Adrienne Elberfeld

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Six Sigma... Getting Real about Results in
Healthcare

• Adrienne Elberfeld
• Six Sigma Master Black Belt
• Virtua Health
• Marlton, NJ

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Virtua Facilities
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Virtua Locations
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Virtua Health

• 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
• 7000 employees 1700 physicians
• 7,000 deliveries
• 600 million in revenues
• STAR Culture

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Virtua Imperatives 2005

• Dramatically improve patient satisfaction scores.
• Advance Virtuas POE development.
• Continue implementation of medical staff
  development plan.
• Continue to improve and sustain global clinical
  quality and patient safety metrics.
• Continue rigor in cost expense management,
  revenue enhancement and reduced length of stay.
• Recognize and continuously develop best people
  and monitor employee satisfaction.
• Begin facilities planning and development of
  ambulatory sites and regional medical centers.

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The STAR
PERFORMANCE EXCELLENCE
MISSION AND VALUES
STRATEGIC INITIATIVES
Best People
Resource Stewardship
Excellent Service
Outstanding Patient Experience
Clinical Quality Safety
Caring Culture
Achieve Vision and Receive Recognition
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The STAR Initiative

• An organization wide cultural transformation
  initiative that will assure that Virtua fulfills
  its covenant with the community, achieves its
  vision, and is highly successful over the
  long-term.
• Three Objectives

1) Focus the work on creating an
outstanding experience for patients 2) Become
a high performing organization 3) Be
recognized for our excellence
We Know Where We Want to Go, How Are We Going to
Get There?
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Its Great to Have a Philosophy . . . But We
Need a Strategy !!
Current State STAR Commitment
Desired State STAR Performance
Six Sigma is our strategy on our journey through
the maze
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The Tool Chest

• Paths to Change
• Strategic Decision
• Operational issue Requiring a Decision
• Wisdom of the Group Problem
• Analytical Problem

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VIRTUAS QUALITY JOURNEY
Virtua Health Quality Management, Six Sigma,
Workout 2000 and beyond
WJ Re-engineering / Patient Centered Care mid
1990s MH Metric Focused Quality Improvement
(AQP) / Patient Focused Care mid 1990s
WJ Total Quality Management early 1990s MH
Total Quality Management 1990 - 1995
WJ Quality Assessment late 1980s MH Quality
Assessment mid to late 80s (Leadership explores
Total Quality Management Concepts with VHA 1988
- 1990)
WJ Quality Assurance mid 1980s MH Quality
Assurance mid 1970s to mid 1980s
WJ Quality Circles early - late 1980s MH
Morbidity and Mortality Reviews, Quality
Audits
April 2001
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What is Six Sigma?

• Methodology for achieving goals and objectives
• Quantitative technique for problem solving
• Comprehensive improvement process

Tools For Driving Sustainable Change
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Solid tools but.
What Makes Six Sigma Different? Adapted with
permission from Hamadi Said, US Mint
Philadelphia, PA
TQM
Six Sigma
Real results that matter to customers.

• Quality tool
• Vague goals
• No standard metrics
• Open-ended, unstructured
• Department-based
• Focus on product quality

• Business tool
• Clear goals/deliverables
• Clear, consistent metrics
• Rigorous timeline
• Business-based
• Focus on customer

Six Sigma builds on Lessons Learned from prior
approaches
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The Nature of Variation
Precise but not Accurate
Mean is not Centered ( it is Off Target) the
Variation is Small
Accurate but not Precise
Mean is Centered ( it is On Target), but there
is Large Variation (Big Sigma!)
. . . So how does this principle translate into
the real world?
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Six Sigma is A Quantitative Methodology
Y f(X1X2X3..Xn)
Today
CustomerSpec
s DPMO
Target
3s
6.6 Defects
2 308,537 3 66,807 4 6,210 5 233 6 3.4
1s
2s
3s
Target
Desired State
6s
No Defects!

• Sigma Standard Deviation
• Goal Eliminate Defects

3s
6s
Move the MeanReduce Variability
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Why Six Sigma as a Tool?
A Health System The Size of Virtua Fills
400,000 New In-Patient Medication Orders Per
Year
s Script Errors / Yr Correct
Error Rates at
2 123,415 69.1 3 26,723 93.3 4 2,484 99.4 5
93 99.98 6 1.4 99.99966
2s to 6s
Six Sigma Means 1-2 Incorrect Orders Per Year
Six Sigma Can Make a Difference in Healthcare
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Overall Approach
What is Six Sigma?
Practical Problem
Statistical Problem
Statistical Solution
Practical Solution
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What is Six Sigma?
Six Sigma Methodologies
DMAIC To improve any existing product or
process
Who are the customers and what are their
priorities?
What are the most important causes of the defects?
How can we maintain the improvements?
How is the process performing and how is it
measured?
How do we remove the causes of the defects?
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The DMAIC Process
Strategic Plan
Operations Plan
Project Scoping
Project Conclusion
What is the right operational area for a project?
Define
Control
What is the right process result to address?
What does the customer expect?
What measurements will the process owner use to
confirm sustained improvements? What system and
structure changes support sustained gains?
Measure
How is the current process performing?
Analyze
What are the most important factors driving the
process results? What changes will deliver the
desired process result?
Improve
How well did the changes improve the process?
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Define
Y f (x)
DEFINE PHASE Focus on the Y
How do my customers look at me?
Project Funnel
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Measure
Y f (x)
Define Phase Focus on the Y
Measure Phase Focus on the Y
Project Funnel
What do I want to improve? Whats the best way
to measure? Can I trust the output data?
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Analyze
Y f
X1 X2 X3 X4 X5 X6 X7 X8 X9 X10 X11 X12 X13 X14
Define Phase Focus on the Y
Measure Phase Focus on the Y
X1 X2 X3 X4 X5 X6 X7 X8 X9 X10 X11 X12 X13
X14
Analyze Phase List prioritize Xs
How good am I today? How good do I need to
be? What factors make a difference?
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Analyze
X1 X2 X3 X4 X5 X6 X7 X8 X9 X10 X11 X12 X13
X14
Define Phase Focus on the Y
Measure Phase Focus on the Y
Analyze Phase Identify vital Xs
How good am I today? How good do I need to
be? What factors make a difference?
Y f

X7
X2
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Improve
Define Phase Focus on the Y
Measure Phase Focus on the Y
Analyze Phase Identify vital Xs
Improve Phase Focus on vital Xs
Y f
Whats at the root of the problem? How can I
predict the output?

X2 X7
X2
X7
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Control
Define Phase Focus on the Y
Y X7
Measure Phase Focus on the Y
Analyze Phase Identify vital Xs
Improve Phase Focus on vital Xs
Control Phase Sustain improvements
Have I reached my goal? How can I sustain the
improvement?
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DMAIC Training Project Management Plan
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Project Management

• Master Black Belt role
• Driven by the R document cycle
• Tracking software
• Formal Project Management software - (November
  2004 implementation of e-project)
• Good Enough for Now software

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The Work-OutTM Process - An Enabling Technology
Work-OutTM Is
Key Outcomes

• A 1-2 day session that involves employees to fix
  the problem
• Concentrated, empowered decision making
• Leadership responds with immediate decision or
  alternative direction
• Follow up ensures completion of action plans

• Process to drive improvement
• Opportunity to engage and empower people
• Results-based
• Decisions
• Accountability
• Follow up

Tool That Drives Decisions and Actions for
Employees
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Whats a Work-Out?

• Addresses an important process
• Facilitated by a STAR coach (130 trained)
• Gives immediate feedback to staff
• Examples
• Create a new process for Root Cause Analysis
• Create a process to deliver patient satisfaction
  data to leaders and managers
• Fix night call schedule for residents
• Fix transport process for LTC patients
• Total 161 so far

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The Change Acceleration Process
Leading Change
Creating A Shared Need
Shaping A Vision
Mobilizing Commitment
Current State
Transition State
Improved State
Making Change Last
Monitoring Progress
Changing Systems and Structures
Simple, Yet Powerful Model to Assure that Change
Happens
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Summary Six Sigma Methodologies
Q x A E
Six Sigma
Change Acceleration Process
Effective Results
Work-Out
The Effectiveness (E) of the result is equal to
the Quality (Q) of the solution times the
Acceptance (A) of the idea.
A Proven Formula For Results
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How they work together
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Whats Different About Six Sigma?

• Quantitative Where is the bang for your buck?
• Accelerates and sustains change
• Applicable to all parts of the system
• Reduce defects----Increase dollars

More Than Just Another Flavor of the Month
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Six Sigma Personnel

• Master Black Belt Full time advanced training
  in Six Sigma leads initiative, consults,
  teaches, and leads projects.
• Black Belt Full time trained in Six Sigma
  leads projects and assists green belts.
• Six Sigma Analyst Full time trained in Six
  Sigma and reports directly to campus COO
• Green Belt Part time trained in Six Sigma
  undertakes one project every nine months.
• STAR Coach Part time trained in CAP and
  Work-Out leads two projects a year.

Accepted Nomenclature Adapted to Virtua
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Virtua Health The Initial Investment

• Commitment of leadership CEO and Board
• Executive sponsor
• Project manager
• Training from GE
• Six full time blackbelts
• 60 STAR coaches
• Leadership Coalition
• Resources for internal communications

1.4 Million!
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Six Sigma Why partner with GE?

• Need for tools to improve performance and to
  initiate and sustain change
• Proven track record at GE
• Tell you what you need to hear, not what you want
  to hear
• Clear commitment to our success and independence
• Complete package

The Right Company and Capabilities
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What Makes a Good Target for a Six Sigma Project?

• Addresses an important business objective
• Data driven
• Process Map and Measurable Output
• Foundation team (key staff) is the driver of the
  project
• Black Belt leads the team as a consultant
• Average time to completion 6 months

Large and Complex Undertaking
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Driving the Project ..
Process Owner and Project Team
Black Belt and Project Team
Define
Measure
Analyze
Improve
Control
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Evolution of Six Sigma at Virtua
Commitment and Flexibility
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Cardiac Meds
A PRO/CMS
Quality Indicators Project
What the Cardiac Meds Team Did
Why They Did It

• Gaged current data collection system

• Improve quality and consistency of data

• Created a cardiac discharge instruction sheet

• Increase compliance from docs and support
  accurate data collection

• Contained defects immediately while
  implementing more sustainable systems and
  structures to support improvements

• To obtain immediate results to achieve aggressive
  system targets

Project Results

• Project requested by physician leadership
• Documentation was more of a problem than the
  actual delivery of care
• Major progress in achieving physician support for
  process improvement (including physicians firmly
  addressing physician outliers!)

Project started in 7/02. All PRO indicators were
achieved for Q4 02. Project closed out in July
03 continued success sustained!
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Home Care HHRG Case Weight Mix
and Coding
Why They Did It

• What the Team Did

• Established standards in completion of initial
  OASIS form

• Increase in initial HHRG case weight mix
  broader knowledge base of MO questions

• Surpassed the Medicare threshold for OASIS lock
  within 7 days

• Decrease in technical denials and increase in
  cash flow

• Decreased percentage of LUPAs to 15

• Decrease in adjustments (refunds) to government

Project Results
Medicare Length of Stay

• Enhanced Care Manager role in team
• Implementation of standard operating procedures
  for both agencies, two bargaining units through
  use of WorkOuts
• Weekly review of lock days for concurrent review
  by manager
• Substantial ROI to purchase new computerized
  system
• On-going sustainable changes in place during
  training and implementation of new system

Overall Case Weight Mix Average 1.34 Agency
OASIS Lock Within 7 Days 92 Percentage of
Agency LUPAs 15
Total Project Benefit Estimate 1,200,000
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Advantages to Virtua Health

• Results measured in dollars, quality and service
• Common language
• Breaks down silos
• Physicians like it
• Faster decisions and implementation
• A method to accelerate and sustain change
• Creates clarity and objective measures of success

All in all, a Great Return on Investment
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Key Success Factors

• Six Sigma should be undertaken with a clear
  vision of where you want to be
• Introduce Six Sigma as a tool, not a philosophy
• CEO must own it
• Make Six Sigma a system wide effort.Focus on
  , productivity and patient issues
• Measure, measure measureDeal with information
  issues
• Hold people accountable for using Six Sigma to
  achieve outcomes that are important to the
  organization
• Invest in resources and make a long term
  commitment
• Change the systems and structures to support the
  effort

It Has to Become the Way You Do Your Work
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Lessons Learned

• Clear objectives, measurable outcomes and
  doable projects are a must----scope the
  projects
• It is about the process
• There is plenty of fat in healthcare
• Hold people accountable to use the tools to get
  results----Resistance to change and
  accountability is high and in high places
• Teach management how to use the tools
• Hit the areas that are ready and
  fertile--Finance!
• Over communicate by a factor of 1000

Q X A E!
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Lessons Learned

• Be flexible and patient
• Deal with the problem of bad data
• Use CAP
• Sponsor Education is critical-teach them how to
  ask good questions-implementation of Yellow Belt
  training
• It is all about the customer
• It is a process that shines the light, there is
  nowhere to hide
• Can help identify future leaders
• Massive staff empowerment
• Common language
• This is constantly evolvingthere is always
  something to improve

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Six Sigma Leadership Development

• Emerging leaders
• Time limited position
• Rotating Internship
• Developing business rigor and results orientation
• Infecting the organization with excellence and
  competence

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Leadership Developmentsome success stories

• Director Patient Billing Services ? Black Belt
  ? AVP Home Care ?VP Operations
• Director Quality ? Master Black Belt ? VP
  Quality
• Nurse Manager Med Surg ? Black Belt ? Quality
  Director Home Care ?Home Care Director of Nursing
• HR IS ? Black Belt ? Cardiology Product Line at
  Marlton
• Nurse Manager Emergency Department ?Master
  Black Belt ?Virtua Enterprise Manager
• AVP Community Services ?Black Belt ?VP Nursing
  Services
• AVP Operations ?Black Belt ?Director of Finance

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Should You Use Six Sigma?

• Purpose?
• Vision
• Motivation
• Commitment?
• CEO
• At least 3 years
• Investment
• Capacity?
• Culture
• Accountability
• Skills of the managers

Are You Willing to Destroy the Good to Get Better?
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Questions