Six Sigma Approach to Reduction of Infections Lois Yingling, RNC, MSN, CPHQ, Black Belt Florida Hospital Orlando, Florida

Objectives At the conclusion of the presentation participants will: At the conclusion of the presentation participants will:  List the 5 steps of Six Sigma  Identify components of the IHI central line bundle  Appreciate the value of a systematic approach to process improvement

Overview  Who is Florida Hospital  Bloodstream infections  Five steps of Six Sigma  Define  Measure  Analyze  Improve  Control  Lessons learned with CDT

Who is Florida Hospital?  Founded in 1908 by Adventist Church  Oldest & largest healthcare system in Central Florida  Seven campuses in 3 counties  Licensed for over 1800 beds  Third largest employer in Central Florida  Largest Medicare population in the nation  Recognized as one of America’s Best Hospitals in U.S. News & World Report for the seventh year in a row  HealthGrades 2005 Award for Excellence in Patient Safety

D MAIC Define

Why Bloodstream Infection (BSI)  Published mortality rates as high as 35%  Baseline CVC related BSI: 13%  Additional therapy costs $56,000  Baseline CVC related BSI: $16,699 variable cost  Increased length of stay  Baseline CVC related BSI: 20.6 additional days per case

National Interest  Institute for Healthcare Quality (IHI)  Central line bundle  Hand hygiene  Maximal barrier precautions  Chlorhexadine skin antisepsis  Appropriate care of site and line system  No routine replacement  Center for Disease Control (CDC)  Guidelines

D M AIC Measure

Scope  In Scope:  Inpatients system-wide >17 y/o  Positive blood culture within 48 hours of admission (2 weeks re- admission)  Confirmed based on CDC definition  CVC  Out of Scope  PICC lines  Tunneled, port, dialysis, peripherals

Project Description/ Problem Statement Based on 2003 & annualized 2004 data:  43% of BSIs were secondary to CVCs  LOS is increased by 20.6 days per case  Variable treatment cost is increased by $16,699 per case Goal:  Decrease the number of CVC related cases by 10%, a decrease of 16 cases per year

Baseline Process in control, no special cause variation

Gauge Repeatability 100% One person repeatedly measures same unit

Gauge Reproducibility 90% Two or more persons measure the same unit

DM A IC Analyze

Process Capability Y1 All BSI Overall Z.USL Sigma 0

Vital Xs

DMA I C Improve

Interventions & Results

Statistical Significance   Two-Sample T-Test and CI: Historical VS New Mean   Two-sample T for Rate   C7 N Mean StDev SE Mean   (Jan November 2003)   (Nov January 2005)   Difference = mu (1) - mu (2)   Estimate for difference:   95% CI for difference: ( , )   T-Test of difference = 0 (vs not =): T-Value = 5.21   P-Value = DF = 19 Difference between historical & new mean is statistically significant

Error Proofing Trays Custom Trays:  Anesthesia Trays - no sterile garb  ED & Unit Trays – sterile garb Issue:  Anesthesia trays without sterile garb distributed to units Error Proof:  All custom trays include sterile garb and antimicrobial catheter

DMAI C Control

Reliable Measurements BSI Rate is based on CDC definition. CVC related BSI extrapolated from total BSI cases.

Current Status Process is in Control

Target: 5 or Less/Month

Process Capability Y1 All BSI overall Z.USL 0.30 current Sigma 1.8

Owner Accountability

Results  Capacity YTD April  Actual 296 Days  Target 110 Days  Variance 186 Days  Dollar Savings YTD April  Actual $207,196  Target $77,233  Variance $129,963

CDT: Lessons Learned

Scope: Containment  In Scope:  Inpatients system-wide >17 y/o  Diarrhea with confirmed assay diagnosis of CDT  Out of Scope  Outpatients  Inpatients without diarrhea & confirmed assay diagnosis of CDT

Scope: Prevention  In Scope:  Inpatients system-wide, except Campus 3, >17 y/o with a history of a surgical procedure on the SIP list  Diarrhea with confirmed assay diagnosis CDT  Out of Scope  All patients admitted to Campus 3  All medical patients and all surgical patients not on SIP list

CDT Baseline Out of Control Baseline 2003 through June 2004

CDT Rate 100% Assay Testing increased Case Finding

Containment  April 2005  Terminal Cleans with bleach for rooms of CDT patients  May 2005  Error Proofing  Terminal Cleans for all rooms  July Pilot Campus 6  New non-bleach product  Kills spores  No damage to furniture Bleach

CDT Rate

CDT Cases/Month Terminal bleach clean CDT rooms Terminal bleach clean all Rooms June 2005: Target 152 or less/month

Prevention  Right Antibiotic  Right time  Within one hour of incision  Right duration  Discontinue within 24 hours for prophylaxis  Document if treating infection

Business Case  Improved clinical quality (absence of infection)  Capacity opportunity of 1639 days  Financial opportunity of $1,298,484

Summary Six Sigma:  Well defined methodology  Systematic approach  Robust  Data driven  Directional  Statistical application for other initiatives

“Alice came to a fork in the road. ‘Which road do I take?’ she asked. ‘Where do you want to go?’ responded the Cheshire cat? ‘I don’t know.’ Alice answered. ‘Then’ said the cat, ‘it doesn’t matter.’” “Alice came to a fork in the road. ‘Which road do I take?’ she asked. ‘Where do you want to go?’ responded the Cheshire cat? ‘I don’t know.’ Alice answered. ‘Then’ said the cat, ‘it doesn’t matter.’” From “Alice in Wonderland” by Lewis Carroll