The Quality Colloquium

1
Leadership for Reliable Systems August 21, 2006
The Quality Colloquium
Stephen R. Mayfield Senior Vice
President smayfield_at_aha.org
2
Visualize Success
We Dont all SEE the Same Thing
3
Seeing Differently

• De Kalb, Illinois
• DeKalb, Georgia

4
Leaders Create the Vision and Set Direction
Would you tell me please which way I ought to go
from here? asked Alice. That depends a good
deal on where you want to get to, said the
cat. I dont much care, said Alice.
Then it doesnt matter which way you go,
said the cat.
5
Leaders Create Expectations

• Leaders -gt
• Values -gt
• Behaviors -gt
• Culture -gt
• Performance

Courtesy of Ann Rhoades
6
Leaders Must

• Eliminate Preventable Harm
• Develop Highly Reliable Systems
• Improve Outcomes Year-to-Year
• Reduce Costs of Care Year-to-Year

7
Unceasing Efforts to

• Remove Waste
• Eliminate Defects
• Reduce Variability
• All work is a system, every system has processes
  and every process has waste and variability.

8
Relentless Pursuit of Waste

• Public perception, the Camry Effect and Community
  Contribution

9
(No Transcript)
10
Change in Cost of Insurance Premiums and Co-Pays
2000
2006
2002
11
The Camry Effect
12
Other Approaches Exist

• Juran There is 30 waste in most healthcare
  processes
• Dartmouth study Providers in Salt Lake are
  number one, if all providers emulated their
  efficiency CMS could save 30 in expenditures.

13
Reliability and the Four Components of Care
Delivery
Patient Information
Clinical Decision
Care Process
Patient Flow
14
Visualize Success
We Need to SEE our Processes
15
Our Approach to Date is not Yielding Desired Rate
of Change

• We have believed that
• If we have enough of the right data
• Analysis will indicate compelling need to change
  
• Change will therefore occur

16
We need to Learn to see our processes in a
different light
17
Reliability and the Four Components of Care
Delivery
Patient Information
Clinical Decision
Care Process
Patient Flow
18
Systems of Care and Simple MetricsInformation -gt
Clinical Decisions -gt Care Processes -gt Patient
Flow
Evidenced Based Medicine
Clinical Information System
Outcome Indicators (LOS, Mortality, Infection,
Readmits)
Financial System
Clinical Best Practices
Charges
Cp1 Cp2 Cp3.
Cp1 Cp2 Cp3.
Cp1 Cp2 Cp3.
Process Measures (Waste, SMR, Cycle Time
Variances, etc.)
Patient
Patient
Patient
Patient
Patient Flow
19
Innovation in Reliable Care
Evidenced Based Medicine
EMR Orders
Free of Preventable Harm
CPOE
Clinical Information System
Outcome Indicators (LOS, Mortality, Infection,
Readmits)
Financial System
Clinical Best Practices
Charges
RFID Sponges
Timely Resulting
Cp1 Cp2 Cp3.
Cp1 Cp2 Cp3.
Cp1 Cp2 Cp3.
Process Measures (SMR, Cycle Time Variances, etc.)
I.D. and Match
Safe Meds
Accurate Labs
Patient
Patient
Patient
Patient
Patient Flow
RFID Location
20
Lean Six Sigma More Value
Steps 3s 4s 5s 6s

• 1 93.32 99.379 99.9767
  99.99997
• 7 61.63 95.733 99.839
  99.9976
• 10 50.08 93.96 99.768
  99.9966
• 20 25.08 88.29
  99.536 99.9932
• 40 6.29 77.94
  99.074 99.9864

Lean Reduces non-value add steps
Six Sigma improves quality of value-add steps
21
Leaders Must

• Eliminate Preventable Harm
• Develop Highly Reliable Systems
• Improve Outcomes Year-to-Year
• Reduce Costs of Care Year-to-Year

22
Unceasing Efforts to

• Remove Waste
• Eliminate Defects
• Reduce Variability
• All work is a system, every system has processes
  and every process has waste and variability.

23
Cost of Poor Quality and Defects
24
The 8 Deadly Wastes

• Overproduction
• Waits/Delays
• Transport
• Process
• Movement
• Inventory
• Defects
• Underutilization

25
(No Transcript)
26
Laboratory Improvements Six Sigma Methods
27
Laboratory
28
High Level Phlebotomy Flow

• MQC

29
Detailed Phlebotomy Flow

• MQC

30
(No Transcript)
31
Data Collection

• Design instrument
• Develop plan
• Collect Information
• Found 3 Problems Matching, Batching Attaching

32
Over 40 specific defects identified in 6 classes

• Label defects (unlabeled, misplaced, wrong
  patient labels, misaligned, etc.)
• Patient ID band defects ( improper matching, no
  label, wrong label, etc.)
• Unsuccessful draw (not first stick, second
  phlebotomist required)
• Unacceptable specimen/recollect (wrong tube,
  clotted, hemolyzed, insufficient quantity,
  contaminated, overfilled, etc.)

33
Surounded by Defects !
34
Prevention Appraisal Failure Visible Defects
and Direct Costs are The Tip of the Iceberg!
35
(No Transcript)
36
Defect Rate Driven to Zero!
37
Improving Interventional Flow with Lean Six Sigma
38
SIPOC Interventional Scheduling
Suppliers
Inputs
Process
Customers
Requirements
Outputs

• Physician
• Patient
• Radiologist
• Pathology/Lab
• Nursing/ I.P.
• Registration

Convenient Accurate Results Timely On
Demand Convenient Clear expectations Timely
Results Results Previous Exam Good
History Convenient Schedule HP Accurate
Scheduling Completed record Demographic
info Payer info ICD 9
See Below

• Physicians

Completed Procedure Specimen Obtained Results in
System
Orders Patient Information Schedule
Information Capacity Staffing
Receive call from Physician for Interventional
test
Approve Test
Contact ordering Physician, Schedule test
Patient enters our system (Orders, Labs, HP)
Administer and complete test
39
Detailed Flow Chart
40
Data Collection

• Data Collection

bserving the Process
41
Analysis
42
CurrentProcess vs.Delay
43
Effect of Inpatient inserted in Schedule
44
Sometimes the System Just Gets You
45
MinMax
609 Min
234 Min
62 Min
46
Costs of Poor Quality
47
Visible Defects and Hidden Costs
48
The 8 Deadly Wastes

• Overproduction
• Waits/Delays
• Transport
• Process
• Movement
• Inventory
• Defects
• Underutilization

49
One Hospitals ApproachLatent CostsIdentified
OpportunitiesRealized Gains
50
One Example of Latent Costs
51
It Can Be done One Example
52
Visualize Success
We Need to SEE our Processes
53
Pursuing Excellence by Improving Care and
Increasing Affordability
54
Our Mission

• The AHA Quality Center is a resource of the AHA
  designed to help providers accelerate their
  quality improvement processes to achieve better
  outcomes for patients and improve organizational
  performance.  
• In collaboration with leading quality improvement
  stakeholders, it provides access to leading
  practices, tools and resources that support
  providers to achieve better patient outcomes,
  improved operational performance, enhanced safety
  and increased satisfaction. 

55
Increasing Pressure on Hospitals Providers

• Need for accurate patient I.D. and Matching.
• Increasing numbers of older and more acute
  patients.
• Increased volumes through the E.D.
• Increasing incidence of HAI.
• Pay for Performance initiatives.
• Reduced reimbursements.
• Pressure for public reporting.

• Medication errors and harm.
• Patient falls.
• Poor handoffs.
• Delays, queues, bottlenecks.
• Incomplete information for decisions.
• Rework.
• Staffing and resources.
• Pressure to define and assess Quality.

56
The Quality Center will support the continuum of
care

• Improve throughput and reduce LOS.
• Reduce readmissions.
• Improve patient identification and matching.
• Reduce Healthcare associated infections (HAI).
• Improve medication safety.
• Reduce incidence of falls.
• Improve top clinical processes.
• Reduce mortality.
• Improve financial performance
• (C/Adj/DC).

57
Unceasing Efforts to

• Remove Waste
• Eliminate Defects
• Reduce Variability
• All work is a system, every system has processes
  and every process has waste and variability.

58
Some Wicked Questions

• What are we trying to accomplish with respect to
  our performance?
• What level of quality and safety are we pursuing?
• How do we measure it?
• How is our performance changing?
• What are we doing to improve it?
• What are our latent costs?
• What are our Costs of Poor Quality?
• How is the CFO involved?

59
Leaders Must

• Eliminate Preventable Harm
• Develop Highly Reliable Systems
• Improve Outcomes Year-to-Year
• Reduce Costs of Care Year-to-Year

60
We need to Learn to see our processes in a
different light
61
Leadership for Reliable Systems August 21, 2006
The Quality Colloquium
Stephen R. Mayfield Senior Vice
President smayfield_at_aha.org