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Achieving Physician Buy-in for Performance Improvement:

Leveraging 6 Sigma Management SystemLeveraging 6 Sigma Management Systematat

OSF Saint Francis Medical CenterOSF Saint Francis Medical Center

Tim C. Miller, M.D.Tim C. Miller, M.D.Vice President, CMO & Director of Academic AffairsVice President, CMO & Director of Academic Affairs

&&

Tom ThomasTom Thomas6 Sigma Black Belt6 Sigma Black Belt

WCBF’s 7WCBF’s 7thth Annual Lean, Six Sigma and Process Improvement in Healthcare Summit Annual Lean, Six Sigma and Process Improvement in Healthcare Summit

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Achieving Physicians Buy-in for Achieving Physicians Buy-in for Performance ImprovementPerformance Improvement

OBJECTIVESOBJECTIVES

A.A. Traditional PI and the Physician CultureTraditional PI and the Physician Culture

B.B. New Order of PI for PhysiciansNew Order of PI for Physicians

C.C.Credibly Engaging Physicians & ResidentsCredibly Engaging Physicians & Residents

D.D.Experiences, Results, & Lessons LearnedExperiences, Results, & Lessons Learned

18771877

20072007

• 570 Beds

• 27,000 Discharges

• 520 Attending Staff

• 944 Total Credentialed Providers

• Academic Medical Center

OSF Saint Francis Medical CenterOSF Saint Francis Medical Center

Peoria, Illinois

Traditional Traditional Performance Improvement Performance Improvement

andandThe Physician CultureThe Physician Culture

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Traditional Physician CultureTraditional Physician Culture

Traditional Physician Training:

• Is Independent, Autonomous, Scientific

• Is Focused on the Individual Versus System Thinking

• Maximizes Individual Competence Rather than Team-based Learning

• Is Concerned with Individual Patient Safety and Outcomes

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Traditional HealthcareTraditional HealthcarePerformance ImprovementPerformance Improvement

• Attempts to benchmark facilities with similar service lines...

Our hospital is different. • Impossible to achieve exceptionally high levels of

quality... Patients are non-compliant, co-morbidities… My patients are different.

• Poor data, validity suspect...We can’t trust the data.

• Complexity of human diseases compared to assembly-line “widgets”…

We will never be able to attain 6-Sigma levels.• Driven by bottom line or external market

conditions... It’s all about the money.

Creating a New OrderCreating a New Orderof Performance Improvement of Performance Improvement

with Physicianswith Physicians

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• Since the first IOM Report, there has been a public outcry for immediate and comprehensive improvement in healthcare quality and safety.

• CMS, Joint Commission, and other regulatory agencies and payers have responded by raising the performance bar to new levels with significant consequences for performance failure.

• These conditions are challenging the old order of relationships.

BurningBurningPlatformPlatform

Critical Shift in HealthcareCritical Shift in Healthcare

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Learning from ManufacturingLearning from Manufacturing

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ADMISSIONS - 34,160 TotalADMISSIONS - 34,160 Total

(Payor Source)

0 2 4 6 8 10 12

Commercial

Self-Pay

Managed Care

OSF

BC

Caterpillar

Medicaid

Medicare

Thousands~ FY 2006~ FY 2006

10.65

6.546

4.392

3.86

2.854

2.34

2.128

1.39

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Improvement MethodologiesImprovement Methodologies

MethodologyWars

IHICollaboratives6 Sigma

Lean &Kaizan

TQM/CQI

EBM

Nursing Research KEEP

IT

SIMPLE

!

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Ad

equ

ate

Hu

man

R

eso

urc

es

Living Our Values Every Day

OSF Mission

Imp

rove

Cap

acit

y

Imp

rove

d P

atie

nt

Saf

ety

Imp

rove

d S

ervi

ce

Imp

rove

d C

ost

an

d

Rei

mb

urs

emen

t

CommunitySafetyQualityServiceValue

6 Sigma6 SigmaThe Unifying Framework for ImprovementThe Unifying Framework for Improvement

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• The organizational commitment and involvement that engages and further develops its people - starts with CEO

• Improving performance by improving key processes

• Focusing highly skilled, highly trained people on your highest priorities

Attributes of Attributes of The 6 Sigma Culture The 6 Sigma Culture

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• Data-driven, fact-based decision making

• Rigorous alignment of actions with strategy

• Aligned with evidence based practice

• Measuring clinical outcomes and continuous performance reporting

Attributes of Attributes of The 6 Sigma CultureThe 6 Sigma Culture

Build and Maintain CredibilityBuild and Maintain Credibility

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Operations First

Demonstrate use of 6 Sigma to address MD complaints with operations!

Target key operations processes that frustrate physicians to demonstrate the improvement power of 6 Sigma

Y = f (x)

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Strategy:Strategy: Best Quality Best Quality

September 5, 2007; Page D1September 5, 2007; Page D1

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Strategy: GrowthStrategy: Growth• CT Scanner utilization

– CFH 35% increase in from 52% to 70%– Main Campus 26% increase

• General Radiology Throughput – 37% improvement cycle time IP arrive to complete

• OP Radiology – 50% reduction in delays and cancellations

• Interventional Radiology (IR) Patient Throughput – 3.7 additional CT cases per day– 6.3 additional IR cases per week– Decreased direct cost of procedure 26.2% and 25.7%

respectively

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Strategy: GrowthStrategy: Growth• Operating Room Utilization

– 24% improvement of SFMC OR from 63% to 78%– 71% improvement CFH Ambulatory OR from 35% to

60%

• Capacity Project Portfolio– 44% improvement in Patient diversions from 102 to

57– IT Enabled Bed Management Process Improvement– Admission Process Improvement– Capacity Management Process

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Listen, Leverage, & Engage MD ChampionsListen, Leverage, & Engage MD Champions

• Where Are MD Concerns About Quality?

• Create Solid Wins Early

• Don’t Make Lack Of Baseline Data A Deal Breaker

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6 Sigma Relationship to EBM6 Sigma Relationship to EBM

6 Sigma doesn’t create clinical evidence – it helps us use it consistently

6 Sigma Targets Reducing Variation And Elimination Of Errors to Reliably Deliver Quality Care In A Safe Environment

Y = f (x)

SFMC Project ExamplesSFMC Project Examples

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Reducing Ventilator Acquired PneumoniaReducing Ventilator Acquired Pneumonia

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Strategy: Best QualityReducing BSI

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2Q

FY

03

3Q

FY

03

4Q

FY

03

1Q

FY

04

2Q

FY

04

3Q

FY

04

4Q

FY

04

1Q

FY

05

2Q

FY

05

3Q

FY

05

4Q

FY

05

1Q

FY

06

2Q

FY

06

3Q

FY

06

4Q

FY

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1Q

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07

2Q

FY

07

3Q

FY

07

4Q

FY

07

Quarter

Cen

tral

Lin

e D

ays

0

10

20

30

40

50

60

70

BS

I E

ven

ts

CL Days

BSI

4Q07 Based on 2 Months Reported

REDUCING BSI

25

Quarter

Individual V

alue

4QFY072QFY074QFY062QFY064QFY052QFY054QFY042QFY044QFY032QFY03

12

10

8

6

4

2

0

_X=1.97

UCL=3.70

LCL=0.24

BSI RateInfections per 1000 Central Line Days

KickoffRN Bundle

Red Rule

Clinical Projects & Outcomes Clinical Projects & Outcomes Reducing Blood Stream InfectionsReducing Blood Stream Infections

6-Sigma6-SigmaPhysician InvolvementPhysician Involvement

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6-Sigma Projects Portfolio6-Sigma Projects Portfolio

~ February 2007~ February 2007

18

46

41

67

6

0 20 40 60 80

Capacity/Growth

Service

FinancialImprovement

ClinicalQuality/Safety

Community ofCaregivers

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6 Sigma Projects Completed6 Sigma Projects Completed

0 10 20 30 40 50 60

Capacity/Growth

Service

Financial Improvement

Clinical Quality/Safety

Community of Caregivers

MD Involvement No MD Involvement

~ February 2007~ February 2007

4

48

30

29

12

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6-Sigma Active Projects6-Sigma Active Projects

~ September 2007~ September 2007

0 5 10 15 20

Capacity/Growth

Service

Financial Improvement

Clinical Quality/Safety

Community of Caregivers

MD Involvement No MD Involvement

2

19

11

17

6

6-Sigma6-SigmaAcademic IntegrationAcademic IntegrationResident InvolvementResident Involvement

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6-Sigma6-SigmaOTHER GME ALIGNMENTOTHER GME ALIGNMENT

• Member of “Sentinel Event” Teams

• Member of “Near Miss” Teams

• Coordinate New Projects with Clinical/Academic Strategies

• TAL (Teaching, Administration and Leadership) video

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Engaging PhysiciansEngaging Physicians

I heard that you are a certified 6 Sigma Black Belt Zombie. Is that true?

He didn’t seem dangerous, Dr. Smith.

I’m an assertive and innovative professional, experienced in lean, six sigma and process improvement in healthcare.

I just sat through a 3-hour project review meeting.

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• Project Example: Quality Quest and Evidence-Based Standards

• Quality Quest is a strategic partnership between OSF HealthCare System and Caterpillar Inc.

• Goal: Improving the quality and efficiency of healthcare delivery and improve health in the tri-state area.

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To establish the consistent application of evidence-based care standards for Central Illinois tri-county area health providers.

Project GoalProject Goal::

• Identify, evaluate, and recommend evidence-based guidelines/protocol sets

• Recommend endorsement and adoption process to gain acceptance and use

• Identify implementation and maintenance support requirements• Identify operational processes and relationships

Deliverables:Deliverables:

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• 17 community physicians representing all 4 major hospitals at all levels and types of service

• 2 executive level nurses

• 1 change agent expert

• 1 6 Sigma Black Belt

Who did we bring to the table?Who did we bring to the table?

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• Healthcare is local

• Respect

• Process & Environment

• Opportunity to be a part of the change

• Talents & Expertise

• SBAR

How did we get them there?How did we get them there?

““WWe are going to ask you to do some tough thingse are going to ask you to do some tough things…”…”

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Articulate the Burning PlatformArticulate the Burning Platform

What will m

ake you

uncomfortable

enough that you will

want to be a part o

f

the change?

In the future, everybody will have 15 minutes of quality health care.

State Ranking on Quality Dimension

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• Constantly articulate the vision

• Establish aggressive agendas & timelines

• Extensive sub-team work

• Scientific approach

• Take-aways (WIFM)

How did we keep them there?How did we keep them there?

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Clear goalsExposed and validated concernsLeveraged a physician championDetailed project plan with all meetings

scheduled before kick-offSpecific tasks linked to specialtyChange management principlesCommunication

What we did right…What we did right…

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What did we do wrong?What did we do wrong?

ØTeam too large to function as a group

ØAvoid tedious tasks (i.e. creating surveys)

ØBenefit of meeting 1-on-1 with team

members

ØTimelines (i.e. Resident Hand Off Project)

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4 Major hospitals

represented by 17 physicians

and 2 of the communities largest payers

CAME TO AN AGREEMENT

on 1 set of Evidence Based Standards guidelines

for the Tri-County area

IN JUST 90 DAYS

Project Outcome…Project Outcome…

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Involving Physicians Involving Physicians “Rules of the Road”“Rules of the Road”

• Establish and Maintain Credibility Aggressive Agenda No Agenda, No Meeting Send Materials for Pre-meeting Prep Provide Key Articles from Scientific

Journals Provide Bibliography or References for

Further Reading• Respect MD Time and Be Flexible with

Participation Methods

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Engaging PhysiciansEngaging Physicians“If physicians participate on teams, communicate their needs and help design improvement strategies, it is more likely that their concepts will become an integral part of the improvement plans.

Physicians should not act as innocent bystanders in process improvement but must actively participate and support teams in performing the hard work that goes along with it.”

~ Lee Adler, D.O. (iSixSigma Magazine)

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““Why don’t clinicians engage Why don’t clinicians engage with quality improvement?”with quality improvement?”

Editorial: J. Health Serv Res Policy Vol 3 July 2007

• Limited understanding of QI methods

• Suspicious of differing definitions of clinical quality

• Belief that high quality care is already present – especially locally

• Waste of scarce personnel and resources

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Finally ...Finally ...

6 Sigma Works6 Sigma Works Operations Must Go First Operations Must Go First Data Credibility is EssentialData Credibility is Essential We Must Include the MDsWe Must Include the MDs

- Find and Develop MD Champions- Find and Develop MD Champions

- Meet Them Where They Are- Meet Them Where They Are

Communicate & Celebrate Success!Communicate & Celebrate Success!