Using Lean Six Sigma in Process Improvement Aneita Paiano, MBA, MT(ASCP) The Joint Commission Laboratory Surveyor Linda Kaufman, MT(ASCP) Laboratory Manager Denver Health Medical Center

2

Objectives • Describe how Lean Six Sigma tools such as Rapid Process Improvement™ (RPI) can be applied to laboratory process improvement and initiatives such as improved hand hygiene. • Identify how a formalized methodology like Lean Six Sigma assists in meeting The Joint Commission accrediting requirements. • Define “high reliability” as it applies to health care organizations. • Identify Clinical and Laboratory Standards Institute (CLSI) resource documents that can be used as references for process improvement activities.

Lean Six Sigma History • Developed by Motorola 1987 • Allied Signal (Larry Bossidy) 1993 • General Electric (Jack Welsh) 1995 • Health Care 2000 • 99% quality (3.8 Sigma) 5000 incorrect surgeries per week but 6 sigma quality 99.9996% 1.7 per week

Six Sigma Methodology - DMAIC ML2

• Define in numerical terms problems or opportunities • Measure current levels of performance • Analyze and determine root cause analysis (RCA) of the problem • Improve the current situation • Control the new process

Define • • • • •

Select project and team Define project scope Identify problem statement Develop project charter, ie, A3 Develop a SIPOC map (suppliers, inputs, process, output, customers) • Listen to voice of the customer (VOC)

Slide 5 ML2

I agree with Dan's suggestion. The initial words could still be emphasized by appearing in a different color than the rest of the words in the statement. Also, since these statements would then become sentences, insert a period at the end of each. If a version of the current format is maintained, be consistent with the punctuation between the word and the statement. For example, the first two bullets currently use en dashes, while the next uses a hyphen, and the last two use neither. Megan Larrisey, 9/20/2011

Measure • Collect baseline data • Determine tools to monitor project: descriptive statistics, run chart, control chart, check sheet, Pareto chart, cause and effect diagram, tree diagram, 5 why’s, failure modes and effects analysis (FMEA), process flowchart

Analyze • Questions about data (confidence intervals, hypothesis testing), variation analysis • Gap analysis • Process map, cause and effect diagram, RCA, FMEA • CLSI documents • Westgard QC- Six Sigma Calculators • The Joint Commission

dk19

Slide 9 dk19 Can legibility issues be corrected ??? 1. character crashes on y-axis 2. major character crashes on x-axis Daniel Koesterer, 9/20/2011

Control Charts

Run Chart

Ishikawa Diagram

Fault Tree Analysis

Related CLSI Documents ML16 ML15

• I/LA28-A2 - Quality Assurance for Design Control and Implementation of Immunohistochemistry Assays; ML17 Approved Guideline - Second Edition ML18

• GP22-A3 – Quality Management System: Continual Improvement; Approved Guideline—Third Edition • GP35-A - Development and Use of Quality Indicators for Process Improvement and Monitoring of Laboratory Quality; Approved Guideline • HS1-A2 - A Quality Management System Model for Health Care

Slide 12 ML15

Document titles should be italicized instead of underlined. Megan Larrisey, 9/20/2011

ML16

Insert an en dash in between the document code and title, with a space on either side. Also, delete extra two spaces between document code and document title. (This comment applies to each of these documents.) Megan Larrisey, 9/20/2011

ML17

Insert em dash between "Guideline" and "Second," with no space on either side. Megan Larrisey, 9/20/2011

ML18

Replace this citation with the current version of GP22. GP22-A3 – Quality Management System: Continual Improvement; Approved Guideline—Third Edition (Italicize the document title.) Megan Larrisey, 9/20/2011

Other References dk23

• Westgard, James O., Six Sigma Risk Analysis ML19

dk22

• The Joint Commission, Failure Modes Effects ML20 Analysis in Healthcare, a Proactive Risk Analysis

Improve • • • • • •

dk25

Develop a solution and action plan Implement solution dk27 Perform creative thinking, brainstorming ML21 Error proof, reduce variability Change management Work-OutTM sessions

Slide 13 dk22 Closer to "exact" title wanted ??? Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition Daniel Koesterer, 9/20/2011

dk23 Underlines not really necessary; italics would probably be better Daniel Koesterer, 9/20/2011

ML19

Delete extra space before "Failure." Megan Larrisey, 9/20/2011

ML20

Yes, we should go with the exact title, as Dan suggests. Megan Larrisey, 9/20/2011

Slide 14 dk27

Action verbs wanted for these bullets ??? Suggest: Use creative thinking and brainstorming Reduce variability and implement error proof processes Change management to help in adapting to changes Work out sessions [what does this mean ???] Daniel Koesterer, 9/20/2011

ML21

If Dan's edits are adopted, insert hyphen in "error proof" (ie, error-proof) and insert periods at the end of each sentence. Megan Larrisey, 9/20/2011

Slide 15 dk25

Do not obscure CLSI logo on the slide. Daniel Koesterer, 9/20/2011

Control • Standardization • Acceptance • Accountability • Continued success

General Electric Medical Systems: Change Acceleration Process

RPI, DMAIC, and The Joint Commission Survey • The Joint Commission Center For Transforming Healthcare is using Robust Process ImprovementTM (RPI) internally and externally as we work with hospitals and health care systems to improve quality, safety, and efficiency. • RPI combines Lean Six Sigma, Work-Out , Change Management, and other improvement tools to improve quality and efficiency.

The Joint Commission Laboratory Standards: Performance Improvement • PI.01.01.01 The laboratory collects data to monitor its performance. • PI.02.01.01 The laboratory compiles and analyzes data. • PI.03.01.01 The laboratory improves performance.

The Joint Commission Laboratory Standards: Leadership • LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the laboratory. • LD.03.02.01 The laboratory uses data and information to understand variation in the performance of processes supporting safety and quality. • LD.03.03.01 Leaders use laboratory-wide planning to establish structures and processes that focus on safety and quality.

The Joint Commission Laboratory Standards: Leadership • LD.03.04.01 The laboratory communicates information related to safety to those who need it. • LD.03.05.01 Leaders implement changes in existing processes to improve the performance of the laboratory. • LD.03.06.01 Those who work in the laboratory are focused on improving safety and quality.

The Joint Commission Laboratory Standards: National Patient Safety Goals • NPSG.01.01.01 Use at least two patient identifiers when providing laboratory services. • NPSG.02.03.01 Report critical results of tests and diagnostic procedures on a timely basis. • NPSG.07.01.01 Reduce the risk of health care associated infections. Comply with either Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) hand hygiene guidelines.

dk38

The Health Care Quality Challenge • More than 400 000 harmful, preventable outcomes occur in hospitals every year. • The costs associated with unsafe care and poor quality in hospitals are unacceptable. • There is a strong demand from health care organizations for specific guidance on how to solve these problems. • Health care organizations want highly effective, durable solutions and are ready to implement them.

24

Slide 24 dk38 Two words: Health Care Per CLSI style, add periods after each bullet. Source: Editorial: THE HEALTH CARE QUALITY CHALLENGE AND THE CLINICAL NURSE LEADER ROLE (CNL) Marietta Stanton Editorial Board Member Daniel Koesterer, 9/20/2011

Why the Center Was Created • In keeping with its objective to transform health care into a high reliability industry and to ensure patients receive the safest, highest quality care they expect and deserve, the Joint Commission Center for Transforming Healthcare was established in 2009. • The Center presents a new approach to address critical safety and quality problems sought by The Joint Commission, health care organizations, patients and their families, physicians and clinicians, and other public and private stakeholders.

25

Health Care Associated Infection Statistics • Nearly 2 million patients in the United States contract a health care associated infection (HAI) annually. • With nearly 100 000 deaths each year, HAIs are the fourth largest killer in the United States and cause more deaths every year than AIDS, breast cancer, and auto accidents combined. • Two-thirds of those deaths result from bloodstream infections and ventilator-associated pneumonia. • HAIs add nearly $9000 in expenses per infected patient in hospitals and cost US hospitals between $4 to $29 billion. 28

Main Causes for Failure to Wash Hands • Ineffective placement of dispensers or sinks • Hand hygiene compliance data not collected or reported accurately or frequently • Lack of accountability and just-in-time coaching • Hand hygiene not stressed enough by safety culture at all levels

m6

Main Causes for Failure to Wash Hands (cont) dk49

• Ineffective of insufficient education • Hands full • Perception that wearing gloves interferes with process • Perception that hand hygiene is not needed when wearing glovesm7 dk50 • Healthcare workers forgot • Distractions

Slide 31 dk49 change to "or" Daniel Koesterer, 9/20/2011

dk50 Two words: Health care Daniel Koesterer, 9/20/2011

m6

For consistency with how we usually abbreviate "continued" in slide, use: Main Causes for Failure to Wash Hands (Cont'd) mlarrisey, 9/21/2011

m7

Revise to: Forgetfulness on the part of health care workers mlarrisey, 9/21/2011

Targeted Solutions dk52 • Targeted hand hygiene solutions from the Center use the acronym “HANDS” to ensure

– – – – –

Habit Active Feedback No One Excused Data Driven Systems

34

Targeted Solutions ToolTM • The Targeted Solutions Tool (TST) was developed dk54 dk53 by The Joint Commission center for transforming dk55 health care to: m8 m9

– Enhance the efforts of The Joint Commission dk59 accredited health care organizations are already making to tackle these difficult and pressing problems. dk60 – Facilitate the spread and use of the learnings from the m10 center’s projects, including the identification of root causes and the targeted solutions that address causes of failures. 36

Slide 34 dk52 Change to: Joint Commission Center for Transforming Healthcare

Also is consistent with the exact title on slide 36! Daniel Koesterer, 9/20/2011

Slide 36 dk53 Upper case "C" Daniel Koesterer, 9/20/2011

dk54 Upper case "T" Daniel Koesterer, 9/20/2011

dk55 Upper case "H" Daniel Koesterer, 9/20/2011

dk59

Suggest: ...organizations, which are already tackling these... Daniel Koesterer, 9/20/2011

dk60 delete "the" Daniel Koesterer, 9/20/2011

m8

In this instance, "Healthcare" is one word as this is the name of the Center. mlarrisey, 9/21/2011

m9

Add en dash after "The Joint Commission," as this, combined with "accredited" is serving as an adjective in this context. "The Joint Commission–accredited" mlarrisey, 9/21/2011

m10

Capitalize "C" in "center's" as this has been done previously when referring to The Joint Commission Center. mlarrisey, 9/21/2011

Targeted Solutions Tool Process dk64 m11

• The TSTapplication is a step-by-step process that encapsulates the work of the Center to bring solutions to accredited health care organizations by: – Measuring an organization’s actual performance – Identifying specific causes to breakdowns in care – Directing organizations to proven solutions that are customized to address their particular barriers to excellent performance

37

m12

TST Steps • The TST has six steps designed to provide users dk65 with a step-by-step guide through the project: Step 1: Getting Started Step 2: Training Observers Step 3: Measuring Compliance Step 4: Determining Factors Step 5: Implementing Solutions Step 6: Sustaining the Gains

38

m13

Hand Hygiene/TST Utilization Update m14 • As of August 6, 2011, there were: m15

dk67

dk68

– 245,831 Hand Hygiene observations in the database m16 – 67,743 unique visitors to the Targeted Solutions Tool m17 – 1,979 projects with “In Progress” status in the database dk69 dk70 – 758 projects entered Hand Hygiene observations – 175 distinct organizations have projects with observation data (one organization can have multiple projects)

39

Slide 37 dk64 Can this bullet be changed to: The TST is a step-by-step process to help bring solutions to accredited health care organizations by: without changing it's meaning? Slide 36 already states that: The TST was developed by The Joint... Daniel Koesterer, 9/20/2011

m11

Insert space between "TST" and "application." mlarrisey, 9/21/2011

Slide 38 dk65

Change to "a" Daniel Koesterer, 9/20/2011

m12

Spell out Targeted Solution Tool in headings. mlarrisey, 9/21/2011

Slide 39 dk67 Lower case "h" Daniel Koesterer, 9/20/2011

dk68 Lower case "h" Daniel Koesterer, 9/20/2011

dk69 Lower case "h" Daniel Koesterer, 9/20/2011

dk70 Lower case "h" Daniel Koesterer, 9/20/2011

m13

Spell out "Targeted Solutions Tool" in headings. mlarrisey, 9/21/2011

m14

Bold the comma after "2011," since "2011" is bold. mlarrisey, 9/21/2011

m15

Remove comma: 245 831 mlarrisey, 9/21/2011

m16

Remove comma: 67 743 mlarrisey, 9/21/2011

m17

Remove comma:1979 mlarrisey, 9/21/2011

dk72

Additional Information About the TST m18

• Joint Commission Customer Service at (630) 7925800 m19 dk71

• E-mail: [email protected] (include your name, your organization’s name, and your organization’s ID number)

40

Road to High Reliability • Leadership dk73 • Safety Culture dk74 • Capacity to Execute Robust Process Improvement

dk75 m20

Chassin, Mark and Loeb, Jerob;dk76 “ The Ongoing Quality Improvement Journey, Next Stop, High Reliability”, Health Affairs, April 2011

High Reliability Leadership • Commitment of management • Reflected in vision/mission statements

Safety culture • Trust • Report • Improve Capacity to execute dk77 dk78 dk79 robust process dk80 improvement

Slide 40 dk71 Delete hyperlink; ensure underscore is retained within tst_support Daniel Koesterer, 9/20/2011

dk72 Delete "the" Daniel Koesterer, 9/20/2011

m18

Spell out "Targeted Solutions Tool." mlarrisey, 9/21/2011

m19

Per CLSI style, reformat phone number to: 630.792.5800 mlarrisey, 9/21/2011

Slide 41 dk73 Lower case "c" Daniel Koesterer, 9/20/2011

dk74 Lower case "e" Daniel Koesterer, 9/20/2011

dk75 Not sure if this is overkill, AMA style is: Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Affairs. 2011;30(4):559-568. Set Health Affairs in italics. Daniel Koesterer, 9/20/2011

dk76 This is a "d." Daniel Koesterer, 9/20/2011

m20

If the AMA-style citation is used, abbreviate the journal title to "Health Aff" (in addition to italicizing). mlarrisey, 9/21/2011

Slide 42 dk77 Add line space after Improve bullet Capacity to execute Robust Process Improvement

Ensure this is aligned Daniel Koesterer, 9/20/2011

dk78 Cap "R" Daniel Koesterer, 9/20/2011

dk79

Slide 42 (Continued) Cap "P" Daniel Koesterer, 9/20/2011

dk80 Cap "I" Daniel Koesterer, 9/20/2011

dk81

dk82

CLSI Related Documents: m21 m22

• I/LA28-A2 Quality Assurance for Design Control and Implementation of Immunohistochemistry Assays; Approved Guidelinem23 Second Edition m24

• GP22-A2 Continuous Quality Improvement: Integrating Five Key Quality System Components • GP35-A Development and Use of Quality Indicators for Process Improvement and Monitoring of Laboratory Quality; Approved Guideline m25

• HS1-A2 A Quality Management System Model for Health Care

m26

LEAN as a Quality Improvement Tool Linda Kaufman, MT(ASCP) Denver Health Laboratory September 22, 2011

44

This Session Will m30

dk83

m27

• Discuss basic LEAN concepts m28 • Teach the use of an A3 as a Tool for Tracking LEAN quality improvements m29 • Demonstrate A3 utilizing blood culture contamination rates as the improvement activity • Understand the importance of observations in the gembadk84 to find the least wasteful improvements

45

Slide 43 dk81 transpose to read: Related CLSI Documents Daniel Koesterer, 9/20/2011

dk82 Delete colon Daniel Koesterer, 9/20/2011

m21

Insert an en dash between each document code and title: I/LA28-A2 – Quality Assurance... Also, delete extra space between document codes and titles. mlarrisey, 9/21/2011

m22

Instead of underlining the document titles, italicize them. mlarrisey, 9/21/2011

m23

Insert an em dash between "Guideline" and "Second," with no space on either side. "Approved Guideline—Second Edition" mlarrisey, 9/21/2011

m24

Replace citation with current version of GP22: GP22-A3 – Quality Management System: Continual Improvement: Approved Guideline—Third Edition (Italicize the document title.) mlarrisey, 9/21/2011

m25

Remove HS01, as it has been replaced by the latest revision of GP26: GP26-A4 – Quality Management System: A Model for Laboratory Services; Approved Guideline—Fourth Edition mlarrisey, 9/21/2011

Slide 44 m26

For consistency with the previous presentation, don't use all caps for "LEAN." Based on the websites I've looked at it, I think the proper way to represent it is "Lean." mlarrisey, 9/21/2011

Slide 45 dk83 Add colon after "Will" and add periods after each bullet. This Session Will: Daniel Koesterer, 9/20/2011

dk84 Suggest putting gemba in quotes as this term is associated with LEAN concepts "gemba" Daniel Koesterer, 9/20/2011

m27

Change "LEAN" to "Lean" throughout presentation. mlarrisey, 9/21/2011

Slide 45 (Continued) m28

Should this be "A3 template" or "A3 report"? See: http://www.systems2win.com/lk/kaizen/A3.htm mlarrisey, 9/21/2011

m29

Change "utilizing" to "using." mlarrisey, 9/21/2011

m30

Insert periods at the end of each bullet. mlarrisey, 9/21/2011

What is Lean? dk86

m31

“ Is a systematic approach of continuous improvement used for the identification and elimination of waste to provide value to the customer.”

A Little Lean History • Ford Production – In 1913, Ford combined consistently interchangeable parts with standard work and moving conveyance to create what he called flow dk90 production.

• Toyota Production System (TPS) m32 dk88

m33

dk91

– Just after World War II, Toyoda & Ohno engineers at Toyota, believed that m34 a series of simple innovations might provide continuity in process flow. The Japanese engineers visited Ford’s plant in Michigan, and invented the TPS/LEAN systems dk89

–

m35

dk92

& Taiichi Ohno (大野 耐)

Toyota Philosophy m37

• Create continuous process flow to bring problems to the surface • Use “pull” to avoid overproduction • m36 Level out the workload (hejunka)dk93 • Get quality right the first time • Standardize tasks • Use visual controls so no problems are hidden • Use only reliable, thoroughly tested technology that serves your people and processes

Slide 46 dk86

Could not find this exact quote; therefore, suggest removing quotes and setting non-italics, and adding the word, "LEAN." LEAN is a systematic approach... Daniel Koesterer, 9/20/2011

m31

Close up space between quotation mark and "Is," if the quotation marks are maintained. Also, if quotes are maintained, consider removing "is" and capitalizing "A." mlarrisey, 9/21/2011

Slide 47 dk88 Delete extra space Daniel Koesterer, 9/20/2011

dk89 Add period. Daniel Koesterer, 9/20/2011

dk90 Suggest setting in quotes: ...what he called "flow production." Daniel Koesterer, 9/20/2011

dk91 Delete extra space. Daniel Koesterer, 9/20/2011

dk92 Set in blue type; delete hyperlink/underline! Daniel Koesterer, 9/20/2011

m32

Change ampersand to "and." mlarrisey, 9/21/2011

m33

Insert comma after "Ohno." mlarrisey, 9/21/2011

m34

Delete extra space before "The." mlarrisey, 9/21/2011

m35

Change ampersand to "and." mlarrisey, 9/21/2011

Slide 48 dk93 Suggest setting in quotes as this is a term specific to LEAN/6 Sigma Daniel Koesterer, 9/20/2011

m36

Consider revising to "Achieve high quality the first time." mlarrisey, 9/21/2011

m37

Insert periods at the end of each bullet point. mlarrisey, 9/21/2011

Value Added dk94

m38

dk97

• Service Value: An aspect of a product or service that a customer is willing to pay for – STAT courier pick-up in an outreach m39program – Results fordk95 treatment by physician are value added • Value Added: Service that increases value to the patient, physician dk96 or patient care staff – Turnaround Times – Result Accuracy, as in blood cultures with no m40 contaminations • Non-value added service is one that is required by process dk98 but has no direct impact for the patient m41 – Processes to get results are non-value added but required by regulationsm42 • Calibrations of equipment m43 m44 • QC prior to running and reporting test 49

Waste •

dk99

The original seven muda (Wastes) are: – Transportation (moving product not actually required to perform the processing) – Inventory (all components not being processed) – Motion (moving or walking more than is required to perform the processing) – Waiting (waiting for the next production step) – m45 Overproduction (production of tests outside of need or protocols) – Over Processing (Poor equipment tooling) • Repeating testing because QC was not within rules • Recollecting specimen due to quality, lack of labeling – Direct patient impact of service level • Sticking the patient multiple times per day – Defects (the effort involved in inspecting for and fixing defects) – An eighth waste was defined by Womack et al. (2003); as manufacturing dk100 goods or services that do not meet customer demand or specifications. – Tests performed but not ordered 50

A3 Outline dk101

dk102 • Howm46does one capture LEAN Activities? • One page report called an A3 • Nine boxes in which one records:

• • • • • • • • •

Reason for action dk103 Current State dk104 Future Target State dk105 Gap Analysis dk106 Solution Approach dk107 Rapid Experiments dk108 Completion Plan dk109 Confirmed State Insights 51

Slide 49 dk94

Lower case "v" value Daniel Koesterer, 9/20/2011

dk95 Suggest matching style of 3rd bullet: Value added service is one that increases... Daniel Koesterer, 9/20/2011

dk96 Add serial comma after physician ...value to the patient, physician, or patient care staff Daniel Koesterer, 9/20/2011

dk97 Change to avoid ending statement with "for" ...a product or service for which a customer is willing to pay Daniel Koesterer, 9/20/2011

dk98 Add comma ...by process, but has no direct impact... Daniel Koesterer, 9/20/2011

m38

Delete extra space before "An." mlarrisey, 9/21/2011

m39

Is "are value added" necessary? I think this is implied by the heading. Also, this makes the two sub-bullets nonparallel. mlarrisey, 9/21/2011

m40

Generally, we would not use a hyphen in "non-value" (per our style) but if this is a specific Six Sigma term, it should be maintained. CSLI style would revise it to: Nonvalue–added mlarrisey, 9/21/2011

m41

Insert period after "patient." mlarrisey, 9/21/2011

m42

Insert period after "regulations." mlarrisey, 9/21/2011

m43

Spell out "Quality control": Quality control (QC) before running... mlarrisey, 9/21/2011

m44

Per CLSI style, change "prior to" to "before." mlarrisey, 9/21/2011

Slide 50 dk99 Suggest setting "muda" in quotes " and lower case "w" in wastes Daniel Koesterer, 9/20/2011

dk100 Set as 2nd bullet on the page as this is an additional piece of related information and not one of the seven muda ("wastes") Daniel Koesterer, 9/20/2011

m45

Unless this term is specific to Six Sigma, delete the space: "Overprocessing" mlarrisey, 9/21/2011

Slide 51 dk101 If this is one piece of defining an A3 Outline, suggest re-wording from a question to a statement: Captures LEAN activities Daniel Koesterer, 9/20/2011

dk102 Lower case "a" activities Daniel Koesterer, 9/20/2011

dk103 Lower case "s"

Current state

Daniel Koesterer, 9/20/2011

dk104 lower case "t" and "s"

Future target state

Daniel Koesterer, 9/20/2011

dk105 Lower case "a" analysis Daniel Koesterer, 9/20/2011

dk106

Lower case "a" approach Daniel Koesterer, 9/20/2011

dk107 Lower case "e"

experiments

Daniel Koesterer, 9/20/2011

dk108 Lower case "p" plan Daniel Koesterer, 9/20/2011

dk109 Lower case "s"

state

Daniel Koesterer, 9/20/2011

m46

Hyphenate: "One-page." mlarrisey, 9/21/2011

What is an A3? dk110


Method for reporting lean activities dk111

dk112


A3 is actually the size of sheet of paper 11” X 13” dk115

dk116

◦ It was the “order name” of paper that went into a copier m47 dk113 ◦ The A3 has nine blocks utilized to record LEAN efforts


The A3 is a simple way to track a LEAN project for timeline completion and metric outcomes ◦ In a glance oncedk119 can: dk117

dk120 dk118  Understand the problem and the scope of the LEAN activity  See process change with metric outcomes to record improvements  See solutions and the scheduled changes with assigned responsibilities

m48

52

Reason for Action • Reason for Actiondk121 – Why is this LEAN improvement important? dk123 – Motivate dk122 for participation in the changes m49

• Create a problem statement • Set the boundaries – Resist creep • Ensure data speaks to the problem 53

Reason for Action dk124

dk125

• Denver Health blood culture contamination rates dk126 exceed the national benchmarks of 3%: dk129

– Leading to increased length of stay (LOS) dk130 dk127 – Use of costly antibiotics, expensive testing, and supply costs – dk131 High contamination rates have led to lack of physician confidence in testing results m51

• Emergency department contamination rates are the highest in the health system and will therefore dk132 be the focus improvements. 54

Slide 52 dk110 Set uppercase

LEAN

Daniel Koesterer, 9/20/2011

dk111 Add "a" a sheet of paper Daniel Koesterer, 9/20/2011

dk112 Transpose paper and 11’’ × 13’’ to read: ...a sheet of 11’’ × 13’’ paper Use multiplication symbol "× " Daniel Koesterer, 9/20/2011

dk113 Change to "used" Daniel Koesterer, 9/20/2011

dk115 Change to "A3" Daniel Koesterer, 9/20/2011

dk116 Change to "one size of copier paper" A3 was the "order name" of one size of copier paper Daniel Koesterer, 9/20/2011

dk117 Suggest deleting the sub-bullet. Add as second sentence to the 3rd bullet.

The A3 is a simple way...and metric outcomes. In a glance, one can: Daniel Koesterer, 9/20/2011

dk118 Set these as sub-bullets to the 3rd bullet. Daniel Koesterer, 9/20/2011

dk119 Add comma after "glance" Change "once" to "one" In a glance, one can: Daniel Koesterer, 9/20/2011

dk120 Delete "the" Daniel Koesterer, 9/20/2011

m47

Insert period at the end of each of these bullets. mlarrisey, 9/21/2011

m48

Insert periods at the end of each of these bullets.

Slide 52 (Continued) mlarrisey, 9/21/2011

Slide 53 dk121 Does this need to be repeated? This is the slide header. Daniel Koesterer, 9/20/2011

dk122 Delete extra space before "for' Daniel Koesterer, 9/20/2011

dk123 Suggest deleting "the" Does "process" fit here? Motivate for participation in process changes Daniel Koesterer, 9/20/2011

m49

Insert periods at the end of the 2nd, 3rd, and 4th bullets. mlarrisey, 9/21/2011

Slide 54 dk124 Add "At"

At Denver Health, blood culture...

Daniel Koesterer, 9/20/2011

dk125 Add comma after "Health" At Denver Health, blood culture... Daniel Koesterer, 9/20/2011

dk126 Add "ed" to exceed

exceeded

Daniel Koesterer, 9/20/2011

dk127 Delete extra space Daniel Koesterer, 9/20/2011

dk129 Change to "Led" Daniel Koesterer, 9/20/2011

dk130 Change to "Use" to "Required use" Daniel Koesterer, 9/20/2011

dk131 Delete "High contamination rates have" and begin bullet with "Led" Daniel Koesterer, 9/20/2011

dk132

Add "of" Daniel Koesterer, 9/20/2011

Slide 54 (Continued) m51

Insert "ED" after "Emergency department," as this abbreviation is used on upcoming slides. mlarrisey, 9/21/2011

dk133

Current State dk136
Blood Culture contamination rates exceeded national benchmark of 3.0% m50 m52

◦ Emergency Department m53 (ED) contamination rates ranged from 2.6% to 9.4% in 2009, overall contamination rates were 5.9% m54 m55 ◦ Phlebotomy rates remained at or below 3% in 2009 dk143

m56

dk137


ED staff drew 250-300 cultures per month

dk138 ◦ Over 100 ED staff performed Blood Culture draws dk139 ◦ Up to 80% of the ED staff drew fewer than 3 Blood Cultures per year dk141 averaged 25% yearly ◦ ED staff turn-over dk140 dk142 ◦ Competencies were not on record for all staff drawing Blood Cultures

55

dk134

Current State

dk135

56

m57

Waste Walk in the ED Gemba

dk145

dk146 dk144
Blood Culture draw procedures were not followed:m58


Cleansing of the draw site did not adhere to outlined technique
Timing for application of antiseptic to draw time was not followed m59
Blood Cultures were drawn at the time of the IV insert to m60 “save the patient a stick” dk147
Transfers of blood from syringe to Blood Culture vial did dk148 not utilize the sterile transfer device

m61

57

Slide 55 dk133 Is this the "Current" state? This slide and Slide 56 cite 2009. Is there a better header? See Slide 53...would a better header for this slide be: Defining the Problem ? If "yes," use this header on Slide 56 also? Daniel Koesterer, 9/20/2011

dk136

Lower case "c" Daniel Koesterer, 9/20/2011

dk137 Add "blood" for clarity Daniel Koesterer, 9/20/2011

dk138 Lower case "b" and "c"

blood culture

Daniel Koesterer, 9/20/2011

dk139 Lower case "b" and "c"

blood cultures

Daniel Koesterer, 9/20/2011

dk140 Lower case "b" and "c"

blood cultures

Daniel Koesterer, 9/20/2011

dk141 Delete hyphen; one word:

turnover

Daniel Koesterer, 9/20/2011

dk143 Suggest changing to en dash 250–300 Daniel Koesterer, 9/20/2011

m50

Insert period after "3.0%." mlarrisey, 9/21/2011

m52

Delete full term and just use "ED," as this is spelled out on previous slide. mlarrisey, 9/21/2011

m53

Replace comma with semicolon. mlarrisey, 9/21/2011

m54

Insert period after "5.9%." mlarrisey, 9/21/2011

m55

Insert period after "2009." mlarrisey, 9/21/2011

m56

Insert period at the end of bullet and sub-bullets. mlarrisey, 9/21/2011

dk142 Suggest changing to:

who drew

...for all staff who drew blood cultures Daniel Koesterer, 9/20/2011

Slide 56 dk134

See comments regarding header on Slide 55 Daniel Koesterer, 9/20/2011

dk135 See y-axis label: ensure that "Contamination" is spelled correctly; it looks like two lower case "Ls"

This also applies to the y-axis label in the graph below (in gold). The "i" in "Contaminated" looks like a lower case "L" Daniel Koesterer, 9/20/2011

Slide 57 dk144 Suggest deleting the bullet that preceeds this statement Daniel Koesterer, 9/20/2011

dk145 Suggest adding quotes

"Gemba"

Daniel Koesterer, 9/20/2011

dk146

Lower case "c" Daniel Koesterer, 9/20/2011

dk147 Lower case "b" and "c"

blood culture

Daniel Koesterer, 9/20/2011

dk148 Change to "use" Daniel Koesterer, 9/20/2011

m57

Spell out "Emergency Department" in heading. mlarrisey, 9/21/2011

m58

Delete colon and replace with period. mlarrisey, 9/21/2011

m59

Lowercase the 'c' in "Cultures." mlarrisey, 9/21/2011

m60

Insert period between "stick" and end quote. mlarrisey, 9/21/2011

m61

Insert periods at the end of each bullet. mlarrisey, 9/21/2011

m62

dk149 m63

Waste Walk in ED cont’d m65


Tops of the culture bottles were not cleaned dk150
Needles were stabbed through alcohol swabs lying on tops of vials dk151
Cultures drawn without physician order then discarded dk152
Cultures were drawn but not labeled at bedside
Cultures were not drawn in appropriate draw order m64 dk153
Labeling often obstructed barcoding on vials causing issues with reads on instrumentation in Microbiology
Bottles were not filled to provide optimal blood volumes for bacterial growth dk155
Culture bottles were found in excess of 20X the need based on volumes 58

Current State: Physician’s Gemba m66


Physicians did not feel they could rely on results when drawn in the ED – Cultures were immediately ordered and redrawn upon admission when sepsis suspected

• Contaminations led to increased LOS until two consecutive cultures were negative • Contaminations led to expensive antibiotic therapy which was often unnecessary • Additional LOS inflated the cost of the patient stay by an estimated $5000/day 59

m67

Future State for ED & Physicians m68 m69 • Phlebotomists draw Blood Cultures in ED

• Use experts to ensure procedural requirements followed m75

• ED can ensure coverage for protocols whenm71 phlebotomy m70 cannot arrive within hour (10-15 X/mo) m72 • Provide Health Care Techs education module used in MICU m73 m74 • Keep number of staff trained to minimum (10-20) • Report statistics monthly in update with ED

m76

• Broadcast to physicians the changes in draw protocols in ED and statistical updates • Alleviate unnecessary blood culture orders m77

• LOS will decrease, supply costs & FTE effort 60

Slide 58 dk149 Match previous slide title Waste Walk in the ED "Gemba" (contd) Daniel Koesterer, 9/20/2011

dk150 Is bullet worded better as: Needles were passed through alcohol swabs that were positioned on the tops of vials ??? Daniel Koesterer, 9/20/2011

dk151

Bullet worded better as: Cultures were drawn without a physician's order, but later were discarded ??? Worded this way to show the waste. Daniel Koesterer, 9/20/2011

dk152 Add a comma after "drawn" Cultures were drawn, but not labeled... Daniel Koesterer, 9/20/2011

dk153

Suggest changing to "the barcode" Daniel Koesterer, 9/20/2011

dk155 Use multiplication symbol "× "

20×

Daniel Koesterer, 9/20/2011

m62

Spell out "Emergency Department" in headings. mlarrisey, 9/21/2011

m63

For consistency with how we represent "continued" in PowerPoints, use: "Waste Walk in Emergency Department (Cont'd) mlarrisey, 9/21/2011

m64

Revise to: "Labeling often obstructed the bar codes on vials, which caused issues with reads on instrumentation in microbiology." (For consistency with AUTO12 [the specimen label document] "bar code" is two words.) mlarrisey, 9/21/2011

m65

Insert periods at the end of each bullet point. mlarrisey, 9/21/2011

Slide 59 m66

Add periods at the end of each bullet point. mlarrisey, 9/21/2011

Slide 60 m67

Spell out "Emergency Department" and change ampersand to "and." mlarrisey, 9/21/2011

m68

Lowercase "b" and "c": blood cultures mlarrisey, 9/21/2011

m69

Add period after "ED." mlarrisey, 9/21/2011

m70

Delete extra space before parenthetical text. mlarrisey, 9/21/2011

m71

I'm not sure what "mo" stands for here, but the "X" should be changed to the multilplcation symbol: × mlarrisey, 9/21/2011

m72

Lowercase the 'h' and 'c' in "health care," and spell out "technicians." mlarrisey, 9/21/2011

m73

Spell out "medical intensive care unit," as this acronym is not used again. mlarrisey, 9/21/2011

m74

Replace hyphen with en dash. mlarrisey, 9/21/2011

m75

Insert period at the end of bullet and the three sub-bullets. mlarrisey, 9/21/2011

m76

Insert period at the end of the bullet and sub-bullet. mlarrisey, 9/21/2011

m77

1. What does "FTE" stand for? Is this "full-time effort"? If so, following with "effort" is redundant. 2. "LOS will decrease" should be separate from the rest of the statement, as it seems that two separate thoughts are intended. The current wording suggests that verbs describing the activity of the LOS will follow, but that is not the case. mlarrisey, 9/21/2011

Gap Analysis

m78

• The goal of gap analysis is to identify the difference between the optimal use of resources and the current level • The gap analysis process involves determining, m79 documenting and agreeing about the variance between current capabilities and change for future • Benchmarking and other metrics are important to this analysis. 61

Gap Analysis • Lack of consistentm80 documented education for ED staff – Low volume of Blood Culture draws across large volume of ED staff m81

• Lack of orders when Blood Cultures drawn • Poor inventory management of culture vials • Lack of consistent communication and information sharing regarding laboratory collected contamination rates m82

62

m86

Solution Approach

If…

m83 Phlebotomy performs Blood Culture Draws in the ED A small team in ED is oriented and competent

• •

• • m88 Par rates for Blood Cultures vials are set

• •

m90 Education modules are loaded into staff member MC Strategy files m91 Orders are required prior to draw m92 Lab and ED meet routinely

m85 m84 Expert technique will decrease ED Blood Culture contamination rates Protocols requiring draws that phlebotomy cannot attend will meet requirements for loading antibiotics The smaller ED team will glean experience and expertise m87 Mediation for problem solving is more immediate

Then…

• •

Vials can be adjusted to required supply volumes based onm89 utilization statistics Central Stores can distribute to track stock across the facility There will be decreased supply costs Tracking and accountability for fulfilling the modules will be available for reviews and competency mediation

•

Waste for discarded supplies will discontinue

• •

Competencies can be addressed immediately Accountability can be assigned for education and follow-up Statistics will speak for themselves

•

63

Slide 61 m78

Insert period at the end of 2nd and 3rd bullet. mlarrisey, 9/21/2011

m79

Insert comma after "documenting." mlarrisey, 9/21/2011

Slide 62 m80

Lowercase 'b' and 'c': "blood culture" mlarrisey, 9/21/2011

m81

Lowercase 'b' and 'c': "blood culture" mlarrisey, 9/21/2011

m82

Insert hyphen, as "laboratory collected" is decribing the contamination rates. laboratory-collected mlarrisey, 9/21/2011

Slide 63 m83

Lowercase: blood culture draws mlarrisey, 9/21/2011

m84

Lowercase: blood culture mlarrisey, 9/21/2011

m85

Insert a period at the end of each bullet in the "Then..." column. mlarrisey, 9/21/2011

m86

Insert a period at the end of each bullet in the "If..." column. mlarrisey, 9/21/2011

m87

Change "is" to "will be," for consistency. mlarrisey, 9/21/2011

m88

Lowercase: blood cultures mlarrisey, 9/21/2011

m89

Is it necessary for "Stores" to be capitalized? mlarrisey, 9/21/2011

m90

What does "MC" stand for in "MC Strategy"? Does this need to be spelled out? mlarrisey, 9/21/2011

m91

Per CLSI style, change "prior to" to "before." mlarrisey, 9/21/2011

m92

Spell out "Laboratory." mlarrisey, 9/21/2011

Rapid Experiments m93

• m97

Rapid experiments trial them94 future state – Anticipate innovative “out of the box” thinking and processes m95 – Experiment to discover and tweak based on discovery – Integrate new and traditional technologies to unlock performance – Educate early about rapid experimentation m96 – Fail early and often but avoid 'mistakes' – Listen and understand the angst of doing something new 64

m98

Rapid Experiments in ED • Placed phlebotomist in ED to draw m99 – Successful, but waste apparent as Phlebotomist not busy 90% of the time • Need method to “pull” phlebotomist to ED for culture draws m100 • Orders placed for Blood Cultures – Need to centralize location for pick-up m101– Need room number on requisition m102 • 6S to reduce inventory and centralize location of ED Blood Culture vials – One person responsible for inventory m103 – CS agreed to centralize distribution of vials 65

Completion Plan • • • •

Who? Where? Why? What? When? How? Actions to be taken m104 Responsible person/s Times, dates to complete plan – This work plan takes into consideration: • • • • • • • •

Project objectives Budget Purchasing Schedule Materials Personnel Mitigation Communication/Training 66

Slide 64 m93

Is a separator missing from this bullet? The current format suggests that "trial" is a verb. Should it be: "Rapid experiments trial: the future state" If so, consider removing "Rapid experiments trial" from the bullet, as it already appears in the heading and it can be implied that this is what "the future state" refers to. mlarrisey, 9/21/2011

m94

Insert hyphens: "out-of-the-box" mlarrisey, 9/21/2011

m95

Insert comma after "tweak." mlarrisey, 9/21/2011

m96

Change single quotes to quotation marks: "mistakes" mlarrisey, 9/21/2011

m97

Insert period at the end of each sub-bullet. mlarrisey, 9/21/2011

Slide 65 m98

Spell out "Emergency Department." mlarrisey, 9/21/2011

m99

Lowercase 'P' in "Phlebotomist." mlarrisey, 9/21/2011

m100

Lowercase: "blood cultures" mlarrisey, 9/21/2011

m101

Is "6S" "Six Sigma"? If so, spell out. This abbreviation has not been used in the presentation. mlarrisey, 9/21/2011

m102

Lowercase "blood culture" mlarrisey, 9/21/2011

m103

What does "CS" stand for? Spell out for clarity. mlarrisey, 9/21/2011

Slide 66 m104

Instead of back slash, use parentheses: person(s) mlarrisey, 9/21/2011

m105

Completion plan What

Who m106 • Sr. Phlebotomist obtain pagers m107 • Sr. Phlebotomist/ED RN educator script calls • RN educators will educate staff about change

When

Orders need to be placed m109 for Cultures

•

One month

Done

Inventory Control

•

Within next week

Done

Within next week

Done

Phlebotomist in ED

•

ED education to physicians and RNs regarding changes through ED Administrative Committee o Room numbers in ED suites must be on requisition to expedite draws o Location of centralized m110 requisitions o No Blood Culture draws without orders m111 Microbiology Supervisor and CS Manager meet to determine ordering and distribution of vials and responsibilities m112 Develop tracking report for Blood Culture Vial inventory and where distributed

Completion Date Within next 3 Done days m108 Within next 2 wks Done

67

Metrics to Report and Track • Reported in categories – Quality m113 – Financial Impact – Human resources impact

• Confirmed state – Statistical tracking of metrics or quality outcomes • Numerator • Denominator

– – – –

Numbers that are easy to retrieve, obtain Accuracy of the data Reproducibility and ease of gathering the data m114 Method for re-evaluation when metrics not met 68

Confirmed State Measure m115 Number of total

Initial m116

250-300/month

Blood Cultures drawn by ED

Target m117

Less than 20/month m119

Number of m118 contaminated Blood Cultures drawn by ED

Average of 15/month (Averaged 5.9% overall 2009)

1-2 contaminated Blood Cultures/month

Denver Health Blood Culture m121 Contamination Rates

3.1%

2.5%

0

$150,000/Qtr

m122

Cost Savings

m120

m123

69

Slide 67 m105

Capitalize the 'p' in "plan." mlarrisey, 9/21/2011

m106

Spell out "Senior" and lowercase "Phlebotomist" in this column. mlarrisey, 9/21/2011

m107

Spell out "RN" on first mention: Senior phlebotomist/ED registered nurse (RN) educator script calls mlarrisey, 9/21/2011

m108

Spell out "weeks." mlarrisey, 9/21/2011

m109

Lowercase 'C' in "Cultures." mlarrisey, 9/21/2011

m110

Lowercase: "blood cultures" mlarrisey, 9/21/2011

m111

What is "CS"? If this is spelled out on previous slide where I made this comment, it can remain abbreviated here. mlarrisey, 9/21/2011

m112

Lowercase: "blood culture vial" mlarrisey, 9/21/2011

Slide 68 m113

Lowercase 'I' in "Impact." mlarrisey, 9/21/2011

m114

Delete hyphen: reevaluation mlarrisey, 9/21/2011

Slide 69 m115

Lowercase: blood cultures mlarrisey, 9/21/2011

m116

Replace hyphen with en dash. mlarrisey, 9/21/2011

m117

Replace "Less than" with "