what it means to be a six sigma organization

What it means to be…

A Six Sigma Organization

Decatur Memorial Decatur Memorial HospitalHospital

Decatur Memorial HospitalBrief Overview

• Located in Decatur, IL• Founded January 1st, 1916• Community based, Not-for-profit• Capture over 65% of market share in our area• 30+ satellite facilities reaching all of Macon

County as well as Dewitt and Moultrie counties• 43 owned physician practices

Annual Operating Statistics2005

• Licensed Beds = 356• Inpatient Stays = 12,463• Outpatient Visits = 302,054• Emergency Center Visits = 48,913• Average Daily Census = 155.3• Average Length of Stay = 4.4 days• Number of Employees = 2492

Where have we been...— Facilitator Training (CAP/WorkOut)

— Executive Training

— Deployment Partner Training - Black/Green Belts

— Incorporate Six Sigma Awareness - New Hire Orientation

— Complete Initial Belt Training (2 projects)

— Master Black Belt Training

— Begin In house Training Waves – Black/Green Belts

— Corporate Project Tracking

— Integration of I21

— Begin In house Yellow Belt training

— Decentralization of belts

— Decentralization of project accountability

Oct ‘01

Oct ‘01

Nov ‘01

Feb ‘02

Nov ’02

Oct/Nov ‘02

Jan ‘03

Jun ‘04

Aug ’04

Jan ’05

Jul ’05

Jan ‘06

1

234

5

Imagine 21

• Fifth Discipline – Personal Mastery

• Emotional Tension vs Creative Tension

• The need for a vision

• Beliefs about Reality vs the Truth

• If you dwell in the past, then tomorrow looks like today

• Commitment to the Truth

Vision

CR

Learnings from our Deployment

1. Deployment champions (Executive Staff) need to be “Kool Aid” drinkers.

2. Seek middle management buy-in and understanding.

3. Never conduct a training session without a meaningful project attached, otherwise is an exercise in futility.

4. Teach the most meaningful tools.

5. Results are the goal, not the training.

6. Realize Six Sigma is not for a select group of belts, it is an organization approach to improvement – stick with it.

7. Incorporate Six Sigma training into employee development plans.

8. Give Six Sigma care and feeding.

Nosocomial Infection StrategiesA Six Sigma Approach

IT’S A CULTURE!!!

What is the compelling need to change?

An honest assessment of Current State!

How many black dots are there?

1. Zero Nosocomial Infections is impossible.2. I always wash my hands.

… We see things not as they are, but as we believe them to be …


Are these your finger tips?

Unit by Unit Assessment

Every place and Every one is in play

OR Evaluations

Every place and Everyone is in play1. Right solutions2. Right duration3. Right procedures


Surgical Wounds

Primary Blood Stream

UTI

• Appropriate antibiotic within 60 mins of surgery start• Appropriately discontinued prophylactic antibiotic within 24hrs• Staff enter/exit OR during case• Surgical Scrub Techniques, attire, gloving• Hand Hygiene

• Use and disposal of needles and other sharps, • Instrument decontamination, cleaning, sterilization, disinfection and storage,• Housekeeping and waste disposal.

• Central Line Dressings / Insertion – Maximal Barrier Precautions (handwashing, wearing a cap, mask, sterile gown and gloves )

• Glucose Control• Hand Hygiene

• Monitoring catheter days by patient• Ongoing monitoring of flow• Hand Hygiene

NI – Current State, trend analysis

2003 = 142

2004 = 128

2005 = 109

43% 24%

21%

A first project… ICU/CVU focus

Nosocomial Infections

documentation

dressing changes

pre-op bath

clippers

dressing changes

insertion technique

catheter type

catheter days

closed system

catheter type

sputum cultures

Mouthwash

Evac ETT

HOB > 30

isolation procedure

clean equipment

isolation compliance

hand hygiene complia

staff training

staff awareness

People

Env ironment

Pneumonia

UTI

Blood stream inf ection

Surgical Site

Cause-and-Effect Diagram

Low hanging fruitClippers for shaving all CABG patientsImproved isolation processMore specific isolation signage Easy to access references on isolation

typesImproved signage re hand hygieneImproved location of hand cleaning

foamStaff education re isolation and hand

hygiene

Six Sigma team and tools…

What are the X’s?

• Compliance with Hand Hygiene Policy

• Head of Bed of Ventilator Patients

• Central Line Dressing Intact and <72 hours

Project Successes:

1. Sustained awareness of Nosocomial Infections at

all levels

2. Creation of improved tracking mechanisms

3. Surgical Site Infections Project – Pre SCIP

4. Timeliness of Antibiotics in Pneumonia

Local Success = Organization Need

Surgical Wound Infection

Antibiotics delivered within 1 hour of Surgery Start time

Baseline DPMO: 209,677Project Close: 22,700 90% Reduction in DPMOLatest Month: 85,000 60% Sustained reduction

Antibiotics delivered within 1 hour of Surgery Start time

Baseline DPMO: 209,677Project Close: 22,700 90% Reduction in DPMOLatest Month: 85,000 60% Sustained reduction

Traffic Flow in/out of OR


Hand Hygiene Compliance• What get’s measured, gets done.

Patient Safety Oversight Committee• All Six Sigma project progress is reviewed

• All Nosocomial infections are reviewed and Root

Cause Analysis done data analyzed for trends

IT’S A CULTURE!!!

Root Cause - Structure

Note: Minimize variability in investigation process

Redesign Medication Delivery System

$ 0.8157 per dose savings

x 883,000 doses per year

$720,000

Med Ordered

Critical Process Factors

1. “Complete Order”

2. Patient Information

3. Successful Transmission

Med Delivered


1. Types / Numbers of Meds

2. Delivery Locations

3. Delivery Times

4. Tech Availability

Order Verified


1. Pharmacist

2. “Packaged Meds”

Med Administered


1. Meds Due Prompt

2. Medications

3. Patient / Nurse

4. “Correct” Med Administration Process

Order Filled


1. “Complete Order”

2. Meds Available

3. Personnel to Prepare

4. “Label”


Pharmacy

Scan not readable - Call floor

to re-scan

Order scanned with no patient name - Call

floor to re-scan

Incomplete Med Orders - (No Route,

strength)Call MD to Clarify

MD Handwriting Illegible

- Clarify with MD

Medication Ordered

Order Scanned to Pharmacy

Order Faxed to Pharmacy

Order Phone Call - received per pharmacy -

MD only

Enter Order in HBOC

Pharmacy System

Pharmacy Personnel Scan Order into Pyxis

Connect for order entry



Order faxed with no patient name - Call

floor to re-fax


- Clarify with MD

Fax not readable - Call floor

to re-fax

Nurse must write as

"telephone order" from

MD

Nurse phoning in

order

Write Order on Physician Order Sheet

Scan in PyxisFile in

appropriate folder

Send copy to floor

Order re-written by R.Ph. on

Physician Order Sheet

Order placed on cart by

Pharmacist




Pharmacist


Pharmacist




Pharmacist



Non-Formulary Drug Med

Order

Contact MD for Formulary Substitution if no P&T auto-sub in place

Sub OK

R.Ph. Writes Order in Chart

Yes

Call floor to see if family can bring in

Send MD formulary

request form & obtain the

item

No

Label Generated for filling if not floor

stock

IV Label generated for filling

Med Label generated

for unit dose filling

Order filled by tech - placed

in baggie - label

affixed & signed - to be checked by

R.Ph.

Bag contents verified by R.Ph. and

R.Ph. sign off

Tech places in appropriate bin for next

delivery round

Medication in Pharmacy

Bins -Ready for Delivery

Stat

No

Tech delivers or tubes

Yes

Printer jam/off-line

No techs to fill unit does

meds

Med not available from manufacturer

Non-formulary Out-of-Stock

Filled incorrectly by tech (wrong dose, wrong

drug)

R.Ph. checking discovers

order entry error

IV Label sent to IV Room for

Preparation

Conventional IV Product - Iv technician to

obtain components

and compound

Pharmacist Checks

IV - Initials Label Correct

CRRT Solutions and TPN Products Pharmacist Enter Order into Abbott

Compounding Computer

Draws up IV components -

Leaves for Pharmacist to

Check

IV Technician completes IV - takes to Unit

Bins for Delivery

Stat

Tubes to Floor

Order Entered - Required

2nd Pharmacist

Check

TPN Label generated

from Abbott Compounder

Components drawn up for

Compounding by Technician

Components Checked by

one Pharmacist


second Pharmacist

TPN Compounded by Technician

Placed in refrigerator

for 5PM Delivery for 6PM Start

Chemotherapy - Oncology Pharmacist

enters Chemo Order

Oncology Order 2nds Checked by

Another Pharmacist

Oncology Pharmacist Compounds

under horizontal

hood

Oncology Product Completed -

Oncology Pharmacist delivers to Oncology Nurse

No

Yes

Technician on duty not

trained for IV Compounding

Delay in Label being sent to

IV Room - Tech not available

Omnicell Restock

Medication

IV's Large Volume Not Refrigerated

IV's Large Volume

Refrigerated

IVPB Syringes / Bags

Refrigerated

IVPB Syringes / Bags Not

Refrigerated

Unit Dose Oral Meds

Unit Dose Meds

Refrigerated

Locked Drawer

Not Enough Room in Drawer

Pt in Isolation Put IV on

Unlocked Cart Outside Room - ICU/IMC/CVU

Pt getting Bath or

Procedure

Early AM - Unable

to see in Room - ICU/I

MC/CVU

Demand IV Already in

Drawer

Refrig on Omni Refrig

STAT - NOW to Nurse

Which Nurse? Where is Nurse?

Demanded Med Already

in Refrig

Calls - Unable to find

Med - Don't Look in Refrig

Locked Draw

STAT - NOW to Nurse


Early AM - Unable


MC/CVU





Drawer

Pt getting Bath or

Procedure

Meds Delivered to Refrig in Omnicell Nursing Units

- IMB-ICU-OB

To Refrig on Nursing Units - Peds-4100-5100-6400

STAT - NOW to Nurse



-IMC-ICU-OB


STAT - NOW to Nurse


Locked Drawer

STAT - NOWShould be

delivered to specific nurse

within 15 minutes


Demand Med Already in Drawer


Fill Order Corrected

Tech places follow-up

phone call if tubed

Family did not bring in, call family again to bring in

med

Notify MD med not

given, family did not bring

in

Enter Order HBOC Floor

Stock in Omnicell

Med Available in Omnicell for

Administration

Pharmacy

Scan not readable - Call floor

to re-scan

Order scanned with no patient name - Call

floor to re-scan




- Clarify with MD

Medication

Ordered

Order Scanned to

Pharmacy

Order Faxed

to Pharmacy

Order Phone

Call - received per pharmacy -

MD only

Enter Order in HBOC

Pharmacy System

Pharmacy Personnel Scan Order into Pyxis

Connect for order entry



Order faxed with no patient name - Call

floor to re-fax


- Clarify with MD

Fax not readable - Call floor

to re-fax

Nurse must write as

"telephone order" from

MD

Nurse phoning in

order

Write Order on Physician Order Sheet

Scan in PyxisFile in

appropriate folder

Send copy to floor




Pharmacist




Pharmacist


Pharmacist




Pharmacist



Non-Formulary Drug Med

Order

Contact MD for Formulary Substitution if no P&T auto-sub in place

Sub OK

R.Ph. Writes Order in Chart

Yes

Call floor to see if family can bring in

Send MD formulary

request form & obtain the

item

No

Label Generated for filling if not floor

stock

IV Label

generated

for filling

IV Label sent to IV Room for

Preparation

Conventional IV Product - Iv technician to

obtain components

and compound

Pharmacist Checks

IV - Initials Label Correct

CRRT Solutions and TPN Products Pharmacist Enter Order into Abbott

Compounding Computer

Draws up IV components -

Leaves for Pharmacist to

Check

IV Technician completes IV - takes to Unit

Bins for Delivery

Stat

Tubes to Floor

Order Entered - Required

2nd Pharmacist

Check

TPN Label generated

from Abbott Compounder

Components drawn up for

Compounding by Technician


one Pharmacist


second Pharmacist

TPN Compounded by Technician

Placed in refrigerator

for 5PM Delivery for 6PM Start

Chemotherapy - Oncology Pharmacist

enters Chemo Order

Oncology Order 2nds Checked by

Another Pharmacist

Oncology Pharmacist Compounds

under horizontal

hood

Oncology Product Completed -

Oncology Pharmacist delivers to Oncology Nurse

Yes

Technician on duty not

trained for IV Compounding

Delay in Label being sent to

IV Room - Tech not available

IV's Large Volume Not Refrigerated

IV's Large Volume

Refrigerated

IVPB Syringes / Bags

Refrigerated

IVPB Syringes / Bags Not

Refrigerated

Locked Drawer




Pt getting Bath or

Procedure

Early AM - Unable


MC/CVU


Drawer


- IMB-ICU-OB


STAT - NOW to Nurse



-IMC-ICU-OB


STAT - NOW to Nurse


Locked Drawer

STAT - NOWShould be

delivered to specific nurse

within 15 minutes



Family did not bring in, call family again to bring in

med

Notify MD med not

given, family did not bring

in

Enter Order

HBOC Floor

Stock in

Omnicell

Med Available in Omnicell for

Administration

EliminatedEliminated

Most

Eliminated

Major Changes…

Pharmacy:• Med Labeling for Unit dosing• Medication verification and floor delivery• IV Bag handling • Communication processes

Nursing• Workflow (Where do I get my meds?)• Communication processes

Medication Errors (Total C and Above)January 2004 thru December 2005

55 6

1

50 5

6

41

17

49

48

56

35

65 67 7

2

67

45 5

1

43 46

43 4

8

31

38

25

0

10

20

30

40

50

60

70

80

Jan

-04

Feb

-04

Mar-

04

Ap

r-04

May-0

4

Ju

n-0

4

Ju

l-04

Au

g-0

4

Sep

-04

Oct-

04

No

v-0

4

Dec-0

4

Jan

-05

Feb

-05

Mar-

05

Ap

r-05

May-0

5

Ju

n-0

5

Ju

l-05

Au

g-0

5

Sep

-05

Oct-

05

No

v-0

5

Dec-0

5

Medication Errors CJanuary 2004 thru December 2005

49 5

4

41 4

6

39

13

46

39

51

33

60

60

60

59

39

46

39

39 40 42

26

33

22

0

10

20

30

40

50

60

70

Jan

-04

Feb

-04

Mar-

04

Ap

r-04

May-0

4

Ju

n-0

4

Ju

l-04

Au

g-0

4

Sep

-04

Oct-

04

No

v-0

4

Dec-0

4

Jan

-05

Feb

-05

Mar-

05

Ap

r-05

May-0

5

Ju

n-0

5

Ju

l-05

Au

g-0

5

Sep

-05

Oct-

05

No

v-0

5

Dec-0

5

Medication Errors DJanuary 2004 thru December 2005

6

7

9

10

2

4

2

9

5

2

3

6

9

8

5

2

3

6

2

5

4

5

3

0

2

4

6

8

10

12

Jan

-04

Feb

-04

Mar-

04

Ap

r-04

May-0

4

Ju

n-0

4

Ju

l-04

Au

g-0

4

Sep

-04

Oct-

04

No

v-0

4

Dec-0

4

Jan

-05

Feb

-05

Mar-

05

Ap

r-05

May-0

5

Ju

n-0

5

Ju

l-05

Au

g-0

5

Sep

-05

Oct-

05

No

v-0

5

Dec-0

5

Medication Errors EJanuary 2004 thru December 2005

0

0.5

1

1.5

2

2.5

3

3.5

Jan

-04

Feb

-04

Mar-

04

Ap

r-04

May-0

4

Ju

n-0

4

Ju

l-04

Au

g-0

4

Sep

-04

Oct-

04

No

v-0

4

Dec-0

4

Jan

-05

Feb

-05

Mar-

05

Ap

r-05

May-0

5

Ju

n-0

5

Ju

l-05

Au

g-0

5

Sep

-05

Oct-

05

No

v-0

5

Dec-0

5

The Quality Side

A Circumstances or events that have the capacity to cause errorB An error occurred; medication did not reach the patientC An error occurred that reached the patient but did not cause patient harmD An error occurred that resulted in the need for increased patient monitoring but no patient harmE An error occurred that results in the need for treatment or intervention and caused temporary patient harmF An error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harmG An error occurred that results in permanent patient harmH An error occurred that results in a near-death eventI An error occurred that resulted in patient death

What percentage of the time is the medication entered into Care Manager for administration in a timely manner?

Mean - 65.8% 82.7%

What percentage of the time are the routine medications available for administration when due?

Mean - 74.9% 85.4%

What percentage of the time are stat medications available when needed?

Mean - 59.6% 78.6%

How many times per shift are you engaged in conversations with pharmacy about medication questions / issues?

Mean - 4.3 / Shift 1.4 / Shift

Note:

All questions show statistical significant difference at 95% confidence

Voice of the CustomerNursing Personnel

Project Successes

• Patient Safety improved as demonstrated in reduction of

Medication Errors

• Increased personnel efficiency – Nursing - Reduced Medication Collection Time

• Before: 2.14 mins per patient

• After: 0.72 mins per patient

– Pharmacy - Reduced Pharmacy Technicians

• 2 technicians because of change in medication delivery process

• Before: Ordered to Floor time= 109 mins (overall)

• After: Ordered to Floor time = 21 mins (Omni), 44 mins

(non Omni)

• Increased satisfaction patient / nrsg / phrm / MD

Enabling Technology

Floor Units Type• 6400 2 2-Cell (400 Meds)• 5400 W 1 2-Cell• 5400 S 1 2-Cell• 5100 3 3-Cell (730 Meds)• 4100 3 3-Cell• ICU 1 2-Cell• IMC 1 2-Cell• OB 1 2-Cell• Peds 1 1-Cell (230 Meds)• Ortho 2 3-Cell• Pharmacy 2 Carousels

• 1 RX 2500 Meds • 1 IV 800 Meds

• Ospak-400 Automated U/D

Note: All savings reflect deductions of depreciation and leases.

Acute Myocardial Infarction

AMI Core Measures

What is a Defect? What are the process specifications?1. No Pre or Post arrival EKG2. No ASA w/in 24 hrs before or after arrival (with no Contraindication documented)

3. No Beta blocker w/in 24 hrs before or after arrival (with no Contraindication documented)

4. No ASA prescribed at discharge (with no Contraindication documented)

5. No Beta blocker prescribed at discharge (with no Contraindication documented)

6. No LVSD documented7. If LVSD documented @ <40% , No Ace Inhibitor prescribed at discharge

Defect:Any one of these 7 questions answered “NO”

Before:DPMO = 117,381Zst = 2.69

Oct, Nov, Dec combined)

AMI Core Measure

On admission: what did we learn?

• No set Lab protocol for verifying MI

• No standard order set (ECC/CVU/House wide)

On discharge: what did we learn?

• No process for prompting core measures accounted for on discharge.

• Standard Operating Procedures should be project focus.

AMI Core Measure

Key Findings / Actions Taken

• ECC using new treatment protocol for people who are

diagnosed with MI

• Establish Panic Troponin Level in Lab

• Create Daily “Troponin” report

• Cardiology nurses follow-up on Troponin report daily

• Create Physician prompts to be placed on chart by

Cardiology nurses

• Create and implement new discharge instructions-Care

Manager

AMI Core Measure

Implementation CompletePercentage of all measures met by month

Medicare “High Quality Performer”

• Health Services Advisory Group Inc. (HSAG), the Medicare Quality Improvement Organization (QIO) of Arizona, identified Decatur Memorial Hospital as a “High Performer” in a study initiated in October 2003 focusing on care given within the core measures.

• The study, “Identification and Synthesis of Components Essential to Achieving ‘High Performer’ Status in Various Provider Types”, had as its objective: to identify high performer hospitals and analyze their distinguishing characteristics to help the QIO program transform and accelerate healthcare quality improvement.

• Six Sigma is one of the distinguishing characteristics.

Inserting a video clip here…

This is why…We do Six Sigma…

Impact on our CommunityImpact on Quality

Impact on FinancialsImpact on our People

what it means to be a six sigma organization

Documents

sigma training

training session

sigma organization

sigma team

sigma care

gloving hand hygiene

isolation process

meaningful project