Applying DMAIC principles to improve patient safety


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Applying DMAIC principles to improve patient safety

  1. 1. Applying DMAIC principles to improve patient safety Kristopher Goetz, MA Manager, Performance and Innovation
  2. 2. 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
  3. 3. Northwestern Memorial Hospital Chicago, 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 RatingFeinberg and Galter pavilions Prentice Women’s Hospital
  4. 4. Northwestern Memorial is Widely Recognized for Excellence “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 Most Wired” hospitals and healthcare systems. “100 Best Companies for Working Mothers” Named to Working Mother magazine’s list for 10 consecutive years.
  5. 5. 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
  6. 6. An approach to process improvement at a major academic medical center
  7. 7. Process Improvement at NMH GOALDeliver Measurable Results which Significantly Impact the Strategic Plan 7
  8. 8. 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
  9. 9. Process Improvement Program Overview Process Improvement Delivers Measurable Results• Established DMAIC-based Process • 1st Physicians and Nurses trained as Improvement program Improvement Leaders• Implemented infrastructure for project selection, • Enhanced project selection process to improve oversight and financial benefit reviews alignment with organizational priorities• Trained initial wave of 13 Improvement Leaders • Increased use of Rapid Improvement workshops • Launched a series of Improvement Portfolios to address complex system issues 2002 2003 2004 2005 2006 2007 2008 2009 • 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
  10. 10. Structures and processes employed at Northwestern Memorial Hospital
  11. 11. DMAIC Methodology DMAIC provides an easily governed systematic process to deliver measurable results Define Measure Analyze Improve ControlWho are the customers and What are the most How do we ensure that what is the problem from important drivers of poor we sustain the improved their perspective? performance? performance? How is the process How do we remove the performing today and how drivers of poor is it measured? performance? 11
  12. 12. 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 12
  13. 13. Process Improvement Training FY 09 Class FY 09Introduction to Process Improvement and DMAIC Schedule ParticipantsThis class provides individuals with a basic understanding of the DMAIC methodology, lean principles and 9.23.08change management. Participants will learn basic tools that will help them to lead and executeimprovements within their specific teams. 11.18.08 1.20.09 ~150(Time Commitment: 8 hours) 3.17.09 5.19.09 7.21.09Lean Principles and Tools for DMAICThis class gives individuals the opportunity to gain a deeper understanding of Lean principles and 10.28.08philosophy. The class will cover the key principles of Lean thinking and how to identify a Leanopportunity during a DMAIC project and how to translate Lean thinking into action (value stream 12.16.08 2.17.09 ~100mapping, push vs. pull model, eight wastes, 5S, set-up reduction, kanban). 4.21.09(Time Commitment: 8 hours) 6.16.09 8.18.09Excel for DMAICThis class will teach participants to efficiently understand and analyze data using Microsoft Excel within 10.21.08the context of the DMAIC process improvement methodology. Topics include manipulating raw data usingformulas and pivot tables, custom graphing strategies, and tactics to best tell the analytical story. 12.9.08 2.12.09 ~80Time Commitment: 4 Hours) 4.14.09 6.9.09 8.11.09DMAIC Improvement Leader TrainingThis class is designed for individuals assigned to lead a DMAIC improvement project and will provide an Trainingin-depth exposure to the tools and methods necessary to successfully lead and achieve results using theDMAIC methodology, lean thinking and change management techniques. Application of methods along conducted from Nov 08 18with hands-on exercises will help to ensure rapid learning, knowledge retention, and immediate to Apr 09.application. The expectation is for the student to lead future projects and serve as a local DMAICresource for their department.(Time Commitment: planned 14 sessions at 4-8hrs/session; a total of 64 hrs between Oct08 and Mar09) *Ad hoc training occurs as needed (i.e. surgical residents, NMH interns, patient accounting)
  14. 14. 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 timeSource: Agency for Healthcare Research and Quality (AHRQ)
  15. 15. 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?” Key Metric(s): “Here’s how you’ll know I’m on track” “Here’s how you’ll know I’m on track”“Here’s how I’ll know that we’ve have made an impact” Milestones: Milestones: Description Description Date (mo/yr) Date (mo/yr) “Yes, I can measure this “ #1 #1 #2 #2 “No, it does not require manual data pulls” #3 #3
  16. 16. Ownership and Accountability Role Definition is a Critical Success Factor Project Executive Sponsor Clinical Sponsor Project Sponsor Improvement Leader Process Owner Team MembersImprovement Leader Directs/Mentors Project … Process Owner Implements
  17. 17. Ownership and AccountabilityImprovement 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
  18. 18. Improvement Leader & ProcessEffort & Accountability Owner Effort and Accountability Improvement for Success of Project Leader Process Owner D M A I C
  19. 19. DMAIC Case Study: Reducing Pressure ulcer Prevalence
  20. 20. Project Charter Pressure Ulcer: Phase II Overview • 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 Key Metrics Milestones: Milestones: Outcomes Description Description Date (mo/yr) Date (mo/yr) • Nosocomial Pressure Ulcers prevalence #1 #1 Define Define Jan 2007 (phase 1) Jan 2007 (phase 1) • Nursing unit of origin #2 #2 Measure Measure Sep 2007 Sep 2007 • Nosocomial Pressure Ulcer Stage Process #3 #3 Analyze Analyze Nov 2007 Nov 2007 • Compliance and accuracy of skin assessment #4 #4 Improve Improve Dec 2007 Dec 2007 • Braden Scale Assessment upon admission and q24 hours #5 #5 Control Control Jun2008 Jun2008Executive Sponsor: Michelle Janney Sponsors: Carol Payson Clinical Sponsors: Dr. Chithra Perumalswami, Dr. Cory RitterProcess Owners: Julie Garrett Improvement Leader: Kris Goetz
  21. 21. Pressure Ulcer: Phase II – Define NMH Continued Focus • 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”D M A I C
  22. 22. Pressure Ulcer: Phase II – Measure High Level Process Map ADMISSION ASSESSMENT (Multidisciplinary Coordination) Comprehensive skin assessment upon Pressure Ulcer Risk Identifying high risk Nosocomial admission Assessment groups Pressure Ulcer treatment Communication Documentation INTERVENTION ACTIONS: Prevention & Treatment CRITICAL THINKING (Multidisciplinary Team) INDIVIDUALIZED PREVENTION OR TREATMENT PLAN IMPLEMENTATION OF INDIVIDUALIZED PLAN (Multidisciplinary Team)D M A I C
  23. 23. Pressure Ulcer: Phase II – Analyze Rapid Design Workshops…. • Conducted three “deep dive” sessions 1. Skin Assessment 2. Pressure ulcer risk assessment 3. Pressure ulcer treatment • Participation by front line nurses, APNs, managers, and directors …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 performanceD M A I C
  24. 24. Pressure Ulcer: Improvement Initiatives Key Drivers of Variance Implemented Improvements • Development of new “always practice” • Current skin/pressure ulcer documentation forms − Combining/simplifying documentation don’t flow with daily practice − Assessment q shift • Educational training for every nurse at NMH • “I don’t know what to do” • Skin expert nurse/PCT program • Skin resource binder at every nursing station • Skin care pocket cards • Nurse documentation on pressure ulcers to populate • Lack of MD, RN, PCT communication MD note • Multidisciplinary rounding on skin • Interventions are too general - not applicable to • Identify and direct specific preventive treatments all patients based on specific areas of risk • Inpatient units are the only areas performing skin • Skin assessment in ED, ASU, and SDS assessments • More frequent feedback on performance • Skin assessment productivity boards in each report room enabling daily trackingD M A I C
  25. 25. Pressure Ulcer: Prevalence and Compliance 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. Nosocomial Pressure Ulcer Prevalence Braden Assessment Compliance (Lower is better) 50% Goal= 95% 45% 100% 40% New “always practice” 4/22 100%Prevalence 90% Compliance 35% 80% 30% 70% 25% 60% 50% 20% 40% 15% 30% 10% 20% 5. 3% NMH 10% 5% 487 pts. 0% 0% y) .) 20 3 20 Y20 Q1 20 Q3 Q2 20 Q4 20 Q1 FY Q2 20 1 20 Q2 20 Q4 09 Q ar FY (Ma FY 07Q FY 7 Q 20 y.) (M .) 20 08 (M FY 07 FY 07 20 Y2 Q1 08 3 (M 2 20 Q4 20 Q1 20 Q2 3 20 1 20 2 20 3 20 Q4 FY F 08 FY 8 08 FY 08 FY 09 09 ar FY 07Q FY 07Q FY 07Q Q Q Q 0 a 20 3 20 FY 07 FY F 08 FY 08 08 FY 08 FY 09 FY 09 09 FY 20 0 3 0 Q FY FY 20 NMH <= 24 hrs. BPE Goal (95% ) NMH Score BPE goal Definition: Percent patients with nosocomial Definition: Percent patients with Braden Scale risk pressure ulcer on day of prevalence study. assessment within 24 hours on day of study. D M A I C
  26. 26. Pressure Ulcer: Phase II – Results DMAIC team interventions have significantly reduced stage 3, 4 and 5 pressure ulcersD M A I C
  27. 27. Pressure Ulcer: Phase II – Control DMAIC 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?”
  28. 28. Additional examples demonstrating the benefit of DMAIC
  29. 29. Preventable Codes Outside ICU Per 1,000 Patient DaysSince the implementation of the Rapid Response team (RRT) in January 2006, there have been ~ 21,500 patient evaluationsperformed by the RRT, an average of 450-500 per month. Intervention (change in clinical management) is needed approximately40% of the time, and transfer to the ICU 12-15%. The impact is an overall 71% decrease in the rate of preventable codes outside theICU, amounting to ~ 110 codes avoided/prevented per year. Preventable Codes Per Patient Days (Lower is better)• Clinical judgment – Staff nurses are trained to 1.2 recognize the signs of decomposition and to 1 activate the RRT• Proactive rounding – RRT nurses round on all 0.8 ICU transfers within 24 hours of transfer 0.6• Electronic surveillance - Electronic vital sign data is used to supplement clinician judgment, 0.4 reduce the subjectivity of activating the RRT team and to earlier identify patients at risk 0.2 0 FY Q3 FY 4 FY 1 FY Q2 FY 3 FY 4 FY Q1 FY 2 FY 3 FY Q4 FY 1 FY 2 FY Q3 4 Q Q Q Q Q Q Q Q Q 06 06 07 07 07 07 08 08 08 08 09 09 09 09 FY Preventable Codes/Pt Days Linear (Preventable Codes/Pt Days ) 29
  30. 30. AMI - Percutaneous Coronary Intervention within 90 minutes of arrival 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. Compliance with PCI within 90 Minutes Median Time to PCI (Lower is Better)100% 15090% 14080% 130 12070% 110 Time in Minutes60% 100 9050% 80 Time requirement changed 7040% from 120 to 90 minutes 6030% 50 4020% 30 National Best Decile: 88% 2010% 10 0% 0 FY 1 FY 2 FY 3 FY 4 FY 1 FY 2 FY 3 FY 4 FY 1 FY 2 3 1 2 3 4 1 2 3 4 1 2 3 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q 06 06 06 06 07 07 07 07 08 08 08 06 06 06 06 07 07 07 07 08 08 08 FY FY FY FY FY FY FY FY FY FY FY FY % Compliant with Guideline NMH Goal Median Time to PCI NMH Goal
  31. 31. Heart Failure: Compliance with Core Measures• Heart Failure Core Measures in aggregate and discharge instructions exceed goal of 95% for the first time since 2006. Improvementsdue 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 noticeableimprovements. Further, an HF operation group is developing standard care processes for all HF patients which will help to maintaincompliance for the future. Compliance with Discharge Education 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7 8 07 7 8 7 7 08 7 08 8 7 7 07 7 08 08 8 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 l-0 l-0 r- g- b- n- n- n- ay ay ug pr ov ct ar ar ep ec Ap Ju Ju Au Fe Ju Ja Ju O A M M M M N A D S Aggregate DC instructions for HF % Medication instructions % Diet instructions % Activity instructions % Follow-up instructions % Weight instructions % Symptom management instructions NMH Goal
  32. 32. Realizing cumulative benefit and lessons learned
  33. 33. Process Improvement Program Overview Process Improvement Delivers Measurable Results2002 2009 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
  34. 34. 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
  35. 35. Questions?