USING SIX SIGMA FOR PROCESS IMPROVEMENT IN HEALTHCARE Is 99% Good Enough?
Three hospital campuses Six Sigma In Healthcare 380 acute care beds 110 long-term care Bowling Green Scottsville Franklin
Full range acute & tertiary
Open Heart Surgery
Neonatal Intensive Care
Emergency Medical Services
Primary Care Walk-in Clinics
OP Rehab Center
Long Term Acute Care Hospital
Health and Wellness Center
Six Sigma In Healthcare Introduction In late 1997, President and Chief Executive Officer of Commonwealth Health Corporation, (CHC), attended a conference and listened with interest as General Electric’s CEO spoke of his vision for GE as a World Class Six Sigma company. This innovative approach to quality and error reduction was at this point already receiving high marks for its transformational abilities at all levels of corporate enterprise. Later conversations between the two leaders revealed a shared passion for excellence and commitment to quality. This initial encounter soon led CHC to embrace this vision of quality at Commonwealth Health Corporation.
Six Sigma In Healthcare What is Six Sigma? Measure of Quality: Expresses how close a process or service comes to meeting its customers’ expectation. Method for Continuous Improvement: Uses a rigid framework to approach process improvement. Mindset for Culture Change: When successful, Six Sigma fundamentally changes the culture and operating philosophy of the company. It becomes “the way to do our job”.
Six Sigma In Healthcare Z or Sigma Level Sigma Level Defect Rate Defects per Million 2 30.8% 308,537 3 6.7% 66,807 4 0.62% 6,210 5 0.0233% 233 6 0.00034% 3.4 By using the Sigma level to express how good a process is, we are able to compare dissimilar processes. Example: Radiology report turnaround time is at 2 sigma while an ambulance’s arrival on the scene is 4.3 sigma.
Is 99% Good Enough? Six Sigma In Healthcare 99% Good (3.8 Sigma) 99.99966% Good (6 Sigma) 200,000 wrong drug 68 wrong prescriptions prescriptions each year each year 5,000 incorrect surgical 1.7 incorrect surgical operations each week operations each week 50 newborn babies dropped One newborn baby dropped at birth each day every 2 months
Six Sigma In Healthcare What Makes Six Sigma Different?
Methodology is robust
Process is measured using the customer’s specification rather than
Functional Structure Six Sigma In Healthcare PRESIDENT AND CEO Hospital CEO & Sponsor EVP & Sponsor EVP & Sponsor Press Ganey Score & Target Timeliness Z Score & Target Cost Efficiency & Target Master Black Belts Brown Belts Champions & Sponsors Green Belts Change Agents
Project Profile: Radiology Staffing Efficiency Six Sigma In Healthcare Baseline: .3 Sigma DPMM = 382,000 Critical X: Staff Schedule Controlled Process: 1.15 Sigma DPMM = 125,000 Operational Problem: Labor Costs Too High in Radiology Defect: Occurs any Time Staffing Exceeds Labor Resources Required For Exam Volume
Staff Used CAP &
Work-out ™ to
14 Positions Eliminated
1 st Yr. Savings $860,000
Six Sigma In Healthcare Financial Returns Radiology Cost Per Procedure
Senior Management’s Involvement Six Sigma In Healthcare
Define Problem Statement As employers continue to pass more of the cost to their employees through larger deductibles, higher co-pays, lower percentage of reimbursement, etc., reducing the loss that results from the patient’s portion not being paid becomes increasingly important. Measuring the length of time involved from point of service until payment is received on the self-pay portion of the patients bill on commercial accounts.
Measure Scope of Problem Defect : any length of time greater than 104 days Z ST = 1.36 DPPM = 556,922
Analyze Root of Problem Emergency Room charges account for 40% of the defects.
Analyze Root of Problem Mood Median Test: stacked versus subs Mood median test for stacked Chi-Square = 10135.57 DF = 4 P = 0.000 Individual 95.0% CIs subs N<= N> Median Q3-Q1 ---------+---------+---------+------- Amt. of 4531 590 1.0 1.0 + Coded Bi 3221 1900 3.0 2.0 + coded lo 74 5020 20.0 7.0 +-) coded ty 1787 3334 7.0 4.0 + Primary 3970 1151 2.0 2.0 + ---------+---------+---------+------- 6.0 12.0 18.0 Overall median = 3.0 There is a statistical difference in the medians based on location (Emergency Department).
Improve Pilot POINT OF SERVICE COLLECTIONS INITIATIVE EMERGENCY DEPARTMENT Modified ED patient flow processes to ensure all eligible patients are routed through a formal “checkout” after being treated and discharged by clinicians. Developed job description for Financial Counselor position. Interviewed and hired a Financial Counselor. Developed training schedule, which started on March 21 st . Went through a very extensive training schedule including tutorials on collection techniques and role-playing. Training with CFM, Hillcrest Credit Agency, Patient Registration, and Six Sigma representatives. Hours for the position are Sunday through Thursday, 1:00pm through 9:00pm. Comprehensive education and dialogue took place prior to rolling out the new processes to secure buy-in and compliance from staff. Developed a new policy and procedure for post dated checks which allows us to collect money while ensuring the post dated checks are not deposited before the agreed date. This new policy allows for a check to be written with a payable/deposit date up to 5 days from the time of service.
Improve Pilot POINT OF SERVICE COLLECTIONS INITIATIVE EMERGENCY DEPARTMENT Developed a comprehensive reference manual for the Financial Counselor. Developed a patient education leaflet to distribute to all patients at time of registration. Murray Raines reviewed prior to implementation. Developed standardized cash collection procedures and forms. Developed necessary tools for ongoing performance analysis. These include sample scripting, payer matrix, key metrics to be completed daily, and monthly trend analysis. Will use the monthly trend analysis to benchmark progress against goals, highlight shortcomings and target interventions. Financial Counselor scripts have been developed specific for self-pay patients as well as insured patients with co-pays.
Improve Pilot POINT OF SERVICE COLLECTIONS INITIATIVE EMERGENCY DEPARTMENT The newly designed process includes the nurse bringing patients to the checkout desk after treatment. We are currently working with the nursing staff to increase compliance of routing patients to the financial counselor desk. Careful scripting has enhanced customer interactions. The first full week of implementation was April 3 rd and to date, we have had no official complaints.
Improve Results Totals Dollars collected during this time frame $1,613 $9,141 7 Weeks (35 days) Prior to Pilot 7 Weeks (35 days) During Pilot
Improve Results Chi-Square Test: GOOD, BAD Expected counts are printed below observed counts GOOD BAD Total 1 22 13 35 (Before Pilot) 28.00 7.00 2 34 1 35 (After Pilot) 28.00 7.00 Total 56 14 70 Chi-Sq = 1.286 + 5.143 + 1.286 + 5.143 = 12.857 DF = 1, P-Value = 0.000 P value of 0 indicates a statistical difference in the number of days that money was collected prior to and after the pilot. The same 7 week time period was used (35 days).
Improve Results Chi-Square Test: Re-Measure Pass, Re-Measure Fail Expected counts are printed below observed counts Re-Measu Re-Measu Total 1 37 3304 3341 (BEFORE PILOT) 122.69 3218.31 2 209 3149 3358 (AFTER PILOT) 123.31 3234.69 Total 246 6453 6699 Chi-Sq = 59.846 + 2.281 + 59.543 + 2.270 = 123.941 DF = 1, P-Value = 0.000 P value of 0 indicates a statistical difference in the number of patients that money was collected from prior to and after the pilot. The same 7 week time period was used (35 days).
Improve Results Identifying incorrect information given at time of registration and making corrections (re-scanning correct insurance card, etc.), reducing re-work and increasing turn around time on payment. Continuing to work on clinical compliance (24 hour mandate should show marked improvement). With relatively little investment, the analysis suggests potential increases in POS annual cash collections in the ED by approximately $203,712. During this 35 day time frame, promissory notes amounting to $11,716 have been signed at POS. No attempts made at POS previously. Deter future unnecessary visits to the Emergency Room.
Control Financial Results Finalized cost based on a 92.3% reduction in the rate of defects = $1,388,401
Control Sustaining Success Presented findings to stakeholders and corporate sponsors. Met with Director/Supervisor of ER registration and turned project over. Reviewed re-measure dates and procedures for collecting and monitoring. Developed procedure for collecting data and updating dashboards. Provided dashboards and training/instructions for updating and distribution. Leveraged learnings in Outpatient setting. Completed project binder.
Control Transfer the Learnings Based on the success of the Emergency Department project, we started a similar project in the Outpatient areas and are currently transferring those learnings to our Scottsville and Franklin hospitals for their Emergency Departments and Outpatient areas. Prior to the project, there was virtually no point of service collection. We now collect more that $10,000 in the ED most months at our Bowling Green location. In the Outpatient areas, we previously collected about $5,000 in a three-month period. After applying the same methodology, monthly collections for outpatients have increased to $50,000 each month. The Point of Service collection projects are in the pilot phase preparing for implementation. We anticipate equally good results in those locations.