LEAN Six Sigma and Patient Safety

1. LEAN Six Sigma and Patient Safety Mary Reich Cooper, M.D., J.D Chief Quality Officer, Lifespan Corporation Edward W. Craven, MBA, CPHQ NewYork-Presbyterian Hospital

2. WHY? • Medicare Says It Won’t Cover Hospital Errors • Sign In to E-Mail or Save This By ROBERT PEAR Published: August 19, 2007 WASHINGTON, Aug. 18 — In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

3. WHY? “For discharges occurring on or after October 1, 2008, the diagnosis-related group to be assigned shall be a diagnosis-related group that does not result in a higher payment based on the presence of a secondary diagnosis code”

4. No Extra Payment WHY? 1. Serious Preventable Event - Object left in surgery 2. Serious Preventable Event - Air embolism 3. Serious Preventable Event - Blood incompatibility 4. Catheter Associated UTI 5. Pressure Ulcers (Decubitus Ulcers) . Vascular Catheter Associated Infection 7. Surgical Site Infection - Mediastinitis after Coronary Artery Bypass Graft (CABG) surgery 8. Falls

5. WHY? Transactional Level of Data Collection Rewards for Each Time 74 Different Measures Available Effectiveness and Safety

6. Agenda • WHY do we need to have this discussion? • WHO are we? • WHEN did we start? • HOW have we approached this topic? • WHAT have we achieved?

7. NewYork-Presbyterian Hospital WHO? Full asset merger of The New York Hospital, founded in 1771 and the 2nd oldest hospital in the US, and The Presbyterian Hospital of New York, founded in 1868, into one Article 28 corporation which includes: • 2,224 Certified Beds • 110,000 Discharges • 11,000 Births • 88,000 Surgeries • 1,036,000 Ambulatory Visits • 17,500 Employees • $2.8 Billion Operating Budget

8. Lifespan Corporation WHO?

9. Experience in LEAN and Six Sigma WHEN? • Designed and implemented NYP plan • Hired and supervised forty black belts • Program ongoing since 2002 • $74 million in benefits through June 2007 • National award winners and speakers

10. HOW? Patient Safety Quality Outcomes Define Measure Report Out GE Healthcare Performance Solutions December 13, 2004

11. Quality Outcomes Pillars for Success HOW? LOS Capacity Patient Care Patient, Family, MD, Staff Satisfaction Malpractice Liability Restraints Patient Falls Pressure Ulcers Blood Stream Infections Deep Vein Thrombosis NYP/A NYP/A NYP/C NYP/WC NYP/WC

12. Project Approach HOW? • Complete Literature Search • Identify Best Practices • Conduct GAP Analysis • Prioritize GAPS • Conduct Brainstorming Session to Identify Critical X’s • Decide on DMAIC or Solution/Best Practice Implementation • AIC or Work-Out and Change Acceleration Process • Monitor progress • Deliverables Met • Project Transfer to NYPH • On-going control

13. BSI Site Selection Data WHY? 90th 50th Benchmarks from National Nosocomial Infection Surveillance [NNIS]; Major Teaching Hospital Med/Surg ICU; 50th percentile = 4.9, 90th percentile = 7.7

14. Blood Stream Infection Project Opportunity HOW? Problem Statement The Weill Cornell CCU current has BSI rate of 8 BSI per 1000 catheter days. Based on 2003 and 2004 data the BSI rate was as high as 11 BSI’s per 1000 catheter days. The rate is approaching the National Nosocomial Infection Surveillance (NNIS) 90th Percentile. Process Culture Analyzed BSI Detected Culture Obtained From Patient Patient Treated Patient Discharged Infection Removed Tangible Benefits Intangible Benefits • Patients and family satisfaction is increased with decreased length of stay in ICU • Increase communication and best practice sharing between Epidemiology and Infection Control across campuses • Lowered legal burden from hospital malpractice claims and financial settlements/awards • Decreased length of stay (LOS) • Increase ICU Capacity • Reduce IV Antibiotics Usage

15. Blood Stream Infection Project Scope/Enablers/Restrainers HOW? • In Scope: • Weill Cornell CCU & SICU Central Line Catheter Related BSI’s. Catheters inserted both inside & outside of CCU & SICU • Out of Scope: • Non central and other BSI’s • Other locations: Columbia, Allen Pavilion, CHONY and other Weill Cornell ICU’s • Days spent elsewhere within Hospital Project Restrainers Project Enablers • Limited buy in and agreement to participate from specific staff. • This will be mitigated by using CAP tools early to communicate the necessity of pursuing this project. creating a shared need, shaping a vision and mobilizing commitment • Gaining consensus that there is a true problem will be necessary early and throughout the life of this project • Strong history of success in lowering BSI rates in ICUs with focus and effort by Epidemiology and unit staff • Causes and drivers of BSI are well established in medical literature

16. Critical X’s • Technique • Training • Supplies and Kits • Line Upkeep

17. 2007: Central Line Infections WHAT? • ICU’s • NNIS Data • Publicly Reported Data • Mystery Shoppers for Hand Hygiene • Standardized Protocol for Insertions • Carts, Barriers, and Kits • EpiPortal

21. BSI ICU Results2007 Months without an Infection WHAT?

22. QUESTIONS? mcooper @ lifespan.org edc9008 @ nyp.org