforce issues•Financial constraints•Rising consumerism•Un and Under-insured•Leadership challenges

“To a large extent, health care systems were not designed with any scientific approaches in mind. Too often there are long waits, high levels of waste, frustration for patients and clinicians alike, and unsafe care. A bold effort to design health care scheduling systems, process flows, safety procedures, and even physical space will pay off in better, less expensive, safer experiences for patients and staff alike.” – Don Berwick, IHI

Time cover story - May 1, 2006

Q: What Scares Doctors?

A: Being the Patient

The high cost of poor quality:

New payment rules from CMS • Along with human suffering, treating medical

errors such as hospital-acquired infections come with a high financial cost.

• Roughly 1 in 10 Americans will acquire an infection as a result of their hospital stay, and this stay will be lengthened in order to provide appropriate treatment.

• Hospitals will no longer be reimbursed by CMS for certain errors and the additional resources they require.

Change is imperative!Centers for Medicare and Medicaid Services (CMS), HHS CMS-1533-FC, Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates.

Hospitals must also redesign processes and address the human side of change.

Simply overlaying 21st century technologies on top of 20th century workflow will not yield the necessary cost, quality and efficiency benefits.

Technology alone isn’t the answer…

Overcoming the barriers

1. Culture• Overcome resistance• Shape common goals

2. Alignment and accountability• Ensure clear linkage between

improvement initiatives, performance and strategic goals

• Develop consistent management structure

3. Control• Put mechanisms in place to monitor

and maintain results long-term

Getting there from here

• Transformation in healthcare won’t happen without transparency.

•Transparency can’t happen without culture change.

•Culture change won’t happen without a bold vision, a common toolset and unwavering commitment.

Six Sigma Background and

Basics

Where did Six Sigma Come From?

• During the first five years, even suppliers were required to participate in the process

• Six Sigma was adopted by Allied Signal and GE and further developed into a true management system

• Success led to global deployment across a variety of companies and industries – including healthcare!

• Initially developed at Motorola in the 1980s to improve processes, meet customer expectations and maintain market leadership

What does Six Sigma mean?The term “Sigma” is a measurement of how far a given process deviates from perfection – a measure of the number of “defects”. Six Sigma correlates to just 3.4 defects per million opportunities.

A quality improvement methodology that applies statistics to measure and reduce variation in processes.

A management system that is comprehensive and flexible for achieving, sustaining, and maximizing success.

2

3

4

56

308,537

66,807

6,210

233

3.4

BB DPMODPMO

Key Concepts

Critical to Quality (CTQ)Critical to Quality (CTQ):: Attributes most important

to the customer

DefectDefect:: Failing to deliver what the customer wants

Process CapabilityProcess Capability:: What your process can deliver

Stable OperationsStable Operations:: Ensuring consistent, predictable

processes to improve what the customer perceives

How does the customer view my process?

What does the customer look at to measure performance?

Time to Park Car

Registration

Walk to Procedur

e Area

Procedure Time

Time to drive to facility

Hospital’s Viewof “Registration”

Patient’s Viewof

“Registration”

An Enabler for Cultural Change

Lobby Time

Target CustomerSpecificatio

n

3s 3s 6.6% Defects

BEFORE

w i d e v a r i a n c e

Six Sigma illustrated

No Defects 6sAFTER

slim variance

Target CustomerSpecificatio

n

6s

Patients don’t feel the averages, they feel the variability

GoalSix Sigma refers to a process that produces only 3.4 Defects Per Million Opportunities

2 308,5373 66,8074 6,2105 2336 3.4

Sigma Level

Statistically...DPMO

~93.3% “Good”

99.99966% “Good”

How good are we today?

20,000 lost articles of mail per hour

The Classical View of Quality

“99% Good” (Z = 3.8)

Seven lost articles of mail per hour

The Six Sigma View of Quality

“99.99966% Good” (Z = 6)

One hour without electricity every 34 years

68 wrong drug prescriptions each year

No electricity for almost 7 hours each month

200,000 wrong drug prescriptions each year

One short or long landing at most major airports every five years

2 short or long landings at most major airports daily

5,000 incorrect surgical operations per week

1.7 incorrect surgical operations per week

One minute of unsafe drinking water every seven months

Unsafe drinking water almost 15 minutes each day

How good do we need to be?

Define CTQs

Statistical Problem

Practical Problem

Statistical Solution

Practical Solution

The DMAIC Methodology

...measure your target metricand know your measure is good...

…look for root causes andgenerate a prioritized listing of them.

... determine and confirm theoptimal solution ...

…be sure the problem doesn’t come back… sustain it

and relate it to the customer.., ... define the problem, clarify

Sample fishbone diagram – poor x-ray quality

1. Form cross-functional team

2. Construct cause-and-effect diagram, listing potential causes on each branch

3. Prioritize causes on each branch – select important causes and ignore trivial ones

4. Conduct detailed analysis and develop an action plan

5. Follow up until action is completed and results are verified

6. If results are unsatisfactory, use statistical tools (such as Regression Analysis) to further analyze the problem

Key roles and responsibilities

Team Members: Individuals who receive specific Six Sigma training and who support projects in their areas

Champions/Sponsors: Trained business leaders who lead the deployment of Six Sigma in a significant business area

Black Belts: Fully-trained Six Sigma experts who lead improvement teams, work projects across the business and mentor Green Belts

Green Belts: Fully-trained individuals who apply Six Sigma skills to projects in their job areas

Master Black Belts: Fully-trained quality leaders responsible for Six Sigma strategy, training, mentoring, deployment and results

Translating Goals into ResultsThe Big Ys

Clinical excellence

Patient safety

Financial results

Patient satisfaction

Physician/staff satisfaction

Community service

ALL DRIVEN BY

PROCESSES

Wait Times/Delays

Lab TAT

Radiology TAT

PACU/ED Admit to Bed

World Class Team

Reimbursement

Accuracy of Patient Info

Medical NecessityValidation

POS Collections

Productivity

Nursing Documentation

Pain Management

Patient Flow

Discharge Process

ICU Throughput

Appropriate Placement

CTQ’s Top Financial Performance

Excellent Service

GrowthClinical Quality

Quality Measures

Core Measures Performance

(CHF)

Communication of Quality-Public

Certifications/Accreditations

Linking Projects to Healthcare “Y”s

ICU Clinical Effectiveness

Reconciliation of Patient Medicine

Patient Classification

Process

On Base Implementation

Cath Lab Scheduling

System

Reduce FPC No Shows

Perioperative Service Needs

• Quality• Capacity• Net Revenue

• Lean Preop Process• Staffing/anesthesia time• Preference Cards• Equipment

replenishment

• Preop delays• Surgeon NA• Anesthesia NA• Equipment/

Supplies NA

• Block Time Allocation/Util

• Case Time Alloc• Add-on Mgmt • Scheduling Guidelines

•Work-Out: Work Process, Roles, Responsibilities, Communication

•Kaizan Event: TAT

• Staff roles• Setup/Cleanup

process• Communication

• Level Loading Blocks/ Cases across days/time by clinical service

• Match sched to staffing• New guidelines: Add-ons

First Case Start Time

Room Turnover Time

Room Utilization

Performance Metrics

Core BusinessMetrics

Critical Factors

Project Solutions

Patient Safety • Anesthesia Time• Right Side• Instrument Counts

• Process for identifying, reporting, taking corrective action

PatientSatisfaction

Physician –Staff

Satisfaction

Community Relationship

FinancialViability

Projects and Work-Outs

Becoming a Better Healthcare Provider

Business Processes

HospitalManagement Processes

ClinicalCare

Processes

Tools

Outcome

Per

form

ance

Exc

elle

nce

It’s really not about projects – they are a means to an end!

PatientSafety

The Ultimate Goal

In simple terms…

• Listen to the customer• Define their expectations• Measure how many times we get it wrong• Fix it• Prove the fix is real and meaningful

• Make it stick !!!!!

Related Methodologies and Change Management

Techniques

Large scale improvements require precise

coordination and a common “cadence”to advance smoothly

62% of initiatives fail due to lack of

leadership commitment

Change Acceleration Process (CAP)

Changing Systems & Structures

CurrentState

TransitionState

ImprovedState

Creating a Shared Need

Shaping a Vision

Mobilizing Commitment

Making Change Last

Monitoring Progress

Leading Change

Stakeholder Analysis

UCSS 36

Change Acceleration Process

Stakeholder Analysis

Steps: 1. Brainstorm key stakeholders by name Plot where individuals currently are with regard to desired change (= current).

2. Plot where individuals need at the minimum level to be (X = desired) in order to successfully accomplish desired change-identify gaps between current and desired.

3. Indicate how individuals are linked to each other, draw lines to indicate an influence link using an arrow ( ) to indicate who influences whom.

r 3/96 4. Plan action steps for closing gaps with influence strategy.

Names StronglyAgainst

ModeratelyAgainst

Neutral ModeratelySupportive

StronglySupportive

xDr. XYZ

Dr. R

Influence loop

Exercise: Stakeholder AnalysisTake home assignment for your current project:

1. Brainstorm key stakeholders by name

2. Plot where individuals currently are with regard to desired change ( = current).

3. Plot where individuals need to be at the minimum level (X = desired) in order to successfully accomplish desired change-identify gaps between current and desired.

4. Indicate how individuals are linked to each other, draw lines to indicate an influence link, using an arrow to indicate who influences whom.

5. Plan action steps for closing gaps with influence strategy.

UCSS 36

Change Acceleration Process

Stakeholder Analysis

Steps: 1. Brainstorm key stakeholders by name Plot where individuals currently are with regard to desired change (= current).

2. Plot where individuals need at the minimum level to be (X = desired) in order to successfully accomplish desired change-identify gaps between current and desired.

3. Indicate how individuals are linked to each other, draw lines to indicate an influence link using an arrow ( ) to indicate who influences whom.

r 3/96 4. Plan action steps for closing gaps with influence strategy.

Names StronglyAgainst

ModeratelyAgainst

Neutral ModeratelySupportive

StronglySupportive

Define the Problem

BrainstormIssues/Barriers

CategorizeIssues/Barriers

Define “Headers” for Categories

Prioritize Categories

2 10 9 4 6vo

tes

Brainstorm Potential Solutions

AssessPotential Solutions

Pay-o

ff

Develop Action Plans

Share Action Plans

Report-Out Action Plans

Kick-Off

Ground Rules, Introductions,

Roles, etc

Mission

What: Who: When: Resources

Work-OutTypical Session

What is Lean?

The relentless pursuit of the perfect process through waste elimination…

In healthcare, Lean is about shortening the time between the patient entering and leaving a care facility by eliminating all

non-value added time, motion, and steps.

We Spend 75-95% of Our Time Doing Things That Increase

Our Costs and Create No Value for the Customer!

The 5 steps to Lean Thinking …

The continuous movement of products, services and information from end to end through the process

Define value from the customer’s perspective and express value in terms of a specific product

Nothing is done by the upstream process until the downstream customer signals the need

The complete elimination of waste so all activities create value for the customer

2 Map the

Value Stream

3Establish

Flow

4Implement

Pull

5Work to

Perfection

1Specify Value

Map all of the steps…value added & non-value added…that bring a product of service to the customer

What are your customers willing to pay for?

Lean Thinking Process

Best practice, patient satisfactionresults, benchmarks, suggestions,complaints

Inefficient processes, waits, rework,errors, substandard performance

How do you know you have a problem?

Is data available?

What is expected performance or CTQ’s?

What is payback/benefits of project?

Do you have the appropriate sponsor?

Project funnel and tool selection

Six Sigma DMAIC

Voice of Customer

Opportunities

Scoping

Projects

Priority Setting

Low Hanging

Fruit

Work-Out

Tool Selection

Lean

CAP

Mgmt Engineering

Study

CQI Team

Change Acceleration Process (CAP) – a process that proactively plans for change acceptance for successful implementation

Work-Out - a process that promotes rapid problem solving via involvement and accountability

Lean - an improvement methodology focused on eliminating waste through detailed analysis of workflow in relation to time

Six Sigma – an improvement methodologydriven by the statistical analysis of datato identify causes of unwanted variation and defects

Synergistic Tools and Processes

Healthcare Case Study Examples

•Improving process/safety for medication administration

•Reduction in Blood Stream Infections in ICU

•Reducing ventilator acquired pneumonia

•Emergency Department Patient Wait Time

•Improved Patient Throughput in Radiology

•Reduction in Lost Films

•MR Exam Scheduling Improvement

•Staff Recruitment and Retention

•Operating Room Case Cart Accuracy

•Physician (Professional Fee) Billing Accuracy

•Appointment Backlog for Hospital-Based Orthopedic Clinic

•Quality of Care and Satisfaction of Families in Newborn ICU

Healthcare Project Examples

Pioneers in Six Sigma for Healthcare

Commonwealth Health Corporation web site – www.chc.net

In March 1998, John C. Desmarais, Commonwealth Health Corporation's President and Chief Executive Officer, introduced CHC to Six Sigma, a quality initiative program developed by Motorola and perfected by General Electric. • By the end of 2001, over 2000 employees had

attended at least one full day of Six Sigma awareness training,

• Initial projects generated annualized savings of $276,188 in billing, decreased annual radiology expenses by $595,296, and reduced errors in the MR ordering process by 90%.

• Within 18 months, CHC had increased efficiency, improved the patient experience, eliminated over $800,000 in costs and reenergized the culture.

Project Description :PS - Moving “Treat-to-Street” patients through the ED takes too long. PD - One-third of our patients wait longer than 60 minutes to be seen by a physician.

Project Description :PS - Moving “Treat-to-Street” patients through the ED takes too long. PD - One-third of our patients wait longer than 60 minutes to be seen by a physician.

Project Scope:In Scope - Treat to Street pts, Staffing patterns (ED MDs & RNs), Equip’t, FTEs, Registration, Lab, X-R.

Out of Scope - ED Admits, ED Hold Hours, Bed Control, Housekeeping, Transport to Floor, MR, US, CT, Pharm.

Project Scope:In Scope - Treat to Street pts, Staffing patterns (ED MDs & RNs), Equip’t, FTEs, Registration, Lab, X-R.

Out of Scope - ED Admits, ED Hold Hours, Bed Control, Housekeeping, Transport to Floor, MR, US, CT, Pharm.

Potential Benefits: • Decrease LWBS

• Increase patient satisfaction (Press Ganey #s)• Reduce ED LOS (Soft Dollars)

Potential Benefits: • Decrease LWBS

• Increase patient satisfaction (Press Ganey #s)• Reduce ED LOS (Soft Dollars)

Alignment with Strategic Plan:• Customer Service• Growth• Efficiency

Alignment with Strategic Plan:• Customer Service• Growth• Efficiency

Project Title: ED ThroughputProject Title: ED Throughput

Customer(s):Patients, Physicians

Customer(s):Patients, Physicians

Case Study: Improving ED Throughput

What is the Right Y (CTQ) to Measure? How will it be measured? Y = Door to Doc Time. From the time a patient enters through the door until the physician

enters the exam room to assess the patient, measured in minutes.

What is the Right Y (CTQ) to Measure? How will it be measured? Y = Door to Doc Time. From the time a patient enters through the door until the physician

enters the exam room to assess the patient, measured in minutes.

What is our goal? We will improve the average ED Throughput Time for Treat and Street Patients by 40%. This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes. We will improve our throughput yield of patients seeing a physician within 60 minutes (USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over 7,500 customers.

What is our goal? We will improve the average ED Throughput Time for Treat and Street Patients by 40%. This will reduce the weighted average Door-to-Doc time from 65 minutes to 40 minutes. We will improve our throughput yield of patients seeing a physician within 60 minutes (USL) from 67% current to 80%. This reduction in our defect rate of 13% represents over 7,500 customers.

Measure

What are the specification limits? (LSL, USL) What is the Target? Based upon our VOC data, we have set a USL of 60 minutes and a Target Mean of 40 minutes.

What are the specification limits? (LSL, USL) What is the Target? Based upon our VOC data, we have set a USL of 60 minutes and a Target Mean of 40 minutes.

Value Stream Map Opportunities for Performance Improvements:Value Stream Map Opportunities for Performance Improvements:

Analyze

Door-to-Doc Subcycle

Other Flow

(blood, etc.)

Patient Wait Time

Phone Call

ED Waiting Room

TriageEKG, Draw Blood, UA, Order X-Ray, administer Pain med

2- RNs

1 Tech

Front Desk / QR

Treatment

X-Ray – In ED

Lab

Team Area

Tube/blood

MD

Portable

Fax written

report/ED

Call critical values

Arr QR QR Triage Triage Bed Bed MD

6.3 min 11.6 min 23.5 min 22.9 min

Current Average Cycle Times

Patient Flow

People Flow

(RN, MD, etc.)

E-Info Flow

AnalyzeStatistical AnalysisStatistical Analysis

Door-to-Doc

Environment

Measurements

Methods

Materials

Machines

People

Associate Attributes

Physicians

Nurses

Registration

Patient Attributes

Office Equipt

Pyxis

EKG

Computers (screens)

Dynamap

Supplies

Software

Chart

Triage Sheets

Ancillary Svcs

Transportation

Advanced Triage

Financial Metrics

LWBS

Satisfaction

Time

Triage Level

Staffing

Seasonality

Door-to-Doc Causes (Xs)Hypothetical

Driver (X)

StatisticallyProven (X)

Nurses

X-Ray

Day of Week

Shift

Bed Available

Census

Lab

Analyze

What X’s (inputs) are causing most of our variation? Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open`

What X’s (inputs) are causing most of our variation? Results for: Historical DOE Door to Doctor TimeFactorial Fit: D2D versus Express Care, X-Ray, Bed Open`

Estimated Effects and Coefficients for D2D (coded units)

Term Effect Coef SE Coef T PConstant 87.34 2.547 34.30 0.000Express Care 35.56 17.78 2.547 6.98 0.000X-Ray 36.06 18.03 2.547 7.08 0.000Bed Open -37.81 -18.91 2.547 -7.42 0.000Express Care*X-Ray 33.69 16.84 2.547 6.61 0.000Express Care*Bed Open 32.56 16.28 2.547 6.39 0.000X-Ray*Bed Open 14.06 7.03 2.547 2.76 0.025Express Care*X-Ray*Bed Open 5.19 2.59 2.547 1.02 0.338

S = 10.1865 R-Sq = 96.87% R-Sq(adj) = 94.12%

Analysis of Variance for D2D (coded units)

Source DF Seq SS Adj SS Adj MS F PMain Effects 3 15979.9 15979.9 5326.6 51.33 0.0002-Way Interactions 3 9571.7 9571.7 3190.6 30.75 0.0003-Way Interactions 1 107.6 107.6 107.6 1.04 0.338Residual Error 8 830.1 830.1 103.8 Pure Error 8 830.1 830.1 103.8Total 15 26489.4

What X’s (inputs) have we chosen to improve? 1. Bed Availability

– The Measure Phase data demonstrated that Door-to-Doctor time increased by two tothree times when there is no bed open for the patient.

2. Ancillary Services

– The data further showed that the time it takes to perform an X-Ray or Lab testing is statistically significant in relation to Door-to-Doctor time.

3. Express Care

– Lower acuity patients (i.e. Level 3 / Express Care) wait longer to see a physician than do higher acuity patients (i.e. Level 1).

What X’s (inputs) have we chosen to improve? 1. Bed Availability

– The Measure Phase data demonstrated that Door-to-Doctor time increased by two tothree times when there is no bed open for the patient.

2. Ancillary Services

– The data further showed that the time it takes to perform an X-Ray or Lab testing is statistically significant in relation to Door-to-Doctor time.

3. Express Care

– Lower acuity patients (i.e. Level 3 / Express Care) wait longer to see a physician than do higher acuity patients (i.e. Level 1).

What do we want to know?Screen Potential Causes?Discover Variable Relationships?Establish Operating Tolerances?

What do we want to know?Screen Potential Causes?Discover Variable Relationships?Establish Operating Tolerances?

Improve

Value Stream Map Key Points / Opportunities for Improvement:Value Stream Map Key Points / Opportunities for Improvement:

Improve

Registration

If rooms ful may reg pt while waiting.

ED Waiting Room

TriageEKG, Draw Blood, UA, Order X-Ray, administer Pain med

2- RNs

1 Tech

Front Desk / QR

Bedside Registration

Patient Flow

People Flow

(RN, MD, etc.)

E-Info Flow

Patient Wait Time

Impacts:1 – Inc. Patient Satisfaction2 – Red. time by 8.7 minutes3 – Red. variability in process

Non-value addedstep removed

Non-value addedstep removed

What is the mean and median of our process? What is the standard deviation?

Measure Phase Control Phase + % Mean score 64.3 minutes 39.8 minutes 38.1% Median 38.5 minutes 34.0 minutes 11.7% Standard Deviation 44.7 minutes 27.7 minutes 38.0% HI/LO 241 / 11 minutes 129 / 4 minutes 46.5% (HI; outliers) Range 230 minutes 125 minutes 45.7%

What is the mean and median of our process? What is the standard deviation?

Measure Phase Control Phase + % Mean score 64.3 minutes 39.8 minutes 38.1% Median 38.5 minutes 34.0 minutes 11.7% Standard Deviation 44.7 minutes 27.7 minutes 38.0% HI/LO 241 / 11 minutes 129 / 4 minutes 46.5% (HI; outliers) Range 230 minutes 125 minutes 45.7%

What is our process capability (Z score, DPMO, Yield %)? Z Short-Term Score = 1.912.350.44 DPMO = 333,333 175,000 <109,523> Yield % = 66.7% 82.5% 15.8%

What is our process capability (Z score, DPMO, Yield %)? Z Short-Term Score = 1.912.350.44 DPMO = 333,333 175,000 <109,523> Yield % = 66.7% 82.5% 15.8%

Improve

What are our financial results? How were they calculated? Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and the corresponding admissions as well as a conservative (5%) recognition as a result of throughput improvement.

What are our financial results? How were they calculated? Our Financial Impact is $1,120,650 and reflects the improvement in LWBS visits and the corresponding admissions as well as a conservative (5%) recognition as a result of throughput improvement.

Control

What is the plan for monitoring/ auditing the process? What is the Control Plan?

What is the plan for monitoring/ auditing the process? What is the Control Plan?

MetricTarget Values Measurement Definition

Measurement Method

Upper/Lower Spec Limits

Control Method Frequency

Responsibility (Who will measure) Alert Flags

Door to Doctor Time< 60 minutes; Yield = 80%

Time begins when a patient crosses the reaches Quick Registration. This time is completed when a physician greets the patient at the bedside. Manual - CDR Web USL = 60 minutes

Dashboard; Xbar-R Chart Weekly M. Kelly-Nichols

Two out of three weeks where 80% of patients are not seen by a physician within 60 minutes.

LWBS% < 1.0%

Patient leaves the ED after at least completing the Quick Reg process but before physician performs examination.

Automated - ED Tracking

USL = 1.0% of ED visits

Dashboard; Xbar-R Chart Weekly M. Kelly-Nichols

Two out of three weeks where LWBS % exceeds 1.0%.

Project Title: Linen Utilization

Project Description: To Identify opportunities within the organization which allows for better linen utilization without compromising quality or patient care.

Project Title: Linen Utilization

Project Description: To Identify opportunities within the organization which allows for better linen utilization without compromising quality or patient care.

Project Scope: The use of linen for inpatients.Project Scope: The use of linen for inpatients.

Problem Statement: Currently, our linen usage is higher than what is expected for a facility of our size and acuity level. We need to look for ways to better utilize our daily linen supply and lower our overall pounds per patient day as well as our cost per patient day.

Problem Statement: Currently, our linen usage is higher than what is expected for a facility of our size and acuity level. We need to look for ways to better utilize our daily linen supply and lower our overall pounds per patient day as well as our cost per patient day.

Case Study: Linen Utilization

What is the Right Y (CTQ) to Measure? How will it be measured?Y = Pounds Per Patient Day of Linen Used Pounds Per Patient Day of Linen Used by Service Line

What is the Right Y (CTQ) to Measure? How will it be measured?Y = Pounds Per Patient Day of Linen Used Pounds Per Patient Day of Linen Used by Service Line

What are the data sources? How will the data be collected? Data Sources include the Linen Distribution Program currently in place, as well as national benchmark data.

What are the data sources? How will the data be collected? Data Sources include the Linen Distribution Program currently in place, as well as national benchmark data.

What is our goal?To reduce the overall linen utilization to between 14 and 16 pounds per patient day.

What is our goal?To reduce the overall linen utilization to between 14 and 16 pounds per patient day.

Step 1Inventory of linen is taken in Linen room.

Step 2Linen order for the next day is placed with Tartan.

Step 3Linen is received the following morning.

Step 4Exchange carts from previous day are filled.

Step 5Linen re-stock amounts are recorded in Textile tracking program.

Step 6Linen carts are exchanged for those already on Nursing Units.

Step 7Secondary deliveries are made to units as required at 12 hour mark.

High Level Process Map

What is a defect, unit, opportunity?Defects= Missed Delivery and Stock Outs, and any reading <14 or >18 lbs per patient dayUnits = Pounds per Patient DayOpportunity = monthly data per unit

What is a defect, unit, opportunity?Defects= Missed Delivery and Stock Outs, and any reading <14 or >18 lbs per patient dayUnits = Pounds per Patient DayOpportunity = monthly data per unit

What X’s (inputs) are causing most of our variation?Usage variations, training, old behaviors.

What X’s (inputs) are causing most of our variation?Usage variations, training, old behaviors.

What are the specification limits? (LSL, USL)LSL= 14 Pounds per Patient Day AverageUSL= 18 Pounds per Patient Day Average

What are the specification limits? (LSL, USL)LSL= 14 Pounds per Patient Day AverageUSL= 18 Pounds per Patient Day Average

Graphical AnalysisLinen Usage by Unit

August 2003

10.7

7

9.02

9.66

10.7

7

8.63

8.04

9.92

9.1

10.5

3

8.74

17.0

717

.41

10.3

7

16.3

2

13.2

413

.24

15.3

8

10.1

3

13.2

413

.62

13.3

513

.35

19.0

2

13.3

5

18.8

8

14.4

5

7

9

11

13

15

17

19

21

8 S L&D 7 North 7 South 6 NorthRehab

6 SouthSNF

5 NorthResp.

5 SouthOnc

4 NorthCVDOU

4 SouthDOU

CCU CSU ICU GSHAVG

Unit

Po

un

ds

Avg. lbs/PD National Avg.

Patient Linen, $771,000.00

Scrubs, $125,000.00

Ancillary Areas, $138,000.00

Patient Linen Scrubs Ancillary Areas

Linen Pounds Per patient Day

19.76

20.75

19.79

20.9

19.42

20.37 20.17

19.4719.89

18.7

16.1

17.17 17.0116.44

17.1 17.3 17.3

16.1

10

12

14

16

18

20

22

Mar

-02

Apr-02

May

-02

Jun-0

2

Jul-0

2

Aug-02

Sep-0

2

Oct

-02

Nov-02

Dec-0

2

Jan-0

3

Feb-0

3

Mar

-03

Apr-03

May

-03

Jun-0

3

Jul-0

3

Aug-03

Sep-0

3

Month

Po

un

ds

per

Pat

ien

t D

ay

0Subgroup 10 20

15

16

17

18

19

20

21

22

23

Indi

vid

ual

Va

lue

Mean=16.81

UCL=18.28

LCL=15.35

1 2

0

1

2

3

Mov

ing

Ran

ge

R=0.5514

UCL=1.802

LCL=0

1 2

Control Chart- Pounds Per Patient Day

Achieved goal of 14 Pounds per Patient Day. Education and focus on Scrubs, and ancillary usage will contribute to maintaining this goal.

Achieved goal of 14 Pounds per Patient Day. Education and focus on Scrubs, and ancillary usage will contribute to maintaining this goal.

What are our financial results? How were they calculated?

Our Per Patient Day costs for linen have decreased by 20% over 2002. From an average of 20lbs to an average of 16lbs.

What are our financial results? How were they calculated?

Our Per Patient Day costs for linen have decreased by 20% over 2002. From an average of 20lbs to an average of 16lbs.

What is the WWW (Who-What-When) plan for turning the project over to the process owner? What is the plan for monitoring/auditing the process?

The process is a permanent one and will be tracked through reports given to the units, Executive Sponsor, and the Linen Utilization Committee.

The Linen Utilization Committee will oversee the process and progress.

What is the WWW (Who-What-When) plan for turning the project over to the process owner? What is the plan for monitoring/auditing the process?

The process is a permanent one and will be tracked through reports given to the units, Executive Sponsor, and the Linen Utilization Committee.

The Linen Utilization Committee will oversee the process and progress.

Customer Need…

Four hospital system enjoying 50% market share

Materials management improvements needed to leverage economies of scale, utilize best practices, and prevent inefficiencies:• Pricing structure for orthopedic implants

highly variable• Inconsistent orthopedic implant

utilization• Deficiencies in OR charge master

capture• Gap in OR supplies between what

patient pays vs. what hospital is charged

• OR “on hand” inventory management needed

Process Improvement to Reduce Cost

Case Study: Supply Chain Improvement

Barry D. Brown Health Education

Center at Virtua West Jersey Hospital

Voorhees

Solutions… •Orthopedic Implant Pricing Cap… Determined

actual versus lowest and average prices to establish a fair cap price.

•Orthopedic Implant Demand Matching… Examined 132 medical records and compared implants used against widely accepted industry criteria for implant selection by orthopedist

•Charge Master Review… Reviewed OR charge master systems and identified opportunities for improvement and standardization

•Price Point Reduction… Identified price reduction opportunities

•OR Inventory Reduction… HISI contracted to conduct physical inventories in four ORs and two surgical centers

Reduce Costs

Sustainable Results With Bottom Line Impact

Results

• Project results along with data shifted purchases to a primary orthopedic implant vendor, savings of $159,000 were attained.

• Annual savings of $239,400 through demand matching template at all hospital sites that do hip and knee replacement surgery.

• Patient billing data review in FY2000 indicated potential loss of greater than $200,000 annually due to missing charges, much of which was rectified with the corrections in the current charge masters.

• Project savings attained totaled $63,845 plus shared savings with orthopedic cap project.

• Conservative inventory reduction by facility: Facility A $187k, Facility B $92k, Facility C $47k, and Facility D $18k. Represents an 8% reduction of the $4.1MM of baseline inventory on hand.

Improve Quality

Summary, Keys to Success and Q&A

Better patient safety with 91% improvement in post-surgery antibiotic use, delivering annual savings over $1 million at hospital in Southeast

Achieving 35% higher “take home baby” rate with increase in successful implantation at hospital in Northeast

The Big “Why”

Shorter ED wait times allow 28 more patients per day to be seen, with potential financial impact over $13 million annually at hospital in Southern California

Think about it….

Are the mission, vision and values of your health system merely bullet points on a web site, or are they clearly understood and activated across the organization?

Are people empowered to drive change and accountable for results?

Culture Change

• Gain leadership support and don’t skimp on planning!

• Identify opportunities and define the value proposition

• Ensure strategic alignment with organizational objectives and incentives

• Develop a business case, identify team leaders and build a plan for deployment

• Establish measurements and evaluate performance

• Manage change through ongoing communication efforts

• Monitor results and sustain improvement through review and recognition

Keys to implementing Six Sigma in healthcare

…and network with others who have embarked on similar initiatives!

For more information contact:

Carolyn Pexton

925-275-0726

[email protected]

And visit the iSixSigma healthcare portal

www.healthcare.isixsigma.com