Transcript Document

Improving the efficiency of requesting
from primary care Conclusions from a Six Sigma Project.
Dr Sharman Harris
Mrs Eileen Smith, Mr Gwyn Hughes-Evans,
Mrs Avril Wayte, Mr P Morris and Dr Keith Griffiths.
Department of Clinical Chemistry, Ysbyty Gwynedd,
Bangor, North Wales.
Introduction
 Publication of chronic disease management
guidelines and targets for primary care has
produced increased demand for laboratory tests unfunded.
 Demand management has an essential role in
modernisation of Pathology services (Carter review,
2006).
 Poor IT links (primary/secondary care) currently
hinder solutions.
Background
 Trust Six Sigma Management training
(Consultancy).
 Clinical Chemistry Six Sigma project.
 Zero cost after initial Six Sigma training.
Improvement Opportunity (Business Case)
Why & Why Now?
HbA1c annual workload
•Recent internal audit - approx.
20% HbA1c tests inappropriate
•Pathology requested to
develop strategy to manage
service within historic funding
levels.
5000
0
Year
2005- projected
•Proposals from 2005/06 SAFF
workload
10000
2003-2004
with current funding.
15000
2001-2002
•Demand cannot be supported
20000
1999-2000
•Inconvenience to Patients.
Number of tests
(clinically/GMS contract).
25000
Project Aims
 Apply Six Sigma methodology to the requesting
process to reduce inappropriate requests for
HbA1c.
 Produce a model system for demand management of
other chronic disease monitoring tests from primary
care (TFT’s, lipids, U&Es [eGFR] ).
What is SIX SIGMA?
 A quality management tool to improve efficiency systematic approach.
 Aims to reduce variation in a process.
 Customer orientated approach - VOC, CTQ’s, SIPOC
diagrams, scoping, brainstorming.
 Laboratory QC processes - 6 SD ( 3SD).
Define
Measure
Analyse
Improve
Control
Project Team
 Dr Keith Griffiths (Sponsor),
Dr Sharman Harris (project lead), Mrs Eileen Smith,
Mr Gwyn Evans, Mrs Avril Wayte (Clinical Chemistry).
 Mr Peter Morris (Modernisation).
 Dr Tony Wilton (Consultant Endocrinologist), Mrs
Olwen Chera (ICP coordinator).
 Mrs Tina Bailey (Diagnostics DGM).
 LHB commissioners, Dr David Lupton (GP/LHB),
Practice nurses, LHB data analysts (Karyn Donnelly,
Gemma Nosworthy, Helen Adams).
Define phase

Defect definition -
Stable patients (HbA1c <7.4%) having more than
2 tests/year.
Based on NICE guidelines (2004) - Agreed with
laboratory, Consultant endocrinologist and GP/LHB
representative.

Project scoped (in frame / out of frame)
In - HbA1c requests, stable patients, primary and
secondary care.
Out - All other tests, unstable, pregnant, newly
diagnosed.
VOC
Customer
CTQ’s
Patient
Best care, least inconvenience
(2 tests /year if stable)
Trust/LHB
Cost effective utilisation of
resources to meet standards
(only resource clinically effective
tests)
GP/Practice nurses
Access to results, effective pt
management, GMS contract
(result access, clear guidelines)
Secondary care
Access to all results on pts.
(result access, lab computer training)
Measurement Phase
 Data gather of all HbA1c results over last 24
months < 7.4%, using Telepath laboratory computer
system.
 Group data into patients, computer count of number
of results per patient using Excel.
Baseline Sigma Value (1)
 Number of units processed ie Total HbA1c results on stable diabetics (<7.4%) in 12 months
• N = 10413
• Total number of defects measure I.e Inappropriate HbA1c results (> 2 results per stable
patient)
• D = 1038
 Number of defect opportunities per unit
• 0=1
1,000,000 x D
Calculate No of
Defects per
million
opportunities
NxO
1,000,000 x 1038
10413 x 1
= 99,683
Look up the process sigma value in a sigma conversion table. ( 2.7)
Analysis Phase
 Request process mapping.
 Brainstorming-Why?
change in practice, GMS contract.
 Data segmentation (3 LHBs, practices).
 Questionnaires (85% return rate).
 Database collaboration (Trust/LHB) - number
of patients and diabetics per practice etc
SIPOC/Process of HbA1c test requesting
Patient appointment
generated
Patient attends clinic for
HbA1c blood test when
required and correct
sample taken
•Laboratory - small
but central part
(most of process not
in department or
hospital).
• Laboratory affected
if process inefficient
via budget, (but has
no control).
Test transported
Laboratory tests sample
and returns electronic
and paper report
efficiently
Patient attends clinic
appointment where
HbA1c reviewed
Result acted on to
benefit patient
management - next
appointment set.
• All
effort into
increasing laboratory
efficiency / reducing
cost to minimum won’t
cure an inefficient
process.
• Laboratory has
opportunity to
overview the process data
Improvement phase
 Pilot study ( 3 practices 1 from each LHB) - practice
visits.
 Production of a series of 1 page user guidelines
(Practice nurses) - collaborative, LHB circulation.
 Laboratory open evening (Practice nurses) ,
Practice Manager’s meetings - increase awareness.
 Recalculate Interim Six Sigma value = 3.
Control phase
• Weekly control Charts - circulated to LHBs
at Monthly Community Pathology group meeting.
• Expand Project to cover TFTs, Lipids and
U&Es (eGFR).
Problems
 Weekly control chart
 Change Report Format !
- Number of requests generated per practice
summarised as anonymous index (accounts for total
number of patients and diabetics per practice).
Individual practice requesting indices (for HbA1c, TFT,
Lipids, U&Es) produced in a report and circulated via
LHBs.
Solutions - clearer feedback
 3 month report (12 month pilot) - circulated to
individual practices via LHBs.
You are Practice 42 (anonymous)
PRIMARY CARE
The following practices have HbA1c
requesting indices significantly higher than
average.
REQUEST
MONITORING
REPORT
Practices 20 and 42.
Conwy, Gwynedd and Anglesey LHBs - HbA1c requests July-September 2006
80
Requesting index per registered diabetic
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Practice ID number
Conclusions
 Partnership working with budget providers and
primary care.
 Ongoing project (multidisciplinary).
 Workload from primary care - plateau (12 month
pilot).
Conclusions
 Initial set up of Six Sigma project is labour intensive
but template is then easily transferable.
 Lessons in Communication to users - ability to
adapt our approach.
 IT is the ultimate aid to demand management
but ………..
Excuses, Excuses!
[email protected]