Lean Transformation in Healthcare

Home » Posts tagged 'What is six sigma?'

Tag Archives: What is six sigma?

Excellence in Healthcare Delivery

Advertisements

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

Advertisements

What is Six Sigma?

Six Sigma at General Electric


General Electric enjoys the distinction of having the highest market capitalization of any public company in the world – $321 billion. Former CEO, Jack Welch attributes much of this success to the company’s Six Sigma program. Since 1995, GE has reaped more than $14 billion in cost reductions alone from their investment in Six Sigma. Here are a couple of GE success stories:

  • By changing test & repair processes, a Six Sigma Team improved on-time delivery, increased productivity and saved  $4 million dollars for GE Appliances.
  • At a GE Plastics plant, a Six Sigma Team reduced lead time for matching colors of resins by 85% a distinct and real competitive advantage in the fast-paced global market for plastics.

What exactly is Six Sigma?

In laymen’s terms, Six Sigma performance is achieving perfection in the manufacturing of products and delivery of services. The mathematical symbol σ (sigma) is a Greek letter that represents variation. A sigma value, or standard deviation, indicates how well a process is performing. A process is performing at a 6σ level if it achieves 3.4 errors out of every million opportunities (3.4 EPMO).  This level of performance, in manufacturing and in service outcomes, implies the process is 99.9997 effective or “process perfect”. What does that mean to every day working professionals?  It means:

  1. 10,800,000 mishandled healthcare claims would not be mishandled.
  2. 18,900 US Savings bonds lost monthly would not be lost.
  3. 54,000 checks lost nightly by a single large bank would not be lost.
  4. 4,050 incorrect telephone bills sent out monthly by a modest sized telecommunications company would not be sent out.
  5. 540,000 erroneous call details recorded daily by a regional telecom company would not be recorded.
  6. 270,000,000 erroneous credit card transactions recorded each year would not be recorded.

With numbers like these, it’s easy to see that the modern world of business demands extremely high levels of error free performance. Six Sigma rose in response to this realization.

Six Sigma Means Freedom from Deficiencies

Products and services with deficiencies create customer dissatisfaction. They are also costly to a company because mistakes must be identified and corrected, and the customer must be appeased. What is more, the original work is wasted. In the world of Six Sigma these costs are referred to as the cost of poor quality (COPQ). For most companies, costs associated with wasted effort and corrected work is between 20 and 40 percent of total operating expenses. These costs can be found in all operational and administrative areas. All these costs can be trimmed when quality is improved by reducing deficiencies. Here are just a few examples:

  • By cutting defects in work out processes by 96%, GE Capital was able to offer borrowers quicker solutions while reducing claims payments by $8 million.
  • Prudential Financial estimates that Bank of America will save nearly $1.2 billion, by reducing deficiencies, in its first year of deploying Six Sigma.
  • In its first year of limited deployment of Six Sigma, Phelps Dodge saved over $80 million.

These are many reasons why investing in Six Sigma programs is increasingly considered a mission-critical business strategy, even among mid-sized and smaller firms.

Learn more about High Quality, Affordable Lean Six Sigma Training for Healthcare visit: www.helpingmakeithappen.com

®All rights reserved 2012

%d bloggers like this: