LEAN Six Sigma and Patient Safety

Mary Reich Cooper, M.D., J.DChief Quality Officer, Lifespan Corporation

Edward W. Craven, MBA, CPHQNewYork-Presbyterian Hospital

Medicare Says It Won’t Cover Hospital Errors •Sign In to E-Mail or Save This

By ROBERT PEAR

Published: August 19, 2007WASHINGTON, Aug. 18 — In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

WHY?

“For discharges occurring on or after October 1, 2008, the diagnosis-related group to be assigned shall be a diagnosis-related group that does not result in a higher payment based on the presence of a secondary diagnosis code”

WHY?

No Extra Payment

1. Serious Preventable Event - Object left in surgery

2. Serious Preventable Event - Air embolism

3. Serious Preventable Event - Blood incompatibility

4. Catheter Associated UTI

5. Pressure Ulcers (Decubitus Ulcers)

. Vascular Catheter Associated Infection

7. Surgical Site Infection - Mediastinitis after Coronary Artery Bypass Graft (CABG) surgery

8. Falls

WHY?

Transactional Level of Data Collection

Rewards for Each Time

74 Different Measures Available

Effectiveness and Safety

WHY?

Agenda

WHY do we need to have this discussion? WHO are we? WHEN did we start? HOW have we approached this topic? WHAT have we achieved?

NewYork-Presbyterian HospitalNewYork-Presbyterian Hospital

Full asset merger of The New York Hospital, founded in 1771 and the 2nd oldest hospital in the US, and The Presbyterian Hospital of New York, founded in 1868, into one Article 28 corporation which includes:

2,224 Certified Beds

110,000 Discharges

11,000 Births

88,000 Surgeries

1,036,000 Ambulatory Visits

17,500 Employees

$2.8 Billion Operating Budget

WHO?

Lifespan Corporation

Employees10,941

Affiliated Physicians2,519

Licensed Beds1,174

Total Assets$1.77 Billion

Patient Discharges52,680

Emergency Department Visits198,447

Outpatient Visits292,029

Net Patient Revenue$1.11 Billion  

Research Funding$66.8 Million  

Uncompensated Care at Cost$53.207 Million

WHO?

Experience in LEAN and Six Sigma

Designed and implemented NYP plan Hired and supervised forty black belts Program ongoing since 2002 $74 million in benefits through June 2007 National award winners and speakers

WHEN?

Patient SafetyQuality Outcomes Define Measure Report Out

GE Healthcare Performance SolutionsDecember 13, 2004

HOW?

Quality Outcomes Pillars for Success

NYP/WC NYP/A NYP/WC NYP/CNYP/A

Blo

od

Str

eam

In

fect

ion

s

Pat

ien

t F

alls

Pre

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re U

lcer

s

Res

trai

nts

Dee

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ein

Th

rom

bo

sis

LOS

Capacity Patient Care

Patient, Family, MD, Staff Satisfaction Malpractice Liability

HOW?

Project Approach

• Complete Literature Search

• Identify Best Practices

• Conduct GAP Analysis

• Prioritize GAPS

• Conduct Brainstorming Session to Identify Critical X’s

• Decide on DMAIC or Solution/Best Practice Implementation

• AIC or Work-Out and Change Acceleration Process

• Monitor progress

• Deliverables Met

• Project Transfer to NYPH

• On-going control

HOW?

BSI Site Selection Data

Benchmarks from National Nosocomial Infection Surveillance [NNIS];Major Teaching Hospital Med/Surg ICU; 50th percentile = 4.9, 90th percentile = 7.7

NYPH Adult ICU Central Line Related BSI2-year Average Rate (03 & 04)

2

3

4

5

6

7

8

9

10

CV

C-B

SI/

1,0

00

CV

C D

ay

s

CTICU Cornell

MICU Allen

CCU Columbia

SICU Columbia

CTICU Columbia

MICU Columbia

CCU Cornell

SICU Cornell

MICU Cornell

NYPH Adult ICU Central Line Related BSI2-year Average Rate (03 & 04)

2

3

4

5

6

7

8

9

10

CV

C-B

SI/

1,0

00

CV

C D

ay

s

CTICU Cornell

MICU Allen

CCU Columbia

SICU Columbia

CTICU Columbia

MICU Columbia

CCU Cornell

SICU Cornell

MICU Cornell

90th

50th

WHY?

Blood Stream Infection Project Opportunity

Tangible Benefits Intangible Benefits

Culture ObtainedFrom

Patient

CultureAnalyzed

BSI DetectedPatientTreated

InfectionRemoved

PatientDischarged

• Decreased length of stay (LOS) • Increase ICU Capacity• Reduce IV Antibiotics Usage

• Patients and family satisfaction is increased with decreased length of stay in ICU • Increase communication and best practice sharing between Epidemiology and Infection Control across campuses•Lowered legal burden from hospital malpractice claims and financial settlements/awards

Process

Problem Statement The Weill Cornell CCU current has BSI rate of 8 BSI per 1000 catheter days. Based on 2003 and 2004 data the BSI rate was as high as 11 BSI’s per 1000 catheter days. The rate is approaching the National Nosocomial Infection Surveillance (NNIS) 90 th Percentile.

HOW?

Blood Stream Infection Project Scope/Enablers/Restrainers

Project Enablers Project Restrainers

• Strong history of success in lowering BSI rates in ICUs with focus and effort by Epidemiology and unit staff

• Causes and drivers of BSI are well established in medical literature

• Limited buy in and agreement to participate from specific staff.

This will be mitigated by using CAP tools early to communicate the necessity of pursuing this project. creating a shared need, shaping a vision and mobilizing commitment Gaining consensus that there is a true problem will be necessary early and throughout the life of this project

In Scope:Weill Cornell CCU & SICU Central Line Catheter Related BSI’s. Catheters inserted both inside & outside of CCU & SICU

Out of Scope: Non central and other BSI’s

Other locations: Columbia, Allen Pavilion, CHONY and other Weill Cornell ICU’s

Days spent elsewhere within Hospital

HOW?

Critical X’s

Technique Training Supplies and Kits Line Upkeep

2007: Central Line Infections

ICU’sNNIS DataPublicly Reported DataMystery Shoppers for Hand HygieneStandardized Protocol for InsertionsCarts, Barriers, and KitsEpiPortal

WHAT?

BSI ICU Results2007 Months without an Infection

0

1

2

3

4

5

6

7BurnCCUCTICUMICUNEURO ICUPICUSICUNICU > 1500NICU > 2500m

WHAT?

QUESTIONS?

mcooper @ lifespan.org

edc9008 @ nyp.org