1

Successfully Using Six Sigma

(6σ) to Improve Nursing Quality

Indictors

Joann Hatton, RN MS, 6σ Black Belt

Director of Nursing Professional Practice

Heritage Valley Health System

Beaver, PA

Objectives

1. Describe how Six Sigma can be used to

improve nursing quality indicators.

2. Describe how the DMAIC process

identified the critical steps surrounding

the incidence or pressure ulcers.

2

About Heritage Valley Health System

• The Medical Center, Beaver, with 358 beds

• Sewickley Valley Hospital, with 191 beds

• Five affiliated physician groups: Tri-State Medical

Group, Sewickley Valley Medical Group, Tri-State

Obstetrics and Gynecology, Tri-State Gynecology,

Tri-State Pediatric Associates

• Sewickley Valley Hospital and The Medical Center

foundations

•• Quality Method: Six SigmaQuality Method: Six Sigma

Recommended by the JCAHO

““Best PracticeBest Practice””

for Six Sigma for Six Sigma

ImplementationImplementation

(April 2005)(April 2005)

The Medical Center was recently named as one of

the nation's 2005 Performance Improvement

Leaders by Solucient® 100 Top Hospitals

What is Six Sigma?

• A method to analyze VariationVariation

• Has a strong metric component; it is Data DrivenData Driven

• A process to reduce variation so that acceptable

performance is within Six Standard Deviations (6 σ)

3

Reducing variability is the essence of six sigma

Six Sigma Concept

Every Human Activity Has Variability...

MeanMean

1σσσσ1σσσσ

TargetTarget

Errors

UpperCustomer

Specification

LowerCustomer

Specification

Six Sigma Concept

A process to reduce defects per million

opportunities (DPMO)

σσσσσσσσ DPMODPMO

2

3

4

5

6

308,537

66,807

6,210

233

3.4

Quantitative methodology, utilizing measurements and

scientific process

Defect

pressure ulcer, patient fall,

antibiotic delay, central line

infection, med omitted

4

DMAIC: A Problem Solving Methodology

DefineDefine MeasureMeasure AnalyzeAnalyze ImproveImprove ControlControl

Project Selection

Team Formation

Define

Opportunities

Project Selection

Team Formation

Define

Opportunities

Measure the ProcessMeasure the Process

Analyze Data

Collected

Analyze Data

Collected

Innovate

Solutions

Make

Improvements

Innovate

Solutions

Make

Improvements

“Sustain

The

Gain”

““SustainSustain

The The

GainGain””

We are forced, after improvement, to remeasure,

analyze and then control the process

Six Sigma: A Set of ToolsSix Sigma: A Set of Tools

Process Flow DiagramProcess Flow Diagram

RISK PRIORITY NUMBER (RPN) =

SEVERITY X 0CCURRENCEX ESCAPED DETECTION

5 4 3 2 1

Severe High Moderate Minor Negligible

Occurrence Very High High Moderate Low Very Low

(OCC)

Severity

(SEV)

Escaped Very High High Moderate Low Very Low

Detection

(DET)

Category

Score

Failure Modes and Effects Analysis - FMEAFailure Modes and Effects Analysis - FMEA

Control ChartsControl Charts

Item

Operator 1 Operator 3

Test 1 Test 2 Test 1

Operator 2

Test 1 Test 2 Test 2

1

2

3

4

5

6

7

8

9

1

0

Glass Inspection Test

Measurement System Analysis

Measurement System Analysis

Cause and Effect DiagramCause and Effect Diagram

Procedures

GOAL

EquipmentMeasurement

Environments

People

Material

5

Six Sigma Project:

Preventing Hospital Acquired Pressure Ulcers

Why Reduce Hospital Acquired Pressure Ulcers?

1. Nursing Quality Indicator (NDNQI)- Magnet Status- Regulatory Agencies - DOH

2. Health Care Cost- Increase Health Care Cost - Increase LOS- Increase Use of Resources/Materials- Potential For Litigation

3. Increased Mortality - Due to complications (Sepsis)

4. Patient Satisfaction 5. Perception that the rate of hospital acquired pressure ulcer was higher than expected.

define

Our Profile of a Patient with

“Decubitus Ulcer”

A review of 226 cases from July 2005 to Jan 2006 with ICD-9

Principle or Secondary diagnosis of 707 (decubitus ulcer)

showed:

– Mean age 71 with a range of 17-92

– 56% female and 44% male

– Top 5 diagnosis codes:

• heart failure, hypertension, urinary track infection, atrial fibrillation and COPD.

– Top 2 DRGs: heart failure and septicemia

– Discharging nursing unit:

• A1 (46%), B3 (32%) and A3 (9%)

– 49% Medicare and 25% Security Blue

– LOS average 7.6 days +/- 6.3 days

– Discharge Status: SNF 40%, Home 23%, HH 18%

• Expired n = 16 (7%)

define

6

Skin Care Committee Team Members

• Nursing Administration

– Joann Hatton RN Director of Nursing

– Kathy Hoffman RN CWOCN Nurse

– Gail Inman RN CWOCN Nurse

• Critical Care

– Cheryl Decker RN

• CardioPulmonary Step Down

– Kathy Starkey RN Level 3

• Medical Surgical Units

– Kristen Majetic RN A3 Med Surg

– Lisa McLean RN Level 2 Med Surg

– Kristen Coster RN Level 1 Med Surg

– Ting Andrews LPN Level 1 Med Surg

• Psychiatric Unit

– Pat Martyak RN

define

IPO

Preventing

Hospital

Acquired

Pressure

Ulcers

•People

•Patients

•Families

•Nurses

•Clinical Techs

•CWOCN Nurse

•Physicians

•Policies / Procedures

•Risk Assessment

•Nutrition Screen

•Documentation Tool

•Event Reporting

•Training /Education

•Skill/knowledge

•Competency

•Equipment / Supplies

•Bed Surfaces

•Pressure Relief Devices

•Dressings

•Wound care products

•Quality

•Reduced Incidence pressure

ulcers

•Practicing evidenced based

nursing (ie risk assessment)

•Competent and

knowledgeable staff

•Customer Satisfaction

•Improved patient/family

satisfaction

•Improved physician

satisfaction

•Improved relationships

•HR

•Improved nursing satisfaction

•Positive impact on nursing

retention

•Financial

•Reduced patient costs

•Reduced LOS

Inputs Outputs

define

7

PROCESS

FLOW

Skin / Risk Assessment Process FlowPatient Admitted to

Hospital

At Risk?

Skin Assessment Completed

by RN (Admission

Assessment)

Skin

Breakdown

Present?

Stage 1

Stage 2

Stage 3

Stage 4

Unstageable

Event Report

Risk Assessment Completed

by RN (Braden Scale)

High Risk < 12

Low to Moderate Risk

12-18

Not Currently at Risk

>18

Risk Assessment Completed

by RN (Braden Scale)

Follow Skin Care

Protocol according to

Risk and Stage

yes

no

Implement Prevention Strategies and

reassess Braden Scale daily.

Implement Prevention Strategies and if

other major risk factors are present,

advance to next level of risk

Implement Prevention Strategies and

consult CWOCN

TMC: All Units

measure

Data Source: NDNQIData Source: NDNQI

Percent of Surveyed Patients w ith Hospital Aquired Pressure Ulcers

The Medical Center

25.00

6.12

8.86

13.33

8.30

4.10

6.10

25.00

4.16 4.34

8.67

15.80

2.17

0 0 0 0

3.00

7.10

10.10

0 0

8.3

0

4.804.8

2.51.38

0 0 0

1.38

0

5

10

15

20

25

30

Critical Care CardioPulmonary Level 1 Level 2 A3 Psych TMC

4Q04 1Q05 2Q05 3Q05 4Q05

Target < 11.29 Target < 7.42 Target < 5.39 Target < 8.03

8

Hillrom Study March 2005

= TMCAnalysis: TMC rates below Benchmarks

measure

TMC DataTMC Data

What Have We Learned?

MANPOWERMANPOWER

� Staff Education

– Lack of knowledge on protocol/policy

– Lack of knowledge on products

– Competency (has not been one for past 4

years)

– Policy / Protocol not up to date

analyze / improve

1. Revised Skin Care Protocol Aug 2005 to

reflect evidence based practice. Included

easy to follow tables on equipment and

products. Completed

2. Provided Staff Education In Progress

� On line learning module for RNs on

Risk Assessment

� Incorporated Assessment / Staging

into Annual Nursing Seminar.

� Skills lab for CTs (turning,

positioning, reducing shearing and

friction)

1. Revised Skin Care Protocol Aug 2005 to

reflect evidence based practice. Included

easy to follow tables on equipment and

products. Completed

2. Provided Staff Education In Progress

� On line learning module for RNs on

Risk Assessment

� Incorporated Assessment / Staging

into Annual Nursing Seminar.

� Skills lab for CTs (turning,

positioning, reducing shearing and

friction)

Analysis: Failure ModesAnalysis: Failure Modes Improvement StepsImprovement Steps

9

What Have We Learned?

MANPOWER

� Role of CWOCN nurse not clear

– Hospital culture (expect ET to do it)

– Inappropriate consults

– CWOCN workload

analyze /improve

Further study and define role of CWOCN

Completed

1. July 2005 Kathy Hoffman CWOCN

reassigned full time at TMC with Gail Inman

providing support coverage.

2. In addition to seeing patients, focus on

customer service and coaching / mentoring of

RNs, CTs and students

3. Monthly tracking of caseloads – looking at

workload and types of consults.

4. Focus on improved event reporting / FU

5. Job Description revised

6. Participation in Western PA WOCN Assoc.

Further study and define role of CWOCN

Completed

1. July 2005 Kathy Hoffman CWOCN

reassigned full time at TMC with Gail Inman

providing support coverage.

2. In addition to seeing patients, focus on

customer service and coaching / mentoring of

RNs, CTs and students

3. Monthly tracking of caseloads – looking at

workload and types of consults.

4. Focus on improved event reporting / FU

5. Job Description revised

6. Participation in Western PA WOCN Assoc.

Analysis: Failure ModesAnalysis: Failure Modes Improvement StepsImprovement Steps

Role of CWOCN

32%

30%

11%

11%

12%4%

Pressure Ulcers

Ostomies

Leg Ulcers

Wounds

Derm

Other (burns, fistulas,

tubes,drains)

CWOCN Monthly Visits

189

219219

161

222

202

0

50

100

150

200

250

Ju

ly

Se

pte

mb

er

Oc

tob

er

No

ve

mb

er

De

ce

mb

er

Ja

nu

ary

Average 202 visits per monthCWOCN Visits per Day

10.410.1

9.69.5

11.0

7.7

9.2

6

7

8

9

10

11

12

July

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Fy06

Average visits per day

Visits by Reason for Consult

Volume of Visits

10

What Have We Learned?

MANPOWER

� Skin Care Committee

– Only meets quarterly

– Ill defined - unclear focus other than

audits

– focus not on PI

– No management involvement /

accountability

– Not all units represented

– Managers not really aware of what they

did

analyze /improve

Resurrect Skin Care Committee with

newly defined charter. Completed1. Decided quarterly was sufficient in

2006

2. All units now represented

3. NDNQI results shared with members

4. Each meeting focus on a PI topic and

education

5. Competency completed on all members

Aug 2005

6. DON Professional Practice attends

mtgs

7. Summary of meeting and findings

communicated via email to nursing

leadership within 24 hours of mtg.

Resurrect Skin Care Committee with

newly defined charter. Completed1. Decided quarterly was sufficient in

2006

2. All units now represented

3. NDNQI results shared with members

4. Each meeting focus on a PI topic and

education

5. Competency completed on all members

Aug 2005

6. DON Professional Practice attends

mtgs

7. Summary of meeting and findings

communicated via email to nursing

leadership within 24 hours of mtg.

Analysis: Failure ModesAnalysis: Failure Modes Improvement StepsImprovement Steps

What Have We Learned?

MEASUREMENTMEASUREMENT

• Question validity of data

– Audit process not clearly defined

– Not using current NDNQI forms and data

definitions

• Only completed quarterly

– No real time feedback to Mgrs

• “feel” rates are higher than reported in

prevalence studies

analyze /improve

Revised Measurement / Auditing Process Aug

2005 Completed

1. Using current NDNQI forms

2. DON PP and CWOCN completed NDNQI

online tutorial

3. Review data collection methodology with skin

care committee prior to each quarterly audit.

4. Attended conference call by NDNQI on

improving reliability and validity of data.

5. Review audits at mid day and at end of day to

ensure accuracy and completeness

6. Nursing assumed responsibility for data entry

into NDNQI web based system.

7. Manager’s review and initial audit tool at the

end of the day.

8. CWOCN weekly tracks incidence of pressure

ulcers.

Revised Measurement / Auditing Process Aug

2005 Completed

1. Using current NDNQI forms

2. DON PP and CWOCN completed NDNQI

online tutorial

3. Review data collection methodology with skin

care committee prior to each quarterly audit.

4. Attended conference call by NDNQI on

improving reliability and validity of data.

5. Review audits at mid day and at end of day to

ensure accuracy and completeness

6. Nursing assumed responsibility for data entry

into NDNQI web based system.

7. Manager’s review and initial audit tool at the

end of the day.

8. CWOCN weekly tracks incidence of pressure

ulcers.

Analysis: Failure ModesAnalysis: Failure Modes Improvement StepsImprovement Steps

11

What Have We Learned?

MACHINESMACHINES

� Bed Utilization - high rental fees

– over and under utilization

– monitoring bed usage (what reports are

out there?)

– mattresses and beds are old

analyze /improve

Plan for replacing all beds in 5 year

capital plan In Progress1. All Critical Care beds replaced Nov 05

2. Preventive surface included in all beds

3. Stopped using mattress overlays

Plan for replacing all beds in 5 year

capital plan In Progress1. All Critical Care beds replaced Nov 05

2. Preventive surface included in all beds

3. Stopped using mattress overlays

MATERIALS

� Lack of knowledge on

- which products available at TMC

- when to use which product

- where products are kept

MATERIALSMATERIALS

� Lack of knowledge on

- which products available at TMC

- when to use which product

- where products are kept

Included one page tables on equipment

and products as an attachment in the

Skin Care Protocol. In Progress

1. CWOCN focus on 1:1 coaching /

mentoring at the bedside.

2. CWOCN participates in value analysis

process / committee.

Included one page tables on equipment

and products as an attachment in the

Skin Care Protocol. In Progress

1. CWOCN focus on 1:1 coaching /

mentoring at the bedside.

2. CWOCN participates in value analysis

process / committee.

Analysis: Failure ModesAnalysis: Failure Modes Improvement StepsImprovement Steps

What Have We Learned?

1. Policy on Admission Assessment

revised

− Moved Braden Scale with

Integumentary section of the form

− defined areas of responsibilities

2. Skin Care Protocol revised to

specifically define the process for

documentation, risk assessment and

event reporting.

− Changed from on admission to daily

− Added risk tools to daily graphics

3. Focus on event reporting of pressure

ulcers noted on admission by Mgrs,

supervisors and CWOCN.

4. Educational sessions for nursing to

focus on Risk Assessment and

documentation.

Completed

METHODSMETHODS

� Documentation

– New admission assessment form:

• Small print, limited education on use

• Unclear who completes what section of form

– Patient not “captured” on admission

• Event Report not always completed

• Patients not “captured” ICDM coding on discharge

� Risk Assessment

– Skin Assessment not consistently completed on admission

– Braden Scale not done or not done correctly on admission

• Practice varies on some units from 0-100%!

• Mean is around 45-50%

– No reassessment of Braden during hospital stay

– Protocol not initiated when risk present

analyze /improve

12

Documentation

• Document the patient’s initial Braden Scale on the Admission Assessment as usual

• Record the daily reassessment on the Clinical Record

Documentation

Document pressure ulcer prevention measures on the Clinical Record and update plan of care.

Can I delegate the

documentation of

the frequent

observations to my

ClinTech?

YES, you are

encouraged to do

this!

13

ResultsThe project results so far have been

impressive:

1. Reduction in hospital acquired

pressure ulcers from 6.9 to 3.5 (Sigma

level from 2.9 to 3.5)

2. Incorporation of risk assessment from

“on admission” to daily with an

improvement in documentation of risk

assessment from 50% to 96%.

control

Hospital Acquired Pressure Ulcers

The Medical Center

UCL=18.281

LCL=-4.296

CEN=6.993UCL=9.806

LCL=-2.728

CEN=3.539

-10

-5

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 161Q03 2Q03 3Q03 4Q03 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06

Sigma level 2.9 (69,444 DPM) Sigma level 3.5 (23,148 DPM)

Results Hospital comparison to NDNQI

14

Results: Critical Care

Summary

• Skin care remains an important measure of quality for nursing

• Incidence of pressure ulcers remains a significant problem in most hospitals. Using a six sigma problem solving approach within nursing can identify and eliminate barriers nurses face in caring for their patients.

• The FMEA assisted us in developing processes to prevent and mitigate those instances that escaped the initial process.