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Using Six Sigma to Reduce Pressure Ulcers at a Hospital

Since 2001, Thibodaux Regional Medical Center (TRMC) in Louisiana has applied Six Sigma and change management methods to a range of clinical and operational issues. One project that clearly aligned with the hospital’s strategic plan was an initiative to reduce nosocomial or hospital-acquired pressure ulcers, because this is one of the key performance metrics indicating quality of care.

Although the pressure ulcer rate at the medical center was much better than the industry average, the continuous quality improvement data detected an increase between the last quarter of 2003 and the second quarter of 2004.

In October 2004, a Six Sigma project to address this issue was approved by the hospital’s senior executives. A team began to clarify the problem statement. Their vision was to be the “Skin Savers” by resolving issues leading to the development of nosocomial pressure ulcers. The project team included a Black Belt, enterostomal therapy registered nurse (ETRN), medical surgical RN, ICU RN, rehab RN and RN educator.

Scoping the Project

Through the scoping process, the team determined that inpatients with a length of stay longer than 72 hours would be included, while pediatric patients would be excluded. The project Y was defined as the nosocomial rate of Stage 2, 3 and 4 pressure ulcers calculated per 1,000 patient days. Targets were established to eliminate nosocomial Stage 3 and Stage 4 pressure ulcers and reduce Stage 2 pressure ulcers from 4.0 to less than 1.6 skin breaks per 1,000 patient days by the end of the second quarter of 2005.

The team developed a threats and opportunities matrix to help validate the need for change (Table 1). They encountered some initial resistance from staff, but were able to build acceptance as the project began to unfold.

Table 1: Threats and Opportunities Matrix
Threat Opportunity
Short Term Increase length of stay Improve quality of care
Increase costs Decrease medical complications to patient
Increase medical complications to patient
Long Term Decrease patient satisfaction Improve preventative care measures
Increase morbidity rate Improve hospital status/image
Decrease physician satisfaction Increase profitability
Increase number of lawsuits Improve customer satisfaction
Decrease reimbursement
Loss of accreditation

Measurement and Analysis

During the Measure phase, the team detailed the current process, including inputs and outputs. Using cause and effect tools, process steps having the greatest impact on the customer were identified as opportunities for improvement. The team also reviewed historical data and determined that overall process capability was acceptable, but that the sub-processes had a great deal of room for improvement. Improving these sub-processes would positively affect the overall process and further improve quality of care.

Measurement system analysis on the interpretation of the Braden Scale was performed to verify that results obtained by staff RNs were consistent with the results obtained by the enterostomal therapy RN, because this is the tool used to identify patients at risk of developing a pressure ulcer. This analysis indicated that the current process of individual interpretation was unreliable and would need to be standardized and re-evaluated during the course of the project.

A cause and effect matrix was constructed to rate the outputs of the process based on customer priorities and to rate the effect of the inputs on each output (Figure 1). The matrix identified areas in the process that have the most effect on the overall outcome, and consequently the areas that need to be focused on for improvement (Table 2).

The team identified several critical Xs affecting the process:

  • Frequency of the Braden Scale – The Braden Scale is an assessment tool used to identify patients at risk of developing pressure ulcers. Policy dictates how frequently this assessment is performed.
  • Heel protectors in use – Heel protectors are one of the basic preventative treatment measures taken to prevent pressure ulcers.
  • Incontinence protocol followed – Protocol must be followed to prevent against constant moisture on the patient’s skin that can lead to a pressure ulcer.
  • Proper bed – Special beds to relieve pressure on various parts of the body are used for high-risk patients as a preventative measure.
  • Q2H (every two hours) turning – Rotating the patient’s body position every two hours is done to prevent development of pressure ulcers.

Figure 1: Cause-and-Effect Matrix

Table 2: Data Analysis

Process

Defects

Opportunities

% Defective

Z Score

Overall Process

64

16,311

0.39

2.66

Braden Scale Frequency

10

76

13.16

1.12

Proper Bed

24

76

31.58

0.48

Q2H Turning

49

76

64.47

-0.37

Data analysis revealed that the bed type was not a critical factor in the process, but the use of heel protectors, incontinence protocol compliance, and Q2H turning were critical to the process of preventing nosocomial pressure ulcers. The impact of the Braden Scale frequency of performance was not identified until further analysis was performed (Figure 2).

Figure 2: One-Way Analysis of Means for Sub-Process Defects

Evaluating data specific to at-risk patients, the team separated populations who developed nosocomial pressure ulcers from those who did not have skin breakdowns. The Braden Scale result at the time of inpatient admission from each population was analyzed to see the effect on development of a nosocomial pressure ulcer. One unexpected finding was that the admit Braden Scale result was higher for patients who develop nosocomial pressure ulcers than for those who do not develop them, showing that patients at risk are not being identified in a timely manner, thus delaying the initiation of necessary preventative measures.

The team then looked at defects for Braden Scale frequency of performance for each population of patients using a chi square test. They found the frequency of Braden Scale performance did have an effect on the development of nosocomial pressure ulcers. This was confirmed with binary logistic regression analysis (Table 3).

Table 3: Binary Logistic Regression Analysis
Process

Coefficient

Odds

Probability

Odds Ratio

No Defects

–0.5222

0.59

0.37

N/A

Braden Scale Defects

2.54322

7.55

0.88

12.72

Bed Defects

1.56220

2.83

0.74

4.77

Q2 Turn Defects

–2.16870

0.07

0.07

0.11

The most significant X is the Braden Scale frequency of performance. This analysis confirmed the need to increase the frequency of Braden Scale performance to identify at-risk patients.

Recommendations for Improvement

During the Improve phase, recommended changes were identified for each cause of failure on the FMEA with a risk priority number of greater than 200. Some of the recommendations include:

  • Frequency of Braden Scale performance to be increased to every five days
  • Braden Scale assessment in hospital information system (HIS) to include descriptions for each response
  • Global competency test on interpretation of Braden Scale to be repeated annually
  • Prompts to be added in HIS to initiate prevention/treatment protocols
  • ET Accountability Tracking Tool to be issued for non-compliance with prevention and treatment protocols as needed

The Braden Scale R&R was repeated after improvements were made on the interpretation of results. The data revealed an exact match between RNs and the ETRN 40 percent of the time, and RNs were within the acceptable limits (+/– 2) 80 percent of the time. Standard deviation was 1.9, placing the results within the specification limits. The data indicated that the RNs tend to interpret results slightly lower than the ETRN, which is a better side to err on because lower Braden Scale results identify patients at risk of developing pressure ulcers.

The Control Phase

Another round of data collection began during the Control phase to demonstrate the impact of the improvements that had been implemented. A formal control plan was developed to ensure that improvements would be sustained over time, and the project was turned over to the process owner with follow-up issues documented in the Project Transition Action Plan.

The team implemented multiple improvements, including compilation of a document concerning expectations for skin assessment with input from nursing and staff. They also gave a global competency test on interpretation of the Braden Scale, which will be repeated annually. The Braden Scale frequency was increased to five days, and they corrected the HIS calculation to trigger clinical alerts for repeat of the Braden Scale. Prompts were added for initiating the Braden Scale, and monthly chart audits were developed for documentation of Q2H turning. A turning schedule was posted in patient rooms to identify need and document results of Q2H turning of patient. Additional solutions included the following:

  • ETRN to attend RN orientation to discuss skin issues
  • Revise treatment protocol to be more detailed
  • Wound care products to be reorganized on units
  • Unit educators to address skin issues during annual competency testing
  • CNA and RN to report at shift change to identify patients with skin issues
  • Task list to be created for CNAs
  • ET accountability tracking tool to be issued for non-compliance with prevention and treatment protocols as needed

Results and Recognition

Since this was a quality-focused project, the benefits are measured in cost avoidance and an overall improved quality of care. A 60 percent reduction in the overall nosocomial pressure ulcer rate resulted in an annual cost avoidance of approximately $300,000.

To make sure their initiatives are producing a positive impact on the patient care environment, the hospital continuously measures patient and employee satisfaction through Press Ganey. Inpatient satisfaction is consistently ranked in the 99th percentile and employee satisfaction in the 97th percentile. TRMC also has received recognition in the industry for their achievements, including the Louisiana Performance Excellence Award for Quality Leadership (Baldrige criteria), Studer Firestarter Award and Press Ganey Excellence Award.

“This project is a perfect example of the need to verify underlying causes using valid data, rather than trusting your instincts alone,” said Sheri Eschete, Black Belt and leader of the pressure ulcer project at TRMC. “Six Sigma provided us with the tools to get to the real problem so that we could make the right improvements. There had been a perception that not turning the patients often enough was the issue, but the data revealed that it was really the frequency of the Braden Scale. Leveraging the data helped us to convince others and implement appropriate changes.”

The nosocomial pressure ulcer rate is monitored monthly as one of the patient-focused outcome indicators of quality care. The results are maintained on the performance improvement dashboard (Figures 3 and 4).

Figure 3: Stage 3 and 4 Nosocomial Ulcers

Figure 4: Stage 2 Nosocomial Ulcers

Learn more about lean six sigma in healthcare :  Six Sigma Master Class – Improving Healthcare Processes

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How to Use Value Stream Maps in Healthcare

Carly Barry 27 February, 2013

While value stream mapping, or VSM, is a key tool used in many Lean Six Sigma projects for manufacturing, it’s also widely used in healthcare.

Value stream mapping can help you map, visualize, and understand the flow of patients, materials (e.g., bags of screened blood or plasma), and information. The “value stream” is all of the actions required to complete a particular process, and the goal of VSM is to identify improvements that can be made to reduce waste (e.g., patient wait times).

Value Stream Map - example from manufacturing

How is VSM applied to healthcare?

When used within healthcare, one obvious application for VSM is mapping a patient’s path to treatment to improve service and minimize delays.

To accurately map a system, obtaining high-quality, reliable data about the flow of information and the time a patient spends at or between steps is key. Accurately timing process steps and using multi-departmental teams is essential to obtain a true picture of what’s going on.

To map a patient’s path to treatment, a current state map can be created in a VSM tool (we offer a powerful one in Companion by Minitab) to act as a baseline and to identify areas for improvement:

Current State Value Stream Map

In this example, the first step a patient takes is to visit his general physician (abbrev. “GP” above), and this is represented as a rectangular process shape in the VSM. The time the patient spends at this step can be broken down into value-added (“VA”) and non value-added (“NVA”) cycle times. VA is time the customer is willing to pay for: that is, the 20 minutes spent consulting with the GP. NVA is the time the customer is not willing to pay for, i.e., the 20 minutes spent in the waiting room before the appointment.

The dotted line arrow between process steps is called a push arrow. This shows that once a patient completes a step, they are “pushed” to the next step. This is inefficient, and a more efficient process can be designed by changing push steps to continuous flow or “pull” steps. The yellow triangles indicate the time a patient spends waiting for the next process. These steps are a non-value added action for the patient.

While VSM can certainly be done by-hand on paper, using computer-based tools like those in Quality Companion makes the process a lot easier. For example, Quality Companion automatically calculates and displays a timeline underneath the VSM, which adds up the total time to go through the entire system (aka “lead time”) and displays summary information.

By identifying all of the steps, you can start to map the whole process out, moving from left to right. Once you have mapped out the entire system, an ideal future state map can be created, and possibly a series of future states in between. These can identify areas for improvement, and once implemented, they can become the “new” current state map as part of an iterative quality improvement process.

How do you improve the current state map?

When looking for areas of improvement, try to focus on changes to improve the flow of patients through the process. Continuous flow is the ideal and moves patients through the system without them having to wait. However, continuous flow is not always possible, so instead other changes might be introduced—such as first-in first-out (FIFO).

Also be sure to take a look at the takt time, which can help you decipher the pace of customer demand. In this case, takt time can be interpreted as the number of patients that can be treated per unit of time. Quality Companion will calculate takt time automatically.

Once you have completed the current and future state maps, you can compare the two, quantify improvement opportunities, and look at how to implement the changes. In this example, the triage and sort/appointment steps might be combined so that fewer visits to the hospital were required by the patient and they receive treatment faster.

To see another example value stream mapping, check out this video that features a scenario from Companion’s extensive help system:

Learn more about lean six sigma in healthcare :  Six Sigma Master Class – Improving Healthcare Processes

Congratulations Felicia Sadler on becoming a Certified Lean Six Sigma Black Belt!

1/07/2016 For Immediate Release – Phoenix, Arizona * United States

TPMG would like to congratulate Felicia Sadler for successfully completing the Lean Six Sigma Excellence in Healthcare Delivery Black Belt Certification program and earning her lean six sigma black belt!  She successfully completed a rigorous 16 unit – 65 lesson online blended lean six sigma black belt workshop by passing the certification examination with distinction.  In addition, she service as a Malcolm Baldrige examiner on the Tennessee Center for Performance Excellence Board of Examiners.  Ms. Sadler was selected to serve on a Level 4 team which evaluated an applicant from the healthcare sector.  As a member of the team she:

  • Conducted an independent review of the written application addressing all 17 items of the Criteria for Performance Excellence.
  • Consolidated findings from Independent Review for assigned items during the Consensus Review stage.
  • Participated in Consensus Meetings to reach agreement on the organization’s strengths and opportunities for improvement to verify/clarify during site visit.
  • Participated in a 3-day Site Visit at the applicant’s facility, where the team interviewed staff, reviewed documents, and toured facilities.
  • Participated in post-site visit meeting to review findings, and finalize feedback comments.

Congratulations Felicia!

Felecia is Vice President of Quality and Performance at Prophecy Healthcare.  She holds a BSN in Nursing from South University and an MJ in Health Law from Loyola University Chicago School of Law.  Felicia has over 25 years of successful experience as a nurse, clinical educator and healthcare administrator.

The Performance Management Group’s Lean Six Sigma Excellence in Healthcare Delivery Black Belt Certification Program is specifically designed for professionals who work for healthcare clinics, hospitals and systems. TPMG has been certifying green belts and black belts for more than 15 years. The company provides lean six sigma certification on-site, online, and on-campus (at the University of Phoenix) nationwide. For more information regarding lean six sigma training, certification and consulting – contact TPMG llc at 623.643.9837 or logon to www.helpingmakeithappen.com.

Congratulations Kathleen Harland on becoming a Certified Lean Six Sigma Green Belt!

8/27/2015 For Immediate Release – Phoenix, Arizona * United States

TPMG would like to congratulate Kathleen Harlan for successfully completing the Lean Six Sigma Excellence in Healthcare Delivery Green Belt Certification program and earning her lean six sigma green belt!  She successfully completed a rigorous 10 unit – 45 lesson online lean six sigma green belt workshop by passing the certification examination with distinction.  This accomplishment acknowledges she has fulfilled the requirements for the green belt program of study and, from this day forward, is certified as a Lean Six Sigma Green Belt.  By completing this distinctive course, she is qualified and authorized to implement lean applications and performance management systems.  Congratulations Kathy!

Kathy is Sr. Director Standardization Programs at Novation (VHA, UHC, CHA) and has more than 15 years experience in the healthcare industry.  She holds a B.Sci. in Business Administration from The University of Texas at Dallas and an MBA from The University of Texas at Arlington.

The Performance Management Group’s Lean Six Sigma Excellence in Healthcare Delivery Green Belt Certification Program is specifically designed for professionals who work for healthcare clinics, hospitals and systems. TPMG has been certifying green belts and black belts for more than 15 years. The company provides lean six sigma certification on-site, online, and on-campus (at the University of Phoenix) nationwide. For more information regarding lean six sigma training, certification and consulting – contact TPMG llc at 623.643.9837 or logon to www.helpingmakeithappen.com.

Congratulations John Elliott on becoming a Certified Lean Six Sigma Black Belt!

8/27/2015 For Immediate Release – Phoenix, Arizona * United States

TPMG would like to congratulate John P. Elliott for successfully completing the Lean Six Sigma Excellence in Healthcare Delivery Black Belt Certification program and earning his lean six sigma black belt!  He successfully completed a rigorous 16 unit – 65 lesson online blended lean six sigma black belt workshop by passing the certification examination with distinction.  The goal of Johns’s lean six sigma black belt project was to increase the utilization of his system’s infusion center.  His black belt project successfully realized a 47% increase in utilization along with more than an 80% increase in daily revenue.   To alleviate the staff of these impediments, the team implemented several solutions, primarily in the scheduling and communication areas. The solutions currently in place had a significant impact on Chair Turns, Net Profit, and Chair Utilization. Congratulations John!

John is a Director of Healthcare Engineering at Tallahassee Memorial Hospital.  He holds a B.Sci. Industrial Engineering from Mississippi State University and a Masters Degree in Hospital Administration from Tulane School of Public Health and Tropical Medicine.  John has over 25 years of successful experience in both large NFP and FP healthcare systems, inclusive of healthcare financial and operational management consulting and is also a Fellow for American College of Healthcare Executives

The Performance Management Group’s Lean Six Sigma Excellence in Healthcare Delivery Black Belt Certification Program is specifically designed for professionals who work for healthcare clinics, hospitals and systems. TPMG has been certifying green belts and black belts for more than 15 years. The company provides lean six sigma certification on-site, online, and on-campus (at the University of Phoenix) nationwide. For more information regarding lean six sigma training, certification and consulting – contact TPMG llc at 623.643.9837 or logon to www.helpingmakeithappen.com.

Lean Healthcare Master Black Belt Services

We Did It!

We did it 3

We successfully established a high quality and effective lean healthcare program in our organization at 30% of the traditional consulting cost.

Our Program Consists of:

Lean 6σ Healthcare Program Office

1.  Established Lean 6σ vision and strategy

2.  Defined and facilitated governance model

3.  Managed DMAIC and Kaizen projects (average project savings of $223k per year)

4. Portfolio management, project evaluation and prioritization system

5. Systematic project reporting, updating and communication

6. Trained and certified “home grown” black belts, green belts and leaders

Learn about how we did it with TPMG!  Schedule a complimentary/no obligation analysis or advisory session with a TPMG faculty member or performance manager.    Click Here!

Download a Lean Transformation in Healthcare Service Description – Click Here!

Lean Healthcare Professional Services

Lean Healthcare – We Did It!

we did it 1

We Did It!!!!

We successfully established a high quality and effective lean healthcare program in our organization at 30% of the traditional consulting cost. Learn about how we did it with TPMG!

Our Program Consists of:

Lean 6σ Healthcare Program Office

1.  Established Lean 6σ vision and strategy

2.  Defined and facilitated governance model

3.  Managed DMAIC and Kaizen projects (average project savings of $223k per year)

4. Portfolio management, project evaluation and prioritization system

5. Systematic project reporting, updating and communication

6. Trained and certified “home grown” black belts, green belts and leaders

Schedule a complimentary/no obligation analysis or advisory session with a TPMG faculty member or performance manager.    Click Here!

Download a Lean Transformation in Healthcare Service Description – Click Here!

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