1. Using Six Sigma to Improve Cardiac Medication Administration and CAT Scan Capacity Susan McGann RN, BSN Adrienne Elberfeld Harvard Quality Colloquium August 22, 2005

2. Virtua Health….Today ¶ Four hospital system in Southern New Jersey ¶ Two Long Term Care Facilities ¶ Two Home Health Agencies ¶ Two Free Standing Surgical Centers ¶ Ambulatory Care - Camden ¶ Fitness Center ¶ 8000 employees + 2000 physicians ¶ 7,000 deliveries ¶ $650 million in revenues ¶ STAR Culture

3. Virtua Facilities

4. The Virtua STAR Caring Culture Excellent Service Clinical Quality & Safety Resource Stewardship Best People Outstanding Patient Experience

5. Virtua Health…. The Future ¶ Change in HR Structure and Process ¶ Focus on Programs of Excellence ¶ Building a Greenfield site ¶ Potential consolidation of multiple sites ¶ Ambulatory Strategy ¶ Growth in the North ¶ Additional Strategic Partnerships

6. R0 Cardiac Medication Indicators Project Title: Cardiac Medication: Indicators Six Sigma Project Sponsors: Jim Dwyer, Ann Campbell, Ellen Guarnieri, Adrienne Kirby, Mike Kotzen Champions: Pat Orchard & Jane Slaterbeck Master BB: Mark Van Kooy Black Belt: Adrienne Elberfeld Green Belt: Ted Gall Finance Approver: Gerry Lowe Project Start Date: July 22, 2002 Team Members: Jay Brewin, Darlene Euler, Christine Gerber, Val Torres, Kathy Halstead, Kathy Plumb, Cindy D’Esterre, Lori Edell, Heather Scheckner, Angie Smolskis, Pat Quackenbush, Ronald Kieft, Michelle Weaks, Robert Singer, Vince Spagnuolo, Steve Fox Project Description: Increase quality of patient care by use/non-use and appropriate documentation of aspirin, beta-blockers, and ACE inhibitors in CHF or AMI patients to achieve or exceed Virtua benchmark goals. Project Scope: To have all four acute care facilities, within all medical disciplines, meet the standards of Core/JCAHO guidelines Potential Benefits: To achieve improved outcomes for patients with AMI/CHF diagnosis by adhering to evidence based practice through education, documentation, and compliance while meeting regulatory standards and enhancing quality of patient care at Virtua. Alignment with Strategic Plan: IIA-Cardiology; Global MICP Goals for Virtua. Define

7. QRA Chart Review Gage R&R Measure Percentage of time QRA’s agreed on assessment During this gage, it was determined that there was variation between the QRA’s review of charts A Workout was held on September 18th with the QRA’s and Case Management Directors to develop SOP’s in reviewing of all CHF and AMI patients for core indicators

8. Root Cause Analysis Identified through Containment Issue Concurrent reviews of AMI & CHF patients Ongoing information needed for medical staff and nursing staff of the core indicators Cardiac POE needs real time access to Clinical Care Advisor to review data Conclusion Between Case Management, Quality & Nursing charts needed to coordinate efforts in reviewing charts Have team members develop a storyboard template with pathways and indicators to be available at key areas throughout the facility Coordinate with IS accessibility to system Solution Met with CCM’s, Case Management & Quality to educate on core indicators Identified key areas, (physician lounges, Cardiac specific units, nursing specific areas), and posted storyboards that are the same throughout the system Cardiac POE Director, AVP, and Black Belt access to system; able to review ongoing and provide feedback to Case Management Who Team members specific to campus, J. Slaterbeck, A.Elberfeld Team members specific to campus C. Mullin, J. Slaterbeck, B. Rodin Analyze

9. Issue Who is going to perform the task of daily chart reviews concurrent with care? Communication with physicians per need for documentation Coordination of ongoing chart reviews, documentation completion, and data information Conclusion Nursing, case management and quality are all reviewing charts; need to coordinate efforts in regard to the indicators Need one point person to communicate directly with physicians in a timely manner Need to appoint point people within the facility to ensure that activities are being completed and coordinated Solution Case Management to take the lead on chart reviews for patients with AMI, CHF & related diagnosis. Support from quality & nursing If nursing and/or case mgt has direct contact with physician, they give necessary feedback. Next step is the facility QRA and physician champion Case Management to coordinate with nursing & quality; all paperwork forwarded to Black Belt & VP Quality Who Case Mtg Directors, Quality Directors, CCM’s Case Mgt, QRA’s, B. Singer, V. Spagnuolo, S. Fox Case Mgt, QRA’s, C. Mullin, A. Elberfeld Analyze Root Cause Analysis Identified through Containment (continued)

10. Root Cause Analysis Improve

11. Realized Results of Implemented Solutions ImprovementY BenefitQuality Benefit Control

12. P Chart Control

13. Define R0 CT Scan Capacity Project Title: CT Scan Six Sigma Project Sponsors: Ellen Master BB: Adrienne Elberfeld Black Belt: Kathy Eichlin Green Belt: John Graydon, Wendy Seiler Finance Approver: Rex Rueblinger Project Start Date: July 28, 2004 Project Description: Increase capacity by reducing in and out of room times for the CT Scan to adhere to GE industry benchmarks of 15 minutes without contrast and 25 minutes of with contrast. Project Scope: Marlton CT Scan department Potential Benefits: A more efficient process will lead to increased capacity thereby increasing opportunities for increased volumes. Alignment with Strategic Plan: Resource Stewardship Patient Satisfaction Team Members: Beverly Crawford, Melody DeLaurentis, JoAnn Domingo, Audrey Fley, Darryl Fussell, Cynthia Koller, Jo Nast, Heather Pierce, Donna Rapp, Elizabeth Zadsielski

14. Y1 Mean = 13.6333 Standard Deviation = 6.6993 Z Score = 2.78 Mode = 9 Percent of Defects = 11.1% Y2 Mean = 23.4688 Standard Deviation = 6.9884 Z Score = 1.90 Mode = 20, 21 and 24 Percent of Defects = 34.4% Measure Descriptive Statistics

15. Y3 Mean = 11.3671 Standard Deviation = 4.2972 Z Score = 2.58 Mode = 7 Percent of Defects = 13.98% The problem is too much standard deviation/ variation in the process!! Measure Descriptive Statistics

16. Levene’s test –Test for equal variances for continuous data that is not normally distributed. There is a statistical difference in the variance! T Test for Equal Variances Analyze

17. A Pareto Chart shows where within the process the greatest opportunity exists for improvement. Here we see opportunities for the need for improvement with interruptions caused by the phone, door interruptions and assistance needed to move a patient resulting in 59 % of CAT Scan Delays. Use LEAN opportunities to streamline process. Pareto Chart Analyze

18. Two-sample T for Before-Avg. Time vs After-Avg. Time N Mean StDev SE Mean Before-A 62 14.95 9.87 1.3 After-Av 106 11.65 5.21 0.51 Difference = mu Before-Avg. Time - mu After-Avg. Time Estimate for difference: 3.30 95% CI for difference: (0.61, 5.99) T-Test of difference = 0 (vs not =): T-Value = 2.44 P-Value = 0.017 DF = 81 P-value was less than.05, therefore, there is a statistical difference! Y1-Abdomen-Pelvis Without Contrast One-way ANOVA: Before-Avg. Time, After-Avg. Time Analysis of Variance Source DF SS MS F P Factor 1 426.2 426.2 8.04 0.005 Error 166 8794.9 53.0 Total 167 9221.1 Individual 95% CIs For Mean Based on Pooled StDev Level N Mean StDev ---------+---------+---------+------- Before-A 62 14.952 9.869 (--------*--------) After-Av 106 11.651 5.214 (------*------) ---------+---------+---------+------- Pooled StDev = 7.279 12.0 14.0 16.0 2 Sample T Test & ANOVA Y1 Improve

19. Two-sample T for Before-Avg. Time vs After-Avg. Time N Mean StDev SE Mean Before-A 32 23.47 6.99 1.2 After-Av 20 18.05 4.93 1.1 Difference = mu Before-Avg. Time - mu After-Avg. Time Estimate for difference: 5.42 95% CI for difference: (2.09, 8.74) T-Test of difference = 0 (vs not =): T-Value = 3.27 P-Value = 0.002 DF = 49 Y2-Abdomen-Pelvis With Contrast One-way ANOVA: Before-Avg. Time, After-Avg. Time Analysis of Variance Source DF SS MS F P Factor 1 361.4 361.4 9.15 0.004 Error 50 1974.9 39.5 Total 51 2336.3 Individual 95% CIs For Mean Based on Pooled StDev Level N Mean StDev ----------+---------+---------+----- - Before-A 32 23.469 6.988 (------*-------) After-Av 20 18.050 4.925 (--------*---------) ----------+---------+---------+------ Pooled StDev = 6.285 18.0 21.0 24.0 P-value was less than.05, therefore, there is a statistical difference! 2 Sample T Test & ANOVA Y1 Improve

20. P-value was less than.05, therefore, there is a statistical difference! Mood’s Median/Non-Normal Data Improve

21. I & MR Control Chart Can we see the improvement on the chart post SOP implementation? Take away: Process is capable and in control. Control

22. I & MR Control Chart Can we see the improvement on the chart post SOP implementation? Control Take away: Process is capable and in control.

23. I & MR Control Chart Can we see the improvement on the chart post SOP implementation? Take away: Process is capable and in control. Control

24. The “other results” ¶ Ahead of the ‘hospital’ curve ¶ Data driven organization ¶ The dots are connected: n Strategy, Operations, Quality, Finance, People ¶ Financial up-spin ¶ Leadership Development The Results Go Well Beyond the Project!