Using Six Sigma for Process Improvement - · PDF filePracticing Six Sigma as the Designers...

Practicing Six Sigma as the Designers Intended

Using Six Sigma for Process Improvement

CATHOLIC HEALTH SERVICES

The Ruby Team project at St. Anthony’s Rehabilitation Hospital represents, by all measures, a near-perfect Six Sigma implementation

Mark Testa, EE, MBB Presentation by:

Uniform Data System for Medical Rehabilitation 2012 UDSMR® Annual Conference Buffalo, New York August 9–10, 2012 FIM, UDS-PRO, and UDSMR are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

2

Access

FinancialStability

Excellence

CommunityInvolvement/

Advocacy

Collaboration/Partnerships

OrganizationalEffectiveness

To provide health care and services to those in need

To nurture an awareness of their relationship with God

To

assi

st p

eopl

e to

who

lene

ssT

o minim

ize human suffering

Catholic Health Services: CHS Mission & Goals: A Non-Profit Health Care Provider

3

Catholic Health Services: CHS Stakeholders:

■ 6500+ Persons Served Each Day

■ 10,000+ New People Request Our Services Each Year

■ 2,200 Employees

■ $11,000,000 of Charitable/Uncompensated Care in 2011


Catholic Health Services is the largest, most comprehensive, post acute continuum of care

system in the southeast United States

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Catholic Health Services: CHS Prominent South Florida Post Acute Care Network:

■ 4 Sub-Acute Nursing and Rehabilitation Centers – 200 Beds

■ 3 Long-Term Care Facilities – 433 Beds

■ 3 Rehabilitation Hospitals – 88 Beds –1660 Patients 2011

■ Hospice Care

■ 4 Outpatient Therapy Clinics

■ 3 Physician Specialty Clinics

■ 2 Assisted Living Facilities – 124 Beds

■ 2 Home Health Agencies


Encompassing: 8 Service Lines 30 Facilities

5

Catholic Health Services: CHS Rehabilitation Hospitals Earn Top Ranking by UDSMR

CATHOLIC HEALTH SERVICES Note: 791 Facilities Included in 2011 UDSMR® Percentile Ranking

St. Catherine’s East & West

Ranked 97th Percentile for Outcomes

In 2011

97th

St. Anthony’s Ranked

93rd Percentile for Outcomes

In 2011

93rd

Up from: 25th Percentile in 2008 46th Percentile in 2009

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What is Six Sigma ?

Six Sigma is a business management strategy which seeks to improve the quality of process outputs by identifying and removing the root causes of defects and key sources of variation § Data driven § Rigorous § Process oriented § Customer centric § Variance based § Statistically sound


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How Did This Marriage Come About ?


Six Sigma Methodology

Acute Inpatient

Rehabilitation

8

More Specifically …


Retired Electronics

Vibrant Healthcare Network

Six Sigma Demands Bold / Engaged / Top Down Leadership

A new day was dawning for Healthcare in the U.S.

and the challenges are analogous to those faced by Corporate America in the 80s as the result of Asian competition

.... this was the burning platform from which Six Sigma was born

They acknowledged:

Engineer

.... At Catholic Health Services we are blessed with forward facing leadership at both the CEO and COO levels

Motorola Certified Six Sigma Master Black Belt

so why not look to Six Sigma in these challenging Healthcare times

9

How Was Six Sigma Launched At CHS ?

2. DMAIC: Structured Problem Solving Methodology

3. Actionable Data

Establishing a Six Sigma Foundation

Every organization is unique ………

1. Bullet Proof Metrics


Early Steps in the Right Direction = Big Returns

10

Bullet Proof Metrics

Customer Centric

Variance Based

Distortion Free

Deep and Wide

Displayed Graphically

Mark Testa


11


Customer Centric

Mark Testa

Measure what the customer feels Internal metrics can not be the end game

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Customer Centric

Variance Based Reduce the variation and shift the mean

Mark Testa


Significance Testing is mission critical

13


Customer Centric Measure what the customer feels Internal metrics can not be the end game


Distortion Free Data distortion leads to inconclusive results Timeliness is a source of distortion

Mark Testa


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Customer Centric


Distortion Free Data distortion leads to inconclusive results

Deep and Wide Summary data is an output … not an input Analytics demand patient level data

Mark Testa


Timeliness is a source of distortion


15


Customer Centric


Distortion Free

Displayed Graphically Display in a manner that invokes right action

Mark Testa


Deep and Wide Summary data is an output … not an input Analytics demand patient level data

Timeliness is a source of distortion Data distortion leads to inconclusive results


16

UDSMR® Published Metric: External Gold Standard


Internal metrics that are deployed need to be Externally anchored ….

Seek always to understand how you are being measured

207 of the 400 patients met Targeted Performance Levels

Categorical Metric 48% Defective

Know the Rules of the Game

Facility Sub score

(% of Target)

2009 Overall National Ranking: 25th Percentile

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DMAIC: Structured Problem Solving

Used when an existing process is failing to meet customer requirements or is not performing adequately.


Improve

Control

Measure

Define

Analyze

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DMAIC: Structured Problem Solving


First Things

Fun Things

Highest Leverage

Nearly all organizations in the U.S. are Front End challenged ………

Don’t Seek Solutions to Problems You Don’t Understand

Improve

Control

Measure

Define

Analyze Don’t Purchase Solutions That Will Forever Be In Search of a Problem

And

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CHS Digital Six Sigma Playbook

SERVICES

CATHOLIC HEALTH

Digital Six Sigma Playbook

DMAIC Edition


2012

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Define Phase CHS Playbook M C I A D

Define Phase

Six Sigma Wisdom

1. Two-thirds of the Six Sigma projects that fail, fail because the project was poorly defined

2. The fate of the team is largely cast during this chartering phase

3. As a leader, your impact will never be greater than during this formative period

During the Define Phase, a team and its sponsors reach agreement on what the project is and what it should accomplish. This agreement is documented in a one page Project Charter. Six Sigma is a rigorous process and the Project Charter is the Enforcer of this rigor.

Mark Testa

PEM Performance Improvement Scorecard Linkage: Big Y: Become the Rehabilitation Provider of Choice by 2013 Small Y: UDSMR® Published National Percentile Ranking Vital X: FIM® Change

Project Risk Assessment Score: 19 of 20 Success probability: High

Business Case: The UDSMR® Program Evaluation Model (PEM) metric is a nationally recognized barometer of healthcare quality specific to Inpatient Rehabilitation Facilities. It promotes delivery of care that is effective, efficient, timely, safe, equitable and patient centric. Acute Hospitals seeking Best-in-Class, Post Acute Care Partners will look to PEM metric performance and rank

Opportunity Statement: For the full year of 2008, St. Anthony’s Rehabilitation Hospital received a National Percentile Ranking of 25% Focus on the Case Level Indicators weighted 60% in the PEM Model

Defect definition: Any patient whose FIM® Change (discharge FIM® rating minus admission FIM® rating) is lower than Targeted Performance Levels

Year-to-date November 2009 baseline: 37.2% defective

Goal Statement: Reduce the FIM® Change defect rate by 50% by May 2010 Defect Rate Target = 18.6%

Project Scope: In Scope: • FIM® Change: One of three equally weighted Case-Level

Indicators • All admissions to St. Anthony’s Rehabilitation Hospital Out of Scope: • All Other Components of the PEM Model

Project Plan Team Structure: Project Leader: Sponsor: Black Belt: Champions:

Team Members:

Task/Phase Start Date Target End Actual End Define Measure Analyze Improve

Control

M C I A D

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Does the FIM® instrument support the organization’s mission ?

Patient Outcomes: To assist people to wholeness • Higher FIM® scores correlate well to higher probability of returning home • A return to Community extends and enhances Quality of Life

Professional Development: To create a Learning Organization • Professionals grow by challenging themselves with ever more demanding goals • Goals are effective only in the presence of performance feedback

Healthcare Reform: To become the Healthcare provider of choice • In a Bundled Service environment, Quality and Cost will be King

Making a Compelling Case for the Project Metric

Can the FIM® instrument support a performance-based culture ?


Good reason to pursue every FIM® point

Patient Centric Data Super Set Created

Deep and Wide Actionable Data

Made Possible by the Powerful UDS-PRO® Database Export Functionality Structured to Support All Manner of Statistical Analysis

•Included FIM® ratings for all admission, interim and discharge assessments •Extensive patient demographics

•Includes all CHS data entered into the UDS-PRO® System from 2007 to the present •8600 patient records with 350 data fields per record: 3,010,000 data elements

0.0

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90

10

All

Cam

puse

s(20

09)

% C

omm

unity

0 10 20 30 40 50 60 70 80 90 100 110 1

Mid Pt FIM Score

Percent to community = .0090 * total discharge FIM® rating + .0428

RSquare

RSquare Adj

Root Mean Square Error

Mean of Response

Observations (or Sum Wgts)

0.965786

0.961984

0.059538

0.630933

11

Summary of Fit

Model

Error

C. Total

Source

1

9

10

DF

0.90055657

0.03190329

0.93245986

Sum of

Squares

0.900557

0.003545

Mean Square

254.0493

F Ratio

<.0001 *

Prob > F

Analysis of Variance

n = 1392

Probability of Discharging to Community Regression Analysis Supports the Robust Nature of the FIM® Metric Design

All Campuses 2009

Customer Centric

It says to the clinician…. for each and every FIM® point earned, there is an increased probability that your patient will return Home

Functional independence is earned one point at a time

Textbook Threshold

25

Categorical Nature of the UDSMR® PEM Metric


Discharge FIM® Rating

# of

Pat

ient

s

42% Defective

70 Targeted Performance Level

Each patient undergoing rehabilitation has only two possible outcomes: 1. Meets the Performance Standard 2. Does not meet the Performance Standard:

In the Categorical World of the PEM Metric

Fail Pass

The Latter Being a Defect in Six Sigma speak ………

Clarification: the patient is not a defect the outcome is !

26


70 90 110 50

83 Mean

A

B

C

In a Parametric World Ruled by Averages, Outcomes for High Scoring Patients Offset the Outcomes for Lower Scoring Patients

Example: Average Discharge FIM® Rating of 83 Meets Targeted

Performance Level

Targeted Performance Level

Why a Categorical Metric ? It Embodies the Belief That No Patient Should Be Left Behind

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Why a Categorical Metric ? It Embodies the Belief That No Patient Should Be Left Behind


70 90 110 50

In a Categorical World, Low Patient Outcomes Are Never Averaged Away.

Patient Outcomes Failing to Meet Targeted Performance Levels Are Logged as Defects to the Organization… as they should be

Categorical Metric: 33% Defective

A

B

C


Defective Outcome

Fail Pass

28

Six Sigma Improvement Methodology Hypothetical Example: Shifting the Mean / Reducing the Variation



# of

Pat

ient

s

42% Defective

70

Mean 83


Starting Point 42% defective

6

29

With a Categorical Metric Shifting the Mean Reduces Defects


70 Discharge FIM® Rating

# of

Pat

ient

s

18% Defective

Mean 88


6

Mean Shift 18% defective

30


70 Discharge FIM® Rating

# of

Pat

ient

s

5% Defective

88 Mean


With a Categorical Metric Decreasing Variation Reduces Defects Even Further

6

Variation Reduction 5% defective

31

With a Categorical Metric Setting the Key Targeted Performance Levels Is Critical

Internal and External Benchmarks: Best-in-Class • Observe what is possible • Calibrate expectations

Published National Norms: • eRehabData • Joint Commission • UDSMR

Historical In-House Performance: • Extrapolate from existing outcome trends • Leverage Clinician goal setting competencies

Categorical Levels Are Updated Periodically to Encourage Continuous Improvement

FIM® Item Entitlements

Facility: St. Anthony's Rehabilitation Hospital CMG 0110 Total FIM® Change Goal: 23.59

FIM® Item Entitlements Item Admission Discharge FIM® Change Stairs 1.0 1.7 0.7

Tub Shower 1.2 2.5 1.3

Toileting 1.1 2.5 1.4

Dressing Lower 1.2 2.6 1.4

Bladder 1.4 2.8 1.4

Walk Wheelchair 1.1 2.8 1.7

Bathing 1.5 2.9 1.4

Toilet 1.3 3.0 1.7

Bed Chair Wheelchair 1.3 3.1 1.8

Dressing Upper 1.7 3.4 1.7

Bowel 2.3 3.5 1.2

Grooming 2.3 4.0 1.6

Eating 2.9 4.3 1.4

Problem Solving 2.6 3.5 0.9

Memory 2.8 3.7 1.0

Expression 3.1 4.2 1.0

Interaction 3.4 4.4 1.0

Comprehension 3.4 4.4 1.0 Total 35.7 59.3 23.6

Note: Entitlements based on 2007 National Averages

FIM® Item Entitlements Allocating Total FIM® Change Discharge Goal to Individual FIM® Items

Entitlements assigned for both Admission and Discharge based on the profile of national averages specific to each CMG

National FIM® Item Profile for Stroke CMG 0110

Discharge

Admission

Testing Relationship Between Goal and Actual Outcome St. Anthony’s Rehabilitation Hospital 2009/2010 July

Our Clinicians demonstrated predictive skills that are being further developed into a core competency

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80

90

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11

12

Dis

char

ge T

otal

FIM

(TM

) Sco

re

40 50 60 70 80 90 100 110 120

Discharge Total FIM Goal

Discharge Total FIM® Score = -12.0673 + 1.0892 * Discharge Total FIM® Goal

Model

Error

C. Total

Source

1

657

658

DF

197063.14

96230.66

293293.80

Sum of

Squares

197063

146

Mean Square

1345.418

F Ratio

<.0001 *

Prob > F

Analysis of Variance

RSquare

RSquare Adj

Root Mean Square Error

Mean of Response

Observations (or Sum Wgts)

0.671897

0.671397

12.10247

84.87557

659

Summary of Fit

n = 680

Clinician Established Goal

Actu

al D

isch

arge

FIM

® R

atin

g

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Measure Phase CHS Playbook M C I A D

Measure Phase

Six Sigma Wisdom

1. Average based measures give you only half the picture with regard to performance.

The purpose of the Measure Phase is to establish techniques for collecting data about current performance. This data will be utilized to identify and prioritize improvement opportunities as well as solidify a strategy for measuring improvement.

Mark Testa 9/30/09

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Normal Distributions have a predictive nature The Empirical Rule: 68-95-99.7


68%

Applies to Normal Distributions

95%

+1s -1s -2s +2s +3s -3s mean

99.7%

Standard Deviation

Metrics Need to Be Variance Based

36

Why is it important ?

*

*

* *

* *

*

Jan Feb Mar Apr May Jun Jul Aug Sep

Simple Run Charts are Lacking in this regard

A

B

C

C

B

A

Visual data needs to Invoke Right Action


Display Graphically to Invoke Right Action

Pizza Party

37

Why is it important ?

*

*

* *

* *

*

Jan Feb Mar Apr May Jun Jul

*

*

Aug Sep

A

B

C

C

B

A

Visual data needs to Invoke Right Action

What is the Right Action ? What is the Right Question ?


Display Graphically to Invoke Right Action

Simple Run Charts are Lacking in this regard

Beatings Begin

38

Analyze Phase CHS Playbook M C I A D

Analyze Phase

Six Sigma Wisdom

1. Implementing low hanging fruit solutions can get you 10% to 20% improvement but may not be sustainable

2. A Six Sigma solution with data and analysis can find the 50% improvements that are sustainable

3. If as an organization you are willing to question your Beliefs, 68% to 100% improvements are possible

The purpose of the Analyze Phase is to conduct a data based search for the vital few root causes and to statistically validate them. Your role as a leader is to ensure that the team does not prematurely jump to solutions and that they use data and analysis to discover the most significant causes.

Mark Testa 9/30/09

39

Question your beliefs


Beliefs

Behaviors

Performance

Does your data support your organizational beliefs ? Can these beliefs be validated statistically ?

Prepare the Launch Pad:

40

Be a Player Not an Observer

What’s Required to Get the Team in the Game

1. Know the Rules of the Game 2. Know your Position/Role on the team 3. Know the Score at all times 4. Know what the Goal is 5. Know the time remaining on the clock

Anecdotal Evidence Active Management Opinions Knowing

Discharge FIM® Over/Under Targeted Performance Levels St. Anthony’s Rehabilitation Hospital: Full Year 2009 Starting Data Set

0%

3%

10%

25%

30%

24%

5%

2%

0% 0

-30 -20 -10 0 10 20 30 40 50

100.0%

99.5%

97.5%

90.0%

75.0%

50.0%

25.0%

10.0%

2.5%

0.5%

0.0%

maximum

quartile

median

quartile

minimum

54.41

37.8582

28.474

17.722

11.41

3.89

-4.48

-12.866

-22.014

-27.155

-30.41

Quantiles

Mean

Std Dev

Std Err Mean

Upper 95% Mean

Lower 95% Mean

N

3

1

0

4

2

4

Moments

Full Year 2009

38%

Histograms are the “go to tool” for visualizing your data and identifying opportunities

Distribution straddles the Pass/Fail line with 55% of patients teetering on the edge.

Normalized Across all CMGs

Variance Based


Display Data to Invoke Right Action

All discharge FIM® scores are organized into “buckets” 10 FIM® points wide

42

Improve Phase CHS Playbook M C I A D

Improve Phase

Six Sigma Wisdom

1. Teams have a tendency to adopt pet ideas especially under the influence of strong sponsors. Solutions looking for a Problem often arise at this stage.

The purpose of the Improve Phase is to demonstrate, with fact and data, that the proposed solutions solve the problem. Final decisions must be data driven

Mark Testa 9/30/09

Awareness and Access to Performance Feedback

UDSMR®

Model

PEM Metric

Establish Variance

Data Rich Patient Care Environment

Methodology

Targeted

Performance

Levels

Based

Metrics

Interdisciplinary

Structure

Awareness and Access to

Performance Feedback

Install

Strengthen

Team

… Teams don’t get better by just trying harder. Leaders need to create a learning environment

Control Chart Top Line Metrics

Variance Based

St. Anthony’s FIM® Change % Defective St. Anthony’s Length of Stay Efficiency

St. Anthony’s Discharge % Defective

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60

Prop

ortio

n fo

r % D

efec

tive

with

out E

T to

Acu

te

C

B

A

C

B

A

02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02

Month/Yr

μ0=0.3557

LCL=0.2121

UCL=0.4993

P of % Defective without ET to Acute

Feb 2008 – Feb 2010

44.4% Feb.

35.6%

18.6% Goal

Process was out of statistical control

Should expect 68% of the plot points in Zone C

FIM® Tracking Sheet

Know the Score at All Times

Tracking sheet is updated each time a patient record is closed and provides daily feedback on month-to-date performance

18.6% Defective

0

0

Perf. Target A B C D E F G H I J K L M N O P Q R S T U V

UDSMR® Patient Profile

Know the Score at All Times

Utilized as a communication and marketing tool with physicians

Goal TRAC A Spreadsheet on Steroids

Know What the Goal Is Know the Score at All Times

Moving Beyond Clinical Silos

Manage Entitlements Establish Accountability

Set Priorities

48

Interdisciplinary Team Advocate Role

• Enhance accuracy of clinician’s “FIM® meters”

• Ensure the integrity of data, metrics and clinician accountability

• Provide continuity/communication between all disciplines

• Facilitate a Team Consensus Process among clinicians; seeking to establish a holistic, shared perception of a patient’s outcomes

• Provide this Consensus information to the PPS Coordinator for consideration

Know Your Position/Role On the Team

Core Interdisciplinary Team Consensus Process

Interdisciplinary Team Advocate Seeks Consensus 24 Hour Period Prior to Discharge

SLP OT

PT NSG

DR CM

PT

OT SLP

NSG

Core Team

Interdisciplinary Team

Team Advocate

PPS Coordinator: A Quality Resource: confirms that the Clinician notes in the medical record support the consensus scoring … if not, the medical record takes precedence.

Interdisciplinary Team

Note: consensus form is a communications tool and does not become part of Medical Record

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

PEM Annual Report

(with ranking) Annually

Quarterly

Monthly

Weekly

Feb Mar Apr May Jun Aug Sep Jul Oct Nov Dec

Month-to-Date FIM® Tracking Sheet

PEM Qtrly Rpt

PEM Qtrly Rpt

PEM Qtrly Rpt

PEM Qtrly Rpt

Analytics at the Point of Care Relevant, Timely and Accurate Feedback

Daily

Collapsing time required to access performance data

First 3 Days Last 24 Hrs.

Today, at point of care, the clinician knows and manages goal performance in real time

51

Today’s Team is Fully Suited and On the Field

1. Know the Rules of the Game 2. Know your Position/Role on the team 3. Know the Score at all times 4. Know what the Goal is 5. Know the time remaining on the clock

Before Now 2.2 9.7 2.8 2.0 2.8 4.0

9.7 9.0 9.7 8.5

Score 0 to 10 with 10 being fully aware

Survey taken of Ruby Team members 7/1/10

Anecdotal Evidence Opinions

Active Management Knowing

This Not This

Now for the Results …..

St. Anthony’s FIM® Change % Defective

Test 1: One point beyond Zone A Test 2: Nine points in a row in a single (upper or lower) side of Zone C or beyond Test 3: Six points in a row steadily increasing or decreasing (whole chart) Test 4: Two out of three points in a row in Zone A or beyond (upper or lower) Test 5: Four out of five points in Zone B or beyond (upper or lower)

Western Electric Rules for Significance Testing

Project targets a 48% reduction in FIM® Change defects to 18.6%

A new statistically significant process mean of 12.4% was established by the Ruby Team in June; far exceeding the chartered percent defective goal of 18.6% . This represents a 69% reduction in defects as reflected in the new process mean

69% Improvement

-10

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C

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C

B

A

1 2

09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12

Month/Year

Goal 18.6%

Sep 2008 – Dec 2010

40.4%

12.4%

New Process Remains Stable for 9 Consecutive Months

0%

3%

10%

25%

30%

24%

5%

2%

0% 0

-30 -20 -10 0 10 20 30 40 50

100.0%

99.5%

97.5%

90.0%

75.0%

50.0%

25.0%

10.0%

2.5%

0.5%

0.0%

maximum

quartile

median

quartile

minimum

54.41

37.8582

28.474

17.722

11.41

3.89

-4.48

-12.866

-22.014

-27.155

-30.41

Quantiles

Mean

Std Dev

Std Err Mean

Upper 95% Mean

Lower 95% Mean

N

3.2354023

12.477931

0.598271

4.4112711

2.0595335

435

Moments

FIM Chg Over/Under

2009 Full Year

3%

1%

6%

14%

24%

30%

17%

4%

-30 -20 -10 0 10 20 30 40 50

100.0%

99.5%

97.5%

90.0%

75.0%

50.0%

25.0%

10.0%

2.5%

0.5%

0.0%

maximum

quartile

median

quartile

minimum

49.31

49.31

43.695

35.52

27.41

20.11

10.29

-0.41

-21.64

-26.95

-26.95

Quantiles

Mean

Std Dev

Std Err Mean

Upper 95% Mean

Lower 95% Mean

N

18.194646

14.613828

1.468745

21.109323

15.27997

99

Moments

FIM Chg Over/Under

Qtr. 2 2010

10%

Shifted the mean: +15 FIM® pts

38%

Average Patient is now achieving outcomes 18 FIM® points above Targeted Performance Levels

3 FIM® points : too close for comfort in a Categorical based PEM metric world

FIM® Change Over/Under Targeted Performance Levels St. Anthony’s Rehabilitation Hospital: Full Year 2009 v.s. Qtr. 2 2010

Average Patient outcome was only 3 FIM® points above Targeted Performance Levels

55

FIM® Change


LOS Efficiency

Benefits

Ancillary Benefits

St. Anthony’s Discharge FIM® % Defective



49% Improvement

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porti

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Trend Discharge Month

39.6%

20.0%

Sep 2008 – Dec 2010

St. Anthony’s Length of Stay Efficiency Sept 2008 through Dec 2010

Length of Stay Efficiency = FIM® Change / Length of Stay FIM® pts per day

64% Improvement

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Mea

n(LO

S Ef

ficien

cy)

C

B

A

C

B

AC

B

A

C

B

A

C

B

A

C

B

A

1 2 3

20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

Discharge Year/Month

FIM® velocity

3.23

3.60

2.19

An additional 1.4 FIM® points per day

3547 Patient Records Profiled / 750 Stroke Patients Identified

CHS Rehabilitation Impairment Group Distribution Stroke Patients Account for 21% of the CHS Case Load

0

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cent

N=3547

1 7 3 6 20 8 14 5 2 15 9 10 16 17 4 13 12 18 19 21 11

RIC

0

20

40

60

80

100

Cum

Per

cent

Plots

1 Stroke 7 Fractured Lower Extremity 3 Non-Traumatic Brain 6 Neurologic Conditions 20 Miscellaneous 8 Replacement of Lower Extremity 14 Cardiac

Top 7 RICs = 80% of the CHS Case Load

21%

Catholic Health Services Internal Use Only M. Testa 05/04/11

80% Cumulative Percent

Top 7 RICs

Pareto of RICs

Stroke Case Mix Group (CMG) Distribution Stroke Case Mix Heavily Weighted Toward Highest Impairment


%

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Perc

ent

0110 0108 0109 0107 0106 0105 0104 0102

CMG wo/Tier

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100

Cum

Per

cent

Plots

68.0%

14.0%

8.5% 4.4%

2.0% 1.7% 1.0% .4%

Highest Impairment Lowest Impairment

Pareto of Stroke CMGs

82% Cumulative Percent

Individual Case Level Indicators

1.01 .8

1.8

2.8

2010

LOS Efficiency

1.45

1.89 National Norm 1.3

2.3

Community 58%

Sub Acute

21%

Acute 21%

Discharge Setting

Tier D 26%

Tier A 66%

Comorbidity Tiering

Expected Rehabilitation Length of Stay 24.2 days

Actual Rehabilitation Length of Stay 16.0 days

Stroke Patient Profile: St. Anthony’s Rehabilitation Hospital 101 Stroke Patient Records: Year 2010: Includes Re-Admits to Acute

Comorbidity

High

Low

Level

Tier B 8%

Tier C 4% Note: National norms are calculated for Joint Commission by UDSMR and are case mix CMG adjusted:

National Average

Upper 95% Confidence Limit

Lower 95% Confidence Limit

22.0

15

20

25

30

35

2010

FIM® Change

26.1

31.1

National Norm

National

61.5

2010


66.7

71.8

Norm

55

60

65

70

75


M481 only

National Norm 55%

National Norm 15%

National Norm 30%

61

Control Phase CHS Playbook M C I A D

Control Phase

Six Sigma Wisdom

The purpose of the Control Phase is to institutionalize the process improvements and monitor ongoing performance.

1. If the Process Owner (Champion) was not part of the project team, there is a high probability that the process changes will meet with resistance at the point of implementation.

Mark Testa

62

Final Project Report and Presentation: Mandatory

In preparing the report, the team reaches consensus on exactly what process changes led to their ultimate success and documents these changes for posterity

If things go awry in the future, the Final Report is a valuable reference tool for quickly regaining control


-10

0.0

10

20

30

40

50

60

70P

ropo

rtion

for %

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ectiv

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with

out E

T to

Acu

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C

B

A

C

B

A

C

B

A

C

B

A

1 2

09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12

Month/Year

Once the process changes became fully institutionalized the process remained in statistical control at the new process mean of 12.4% for 21 consecutive months

40.4%

12.4%

Sep 2008 – Dec 2011

69% Reduction in defects

21 consecutive months

21 Months Into the Control Phase and Still Firing on All Cylinders

Variation in patient outcomes had been dramatically reduced

Control Phase


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10

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30

40

50

60

70Pr

opor

tion

for %

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C

B

A

C

B

A

C

B

A

C

B

A

1 2

09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03

Month/Year

Sep 2008 – Mar 2012

Preparing for the Inevitable


40.4%

12.4%


But then the Inevitable happened ….

Over time and with changes in team membership, defect levels began to rise as process rigor waned. Teams forgot what contributed to their success and old habits returned.

This is not at all unusual and should be expected

What was unusual, is how long it took before it occurred


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10

20

30

40

50

60

70Pr

opor

tion

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Def

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te

C

B

A

C

B

A

C

B

A

C

B

A

1 2

09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05

Month/Year

Sep 2008 – May 2012

12.4%

40.4%



Additionally it was unusual how quickly the situation was remediated

With the Final Project Book in hand, the team quickly identified which of their documented success factors had been abandoned

Preparing for the Inevitable

This is why the Final Project Report is a key Best Practice

Externally Reported Externally Reported FIM® Change

Note: National norms are calculated for Joint Commission by UDSMR and are case mix CMG adjusted:

National Average Upper 99% Confidence Limit


St. Anthony’s

New Process

New Process

Externally Reported Externally Reported Discharge FIM® Rating




St. Anthony’s

New Process

New Process

Externally Reported Externally Reported Length of Stay Efficiency




St. Anthony’s

New Process

New Process

69

UDSMR® Published Metric: External Gold Standard

Year End 2011 Project Report Card

Facility Sub-score

(% of Target)

rd

National Ranked at 93rd Percentile Up from 25th Percentile

St. Anthony’s Rehabilitation Hospital

St. Catherine’s East FIM® Change % Defective The Solution Was Robust and Transferable



Metric Chartered

64% Improvement

Process proves transferable, yielding a new process mean identical to that achieved by the Ruby Team

0.0

10

20

30

40

50

60

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port

ion

for

% D

efec

tive

C

B

A

C

B

A

C

B

A

C

B

A

C

B

A C

B

A

2 3 4

07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06

Trend Discharge Month

Jul 2009 – Jun 2011

34.2%

19.7%

12.3% 12.4% Goal

Internal National Benchmark 10.7% Jun

71

Adopted a Goal Centered Approach to Patient Care

Crafted and Installed Bullet Proof Metrics

Nurtured Interdisciplinary Concept into a Fully Functional Team Environment

Review The Key Ingredients For Success

Provided Real Time Performance Feedback

Introduced Variance Based Tools

Employed Analytics to Test Organizational Beliefs

Established a Data Rich Work Environment

Introduced a Structured Problem Solving Methodology: DMAIC

A Six Sigma Foundation Is Now In Place

…. and we are excited about leveraging our new found competency in Analytics

THANK YOU

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