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The Heart of the Matter: Hospital’s Improved Diagnostic Process Saves Lives and Money

You expect to find many lifesaving techniques in hospitals—expensive medical research, groundbreaking procedures—but when it comes to treating patients with cardiovascular disease, the approach one Taiwanese hospital used might surprise you: data analysis.

Heart disease is one of the leading causes of death in Taiwan, so it’s no wonder the country’s healthcare professionals are looking for ways to improve treatment options.

That’s why a Lean Six Sigma project team at Cathay General Hospital in the city of Taipei examined the emergent angioplasty process for treating patients suffering from acute ST-elevation myocardial infarction (STEMI), a heart attack caused by coronary heart disease. Improving aspects such as the wait time between diagnosis and treatment could help to save many lives.

Doctors and quality managers from the hospital’s Quality Management Center used Minitab Statistical Software to assess the hospital’s process and confidently re-engineer both the diagnosis and treatment processes while increasing savings in medical resources.

The Challenge

A project team at Cathay General Hospital used Minitab Statistical Software to analyze data that would improve treatment for patients suffering from heart attacks. Above, the hospital is shown in its Taipei City, Taiwan, location.

Patients with STEMI are diagnosed through electrocardiogram findings and cardiac markers, and the recommended course of treatment for these patients is angioplasty completed within 90 minutes of arrival.

Medical professionals refer to this period as the door-to-balloon (D2B) time, because angioplasty involves inserting a small balloon inside the blocked blood vessel with a catheter. When inflated at the site of the blockage, the balloon enables blood flow to resume.

To maximize the patients’ chances for survival, the team needed to evaluate each step of the process. They needed to identify which variables were responsible for a D2B time that exceeded the recommended treatment time, and, more importantly, what adjustments could be made to minimize it.

How Minitab Helped

The team analyzed D2B time—which includes an electrocardiogram, the wait time before the operation, and the time for balloon inflation—using Minitab Statistical Software.

However, you can only trust the results of an analysis if you trust the data you’re analyzing. To ensure the data were trustworthy, the project team used Minitab to conduct a Gage R&R Study of their measurement system. This method evaluates a system’s precision, including its repeatability and reproducibility to ensure that measurements are consistent and reliable.

Minitab’s Assistant menu makes it easy to choose and use the right tool, even if you’re not a statistician. The dialog box above helps users create a data collection worksheet for a Gage R&R study.

Once they verified the precision of their measurements, the team analyzed D2B data from 40 STEMI cases that occurred over a nine-month period.

First, they tested the data to see if it followed a normal distribution, which is a key assumption in many types of analysis. The data were not normally distributed, but using Minitab the team easily applied a Box-Cox transformation to normalize it. The team then used the transformed data to create an I-MR control chart to evaluate if their process was stable over time. This type of control chart plots both individual observations (I) and the moving ranges (MR) to show how the mean and variation in the observations change over time.

The I-MR control chart above displays the normalized data from the Box-Cox transformation and identifies unusual sources of variation in the data.

The project team also used Minitab to conduct a process capability analysis to determine whether their process met performance specifications and provide insight into how they might improve their process. In this case, the upper specification limit for D2B time was 90 minutes. The results of the capability analysis confirmed that the hospital’s handling of STEMI cases had significant room for process improvement.

The team examined each step in handling a STEMI patient and identified several areas in which efficiency could be significantly enhanced, including confirming the diagnosis, medicating the patient, preparing for the operation, transferring the patient to the catheterization laboratory, and inflating the balloon.

Results

After assessing the STEMI process, the team implemented improvements such as sending patients who arrive with chest pain directly to an electrocardiogram test, printing treatment sheets automatically as opposed to writing them by hand, making a STEMI medication pack available in the emergency department, contacting the catheterization staff upon diagnosis confirmation, prepackaging all STEMI operation equipment in one box, and discontinuing the use of operation time as a forum to teach staff members who are not familiar with the procedure.

The team then collected additional data and reevaluated the process. Using Minitab to analyze the new data, the team demonstrated that the average D2B time dropped from 139.2 to 57.9 minutes—a 58.4% improvement. Furthermore, capability analysis showed that this new process could meet specifications.

A more efficient process means patients receive angioplasty more quickly, which saves lives. Moreover, the average hospital stay for STEMI patients has decreased by three days since the new process was implemented, and the hospital has saved $4.4 million in medical resources. The project was recognized by the Taiwan Joint Commission of Hospital Accreditation, and was awarded the Symbol of National Quality by the Institute for Biotechnology and Medicine Industry.

Applying data analysis and Lean Six Sigma methods to the health care system doesn’t grab headlines like an experimental surgery might. But as more hospitals use data analysis to make procedures better, faster, and safer, its benefits will be seen every day in the faces of patients whose lives are saved.

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

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Mapping the Healthcare Value Stream

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

Congratulations Michael Cossiart on Becoming a Certified Lean Six Sigma Black Belt!

7/7/2017 For Immediate Release – Phoenix, Arizona * United States

TPMG would like to congratulate Michael Cossiart 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 the rigorous 16 unit – 65 lesson online blended lean six sigma black belt workshop by passing the certification examination with distinction.  The goal of Michael’s lean six sigma black belt certification project was to improve the throughput and productive capacity of his hospital’s radiology department.   His black belt project successfully eliminated 80 hours of non-productive wait time per month, decreased overtime by 44% ($245k annual savings) and increased the capacity to serve 22 more patients per month.  Congratulations Michael!

Michael Cossiart serves as a Program Manager in Performance Improvement at PeaceHealth.  He has more than 14 years professional experience in healthcare and served as an industrial engineer for 3 years at the Boeing Corporation.

Michael earned his Masters in Business Administration  from Western Washington University and holds a Bachelors Degree in Industrial Engineering from the Oregon Institute of Technology.

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.

Pediatric Hospital in Tough Market Pegs Growth to Lean Process Improvement

By Tonya Vinas

Akron Children’s Hospital (ACH), a regional pediatric care system headquartered in Northeast Ohio, could be compared with David, the young lad who courageously brings down a giant in a classic Old Testament tale.

In this story, though, David battles two giants.

Akron is about 35 miles south of Cleveland, where two nationally ranked pediatric hospitals draw families from around the world who need specialized care for their children’s complex medical problems. Parents are attracted to the hospitals’ international reputations for being among the best: The Cleveland Clinic’s Children’s Hospital and University Hospital’s Rainbow Babies and Children’s Hospital are known for breakthrough research, life-saving surgeries and treatments, and other medical innovations. They also aggressively recruit gifted doctors, leading scientists, and other medical experts at the top of their professions.

But ACH, which certainly has a stellar regional reputation, is taking a unique weapon into the field as it battles for a bigger slice of the state’s pediatric care market. While the two Cleveland hospitals have continuous-improvement programs, neither has made continuous improvement a strategic imperative across its entire enterprise as ACH has.

The hospital’s Center for Operations Excellence (COE) is the engine that propels all employees and functions toward the growth goals set by executives and board members in hoshin kanri (strategy deployment) planning. Leaders are confident that the COE and its lean six sigma-focused training and project leadership give ACH enough competitive advantage to succeed, even in the same geographic market as two healthcare giants.

ACH’s expansion plan includes increasing the number of patients served both geographically and within certain sub-specialties; becoming the No. 1 choice for parents and referring physicians through quality achievements and availability of services; improving on infrastructure, quality, and clinical programs; and becoming the primary site for pediatric medical research in Northeast Ohio.

Already, the three-year-old COE has been widely embraced and highly effective. Projects have saved ACH millions of dollars, increased utilization of expensive assets, and reduced wait times and processing for patients and their families. The short-term gains are important, said Doug Dulin, the COE’s senior director, but the learning and commitment that each project builds internally are more crucial.

“What it comes down to is that we have to create a competitive advantage,” said Dulin, who learned the Toyota Production System at Aoyama Seisakusho, a Tier One supplier to Toyota Motor Manufacturing. “So how can we transfer what we’ve already done into every segment of the hospital? That’s how the Center for Operations Excellence fits in. This is a long-term journey.”

Akron Children’s Hospital at a Glance

  • Largest pediatric healthcare system in northeast Ohio.
  • Operating two freestanding pediatric hospitals and offering services at nearly 80 locations.
  • Pediatric specialties draw half a million patients annually, including children, teens, and adults from all 50 states and around the world.

Level-Loading Schedule Improves Quality, Access, and Revenues

In addition to the challenge of having two highly regarded competitors in the market, ACH must do much more with much less. It doesn’t receive the numerous large grants and donations that the others do; and since all of the hospital’s patients are children, it can’t rely on Medicare reimbursements. Also, both the Clinic and UH are closely aligned with Case Western University Medical School in Cleveland, and so have access to more intellectual property, research programs, emerging technologies, and other assets than ACH has.

The hospital system’s smaller and less complex operation, however, seems to have been an advantage for quickly absorbing the lean culture. Evidence of how open all levels of the organization have been to lean is the speed with which a large number of employees — including doctors — have come together to identify problems, find the root causes, and then agree on countermeasures.

“There’s something about the culture at Children’s that allowed this to be very effective, very quickly,” said Board Member Bill Hopkins. “They were just primed for this. It speaks volumes about the commitment from everybody — the leadership, staff doctors, nurses.”

For example, MRI scheduling was one of the first areas the COE addressed because it had potential for significant and fast improvement, and because the hospital had not been able to effectively utilize a second MRI machine it had purchased. The most apparent barrier was a bottleneck in scheduling.

A kaizen event revealed that variability was the root cause:Children are more prone to move during exams when they need to be still, a reality that extends their appointment times because readings frequently need to be delayed or redone. On any given day, more than half of the hospital’s patients are five-years-old or younger, and so are particularly prone to moving during exams. Some children need to be sedated to keep them still. This causes more variability because a doctor needs to administer the sedation, and doctors’ schedules routinely change without notice because of emergencies and other unexpected events. The result was a backlog of patients with appointments, and long wait times for those needing new appointments.

The two-day kaizen — which included radiologists, radiology technologists, schedulers, nurses, and the employees who handle insurance authorization and registration — produced multiple solutions:

  • Modifying the master schedule.
  • Streamlining the insurance authorization Process.
  • Implementing standardized work instructions.

As is often the case with a level-loading solution, modifying the master schedule seemed counterintuitive, but it worked. More time was scheduled for each exam, a change that made it easier for the end-to-end Process to absorb variability and remain level (on schedule). This eliminated the bottlenecks that were causing the long wait times for exams and results. In cycle-time terms, the “appointment-to-results” cycle shrunk drastically as the department got its scheduling Process under control. As a result, more capacity opened, and this allowed an increase in throughput (appointments) without adding resources.

“Before the kaizen, the hospital was doing about 86 MRIs per week. Now, on average, we are doing 112,” Dulin said. “That is good news for our patients and the physicians who are waiting on the results of those tests. Instead of waiting 25 days for an uncomplicated exam, families can now schedule same-day appointments.” (See chart: Outpatient MRI Appointment Wait Times.)

The project significantly improved the hospital’s bottom line, with $1.2 million in additional revenue attributed to the better MRI scheduling.

It also earned ACH an honorary mention award at the International Quality and Productivity Center’s Lean six sigma & Process Improvement Summit in January, 2011. The award was in the category of “Best Process Improvement Project Under 90 Days,” with Akron Children’s competing against five other international companies and organizations that were selected as finalists.

akron_childrens_exam_table

Surgery: Greater Capacity, Higher Quality without $3.5 Million Expansion

Perhaps the most striking example of how lean processes will feed ACH’s efficient growth is the avoidance of spending $3.5 million to enlarge the sterile processing area within the surgery department. According to Mark Watson, president of the ACH Regional Network, surgeons were performing 12,000 operations a year, and the number of cases was increasing. (They performed 14,000 in 2010.) Sterilization technicians had a hard time keeping up, but expanding space and staff would have been a problem.

“Our surgery area is landlocked,” explained Watson, who first introduced the idea of lean Process improvement to the hospital. “In order to give sterile processing more, I would have to take away from someone else. So we started really looking at what was going on in the operating room, and we started with our flash-sterilization rate.”

The team decided this was the most urgent need — a flash sterilization rate of 10 percent was not acceptable, Watson said. (Flash sterilization is the immediate and unscheduled sterilization of instruments that have been dropped or otherwise contaminated during the surgery processes. It is a quality problem that creates variability and waste.) They scheduled a kaizen focused on reducing flash sterilization. The resulting improvements not only reduced flash sterilization to 2 percent, but also opened all the capacity needed to add an additional 4,000 surgeries a year.

“It was amazing what happened in the week-long program,” Watson said. “We fixed flash sterilization, and increased the capacity of the operating room to 16,000 cases. We invested in one flat-screen TV, and we took down one wall. We have a sterile processing department that could handle all the work that was there and more without expanding one square foot.

akron_childrens_baseball_image

(Continuous-improvement ideas contributed by clinical coordinators from Akron Children’s Hospital Radiography School program)

“And now, we’ve done two capacity studies on surgery, and we are running at 64 percent. It will take 2.5 years, but we want to get to 85 percent efficiency, which would mean around $15 million in additional revenue in the same operating room with essentially the same people.”

Low-Tech Solutions Increase Customer Value

In addition to increasing the number of procedures, the hospital is focusing on patient Value in the form of decreasing wait times and increasing accessibility to doctors and services. This supports the goal of being the No. 1 choice for Northeast Ohio parents.

Outpatient doctor visits was an obvious place to start. If there is any customer who is most deserving of getting more from service providers, it’s a parent with a sick child. Emotionally drained and frequently exhausted, such parents Value predictability and kept promises. Less time spent at the doctor’s office means more time to take care of themselves and their families.

The doctors, nurses, and other employees at ACH’s Locust Pediatric Care Group know this. When deciding on a Process improvement goal, their focus was reducing the amount of time that established sick patients spend in the clinic. By its nature, the clinic is an unpredictable place as patients stream in from the city of Akron and surrounding urban and rural communities. Many of the children are poor, recent immigrants, or in foster care. All of them have potentially complex social and medical needs, and all of them receive care regardless of ability to pay.

Through a series of kaizens and A3-based project planning and implementation, the Locust team identified and implemented a number of improvements that reduced patient in-clinic time from 70 minutes (2009) to 43 minutes (2011). Significant improvements included:

  • Converting paper charts to electronic medical records, which helped to streamline the information flow.
  • Implementing visual whiteboards that track patient flow during the appointment.
  • Adding a team-wide “huddle” at the start of the day to prevent problems, such as scheduling issues.
  • Eliminating triage rooms — where patients would be evaluated for priority of care — instead using mobile triage carts in the exam room.

The team is working on more definitive documentation, but early feedback is that customer Value has increased.

“Office flow and access are the two biggest areas at Locust Peds where we can meet and exceed expectations from our patient families,” said Cindy Dormo, vice president for Pediatrics. “Now we’re measuring patient throughput and reviewing feedback from patients, which in the past has included complaints about long wait times, but is now turning favorable.”

Blue Belt Training Brings More People In

Dormo and other top-level executives said a key to the COE’s success is a focus on engaging all levels of the organization. Most recently, the COE team created a Blue Belt training program to focus on department and functional leaders, positions that would be considered “middle management” in a corporate setting. According to Dulin, the Blue Belt program is another example of how the COE program is directly supporting strategic growth goals.

“Our goal is to have this touch everyone. We then have everyone supporting the hospital’s goals, which then improves all of our major systems,” Dulin said.

Taking advantage of interest and enthusiasm generated by the MRI project’s success, the COE team chose the radiology department for the first Blue Belt training program. Every lead technologist, supervisor, manager, director, radiologist, the department chair and vice president participated.

Blue Belt participants learn how best to use the talents of their staff to streamline operations, improve the quality of care provided, and reduce variability and waste. Lessons focus on daily communication among staff members and leadership, learning how to track and improve daily metrics, and creation of standardized processes that stabilize patient flow.

The Blue Belt program is spreading to other departments. The plan is to begin with Dept. of Pediatrics employees, and then expand to surgical subspecialties, the Akron Children’s Heart Center, and Neurodevelopmental Sciences Center. In all at least 300 employees will have completed or been affected by Blue Belt training by the end of 2011.

Lessons Learned and a New Opportunity

Watson, the hospital executive who introduced continuous-improvement at ACH, identified these key factors as contributing to the COE’s early success:

Founding COE leaders: “After the decision was made to go with lean, I spent almost three months selecting people from our organization to help us on our lean journey,” he said.

Watson purposefully chose individuals who were successful, respected by their peers, and brought diverse backgrounds to the effort. These included a doctor with lean six sigma knowledge, a pharmacist who had just completed her Pharm.D., a medical technologist, a nurse, an M.B.A., and an administrator.

akron_childrens_rubin_st_john_etc

(From left, Dr. Mike Rubin, Dr. D. Scott St. John, Dr. Godfrey Gaisie, and Dr. Azam Eghbal from the Radiology Dept. hold their daily accountability meeting as part of continuous-improvement Blue Belt Training.)

Watson also stressed the importance of having a practicing physician on the team. When Dr. David Chand joined ACH after working as a consultant, he dedicated 20% of his time to the COE and the rest to seeing patients. His role in the CEO has since expanded to about 90% of his time, but he will always see patients.

“When you are dealing with physicians, in order to be considered part of the club, you really need to have a stethoscope and see patients,” Watson said. “They like to interact with other physicians who are seeing patients. That’s just the way it is.”

Chand has been invited to work on improvement projects in many areas of the hospital and has become the go-to man for other doctors interested in learning more about the COE, some of whom are in the Process of green-belt certification. His personal A3 projects have included removing non-Value-add time from the residents’ patient-rounding Process (daily in-person visits to patients).

Investing in education and training: Watson said an additional attribute that he looked for in team members was a quest for life-long learning.

After he assembled the team, Watson immediately sent them to a lean six sigma program at Johns Hopkins University, which included six weeks of learning over a four-month period of time (with project work done at ACH). The team then spent a week at Seattle Children’s Hospital to observe and learn from that CI program. In 2010, two team members received master’s degrees in operational efficiency and black belts from Ohio State University. Three others are now going through the course and will graduate in 2011.

Additionally, several department VPs have attended classes at Johns Hopkins and programs at Seattle Children’s Hospital.

“But we made a mistake,” Watson said. “When we started, we started with our front-line people working on projects with the A3 Process. And we had very good engagement from the executive level, vice president and above. But what we left out was that middle manager level.

“Now the middle managers are really enjoying and learning with the Blue Belt program. The A3 Process works much better now that we’ve covered the entire organization in terms of learning what we are doing. Our tagline is Process improvement through people development.

Accepting failures/celebrating success: Not every project will be successful, Watson said, “and if they are all successful, you are not taking enough risks.”

ACH’s ambition is being noticed and rewarded outside of its own facilities. This year, it was awarded a contract by a third Cleveland hospital, MetroHealth Systems, to provide pediatric care in cardiology, gastroenterology, cancer and blood disorders, and critical care.

“We are impressed by how fully Akron Children’s is integrated into the region, how well it has partnered with other hospitals, and its growth, having added 77 individuals to its medical staff in

2009,” said Margaret Stager, chair of the Dept. of Pediatrics at MetroHealth. Previously, UH pediatric specialists were contracted to provide the services.

 Akron Children’s Hospital Center for Operations Excellence

A3 Program

  • Started in January of 2009
  • Eight-week Lean six sigma Training designed for the people who do the work on a daily basis
  • Projects are done on A3 paper using the DMAIC (Define, Measure, Analyze, Improve, Control) methodology
  • Meet weekly for two hours of class time and one hour of coaching

Green Belt Program

  • 10 Green Belts certified through Johns Hopkins Center for Innovation in Quality Patient Care
  •  20 Green Belt candidates working on certification through Akron Children’s Hospital’s Green Belt Training Program.
    • Candidates and projects selected by hospital leadership
    • Ten days of training and project work spread out over five months using DMAIC methodology
    • Tollgate session at the end of each DMAIC step

 Kaizen Program

  •  Two-to-five-day rapid Process improvement events
  •  Strategically driven by hospital leadership
  •  Multi-disciplined teams that cross over Value streams
  •  Key stakeholders from the Value streams work together to solve problems and implement solutions

 Blue Belt Program

  • Manager/Leader Lean six sigma training for departmental certification
  • Basic understanding of Lean six sigma principles and tools: gemba walks, daily huddles, Value stream maps

Akron Children’s Hospital: As the largest pediatric healthcare provider in northeast Ohio with hospital campuses in Akron and the Mahoning Valley, the dedicated team at Akron Children’s Hospital promotes the well-being of children now and in the future. We perform more than 600,000 patient visits each year at more than 85 locations. Our specialists care for infants, children, teens, and adults treating a wide range of conditions from routine primary care to the most complicated injuries and illnesses.

Akron Children’s earned the Gold Seal of Approval from the Joint Commission, as well as Magnet Recognition Status for nursing excellence from the American Nursing Credentialing Center. We are a major teaching affiliate of Northeastern Ohio Universities Colleges of Medicine and Pharmacy, and offer a number of pediatric subspecialty fellowship training programs. Our Rebecca D. Considine Research Institute is committed to advancing the prevention and treatment of pediatric illnesses and supporting the education and training of research staff. For more information, visit http://www.akronchildrens.org.

For more information regarding Lean Transformation in Healthcare, contact TPMG Professional Services at Lean Management Excellence in Healthcare Delivery.

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

Lean Methods: Miami Childrens Hospital

Want to learn more about Lean Six Sigma in Healthcare:  Click Here!

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