Recognizing the Potential of

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August 20, 2007
Recognizing the Potential of Six Sigma in a
Clinical Setting Matiana Gonzalez Vela, Ed.D.,
R.D., Master Black Belt Cary Montalvo, B.S.,
Black Belt Valley Baptist Health System
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and the
Six Sigma

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Six Sigma and the Institute for Healthcare
Improvement

• 100,000 Lives Campaign
• 5 Million Lives Campaign

• Unveiled in December 2004
• Reduce unnecessary hospital deaths by 100,000
• Focused on 6 Interventions shown to have major
  impact on reducing mortality

• Unveiled on December 12, 2006
• Focus is to protect patients from five million
  incidents of medical harm over the next two years
• Builds upon the success of the 100,000 Lives
  Campaign
• Additional 6 Interventions

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The six interventions from the 100,000 Lives
Campaign

• Deploy Rapid Response Teamsat the first sign of
  patient decline
• Deliver Reliable, Evidence-Based Care for Acute
  Myocardial Infarctionto prevent deaths from
  heart attack 
• Prevent Adverse Drug Events (ADEs)by
  implementing medication reconciliation
• Prevent Central Line Infectionsby implementing a
  series of interdependent, scientifically grounded
  steps
• Prevent Surgical Site Infectionsby reliably
  delivering the correct perioperative antibiotics
  at the proper time
• Prevent Ventilator-Associated Pneumoniaby
  implementing a series of interdependent,
  scientifically grounded steps

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Deliver Reliable, Evidence-Based Care for Acute
Myocardial Infarctionto prevent deaths from
heart attack 
Our Criteria y1 Aspirin on arrival y2
Aspirin at discharge y3 ACE/ARB for LVSD y4
Smoking cessation counseling y5 Beta blocker
on arrival y6 Beta blocker at discharge y7
Timely reperfusion (lt90 minutes)

• IHI Criteria
• Early administration of aspirin
• Aspirin at discharge
• ACE-inhibitor or angiotensin blockers (ARB) at
  discharge for patients with systolic dysfunction
• Smoking cessation counseling
• Early administration of beta-blocker
• Beta-blocker at discharge
• Timely initiation of reperfusion (thrombolysis or
  percutaneous intervention)

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Deliver Reliable, Evidence-Based Care for Acute
Myocardial Infarctionto prevent deaths from
heart attack 
Brownsville
Y compliance with Centers for Medicaid
Medicare Services Acute Myocardial Infarction
Core Measures (All or None Strategy)
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Deliver Reliable, Evidence-Based Care for Acute
Myocardial Infarctionto prevent deaths from
heart attack 
Brownsville
Source www.solucient.com
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Deliver Reliable, Evidence-Based Care for Acute
Myocardial Infarctionto prevent deaths from
heart attack 
Harlingen
Y compliance with Centers for Medicaid
Medicare Services Acute Myocardial Infarction
Core Measures (All or None Strategy)
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Deliver Reliable, Evidence-Based Care for Acute
Myocardial Infarctionto prevent deaths from
heart attack 
Harlingen
Source Premier, Inc.
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Foundations of Success
ACCOUNTABILITY
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BROWNSVILLE
Nurse Name
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Prevent Ventilator-Associated Pneumoniaby
implementing a series of interdependent,
scientifically grounded steps

• Our Criteria
• y1 Head of bed (HOB) elevated 30 - 45
  degrees (unless contraindicated)
• y2 Deep Venous Thrombosis (DVT) prophylaxis
  (unless contraindicated)
• y3 Peptic Ulcer Disease (PUD) prophylaxis
• y4 Daily sedation vacation and assess readiness
  to extubate (unless contraindicated)
• y5 Oral care twice a shift

• IHI Criteria
• y1 Head of bed (HOB) elevated 30 - 45
  degrees (unless contraindicated)
• y2 Deep Venous Thrombosis (DVT) prophylaxis
  (unless contraindicated)
• y3 Peptic Ulcer Disease (PUD) prophylaxis
• y4 Daily sedation vacation and assess readiness
  to extubate (unless contraindicated)

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Prevent Ventilator-Associated Pneumoniaby
implementing a series of interdependent,
scientifically grounded steps
Harlingen
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Prevent Ventilator-Associated Pneumoniaby
implementing a series of interdependent,
scientifically grounded steps
Measure Baseline January 2006 - July 2006 Pilot Control August 21,2006 - October 12, 2006 Post Control October 13,2006 - March 28, 2007 Percent Improvement
of Ventilator Patients n 268 N 59 N 246  
of Ventilator Patients Acquiring Pneumonia 9 1 0  
Ventilator Associated Pneumonia Rate 0.034 0.017 0.000 100.0
Mortality Rate (Patients in the ICU acquiring Ventilator Associated Pneumonia) 0.111 0.000 0.000 100.0
Average Ventilator Days (non-VAP patients) 4.4 2.7 1.8 59.1
ALOS 13.2 11.2 11.4 13.6
ICU LOS 5.8 5.8 3.8 34.5
ICU Mortality 59 6 38 25.6
ICU Mortality Rate 0.184 0.102 0.137 25.6
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Source Premier, Inc.
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New interventions targeted at harm

• Prevent Harm from High-Alert Medications...
  starting with a focus on anticoagulants,
  sedatives, narcotics, and insulin
• Prevent Pressure Ulcers... by reliably using
  science-based guidelines for their prevention
• Deliver Reliable, Evidence-Based Care for
  Congestive Heart Failure... to avoid readmissions
• Reduce Methicillin-Resistant Staphylococcus
  Aureus (MRSA) infectionby reliably implementing
  scientifically proven infection control practices
• Reduce Surgical Complications... by reliably
  implementing all of the changes in care
  recommended by SCIP, the Surgical Care
  Improvement Project (www.medqic.org/scip)
• Get Boards on Board by defining and spreading
  the best-known leveraged processes for hospital
  Boards of Directors, so that they can become far
  more effective in accelerating organizational
  progress toward safe care

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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Our Criteria y1 Measurement of Left
Ventricular Function documented y2
On ACEI/ARB or contraindication
documented y3 Smoking cessation counseling
documented y4 Complete discharge
instructions documented

• IHI Criteria
• Left ventricular systolic function assessment
• ACEI/ARB at discharge for CHF patients with
  systolic dysfunction
• Anticoagulant at discharge for CHF patients with
  chronic or recurrent atrial fibrillation (AF)
• Smoking cessation advice and counseling
• Discharge instructions that address activity
  level, diet, discharge medications, follow-up
  appointment, weight monitoring, and what to do if
  symptoms worsen
• Influenza immunization (seasonal)
• Pneumococcal immunization

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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Brownsville
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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Brownsville
Source www.solucient.com
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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid readmissions
Harlingen
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Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure... to avoid
readmissions
Harlingen
Ranked 1 in the Nation for Heart Failure
Management by the Premier/Center for Medicare and
Medicaid Services Hospital Quality Incentive
Demonstration (HQID) project.
Source Premier, Inc.
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Prevent Pressure Ulcers... by reliably using
science-based guidelines for their prevention

• IHI Criteria
• Pressure Ulcer Prevention
• Conduct a Pressure Ulcer Admission Assessment for
  All Patients
• Reassess Risk for All Patients Daily
• Inspect Skin Daily
• Manage Moisture  Keep the Patient Dry and
  Moisturize Skin
• Optimize Nutrition and Hydration
• Minimize Pressure

Our Pressure Ulcer Criteria Prevention y1
Braden on Admission y2 POC
documented for wound care y3 Heels
offloaded y4 Complete wound
assessment y5 Referral for wound necrosis y6
Ancillary Screens completed y7 Turning every 2
hours y8 Skin protectant for incontinence y9
Specialty bed for high risk Management y1 -
Proper assessment to include location, dimension
and staging y2 - Braden scale completed y3 -
Nurse notifies physician of pressure ulcer y4 -
Pain assessment documented to include pre and
post wound care y5 - Time of initial assessment
documented y6 - Time of wound care performed and
documented y7 - Physical Therapy screen
completed y8 - Dietary screen completed
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Prevent Pressure Ulcers... by reliably using
science-based guidelines for their prevention
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Prevent Pressure Ulcers... by reliably using
science-based guidelines for their prevention
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Prevent Pressure Ulcers... by reliably using
science-based guidelines for their prevention
Brownsville Pressure Ulcer Prevention and
Management
Source KCI
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Lessons Learned!!!

• President / CEO Champion is a must!
• Physician Champion / Leader is a must!
• Clean your house before you ask Physicians to
  clean theirs!
• Have a formal mechanism to choose initiatives
  (projects)
• Once an initiative is selected, scope it to a
  manageable range and ensure it fits the DMAIC
  model!
• Greenbelts during training should have vested
  interest in initiative (Green Belt / Owner
  combination works best)
• Training classes should be kept to a manageable
  size

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Lessons Learned!!!

• Allow enough time between the Improve and Control
  Phase to ensure the best possible solutions can
  be implemented and sufficient data collected
• Thoroughly educate Owners on responsibility for
  sustaining improvements in Post-Control period
• Strive for electronic data collection for
  Post-Control Manual data collection is a
  bear!!! (leverage Information Technology
  department)
• Data collection for Post-Control should NEVER be
  a self-report process
• Develop owners manual to ensure continuity when
  unexpected change in owner occurs
• ACCOUNTABILITY goes hand-in-hand with
  TRANSPARENCY

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Discussion