Presentation Points

Overview of Quality Reporting Department

Define the problem

Taking measurements

Analyze collected data

Recommend improvements

Discuss control methods

Abstracts for quality auditing from patients with the following conditions:

CHF, AMI, Stroke, CAP, SCIP, VTE, outpatient SCIP, outpatient AMI/Chest Pain

Time from patient discharge to complete chart abstraction is known to exceed requirements.

◦ Board of Directors interested in getting more timely quality reporting.

◦ Patient care cannot adapt quickly if reporting is delayed.

Requirements

Cycle time requested: 30 days

Maximum time: Abstracts completed by the 15th day of the month following discharge. (Maximum 45 days)

Allowances

Papers scanned into charts 2 days

Physicians to sign-off charts 30 days

IS to send reports to QR 30 days

Designed small Ad-hoc query in quality

database system.

Exported needed data to Excel showing date

stamps of discharge date and completed

abstraction date.

July August

ABSTRACTION DATE DISCHARGE_DATE Elapsed Days ABSTRACTION DATE DISCHARGE_DATE Elapsed Days

09/15/2011 07/01/2011 76 10/03/2011 08/03/2011 61

09/07/2011 07/12/2011 57 10/11/2011 08/30/2011 42

09/08/2011 07/07/2011 63 09/30/2011 08/04/2011 57

09/09/2011 07/01/2011 70 10/11/2011 08/11/2011 61

09/09/2011 07/09/2011 62 10/13/2011 08/10/2011 64

09/09/2011 07/13/2011 58 10/18/2011 08/04/2011 75

09/09/2011 07/02/2011 69 10/17/2011 08/17/2011 61

09/23/2011 07/13/2011 72 09/30/2011 08/04/2011 57

09/21/2011 07/07/2011 76 10/14/2011 08/02/2011 73

09/22/2011 07/06/2011 78 10/17/2011 08/02/2011 76

09/07/2011 07/19/2011 50 10/19/2011 08/10/2011 70

09/19/2011 07/08/2011 73 10/17/2011 08/07/2011 71

09/15/2011 07/08/2011 69 10/11/2011 08/05/2011 67

09/09/2011 07/09/2011 62 10/04/2011 08/18/2011 47

09/15/2011 07/16/2011 61 10/04/2011 08/04/2011 61

09/21/2011 07/02/2011 81 10/14/2011 08/01/2011 74

09/19/2011 07/07/2011 74 10/17/2011 08/02/2011 76

09/07/2011 07/05/2011 64 10/13/2011 08/01/2011 73

09/21/2011 07/06/2011 77 10/04/2011 08/10/2011 55

09/08/2011 07/06/2011 64 10/11/2011 08/03/2011 69

Cycle time is outside of required limits

July ◦ Median days 60

◦ Maximum days 84

August ◦ Median days 56

◦ Maximum days 79

Nothing is happening within 30 days

It was determined earlier that IS ran the reports sending the data from the charts into the reporting system only once per month.

Improvement: Increase frequency of reporting to once per week by pulling data from another system.

Cycle time is just outside of required limits

August ◦ Median days 56

◦ Maximum days 79

September ◦ Median days 35

◦ Maximum days 54

21 day increase in cycle time

In order to accurately chart and control this process the following 5 data points must be available to the Quality Department. ◦ Discharge date

◦ Paper charts scanned date

◦ Chart sign-off date

◦ Reports run / available for abstraction date

◦ Abstraction complete date

Currently only discharge date, and abstraction date are available to Quality Reporting.

Days Elapsed 20 7 6 2

Percent 57.1 20.0 17.1 5.7

Cum % 57.1 77.1 94.3 100.0

C1

Pape

rs sca

nned

into cha

rt

Abstra

ction

Repo

rts G

enerated

Char

t Sign-

off

40

30

20

10

0

100

80

60

40

20

0

Da

ys E

lap

se

d

Pe

rce

nt

Pareto Chart by Department

Days Elapsed 20 7 5 3

Percent 57.1 20.0 14.3 8.6

Cum % 57.1 77.1 91.4 100.0

C1

Pape

rs sca

nned

into cha

rt

Chart S

ign-off

Repo

rts G

enerated

Abstraction

40

30

20

10

0

100

80

60

40

20

0

Da

ys E

lap

se

d

Pe

rce

nt

Pareto Chart by Department

121110987654321

70

60

50

40

30

Weeks

Sam

ple

Mean

__X=36.55

LC L=33.11

UC L=39.99

121110987654321

20

15

10

5

0

Weeks

Sam

ple

Ran

ge

_R=5.97

UC L=12.61

LC L=0

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

11

Control Chart of Weekly Cycle Times

4321

50

40

30

Weeks

Sam

ple

Mean

__X=37.06

UC L=40.19

LC L=33.94

4321

16

12

8

4

0

Weeks

Sam

ple

Ran

ge

_R=8.38

UC L=15.63

LC L=1.14

1

1

1

Xbar-R Chart of September Only

Institute checks of process using newly available data points to check for future conformance, and greatest bottleneck.

Six Sigma Future Project: ◦ Collect future data based on 5 data points, create

and maintain control and distribution and pareto charts.

◦ Identify any processes that need improvement to eliminate or smooth saw-tooth pattern based on future data collection.