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Hospitals Have Room to Grow for Surgery Patient Safety Measures

03/12/2020 4:02 pm

More hospitals are meeting the surgical volume threshold, a key patient safety measure, although there is still room for growth.

March 03, 2020 – Adherence to key patient safety protocol during high-risk surgery may be getting better, but steps lay ahead for organizations delivering a slate of certain medical procedures, according to a new report from the Leapfrog Group.

The report, Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey, looked at how hospitals adhere to certain patient safety protocol when delivering one of eight common but high-risk surgeries.

Specifically, the report investigated how many hospitals deliver certain surgeries and meet what the Leapfrog Group calls its surgical volume threshold for those procedures. The surgical volume threshold refers to the minimum and maximum amount of times an organization administers a surgery.

When a hospital meets the minimum volume threshold, it is doing the surgery frequently enough to have experience in the area. But perform the procedure too often, the hospital runs the risk of spreading resources too thin.

The Leapfrog Group research team looked at how many hospitals meet the recommended volume thresholds for eight surgeries: bariatric surgery for weight loss, carotid endarterectomy, esophageal resection for cancer, lung resection for cancer, open aortic procedures, mitral valve repair and replacement, pancreatic resection for cancer, and rectal cancer surgery.

A higher percentage of hospitals met the surgical volume standard in 2019 than did in 2018, save for esophageal resection for cancer. In 2018, 2.6 percent of organizations hit the volume standard compared to 2.5 percent of hospitals that did in 2019.

However, the overall number of hospitals performing high-risk surgeries and hitting the volume thresholds is still less than ideal. The surgery type with the highest rate of organizations hitting the volume threshold was for bariatric surgery for weight loss, and even then, only 48 percent hit the threshold in 2019.

Next up was carotid endarterectomy, but only about 22 percent hit the threshold.

“The good news is we are seeing progress on surgical safety,” Leah Binder, the president and CEO of the Leapfrog Group, said in a statement. “The bad news is the vast majority of hospitals performing these high-risk procedures are not meeting clear volume standards for safety. This is very disturbing, as a mountain of studies show us that patient risk of complications or death is dramatically higher in low-volume operating rooms.”

“It’s time for hospitals and health systems to upgrade their surgical volume policies,” she added. “It will save lives.”

These figures differed slightly for rural hospitals, with rural hospitals being less likely to hit the volume threshold than urban ones. However, when viewed as a proportion of hospitals offering a high-risk procedure and hitting the volume threshold, rural facilities fared better.

“To the credit of rural hospitals, most choose not to perform elective procedures for which they have inadequate patient volume,” the researchers said. “Hospitals that cannot perform a safe volume of procedures should follow the lead of the vast majority of rural hospitals and refer patients to safer options.”

In other words, rural hospitals are aware of their low volume and make a judicious decision not to offer the procedure. The most common high-risk surgery a rural hospital will opt into is a rectal cancer surgery, and even then, 73.2 percent are opting not to offer that surgery and refer patients to safer options.

The report also looked at protocol to ensure organizations only conduct a certain surgery or procedure when it is absolutely necessary. For cancer surgeries, hospitals must convene a multidisciplinary group to review cases, or they must have national accreditation from the American College of Surgeons.

For other high-risk surgeries, organizations must report on hospital policy for reviewing surgical necessity and preventive measures geared at preventing surgery overuse.

Hospitals are very likely to have adequate procedures in place. Over 70 percent of hospitals had adequate appropriateness procedures in place for cancer surgeries.

Fewer had them in place for other high-risk surgeries. Only 32.1 percent of hospitals had appropriateness procedures in place for open aortic procedures, while 43.2 percent had them in place for Mitral valve repair and replacement. Up to about 60 percent had appropriateness procedures in place for bariatric surgery for weight loss.

When stratifying for hospitals that meet the volume standard, Leapfrog found that hospitals commonly had adequate appropriateness standards. The number of hospitals offering surgery for cancers with appropriateness standards reached up into the low 90 percent for various procedures. For other high-risk surgeries, those numbers crept up to between 55 and 70 percent, depending on the procedure.

“It is critical that hospitals do not perform surgery when the procedure is not appropriate for the patient,” said Binder. “In addition to the increased potential for harm to patients, unnecessary surgeries contribute to the burden of overuse and excess expense in the U.S. health care system.”

This information is key for patient decision-making, the researchers said.

“While progress has been made, far too many hospitals are performing surgeries too infrequently to be deemed safe for patients,” the research team wrote. “Abundant evidence suggests that for certain procedures, patients can save their lives by choosing a hospital and a surgeon with adequate, ongoing experience performing that surgery and as well as a hospital that protects against unnecessary surgery.”

Many hospitals do opt into sharing this kind of data with the Leapfrog Group, but currently there are not requirements for hospitals to do so. This means patients can miss out on important information that could help them make a care access decision based on safety.

“Hospitals should implement policies to ensure safe volumes,” the report authors concluded. “If they cannot achieve a minimum volume for safety, they should not electively perform that procedure. Physicians should be willing to have a conversation with their patients about facility or surgeon alternatives that will improve the patient’s odds of a better outcome.”

Building A Culture of Nurse Excellence to Drive Patient Satisfaction

03/12/2020 3:55 pm

Driving nurse excellence and engagement will be essential to delivering on patient satisfaction and experience.

By Sara Heath

March 10, 2020 – When it comes to nurse engagement, efforts must go a lot further than just driving good job satisfaction. In fact, nurse excellence isn’t entirely about the nurses at all, although they are important. Instead, nurse engagement is an essential means to yield an overall positive patient experience, connecting all of the key elements of healthcare into one cohesive picture.

The call for good patient experiences is not something new. Healthcare has long valued the patient, striving for excellent bedside manner and good clinical quality outcomes. But in an age where healthcare consumerism reigns supreme and CMS reimbursements hinge on good satisfaction scores, driving that positive hospital experience has become even more crucial.

But building that experience is extremely nuanced, most industry experts can appreciate. A good patient experience requires a balance of certain hospitality elements, patient safety, and meaningful interactions between patients and staff.

And that’s hard, experts say. Hospitals only have so many resources to dedicate to facility amenities and clinicians are strapped for time, seriously hindering their ability to connect with patients on a personal level. Patient safety, although essential to clinical quality outcomes, can falter to human error in the most unfortunate cases, despite best efforts. Communicating those lapses then present a whole new challenge.

But those challenges aren’t insurmountable, especially when nurses are engaged. These clinicians are on the frontlines of everything ranging from patient interactions to medical care. So, when nurses thrive, everything else thrives, too, according to Christy Dempsey, DNP, MSN, MBA, CNOR, CENP, FAAN, the chief nursing officer at healthcare consulting firm, Press Ganey.

“A culture of nursing excellence really does impact everything,” Dempsey said in a recent interview with PatientEngagementHIT. “If you have a good culture of nursing excellence, then you’re more likely to have better physician engagement. You’re more likely to see that patient experience of their physicians, not just of the nurses, is better. Clinical quality is better. It’s the rising tide that lifts all boats in healthcare.”

As noted above, nursing excellence looks like a lot more than just good job perks and satisfaction, although those factors can be important. Instead, nursing excellence is about developing and advancing strong nurse leaders, who are then able to advocate for their patients and nurse peers.

“Nursing excellence requires a structure within the organization that supports shared governance so that nurses at every level are helping and involved in making decisions, measuring transparency of data, and establishing performance benchmarks and promoting autonomy for nurses inside that shared governance framework,” Dempsey explained.

Nurturing a culture of provider teamwork and implementing care frameworks that emphasize not just clinical quality, but safety and patient experience as well, is another key hallmark of nursing excellence.

But although the industry has a good model of what nursing excellence is – strong team-based care that gives all stakeholders the tools to succeed – it isn’t always happening.

“We are in an environment that is constantly changing. It’s complex in terms of the patients and the venues, the continuum of care,” Dempsey said. “There are a lot of pressures within healthcare today.”

But it’s those very factors that hamper efforts for nurse excellence that nurse engagement and empowerment can solve. When nurses are empowered, Dempsey maintained, the patient can thrive because the team can thrive.

“Even in today’s complex, constantly changing healthcare environment, that culture of nursing excellence can be fostered, promoted, and then impact everything else that happens in healthcare,” Dempsey asserted.

Healthcare organizations on a journey to nurse excellence need to start where they are today. Understanding their current competency in patient safety, nurse experience, and clinical quality and experience will be important for understanding the root causes of any underperformance they see in their facility, Dempsey instructed.

From there, organizations can design a path forward.

“Define what the nursing professional practice model in your practice is,” Dempsey said. “Once you have determined that, you’ve got to make sure that you have CEO and board support for that model and that the chief nursing officers and nursing leadership are involved in executive level decision making at the C suite and the board level.”

A nursing shared governance that included nurse managers and engages bedside nurses will help organizations build their accountability structure, leading nurses and other stakeholders to take ownership of the process. Stakeholders should also play a hand in writing out job descriptions, performance reviews, and standards for clinical practice.

After that, teams must scale that plan organization-wide.

“You need to establish a communication plan so that you are able to disseminate information and initiatives that help you drive towards nursing excellence,” Dempsey said. “You must have an organizational strategy for data transparency in how you talk about the data. You can’t just post it on the wall. How do you talk about the data and wrap stories around that data to make it come to life? Then, look at the specific work unit information and communication strategies.”

All of this must lead to an optimized work environment, Dempsey continued. Work environment, or the factors that make a job doable and even enjoyable, is even more important that staffing levels, Dempsey reported.

“Optimizing that nursing work environment is so important,” she said. “That includes the leadership development plan, how you are engaging nurses and fostering their development, and how you are providing incentives for professional development.”

Organizations must also assess how they are assuring they have the appropriate resources – both human and material – and emotional support for nurses. This will allow nurses to continue efforts for patient-centered care.

“Make sure that you’re optimizing staffing so that you have the right people taking care of the right patients in the right place at the right time,” Dempsey stated.

“Then, finally, track integrated metrics, so reducing silos both in terms of operations, but also in terms of the way we look at data,” she continued. “Integrate that data so that you can see things and how things move together — or don’t. This will help you draw insights from that integrated data and then build improvement plans, and accountability and ownership plans based on that integrated data.”

All of this will hinge on a culture of team-based care. The organizations that Dempsey sees fully committed to a culture of excellence are already deploying strong team-based care strategies, fostering collaboration, communication, and support across the team. This is a symbiotic relationship, she said, because the culture of excellence also draws on the whole hospital team.

And at the end of the day, that is what will help organizations push to the next level in value-based and patient-centered care.

“Driving nursing excellence is not just a good idea, it makes good fiscal sense,” Dempsey concluded. “It makes good sense to recruit and retain the best and the brightest. It is the rising tide that will help health care. We need to really promote that.”

I trust this article has provided you with insight and approaches that can help you pinpoint those drivers that most strongly influence a patient’s willingness to recommend a hospital. If you are interested in learning more about using these methods, contact us at: TPMG Global® – Improving HCAHPS Scores and The Patient Experience

Making the Journey Toward Culture Change in Healthcare

03/09/2020 5:09 pm

By Anita M. Yelton

Recognition is growing among healthcare leaders of the need for a culture change within their organizations. Moving from recognition to reality, however, is more difficult. The problem lies in the perception – or misperception – of what a culture change actually entails.

Culture change is not a program with a completion date, nor is it a quick fix. It is an ongoing journey – a journey that requires leaders to understand the current state of the organization, establish a clear vision, align behaviors and instill accountability.

Vision Versus Cultural Reality

Facing the need for a culture change, large corporations, not-for-profit institutions and faith-based organizations all say the same thing: “We’re different, we’re unique.” But actually, they share many common challenges and objectives. They all hire people with goals and ambitions, and with expectations as to how they will be treated, accepted, rewarded and promoted.

All too often, however, employee expectations and those of the organization are not fully aligned. This may be despite what the organization professes as its objectives. For employees, it is the culture of the organization that is the reality, not the mission statement that hangs on the wall.

Many senior executives are out of touch with the realities of their organization. Typically, leadership only discovers what is really going on when employee surveys come back with unexpected results. Such evidence dissolves complacency and compels action. In fact, this awareness is usually where the real journey toward culture change begins.

Achieving a culture change within an organization is an ongoing process involving deliberate, intentional steps that include:

Knowledge and Awareness
- Honest assessment of the current culture
- Development of baseline data
- Vision of the desired state
Recognition and Reward
- Demonstration of desired behaviors
- Encouragement and reward for desired behaviors and outcomes
- Determination of the decision-making process (who, what, when, how)
Communication
- Development of an organizational communication strategy
- Delivery of consistent messages throughout the organization
- Frank discussion of tough issues that are frequently avoided
Systems, Structures and Linkage
- Alignment of top leadership and performance management with the organization’s core values and issues
- Determination of core competencies to support the desired culture
- Delineation of goals – including “stretch” goals – for leadership
- Linkage of behaviors, goals and achievements to compensation

Building a Framework for Change

Much can be learned from the successes and failures of organizations attempting to implement large-scale change initiatives. Such an examination reveals the value of using proven tools and techniques such as change acceleration process (for rapid decision-making), Work-Out (when the problem is known but the solution is not) and Lean Six Sigma (to streamline processes and reduce variation). These techniques can give employees a solid framework for addressing the issues they confront on a daily basis.

A simple equation to communicate this framework for sustainable change is Q x A = E, or the quality of the solution times the acceptance of that solution will equal the overall effectiveness. The individual components may be considered common sense, but they are not necessarily common practice.

In addition, it is important that this framework also include:

Clear management and leadership systems with 360-degree feedback
Skip-level meetings (meetings where leaders bypass their direct reports and speak to the next level of the organization)
A consistent operating calendar
A linkage between people, strategy and results.

The mere existence of an internal quality program cannot bring about a culture change. Leaders must focus on and balance all elements of the equation to begin the journey toward change and achieve sustainable results.

‘A’ Side of Equation Is Essential

Employee acceptance is essential. Many organizations have declared their mission, written goals, produced vision statements and embraced a philosophy or set of values that fits their organization. These affirmations often include such lofty themes as empowerment, boundarylessness, customer focus, passion for excellence, accountability, quality mindset, employees as partners and so on. They are conveyed to all employees, reinforced in communication and are used to measure performance.

However, often there is no structure to support the realization of these organizational objectives. The employees frequently lack a genuine commitment to their company’s stated goals, mission, value statements and general philosophies because:

They feel they have no input into the process.
The statements are long, vague and do not relate directly to employees’ work.
Goals and values are only communicated once a year and then not mentioned again.
The statements are constantly being changed or revised.
The leadership team is inconsistent in its actions and behaviors in support of the goals and values.

The failure to support goals and values could stem from such management practices as giving individual rewards and recognition versus team projects and rewards; identifying and grooming individuals with high potential for selected management positions while ignoring others who contribute to the team’s success; relying on employee comparisons and rankings that may be subjective instead of objective; discriminating within training, development, salary and promotions; and talking to instead of with employees. Other problems could include leadership actions that fail to “walk the talk,” an unwillingness on the part of management to accept feedback, a lack of upper management diversity and high turnover.

Such organizational shortcomings are often a matter of focus. In an effort to reduce cost, raise quality, boost productivity and surpass the competition in the marketplace, management may neglect such issues without realizing the impact it can have on employees, and thus the entire organization. Further, when confronted with the problems of stressed, overworked and burned-out employees, management often dismisses the complaints as trivial. The employees are sometimes labeled as “not being team players” or “not the stuff leaders are made of.”

The general feeling is that “healthcare is a caring profession” – an environment in which it is difficult to discuss performance issues. Tough conversations about people and performance often do not take place in order to avoid difficult or confrontational situations. Action items, decisions and accountability may never be discussed in meetings, where behavior is polite and politically correct. In fact, some of the most important conversations and decisions take place in the hallways after meetings. The fact to remember is that, wherever they take place, face-to-face communication is critical to establishing an honest, open dialogue across the organization.

Conclusion: A Path Toward Culture Change

Healthcare faces many challenges today in the quest to deliver the best and most cost-effective services for patients. One important challenge is to institute a culture change that enables staff, clinicians and managers to feel empowered and adequately equipped to address the problems which can be resolved only by altering their work environment. They need to know they can propose and implement viable solutions to real problems. Visionary healthcare organizations that are seeking to transform the way they deliver care must begin by finding a path toward a culture change.

The Economic Cost of Physician Burnout

03/04/2020 4:00 pm

25 Sep 2019|by Michael Blanding

Physician burnout costs the United States health care industry $4.6 billion a year, a number that brings a new spotlight to an age-old problem.

In a paper published in the journal Annals of Internal Medicine this past June, a research team of seven co-authors, most of them doctors, concluded that the dollar losses were related to physician turnover and reduced clinical hours.

The research adds to previous work showing how physician stress generates negative clinical and organizational outcomes. No studies have previously been attempted to put a figure on burnout in the US on a national level. In part, that’s due to the difficulty of calculating the economic cost of all of the factors involved. For instance, some studies have associated burnout with an increase in medical errors, but calculating those costs are nearly impossible.

“Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians,” the study states.

“Essentially it’s this feeling of being overwhelmed. You don’t feel like what you are doing is meaningful anymore.”

It’s well understood that doctors are constantly asked to do more with less. In addition to a demand for physicians that outstrips the supply, new laws around electronic record-keeping have increased the administrative burden on doctors as well.

“Physicians don’t sign up for the job to stare at a screen. They are doing this to provide care for people,” says one of the study’s co-authors, Joel Goh, a visiting scholar in the Technology & Operations Management Unit at Harvard Business School. “It creates a high level of dissonance for them.”

According to one study, more than half of all doctors in the US report feeling at least one symptom of burnout: emotional exhaustion, a feeling of detachment, or a diminished sense of personal accomplishment—twice the rate of the general working population.

“Essentially it’s this feeling of being overwhelmed,” says Goh, who is also an assistant professor at the National University of Singapore (NUS) Business School. “You don’t feel like what you are doing is meaningful anymore.”

What’s the economic price of burnout?

Even though physician burnout is widespread, it’s difficult to put a price tag on the phenomenon in a way that medical institutions can understand. In past research, Goh focused on calculating the cost of workplace stress on medical costs in the US. That led Christine Sinsky, vice president of the American Medical Association, to contact Goh to ask if he could calculate the medical costs of stress experienced by doctors themselves. Sinsky is one of the authors of the latest paper.

“It was a great opportunity to explore this issue with thought leaders on the subject,” Goh says. “I could provide my technical skills on modeling, and they could provide their contextual knowledge.”

The researchers focused on one aspect of the problem they could measure: lost income due to reduced hours and turnover.

To do so, they used a 2014 survey of some 7,000 doctors that asked questions about burnout and short-term career plans to estimate the percentage of doctors planning to reduce their hours or leave their jobs due to burnout. They then correlated those numbers with the percentage of burnout experienced by doctors in different age groups and medical disciplines in order to estimate the overall effects of burnout on staffing nationwide.

They then created a formula to calculate the cost of lost hours—as well as the search, hiring, and training costs of filling vacant positions—to arrive at a total price tag for burnout from turnover.

A not insignificant number

Their final estimate, $4.6 billion annually, “is a decent amount that people should care about,” Goh says. Drilling down to an organization level, that number comes out to $7,600 per physician per year. Most of that cost, they determined, comes from turnover, which had five times the impact of reduced hours, due to all of the associated costs of filling a full-time equivalent position.

Of course, cost isn’t the only reason to deal with the issue of doctor burnout. “Organizations have an ethical imperative to take care of their employees,” Goh says. And doing so could help take care of patients as well by reducing medical errors.

Even so, the study shows that doing the right thing ethically can also make sense to the bottom line. “It’s not just going to be a waste of resources trying to deal with this problem,” Goh says. “Aside from all of the positive outcomes you generate, it’s probably a good financial return on investment as well.”

Goh and his colleagues further help organizations calculate that cost with a spreadsheet tool they developed that any organization can use to plug in their own figures and calculate their own potential costs of not dealing with burnout.

“In every other management decision, you try to have as complete a picture as possible,” he says. “This helps fill in some of those data points, not to supplant the ethical considerations, but to provide a more complete picture.”

For those ready to deal with the problem, says Goh, a range of interventions have been shown to be successful, including mindfulness exercises and stress-management training. To really make an impact, however, wider organizational changes are probably needed.

“One way to make a difference is by increasing the amount of administrative support doctors receive, so they are relieved of those burdens,” Goh says. “It may seem costly to hire that additional staff, but it will probably be beneficial in the long run.”

Case Study: Surmounting Staff Scheduling at Valley Baptist Health System

03/02/2020 6:46 pm

By Carolyn Pexton and Blake Hubbard

Located in Harlingen, Texas, Valley Baptist Health System is a full-service, not-for-profit community health network ably serving the population of south Texas and beyond. The system is comprised of multiple organizations including Valley Baptist Medical Center, a 611-bed acute care hospital providing the number one rated orthopedics service in Texas, a state of the art children’s center and a lead level III trauma facility. The organization also serves as a teaching facility for The University of Texas Health Science Center.

In 2002, Valley Baptist Health System began to implement GE’s Six Sigma approach as a rigorous methodology for process improvement and a philosophy for organizational transformation. The adoption of Six Sigma at Valley Baptist fostered a revitalized culture that embraces the voice of the customer, breaks down barriers to change and raises the bar on performance expectations. Through this initiative, the team at Valley Baptist began to examine the most critical opportunities for improvement and select projects that would align with strategic objectives and produce measurable results.

As with most healthcare providers today, maintaining appropriate staffing levels and improving productivity are among the top concerns at Valley Baptist. During the initial wave of Six Sigma training projects, the team at Valley Baptist launched an effort to review and improve the staff scheduling process for one nursing unit in orthopedics. Within this particular unit, there had been a history of overtime and use of agency hours that did not seem to correlate with changes in patient volume. Patient census would fluctuate while staffing levels remained the same, and the higher hourly wage for overtime and agencies had begun to strain the overall labor budget.

The primary focus for this project was to improve the unit’s ability to responsibly meet staffing targets while protecting the quality of patient care. It is a challenge to reach that optimal level – avoiding overstaffing yet appropriately meeting daily needs. Paramount in this effort was the notion that targets would be met without adversely impacting customers. Patient satisfaction scores had to remain constant or increase, and this mandate was built into the project and measured through the use of upper and lower specification limits.

A cross functional project team was assembled including the chief nursing officer as sponsor, the assistant vice president from human resources, the nursing house supervisor, the nurse manager from the cardiac care unit, a representative from IT and a charge nurse. The introduction of any new change initiative can elicit skepticism, but since Six Sigma concentrates on fixing the process rather than assigning blame, once the approach was understood much of the skepticism subsided. Stakeholder analysis and other CAP (change acceleration process) tools helped to surface concerns and improve communication.

Also supporting this project were metrics to measure productivity for nurses and managers that had been introduced through the adoption of Six Sigma. The dual emphasis on productivity and quality provides a framework for offering cost effective care and aligns with the customer-centered mission at Valley Baptist.

Defining the Goal

During the Define phase of the project, the team concentrated on clearly identifying the problem and establishing goals. The nursing units in general had struggled to meet their staffing targets and were over budget on labor costs. For this project, the team decided to focus on one orthopedics nursing unit based on three criteria: the unit was not extremely specialized or unique so it offered the best representation of nursing as a whole; the manager was very supportive of the initiative; and this unit offered clear opportunity for improvement and results.

To understand the current scheduling process, the project team used the SIPOC tool to develop a high-level process map. SIPOC stands for suppliers, inputs, process, output and customers. Inputs are obtained from suppliers, value is added through your process, and an output is provided that meets or exceeds your customer’s requirements. SIPOC is extremely useful during process mapping.

Measuring and Analyzing the Issues

As they moved through the Measure and Analyze phases, the project team focused on data collection and the identification of the critical “Xs” that were impacting staff scheduling. Historical data was gathered from the payroll system to analyze regular time, overtime, agency use, sick time, vacation, jury, funeral leave and FMLA. They examined 24 pay periods for each data point. Fortunately, the team was able to extract the data they needed from existing systems and avoid manual data collection, which is more labor intensive and can increase the project timeline.

Given the availability of continuous data for the “Y” or effect and the potential Xs or causes, regression analysis was the tool chosen to help the team understand the relationship between variation from the staffing goals and vacation, FMLA, sick leave, overtime, agency nurse usage, and so on. Through regression analysis, they were able to determine that three critical Xs could explain 95 percent of the variation: agency use, overtime and census. The next step would be to understand underlying factors – data would point the team to interesting findings that disputed their original theories.

The Improve Phase

During the Improve phase, the team used many of the CAP and Work-out tools. Such acceptance-building techniques are key to success, since improvements introduce changes in process and human behavior. The team conducted a Work-out session to develop new standard operating procedures for better management of overtime and agency usage – critical drivers in staffing.

The chief nursing officer attended the sessions to underscore the importance of this initiative from a leadership perspective. The project team used the process map to indicate where they might have opportunities for improvement, and then conducted separate Work-outs on each area. They brought in nursing staff, house supervisors and other stakeholders to participate in the search for solutions.

This project translates to $460,000 in potential savings for one unit. Conservatively, if it were spread across the health system the savings could exceed $5 million.

Never Assume

This project furnished a classic example as to how Six Sigma can be used to either corroborate or dispel original theories. Management at Valley Baptist had initially assumed they were over budget on labor costs due to sick leave, FMLA, vacation and people not showing up, which would have naturally necessitated the additional overtime and agency hours. The data and analysis proved those assumptions to be incorrect.

It turns out there were several factors contributing to the staff scheduling challenges. One illuminating aspect to come from the Work-outs was the realization that nurses didn’t like floating in and out of units – this came up in every session. There were also issues with the staffing matrix which attempted to set parameters based on volume. Compliance was not ideal, and the matrix itself was based on data that was not completely current. Another complication was that maintaining information in the matrix involved labor intensive, manual processes that were difficult to control.

The team discovered the use of overtime was not always need-based. Units would regularly schedule 48 hours for each nurse, with the extra eight hours of overtime built-in as “traditional” usage. This became an accepted practice and although in theory, adjustments are supposed to be made when the patient flow is lighter, this was not happening. On the form used to submit data the nurses would have to guess what hours they might actually work. The matrix might indicate compliance, but the payroll data actually showed them clocked in for 14-15 hours instead of 12.

Another critical issue is that the nursing unit lacked appropriate mechanisms for shift coordination and handoff. There were two fully independent teams between the day and night shifts, and there was not a smooth transition between them. Part of the problem stemmed from a lack of written guidelines governing the overtime between shifts. Nurses would finish their regular 12-hour shift and stay on overtime to complete tasks rather than pass them on to the next shift.

The central metric of this Six Sigma initiative was worked hours divided by equivalent patient days. Valley Baptist Health System defines worked hours as those hours during which an employee was actually working – including regular time and overtime, and excluding non-productive hours such as sick and vacation time. Equivalent patient days is the volume statistic utilized within the Orthopedics Unit. It is the typical patient days number adjusted to reflect short-term observation (STO) patient volume.

Results and the Control Phase

The development of new standard operating procedures has clearly had a positive impact on the organization. This gave staff a plan they can follow and established accountability. The unit began a process for transition meetings between shifts. The outgoing nurse now takes the incoming nurse to the patient’s room, introduces them and provides a report on the current status and whether there are outstanding orders. In addition to improving operations for the hospital, this change has also been well received by patients, as reflected in rising satisfaction scores during the pilot.

The project on staff scheduling has led to an overall reduction in the higher hourly cost of overtime and agency use, and has translated to $460 thousand in potential savings for this one unit. Conservatively, if this project were spread across the health system the savings could exceed $5 million. It is also important to note that this project started at the 0 sigma level and increased to Six Sigma for nine consecutive pay periods.

“At Valley Baptist, we continually seek opportunities to improve productivity,” said Jim Springfield, President and CEO. “This focus is critical for our future success and ability to meet patient needs.”

To ensure results are maintained, managers use control charts and trend reports with data from HR, time and attendance and payroll systems. This provides real time information on productivity, tracking worked hours versus patient days to show alignment with targets on an ongoing basis.

Organizational and Customer Impact

The bottom line is that nurses, management and patients are all happier as a result of this project. With the pilot in the Control phase, Valley Baptist has held Work-outs to determine how they might broaden the SOPs and implement this approach across the system in all nursing units.

“Staff has become much more flexible. We initially encountered some resistance, but using the CAP tools and working through the process helped to create a shared need and vision.”

Leadership involvement and support turned out to be a significant factor in the overall success of the project. This initiative represented a major culture change from previous CQI and TQM approaches to quality improvement. All previous efforts had involved hard work and good intentions, but prior to Six Sigma, they lacked the framework and rigor to institute statistically valid long-term results.

The health system is moving toward autonomy through additional Green Belt and Black Belt training with projects, and through participation in a Master Black Belt course at GE’s Healthcare Institute in Waukesha, Wisconsin. This experience provides instruction and interaction that prepares the MBB to come back and teach within the organization.

“Coming from the HR side, it’s important for organizations to know it’s possible to change the way you’ve always done things, and that employees will adapt to a new approach. If you can overcome the stress surrounding change you can realize increased efficiency. This is a positive way to control staffing without employing slash and burn techniques.”

Irma Pye, senior vice president at Valley Baptist, attended a conference in Utah with other healthcare executives. When the issue of performance improvement and staffing came up, someone mentioned they’d attempted to do a project on this and it had failed because they couldn’t afford to alienate and potentially lose good employees. Irma spoke up and let them know that based on her own recent experience, you can indeed address this issue and it can work if it is approached in the right way using the right techniques.

“Usually, when you ask the department manager to trim labor costs they think it can’t be done because it will antagonize employees . . . they’ll either take a job somewhere else, or stay there with negative feelings which impacts morale. This approach was able to affect change, while avoiding issues of layoffs or pay cuts.”

Using Predictive Analytics to Help Seniors Maintain Their Independence

02/28/2020 5:56 pm

Evan McLaughlin 09 September, 2019

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We might not be able to observe the progressive loss of cognitive and intellectual abilities someone with dementia is experiencing from the outside, but healthcare clinicians can detect it when they observe their ability to bathe, groom or dress themselves deteriorate. Minitab consultant and Insights 2019 speaker David Patrishkoff is researching how to help with the aid of Minitab software.

Activities of Daily Living (ADLs)

The healthcare industry calls basic self-care tasks like one’s ability to properly feed themselves, move around or go to the bathroom “Activities of Daily Living,” or ADLs. Since the 1950s, healthcare professionals have scored ADLs with pre-set criteria (see this worksheet from the National Palliative Care Research Center for example).

After populating a worksheet like this, a healthcare professional can flag the functional capabilities of older adults and use the results to assess their ability to live independently.

What if symptoms could be caught earlier?
Enter Machine Learning and Predictive Analytics

David Patrishkoff

David Patrishkoff

There is evidence that deterioration of ADL scores are preventable. Screening can greatly help as the first step in the process too. For example, preventing elderly patients from falling has been shown to reduce the use of home healthcare, and the associated costs.

Building off of related research, Minitab consultant David Patrishkoff set out to use Machine Learning to help detect ADL deterioration earlier in the process and address it accordingly.

In healthcare, interventions are activities or strategies (such as screenings or vaccinations) to assess, improve, maintain, promote or modify health of individuals or groups. David uses Minitab Statistical Software and Salford Predictive Modeler (SPM) to examine 1,200+ interventions and therapies that nurses and home care workers provide to people across the country, and select the best ones to maintain or improve their independence and their ADLs.

“I start in Minitab with data visualizations and clean up the data, then jump into SPM for the really heavy lifting of very complex data sets,” David said. “I have columns of data where I have one of any 83,000 prescriptions that are prescribed to people. There are 43,000 diagnosis codes too. The algorithms in SPM can deal with highly dimensional data.”

A Master Black Belt who began his career in the automotive industry, David has consulted in about 60 different industries worldwide and trained nearly 30,000 professionals in Lean Six Sigma and patient safety.

Applying Predictive Analytics to Problem-solving

David first began using TreeNet in SPM to enhance his research into causes of traffic accident injuries and deaths, and he is applying some of the same methods now to ADLs and home care.

There is a belief that you have to be a data scientist coding in Python and R to handle these kinds of problems, he notes, but that’s not necessarily true. David recommends learning to use predictive analytics software like SPM to see how you can do better root cause analysis.

David also credits the 64-bit version of Minitab 19 with helping him with larger data sets he was unable to work with in previous versions.

“It helped me tremendously,” he said. “I had old files that were too big and then with the 64-bit Minitab 19 it further helped my analysis.”

What’s Next?

David has been speaking at conferences about his research and how classic Six Sigma and operational excellence practitioners can build on their knowledge of statistical methods to take the next step into the data science revolution. He plans to present and publish further findings next year on how to provide home healthcare clinicians a stable methodology to improve patient outcomes.

Fewer X-Ray Errors Reduce Cancer Risk, Wait Time and Costs Evan McLaughlin 27

02/28/2020 5:49 pm

Evan McLaughlin 27 November, 2019

Clinicians examining a radiograph

In hospital and clinic settings, making the right decisions doesn’t just reduce costs from duplicative work and process inefficiencies — it results in better outcomes for patients. Think about needing to take an extra X-ray because the first captured the wrong foot. Even if it’s the right limb, what if they captured it from the wrong angle?

Over the 14 years he worked in healthcare quality improvement, Art Wheeler saw this and many other process improvement scenarios. Most recently, as decision support manager for quality improvement services at one of the country’s largest not-for-profit freestanding pediatric healthcare networks, he was the primary statistician, as well as a mentor and coach for Six Sigma Black Belts and Green Belts, program managers and project leaders for 8 1/2 years.

An expert in statistical quality control, one of his key responsibilities was ensuring data was collected in a way that was sound and ensured the best chances for detecting statistical significance of any reported improvements. He also developed the charts and writeups for the analysis sections of corresponding published articles and responded to reviewer questions or comments to help ensure acceptance.

Remember that extra X-ray scenario we mentioned earlier? Art served as a consultant on a duplicate X-ray study, which found each unnecessary scan cost facilities an extra $150 to $300 and overall patients were waiting longer. One study of 18 US pediatric emergency departments showed radiology errors are the third most common event in pediatric emergency research networks and human errors rather than equipment issues caused 87% of them.

Besides reducing errors, the team were also motivated to achieve their goal of zero errors at two clinics so they could also reduce lifetime radiation exposure for individuals, which in turn diminishes their risk of developing cancer. Efforts like this were part of the hospital’s “Zero Hero” program – they would measure the time period and the number of cases involved, aim to reduce incidents to zero and record how long they maintained zero incidents.

It wasn’t all black and white though. They needed to understand the context behind the duplicate X-rays to truly make improvements. With a retrospective review of a 14-month period at two facilities, they knew there were good and bad reasons behind the 170+ duplicate X-rays that were recorded, for a duplicate radiograph. Each duplicate radiograph was classified as …

No error, where they intentionally studied from multiple views;
Incorrect location, when the patient’s initial complaint did not match the initial radiograph (e.g. the aforementioned wrong foot);
Incorrect laterality, when it’s the wrong side; or
Unnecessary radiograph, a known issue when a clinical athletic trainer preordered multiple radiographs without physician evaluation and assessment.

The Pareto chart below shows the most common error during the 14-month period was incorrect location.

pareto-chart-radiograph-error-classification-resize

The quality improvement team took steps to meet their zero percent goal in both clinics, which included issuing surveys to patients and families during registration to help document where they needed to be X-rayed and if they had been X-rayed in the past.

The unnecessary radiograph was also a known issue when a clinical athletic trainer preordered multiple radiographs without physician evaluation and assessment. An intervention was made to fix this, making physicians responsible for putting their own radiograph orders in the Electronic Medical Record.

Overall these steps improved communication between physicians, clinical athletic trainers, radiology technologists, patients and families, and greatly contributed to better outcomes for everyone involved.

Lean Healthcare Project Teams

Robotics Process Excellence in Healthcare

02/08/2020 7:27 pm

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Lean management is a proven method for eliminating waste and the cost that comes with it. RPA is an inexpensive software-based technology. It sits on top of other applications, requires no special hardware, and works well in almost any IT environment. That’s not all, you also get highest level of enterprise grade security.

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[View Demonstration: Robotics Process Automation]

Project Description: What is your process improvement?

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Robotics Process Automation – Demo

02/08/2020 7:24 pm / 2 Comments on Robotics Process Automation – Demo

Robotic Process Automation (RPA) is an affordable solution for organizations to streamline their operations and maximize efficiency. Robots used in RPA interact with applications to perform many mundane tasks such as re-keying data, logging into applications, moving files and folders, copying and pasting and much more. RPA is particularly suitable for processes with high human error rates. It’s an inexpensive software-based technology that sits on top of other applications. It requires no special hardware, and works well in almost any IT environment. That’s not all, you also get highest level of enterprise grade security.

Improving Productivity with RPA

We have combined Lean Management, Process Re-engineering and Robotics Process Automation (RPA) into a powerful approach that eliminates waste, improves productivity, and reduces the cost of doing business. Our Operational Excellence (OpEx) services help organizations:

Ensure process performance exceeds business goals.
Measurably increases productivity by more than 25%.
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Automate slow, tedious, time consuming, manual tasks.

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This demo explores how robotics process automation and artificial intelligence are continually redefining the future of work. One minute of work from RPA translates to 15 minutes of human activity. RPA also provides stakeholders with additional flexibility, enabling them to focus on more demanding and value added tasks.

Demo – Customer Account Details

Robotics Process Automation is an affordable solution for organizations to tackle repetitive, low – value added work. Robots used in RPA interact with applications mimicking human actions and can perform many mundane tasks such as re-keying data, logging into applications, moving files and folders, copying and pasting and much more. RPA has been adopted in industries with intense, manual, and administrative processes, such as financial services, insurance and health care. (The information in this demo has been blurred to preserve confidentiality)

Lean Transformation in Healthcare

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