application of six sigma and dfss for the ultimate patient safe environment
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Application of Six Sigma and DFSS For the Ultimate Patient Safe Environment
Karrie Bruegman-May, RN, BSN,CPHQSynergyHealth—St. Joseph’s Hospital
West Bend, WI
Email: [email protected]
Phone: 262-306-7760
Agenda
BackgroundGuiding Principles “Core Process Team” ApproachApplications and Experience Impact of Organizational Culture
The Impetus for Change
Translating what the IOM/ “To Err is Human” means at St. Joseph’s Community HospitalDeath in Hospitals from Medical Errors:
1 death for every 343 to 764 admissions
Translates to: 5 to 12 patient deaths per year
1 patient death per month
The Impetus for Change
Translating what “To Err is Human” means at St. Joseph’s Community Hospital
Adverse Events in Hospitals: 1 in 27 admits to 1 in 34 admits affected
Translates to: 122 to 153 patient events per year or 12 per month 1 patient impacted every 3 days
St. Joseph’s Community HospitalWest Bend, WI
Project: Build and occupy a replacement hospital
Objectives: Design a physical environment that
supports the achievement of a higher level of patient safety and enhances or creates a “culture of safety”
Winston Churchill May 10, 1941
“We shape our buildings,
and afterwards
our buildings shape us.”
Project OverviewFinal Design
143 acre site173,000 square foot facility4 floors80 beds$55 million projected costOpening 8/7/05
Site Plan
The Patient Safety Learning Lab
Through the collaborative, creative efforts of leading experts in a variety of relevant disciplines…..
Create a set of design methods and principles…
To support the redesign of the patient care environment…..
So as to achieve breakthrough levels of patient safety
The Patient Safety Learning Lab The participants:
AMA -IHI MGMA -UW-Milwaukee AHA -University of MN WHA -Center for Patient Safety at
VA JCAHO -APHA NPSF -ISMP VHA -ASQ PSI
Top 10 Recommendations for Facility Design FMEA at each design stage Standardization Involve patients/families Establish a checklist for current/future design Critical information close to the patient Noise reduction Adaptive systems for function in the future Articulate a set of principles Equipment planning Day 1 Begin mock-ups on Day 1
The Patient Safety Learning Lab
Applied Patient Safety Design Principles Visibility of patients to
staff Standardization Automate where possible Scalability, Adaptive,
Flexible Immediate accessibility of
information, close to the point of service
Noise reduction Patients involved with
care
FMEA at each stage of design
Design for the vulnerable patient
Human factors review Minimize fatigue Design Around Precarious
Events
Learning From Precarious Events
Operative/Post-Op Complications, Infections Events Relating to Medication Errors Deaths of Patients in Restraints Inpatient Suicides Transfusion Related Events Correct Tube-Correct Connector-Correct Hole Patient Falls Deaths Related to Surgery at Wrong Site MRI Hazards
Decision to Use FMEA
St. Joseph’s Community Hospital decided that the framework of FMEA would assist in creating a replacement facility aimed at reducing errors and promoting patient safety and satisfaction through design
Design FMEAFailure Mode Effects Analysis
Goal:
Anticipate, identify, and avoid failures associated with the design of a facility, while still on the drawing board
Adjacencies Layout of the Facility As a Whole
Guiding principles establishedKey goals:
Patient safetySeparation of public, patient, and
service trafficMinimize patient transportation
FMEA Use atEach Design Stage
1. Adjacencies
2. Schematics
3. Design development
FMEA Form - Sample
Potentialfailures/effects
mode(s) (day/night)
Severity oroccurrence
High-Med-Low
Adjacency changes tominimize/eliminate
potential failure/effect
Recommendadjacency
change
AdjacencySample Application
Potentialfailures/effects
mode(s) (day/night)
Severity oroccurrence
High-Med-Low
Adjacency changesto minimize or
eliminate potentialfailure/effect
Recommendadjacency
changeTraffic patterns formovement ofmaterials causefood, waste, linen,etc…to cross paths
High Create verticaltransportation ofthese items tominimize servicetraffic in presence ofpatients
DesignateGarden Levelas non-patient, forsupportservices only
Transporting criticalpatients betweenservices creates staffshortage
High Minimize transport:bring services topatient whenpossible or relocateservices closer topatient
Locate ICU &Radiology incloseproximity
Adjacency Sample Application - Behavioral Health
Potentialfailures/effects
mode(s) (day/night)
Severity oroccurrence
High-Med-Low
Adjacency changes tominimize/eliminate
potential failure/effect
Recommendadjacency
changePotentially violentpatients cause risk tomothers/babies in OB
High Create distance betweenvulnerable patients andhigher risk patients
Locate OB on 2nd
floor and BehavHealth on 1st Flr
Potentially violentpatients admittedthrough EDtransported longerdistance to BH unit
High Minimize distance fortransport of BH patientsfrom ED to BH unit
Locate ED andBehav Hlth on 1stFloor
Breach of privacy forpatients transportedthrough publiccorridors to BH unit
High Minimize transport needin public corridors ofBH patients
Locate BehavHlth on 1st floorwith separateentrance
Adjacencies Plan
Original Revised3rd Floor Medical/Surgical Medical/Surgical2nd Floor Behavioral Health
Obstetrics Intensive Care
Medical/Surgical Obstetrics
1st Floor Lab Radiology Emergency Surgery Pharmacy
Radiology Emergency Surgery Behavioral Health Intensive Care
Garden Level Administration Support Services Materials Management Linen Services Kitchen/Cafeteria Loading Dock
Administration Support Services Materials Management Linen Services Kitchen/Cafeteria Loading Dock Pharmacy Lab
Other Design Principles Healing Environment
Connection to Nature Patients involved with Care Family and Friends with
Care Pleasant Diversions
music water features window views
Elimination of Environmental Stressors
Noise Poor Air Quality Lighting Glare
Efficient Error Reduction
Our Attempt at a Patient Safe Room
We have the building on to Process Redesign
St. Joseph’s Community HospitalWest Bend, WI
Objectives: Design/redesign processes that
complement and leverage the physical environment.
Implement IT solutions for EMR/CPOE, bar-coding, materials management and centralized scheduling.
Applied Patient Safety Process Design Guiding Principles Incorporate Lean Thinking where
possibleDefine Value in terms of the customer. Always define in
terms of the patient being the greatest priority.Identify all parts of the Value Stream for potential impact on
processChange batch processes to continuous flowMove to a “pull” model instead of “push”Strive for a defect-free processEmploy Rapid identification & abatement of errorsApply Mistake-proofing techniquesConsider cross training opportunities
Applied Patient Safety Process Design Guiding PrinciplesUse selected data-driven methodologies
with measurable performance goals and objectives that is applicable and appropriate. Six Sigma DMAIC or DMADV
Making the decision to use Lean Six SigmaRapid Action Planning (RAP)PDCAFMEA
Applied Patient Safety Process Design Principles
Consider Human FactorsReduce Noise
Minimize interruptions
Minimize fatigue/boredom
Simplify
Use forcing factors
Employ recovery factors
Use affordances and natural mapping
Applied Patient Safety Process Design Guiding Principles Standardize (specific exceptions for
vulnerable patients as part of the process) Make it Scalable, Adaptable, Flexible (for new
technology or systems) Assure Accessibility of information, close to
point of service
Applied Patient Safety Process Design Guiding Principles
Assure Visibility Know locations of patients, staff, inventory,
equipment Involve patients/customers in the process
Automate where possible Pharmacy systems: Bar coding, CPOE,
automated MAR Scheduling
Applied Patient Safety Process Design Principles Incorporate Fiscal accountability
Define Project as cost savings, revenue increase, or “soft dollars” only
Take into account budget issues (ability to add staff or equipment)
Consider impact on current list of precarious events.
Using the PUGH to help with Guiding Principles
Mu
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Imp
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Tra
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ran
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PV
Tra
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ill
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R
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8 5 Minimum Inventory Handling 2 3 35 4 Defect Free / Mistake Proof 4 4 35 4 Minimize Interruptions 3 3 25 4 Minimize Inventory Carried 2 2 35 4 Manpower 1 3 46 4 Simplify 2 3 23 2 Minimize Equipment Required 1 3 43 2 Minimize Fatigue / Boredom 1 3 24 2 Recovery Factors 1 4 23 2 Resupply After Discharge 1 4 13 2 Scalable / Adaptable / Flexible 1 2 12 1 Affordances / Natural Mapping 2 2 12 1 Minimize Noise 2 2 1
Final Ratings: 72 111 93
“Core Team Concept”
Selection Criteria: Creativity, enthusiasm, visionary Willingness to challenge and change the status quo Ability to work in a team setting Willingness to learn new methodologies including
Lean/Six Sigma/Human Factors Ability to make a 30-month commitment Availability for actual relocation and transition period Application and interview process
Process Design and Transition Team
Barb Knutzen, COO Karrie Bruegman May RN,
Quality and Patient Safety Coordinator, Resident Black Belt
Paula Doyle RN, ICU Pat Gardner MD, VP Medical
Affairs Linda Lange, PTA, Rehab
Services Tom Ruplinger, Environmental
Services
Louise Schut RN, Emergency Department
Misty Stortz, Sonographer, Radiology
Process Design and Transition TeamRole and Responsibilities: Participate as core team members in four major
projects Provide oversight for all other organizational process
redesign Attend weekly process reporting meetings Provide support and expertise for department
directors (facilitation, coaching, tool use) Team leader during relocation and transition in 2005 RAP Facilitators Team Start Date October 1!!!!!!
Process Redesign—Key Processes Emergency Services
Patient Throughput Diagnostic Services Other opportunities identified
2 hour average admission process for med/surg units Outpatient Services
Issues 30 minutes to 6 hours LOS Triage had taken on a life form of it’s own Patient satisfaction scores Variability in radiology result times Admissions will be completed in ED or OPPA
ED project objective Decrease door to Doc time
When triage initiated to 20 min. When not initiated 10 min.
Process Redesign—Key Processes
Admission/Scheduling Centralized scheduling
Present state everyone keeps their own paper schedule, no coordination of Patient Services 19 different scheduling portals
Rework by multiple department
Rapid admission concept Emergency Department delays Project Objective
Reduce to 2 scheduling portals or <
Process Redesign—Key Processes Pharmacy System
Totally manual ordering process 18 ways to order, 14 ways to receive meds
Upgrade of IS technology 2004 Bar-coding technology 2005 Electronic MAR 2005 CPOE 2006 Project Objective:
Reduction in errors on prescriptions, medications, turn-around-time Integration of information technology
Process Redesign—Key Processes Logistics 24/7
Materials Management New IS system 2004 Service to multiple campuses 2005
Food Service Room service concept for all patients 2004
Environmental Services Future additions
Patient transportation 2006 Air traffic control concept 2006
Project Objective 100% Availability of medical supplies at bedside
Other Six Sigma Projects that we found along the way…Radiology Thru-putPatient Transportation
Results of Core Team Concept Developed expertise in
methodologies Understanding of
organizational processes and issues
Increased employee acceptance of process
Multidisciplinary Became “ambassadors”
Confusion of department directors
Greater expertise than management team
Resistance to process change by directors
Required active role of executive champion
Creating a Culture of Safety
• Shared Values and Beliefs about Safety within the Organization
• Always Anticipating Precarious Events• Informed Employees and Medical Staff• Culture of Reporting • Learning Culture• “Just” Culture• Blame-Free Environment Recognizing Human Infallibility• Physician Team Work• Culture of Continuous Improvement• Empowering Families to Participate in Care of Patients• Informed & Activated Patient
Impact on Patient Safe Culture Anonymous Reporting
(facilitated thru joining IHI) Executive Walk Arounds System Redesign Patients Involved with Care Disclosure Human Resource Management Around Patient Safety Physicians Involvement
West Bend Clinic EPIC Evidence Based Medicine
Public reporting of outcomes
MPSRs 2003-2004
943
748820
1002
690804 852
785 745872
1395
2606
3132
1917
2484
2323
2178
2923
3382
2000 2007
2190
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Summary
We used facility design as a catalyst for organizational culture change
St. Joseph’s Community Hospital has used a new approach to create a replacement facility aimed at reducing errors and promoting patient safety and satisfaction through design
We are now working on process design/redesign using a combined methodology approach of Lean Six Sigma and Human Factors.
Six Sigma has been applied to healthcare for several years, but not with the concept of a “core team”.
SummaryKeys for Success
Clear vision Pioneering spirit Intestinal fortitude (medication doesn’t hurt!) Unwavering commitment Executive champion
SummaryKeys for Success
Find the right partner for expertise and support
Careful selection of core team members Investment in education, training Cultivate relationship of core team and
department directors Medical staff buy-in
SummaryKeys for Success
Recognize impact of culture “Culture eats strategy for breakfast every day!”
10 C’s: Communicate, communicate and then
communicate.
Celebrate Daily recommitment
