CVHP: Process Excellence Our Journey to High Reliability

William T. Choctaw, MD, JD Chief Transformation Officer/LSS Deployment Leader Citrus Valley Health Partners

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Copyright © The Joint Commission. Confidential and proprietary information. Not to be reproduced.

Getting There From Here

Can’t be done overnight, or even rapidly

Requires both substantial culture change and new process improvement methods

Citrus Valley Health Partners is began by adopting RPI internally

Partnership with the Joint Commission Center for Transforming Healthcare for 1 year 20 Green Belts 2 Black Belts Sustainability Resources “IT’S ABOUT THE PATIENT”

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Supports Lean Six Sigma activities Lean Six Sigma (LSS) training and certification programs Utilizes strategies, tools, methods including Lean, Six Sigma,

and Change Management Used to improve processes and clinical outcomes

Improves financial stewardship and sustainability Essential to transforming CVHP into a High

Reliable Organization (HRO)

Process Excellence at CVHP

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Process Excellence

Lean Lean Certification

Six Sigma Green Belt

Black Belt

Process Excellence at CVHP

Green Belts trained on Lean Six Sigma DMAIC methodology

Green Belts assigned to improvement projects prioritized by Executive Team 4 - 6 months in duration

Green Belt trainees include front line staff, leadership and physicians

Following certification, Green Belts continues process improvement

Green Belt Training

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2014 Green Belt Projects

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• The All Cause 30 day Heart Failure readmission rate decreased to 16.7%. Continuum of Care

• LWBS rate decreased to 1.5%. ED Flow

• The defective hand-off rate improved to 25%.

Hand Off Communication

• Complete documentation improved to 56%.

Medicare Denial Prevention

• The electronic collection rate for Perinatal Core Measures improved to 91%. MEDITECH

• SSIs decreased from 22 in 2013 to 10 in 2014. Surgical Site Infection

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2014 Green Belt Projects Validated Improvements

P-value < .05

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2014 Green Belt Projects Validated Improvements

P-value < .05

Lean Six Sigma focuses on eliminating waste and defects DMAIC Methodology Statistics, tools and strategies all data driven

CVHP and Lean Six Sigma December 2013: Partnership with The Joint Commission January 2014: Executive team trained February 2014: Wave I Green Belt projects prioritized June 2014: Training of 21 Green Belts began

Two Black Belt trainees selected

Validated improvements

Lean Six Sigma

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2015 Wave II Green Belts

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• Green Belts: Maricar Rojas, RN, Dr. Michele Vargas, Rio Cordova RN, Lelenia Ramirez-Navarro (EVHC)

• Sponsor: Dr. William Choctaw Champion: Lolly Henderson, RN Problem: Boarding of admitted patients in the ED disrupts

patient flow, resulting in a delay in patient care, decreased patient satisfaction, and reduced revenue generation.

Defect: Greater than 2 hours from decision to admit to ED departure

Unit of Improvement: Boarding hours and boarding %

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ED Flow II Project Overview

ED Flow II Current Baseline Performance

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52.9%

70.6%

0% 20% 40% 60% 80% 100%

Goal (25% improvementfrom baseline)

% Boarded(time > 120 minutes)

% Boarded Patients

P-value < 0.05

44.4%

87.2% 76.4%

0%

20%

40%

60%

80%

100%

12am-7am 7am-3pm 3pm-1159pm

% Boarded Patients by Shift

P-value < 0.05

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• Green Belts: Dr. Michael Madanat, Estela Young, Dr. Chinhnam Hatuc(EVHC), Cynthia Routt-Vargas

• Sponsor: Rob Curry • Champion: Tracy Dallarda • Problem: FPH HCAHPS scores for physician communication are

inconsistent reflecting lower patient satisfaction, lower physician engagement, and negatively impacts revenue.

Defect: Inconsistent HCAHPS scores Unit of Improvement: Top box score from patient

satisfaction survey; secondary metric consistency between data points on HCAHPS survey

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HCAHPS Project Overview

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HCAHPS Current Baseline Performance

Question 7: How well did MD answers

Question 8: How well did time spend meet needs

Question 9: How friendly was your MD

Overall Score

Excellent 14 14 20 12 Total 30 30 30 30 % "top box" 46.7% 46.7% 66.7% 40% Project Goal 75% 75% 90% 75% P-value 0.00 0.00 0.00 0.00

46.7% 46.7%

66.7%

40%

90% 90% 90% 90%

0%10%20%30%40%50%60%70%80%90%

100%

Question 7: How well didMD answers

Question 8: How well didtime spend meet needs

Question 9: How friendlywas your MD

Overall Score

FPH % "top box"

Project Goal

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• Green Belts: Nena La Scala, Dr. Jorge Reyno, Kathy Van Allen

• Sponsor: Mary Zimmer • Problem: CVHP is not providing a seamless, patient focused

process to ensure a safe and timely transition for the patient to the post-acute setting. There is a lack of coordinated effort and communication related to DC planning.

Defect: LOS that exceeds expected LOS; time to discharge greater than 2 hours

Unit of Improvement: Length of stay, final discharge order to depart time

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Inpatient Discharge Project Overview

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Inpatient Discharge Current Baseline Performance

2.7

4.3

0123456

LOS Without Weekend Stay LOS WITH Weekend Stay

Q.5M/S Total Hip/Knee Patients Length of Stay

Pvalue < 0.05

1. Weekends lengthen patient stays.

2. The sooner the better for LOS when obtaining orders and authorizations.

72.7%

40.9%

0%

20%

40%

60%

80%

100%

Orders/AuthorizationsDay 1 or 2

Orders/AuthorizationsDay 3+ or not done

% At 3 Day LOS Target

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• Green Belts: Kim Washington-York, Christina Hong, Jason Dennison, CeCe Agudo

• Sponsor: Roger Sharma • Champion: Lourdes Casao • Problem: High utilization of outside registry (OSR) for our

Registered Nurses (RNs) within CVHP nursing departments impacts consistency, cost, and quality of care.

Defect: Workforce shortage that exceeds 45 FTEs Unit of Improvement: RN open positions; outside registry

FTEs

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Nurse Staffing Project Overview

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Nurse Staffing Current Baseline Performance

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• Green Belts: Heidi Saad, Martin Kleinbart, DPM, Tanya Johnson

• Sponsor: Dr. William Choctaw • Champion: Donna Wern • Problem: 37% of 0730 surgeries start on time. This impacts

patient throughput and satisfaction, surgeon satisfaction and workflow. On time is defined as patient “wheels-in” OR suite by 0730.

Defect: Wheels-in after 0730 for scheduled cases Unit of Improvement: 0730 surgery on time starts;

secondary metric surgeon arrival by 0715

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Peri-Operative Area Project Overview

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Peri-Operative Area Current Baseline Performance

47%

60%

75%

0%

20%

40%

60%

80%

100%

Baseline (June- August

2015)

Goal Stretch Goal

QVC 0730 Scheduled Cases Surgeon Arrival to OPHA

Surgeon On Time 0715 34

Total 0730 Cases Reviewed 118

% Surgeon On Time 28.8%

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• Green Belts: Christine Alici, Dr. Anna Leung, Arifa Majeed, Linda Nolton

• Sponsor: Jill Plesh • Champion: Eric Maristela • Problem: Lack of secure password management for access,

transmission, and storage of ePHI makes CVHP and its patients vulnerable to breaches.

Defect: Password management not secured Unit of Improvement: Secure password management

compliance based on four standards: presence of confidentiality agreement, password to secure ePHI,

protocol to deactivate access to ePHI and inventory of devices and hosted applications with ePHI

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Protected Health Information Project Overview

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Protected Health Information Current Baseline Performance

86.5% 78.1%

32.9%

0% 0%

20%

40%

60%

80%

100%

ConfidentialityAgreement or

BusinessAssociate

Agreement inPlace

PHI Protectedwith Password

DeactivationProtocol

Accounting ofPortable Devices

or HostedApplication

Password Management - All Platforms

Platform Overall

Assessment Met

Total Reviewed

Overall Assessment

% Email 25 51 49% Hosted Application 0 26 0% Portable Device 0 78 0%

All Platforms 25 155 16.1% goal 36.1%

100%

0% 0%

20%40%60%80%

100%

PHI Protected withPassword - CVHP Email

Auto Password

PHI Protected withPassword - Various

Departments

Emails Containing PHI

49%

0% 0%

16.1%

0%

20%

40%

60%

80%

100%

Email HostedApplication

Portable Device All Platforms

Overall Assessment

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• Green Belts: Hugo Castro, Kathy Linde • Sponsor: Paul Heredia • Champion: Melissa Howard • Problem: Poor hand hygiene practices places the patient at risk for

harm due to the transmission of pathogens and potential hospital acquired infections.

Defect: Improper hand hygiene technique Unit of Improvement: Compliance with “proper” hand

hygiene techniques per Centers for Disease Control and Citrus Valley Health Partners guidelines

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Safety/Hand Hygiene Project Overview

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Safety/Hand Hygiene Current Baseline Performance

Overall Compliance Hands In & Hands Out

Proper Technique 24 Total Direct Observations 135 % on Met 17.8%

SUBSTANCE USED: Personnel use water and soap or gel TECHNIQUE: Personnel rub the palm, back hand and fingers during hand cleaning DURATION: Personnel spend at least 15 seconds in hand cleaning

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The Cost of Poor Quality

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Unplanned Readmissions Hospital Acquired conditions Patient satisfaction Employee Satisfaction

Lean Six Sigma becoming commonplace in healthcare Allows hospitals to improve the quality of care for patients Reducing errors and waiting times

Focus on delivering quality, safe, compassionate care Uses proven process improvement methodology Define-Measure-Analyze-Improve-Control (DMAIC)

Data driven approach to fix root causes of problems Fixes the process where the work is actually done, by the

people who do the work

Lean Six Sigma and Healthcare

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2015 Green Belt Projects

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•Reduce the time decision to admit ED Flow II

•Improve physician communication HCAHPS

•Improve discharges by 11am Discharge by 11am

•Decrease outside registry use Nurse Staffing

•Increase 0730 on time surgeries Peri-Operative Area

•Improve secure ePHI transmissions Protected Health Information

•Improve hand hygiene compliance Safety Hand Hygiene

Identify and eliminate waste Fix what bugs you Tools focus on daily continuous improvement

Respect for people Increases customer value by eliminating

waste (muda) Creates flow throughout the value stream Projects inexpensive to implement Focus on improving the process, not the people Promotes simple, error proof systems

Lean

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Lean The 8 Wastes

Categorizing Waste

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D Defects O Overproduction W Waiting N Non-Utilized Talent T Transportation I Inventory

M Motion E Extra-Processing

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Lean Examples of Wastes

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Too much inventory Excessive forms Waiting

Staff Motion/ Equipment Transportation

Look for opportunities to improve process, work flow, patient safety and quality care

You are on the front line Fix what bugs you, get involved and submit ideas

Become Lean certified Training courses are offered throughout the year

Want a copy of 2 Second Lean? Contact the Process Excellence Department at ext. 33236

Transforming CVHP Your Role with HRO and LSS

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Safety Culture

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Copyright © The Joint Commission. Confidential and proprietary information. Not to be reproduced.

R – E – L – E – N – T – L – E – S - S

The only impossible journey is the one you never begin.

“TO HELP PEOPLE KEEP WELL IN BODY MIND AND SPIRIT BY PROVIDING QUALITY HEALTHCARE SERVICES IN A SAFE AND COMPASSIONATE ENVIRONMENT”

Our CVHP Mission

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Questions

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