Transcript Using Six Sigma to Improve Cardiac Medication Administration and CAT

Using Six Sigma to Improve Cardiac
Medication Administration and CAT
Scan Capacity
Harvard Quality Colloquium
August 22, 2005
Susan McGann RN, BSN
Adrienne Elberfeld
Virtua Health….Today
 Four hospital system in Southern New Jersey
 Two Long Term Care Facilities
 Two Home Health Agencies
 Two Free Standing Surgical Centers
 Ambulatory Care - Camden
 Fitness Center
 8000 employees + 2000 physicians
 7,000 deliveries
 $650 million in revenues
 STAR Culture
Virtua Facilities
The Virtua STAR
Excellent
Service
Resource
Stewardship
Outstanding
Patient
Experience
Caring
Culture
Clinical
Quality
& Safety
Best
People
Virtua Health…. The Future
Change in HR Structure and Process
Focus on Programs of Excellence
Building a Greenfield site
Potential consolidation of multiple sites
Ambulatory Strategy
Growth in the North
Additional Strategic Partnerships
Define
R0 Cardiac Medication
Indicators Project Description:
Project Title: Cardiac Medication:
Indicators Six Sigma Project
Sponsors: Jim Dwyer, Ann Campbell,
Ellen Guarnieri, Adrienne Kirby, Mike
Kotzen
Champions: Pat Orchard & Jane
Slaterbeck
Master BB: Mark Van Kooy
Black Belt: Adrienne Elberfeld
Green Belt: Ted Gall
Finance Approver: Gerry Lowe
Project Start Date: July 22, 2002
Team Members: Jay Brewin, Darlene
Euler, Christine Gerber, Val Torres,
Kathy Halstead, Kathy Plumb, Cindy
D’Esterre, Lori Edell, Heather
Scheckner, Angie Smolskis, Pat
Quackenbush, Ronald Kieft, Michelle
Weaks, Robert Singer, Vince
Spagnuolo, Steve Fox
Increase quality of patient care by
use/non-use and appropriate
documentation of aspirin, beta-blockers,
and ACE inhibitors in CHF or AMI patients
to achieve or exceed Virtua benchmark
goals.
Project Scope:
To have all four acute care facilities, within
all medical disciplines, meet the standards
of Core/JCAHO guidelines
Potential Benefits:
To achieve improved outcomes for patients
with AMI/CHF diagnosis by adhering to
evidence based practice through education,
documentation, and compliance while
meeting regulatory standards and
enhancing quality of patient care at Virtua.
Alignment with Strategic Plan:
IIA-Cardiology; Global MICP Goals for Virtua.
Measure
QRA Chart Review Gage R&R
Each Appraiser vs Standard
Assessment Agreement
Appraiser # Inspected # Matched Percent (%) 95.0% CI
Appraiser A
12
4
33.3 ( 9.9, 65.1)
Appraiser B
12
11
91.7 ( 61.5, 99.8)
Appraiser C
12
9
75.0 ( 42.8, 94.5)
Appraiser D
12
10
83.3 ( 51.6, 97.9)
• During this gage, it
was determined that
there was variation
between the QRA’s
review of charts
# Matched: Appraiser's assessment across trials agrees with standard.
Assessment Disagreement
Appraiser #
Appraiser A
Appraiser B
Appraiser C
Appraiser D
1/ 0 Percent (%) # 0/1 Percent (%) # Mixed Percent (%)
0
*
8
66.7
0
0.0
0
*
1
8.3
0
0.0
0
*
3
25.0
0
0.0
0
*
2
16.7
0
0.0
# 1/0: Assessments acrosstrials = 1 / standard = 0.
# 0/1: Assessments acrosstrials = 0 / standard = 1.
# Mixed: Assessments acrosstrials are not identical.
Percentage of time
QRA’s agreed on
assessment
Between Appraisers
Assessment Agreement
# Inspected # Matched Percent (%)
12
5
41.7 ( 15.2, 72.3)
95.0% CI
# Matched: All appraisers' assessments agree with each other.
• A Workout was held
on September 18th
with the QRA’s and
Case Management
Directors to develop
SOP’s in reviewing
of all CHF and AMI
patients for core
indicators
Analyze
Root Cause Analysis Identified through
Containment
Issue
Conclusion
Solution
Who
Concurrent reviews of
AMI & CHF patients
Between Case
Management, Quality &
Nursing charts needed to
coordinate efforts in
reviewing charts
Met with CCM’s,
Case Management &
Quality to educate on
core indicators
Team members
specific to campus,
J. Slaterbeck,
A.Elberfeld
Ongoing information
needed for medical
staff and nursing staff
of the core indicators
Cardiac POE needs
real time access to
Clinical Care Advisor
to review data
Have team members
develop a storyboard
template with pathways
and indicators to be
available at key areas
throughout the facility
Coordinate with IS
accessibility to system
Identified key areas,
(physician lounges,
Cardiac specific
units, nursing
specific areas), and
posted storyboards
that are the same
throughout the
system
Cardiac POE
Director, AVP, and
Black Belt access to
system; able to
review ongoing and
provide feedback to
Case Management
Team members
specific to campus
C. Mullin, J.
Slaterbeck, B.
Rodin
Analyze
Root Cause Analysis Identified through Containment
(continued)
Issue
Conclusion
Solution
Who
Who is going to perform
the task of daily chart
reviews concurrent with
care?
Nursing, case
management and
quality are all
reviewing charts;
need to coordinate
efforts in regard to
the indicators
Case Management to
take the lead on chart
reviews for patients
with AMI, CHF & related
diagnosis. Support
from quality & nursing
Case Mtg
Directors,
Quality
Directors,
CCM’s
If nursing and/or case
mgt has direct contact
with physician, they
give necessary
feedback. Next step is
the facility QRA and
physician champion
Case Mgt,
QRA’s, B.
Singer, V.
Spagnuolo, S.
Fox
Case Management to
coordinate with nursing
& quality; all paperwork
forwarded to Black Belt
& VP Quality
Case Mgt,
QRA’s, C.
Mullin, A.
Elberfeld
Communication with
physicians per need for
documentation
Coordination of ongoing
chart reviews,
documentation
completion, and data
information
Need one point
person to
communicate directly
with physicians in a
timely manner
Need to appoint point
people within the
facility to ensure that
activities are being
completed and
coordinated
Improve
Root Cause Analysis
Factor
Root Cause
Proposed Solutions
Inconsistent
availability of patient
census with diagnosis
for Nursing and Case
Management
IS integration with
Canopy system; initial
information input by
ICD-9 code, not
description
Work order placed with
Information Services with actual
cases to research and advise on
proper input process
Physician compliance
in completion of
discharge instructions
Inconsistent followthrough
Directive from Medical Staff
leadership to complete
discharge instructions; two
week trial period in April, 2003
by HIM to tag all charts without
discharge instructions
Consistent practice of
multi-disciplinary care
of the patient across
Virtua
Need for champion at
each campus to lead
initiatives of the
Cardiac Programs of
Excellence
Appointment of Nurse Leader
within each facility to coordinate
activities of Cardiac Programs of
Excellence at local level
MICU run sheets not
available on charts
Medics unable to
complete; shortened
documentation not
part of permanent
chart
Sponsor to work with
Ambulatory Quality Director to
have MICU run sheets
completed & submitted
concurrent with care
Control
Improvement
Realized Results of
Implemented Solutions
Y Benefit
Quality Benefit
MICU run sheets on patient charts within 24
hours of admission
Increased compliance
Compliance with PRO indicators
for aspirin given with 24 for aspirin given within 24 hours
hours
of admission; DOH regulations for
transfer of patient care
Physician completion of written discharge
instructions specific to medications for cardiac
patients
Compliance and proper
documentation of care
for discharge
medication indicators
Increased compliance in
care and documentation
for all indicators
Standard Operating Procedures by Nursing and
Case Management in chart review, stickie
reminders for physicians, and availability of
discharge instructions
Consistent education of nursing per cardiac
medication indicators
Accurate daily census with diagnosis available
through OAS Gold and Canopy
Appointment of a Process Owner at each
hospital to coordinate care with directives from
Cardiac Programs of Excellence
Increased compliance
for medications given
within time frames
Quality of care documented
Coordination of care for the
cardiac patient by the multidisciplinary team
Increased knowledge base of the
nursing staff of the cardiac
medications for AMI and CHF
patients
Increased compliance in Timeliness of care improved
care and documentation
for all indicators
Sustained improvement Sustained results maintained and
in all indicators
reported to CMS and public;
appropriate recognition and
Control
P Chart
Virtua Health Control Chart for Aspirin Within 24 Hrs
Proportion
0.10
UCL=0.09429
0.05
Goal=95% Compliance
Project Started June 03
Feb 05
P=0.02861
0.00
LCL=0
0
10
Sample Number
20
Define
R0 CT Scan Capacity
Project Title: CT Scan Six Sigma
Project
Sponsors: Ellen
Master BB: Adrienne Elberfeld
Black Belt: Kathy Eichlin
Green Belt: John Graydon, Wendy
Seiler
Finance Approver: Rex Rueblinger
Project Start Date: July 28, 2004
Team Members: Beverly Crawford,
Melody DeLaurentis, JoAnn
Domingo, Audrey Fley, Darryl
Fussell, Cynthia Koller, Jo Nast,
Heather Pierce, Donna Rapp,
Elizabeth Zadsielski
Project Description:
Increase capacity by reducing in and
out of room times for the CT Scan to
adhere to GE industry benchmarks of
15 minutes without contrast and 25
minutes of with contrast.
Project Scope:
Marlton CT Scan department
Potential Benefits:
A more efficient process will lead to
increased capacity thereby increasing
opportunities for increased volumes.
Alignment with Strategic Plan:
Resource Stewardship
Patient Satisfaction
Measure
Descriptive Statistics
Descriptive Statistics
Y1-CT Abdomen/Pelvis Without Contrast
Updated 11/10/04
Descriptive Statistics
Y2-Abdomen/Pelvis With Contrast
Variable: Avg Time
Variable: Avg Time
Anderson-Darling Normality Test
A-Squared:
P-Value:
0
8
16
24
32
40
95% Confidence Interval for Mu
Anderson-Darling Normality Test
2.450
0.000
Mean
StDev
Variance
Skew ness
Kurtosis
N
13.0385
6.2464
39.0181
1.99453
5.98253
52
Minimum
1st Quartile
Median
3rd Quartile
Maximum
1.0000
9.0000
11.5000
15.0000
38.0000
A-Squared:
P-Value:
10
15
20
25
30
35
40
95% Confidence Interval for Mu
95% Confidence Interval for Mu
11.2994
10
11
12
13
14
15
5.2348
10.0000
20.5
21.5
22.5
23.5
24.5
25.5
26.5
Minimum
1st Quartile
Median
3rd Quartile
Maximum
10.0000
18.5000
23.5000
28.5000
40.0000
25.9883
95% Confidence Interval for Sigma
7.7464
13.4970
23.4688
6.9884
48.8377
0.280139
-1.4E-01
32
20.9492
19.5
5.6026
95% Confidence Interval for Median
95% Confidence Interval for Median
Mean
StDev
Variance
Skew ness
Kurtosis
N
95% Confidence Interval for Mu
14.7775
95% Confidence Interval for Sigma
0.174
0.918
9.2909
95% Confidence Interval for Median
95% Confidence Interval for Median
20.0000
Y1
Y2
•Mean = 13.6333
•Mean = 23.4688
•Standard Deviation = 6.6993
•Standard Deviation = 6.9884
•Z Score = 2.78
•Z Score = 1.90
•Mode = 9
•Mode = 20, 21 and 24
•Percent of Defects = 11.1%
•Percent of Defects = 34.4%
26.0000
Measure
Descriptive Statistics
Descriptive Statistics
Y3-CT Brain Without Contrast
Variable: Avg Time
Anderson-Darling Normality Test
A-Squared:
P-Value:
2
6
10
14
18
22
95% Confidence Interval for Mu
26
1.166
0.004
Mean
StDev
Variance
Skew ness
Kurtosis
N
11.3671
4.2972
18.4661
0.804413
0.843822
79
Minimum
1st Quartile
Median
3rd Quartile
Maximum
2.0000
8.0000
11.0000
14.0000
25.0000
95% Confidence Interval for Mu
10.4046
10
11
12
12.3296
95% Confidence Interval for Sigma
3.7159
5.0959
95% Confidence Interval for Median
95% Confidence Interval for Median
10.0000
12.0000
Y3
•Mean = 11.3671
•Standard Deviation = 4.2972
•Z Score = 2.58
•Mode = 7
•Percent of Defects = 13.98%
The problem is too
much standard
deviation/ variation
in the process!!
Analyze
T Test for Equal Variances
Test for Equal Variances for multiple
95% Confidence Intervals for Sigmas
Factor Levels
1 CT Tech
Bartlett's Test
Test Statistic: 69.345
P-Value
: 0.000
There is a
statistical
difference in
the variance!
2 CT Techs
Levene's Test
Test Statistic: 5.287
P-Value
3 CT Techs
5
7
9
11
13
15
17
19
Levene’s test
–Test for
equal
variances for
continuous
data that is
not normally
distributed.
: 0.006
Analyze
Pareto Chart
A Pareto Chart shows where within the process the greatest opportunity exists for
improvement. Here we see opportunities for the need for improvement with interruptions
caused by the phone, door interruptions and assistance needed to move a patient resulting
in 59 % of CAT Scan Delays. Use LEAN opportunities to streamline process.
Improve
2 Sample T Test & ANOVA Y1
Boxplots of Before-A and After-Av
(means are indicated by solid circles)
Y1-CAT Scan of Abdomen/Pelvis Without Contrast
Y1-Abdomen-Pelvis Without Contrast
One-way ANOVA: Before-Avg. Time, After-Avg. Time
60
Analysis of Variance
Source
DF
SS
Factor
1
426.2
Error
166 8794.9
Total
167 9221.1
50
40
30
20
10
0
Before-A
After-Av
Two-sample T for Before-Avg. Time vs After-Avg. Time
N
Before-A 62
After-Av 106
Mean
14.95
11.65
MS
426.2
53.0
F
8.04
P
0.005
Individual 95% CIs For Mean
Based on Pooled StDev
Level
N
Mean
StDev ---------+---------+---------+------Before-A 62 14.952
9.869
(--------*--------)
After-Av 106 11.651
5.214 (------*------)
---------+---------+---------+------Pooled StDev = 7.279
12.0
14.0
16.0
StDev SE Mean
9.87
1.3
5.21
0.51
Difference = mu Before-Avg. Time - mu After-Avg. Time
Estimate for difference: 3.30
95% CI for difference: (0.61, 5.99)
T-Test of difference = 0 (vs not =): T-Value = 2.44
P-Value = 0.017 DF = 81
P-value was less than .05, therefore,
there is a statistical difference!
Improve
2 Sample T Test & ANOVA Y1
Boxplots of Before-A and After-Av
(means are indicated by solid circles)
Y2-CAT Scan of Abdomen/Pelvis With Contrast
Y2-Abdomen-Pelvis With Contrast
One-way ANOVA: Before-Avg. Time, After-Avg. Time
40
Analysis of Variance
Source
DF
SS
Factor
1
361.4
Error
50 1974.9
Total
51 2336.3
30
20
10
Before-A
After-Av
Two-sample T for Before-Avg. Time vs After-Avg. Time
N
Before-A 32
After-Av 20
Mean
23.47
18.05
StDev SE Mean
6.99
1.2
4.93
1.1
Difference = mu Before-Avg. Time - mu After-Avg. Time
Estimate for difference: 5.42
95% CI for difference: (2.09, 8.74)
T-Test of difference = 0 (vs not =): T-Value = 3.27
P-Value = 0.002 DF = 49
Level
N
Before-A 32
After-Av 20
Pooled StDev =
Mean
MS
361.4
39.5
F
9.15
P
0.004
Individual 95% CIs For Mean
Based on Pooled StDev
StDev ----------+---------+---------+-----
23.469
18.050
6.988
(------*-------)
4.925 (--------*---------)
----------+---------+---------+-----6.285
18.0
21.0
24.0
P-value was less than .05, therefore,
there is a statistical difference!
Improve
Mood’s Median/Non-Normal Data
P-value was less than .05, therefore,
there is a statistical difference!
Mood median test for CT Scan
Chi-Square = 16.76
Subscrip
After Before-A
N<=
33
30
DF = 1
N>
10
49
Median
8.00
11.00
P = 0.000
Q3-Q1
2.00
6.00
Individual 95.0% CIs
----+---------+---------+---------+-(-----+------)
(-----+------)
----+---------+---------+---------+-7.5
9.0
10.5
12.0
Overall median = 9.00
A 95.0% CI for median(After -) - median(Before-A): (-3.12,-1.00)
Control
I & MR Control Chart
Can we see the improvement
on the chart post SOP
implementation?
I and MR Chart for Y1-Avg Time
Individual Value
Y1-CT Scan Abdomen-Pelvis Without Contrast
70
60
50
40
30
20
10
0
-10
Moving Range
Subgroup
1
1
1
UCL=29.70
LCL=-3.964
0
50
1
40
1
20
11
Mean=12.87
50
30
1
1
100
150
1
1
1
1
1
10
UCL=20.68
R=6.329
LCL=0
0
Take away: Process is capable and in control.
Control
I & MR Control Chart
Can we see the improvement
on the chart post SOP
implementation?
I and MR Chart for Y2 Avg Time
Y2-CAT Scan of Abdomen-Pelvis With Contrast
1
Individual Value
40
UCL=36.04
30
Mean=21.38
20
10
LCL=6.731
0
Subgroup
0
10
20
30
40
50
20
Moving Range
UCL=18.00
10
R=5.510
0
Take away: Process is capable and in control.
LCL=0
Control
Can we see the improvement
on the chart post SOP
implementation?
I & MR Control Chart
I and MR Chart for CT Scan Time
Y3-CT Brain Without Contrast
Individual Value
1
1
1
20
UCL=20.19
10
Mean=10.43
0
LCL=0.6671
Subgroup
0
50
100
20
Moving Range
1
11
1
UCL=11.99
10
R=3.669
0
Take away: Process is capable and in control.
LCL=0
The “other results”
 Ahead of the ‘hospital’ curve
 Data driven organization
 The dots are connected:

Strategy, Operations, Quality, Finance, People
 Financial up-spin
 Leadership Development
The Results Go Well Beyond the Project!