lean six sigma and process improvement in healthcare summit
TRANSCRIPT
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© Pittsburgh Regional Health Initiative 2011 1
View from the Top: “It’s not about tools to achieve success in Lean Six Sigma. It’s about how to get leaders to believe in and EMBRASE quality!”
Karen Wolk Feinstein,PhDPres ident & Chief Execut ive Off icer Lean S i x S i gma and Proces s Improvement i n Hea l thca re Summi t , New Or leans , LA
May 11 , 2011Spreading Quality, Containing Costs.
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© Pittsburgh Regional Health Initiative 2011 2
Who We Are and
How We Approach Transformation
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Who Are We?
Pittsburgh Regional Health Initiative (PRHI) A not‐for‐profit, regional, multi‐stakeholder coalition formed in 1997
An initiative of a business group, the Allegheny Conference on Community Development
PRHI’s messageDramatic quality improvement (approaching zero deficiencies) is the best cost‐containment strategy for health care
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Regional Health Improvement Collaboratives: The Infrastructure for Transformation
Unique to U.S.
Multi Stakeholder Focus
PRHI = oneof the first
NeutralRegional
Measurement/Transparency
40+
A Decade of Growth
1995‐2005
PayersProvidersPurchasersEmployersPatients
Quality Improvement
Disease Management
THE GOAL: Quality ImprovementCost Containment
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Pittsburgh Regional Health Initiative
Founders:
Karen Wolk Feinstein, PhDPresident and CEO since founding
Paul O’NeillAlcoa Chairman 1987‐1999
U.S. Secretary of Treasury 2001‐2002
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PRHI’s Prescription for Transformation
Services That Add Value All Services Add Value
Preventable Complications
Unnecessary Treatments
Inefficiencies
Errors
100% Value
60% Value
40% Waste
NOW FUTURE
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The Problem Was Worse Than We Thought
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How Does the U.S. Measure Up Globally?
Source: Commonwealth Fund Commission on a High Performance Health
Australia Canada Germany NetherlandsNew
ZealandUnited Kingdom
United States
OVERALL RANKING (2010)
Quality Care
Effective Care
Safe Care
Coordinated Care
Patient‐Centered Care
Access
Cost‐Related Problem
Timeliness of Care
Efficiency
Equity
Long, Healthy, Productive Lives
Health Expenditures/ Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290
Country Rankings Excellent Fair Poor
© Pittsburgh Regional Health Initiative 2011
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“Bringing state‐of‐the‐art care to all will require a fundamental, sweeping redesign of the entire health system … merely making incremental improvements in current systems of care will not suffice.”
‐ The Institute of MedicineMarch 2001
The Bottom Line: Transformation of Organizations and Systems
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Moving Beyond Repair to Transformation
PPC for Systems Transformation
PPC for Organizational Transformation
PPC for Repairs
An Early Vision for Perfecting Care
A Method for Perfecting Patient CareSM (PPC)
PPC in New Technologies and New Models
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The Original Vision
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Where Value Derives
THE PATIENT
• Outcomes of Care
• Efficiency of Care
• Zero Defects
Value begins at the frontline
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Toyota Lean Production Thinking: The Basics
Problems identified and solved
Rapid root cause analysis
Organized work areas
Concise communication
Active involvement of managers
“Go and see”
On the floor
Intense respect for the employee:
Every employee has what they need, when they need it to succeed
Career development
Team problem solving to meet customer need
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What We Observed in Health Care
W. Edwards Deming, PhD: “Where Art Thou?”
ChaosUncertaintyRandom BehaviorsWork‐AroundsConfusionDisorderErrorsHigh TurnoverSecrecy
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Where We Beganon the Journey to Transformation
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Our Method:What We Value in Perfecting Patient CareSM (PPC)
One universal improvement method
Meeting patient need is the focus of all work
Frontline clinical teams apply daily problem‐solving methods and work process improvement techniques
Research occurs and is performed at the frontline
Focus is clinical care improvement
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What We Value About PPC (cont’d)
Coaches and Core Champions are “embedded” professionals
Knowledge and learning are elicited and shared across organization
Ultimate goal is perfection— 100% error reduction and best clinical practices
Leadership engagement reaches to highest levels
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“The job of CEOs, COOs, CMOs, CNOs, Presidents, chairs, and chiefs must include dynamically discovering ever better approaches for performances.
What they don’t do is get into the nitty gritty of mastering the skills necessary for discovering greatness–starting with small, safe, skill‐incubating pilots and then expanding to more comprehensive, complex, and sophisticated applications.”
‐ Steven J. SpearAuthor of “Decoding the DNA of the Toyota Production System” and “Fixing Healthcare from the Inside, Today”
Role of Leadership
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The Executive Role in Transformation
Paul O’Neill ‐ Alcoa Chairman, 1987‐1999
Corporate commitment to reduce workplace injury rate to zero
Imported Toyota Production System, manager accountability, real‐time data reporting to Alcoa; reduced workplace injuries by 90% over 12 years
Alcoa became the safest company in the world
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The Champion Role in Transformation
PPC empowers frontline staff…and more
Nurse Navigators
Nurse Managers
Team LeadersSalk Fellows
Patient Safety Fellows
Physician Champions
Clinical Pharmacists
Long‐term Care Workers
Librarians
Hospital Trustees
Emergency Medical Technicians
Caregivers
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PPC University: Preparing Champions
Four‐day, in‐depth course dealing with actual, on‐the‐floor problems – at the point of patient care
Examine PPC principles, using hands‐on exercises
Learn the Rules of Work Redesignand tools
Observe actual clinical problems and solve them!
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Perfecting Patient CareSM (PPC) Training
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Demonstrating the Value of PPC
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STEP ONE: Reducing Hospital‐Acquired Infections
30+ hospitals participating in PRHI’s community‐wide infection control project reported an average 68 percent reduction in CLABs over four yearsResults varied among institutions
The Power of Perfecting Patient CareSM: one hospital virtually eradicated CLABs from its main intensive care units
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PPC Eliminates CLABs in One ICU
After the standardization and additional training, the hospital essentially eliminated CLABs in its CCU
Coronary Care Unit
Pre Improvement
Post Improvement
4%
3%
2%
1%
0%
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68% Dropin CLABs in 34 regional hospitals
50% FewerReadmissionsw/ COPD focus
86% Reductionin medication errors
180 to Zero!Lost patient hours per month due to ambulance diversions
Efficiency Increased 100%
in pathology lab
17% Dropin pediatric clinic
wait times
100% Reductionin nurse turnover
50% Reductionin pap smear
sampling defects
>20% DeclineNosocomialC. difficileinfections
35 to Zero!defective charts
100% Compliancew/guidelines & aspirinuse in a diabetes clinic
PRHI Stories of Success in Acute Care
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Our Methods and Successes Have Attracted Attention
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But, success didn’t spread
beyond individual units — and
sustainability was uncertain.
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Global Vision
Culture of Quality and Safety
Quality Improvement Strategy
Targets and Measurement
Designated Champions and Teams
Training, Education and Coaching
Interdisciplinary/Transitional Collaborations
Research/Experimentation/Registries
Consumer and Purchaser Engagement
Information Technology
Public Reporting
Incentives for High Performance
Transforming Healthcare Organizations: Hit all the notes on the xylophone or no music
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What Does Organizational Transformation Look Like?
PPC for Organizational Transformation
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System‐Wide Transformation:Veterans Affairs (VA) Hospital Attacks HAIs
When Perfection is the Goal
Pittsburgh VA targets elimination of methicillin‐resistant Staphylococcus aureus (MRSA)
Identified lack of standardization for hand hygiene and use of personal protective equipment
Used red tape as visual cue for when to gown and glove
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Hand Hygiene
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What Workers Need – Where They Need It
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Equipment Room Disorganization
Keeping the equipment room clean and organized eliminates time wasted searching for supplies and reduces opportunities for contamination
BEFORE AFTER
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(Orderly?) Supply Room
AFTER
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Unexpected Issue: Poor Transport at the VA
Problem: Wheelchairs weren’t available (or clean) when needed
Solution:Colored labels to identify which unit a wheelchair belongedLocations identified for convenient wheelchair courtesy pointsWheelchairs regularly cleaned and maintained
Outcome:Patients were on time more often for appointments (from ~40% to 90% on‐time rate)Wheelchairs returned to the VA after patient transfers (otherwise would have been lost)
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VA MRSA Intervention Results
85% reduction in MRSA rate
Sustained compliance with hand hygiene, gowning, and gloving
Team continues to identify opportunities to reduce MRSA rates
For more information, go to www.prhi.org to watch a Teachable Moment about this project
0
0.5
1
1.5
2
MR
SA
Infe
ctio
ns
per 1
000
BD
OC
Start of Intervention
2000 2001 2002 2003 2004
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Systemwide Improvement
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PPC: The Transformed Organization
Leadership engagement reaches to highest levels
One universal improvement method
Meeting patient need is the focus of all work
Frontline clinical teams apply daily problem‐solving methods and work process improvement techniques
Research occurs and is performed at the frontline
Focus is clinical care improvement
Coaches and Core Champions are “embedded” professionals
Knowledge and learning are elicited and shared across organization
Ultimate goal is perfection— 100% error reduction and best clinical practices
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PRHI is about VALUE
Spreading Quality
and
Containing CostSpreading Quality,Containing Costs.
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Perfecting Care in Systems
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Treating Chronic Illness Accounts for 75% of Expenditures
Major chronic interventional
34%
Chronic illness management
35%
Major acute/ interventional
23%
Minor acute8%
Preventive use only<1%
Percent of costs associated with medical needs
Source: Luft, Harold. Total Cure. Cambridge, 2008: Harvard University Press. pg. 66
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22.9%
49.5%
65.2%74.6%
81.2%
97.0%
3.0%0%
20%
40%
60%
80%
100%
Top 1% Top 5% Top 10% Top 15% Top 20% Top 50% Bottom 50%
Percent of Population, Ranked by Health Care Spending
Focus on Spending Leads to Complex PatientsP
erce
nt o
f Tot
al
Hea
lth C
are
Spe
ndin
g
The 5% of the U.S. population with highest health care expenses was responsible for nearly half of total health care spending
Concentration of Health Care Spending in the U.S. Population, 2007
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Currently: Where do the $$$ go? Hospital Care
Hospital Care31%
Physician and clinical services21%
Retail sales of prescription durges
10%
Program administration and net cost of private
insurance7%
Investment in research, structures and equipment
7%
Nursing home care6%
Other professional serives and personal care
6%
Dental services4%
Government public health activities
3%
Home health care3%
Retail sales of durable medical equipment
1%
% of Healthcare Spending, U.S., 2008
Source: Modern HealthcareJanuary 11, 2010, pg. 7
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Hospital Errors Lead to More Hospitalizations
Infections Lead to Readmissions
• 1.2% of PA hospital patients contract a hospital‐acquire infection
• 30% of all infected patients are re‐admitted within 30 days of initial discharge due to infection
• 60% of patients who contract surgical site infections are readmitted within 30 days
Source: Pennsylvania Health Care Cost Containment Council, “The Impact of Healthcare‐Associated Infections in Pennsylvania,” 2009
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Transforming Transformation into Two Targets
1• Preventing hospitalizations of complex patients
2• Preventing infection
Ø Target Burnout
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The Readmissions Cycle
Incomplete Primary Care
Emergency RoomInfection
Hospitalizations
$ $
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PRHI’s researchers perform analyses on hospital discharge data
PRHI found that approximately 20% of discharges are readmitted within 30 days
Data Source
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The Complex Patient
Who is frequently hospitalized?
Do you know your customer?
Are you meeting their need?
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Let the Data Guide Our Work
The Complex Patient
HIV/AIDS End of Life
Skilled Nursing
Chronic Disease
Behavioral Health and Substance Abuse
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Why So Many Readmissions?
“Nobody integrates care for the medical condition as a whole and across the full cycle of care, including early detection, treatment, rehabilitation, and long-term management.”
‐Michael E. Porter &
Elizabeth Olmstead Teisberg, PhD
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The Second Systems Vision: Transforming the Care of Complex Patients
Across Ca
re Settings
Essential Services System Requirements
Care Mgt
Clinical Pharmacy
Patient Engagement
Health IT
QI Training
Financial Incentives
Collaboration and
Integration
Medication Reconciliation
Informed Activated Discerning Consumers
Data to Treat,
Measure,Evaluate
Perfect PatientCare
RewardsFor Quality
Hospice/Palliative
Long Term Care
Rehab
Hospital
Emergency Services
Specialty Care
Primary Care
Screening and Tx
Behavioral Health
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What is essential to ourvision for reducingreadmissions?
Care Management
ClinicalPharmacy
Patient Engagement
Behavioral Health
HIT QI Training
Isn’t reimbursed
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Testing our Model:Reducing Preventable Hospitalizations — COPD
Our data mining identified chronic obstructive pulmonary disease (COPD) as prominent cause of hospital admissions (4th highest) and readmissions (3rd highest)
Readmissions in Western PA, 2005-06
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
CHF Pneumonia Depression COPD KidneyFailure
AbnormalHeartbeat
Diabetes Asthma
Diagnosis at Initial Admission
# R
eadm
itted
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
% R
eadm
itted
# ReadmitsReadmit Rate
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Kaizen Uncovers Current Condition
Patient discharged without training on inhaler use
MD gives patient prescription for inhaler, but no training
Patient gets inhaler from pharmacy, but training
Patient fails to use inhaler properly, leading to hospitalization
Patient is treated with nebulizer during hospital stay
DANGEROUS CYCLE
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Breaking the Cycle of COPD Readmissions
MD gives patient prescription for inhaler, but no training
Patient fails to use inhaler properly, leading
to hospitalization
Patient is treated with nebulizer during hospital stay
Patient is discharged without training in use of inhaler
Patient gets inhaler from pharmacy, but no training
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Kaizen Team Breaks Cycle
Team determines two keys:
Hospital – Patient education to address causes of admission
Community – Improved patient education and support in the community
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The Solution Coordinates Transition Between Hospital and Community
Improvedpatient
educationand
support*in the
community
Patienteducationto addresscauses of admission
COMMUNITYHOSPITAL
Patient uses inhaler properly, leading to improved functioning
Patient is discharged WITH training in use of inhaler
MD gives patient prescription for inhaler, but no
training
Patient gets inhaler from pharmacy, but no training
Patient fails to use inhaler properly, leading to
hospitalization
Patient is treated with nebulizer
during hospital stay
Patient is discharged without
training in use of inhaler
+ + +*CareMgt
ClinicalPharmacy
PatientEngagement
BehavioralHealth
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With the goal of reducing readmissions of patients with COPD, learn how a team from UPMC St. Margaret redesigned the way they delivered care.
Teachable Moments
www.prhi.org/ppc_teachablemoments.php
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COPD Readmissions Reduction Results
By focusing on the transitions between care settings:30 readmissions prevented
$160,000+ saved
Net savings of $80,000+ after cost of Care Manager
0%1%2%3%4%5%6%7%8%9%
10%11%12%13%14%15%
Jan-Dec 2008 Jan-Dec 2009
% of Patients Admitted for COPD Exacerbation and Readmitted within
30 Days for COPD or Pneumonia
44% Reduction
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Reducing Preventable Hospitalizations: Behavioral Health Comorbidities
Patients with co‐morbid depression are more likely to be readmitted
% Readmitted with No Secondary
Depression
% Readmitted with Secondary Depression
Asthma 29% 42%COPD 43% 51%
Pneumonia 34% 42%All Other 29% 37%
Source: PRHI Analysis of PHC4 Data 2005‐2006, SW PA
Patients with depression and co‐morbid substance use disorders are more likely to be hospitalized for four days or longer
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A Solution: Integrating Behavioral Health Into Primary Care
Consulting Pharmacist
Performs med. rev. and consults with PCP, PRN
Consulting Psychiatrist
Consults weekly with the
CS/BHCM on all cases
Clinical Specialist (or BHCM)
Brief interventions and self‐
management support
Informed, Activated Patient, Primary Care Physician, and Office Staff
SBIRT IMPACT
All patients are screened for behavioral
health and/or substance abuse issues
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Results of Integrating Behavioral Health into Primary Care
Of patients screened; 24% positive
49% achieved at least 50% reduction in depression symptoms at six months
24% reported ER visit at baseline versus 14% through six months in ITPC
Led to $3.5 Million partnership among Minnesota, Wisconsin and Pennsylvania
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“High‐utilizer work is about building relationships with people who are in crisis. The ones you build a relationship with, you can change behavior…”
‐ Jeffrey Brenner, M.D.Camden Coalition of Healthcare Providers
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New Models of Care:Leading with Behavioral Health
Behavioral Health Specialists
The Nuka Model
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Reducing Preventable Hospitalizations:PPC in Skilled Nursing Facilities (SNFs)
6% of seniors in SNFs = 17+% of healthcare costs
20% of hospital patients discharged to a SNF were readmitted
51% of residents have one or more ER visits
38% have a hospitalizations: 41% are readmitted
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PPC in Skilled Nursing Facility Reduces Unplanned Hospital Admissions
60% decrease in pressure ulcers
25% improved pain management
40% improvement in risk assessment compliance
Unplanned hospital admissions among residents with chronic conditions reduced to zero over a 12‐month period
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Preventing Hospitalizations:New Rules for End of Life
Discussing advance planning with patients before a health crisis
Respecting the patient’s end of life plans
Communicating a realistic prognosis to the patient
Referring patient for palliative care and/or hospice in a timely manner
Estimates show that about 27% of Medicare's annual budget goes to care for patients in their
final year of life
Source: http://www.usatoday.com/money/industries/health/2006‐10‐18‐end‐of‐life‐costs_x.htm
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Disruptive Innovations
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“The challenge we face is not unique to health care. The transformational force that has brought value to other industries is disruptive innovation. The healthcare industry screams for disruption.”
‐ Clayton M. ChristensenThe Innovator’s Prescription: A Disruptive Solution for Health Care
Disruptive Innovations: System Transformations
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Disruptive Innovations
1. Simple, less expensive, “upstream” innovations
2. Serve more with fewer features
Do not overshoot customer need
Show better understanding of customer need
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“Training dosage had most important effect on measures of success. A combination of PPC training, additional training, and coaching were associated with improved outcomes. Social networking or on‐line technology can foster a virtual PPC community.”
‐ Donna O. Farley, PhDRAND: Results from the Retrospective Evaluation Effects of PPC University Training
The Technology Innovation
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The Web‐based Solution: Tomorrow’s HealthCare™
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Perfecting Patient CareSM OnlineDemonstrations & toolsCertification & accredited educationCase studies & examples
Lean tools & techniquesAssessment templatesRegistries Sample interventionsImplementation & planning guides
Individual, team & institute projectsEducational credit & project trackingProject progress assessment tools
Communities of interestBest practice sharingOpen source content developmentDiscussion boards
Process & Quality Improvement
Customized ePortfolio
Professional NetworkingLearning
Tomorrow’s HealthCareTM at a Glance
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“Put everybody in the company to work to accomplish the transformation.”
‐W. Edwards Deming, PhD
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Team Leaders & Managers
Champions
Frontline Staff
PhysiciansHealthcare Executives
Tomorrow’sHealthCare™
• Test• Prove• Collaborate
• Learn• Experiment• Document
• Educate• Motivate• Incentivize• Reward
Tomorrow’s HealthCare™ Participants
• Team up• Improve• Capture
• Manage• Communicate• Measure• Reward• Spread
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Interactive Animated Learning
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You Can’t Reward What You Don’t Measure
Pay for Performance
Hospital Admissions Data
Patient Registries
Electronic Health Records
Tomorrow’s HealthCareTM can be customized to measure what you want to reward
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Lessons From the Field
The combination of PPC and Tomorrow’s HealthCareTM is being tested in many healthcare settings
Hospitals
Skilled Nursing
Behavioral Health
Community Health Centers
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Lean Philosophy is a Way of Life
Not spot repair
Enterprise thinking
Maximization of resources
Adaption for survival and
competitive positioning Vitruvian Man
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What We Teach
Systems thinking
Work derives from customer pull/need
Critical performance pathways extend to and from the organization
Teamwork
Automation and Precision
Efficiency and “work leveling”
Rapid Frequent Problem Solving
Work Redesign begins at the Frontline
Circuit Board Exercise
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Lean Organizations are Adaptive
Change is a constant, Now Accelerating
Policy (payment, regulations, accountability)
Demand
Workforce
Patients
Quality Expectations
Technology
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Chronic Disease Care
Coordination
Pharmacist Consults
Behavioral Health
Screening
Anticoagulation Clinic
Support Reaching “Meaningful Use” EHR Targets
Nurse Care Managers
PCP Refers Patient for PCRC
Management
PRIMARY CARE RESOURCE
CENTER
Self-ManagementSmoking
Cessation
Spirometry
New Models of Care: Hospital‐based Primary Care Resource Center
Supports team‐based care coordination of chronic medical conditions
Provides added‐value primary care support services beyond the means of small practices
Can utilize excess hospital space
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New Models of Care: Secondary Care Centers
United States Care Model
Israeli Care Model Cost‐effective, ambulatory care:operates between primary and hospital care with multi‐disciplinary post‐discharge follow up, team‐based specialty clinics.
United States hospitals have 40% more
acute beds per 1000
population than Israel
Urgi‐CareCenters
Specialists Offices
Ambulatory Surgi‐Centers
Same Day Surgery
Outpatient Imaging
23 Hour OBS Units
Hospitals
HOSPITALS IN THE UNITED STATES
SECONDARY CARE CENTERS IN ISRAEL
Lin Medical Center
Zvulun
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Secondary Care Centers (cont’d)
Asthma
Breast Cancer
Pelvic Floor
COPD Parkinson’s Disease
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PPC for Systems Transformation
PPC for Organizational Transformation
PPC for Repairs
An Early Vision for Perfecting Care
A Method for Perfecting Patient CareSM (PPC)
PPC in New Technologies and New Models
Moving Beyond Repair to Transformation