Six Sigma Approach to Reduction of Infections
Transcript of Six Sigma Approach to Reduction of Infections
Six Sigma ApproachSix Sigma Approachtoto
Reduction of InfectionsReduction of Infections
Lois Yingling, RNC, MSN, CPHQ, Black Belt Lois Yingling, RNC, MSN, CPHQ, Black Belt Florida HospitalFlorida HospitalOrlando, FloridaOrlando, [email protected]@flhosp.org
ObjectivesObjectives
At the conclusion of the At the conclusion of the presentation participants will:presentation participants will:
List the 5 steps of Six SigmaList the 5 steps of Six SigmaIdentify components of the IHI Identify components of the IHI central line bundlecentral line bundleAppreciate the value of a Appreciate the value of a systematic approach to process systematic approach to process improvementimprovement
OverviewOverview
Who is Florida HospitalWho is Florida HospitalBloodstream infectionsBloodstream infections
Five steps of Six Sigma Five steps of Six Sigma DefineDefineMeasureMeasureAnalyzeAnalyzeImproveImproveControlControl
Lessons learned with CDTLessons learned with CDT
Who is Florida Hospital?Who is Florida Hospital?
Founded in 1908 by Adventist ChurchFounded in 1908 by Adventist ChurchOldest & largest healthcare system in Oldest & largest healthcare system in Central FloridaCentral FloridaSeven campuses in 3 countiesSeven campuses in 3 countiesLicensed for over 1800 bedsLicensed for over 1800 bedsThird largest employer in Central FloridaThird largest employer in Central FloridaLargest Medicare population in the nationLargest Medicare population in the nationRecognized as one of America’s Best Recognized as one of America’s Best Hospitals in U.S. News & World Report for Hospitals in U.S. News & World Report for the seventh year in a rowthe seventh year in a rowHealthGrades 2005 Award for Excellence in HealthGrades 2005 Award for Excellence in Patient SafetyPatient Safety
DDMAICMAIC
DefineDefine
Why Bloodstream Why Bloodstream Infection (BSI)Infection (BSI)
Published mortality rates as high as Published mortality rates as high as 35%35%
Baseline CVC related BSI: 13%Baseline CVC related BSI: 13%Additional therapy costs $56,000Additional therapy costs $56,000
Baseline CVC related BSI: $16,699 Baseline CVC related BSI: $16,699 variable costvariable cost
Increased length of stayIncreased length of stayBaseline CVC related BSI: 20.6 Baseline CVC related BSI: 20.6 additional days per caseadditional days per case
National InterestNational InterestInstitute for Healthcare Quality Institute for Healthcare Quality (IHI)(IHI)
Central line bundleCentral line bundleHand hygieneHand hygieneMaximal barrier precautionsMaximal barrier precautionsChlorhexadine skin antisepsisChlorhexadine skin antisepsisAppropriate care of site and line Appropriate care of site and line systemsystemNo routine replacementNo routine replacement
Center for Disease Control (CDC)Center for Disease Control (CDC)GuidelinesGuidelines
DDMMAICAIC
MeasureMeasure
ScopeScopeIn Scope:In Scope:
Inpatients systemInpatients system--wide >17 y/owide >17 y/oPositive blood culture within 48 Positive blood culture within 48 hours of admission (2 weeks rehours of admission (2 weeks re--admission)admission)Confirmed based on CDC definitionConfirmed based on CDC definitionCVCCVC
Out of ScopeOut of ScopePICC linesPICC linesTunneled, port, dialysis, peripheralsTunneled, port, dialysis, peripherals
Project Description/ Project Description/ Problem StatementProblem Statement
Based on 2003 & annualized 2004 data:Based on 2003 & annualized 2004 data:43% of BSIs were secondary to CVCs43% of BSIs were secondary to CVCsLOS is increased by 20.6 days per LOS is increased by 20.6 days per casecaseVariable treatment cost is increased Variable treatment cost is increased by $16,699 per caseby $16,699 per case
Goal:Goal:Decrease the number of CVC related Decrease the number of CVC related cases by 10%, a decrease of 16 cases cases by 10%, a decrease of 16 cases per yearper year
SIPOCHigh Level Process Map
Supplier Input Process Output Customer
Physician Referral
Line
ProtectiveGarb
Tray
Start = line Insertion
Selectdevice
Select site
Don fullbarrier garb
Prep site
Insert line
Care for line& dressing
End = line removal
No BSI
BSI
Patient
Family
BaselineBaseline
Process in control, no special cause variation
Gauge RepeatabilityGauge Repeatability ICP Initial
Surveillance Determination
ICP Second Surveillance Determination
Agree Disagree
Patient Surveillance result
Surveillance result
BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired Total 10 0 100% One person repeatedly measures same unit
Gauge ReproducibilityGauge Reproducibility ICP #1 ICP#2 Agree Disagree Patient Surveillance
result Surveillance result
BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired BSI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Hospital Acquired UTI Surveillance Hospital Acquired Not Hospital
Acquired
CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired CDT Surveillance Hospital Acquired Hospital Acquired Total 9 1 90% Two or more persons measure the same unit
DMDMAAICIC
AnalyzeAnalyze
Process CapabilityProcess Capability
Y1 All BSI Overall Z.USL -1.39 Sigma 0
Vital XsVital Xs
BSI
Education
Patient/Visitor
Catheter Care
Equipment
Site
Technique
Contamination
Prep
Skill level
Sterile barrier
Hand hygiene
PICC Candidate
Femoral
Subclavien
Jugular
Stabilizer
Cost
Non-antimicrobialcatheter
A ntimicrobialcatheter
ContaminationHub care
Dressing
A septic techniue
Line maintenance
Hand hygiene
Handling drsg
Handling catheter
Hand hygiene
Visitors
Patient
Physician
Staff
CVC related blood stream infections cause & effect fishbone
DMADMAIICC
ImproveImprove
Nail P&PChloraprep
Staff BSI Education
Began conversion to antimicrobial catheters in custom trays with sterile garb in all trays except Anesthesia Trays
Hand Hygiene Campaign
Interventions & ResultsInterventions & Results
Statistical SignificanceStatistical Significance
Two-Sample T-Test and CI: Historical VS New Mean
Two-sample T for Rate
C7 N Mean StDev SE Mean1 11 0.658 0.154 0.047 (Jan 2003 - November 2003)2 14 0.355 0.131 0.035 (Nov 2003 - January 2005)
Difference = mu (1) - mu (2)Estimate for difference: 0.30318295% CI for difference: (0.181309, 0.425054)T-Test of difference = 0 (vs not =): T-Value = 5.21 P-Value = 0.000 DF = 19
Difference between historical & new mean
is statistically significant
Error Proofing TraysError Proofing Trays
Custom Trays:Custom Trays:Anesthesia Trays Anesthesia Trays -- no sterile no sterile garbgarbED & Unit Trays ED & Unit Trays –– sterile garbsterile garb
Issue:Issue:Anesthesia trays without Anesthesia trays without sterile garb distributed to unitssterile garb distributed to units
Error Proof:Error Proof:All custom trays include sterile All custom trays include sterile garb and antimicrobial cathetergarb and antimicrobial catheter
DMAIDMAICC
ControlControl
Reliable MeasurementsReliable Measurements
What How X1 X What Where When HowMany
Total Blood Stream Infections Y=BSI Rate
Continuous Data
Positive Blood culture after 48 hours od admission or readmission within 7 days for S&S if BSI
Query Medmined for positive blood cultures
Line Type: CVC Swan Ganz, PICC, tunneled
Infection Control Survelance Criteria for Center for disease Control Definition BSI
System-wide Monthly !00%
X=number of infections secondary to CVC
Discrete data Same as above
Same as above
Extarpolate CVC lines
Confirmed BSI secondary to CVC line
Review records for accuracy
System-wide Monthly !00%
Gage R&R for all new emplyees after 90 days & for all staff annually. Gage R&R may be done more frequently if indicated.
Procedure &Data Form
Sampling Plan What toMeasure Type of
Measure Type of
Data
Clarify Data Collection Goals
Develop Operational Definitionsand Procedures
Operational Definition
Other Conditions to Record
Collecting and Recording
BSI Rate is based on CDC definition.
CVC related BSI extrapolated from total BSI cases.
Current StatusCurrent Status
Ja nua r y 2003 t hr o ugh Ju ly 2005
Per
1000
Pat
ient
Day
s
Jun e
Ma rch
De cembe
r
Sep te
mb erJu
n eMar
c h
De cembe
r
Sept
e mber
J une
M arc h
1 .2
1 .0
0 .8
0 .6
0 .4
0 .2
0 .0
_X =0 .383
UC L=0 .733
LC L=0.033
1 2
I C ha r t o f C V C B S I R a te H is tor ica l V S N e w M e a nDa ta S ource : A IC E
Process is in Control
Target: 5 or Less/MonthTarget: 5 or Less/Month
Process CapabilityProcess Capability
0 .70 .60 .50 .40 .30 .20 .1
U S LP ro ce ss D a ta
S a m p le N 18S tD e v (W ith in ) 0 .1 2359S tD e v (O v e ra ll) 0 .1 3445
LS L *T a rge t *U S L 0 .4 2000S a m p le M e a n 0 .3 8000
P o te n tia l (W ith in ) C a pa b ility
C C pk 0 .1 1
O v e ra ll C a pa b ility
Z .B e nch 0 .3 0Z .LS L *Z .U S L 0 .3 0P pk
Z .B e nch
0 .1 0C pm *
0 .32Z .LS L *Z .U S L 0 .3 2C pk 0 .1 1
O bse rv e d P e rfo rm a nceP P M < LS L *P P M > U S L 388888 .8 9P P M T o ta l 3 88888 .8 9
E xp . W ith in P e rfo rm a nceP P M < LS L *P P M > U S L 373103 .1 9P P M T o ta l 3 73103 .1 9
E xp . O v e ra ll P e rfo rm a nceP P M < LS L *P P M > U S L 383038 .4 7P P M T o ta l 3 83038 .4 7
W ith inO v er all
P r oce s s C a pa bi l i ty o f R a te
Y1 All BSI overall Z.USL 0.30 current Sigma 1.8
Owner AccountabilityOwner Accountability
What Who When Data collection Process Confirmed with IC Director & Manager
Director
Monthly beginning June 2005
Monthly report of CVC BSI Cases & LOS by Campus to Esmond Chan
Director Monthly beginning June 2005
Variable cost/capacity adjustment
Financial Analyst January 2005 & monthly
ResultsResults
Capacity YTD AprilCapacity YTD AprilActual 296 DaysActual 296 DaysTarget 110 DaysTarget 110 DaysVariance 186 Days Variance 186 Days
Dollar Savings YTD April Dollar Savings YTD April Actual $207,196Actual $207,196Target $77,233Target $77,233Variance $129,963Variance $129,963
CDT: Lessons CDT: Lessons LearnedLearned
Scope: ContainmentScope: Containment
In Scope:In Scope:Inpatients systemInpatients system--wide >17 y/owide >17 y/oDiarrhea with confirmed assay Diarrhea with confirmed assay diagnosis of CDTdiagnosis of CDT
Out of ScopeOut of ScopeOutpatientsOutpatientsInpatients without diarrhea & Inpatients without diarrhea & confirmed assay diagnosis of CDTconfirmed assay diagnosis of CDT
Scope: PreventionScope: PreventionIn Scope:In Scope:
Inpatients systemInpatients system--wide, except wide, except Campus 3, >17 y/o with a history of a Campus 3, >17 y/o with a history of a surgical procedure on the SIP listsurgical procedure on the SIP listDiarrhea with confirmed assay Diarrhea with confirmed assay diagnosis CDTdiagnosis CDT
Out of ScopeOut of ScopeAll patients admitted to Campus 3All patients admitted to Campus 3All medical patients and all surgical All medical patients and all surgical patients not on SIP listpatients not on SIP list
CDT Baseline Out of CDT Baseline Out of ControlControl
M ont h
Indi
vidu
al V
alue
June
Ma rc h
Decem be r
Septem be rJu
neMa r ch
Dec embe r
S eptem be rJu
neMa rch
5 .5
5 .0
4 .5
4 .0
3 .5
3 .0
2 .5
2 .0
_X =3.564
UC L=4.530
LC L=2.597
11
1
1
1
1
I C har t of C D T R a te
Baseline 2003 through June 2004
CDT RateCDT Rate
Ja n u a r y 2 0 03 t hr o ug h M a y 2 0 0 4
Per
1000
Pat
ient
Day
s
June
M a rc h
De cem be r
Se p tem be rJu
neM a r ch
De c embe r
S e p tem be rJu
neM a rch
5 .5
5 .0
4 .5
4 .0
3 .5
3 .0
2 .5
2 .0
_X =4 .195
UC L=5 .117
LC L=3 .273
1 21
11
I C ha r t o f C D T R a te P r e -A s s a y V S P os t A s s a yDa ta S ource : A IC E
June 2 0 0 4 t hr o u g h Jun e 2 0 05
100% Assay Testing increased Case Finding
ContainmentContainmentApril 2005April 2005
Terminal Cleans with Terminal Cleans with bleach for rooms of CDT bleach for rooms of CDT patientspatients
May 2005May 2005Error ProofingError ProofingTerminal Cleans for all Terminal Cleans for all roomsrooms
July Pilot Campus 6July Pilot Campus 6New nonNew non--bleach product bleach product
Kills sporesKills sporesNo damage to furnitureNo damage to furniture
Bleach
CDT RateCDT Rate
CDT Cases/Month CDT Cases/Month
Terminal bleach clean CDT rooms
Terminal bleach clean all Rooms
2004 - June 2005: Target 152 or less/month
PreventionPrevention
Right AntibioticRight AntibioticRight timeRight time
Within one hour of incisionWithin one hour of incisionRight durationRight duration
Discontinue within 24 hours for Discontinue within 24 hours for prophylaxisprophylaxisDocument if treating infectionDocument if treating infection
Business CaseBusiness Case
Improved clinical quality Improved clinical quality (absence of infection)(absence of infection)Capacity opportunity of 1639 Capacity opportunity of 1639 daysdaysFinancial opportunity of Financial opportunity of $1,298,484$1,298,484
SummarySummary
Six Sigma:Six Sigma:Well defined methodologyWell defined methodologySystematic approachSystematic approachRobustRobustData drivenData drivenDirectionalDirectionalStatistical application for other Statistical application for other initiativesinitiatives
““Alice came to a fork in the Alice came to a fork in the road. ‘Which road do I road. ‘Which road do I take?’ she asked. ‘Where take?’ she asked. ‘Where do you want to go?’ do you want to go?’ responded the Cheshire responded the Cheshire cat? ‘I don’t know.’ Alice cat? ‘I don’t know.’ Alice answered. ‘Then’ said the answered. ‘Then’ said the cat, ‘it doesn’t matter.’”cat, ‘it doesn’t matter.’”
From “Alice in Wonderland” From “Alice in Wonderland” by Lewis Carrollby Lewis Carroll