Sepsis Process and Quality Improvement:
A LEAN/Six Sigma Approach
Saria Saccocio, MD/MHA
Karen Schwartz, MS, RD, LD, FACHE
Chief Medical Officer
V.P., Performance Management
Bon Secours St. Francis Health System
Problem Statement:
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
• Sepsis is one of the most common,
dangerous, and difficult to treat
conditions in health care today.
• Impact on prolonged length of stay is
significant.
• According to the AHRQ, sepsis is the
most expensive cause of hospitalization
in the US, accounting for more than $24
billion annually.
Bon Secours St. Francis
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
• St. Francis Health System found Sepsis has the
greatest length of stay and cost opportunity
compared to other high volume illnesses.
The primary challenges include:
1. The ability to appropriately screen and
identify patients who are septic
2. The timeliness of initiating diagnostics and
appropriate treatment
3. Ongoing management of sepsis care
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
Current State: NPOA from Premier Sepsis Population Analysis
Sepsis 12 Month Trend
Mortality
Sepsis Mortality O/E
St. Francis Downtown
2.00
1.50
1.00
0.50
0.00
MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB
2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2015 2015
Length of Stay
Sepsis Mortality O/E
St. Francis Eastside
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB
2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2015 2015
Sepsis Length of Stay
St. Francis Downtown
Sepsis Length of Stay
St. Francis Eastside
10.00
15.00
10.00
5.00
0.00
5.00
0.00
MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB
2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2015 2015
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB
2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2015 2015
Approach: LEAN Thinking
• Held Multi-Disciplinary Kaizen
• Assess current state through data analysis
and GEMBA observations/interviews
• Value Stream Mapping
• Evaluate Gap to Best Practice
• Brainstorming
• Future State Planning
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
USED FACILITATIVE LEADERSHIP APPROACH
Patient Flow
Place on 1 of 10
Different Units
Point
of
Entry
Placement
on Inpatient
Unit
Outreach RN
called by RN
Evidence
Base Care
(Bundles)
Discharge
Planning
Sepsis
Identified
in ED
>90% enter
by ED
Patient
Discharged
Post
Discharge
Follow-Up
Readmission
11.3% readmit
to Hospital
Inconsistent staffing of
Outreach Nurse
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
Sepsis
Identified on
Nursing Unit
Inconsistent Discharge
Planning
Gemba Walk Observations
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
Medical Surgical Units:
• Lack of Order Set Utilization
• NO Designated “Code Sepsis”
• Outreach Nurse Staffing Inconsistent
• RN Awareness of Care
Plan/Assess/Timeframes for Sepsis Bundle
• Utilization of Palliative Care and Home
Health Services
Gemba Walk Observations
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
Emergency Department:
• Not Ordering NS Bolus IV @30ml/kg
• Not Ordering Repeat Lactic Acid in 4Hour when Initial Result >2
• Average time from ED Consult to Admit
Order = 31 minutes (Range 1 – 131
minutes)
Gemba Walk Observations
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
Critical Care:
• Standardized Care and Communication for
Sepsis Patients is Lacking
• Alarm Fatigue is an Issue for Higher Acuity
Patients :
SIRS and MEWS are not perceived as helpful
because the acuity of these patients causes
them to trigger routinely
• There is inconsistency in available resources for
ICU to provide an Outreach Nurse
Current State Data
Not Present On Admission (NPOA) Sepsis Cases Analyzed for
Recognition & Treatment Trends
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
• 63% recognized on day shift
• 26% Diagnosed on Day 1
• Over half with no lactate
drawn
• Tachycardia dominant sign at
time or recognition in 5 hours
preceding recognition of
sepsis
• Observations from team:
“We missed everything”
“14-hour ED stay”
3 patients did not meet
Sepsis Criteria
Current State Data
Sepsis Patients: Top 10 Admitting Diagnoses
350
305
300
250
200
184
150
100
50
52
42
34
26
25
19
17
15
QualityAdvisor Custom Comparison Analysis; 5-Digit(ICD-9)-995.91, 995.92,
785.52 (February 2014-January 2015)
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
0
Current State Data
Cost Per Case
Facility
Length of Stay
Facility
Top Decile Peer
Top Decile Peer
7.00
$30,000
$26,079
$26,387
6.10
5.97
6.00
$25,000
5.52
5.00
$20,000
4.42
$16,979
$16,615
4.00
$15,000
$12,728
$12,251
$11,339
3.00
$9,389
$10,000
2.00
$5,000
1.00
Sepsis POA
Observed
Sepsis POA
Expected
Sepsis NPOA
Observed
Sepsis NPOA
Expected
QualityAdvisor Custom Comparison Analysis; 5-Digit(ICD-9)-995.91,
995.92, 785.52 (February 2014-January 2015)
0.00
Observed
Expected
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
$0
Cost Benefit Calculation
Facility
Annual
Volume
Actual LOS
Risk Adjusted
Expected LOS
Excess Days
Bon Secours St.
Francis Downtown
877
7.40
7.01
1392
Bon Secours St.
Francis Eastside
203
4.96
5.87
150
Grand Total
1080
6.94
6.80
1542
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
Total system annual opportunity of $616,884
Excludes outliers and ages 0-17
Excess days multiplied by $400/cost per day
Days saved would open up an additional 4 beds per
day
Future State
• Focus on Severe Sepsis & NPOA
• Comprehensive Early Treatment Protocol (EMS)
• Model after existing organized care approaches
• Initiate in ED and transition to Patient Care
Units
• Use existing resources
• Time-Based (first 6 hours of care) address:
Recognition
Appropriate End-Point Driven Resuscitation
Appropriate Early Antibiotics & Fluid Administration
Follow up
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
1.
2.
3.
4.
Future State
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
• Implement Sepsis Code & Rapid Response Teams to
support identification at first sign of possible sepsis
• Optimize electronic surveillance to continuously screen
& activate Sepsis Code response system and support
follow through of evidence-based interventions
• Institute and hardwire best practice, evidence-based
order sets and care pathways
• Physician and Nursing education on standard process
and access to order sets
• Patient education and engagement improvement by
implementing Sepsis Nurse Coordinator
Results:
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
• Length of stay reduction
• New standard process for patient education
• Implementation of Sepsis Nurse Coordinator –
improved patient satisfaction and education
• Standard work through new order sets for
nursing and physicians
• Rapid Response Team response process and
early identification
LEAN SIX SIGMA HEALTHCARE SYMPOSIUM
Changing What’s Possible in Healthcare
2015
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