1. What did the team do? The project was What happened next? Temporarily Suspended

2. Change is Good New ED Leadership New CEO New Associate Dean Clinical Affairs New Medical School Dean The Decade Plan

3. Increased Boarding No Vacancy Increased Saturation Frequency Increased Patient Acuity Increased Wait Time Patient Satisfaction Plummeted Change is Good

4. Current State of ED Local Affairs  Things had to get worse before they got better, especially to influence physician behavior change  A renewed commitment to reducing wait times and developing new local leaders capable of managing change  Physician and department performance expectations have been linked. Incentives based on patient satisfaction and program metrics, and physician performance metrics dashboards – This is big!  Spin off initiatives that positively impact ED wait times by addressing patient admissions have been implemented: Short Stay Unit, Discharge by Noon Program, Difficult Discharge Initiative  New process improvement projects in the pipeline to “lean out” the ED admission process and address ED patient boarding

5.  Program level executive support is critical  Selectivity of Black Belts / Project Managers (skills, experience, credibility)  Project selection is key. The initiative must be important to local stakeholders and executive administrators as Project Sponsors  Sponsor role is critical: Do not proceed with a reluctant sponsor  Data is power: Removes subjectivity, opinions and feelings from decisions—use of PDCA thinking—scientific method!  Six Sigma program establishment is a multi-year endeavor, especially when adapting industry methodologies to healthcare  Demonstrated repeated success is a key to culture change Lessons Learned

6.  Improvement initiative efforts may be confounded by the diversity of competing priorities and incentives of a large academic medical center  Making the link to the passions of doctors and nurses (patient care) was the breakthrough  Temporarily suspending project implementation may be the right thing to do  Even moderately successful projects have value  You don’t have to be a Six Sigma Organization to be successful with the methods, tools and “acceptance management” Lessons Learned

7. Six Sigma: The AMH Evolution 2001-2003  Patient Safety & Satisfaction  “Best Place to Care”  Market Share  Reduce Process Variation 2003-2005  Financials  Business Processes 2006   Patient Safety  Patient Outcomes  Morbidity & Mortality

8. Current State of Global Affairs The 7 Year Road to Culture Change What hasn’t changed?  Volume & intensity (e.g. Acuity)  Market & economy (e.g. Payor requirements)  Technology emphasis( e.g. RFID)  People (From leadership to mid mgt. to staff and physicians, including new ED Chair) new ED Chair)  Even the facilities The Decade Plan and Organizational Quality Dashboard The Decade Plan and Organizational Quality Dashboard  Provide clear and specific strategic objectives with accountability expectations expectations  Selection and Alignment of improvement initiatives  User involvement in development of 2008 - 2010 Medical Center Quality Plan and Metrics/Dashboard Quality Plan and Metrics/Dashboard New organizational “Quality” structure New organizational “Quality” structure

9. What Drives Improvement Projects?  Organizational Quality Dashboard based on the Medical Center’s Goals  I Care: Pt. Satisfaction  I Heal: Quality Outcomes (e.g. mortality)  I Build: Operating Margin and Financial Stewardship  Payors / Medicare  Withholding of payment r/t Hospital Acquired Conditions not present on admission (e.g. Nosocomial Infections)  Joint Commission (Accreditation Organizations) & CMS (Center’s for Medicare & Medicaid Services)  Joint Commission & CMS Standards – Survey Process  Patient Safety Objectives  Core Measures: Best Practices (Publicly Reported)  Voluntary Participation in Benchmark & Best Practice Programs  Consumerism and the Internet Effect  Quality Rounds: “Get out of your chair”

10. What have AMH been doing lately?  ED Boarding – Patient flow imitative / bed availability: System thinking opportunity  ED Admission – Process improvement from time of bed assignment to transfer  Patient Identification – Goal: Right Patient / Right Treatment / Right Time (Reduce “wrong patient” errors)  Medication Errors – Administration, Prescribing, Preparation and Dispensing  Replacement Meds – Reduce the number of medication order fulfillment “do-overs”  Hospital Acquired Urinary Tract Infection Reduction (Nosocomial Infection)  Blood Utilization – Due to new restrictions on blood donors / decrease in donors / increased need / increasing product cost  Glycemic Control – Current research correlates increased complications with less than optimally control blood sugar levels  The Lean Lab Project – Reduce waste from product and operator flows, Improve Efficiency, Space Allocation, Kan Ban Inventory System, etc.  Emergency Response Program – Pre-Code system to reduce cardiac and respiratory arrest on acute patient care units  RFID Project – Radio Frequency Locator System for Equipment, Specimens, Blood Products, Medications, Patients, Staff  Expansion/Renovation Communication WorkOut – Between Operational Departments (Facilities) and Clinical Departments (Patient Care Areas)