Using Six Sigma to Improve Cardiac Medication Administration and CAT Scan Capacity

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Using Six Sigma to Improve Cardiac Medication
Administration and CAT Scan Capacity
Harvard Quality Colloquium August 22, 2005
Susan McGann RN, BSN Adrienne Elberfeld
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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

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Virtua Facilities
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The Virtua STAR
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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

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R0 Cardiac Medication Indicators
Project Description 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 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
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.
Team Members Jay Brewin, Darlene Euler,
Christine Gerber, Val Torres, Kathy Halstead,
Kathy Plumb, Cindy DEsterre, Lori Edell, Heather
Scheckner, Angie Smolskis, Pat Quackenbush,
Ronald Kieft, Michelle Weaks, Robert Singer,
Vince Spagnuolo, Steve Fox
Alignment with Strategic PlanIIA-Cardiology
Global MICP Goals for Virtua.
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QRA Chart Review Gage RR

• During this gage, it was determined that there
  was variation between the QRAs review of charts
• A Workout was held on September 18th with the
  QRAs and Case Management Directors to develop
  SOPs in reviewing of all CHF and AMI patients
  for core indicators

Percentage of time QRAs agreed on assessment
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Root Cause Analysis Identified through Containment
Issue Concurrent reviews of AMI CHF
patients 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
Solution Met with CCMs, Case Management
Quality to educate on core indicators 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
Conclusion Between Case Management, Quality
Nursing charts needed to coordinate efforts in
reviewing charts 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
Who Team members specific to campus, J.
Slaterbeck, A.Elberfeld Team members specific
to campus C. Mullin, J. Slaterbeck, B. Rodin
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Root Cause Analysis Identified through
Containment (continued)
Solution Case Management to take the lead on
chart reviews for patients with AMI, CHF
related diagnosis. Support from quality
nursing 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 Management to coordinate
with nursing quality all paperwork forwarded
to Black Belt VP Quality
Who Case Mtg Directors, Quality Directors,
CCMs Case Mgt, QRAs, B. Singer, V. Spagnuolo,
S. Fox Case Mgt, QRAs, C. Mullin, A. Elberfeld
Conclusion Nursing, case management and quality
are all reviewing charts need to coordinate
efforts in regard to the indicators 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
Issue Who is going to perform the task of daily
chart reviews concurrent with care? Communicatio
n with physicians per need for documentation C
oordination of ongoing chart reviews,
documentation completion, and data information
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Root Cause Analysis
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Realized Results of Implemented Solutions
Improvement
Y Benefit
Quality Benefit
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P Chart
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R0 CT Scan Capacity
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 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
Project Scope Marlton CT Scan department
Potential Benefits A more efficient process will
lead to increased capacity thereby increasing
opportunities for increased volumes.
Team Members Beverly Crawford, Melody
DeLaurentis, JoAnn Domingo, Audrey Fley, Darryl
Fussell, Cynthia Koller, Jo Nast, Heather Pierce,
Donna Rapp, Elizabeth Zadsielski
Alignment with Strategic PlanResource
Stewardship Patient Satisfaction
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Descriptive Statistics

• Y1
• Mean 13.6333
• Standard Deviation 6.6993
• Z Score 2.78
• Mode 9
• Percent of Defects 11.1

• Y2
• Mean 23.4688
• Standard Deviation 6.9884
• Z Score 1.90
• Mode 20, 21 and 24
• Percent of Defects 34.4

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Descriptive Statistics

• 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!!
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T Test for Equal Variances
Levenes test Test for equal variances for
continuous data that is not normally
distributed. There is a statistical difference
in the variance!
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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.
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2 Sample T Test ANOVA Y1
Y1-Abdomen-Pelvis Without Contrast One-way ANOVA
Before-Avg. Time, After-Avg. Time Analysis of
Variance Source DF SS MS
F P Factor 1 426.2 426.2
8.04 0.005 Error 166 8794.9
53.0 Total 167 9221.1
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 (------------)
---------------------------------- Poo
led StDev 7.279 12.0
14.0 16.0
Two-sample T for Before-Avg. Time vs After-Avg.
Time N Mean StDev
SE Mean Before-A 62 14.95 9.87
1.3 After-Av 106 11.65 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!
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2 Sample T Test ANOVA Y1
Y2-Abdomen-Pelvis With Contrast One-way ANOVA
Before-Avg. Time, After-Avg. Time Analysis of
Variance Source DF SS MS
F P Factor 1 361.4 361.4
9.15 0.004 Error 50 1974.9
39.5 Total 51 2336.3
Individual 95 CIs For Mean
Based on Pooled
StDev Level N Mean StDev
---------------------------------- Before-A
32 23.469 6.988
(-------------) After-Av 20 18.050
4.925 (-----------------)
--------------------------------
-- Pooled StDev 6.285 18.0
21.0 24.0
Two-sample T for Before-Avg. Time vs After-Avg.
Time N Mean StDev
SE Mean Before-A 32 23.47 6.99
1.2 After-Av 20 18.05 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
P-value was less than .05, therefore, there is a
statistical difference!
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Moods Median/Non-Normal Data
P-value was less than .05, therefore, there is a
statistical difference!
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Can we see the improvement on the chart post SOP
implementation?
I MR Control Chart
Take away Process is capable and in control.
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Can we see the improvement on the chart post SOP
implementation?
I MR Control Chart
Take away Process is capable and in control.
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Can we see the improvement on the chart post SOP
implementation?
I MR Control Chart
Take away Process is capable and in control.
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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!
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Questions