Adrienne Elberfeld Six Sigma Master Black Belt Virtua Health Marlton, NJ Six Sigma... Getting Real about Results in Healthcare
Four hospital system in Southern New Jersey
Two Long Term Care Facilities
Two Home Health Agencies
Two Free Standing Surgical Centers
Ambulatory Care - Camden
7000 employees + 1700 physicians
$600 million in revenues
Dramatically improve patient satisfaction scores.
Advance Virtua’s POE development.
Continue implementation of medical staff development plan.
Continue to improve and sustain global clinical quality and patient safety metrics.
Continue rigor in cost expense management, revenue enhancement and reduced length of stay.
Recognize and continuously develop best people and monitor employee satisfaction.
Begin facilities planning and development of ambulatory sites and regional medical centers.
Virtua Imperatives 2005
The “STAR”… PERFORMANCE EXCELLENCE Clinical Quality & Safety Caring Culture Best People Excellent Service Resource Stewardship Outstanding Patient Experience Achieve Vision and Receive Recognition MISSION AND VALUES STRATEGIC INITIATIVES
The STAR Initiative
An organization wide cultural transformation initiative that will assure that Virtua fulfills its covenant with the community, achieves its vision, and is highly successful over the long-term.
1) Focus the work on creating an outstanding experience for patients
2) Become a high performing organization
3) Be recognized for our excellence
We Know Where We Want to Go, How Are We Going to Get There?
Current State: STAR Commitment Desired State: STAR Performance It’s Great to Have a Philosophy . . . But We Need a Strategy !! Six Sigma is our strategy on our journey through the maze
The Tool Chest
Paths to Change
Operational issue Requiring a Decision
“ Wisdom of the Group” Problem
Change Acceleration WorkOut Six Sigma
VIRTUA’S QUALITY JOURNEY WJ: Quality Circles: early - late 1980s MH: Morbidity and Mortality Reviews, Quality Audits WJ : Quality Assurance: mid 1980’s MH: Quality Assurance: mid 1970’s to mid 1980’s WJ: Quality Assessment: late 1980’s MH: Quality Assessment mid to late 80’s (Leadership explores Total Quality Management Concepts with VHA 1988 - 1990) WJ: Total Quality Management: early 1990s MH: Total Quality Management 1990 - 1995 WJ: Re-engineering / Patient Centered Care: mid 1990’s MH: Metric Focused Quality Improvement (AQP) / Patient Focused Care: mid 1990’s Virtua Health : Quality Management, Six Sigma, Workout: 2000 and beyond April 2001
What is Six Sigma?…
Methodology for achieving goals and objectives
Quantitative technique for problem solving
Comprehensive improvement process
Tools For Driving Sustainable Change
Solid tools but….
No standard metrics
Focus on product quality
Real results that matter to customers….
Clear, consistent metrics
Focus on customer
Six Sigma builds on Lessons Learned from prior approaches TQM Six Sigma What Makes Six Sigma Different? Adapted with permission from Hamadi Said, US Mint Philadelphia, PA
The Nature of Variation . . . So how does this principle translate into the real world? Mean is Centered ( it is On Target), but there is Large Variation (Big Sigma!) Accurate but not Precise Mean is not Centered ( it is Off Target); the Variation is Small Precise but not Accurate
Why Six Sigma as a Tool?… A Health System The Size of Virtua Fills ~400,000 New In-Patient Medication Orders Per Year… Six Sigma Can Make a Difference in Healthcare Error Rates at 2 to 6 2 123,415 69.1% 3 26,723 93.3% 4 2,484 99.4% 5 93 99.98% 6 1.4 99.99966% Script Errors / Yr % Correct … Six Sigma Means 1-2 Incorrect Orders Per Year
Overall Approach Practical Problem Statistical Problem Statistical Solution Practical Solution What is Six Sigma?
DMAIC: To improve any existing product or process Six Sigma Methodologies Who are the customers and what are their priorities? How is the process performing and how is it measured? What are the most important causes of the defects? How do we remove the causes of the defects? How can we maintain the improvements? What is Six Sigma? Define Measure Analyze Improve Control
What measurements will the process owner use to confirm sustained improvements? What system and structure changes support sustained gains? Define Project Scoping Operations Plan Strategic Plan Control Improve Analyze Measure What is the right operational area for a project? What is the right process result to address? What does the customer expect? How is the current process performing? What are the most important factors driving the process results? What changes will deliver the desired process result? How well did the changes improve the process? Project Conclusion The DMAIC Process
Define DEFINE PHASE: Focus on the Y Y = f (x) Project Funnel “ How do my customers look at me?”
Measure Define Phase: Focus on the Y Y = f (x) Measure Phase: Focus on the Y Project Funnel “ What do I want to improve?” “ What’s the best way to measure?” “ Can I trust the output data?”
Analyze X 1 X 2 X 3 X 4 X 5 X 6 X 7 X 8 X 9 X 10 X 11 X 12 X 13 X 14 Define Phase: Focus on the Y X 1 X 2 X 3 X 4 X 5 X 6 X 7 X 8 X 9 X 10 X 11 X 12 X 13 X 14 Y = f Measure Phase: Focus on the Y Analyze Phase: List & prioritize X’s “ How good am I today?” “ How good do I need to be?” “ What factors make a difference?”
Analyze Define Phase: Focus on the Y Measure Phase: Focus on the Y Analyze Phase: Identify vital X’s Y = f + X 1 X 2 X 3 X 4 X 5 X 6 X 7 X 8 X 9 X 10 X 11 X 12 X 13 X 14 X 2 X 7 “ How good am I today?” “ How good do I need to be?” “ What factors make a difference?”
Improve Define Phase: Focus on the Y Measure Phase: Focus on the Y Analyze Phase: Identify vital X’s Improve Phase: Focus on vital X’s + X 2 X 7 X 2 + X 7 Y = f “ What’s at the root of the problem?” “ How can I predict the output?”
Control Y X 7 Define Phase: Focus on the Y Measure Phase: Focus on the Y Improve Phase: Focus on vital X’s Control Phase: Sustain improvements Analyze Phase: Identify vital X’s “ Have I reached my goal?” “ How can I sustain the improvement?”
DMAIC Training & Project Management Plan Define Project Measure TRAINING REVIEWS R0 The Fundamentals Define & CAP Application R1 Application Analyze Improve R2 Application R3 Application Control & CAP R4 4 weeks 4 weeks 6 weeks 6 weeks 6 weeks
Master Black Belt role
Driven by the “R” document cycle
Formal Project Management software - (November 2004 implementation of e-project)
“Good Enough for Now” software
The Work-Out TM Process - An Enabling Technology
A 1-2 day session that involves employees to fix the problem
Concentrated, empowered decision making
Leadership responds with immediate decision or alternative direction
Follow up ensures completion of action plans
Work-Out TM Is… Key Outcomes Tool That Drives Decisions and Actions for Employees
Process to drive improvement
Opportunity to engage and empower people
What’s a Work-Out?
Addresses an important process
Facilitated by a STAR coach (130 trained)
Gives immediate feedback to staff
Create a new process for Root Cause Analysis
Create a process to deliver patient satisfaction data to leaders and managers
Fix night call schedule for residents
Fix transport process for LTC patients
Total: 161 so far
The Change Acceleration Process Leading Change Changing Systems and Structures Current State Transition State Improved State Creating A Shared Need Shaping A Vision Mobilizing Commitment Making Change Last Monitoring Progress Simple, Yet Powerful Model to Assure that Change Happens
Summary: Six Sigma Methodologies Six Sigma Change Acceleration Process Effective Results Work-Out ™ Q x A = E The Effectiveness (E) of the result is equal to the Quality (Q) of the solution times the Acceptance (A) of the idea. A Proven Formula For Results
How they work together: Change Acceleration Process Change Acceleration Process Change Acceleration Process Change Acceleration Process Change Acceleration Process Six Sigma project Decisions Implementation Implementation Development WorkOut Detailed Analysis Six Sigma project
What’s Different About Six Sigma?
Quantitative: Where is the bang for your buck?
Accelerates and sustains change
Applicable to all parts of the system
Reduce defects----Increase dollars
More Than Just Another Flavor of the Month
Six Sigma Personnel
Master Black Belt : Full time; advanced training in Six Sigma; leads initiative, consults, teaches, and leads projects.
Black Belt : Full time; trained in Six Sigma; leads projects and assists green belts.
Six Sigma Analyst : Full time; trained in Six Sigma and reports directly to campus COO
Green Belt : Part time; trained in Six Sigma; undertakes one project every nine months.
STAR Coach : Part time; trained in CAP and Work-Out; leads two projects a year.
Accepted Nomenclature Adapted to Virtua
Virtua Health: The Initial Investment
Commitment of leadership: CEO and Board
Training from GE
Six full time blackbelts
60 STAR coaches
Resources for internal communications
Need for tools to improve performance and to initiate and sustain change
Proven track record at GE
Tell you what you need to hear, not what you want to hear
Clear commitment to our success and independence
Six Sigma: Why partner with GE? The Right Company and Capabilities
What Makes a Good Target for a Six Sigma Project?
Addresses an important business objective
Process Map and Measurable Output
Foundation team (key staff) is the driver of the project
Black Belt leads the team as a consultant
Average time to completion ~6 months
Large and Complex Undertaking
Driving the Project ….. Black Belt and Project Team Process Owner and Project Team Define Measure Analyze Improve Control
Evolution of Six Sigma at Virtua Commitment and Flexibility
Cardiac Meds: A PRO/CMS Quality Indicators Project What the Cardiac Meds Team Did … Why They Did It … Project started in 7/02. All PRO indicators were achieved for Q4 ‘02. Project closed out in July ’03; continued success sustained!
Gaged current data collection system
Project requested by physician leadership
Documentation was more of a problem than the actual delivery of care
Major progress in achieving physician support for process improvement (including physicians firmly addressing physician outliers!)
Improve quality and consistency of data
Created a cardiac discharge instruction sheet
“ Contained” defects immediately while implementing more sustainable systems and structures to support improvements
To obtain immediate results to achieve aggressive system targets
Increase compliance from docs and support accurate data collection
Project Results … >90% CHF ACE at DC Results Indicator >95% AMI Beta Blocker at DC >95% AMI Beta Blocker < 24 hrs >95% AMI ASA at Discharge >95% AMA ASA < 24 hrs
Home Care HHRG Case Weight Mix and Coding
What the Team Did …
Why They Did It … Total Project Benefit Estimate $1,200,000 Medicare Length of Stay
Established standards in completion of initial OASIS form
Enhanced Care Manager role in team
Implementation of standard operating procedures for both agencies, two bargaining units through use of WorkOuts
Weekly review of lock days for concurrent review by manager
Substantial ROI to purchase new computerized system
On-going sustainable changes in place during training and implementation of new system
Increase in initial HHRG case weight mix & broader knowledge base of MO questions
Overall Case Weight Mix Average = 1.34 Agency OASIS Lock Within 7 Days = 92% Percentage of Agency LUPA’s = 15%
Decreased percentage of LUPA’s to 15%
Surpassed the Medicare threshold for OASIS lock within 7 days
Decrease in adjustments (refunds) to government
Decrease in technical denials and increase in cash flow
Project Results …
Advantages to Virtua Health
Results measured in dollars, quality and service
Breaks down silos
Physicians like it
Faster decisions and implementation
A method to accelerate and sustain change
Creates clarity and objective measures of success
All in all, a Great Return on Investment
Six Sigma should be undertaken with a clear vision of where you want to be
Introduce Six Sigma as a tool, not a philosophy
CEO must own it
Make Six Sigma a system wide effort….Focus on $$$, productivity and patient issues
Measure, measure measure…Deal with information issues
Hold people accountable for using Six Sigma to achieve outcomes that are important to the organization
Invest in resources and make a long term commitment
Change the systems and structures to support the effort
Key Success Factors It Has to Become the Way You Do Your Work
Clear objectives, measurable outcomes and ‘doable’ projects are a must----scope the projects
It is about the process
There is plenty of ‘fat’ in healthcare
Hold people accountable to use the tools to get results----Resistance to change and accountability is high and in high places
Teach management how to use the tools
Hit the areas that are ready and fertile--Finance!
Over communicate by a factor of 1000
Lessons Learned Q X A = E!
Be flexible and patient
Deal with the problem of bad data
Sponsor Education is critical-teach them how to ask good questions-implementation of Yellow Belt training
It is all about the customer
It is a process that shines the light, there is nowhere to hide
Can help identify future leaders
Massive staff empowerment
This is constantly evolving…there is always something to improve
Six Sigma: Leadership Development
Time limited position
Developing business rigor and results orientation
“Infecting” the organization with excellence and competence
Leadership Development some success stories
Director Patient Billing Services Black Belt AVP Home Care VP Operations
Director Quality Master Black Belt VP Quality
Nurse Manager Med Surg Black Belt Quality Director Home Care Home Care Director of Nursing
HR IS Black Belt Cardiology Product Line at Marlton
Nurse Manager Emergency Department Master Black Belt Virtua Enterprise Manager
AVP Community Services Black Belt VP Nursing Services
AVP Operations Black Belt Director of Finance
Should You Use Six Sigma?
At least 3 years
Skills of the managers
Are You Willing to Destroy the Good to Get Better?