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SIX SIGMAOperational Excellence
Reducing Avoidable Days on Your Telemetry Unit
Todd SperlSix Sigma Master Black BeltSt. John HealthDetroit, MI
Sue CarterDirector of Nursing InformationSix Sigma Green BeltProvidence HospitalSouthfield, MI
Vicki KamalSupervisor Care and Resource ManagementSix Sigma Green BeltProvidence HospitalSouthfield, MI
SIX SIGMAOperational ExcellenceSt. John Health Overview
• Member of Ascension Health• Comprised of 8 hospitals and over 100 medical
facilities in southeast Michigan• Guided by our Mission; Shaped by our Values
• Committed to providing spiritually centered, holistic care
• Sustain and improve the health of individuals in the communities we serve, with special attention to the poor and vulnerable
• $146 million in uncompensated care FY’05
• Vision for the Future• To provide the highest quality patient care
experience in all that we do
• Launched Six Sigma Oct 31st, 2003
SIX SIGMAOperational Excellence
How Six Sigma Is Organized at SJH
• System COO directs deployment of Six Sigma
• System MBB’s directly report to the System COO
• Steering Committee made up of COO, CMO, CFO, EVP-HR, EVP-OE, System VP of Quality, and MBBs
• Each hospital has an Executive Sponsor (Champion) with a reporting relationship to the System COO in addition to the Hospital CEO
• Hospital BB’s directly report to Executive Sponsors with dotted lines to System MBB’s
System COO
SteeringCommittee
MBBs Executive Sponsor
Hospital BBs
SIX SIGMAOperational Excellence
• Service Excellence
• Patient/Family safety concerns
• Physicians seeking the best care for patients
• Costly technology • Labor Shortage
Challenges We Face
• Our competition isn’t sitting still
SIX SIGMAOperational ExcellencePerformance Improvement
at SJH
+
6
5
4
3
2
1
0
-
As scope and complexity increases, the tactic shifts to Six Sigma (DMAIC)
As scope and complexity increases, the tactic shifts to Six Sigma (DMAIC)
DMAIC
Lean DMAIC
Lean
CAP & WorkOut
Leadership Decisions
SIX SIGMAOperational Excellence
Economic Impact of Performance Improvement
PERFORMANCE IMPROVES
Profit Improves
Market share increases
Revenues go up
Productivity improves
Customers sing our praises
Costs go down
Processes improve
Outcomes
Perceptio
ns
(Fred Lee – If Disney Ran Your Hospital)
SIX SIGMAOperational Excellence
Right Place, Right Time
Reducing Avoidable Days in Providence
Hospital’s Telemetry Unit
SIX SIGMAOperational Excellence
Original Problem Statement
• 10 to 20% of monitored beds are being used inappropriately.
• Our project is to reduce inappropriate use of monitored beds to improve patient safety, customer service and patient though put.
Problem Statement…Why do this project?
SIX SIGMAOperational Excellence
Project Goal
• To reduce the number of patients not meeting clinical criteria in monitored beds. These avoidable days cause delays in placing patients into monitored beds from the Emergency Department/ Operating Room and potentially other medical floors.
SIX SIGMAOperational Excellence
Telemetry Process Map
Process Map Before
SIX SIGMAOperational Excellence
• Created Universal Criteria to stay on Telemetry Unit.
• Created a standard process for identifying when a patient should be transferred or discharged.
Solutions Implemented
SIX SIGMAOperational Excellence
Discharge Criteria1. All - inclusive of Endocrine, Pulmonology, Infectious Disease, Nephrology.Per Established Discharge Criteria: 12-24 hours stable:• Vital signs have not generated need for intervention (BP, RR, HR), or interventions
can be performed on med-surg floor. • Pain management can be accomplished on med-surg floor. • Arrhythmia controlled on oral medications (No acute arrhythmia requiring active
treatment, Persistent acceptable stable tachycardia). • Hemodynamically stable off intravenous medications requiring telemetry monitoring
(Stable on oral medications). • Metabolic abnormality that can lead to deterioration corrected or can be managed
effectively on med-surg floor. • Urine output stabilized/appropriate for patient condition. Fluid management/diuresis
can be managed on med-surg floor. • ABG's and/or oximetry at optimal level for patient x 24 hours. • Laboratory data trending toward normal or at level safe for transfer (Hgb, K+, BS,
Pulse Ox > 92, Coags, etc. as related to diagnosis or procedure). • DNR – does it need to be on the step-down? No step-down treatment, no palliation
requiring step-down. Futile care• Bipap/Cpap – New Bipap/Cpap patients and patients who use Bipap/Cpap at home
should be monitored on Intermediate Care to establish respiratory stability for 24 hours on admission. After 24hrs, if necessary he/she may be transferred to a non-monitored unit if able to apply and remove the Bipap/Cpap without assistance.
• Placement in skilled ECF or LTAC• Hospice transfer
SIX SIGMAOperational Excellence
Discharge Criteria
2. Cardiac – Cardiac Surgery• Stable patient 3 days post-MI without clinically important complications (CHF,
arrhythmia, silent ischemia, post-infarct angina, conduction defects, or shock).• Myocardial infarction has been ruled out using enzyme criteria. • AICD or PPM after 24 hours post-insertion.• Heart rate and rhythm stable with device functioning appropriately. 3. Surgery – Vascular – Trauma• Exam of wounds and exam of pulses distal to operative sites are without
change for 12-24 hours and have not required active intervention such as unplanned anticoagulation or bedside drainage during this timeframe.
• Frequency and extent of wound care can be handled on med-surg floor. • Chest tube or other drainage outputs do not require active fluid or blood
produce replacement. 4. Neurology – Neurological surgery• Frequency of neurological checks reduce to every four hours or less frequently,
with no worsening of neurological status over 12-24 hours. • Patient has not required active adjustment of seizure medications due to
breakthrough seizure activity over 12-24 hours. • Stable neurological status x 24 hours.
SIX SIGMAOperational Excellence
Discharge Criteria
Note: Patients not meeting the above
criteria are eligible for transfer to medical floor
Physicians are required to justify the patient requiring stepdown care by noon daily in the daily progress notes.
SIX SIGMAOperational Excellence
NP/RN/CM assess patient
during morning analysis.
Patient meets
established criteria, transfer
to Med/Surg Floor?
Continue Stepdow n Care
No
Yes
Is Patient ready for
transfer to Med/Surg?
Move patientto Med/Surg. Yes
RN/CM consult with NP for
transfer.
Patient meets
established criteria to D/C
home?
NP/RN/CM calls Attending Physician
to discuss D/C status.
Yes
D/C patient home?
Patient is D/C home.
Yes
No
No
No
NP/RN/CM review Physician progress notes.
*Patients meeting established posted transfer/discharge criteria are eligible for transfer to medical floor.
Current Process MapIntermediate Care Transfer/Discharge Process*
Six Sigma Pilot – Seton IntermediatePreliminary Pilot Data Shows Avoidable Stepdown Days Now at 14%!
SIX SIGMAOperational Excellence
Pre-Pilot
Analyze
Pilot
4 weeks
9/19 to 10/16
Control
4 weeks
10/17 to 11/13
N= N= N=
308 137 26
Stepdown LOS - Average 3.79 2.68 3.23
Avoidable Day Average 2.41 1.09 0.35
Avoidable Day SD 1.76 0.30 0.85
% of Avoidable Days 32.90% 19.42% 10.71%
% of Charts w/Avoidable Days 52% 38% 14%
Z-Score (Avoidable Days) 1.9 2.4 2.4
Project Results
SIX SIGMAOperational Excellence
Sample
Sam
ple
Count
Per
Unit
4321
0.5
0.4
0.3
0.2
0.1
0.0
_U=0.1059
UCL=0.4748
LCL=0
U Chart of Days Avoidable
Tests performed with unequal sample sizes
Control Chart
SIX SIGMAOperational Excellence
Project Benefits
• More collaborative work environment between Nursing and Physician
• Empowered Nursing to “transfer” patients to Med/Surg floors in order to free up Telemetry beds
• Changed Physician Behavior
• Improved patient safety, e.g., right patient in the right bed at the right time.
• Realized financial benefits, e.g., correct staffing expense to the correct patient, improved reimbursement.
SIX SIGMAOperational Excellence
Lessons Learned
• Team Leadership
• Project Scope – Need to be flexible
• Nursing, Nursing and Nursing
• Physician Involvement and Buy-in is Key
• Have Fun!
SIX SIGMAOperational Excellence
Extended Team Members
• Dr. Ernie Yoder• Dr. John Fath• Sue Markowitz, Nursing• Sandra Deering, Nursing• Monique Ulman, Nursing• Wendy Cole, Nursing• Denise Mclean, Project Sponsor
Thank You!
SIX SIGMAOperational Excellence
Questions?
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