The GE Toolkit at Virtua Health...Responding to the Health Care ChallengeRichard Miller, CEO Virtua HealthSusan McGann, RN BSNMark Van Kooy, MDQuality ColloquiumAugust 24, 2004

Virtua HealthFour hospital system in Southern New JerseyTwo Long Term Care FacilitiesTwo Home Health AgenciesTwo Free Standing Surgical CentersAmbulatory Care - CamdenFitness Center7000 employees + 1700 physicians7,000 deliveries$600 million in revenuesSTAR Culture

Virtua Imperatives 2004The Strategic PlanVirtuas Leadership and Management SystemsManage Cost and Expense to Best PracticeEnhance RevenueManage Length of StayImplement Medical Staff Development Plan

Systems and Structures for Supporting the STARExcellent serviceBest peopleCaring cultureClinical quality and Patient SafetyResourcestewardshipOutstanding Patient ExperienceStrategy The stake in the groundPerformance New Business ValuesMission and Values Leadership and Management Systems

Current State: STAR CommitmentDesired State: STAR PerformanceIts Great to Have a Philosophy . . . But We Need a Strategy !!Six Sigma is part of our strategy on our journey through the maze

VIRTUAS Performance Journey ContinuesWJ: Quality Circles: early - late 1980sMH: Morbidity and Mortality Reviews, Quality AuditsWJ: Quality Assurance: mid 1980sMH: Quality Assurance: mid 1970s to mid 1980sWJ: Quality Assessment: late 1980sMH: Quality Assessment mid to late 80s (Leadership explores Total Quality Management Concepts with VHA 1988 - 1990)WJ: Total Quality Management: early 1990sMH: Total Quality Management 1990 - 1995WJ: Re-engineering / Patient Centered Care: mid 1990sMH: Metric Focused Quality Improvement (AQP) / Patient Focused Care: mid 1990sVirtua Health: STAR, Six Sigma/CAP/Workout, Becoming a Learning Organization - October 2000Virtua Health: LEAN, Simulation, Management Engineering November 2003

Why GE?Pre-existing relationshipHighly respected for their business processes and leadership developmentPioneer in Six Sigma application and knowledge transferComprehensive Toolkit (Six Sigma, CAP and WorkOutTalented, highly competent consulting and implementation team

Cardiac Medications ProjectDefine Phase

Cardiac Medications: DefineBoard-Medical Staff Quality Retreat in October 2001Issue: Performance MetricsExample: Cardiac Medication AdministrationStatusReported to CMSAvailable on Internet sitesObservation: The data is not validResponse: Its your data

Cardiac Medications: DefinePerformance IssuesClinical performanceData integrityRetreat action stepsCardiac Program of ExcellenceCMS targets included in Management Incentive Compensation Program for 2002Metric: 4th quarter performance at or above CMS targets

VIRTUA HEALTH

Performance on CMS Cardiac Medications Standards

MEASURE

BENCH

MARK

2001

1st Qtr 02

Use of ASA with Acute MI patients within 24 hours of arrival to hospital (%)

90

85

87

Use of beta blockers within 24 hours of arrival to hospital (%) in AMI

90

84

83

Use of aspirin at discharge (%) in AMI

90

86

83

Use of beta blocker at discharge (%) in AMI

90

86

85

Appropriate use/non use of ACEI at discharge (Patients with LVEF < 40% (%) in AMI

90

78

72

Appropriate use/non use of ACEI at discharge (Patients with LVEF < 40%) (%) in CHF

90

89

48

Cardiac Medications: DefineUsual improvement techniques appliedNo movement in metrics by 6/02Use of Six Sigma revisitedProject chartered 7/02

Project Title: Cardiac Medication Indicators Six Sigma ProjectSponsors: Jim Dwyer, Ann Campbell, Ellen Guarnieri, Adrienne Kirby, Mike KotzenChampions: Pat Orchard & Jane SlaterbeckMaster BB: Mark Van KooyBlack Belt: Adrienne ElberfeldGreen Belt: Ted GallFinance Approver: Gerry LoweProject Start Date: July 22, 2002Team Members: Jay Brewin, Darlene Euler, Christine Gerber, Val Torres, Kathy Halstead, Kathy Plumb, Cindy DEsterre, Lori Edell, Heather Scheckner, Angie Smolskis, Pat Quackenbush, Ronald Kieft, Michelle Weaks, Robert Singer, Vince Spagnuolo, Steve FoxAlignment with Strategic Plan: IIA-Cardiology; Global MICP Goals for Virtua.R0 CardiacMedicationIndicatorsProject Scope:To have all four acute care facilities, within all medical disciplines, meet the standards of Core/JCAHO guidelinesProject Description:Increase quality of patient care by use/non-use and appropriate documentation of aspirin, beta-blockers, and ACE inhibitors in CHF or AMI patients to achieve or exceed Virtua benchmark goals.Potential Benefits:To achieve improved outcomes for patients with AMI/CHF diagnosis by adhering to evidence based practice through education, documentation, and compliance while meeting regulatory standards and enhancing quality of patient care at Virtua.

Cardiac Medications ProjectMeasure Phase

QRA Chart Review Gage R&RPercentage of time QRAs agreed on assessment During this gage, it was determined that there was variation between the QRAs review of chartsA Workout was held on September 18th with the QRAs and Case Management Directors to develop SOPs in reviewing of all CHF and AMI patients for core indicators

Each Appraiser vs Standard

Assessment Agreement

Appraiser # Inspected # Matched Percent (%) 95.0% CI

Appraiser A 12 4 33.3 ( 9.9, 65.1)

Appraiser B 12 11 91.7 ( 61.5, 99.8)

Appraiser C 12 9 75.0 ( 42.8, 94.5)

Appraiser D 12 10 83.3 ( 51.6, 97.9)

# Matched: Appraiser's assessment across trials agrees with standard.

Assessment Disagreement

Appraiser # 1/0 Percent (%) # 0/1 Percent (%) # Mixed Percent (%)

Appraiser A 0 * 8 66.7 0 0.0

Appraiser B 0 * 1 8.3 0 0.0

Appraiser C 0 * 3 25.0 0 0.0

Appraiser D 0 * 2 16.7 0 0.0

# 1/0: Assessments across trials = 1 / standard = 0.

# 0/1: Assessments across trials = 0 / standard = 1.

# Mixed: Assessments across trials are not identical.

Between Appraisers

Assessment Agreement

# Inspected # Matched Percent (%) 95.0% CI

12 5 41.7 ( 15.2, 72.3)

# Matched: All appraisers' assessments agree with each other.

Containment

Containment Activities100% chart reviewAll hands on deck!NursingCase ManagementQualityPhysicians

Cardiac Medications ProjectAnalyze Phase

All defects related to a cardiac medication indicator are reviewed by the physician champion at the local site. The champion follows-up directly with the individual physician.

Chart1

12

7

5

5

19

Other Physician Groups40%

Physician 125%

Physician 215%

Physiian 310%

Physician 410%

48 Total Defects46 Documentation Related2 Quality of Care Issues

Defects

WJ Physician Defects July-Dec 2002

WJ Physician Defects 2002

Physician Name or GroupingDefects

Salm12

Schwartz7

Levin5

Williams5

Others (18)19

Sheet2

Sheet3

Best practice at Memorial: Physician based Case Management teams to work directly with doctors in evaluating care of the patient.

Chart1

12

7

5

5

19

Other Physician Groups40%

Allen Salm25%

Andrew Schwartz15%

Neil Levin10%

Sherri Williams10%

48 Total Defects46 Documentation Related2 Quality of Care Issues

Defects

WJ Physician Defects July-Dec 2002

WJ Physician Defects 2002

Physician Name or GroupingDefects

Salm12

Schwartz7

Levin5

Williams5

Others (18)19

Chart2

3

18

Physician 114%

Other Physicians86%

100% Documentation Related Issues

Defects

Memorial Physician Defects Jul-Nov 2002

Memorial Physicians

Physician or GroupingDefects

O'Neil3

Others (12)18

Sheet3

Key takeaway: Patients diagnosed as Respiratory Distress by MICU were 100% of the fall-outs.Need to educate MICU staff per results and review of symptom related diagnosisAnalysis of AMI patients that did not receive aspirin within 24hours

Chart1

4

6

Diagnosis: Respiratory Distress

Campus Breakdown:

Marlton--2Berlin--1Voorhees--1

*one chart previously identified as fall-out, ASA documentedon MICU run sheet

Diagnosis:Pnemonia--1CHF--2Respiratory Distress--1Unknown--2

Campus Breakdown:

Marlton--2Voorhees--2Berlin--1Memorial--1

Number of Pts

MICU Analysis July-Dec 2002 ASA

Method of ArrivalCampusSquadReason/DiagnosisArrival ModeNumber of Pts

MICUMarltonVoorheesRespiratory DistressMICU4

MICUMarltonHaddonfldRespiratory DistressWalkIn6

MICUBerlinAtcoRespiratory Distress

MICUBerlinErialChest Pain

WalkInMarltonCherry HillPneumonia

WalkInMarltonMtLaurelCHF

WalkInMemorialMtLaurel

WalkInVoorheesBarringtonRespiratory Distress

WalkInVoorhees

WalkInBerlinCedarBrkCHF

Sheet2

Sheet3

Cardiac Medications ProjectImprove Phase

Physician Compliance XMethodsPracticeEducation(PRO indicators- what are they?) 7th Scope CAP 4/4/03 CompletedPhysician LeadershipStickers lost in chart (QA stickers) XData collection inconsistent amongst QRAs XWorkOut 9/18/0224 hour compliance in giving Med XContraindication to Med Not Documented XCo-morbid conditions not documented XLack of Documentation XProper Documentation of med given in ED in numerous areas of chart XNeed to identify time drug given XNeed to be consistent across Virtua XEducation - as tool XMultiple D/C instruction forms XNO Pathways for AMI X WorkOut April 8th & 9th, 2003Pathway for CHF not followed XLack of communication/education XNo consequence for non-compliance X,NAppropriate use of ARBs and documentation XKnowledge base/know studies XDocumentationMD not noting importance of documentation XConsistency with documentation among MD disciplines XMeasurementsPatient ConditionAllergy to medication not documented XPhysician not noting the importance of documentation XSticker importance; not using as a tool XNursing Education & Communication XNursing lack of understanding & knowledge XDischarge process XUpdated med list XAccountability for competing d/c form XNo standard d/c form XNeed to document common knowledge XMR completion XCHF TeamImproveThrough WorkOut, pilot of best practice, and coordination of medical leadership with nursing and case management the team was able to standardize practice and reduce the variables

ImproveExpected Results of Proposed SolutionsImprovementY BenefitQuality Benefit

MICU run sheets on patient charts within 24 hours of admission

Increased compliance for aspirin given with 24 hours

Compliance with PRO indicators for aspirin given within 24 hours of admission

Physician completion of written discharge instructions for cardiac patients

Compliance and proper documentation of care for discharge medication indicators

Proper quality of care administered as per PRO indicators and documented

Standard Operating Procedures by Nursing and Case Management in chart review, stickie reminders for physicians, and availability of discharge instructions

Increased compliance in care and documentation for all indicators

Coordination of care for the cardiac patient by the multi-disciplinary team

Consistent education of nursing per cardiac medication indicators

Increased compliance for medications given within time frames

Increased knowledge base of the nursing staff of the cardiac medications for AMI and CHF patients

Accurate daily census with diagnosis available through Oasis Gold and Canopy

Increased compliance in care and documentation for all indicators

Proper quality of care administered as per PRO indicators and documented

Appointment of a Process Owner at each hospital to coordinate care with directives from Cardiac Programs of Excellence

Sustained improvement in all indicators

Data reported to PRO and public benchmarks Virtua in 95% for compliance

Cardiac Medications ProjectControl Phase

VIRTUA HEALTH

Performance on CMS Cardiac Medications Standards

MEASURE

BENCH

MARK

2001

1st Qtr 02

4th Qtr 02

1st Qtr 04

Use of ASA with Acute MI patients within 24 hours of arrival to hospital (%)

90

85

87

95.8

94.2

Use of beta blockers within 24 hours of arrival to hospital (%) in AMI

90

84

83

97.1

98.6

Use of aspirin at discharge (%) in AMI

90

86

83

90

100

Use of beta blocker at discharge (%) in AMI

90

86

85

100

100

Appropriate use/non use of ACEI at discharge (Patients with LVEF < 40% (%) in AMI

90

78

72

100

100

Appropriate use/non use of ACEI at discharge (Patients with LVEF < 40%) (%) in CHF

90

89

48

90.5

90.5

Acute Rehab Services

What the Rehab Team Did Why They Did It First Virtua Project to Achieve Six Sigma Level of Performance!Eliminated case screening for appropriateness by physical therapists, relied on nursing assessmentFlexed staff between facilities to reduce staffing-demand mismatch Moved to bedside PT modelConsults completed within 24 hours achieved Six SigmaPatient and staff satisfaction increasedAchieved targeted increases in PT productivityInappropriate referrals were found to be rare, screening reduced productivityVarying demand between facilities limited productivityPT in department resulted in delayed treatments and reduced productivityProject Results

Acute Anticoagulation Services

What the Team Did Why They Did It Complex Clinical Processes Require Simplification and Error Prevention! WBH protocol performance fully characterizedSuccessful transition to LMWHImproved Lab-Nursing communicationBed scales, new pumps, MARReduced process complexity from 92 to 21 steps Catastrophic failures were drivers of adverse outcomesVariation in approaches was creating opportunities for errorProject Results Transitioned UFH to LMWH for DVT/PE and Acute Coronary Mistake-proofed UFH and LMWH administration processes (inc WBH MAR) Created SOPs for weighing patients and for communicating critical lab resultsLabs were obtained, reported and addressed appropriately in the vast majority of casesRare failures were gross deviations from protocolsSimplification and Mistake-proofing are critical to patient safetyLearnings

Solid tools but.Quality toolVague goalsNo standard metricsOpen-ended, unstructuredDepartment-basedFocus on product qualityReal results that matter to customers.Business toolClear goals/deliverablesClear, consistent metricsRigorous timelineBusiness-basedFocus on customerSix Sigma builds on Lessons Learned from prior approachesTQMSix SigmaWhat Makes Six Sigma Different?Adapted with permission from Hamadi Said, US Mint Philadelphia, PA

Questions or Comments?

There is a strategy to get out of the maze. What is it?

The strategy we will use to get to Six Sigma is the Breakthrough Strategy. Its also important that we stick to the strategy and not change midstream.Suggest that each organization that begins this process looks at their quality journey. It is a visual for where they have been and when years pass and Six Sigma continues, theywill see the difference between previous quality and now.Product Vectors - GEs term for their Programs of ExcellenceGE Medical - technology, IT, CAP/WorkOut/Six Sigma/LEANGE PowerGE CapitalGE Construction/Engineering

Innovation - GE is committed to aggressive new product development and to being a market leader in health care. Ability and interest to think outside the box

Leadership development - long track record of systematic cultivation of leaders and systems and structures for identifying, mentoring and rewarding/retaining outstanding leaders

Focus on results - A business-results mind set that is in their DNA