Applying DMAIC principles to improve patient safety

Kristopher Goetz, MAManager, Performance and Innovation

Agenda

• An approach to process improvement at a major academic medical center

• Structures and processes employed at NMH

• DMAIC case study: Reducing hospital acquired pressure ulcers

• Additional examples illustrating the benefit of DMAIC

• Realizing cumulative benefit and lessons learned

Northwestern Memorial HospitalChicago, Illinois

• 854-bed Academic Medical Center Hospital

• Primary Teaching Affiliate of Northwestern University Feinberg School of Medicine

• Nationally Recognized for Clinical Excellence

• Magnet Recognition for Nursing Excellence

• Honored with the National Quality Health Care Award

• Strong Tradition of Community Service

• Major Employer in City of Chicago• New World-Class

Inpatient/Outpatient Facility Opened in 1999

• New World-Class Women’s Hospital Opened in October 2007

• One of Four Institutions in the U.S. with an Aa+ Bond Rating

Feinberg and Galter pavilions Prentice Women’s Hospital

“America’s Best Hospitals”

Eleven medical specialties recognized in 2009 by U.S. News & World Report.

“Top Hospital”

Named to The Leapfrog Group’s 2009 “Top Hospitals” list for quality and safety of care.

Magnet Recognition

Achieved Magnet status, the gold standard for nursing excellence.

“Consumer Choice”

Sole winner for five consecutive years of the National Research Corporation’s“Consumer Choice” award in market research of Chicago-area consumers. Named “most preferred” Chicago-area hospital for 15 consecutive years.

Patient Satisfaction

Ranked first among Chicago hospitals in Overall Patient Rating by Consumer Reports.

University HealthSystem Consortium

Listed in the top 15 in the University HealthSystem Consortium 2009 Quality and Accountability rankings of academic medical centers.

National Quality Health Care Award

Sole recipient of the prestigious national quality award in 2005, presented by the National Committee for Quality Health Care.

“Most Wired”

Named nine times to Hospital & Health Networks magazine’s list of the “100 MostWired” hospitals and healthcare systems.

“100 Best Companies for Working Mothers”

Named to Working Mother magazine’s list for 10 consecutive years.

Northwestern Memorial is Widely Recognized for Excellence

Key Northwestern Memorial Hospital Statistics

Fiscal Year 2009

• 47,739 Inpatient Admissions• 11,868 Deliveries -- Largest Birthing Center in Illinois• 80,696 Emergency Department Visits• 545,786 Outpatient Registrations• 7,034 Employees• 1,656 Physicians on the Medical Staff

An approach to process improvement at a major academic medical center

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Process Improvement at NMH

GOALDeliver Measurable Results which Significantly

Impact the Strategic Plan

Process Improvement at NMH

• NMH commitment to Quality– Process Improvement Team– Executive Sponsorship– Improvement Council oversight

• Structured approach to process improvement– DMAIC– Lean

• Projects linked to NMH Strategic Plan– Exceptional Care– Develop People, Culture, and Resources– Advance Science and Knowledge

Process Improvement Program OverviewProcess Improvement Delivers Measurable Results

2002 2003 2004 2005 2006 2007 2008

• Established DMAIC-based Process Improvement program

• Implemented infrastructure for project selection, oversight and financial benefit reviews

• Trained initial wave of 13 Improvement Leaders

• Doubled the size of Process Improvement Team• Targeted key drivers of risk• Increased awareness of DMAIC among Medical

Staff• Incorporated the use of Lean principles into

DMAIC framework

• 1st Physicians and Nurses trained as Improvement Leaders

• Enhanced project selection process to improve alignment with organizational priorities

• Increased use of Rapid Improvement workshops• Launched a series of Improvement Portfolios to

address complex system issues

2009

Structures and processes employed at Northwestern Memorial Hospital

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DMAIC provides an easily governed systematic process to deliver measurable results

DMAIC Methodology

Who are the customers and what is the problem from

their perspective?

How is the process performing today and how

is it measured?

What are the most important drivers of poor

performance?

How do we remove the drivers of poor performance?

How do we ensure that we sustain the improved

performance?

Define Measure Analyze Improve Control

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DMAIC Training Program – Interstate PI

• DMAIC, Lean and Rapid Improvement = Lanes• Project Management = Support Structure• Tools (Excel, toolkits, templates) = Side Rails and Lines• Projects = Cars

Introduction to Process Improvement and DMAICFY 09 Class Schedule

FY 09 Participants

This class provides individuals with a basic understanding of the DMAIC methodology, lean principles and change management. Participants will learn basic tools that will help them to lead and execute improvements within their specific teams.(Time Commitment: 8 hours)

9.23.0811.18.081.20.093.17.095.19.097.21.09

~150

Lean Principles and Tools for DMAIC

This class gives individuals the opportunity to gain a deeper understanding of Lean principles and philosophy. The class will cover the key principles of Lean thinking and how to identify a Lean opportunity during a DMAIC project and how to translate Lean thinking into action (value stream mapping, push vs. pull model, eight wastes, 5S, set-up reduction, kanban). (Time Commitment: 8 hours)

10.28.0812.16.082.17.094.21.096.16.098.18.09

~100

Excel for DMAIC

This class will teach participants to efficiently understand and analyze data using Microsoft Excel within the context of the DMAIC process improvement methodology. Topics include manipulating raw data using formulas and pivot tables, custom graphing strategies, and tactics to best tell the analytical story.Time Commitment: 4 Hours)

10.21.0812.9.082.12.094.14.096.9.098.11.09

~80

DMAIC Improvement Leader Training

This class is designed for individuals assigned to lead a DMAIC improvement project and will provide an in-depth exposure to the tools and methods necessary to successfully lead and achieve results using the DMAIC methodology, lean thinking and change management techniques. Application of methods along with hands-on exercises will help to ensure rapid learning, knowledge retention, and immediate application. The expectation is for the student to lead future projects and serve as a local DMAIC resource for their department.(Time Commitment: planned 14 sessions at 4-8hrs/session; a total of 64 hrs between Oct08 and Mar09)

Training conducted from Nov 08 to Apr 09.

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Process Improvement Training

*Ad hoc training occurs as needed (i.e. surgical residents, NMH interns, patient accounting)

Patient safety principles to increase healthcare reliability

• The safest thing to do is the easiest thing to do• Reduce reliance on memory• Use fail-safe systems and forcing functions• Standardize, simplify and reduce processes • Reduce stress in the environment• Enhance access to complete & timely information • Reduce handoffs (e.g. between nursing units)• Improve quality and cycle time

Source: Agency for Healthcare Research and Quality (AHRQ)

Key Metric(s):

“Here’s how I’ll know that we’ve have made an impact”

“Yes, I can measure this “

“No, it does not require manual data pulls”

Every DMAIC project has a clearly defined charter

• Linkage to BPE/BP/Finance: “Why is this a strategic project, specifically, how does it tie in to the NMH Strategic Plan?”

• Problem Statement: “What is wrong with our current process?”

• Goal/Benefit: “What specifically do we want to achieve as measured by X, and when do we want to achieve it?”

• Scope: “For this project, what areas will we improve and over what time period will we do the improvement?”

• System Capabilities/Deliverables: “What new processes will we deliver in order to achieve our goals?”

• Resources Required: “What people, materials, and/or finances will be needed to conduct the project?”

“Here’s how you’ll know I’m on track”Milestones:

Description Date (mo/yr)#1#2#3

“Here’s how you’ll know I’m on track”Milestones:

Description Date (mo/yr)#1#2#3

Ownership and Accountability

Project Sponsor

Improvement Leader Process Owner

Improvement Leader Directs/Mentors Project … Process Owner Implements

Role Definition is a Critical Success Factor

Project Executive Sponsor

Clinical Sponsor

Team Members

Ownership and Accountability

Improvement Council

• Why: Routine check-in to ensure progress and alignment

• What:

• DMAIC phase

• Describe problem using data

• Key drivers of error

• Planned/implemented solutions

• Key outcome metric

• Timeline/ next steps

• Who: VP of Quality and operations, director of process improvement, executive sponsor, sponsor, clinical sponsor, process owner, improvement leader

• When: Bi-monthly

D M A I C

Effo

rt &

Acc

ount

abili

ty

for

Suc

cess

of P

roje

ct ImprovementLeader

ProcessOwner

Improvement Leader & Process Owner Effort and Accountability

DMAIC Case Study: Reducing Pressure ulcer Prevalence

Pressure Ulcer: Phase IIOverview• Linkage to BPE/BP/EFP: Best Patient Experience – Safe and effective care

• Problem Statement: While nursing compliance with the Braden pressure ulcer risk assessment is at its highest levels in more than two years (96%), prevalence of nosocomial pressure ulcers at NMH is increasing. The nosocomial pressure ulcer rate at NMH for Q1 2008 was 11.2% (41 out of 367 patients). This is the highest rate in 4 quarters, is 2.4% higher than the national average of 8.8%. Presence of nosocomial pressure ulcers is a key nursing care indicator reported to NDNQI (Magnet). In addition, effective October 1, 2008, CMS reimbursement will be impacted for patient’s with hospital acquired stage 3 and 4 pressure ulcers.

• Goal/Benefit:− To decrease the number of hospital-acquired (nosocomial) pressure ulcers and meet or exceed national benchmarks

− Elimination of avoidable stage 3 and 4 nosocomial pressure ulcers (BPE never event)

− Achieve greater than 95% performance with “always” practice guidelines (BPE always practice)

− Reduce the nosocomial pressure ulcer rate to national benchmarks

− Document pressure ulcers “present on admission” within 2 calendar days of patient admission

• Scope: All inpatient units in Feinberg; floors 14, 15, and 16 in Prentice and the ED, Ambulatory Surgery, Feinberg OR

• System Capabilities/Deliverables: − Improved pressure ulcer assessment, intervention, and treatment processes that address the stated goal. It is expected to address the following:

− Approach to Identify and document pressure ulcers upon patient’s admission to the hospital (initial patient assessment)

− A standardized multidisciplinary approach to preventing pressure ulcers

− A comprehensive evidence based treatment approach for caring for pressure ulcers while the patient is in the hospital

− Update or add to Documentation Policy to address changes

• Resources Required: Nursing (Management, Staff RNs & PCTs), Physicians, Physical Therapy/Rehab, IT, Nutrition, NM Academy, Process Improvement

Executive Sponsor: Michelle Janney Sponsors: Carol Payson Clinical Sponsors: Dr. Chithra Perumalswami, Dr. Cory RitterProcess Owners:Julie Garrett Improvement Leader: Kris Goetz

Project Charter

Key MetricsOutcomes• Nosocomial Pressure Ulcers prevalence

• Nursing unit of origin • Nosocomial Pressure Ulcer StageProcess• Compliance and accuracy of skin assessment• Braden Scale Assessment upon admission and q24 hours

Milestones:Description Date (mo/yr)

#1 Define Jan 2007 (phase 1)#2 Measure Sep 2007 #3 Analyze Nov 2007 #4 Improve Dec 2007 #5 Control Jun2008

Milestones:Description Date (mo/yr)

#1 Define Jan 2007 (phase 1)#2 Measure Sep 2007 #3 Analyze Nov 2007 #4 Improve Dec 2007 #5 Control Jun2008

Pressure Ulcer: Phase II – DefineNMH Continued Focus

D M A I C

• Pressure ulcer prevalence is rising despite excellent compliance with routine risk assessments

• IHI 5 Million Lives Campaign highlights Pressure Ulcers as a key initiative

• Magnet and NDNQI herald Pressure Ulcer Nosocomial Rates as important nursing care indicators

• Stage 3 and 4 pressure ulcers are considered “never events”

Pressure Ulcer: Phase II – MeasureHigh Level Process Map

D M A I C

ASSESSMENT (Multidisciplinary Coordination)

Nosocomial Pressure Ulcer

treatment

Pressure Ulcer Risk Assessment

Comprehensive skin assessment upon

admission

CRITICAL THINKING (Multidisciplinary Team)

INDIVIDUALIZED PREVENTION OR TREATMENT PLAN

IMPLEMENTATION OF INDIVIDUALIZED PLAN (Multidisciplinary Team)

ADMISSIONC

omm

unication

Docum

entation

Identifying high risk groups

INTERVENTION ACTIONS: Prevention & Treatment

Pressure Ulcer: Phase II – Analyze

D M A I C

…To Uncover Key Drivers of Variance

• Current skin/pressure ulcer documentation forms don’t flow with daily practice• “I don’t know what to do”

• Lack of MD, RN, PCT communication

• Interventions are too general- not applicable to all patients

• Inpatient units are the only areas performing skin assessments• More frequent feedback on performance

Rapid Design Workshops….

• Conducted three “deep dive” sessions

1. Skin Assessment2. Pressure ulcer risk assessment

3. Pressure ulcer treatment

• Participation by front line nurses, APNs, managers, and directors

Pressure Ulcer: Improvement Initiatives

D M A I C

Key Drivers of Variance

• Current skin/pressure ulcer documentation forms don’t flow with daily practice

• “I don’t know what to do”

• Lack of MD, RN, PCT communication

• Interventions are too general - not applicable to all patients

• Inpatient units are the only areas performing skin assessments

• More frequent feedback on performance

Implemented Improvements• Development of new “always practice”

− Combining/simplifying documentation− Assessment q shift

• Educational training for every nurse at NMH• Skin expert nurse/PCT program• Skin resource binder at every nursing station• Skin care pocket cards

• Nurse documentation on pressure ulcers to populate MD note

• Multidisciplinary rounding on skin

• Identify and direct specific preventive treatments based on specific areas of risk

• Skin assessment in ED, ASU, and SDS

• Skin assessment productivity boards in each report room enabling daily tracking

Pressure Ulcer: Prevalence and Compliance

Braden Assessment Compliance

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100%

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NMH <= 24 hrs. BPE Goal (95%)

Definition: Percent patients with Braden Scale risk assessment within 24 hours on day of study.

Nosocomial Pressure Ulcer Prevalence(Lower is better)

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NMH Score BPE goal

Definition: Percent patients with nosocomial pressure ulcer on day of prevalence study.

March results demonstrate 100% compliance with the daily Braden Pressure Ulcer Risk assessment. The rate of hospital acquired pressure ulcers decreased from 8.03% in Q2 FY09 to 5.3% in Q3 FY09. There were no stage 4 pressure ulcers and 9 nursing units reported zero pressure ulcers in Q3 FY09. A process improvement project was launched in Q1 FY09 to further reduce overall prevalence and eliminate avoidable stage 3, 4, and 5

pressure ulcers.

5. 3% NMH487 pts.

100%New “always practice” 4/22

Goal= 95%

D M A I C

Pressure Ulcer: Phase II – ResultsDMAIC team interventions have significantly reduced stage 3, 4 and 5 pressure ulcers

D M A I C

Pressure Ulcer: Phase II – ControlDMAIC team interviewed nurses, physicians and PCTs on every inpatient nursing unit to assess the

impact of our efforts

• 78% had awareness of the project• “Have you heard anything about the pressure ulcer project at the hospital?”

• 76% had knowledge of the project• “Do you know what the improvement efforts are about? • “What are the project goals?”

• 69% reported changes in personal behavior as a result of the DMAIC •“Have you personally started doing anything differently as a result of the project?”

Additional examples demonstrating the benefit of DMAIC

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Preventable Codes Outside ICU Per 1,000 Patient Days

Since the implementation of the Rapid Response team (RRT) in January 2006, there have been ~ 21,500 patient evaluations performed by the RRT, an average of 450-500 per month. Intervention (change in clinical management) is needed approximately 40% of the time, and transfer to the ICU 12-15%. The impact is an overall 71% decrease in the rate of preventable codes outside the ICU, amounting to ~ 110 codes avoided/prevented per year.

• Clinical judgment – Staff nurses are trained to recognize the signs of decomposition and to activate the RRT

• Proactive rounding – RRT nurses round on all ICU transfers within 24 hours of transfer

• Electronic surveillance - Electronic vital sign data is used to supplement clinician judgment, reduce the subjectivity of activating the RRT team and to earlier identify patients at risk

Preventable Codes Per Patient Days(Lower is better)

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Compliance with PCI within 90 Minutes

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% Compliant with Guideline NMH Goal

AMI - Percutaneous Coronary Intervention within 90 minutes of arrival

Time requirement changed from 120 to 90 minutes

National Best Decile: 88%

Improvements have been focused on: reducing time from ED presentation to EKG, ED direct activation of the Cath Lab, improving communication feedback on all potential STEMI cases, and establishing common documentation requirements. work has beeen done to establish a plan for pre-arrival EKGs in partnership with the CFD and off-hours response time of the cath lab team. The results for Q3 show 100% compliance for the PCI within 90 minutes measure.

Median Time to PCI(Lower is Better)

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• Heart Failure Core Measures in aggregate and discharge instructions exceed goal of 95% for the first time since 2006. Improvements due to electronic enhancements made to discharge instructions, the Cardiac MPET.• Pre-formatted discharge instructions in PowerChart and enhancements to the Cardiac MPET have led to noticeable improvements. Further, an HF operation group is developing standard care processes for all HF patients which will help to maintain compliance for the future.

Compliance with Discharge Education

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Aggregate DC instructions for HF % Medication instructions

% Diet instructions % Activity instructions

% Follow-up instructions % Weight instructions

% Symptom management instructions NMH Goal

Heart Failure: Compliance with Core Measures

Realizing cumulative benefit and lessons learned

Process Improvement Program OverviewProcess Improvement Delivers Measurable Results

Cumulative Impact

• 185 projects completed

• 85% reduction in avoidable severe events (since 2004)

• Over 1 million patient interactions impacted

• Over $40 M in annualized financial benefit

• Over 70% of completed projects achieved statistically

significant improvement

2002 2009

Process Improvement at NMH: Lessons Learned

• Importance of strategic alignment

• Buy-in at all levels

• Phased approach to large problems

• Improvement “Portfolios” to address complex system issues

• The value of structured, routine check points

• Use the tools that best address the problem

• Celebrate to build momentum

• The challenge of sustainability

Questions?