Sustaining Lean Six Sigma Projects in Health Care By Paul Murphree, MD, Richard Robert Vath, MD, FCCP, and Larry Daigle

Transcription

1 Quality Sustaining Lean Six Sigma Projects in Health Care By Paul Murphree, MD, Richard Robert Vath, MD, FCCP, and Larry Daigle In this article Take a look at practical steps to take to sustain Lean Six Sigma projects even after they are considered closed. Recent pay-for-performance and realignment of financial payments to promote improved quality have caused hospitals to commission projects to improve their performance for specific clinical issues; such as catheterassociated urinary tract infections (CAUTI), decubitus ulcers, community-acquired pneumonia, and other disease processes. Many hospitals are currently using multiple quality improvement techniques to help address these clinical processes. LSS 1 is being applied increasingly in health care 2 quality improvement efforts that focus on a defined problem within an organization. Additionally, the overall gains supported through these projects nearly universally decline after the major focus of the project. 3 Another program many health care organizations are using to evaluate their overall performance and organizational processes is the Malcolm Baldrige criteria. 4 One of the evaluation tools used by Baldrige examiners is called ADLI, which is an acronym for approach, deployment, learning, and integration. The approach and deployment are typically performed through the active phase of the project life-cycle; however, learning and integration are often not specifically addressed, but both learning and integration should be addressed prior to the final phase of the project. Therefore, applying the ADLI evaluation tool as a checklist at the conclusion of projects may help maintenance of the improvement, and these items are often overlooked by health care organizations at the conclusion of a project. Closing vs. controlling When improvement has been achieved from a quality improvement project, many leaders are ready to close the intense project and declare victory. However, when the Hawthorne 5 effect is removed, performance almost universally declines. Instead of closing a project, the project should be moved into a control phase. While the phrasing may seem insignificant, the psychological impact and organization benefit are quite different. Six-sigma defines the last C in the acronym DMA (define, measure, analyze, improve, and control) as control (not close. ) Control assumes this is still very strategic to the organization, and will be directly or indirectly monitored by the organization for the foreseeable future since the project was selected in the first place for a strategic initiative that is important to the organization. Steps for learning and integration The authors developed a checklist regarding specific items that enhance learning and integration to be addressed before a project enters into the control phase. This checklist is given to the project leaders to ensure that learning and integration have been addressed prior to the control phase (Table 1). These items are presented at the performance improvement oversight committee for acceptance to enter into the control phase of the project. This project leader no longer presents project data, but is tasked with describing what was learned and how the organization should monitor the project. Knowledge about the successful interventions during the project may be captured and used in a control plan. Control plans are a greatly underused tool in health care quality improvement projects. The basic premise of a control plan is to specify who is to take what actions when a significant decline in performance has been detected. An example of a control plan is 44 PEJ january february/2011

2 in Table 2. This requires three basic components for the triggering of the action phase of the control plan: 1. A sensitive measure for ongoing performance monitoring has been selected. 2. The metric is being monitored frequently enough such that performance declines are detected early. 3. Specific actions that caused the improvement during the project are known and ready to be redeployed quickly. Often the limitation of adequate control measures is that data collection is manual during the project phase and thus time-intensive. Through computer-generated reports, reduced number of metrics, simplified data collection, and/or less frequent sampling of the key metric data, the organization can decrease the burden of ongoing monitoring in the control phase. Additionally, as part of the control plan, important educational flyers, letters, data collection tools, and other important tools that had an impact during the project can be saved as attachments to the action plan so that execution is easier and quicker than regenerating these items. Integration of the changed process is required to avoid regression of performance back to the previous levels. Policies and procedures should be updated to reflect any changes in the process. This helps support the changes and also ensures conflicting information is not found in an older policy. Additionally, flowcharts are a powerful supplement to the written procedure, and flowcharts allow busy nurses and other clinicians to understand what the verbal description of the procedure is trying to convey in a much faster and easier to understand manner. These flowcharts also may Table 1. Learning and Integration Steps Completed for Project Learning Strengths and Opportunities for improvement (OFIs) (address all the following if applicable): Project Scope Team and Resources Measures, Analytics, and Knowledge Organizational Barriers and Competing Processes Information Systems/Equipment Other Control Plan done: Measurement for ongoing monitoring defined Significant interventions listed Action Plan for 2 (Green/Red), 3 (Green/Yellow/Red), or 4 (Green/Yellow/ Orange/Red) levels of performance Attached important tools and communication flyers/letters/data forms/ etc. to the control plan Integration Policy and Procedure: written or updated on (date) Policies changed: Computerized forms, alerts, reports, and other IS items have been addressed Flowchart(s) for the new process(es) done and attached to policies Ensure appropriate training for: new team members on-going training (if applicable) Letters for excellent performance to team members written Sent to team member Sent to manager Sent to Human Resources (HR) file (if applicable) Other actions: Presentation / Publication Present to PILC highlights of the above Planned pursuing publication or external presentation? Yes No, why not: ACPE.org 45

3 Table 2. Control Plan Project Description Project: Catheter-Associated Urinary Tract Infection (CAUTI) Reduction Project Project Leader: Jim Smith, RN Measure (Generally 1 or 2 measures are allowed to monitor a controlled project) What is Measured? Total Catheter Days How often is it measured? Monthly How does this get measured? Where do the data originate? Automated via computerized Cerner PowerInsight report called _Event_ Days_By_Nurse_Unit_Lake.rep CAUTI s Quarterly Manually abstracted by using CDC guidelines. Published via. Who is responsible to receive this measure? Infection Control () Interventions List all interventions that made an improvement during the project: 1. Required order for ECU nurse to place catheter. 2. ECU physician education about indications. 3. ECU nurse education and flyers and process flow (include scenario of discontinuing prior to leaving ECU for HF patients that are now able to ambulate prior to sending to inpatient unit). 4. Hospitalist support to the ECU staff for avoiding indwelling urinary catheters. 5. Query physician (on transfer orders) from U to non-u areas to remove catheter. 6. Query physician upon arrival to sub-acute units to discontinue catheter (skilled/rehab). 7. Ensure indications in EMR were the same as described in project. be used for training new employees on the particulars of how an organization performs the procedure. Information system changes should also be addressed. A specific example may help explain how this should be addressed. Many hospitals are addressing indwelling urinary catheters as a part of the financial adjustments made for hospitalacquired conditions from Center for Medicare and Medicaid Services. 6 The initial indications listed in our organization s electronic medical record (EMR) were not diagnosisbased and included such reasons as abdominal distention. The project team changed the indications in the EMR so that unapproved indications (i.e., abdominal distention ) were removed and only the approved indications were added as possible choices (i.e., urinary obstruction. ) Recognition for the team members on the project is critical to build momentum for the culture of quality improvement. Project leaders are tasked with writing an appropriate letter for the team member specifying the contributions. Two levels are typically used: excellence and participation. A letter of excellence is used for those who made significant contributions beyond just participating in the project meetings. A letter is sent to the team member, their supervisor, and their human resources (HR) file. Conclusion Applying learning and integration as a formal check-list approach ensures 46 PEJ january february/2011

4 Action Plan Measurement Who What When Additional Comments Total Catheters days less than 4400 per month Total Catheter days per month Continue monitoring Monthly No action required 1. Ensure indications are present in EMR. 2. Ensure prompt on U transfer still present. 3. Update ED of process and ensure training for new staff (MD, Nurse, etc.) report, monitor Status Green Yellow Total Catheter days 4701 or greater 1. Notify Project leader. 2. Perform all steps in yellow status above. 3. Evaluate process in ECU, U transfers, and sub-acute transfer processes. report, monitor Orange 4. Letter to ECU physicians about CAUTI5. Letter to intensivists and hospitalist to raise awareness. Total Foley days less than 4700 and CAUTI rate above All steps above. 2. Single day Kaizen Blitz to identify all barriers or new process changes. 3. Action dependent upon findings. report, monitor to audit CAUTI monthly instead of quarterly until resolved Red Total Foley days 4701 and/or CAUTI rate above All steps above. 2. Perform second day Kaizen to address issues found. report monitor to audit CAUTI monthly instead of quarterly until resolved Red Attach additional data collection, educational, and instructional forms needed for all actions defined above. ACPE.org 47

5 a systematic method to maximize the likelihood of sustained improved performance from QI projects. Additionally, integration of process changes into the organization makes significant declines back to baseline performance less likely. Lastly, a well-defined control plan allows the organization to quickly and easily address slips in organizational performance for the controlled project. Paul Murphree, DO, ScD., is the medical director of quality and patient safety at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana. He is certified in Lean Black Belt Six Sigma. Paul.Murphree@ololrmc.com Richard Robert Vath, MD, FCCP, is the vice president of medical affairs for Our Lady of the Lake. He is a Certified Lean Six Sigma Green Belt. Richard.Vath@ololrmc.com Larry Daigle is the director of quality management at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana. He is a Certified Lean Six Sigma Green Belt and has been an ISO 9000 auditor. References 1. Kubiak TM and Benbow DW. The Certified Six Sigma Black Belt Handbook, Second Edition. Quality Press, Milwaukee, De Koning H, Verver JPS, Van Den Heuval J, Bisgaard S, Does, RJMM. Lean Six Sigma in Healthcare, Journal for Healthcare Quality,28(3) 2006, pp Brown CC, Sobo EJ, Asch SM, Gifford AL. Measuring the Persistence of Implementation: QUERI Series. Implementation Science, 3, Apr. 2008, Blazey M. Insights to Performance Excellence Quality Press, Milwaukee, Landsberger HA, Hawthorne Revisited, Ithaca, U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services. Hospital-Acquired Conditions. Retrieved on May 1, PEJ january february/2011

6 A Powerful New Way to Connect Physician Leaders! ACPE s Interactive Membership Directory can be used to: My ACPE Search for physician leaders across the country by name, organization, specialty, professional interests and more. Make connections by or phone to exchange solutions to common problems and discuss new ideas to existing challenges. Upload your own photograph and build a detailed profile of yourself including your expertise and interests. Go to acpe.org/myacpe Get connected today! 1 PEJ MARCH APRIL/2010 ACPE.org 49