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Lean Six Sigma Department
March 2012 Executive Report Out
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AI
Lean
Six Sigma
C
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Lean
Six Sigma
C
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Lean
Six Sigma
Define Measure Analyze Improve Control
Zero suicide attempts or deaths by suicide.
Customer: SMV Outpatients
Problem: Between 2011 and 2014, of patients attending the
SMV Outpatient programs, there were recorded suicide
attempts or deaths by suicide.
Sponsor/Green Belt: Christiana Paul
Process Owner: Nancy Burlak & Serene Lause-Gardini
Black Belt: Matt Hayden
Team: S. Griffiths, S. Whittemore; C. Atterton, N. Bavar, V. Campbell, L. Kramer,
L. Hoyt, D. Schwartz, L. McJunkin, J. Ruvo, J. Wojciechowski, C. Westfall,
R. McDade, J. McWaters, C. Huang
Safety Pillar
Goal Statement
Link to Strategic Goals
Team
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb’16
Lean Six Sigma Department
March 2012 Executive Report Out
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Six Sigma
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Six Sigma
Measure / Analyze
 Retrospective analysis of 16 identified
outpatient events; 50 data points
examined.
 Qualitative & Quantitative did not result in a
clear root cause(s)
 Findings Included:
 High variability in workflow and documentation
 No effective prioritization of outpatient
population for risk
 Current Assessment was task, not value added
Define Measure Analyze Improve Control
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb’16
Need for Standard Work & Evidence-
Based Practice
Lean Six Sigma Department
March 2012 Executive Report Out
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Lean
Six Sigma
C
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Lean
Six Sigma
C
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Lean
Six Sigma
Improvements Identified &
Underway
Define Measure Analyze Improve Control
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb’16
 Columbia-Suicide Severity Rating Scale
(C-SSRS)
 Cultural Change Regarding Suicide
Assessment
 Asking can Save A Life; Ask every time, like BP
 Common Definitions
 Develop clinical pathways and expectations
 Link C-SSRS Rating to EBP Treatment Interventions
 Staff Communication and Training
 Suicide Risk Assessment
 Department Protocol
 Safety Planning
 Treatment Planning
Lean Six Sigma Department
March 2012 Executive Report Out
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Lean
Six Sigma
C
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Lean
Six Sigma
C
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Lean
Six Sigma
Lean Six Sigma Department
March 2012 Executive Report Out
C
D
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Lean
Six Sigma
C
D
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Lean
Six Sigma
C
D
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Lean
Six Sigma
Linking C-SSRS Rating
to Evidence Based Practice
Treatment Interventions
Interpersonal Theory of Suicide—
Thomas Joiner
Lean Six Sigma Department
March 2012 Executive Report Out
C
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Lean
Six Sigma
C
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Lean
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C
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Lean
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C-SSRS in our EMR
Lean Six Sigma Department
March 2012 Executive Report Out
C
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Lean
Six Sigma
C
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Lean
Six Sigma
C
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Lean
Six Sigma
The Clinician’s Perspective
Define Measure Analyze Improve Control
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb ‘16

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SMV Outpatient Zero Suicide Initiative Oct ‘14 to Feb’16

  • 1. Lean Six Sigma Department March 2012 Executive Report Out C D M AI Lean Six Sigma C D M AI Lean Six Sigma C D M AI Lean Six Sigma Define Measure Analyze Improve Control Zero suicide attempts or deaths by suicide. Customer: SMV Outpatients Problem: Between 2011 and 2014, of patients attending the SMV Outpatient programs, there were recorded suicide attempts or deaths by suicide. Sponsor/Green Belt: Christiana Paul Process Owner: Nancy Burlak & Serene Lause-Gardini Black Belt: Matt Hayden Team: S. Griffiths, S. Whittemore; C. Atterton, N. Bavar, V. Campbell, L. Kramer, L. Hoyt, D. Schwartz, L. McJunkin, J. Ruvo, J. Wojciechowski, C. Westfall, R. McDade, J. McWaters, C. Huang Safety Pillar Goal Statement Link to Strategic Goals Team SMV Outpatient Zero Suicide Initiative Oct ‘14 to Feb’16
  • 2. Lean Six Sigma Department March 2012 Executive Report Out C D M AI Lean Six Sigma C D M AI Lean Six Sigma C D M AI Lean Six Sigma Measure / Analyze  Retrospective analysis of 16 identified outpatient events; 50 data points examined.  Qualitative & Quantitative did not result in a clear root cause(s)  Findings Included:  High variability in workflow and documentation  No effective prioritization of outpatient population for risk  Current Assessment was task, not value added Define Measure Analyze Improve Control SMV Outpatient Zero Suicide Initiative Oct ‘14 to Feb’16 Need for Standard Work & Evidence- Based Practice
  • 3. Lean Six Sigma Department March 2012 Executive Report Out C D M AI Lean Six Sigma C D M AI Lean Six Sigma C D M AI Lean Six Sigma Improvements Identified & Underway Define Measure Analyze Improve Control SMV Outpatient Zero Suicide Initiative Oct ‘14 to Feb’16  Columbia-Suicide Severity Rating Scale (C-SSRS)  Cultural Change Regarding Suicide Assessment  Asking can Save A Life; Ask every time, like BP  Common Definitions  Develop clinical pathways and expectations  Link C-SSRS Rating to EBP Treatment Interventions  Staff Communication and Training  Suicide Risk Assessment  Department Protocol  Safety Planning  Treatment Planning
  • 4. Lean Six Sigma Department March 2012 Executive Report Out C D M AI Lean Six Sigma C D M AI Lean Six Sigma C D M AI Lean Six Sigma
  • 5. Lean Six Sigma Department March 2012 Executive Report Out C D M AI Lean Six Sigma C D M AI Lean Six Sigma C D M AI Lean Six Sigma Linking C-SSRS Rating to Evidence Based Practice Treatment Interventions Interpersonal Theory of Suicide— Thomas Joiner
  • 6. Lean Six Sigma Department March 2012 Executive Report Out C D M AI Lean Six Sigma C D M AI Lean Six Sigma C D M AI Lean Six Sigma C-SSRS in our EMR
  • 7. Lean Six Sigma Department March 2012 Executive Report Out C D M AI Lean Six Sigma C D M AI Lean Six Sigma C D M AI Lean Six Sigma The Clinician’s Perspective Define Measure Analyze Improve Control SMV Outpatient Zero Suicide Initiative Oct ‘14 to Feb ‘16