9/16/2011

2011 TPHA Annual Conference 1

The Joint Commission’s Core Measure Sets

1) Acute Myocardial Infarction (AMI)2) Children’s Asthma Care (CAC)3) Heart Failure (HF)4) Hospital Based Inpatient Psychiatric Services

(HBIPS)5) Hospital Outpatient Department Measures 6) Perinatal Care (PC)7) Pneumonia (PN)8) Stroke (STK)9) Surgical Care Improvement Project (SCIP)10) Venous Thromboembolism (VTE)

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2011 TPHA Annual Conference 2

1) Elective Delivery – No elective delivery less than 39 weeks

2) Cesarean Section

3) Antenatal Steroids

4) Healthcare – associated bloodstream infections in newborn

5) Exclusive breast milk feeding

Data(Input)

Analysis(Transformation)

Interpretation(Output)

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2011 TPHA Annual Conference 3

Data(Input)

Analysis(Transformation)

Interpretation(Output)

Six Sigma is a process-focused strategy and methodology for Quality Improvement whether in manufacturing, business or healthcare.

It defined a systematic approach to Process Improvement.

It’s not just about improving cycle time but about decreasing errors which translates into saving lives and saving valuable resources.

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2011 TPHA Annual Conference 4

Define the problem Measure the defects and process operation Analyze the data and discover causes of the

problem Improve the process to remove causes of defects Control the process

VOC DOE SPCC Fishbone Diagram Pareto Chart FMEA SIPOC Histogram Run Chart

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2011 TPHA Annual Conference 5

Month Compliance Rate Month Compliance Rate Month Compliance Rate Month Compliance Rate

Jan‐07 82% Jan‐08 74% Jan‐09 94% Jan‐10 93%

Feb‐07 72% Feb‐08 78% Feb‐09 85% Feb‐10 90%

Mar‐07 81% Mar‐08 62% Mar‐09 83% Mar‐10 100%

Apr‐07 38% Apr‐08 84% Apr‐09 87% Apr‐10 100%

May‐07 55% May‐08 82% May‐09 86% May‐10 94%

Jun‐07 45% Jun‐08 88% Jun‐09 96% Jun‐10 93%

Jul‐07 74% Jul‐08 90% Jul‐09 84% Jul‐10 100%

Aug‐07 64% Aug‐08 68% Aug‐09 88% Aug‐10 100%

Sep‐07 71% Sep‐08 78% Sep‐09 93% Sep‐10 93%

Oct‐07 70% Oct‐08 79% Oct‐09 82% Oct‐10 100%

Nov‐07 100% Nov‐08 86% Nov‐09 96% Nov‐10 100%

Dec‐07 76% Dec‐08 90% Dec‐09 89% Dec‐10 100%

Compliance Rate (2007-2010)

They can work to improve the system They can distort the system Or, they can distort the data

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2011 TPHA Annual Conference 6

Hospital 1 24 27 35 864.01% 26 46 39 111

5.16% 37 43 32 112

5.25% 36 35 11 82

3.78%

3914.55

%330

4.08%

Hospital 2 28 25 23 764.94% 25 35 47 107

7.64% 43 55 23 121

8.93% 32 56 25 113

8.28%

4177.37

%453

6.97%

Hospital 3 7 8 3 184.83% 9 9 10 28

7.65% 5 10 3 18

6.10% 9 13 6 28

7.47%

926.53

%126

8.82%

PACU Arrival Temps% of Arrival Temps<36 C (96.8

F)

0% Average Temp and Less Spread of Temps are Desired

The Voice of the Process

Hospital 3 PACUAverage = 7.75% of pts. Expected High = 17.35%Expected Low=0

Hospital 2 PACUAverage = 7.55% of pts. Expected High = 13.33%Expected Low=0

Hospital 1 PACUAverage = 4.23% of pts. Expected High = 6.71%Expected Low=1.76%

Target is 0 % (We want PACU Temp to = 36C)3 standard deviationsLess than a 0.27% chance that we are wrong about spotting a signal (Less Kick butt, good job)Quarterly numbers masks the problem. Patients don’t feel averages!If ou want to hit our target temp of 0% < 36 C then ou must change our process

9/16/2011

2011 TPHA Annual Conference 7

No data have meaning apart from their context

Trust no one who can not, or will not, provide the context from their figures

Graphs make data more accessible to the human mind than do tables. Tables of values should accompany most graphs

Numerical summaries of data (Avg., Histograms, and Ranges) may supplement graphs, but they never replace them.

While every data set contains noise, some data sets may contain signals. Therefore, before you can detect a signal you must filter out the noise.

Process behavior charts filter out the noise of routine variation by construction of the limits.

The distinction between signals and noise is the foundation for every meaningful analysis of data.

The first mistake is Interpreting Noise (normal variation) as if it were a Signal (assignable cause)

The second mistake is Failing to Detect a Signal when it is Present.

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2011 TPHA Annual Conference 8

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2011 TPHA Annual Conference 9

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2011 TPHA Annual Conference 10

Example: Admission Orders to L& D for an Elective C-Section

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2011 TPHA Annual Conference 11

Month Compliance Rate Month Compliance Rate Month Compliance Rate Month Compliance Rate

Jan‐07 82% Jan‐08 74% Jan‐09 94% Jan‐10 93%

Feb‐07 72% Feb‐08 78% Feb‐09 85% Feb‐10 90%

Mar‐07 81% Mar‐08 62% Mar‐09 83% Mar‐10 100%

Apr‐07 38% Apr‐08 84% Apr‐09 87% Apr‐10 100%

May‐07 55% May‐08 82% May‐09 86% May‐10 94%

Jun‐07 45% Jun‐08 88% Jun‐09 96% Jun‐10 93%

Jul‐07 74% Jul‐08 90% Jul‐09 84% Jul‐10 100%

Aug‐07 64% Aug‐08 68% Aug‐09 88% Aug‐10 100%

Sep‐07 71% Sep‐08 78% Sep‐09 93% Sep‐10 93%

Oct‐07 70% Oct‐08 79% Oct‐09 82% Oct‐10 100%

Nov‐07 100% Nov‐08 86% Nov‐09 96% Nov‐10 100%

Dec‐07 76% Dec‐08 90% Dec‐09 89% Dec‐10 100%

Compliance Rate (2007-2010)No Elective Delivery less than 39 weeks

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2011 TPHA Annual Conference 12

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2011 TPHA Annual Conference 13

Obstetrical Carepath (final version)

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2011 TPHA Annual Conference 14

Define the problem Measure the defects and process operation Analyze the data and discover causes of the

problem Improve the process to remove causes of defects Control the process

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2011 TPHA Annual Conference 15

1) No elective delivery less than 39 weeks

2) Surgical Care Improvement Project (SCIP)

3) Venous Thromboembolism (VTE)

Year

Admissions to NICU with gestational age of 36 0/7 to 38 6/7 weeks

Average admissions per month The delta

2009 170 14

2010 84 7 86

2011 (1/1/11 ‐ 9/3/11) 44 5

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2011 TPHA Annual Conference 16

THE DELTA(the decrease in the # of infants admitted to NICU compared to last year) 86

Average length of stay 7

Total # of infant days in a year 602

Average daily facility cost plus physician cost per day $1,500 

Dollars Saved in one year $903,000

Don't fall into the knee jerk reaction trap and make changes in your process without plotting your data in a control chart.

What does you control chart (process behavior chart) tell you. Is there normal variation or is there exceptional variation. Is there a trend? Do you have a stable process?

Variation is the enemy

Follow the Duck

DMAIC

Statistical software: Minitab, MS Excel

9/16/2011

2011 TPHA Annual Conference 17

Issue:Too many mothers and babies are readmitted to 

hospital within 7‐10 days of discharge.

Remind mothers & caregivers to review discharge protocols.

Engage in real‐time depression screening.

Direct mothers to their first postpartum physician visit.

Monitor the well‐being of the mother.

Conduct real‐time patient satisfaction surveys.

Review you postpartum discharge instructions daily. Click here or visit samplesite.com Call your doctor if you have any of the listed symptoms.

How are you? Rate your emotional well‐being on a scale of 1 to 5. Reply 1, 2, 3, 4, or 5. (with 5 being very happy)

Your postpartum appointment is at 3pm tomorrow. Please call 615 555 5555 if you need to cancel or re‐schedule.

Check your surgical incision daily. Contact your doctor if appears red or inflamed, or if there’s drainage from the incision.

How would you rate your postpartum care experience on a scale of 1 to 5? Reply 1, 2, 3, 4, or 5. (with 5 being excellent)

A Mother’s Touch  Postpartum ProtocolTM