Using Six Sigma to Improve Cardiac Medication Administration

Using Six Sigma to Improve Cardiac Medication Administration

Using Six Sigma to Improve Cardiac Medication Administration and CAT Scan Capacity Harvard Quality Colloquium August 22, 2005 Susan McGann RN, BSN Adrienne Elberfeld 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 Virtua Facilities The Virtua STAR Excellent Service Resource Stewardship Outstanding Patient Experience Caring Culture Clinical Quality & Safety Best People 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 Define R0 Cardiac Medication Indicators Project Description: Increase quality of patient care by use/non-use and appropriate documentation of aspirin, betablockers, 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, Project Scope: Adrienne Kirby, Mike Kotzen To have all four acute care Champions: Pat Orchard & Jane facilities, within all medical Slaterbeck disciplines, meet the standards of Master BB: Mark Van Kooy Core/JCAHO guidelines Black Belt: Adrienne Elberfeld Potential Benefits: Green Belt: Ted Gall To achieve improved outcomes for Finance Approver: Gerry Lowe patients with AMI/CHF diagnosis by Project Start Date: July 22, adhering to evidence based practice 2002 through education, documentation, Team Members: Jay Brewin, and compliance while meeting Darlene Euler, Christine regulatory standards and enhancing Gerber, Val Torres, Kathy quality of patient care at Virtua. Halstead, Kathy Plumb, Cindy DEsterre, Lori Edell, Heather Alignment with Strategic Plan: Scheckner, Angie Smolskis, PatIIA-Cardiology; Global MICP Goals for Virtua Quackenbush, Ronald Kieft, Michelle Weaks, Robert Singer, Vince Spagnuolo, Steve Fox Measure QRA Chart Review Gage R&R Each Appraiser vs Standard Assessment Agreement Appraiser #ns I pected#Matched Percent (%) 95.0% CI Appraiser A 12 4 33.3 ( 9.9, 65.1) Appraiser B 12 11 91.7(61.5, 99.8) Appraiser C 12 9 75.0 ( 42.8, 94.5) AppraiserD 12 10 83.3 ( 51.6, 97.9)

During this gage, it was determined that there was variation between the QRAs review of charts #Matched: Appraiser'sassessment across trials agrees withstandard. Assessment Disagreement Appraiser #1/0 Per cent (%) #0/1 Percent (%)#Mixed Percent (%) Appraiser A 0 * 8 66.7 0 0.0 Appraiser B 0 * 1 8.3 0 0.0 Appraiser C 0 * 3 25.0 0 0.0 AppraiserD 0 * 2 16.7 0 0.0 # 1/0: Assessments acrosstrials = 1 / tsandard =0. # 0/1: Assessments acrosstrials = 0 / tsandard =1. #Mixed: Assessments acrosstrials are not identical. Percentage of time QRAs agreed on assessment Between Appraisers Assessment Agreement #Inspected # Matched Percent (%) 12 5 41.7 ( 5.2, 1 72.3) 95.0% CI #Matched: All appraisers'assessments agreewith each other. A Workout was held on

September 18th with the QRAs and Case Management Directors to develop SOPs in reviewing of all CHF and AMI Analyze Root Cause Analysis Identified through Containment Issue Conclusion Solution Who Concurrent reviews of AMI & CHF patients Between Case Management, Quality & Nursing charts needed to coordinate efforts in reviewing charts Met with CCMs, Case Management & Quality to educate on core indicators Team members specific to campus, J. Slaterbeck, A.Elberfeld Have team members develop a storyboard template with pathways and indicators to be available at key areas throughout the facility Identified key areas, (physician lounges, Cardiac specific units, nursing specific areas), and

posted storyboards that are the same throughout the system Team members specific to campus 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 Coordinate with IS accessibility to system Cardiac POE Director, AVP, and Black Belt C. Mullin, J. Slaterbeck, B. Rodin Analyze Root Cause Analysis Identified through Containment (continued) Issue Conclusion Solution Who Who is going to perform the task of daily chart reviews concurrent with care? Nursing, case management and quality are all reviewing charts; need to coordinate efforts in regard to the indicators

Case Management to take the lead on chart reviews for patients with AMI, CHF & related diagnosis. Support from quality & nursing Case Mtg Directors, Quality Directors, CCMs Need one point person to communicate directly with physicians in a timely manner If nursing and/or case mgt has direct contact with physician, they give necessary feedback. Next step is the facility QRA and physician champion Communication with physicians per need for documentation Coordination of ongoing chart reviews, documentation completion, and data information Need to appoint point people within the facility to ensure that activities are Case Management to coordinate with nursing & quality; all paperwork Case Mgt, QRAs, B. Singer, V. Spagnuolo, S. Fox

Case Mgt, QRAs, C. Mullin, A. Elberfeld Improve Root Cause Analysis Factor Root Cause Proposed Solutions MI CU run sheets not available on charts Medics unable to complete; shortened documentation not part of permanent chart Sponsor to work with Ambulatory Quality Director to have MI CU run sheets completed & submitted concurrent with care I nconsistent availability of patient census with diagnosis for Nursing and Case Management I S integration with Canopy system; initial information input by I CD-9 code, not description Work order placed with I nformation Services with actual cases to research and advise on proper input process Physician compliance in completion of discharge instructions I nconsistent followthrough Directive from Medical Staff leadership to complete discharge instructions; two week trial period in April, 2003 by HI M to tag all charts without discharge instructions

Consistent practice of multi-disciplinary care of the patient across Virtua Need for champion at each campus to lead initiatives of the Cardiac Programs of Excellence Appointment of Nurse Leader within each facility to coordinate activities of Cardiac Programs of Excellence at local level Control Realized Results of Implemented Solutions Improvement Y Benefit Quality Benefit MICU run sheets on patient charts within 24 hours of admission Increased compliance Compliance with PRO indicators for aspirin given with 24 for aspirin given within 24 hours hours of admission; DOH regulations for transfer of patient care Physician completion of written discharge instructions specific to medications for cardiac patients Compliance and proper documentation of care for discharge medication indicators Increased compliance in care and documentation for all indicators Standard Operating Procedures by Nursing and Case Management in chart review, stickie reminders for physicians, and availability of discharge instructions Consistent education of nursing per cardiac medication indicators Accurate daily census with diagnosis available through OAS Gold and Canopy Appointment of a Process Owner at each hospital to coordinate care with directives from Cardiac Programs of Excellence

Increased compliance for medications given within time frames Quality of care documented Coordination of care for the cardiac patient by the multidisciplinary team Increased knowledge base of the nursing staffof the cardiac medications for AMI and CHF patients Increased compliance in Timeliness of care improved care and documentation for all indicators Sustained improvement Sustained results maintained and in all indicators reported to CMS and public; appropriate recognition and Control P Chart Virtua Health Control Chart for Aspirin Within 24 Hrs Proportion 0.10 UCL=0.09429 0.05 Goal=95% Compliance Project Started June 03 Feb 05 P=0.02861 0.00 LCL=0 0 10 Sample Number 20 Define R0 CT Scan Capacity 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 Team Members: Beverly Crawford, Melody DeLaurentis, JoAnn Domingo, Audrey Fley, Darryl Fussell, Cynthia Koller, Jo Nast, Heather Pierce, Donna Rapp, Elizabeth Zadsielski 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 Scope: Marlton CT Scan department Potential Benefits: A more efficient process will lead to increased capacity thereby increasing opportunities for increased volumes. Alignment with Strategic Plan: Resource Stewardship Patient Satisfaction Measure Descriptive Statistics Descriptive Statistics Y1-CT Abdomen/Pelvis Without Contrast Updated 11/10/04 Descriptive Statistics Y2-Abdomen/Pelvis With Contrast Variable: Avg Time Variable: Avg Time Anderson-Darling Normality Test A-Squared: P-Value: 0 8 16 24 32

40 95% Confidence Interval for Mu Anderson-Darling Normality Test 2.450 0.000 Mean StDev Variance Skew ness Kurtosis N 13.0385 6.2464 39.0181 1.99453 5.98253 52 Minimum 1st Quartile Median 3rd Quartile Maximum 1.0000 9.0000 11.5000 15.0000 38.0000 A-Squared: P-Value: 10 15 20 25 30 35 40 95% Confidence Interval for Mu 95% Confidence Interval for Mu 11.2994 10 11

12 13 14 15 5.2348 95% Confidence Interval for Median 10.0000 13.4970 23.4688 6.9884 48.8377 0.280139 -1.4E-01 32 Minimum 1st Quartile Median 3rd Quartile Maximum 10.0000 18.5000 23.5000 28.5000 40.0000 20.9492 19.5 20.5 21.5 22.5 23.5 24.5 25.5 26.5 7.7464 95% Confidence Interval for Median Mean StDev Variance Skew ness Kurtosis

N 95% Confidence Interval for Mu 14.7775 95% Confidence Interval for Sigma 0.174 0.918 95% Confidence Interval for Sigma 5.6026 95% Confidence Interval for Median 25.9883 9.2909 95% Confidence Interval for Median 20.0000 Y1 Y2 Mean = 13.6333 Mean = 23.4688 Standard Deviation = 6.6993 Standard Deviation = 6.9884 Z Score = 2.78 Z Score = 1.90 Mode = 9 Mode = 20, 21 and 24 Percent of Defects = Percent of Defects = 26.0000 Measure Descriptive Statistics Descriptive Statistics Y3-CT Brain Without Contrast Variable: Avg Time Anderson-Darling Normality Test A-Squared: P-Value:

2 6 10 14 18 22 95% Confidence Interval for Mu 26 1.166 0.004 Mean StDev Variance Skew ness Kurtosis N 11.3671 4.2972 18.4661 0.804413 0.843822 79 Minimum 1st Quartile Median 3rd Quartile Maximum 2.0000 8.0000 11.0000 14.0000 25.0000 95% Confidence Interval for Mu 10.4046 10 11 12 95% Confidence Interval for Sigma 3.7159 95% Confidence Interval for Median 12.3296 5.0959

95% Confidence Interval for Median 10.0000 12.0000 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!! Analyze T Test for Equal Variances Test for Equal Variances for multiple 95% Confidence Intervals for Sigmas Factor Levels 1 CT Tech Bartlett's Test Test Statistic: 69.345 P-Value : 0.000 2 CT Techs Levene's Test Test Statistic: 5.287 P-Value 3 CT Techs 5 7 9 11 13 15 17 19 : 0.006 Levenes

test Test for equal variances for continuous data that is not normally distributed. There is a statistical difference in the variance! Analyze Pareto Chart CAT Scan Delays 100 500 80 60 300 40 200 Percent Count 400 20 100 0 0 Defect Count Percent Cum % 129 103 93 48 47 25

21 18 17 13 10 8 24 23 23 19 42 17 58 9 67 8 76 4 80 4 84 3 87 3 90 2 92 2 94 1 96 4 100 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 Improve 2 Sample T Test & ANOVA Y1

Boxplots of Before-A and After-Av (means are indicated by solid circles) Y1-CAT Scan of Abdomen/Pelvis Without Contrast 60 Y1-Abdomen-Pelvis Without Contrast One-way ANOVA: Before-Avg. Time, After-Avg. Time 50 40 30 20 10 0 Before-A After-Av Two-sample T for Before-Avg. Time vs After-Avg. Time N Before-A 62 After-Av 106 Mean 14.95 11.65 StDev 9.87 5.21 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 (------*------) ---------+---------+---------+------Pooled StDev = 7.279 12.0 14.0 16.0 SE Mean 1.3 0.51 Difference = mu Before-Avg. Time - mu AfterAvg. 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! Improve 2 Sample T Test & ANOVA Y1 Boxplots of Before-A and After-Av (means are indicated by solid circles) Y2-CAT Scan of Abdomen/Pelvis With Contrast 40 Y2-Abdomen-Pelvis With Contrast One-way ANOVA: Before-Avg. Time, After-Avg. Time Analysis of Variance Source DF SS Factor 1 361.4 Error 50 1974.9 Total 51 2336.3 30 20 10 Before-A After-Av Two-sample T for Before-Avg. Time vs After-Avg. Time N Before-A 32 After-Av 20

Mean 23.47 18.05 StDev 6.99 4.93 SE Mean 1.2 1.1 Difference = mu Before-Avg. Time - mu AfterAvg. 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 Level N +-----Before-A 32 *-------) After-Av 20 MS 361.4 39.5 F 9.15 P 0.004 Individual 95% CIs For Mean Based on Pooled StDev Mean StDev ----------+---------+--------23.469 6.988 (------ 18.050 4.925 (--------*---------) ----------+---------+---------+-----Pooled StDev = 6.285 18.0 21.0 24.0 P-value was less than .05, therefore, there is a statistical difference! Improve Moods Median/Non-Normal Data P-value was less than .05,

therefore, there is a statistical difference! Mood median test for CT Scan Chi-Square = 16.76 Subscrip After Before-A N<= 33 30 DF = 1 N> 10 49 Median 8.00 11.00 P = 0.000 Q3-Q1 2.00 6.00 Individual 95.0% CIs ----+---------+---------+---------+-(-----+------) (-----+------) ----+---------+---------+---------+-7.5 9.0 10.5 12.0 Overall median = 9.00 A 95.0% CI for median(After -) - median(Before-A): (-3.12,-1.00) Control I & MR Control Chart Can Canwe wesee seethe theimprovement improvement on onthe thechart chartpost postSOP SOP implementation? implementation? Individual Value I and MR Chart for Y1-Avg Time Subgroup

Moving Range Y1-CT Scan Abdomen-Pelvis Without Contrast 70 60 50 40 30 20 10 0 -10 1 1 1 UCL=29.70 LCL=-3.964 0 50 1 40 1 20 11 Mean=12.87 50 30 1 1 100 150 1 1 1 1 1 10 UCL=20.68 R=6.329

LCL=0 0 Take Takeaway: away: Process Processis iscapable capableand andin incontrol. control. Control I & MR Control Chart Can Canwe wesee seethe theimprovement improvement on onthe thechart chartpost postSOP SOP implementation? implementation? I and MR Chart for Y2 Avg Time Y2-CAT Scan of Abdomen-Pelvis With Contrast 1 Individual Value 40 UCL=36.04 30 Mean=21.38 20 10 LCL=6.731 0 Subgroup 0 10 20 30

40 Moving Range 20 50 UCL=18.00 10 R=5.510 0 Take Takeaway: away: Process Processis iscapable capableand andin incontrol. control. LCL=0 Control Can Canwe wesee seethe theimprovement improvement on onthe thechart chartpost postSOP SOP implementation? implementation? I & MR Control Chart I and MR Chart for CT Scan Time Y3-CT Brain Without Contrast Individual Value 1 1 UCL=20.19 10 Mean=10.43 0 LCL=0.6671

Subgroup 0 50 20 Moving Range 1 20 11 100 1 1 10 UCL=11.99 R=3.669 0 Take Takeaway: away: Process Processis iscapable capableand andin incontrol. control. LCL=0 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 Projec

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