Measuring Success: Clinical and Operational
Excellence at Valley Baptist Health System
August 22, 2006
Tracy D. Kirkconnell, M.B.A.
Matiana G. Vela, Ed.D., R.D.
Rio Grande Valley
Valley Baptist Health System
•
Valley Baptist Medical Center Harlingen
–
–
–
–
–
–
•
611 Licensed Beds
Lead Level 3 Trauma Center
State of the Art Children’s Center
# 1 Rated Orthopedics Service
Heart & Vascular Institute
Teaching facility for the Regional
Academic Health Center of The
University of Texas Health
Science Center at San Antonio
Valley Baptist Medical Center –
Brownsville
–
–
–
–
243 Licensed Beds
Level 3 Trauma Center
State of the Art Imaging Center
Center of Diabetes Management
•
Other Entities
– Golden Palms Retirement and
Healthcare Center
– Valley Baptist Health Plans
– Advanced Medical Supply (DME)
– Valley Baptist Ambulatory Surgery
Center
– Clinical Pastoral Education Center
– Licensed Vocational Nurse School
– Family Practice Residency
Program
– Internal Medicine Residency
Program
– Home Health & Hospice
– Rehabilitation & Wellness
– Behavioral Health Services
Valley Baptist Health System
• Strategic Initiatives
–
–
–
–
–
Integration
Simplicity
Six Sigma Quality
Relentless Service
Expansion of Services & Regionalization
• Values
–
–
–
–
Disciplined
Entrepreneurial
Performance Oriented
Accountable
How did we begin
implementing Six Sigma?
• CEO Commitment
– Vision
– Leadership
– Resources (time, money, people)
• Partnership with General Electric Medical Systems
–
–
–
–
–
Guidance
Expert Knowledge
Training – Six Sigma, CAP, Work-Out™
Project Mentoring
Transition Assistance
Roles at VBHS
• Master Black Belt – 6 Sigma mentor and educator
• Black Belt – 6 Sigma trained specialist who works on 6
Sigma improvement initiatives on a full time basis
• Green Belt – 6 Sigma trained specialist who uses the Six
Sigma methodology to solve problems as a function of
their normal work
• Yellow Belt – Physicians and Executives trained in basic
6 Sigma methods who assist with problem solving,
initiative sponsorship and solution implementation
• Sponsor – Executive with responsibility to identify 6
Sigma initiatives, assign resources and remove barriers
• Change Agent - Expert in the application of CAP and
Work-Out™ tools
Six Sigma Practitioners at
VBHS
•
•
•
•
•
•
•
•
Certified Master Black Belts (5)
Black Belts (4)
– 3 Harlingen
– 1 Brownsville
Green Belts (61)
– 31 Certified
– 27 Seeking Certification
Yellow Belts (34)
– 15 Executives
– 19 Physicians
Master Change Agents (2)
Change Agents (237)
– 190 Harlingen
– 47 Brownsville
Six Sigma Physician Council (16)
Future
– All Executives will be trained to Yellow Belt level
– All Directors and Managers to Green Belt certification
Six Sigma and the
Art of Medicine
Spirituality
Art
Research Based Disease Management
ICU Glucose Management
6σ
Science
Core Measures
AMI
CHF
Accuracy and Speed
Pneumonia
Medication Management
CABG
Turnaround times
Fundamentals/Foundation
VBHS Confidential & Proprietary
Wait Times
9
Examples of Clinical and
Operational Initiatives
VBHS Confidential & Proprietary Information
May 2, 2006
Heart Failure Management
Christopher H. Hansen, M.D.
FY 2006
6+ Sigma
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
90.0%
80.0%
70.0%
60.0%
58.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = % Compliance with all four CMS Core Measures for Heart Failure
Ju
ne
ay
M
Ap
ril
ar
ch
M
y
Fe
br
ua
r
Ja
nu
ar
y
m
be
r
De
ce
be
r
No
ve
m
O
ct
ob
er
pt
em
be
r
Se
Ba
se
lin
e
3/
1/
04
0.0%
Displayed with Permission of Modern Healthcare.
Copyright Crain Communications, Inc., 2005
Modern Healthcare Magazine
“Right on the Money”
November 14, 2005
CMS Pay for Performance
•Launched October 2003 with 268 hospital participants
•Cash rewards for total of $8.85 million to 123 hospitals the top 20% performers in five clinical areas:
–heart failure, pneumonia, bypass surgery, heart attack and hip and knee replacement.
•Hospitals graded on quality measures, earning a composite quality score in any given focus area.
Acute Myocardial Infarction
Christopher H. Hansen, M.D.
FY 2006
6+ Sigma
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0%
94.6%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = % compliance with CMS AMI Core Measures
Ju
ne
ay
M
A
pr
il
ar
ch
M
ry
Fe
br
ua
ry
nu
a
Ja
em
be
r
D
ec
be
r
N
ov
em
er
ct
ob
O
te
m
Se
p
B
as
el
in
e
3/
1
/0
be
r
4
0.0%
Acute Myocardial Infarction
Lorenzo Pelly, MD
FY 2006
6+ Sigma
100.0% 100.0%
100.0%
100.0% 100.0%
100.0%
100.0%
97.0%
90.0%
94.1%
86.0%
80.0%
81.4%
70.0%
75.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = Compliance to all CMS Core Measures
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
br
ua
r
Fe
nu
ar
y
m
be
ec
e
D
ov
e
N
Ja
r
r
m
be
r
ob
e
O
ct
ep
te
S
B
as
e
lin
e
4/
1/
m
be
r
05
0.0%
Heart Failure Management
Lorenzo Pelly, MD
FY 2006
6+ Sigma
100.0%
100.0%
100.0%
100.0%
97.5%
100.0%
100.0%
85.0%
90.0%
85.1%
80.0%
86.0%
77.8%
70.0%
60.0%
50.0%
52.5%
40.0%
30.0%
20.0%
10.0%
Y = Compliance to all CMS Core Measures
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
br
ua
r
Fe
nu
ar
y
m
be
ec
e
D
ov
e
N
Ja
r
r
m
be
r
ob
e
O
ct
ep
te
S
B
as
e
lin
e
4/
1/
m
be
r
05
0.0%
Adult Intensive Care Unit Glucose Mgmt
Gloria Tobin, CNO
FY 2006
99.2% 97.6%
96.9%
98.5%
100.0%
90.0%
80.0%
70.0%
69.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
ne
Ju
ay
M
A
pr
il
ar
ch
M
br
ua
ry
Fe
ar
y
em
D
ec
Y = Compliance with all 8 Core Measures
Ja
nu
be
r
r
N
ov
em
be
er
ob
O
ct
em
pt
Se
B
as
el
in
e
6/
1/
0
5
-1
1/
14
be
r
/0
6
0.0%
Pressure Ulcer Prevention
Lorenzo Pelly, M.D.
FY 2006
100.0%
90.0%
80.0%
71.7%
70.0%
59.5%
57.6%
60.0%
55.6%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Ba
se
lin
e
Ju
ne
M
ay
Ap
ril
M
ar
ch
Se
pt
em
be
r
O
ct
ob
er
No
ve
m
be
r
De
ce
m
be
r
Ja
nu
ar
y
Fe
br
ua
ry
12
/2
6/
04
-1
1/
08
/0
5
0.0%
Y = % of adherence to risk management strategies and wound care protocols
for patients identified at risk by the nurse
Target = 100%
Advance Directive TAT
Tomas A. Gonzalez, MD
FY 2006
6+ Sigma
100.0%
100.0%
97.7%
100.0%
98.6%
90.0%
80.0%
73.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
br
ua
r
Fe
nu
ar
y
m
be
ec
e
D
ov
e
N
Ja
r
r
m
be
r
ob
e
O
ct
pt
e
Se
B
as
e
lin
e
11
/2
8
m
be
r
/0
5
0.0%
Y = Time elapsed from AD order placed until AD documentation in the medical record
USL=48 hrs
Target=24 hrs
DRG Assurance of Accuracy (VB-B)
Gary Lampi
FY 2006
6+ Sigma
100.0%
100.0%
100.0%
100.0%
90.0%
92.2%
97.3%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = % Accuracy of DRGs (Medicare charts only)
Target = 100%. Six DRGs are included: 14, 15, 79, 89, 320, and 416
Ju
ne
ay
M
pr
il
A
ar
ch
M
Fe
br
ua
ry
y
Ja
nu
ar
ec
em
be
r
D
ov
em
be
r
N
ct
ob
er
O
Se
pt
em
be
r
B
as
el
in
e
3/
15
/0
5
-1
1/
19
/0
5
0.0%
Advance Directive
Tomas A. Gonzalez, MD
FY 2006
100.0%
6+ Sigma
100.0%
94.2%
99.7%
90.0%
96.4%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
24.0%
10.0%
Y = % of adult IP with an Advance Directive or its refusal in the medical record
Target = 100%
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
ob
er
Se
pt
em
be
r
Ba
se
lin
e
11
/2
8/
05
0.0%
Family Practice Residency Clinic Patient Throughput
Linda McKenna
FY 2006
100.0%
6+ Sigma
99.8%
100.0%
99.8%
90.0%
99.99%
84.3%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = Patient appointment time to time patient checks out
USL = 90 minutes
Target = 60 minutes
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
br
ua
r
Fe
nu
ar
y
m
be
ec
e
D
ov
e
N
Ja
r
r
m
be
r
ob
e
O
ct
pt
e
Se
B
as
e
lin
e
11
/2
8
m
be
r
/0
5
0.0%
Decision Support TAT
Pringle Ramsey
FY 2006
6+ Sigma
100.0%
97.7%
100.0%
100.0%
90.0%
100.0%
85.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = Date/Time from Request submitted to date/time request completed
USL = 96 hours (4 working days)
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
ob
er
Se
pt
em
be
r
Ba
se
lin
e
11
/2
8/
05
0.0%
Outpatient Services TAT (VB-B)
Gary Lampi
100.0%
96.2%
93.1%
98.4%
93.8%
90.6%
80.0%
100.0%
98.9%
89.6%
87.6%
90.0%
6+ Sigma
98.0%
70.0%
60.0%
58.9%
50.0%
40.0%
30.0%
20.0%
10.0%
Ju
ne
ay
M
pr
il
A
ar
ch
M
Ja
nu
ar
y
Fe
br
ua
ry
D
ec
em
be
r
r
m
be
ov
e
N
ct
ob
er
O
be
r
Se
pt
em
B
as
el
in
e
3/
7/
05
0.0%
Y= Patient arrives at Outpatient Registration until an outpatient procedure begins
USL = 60 min; Target = 30 min
Patient Registration Accuracy (VB-B)
Gary Lampi
FY 2006
94.4%
100.0%
90.0%
90.0%
89.2%
83.8%
92.3%
80.0%
72.1%
75.1%
83.0%
87.2%
85.2%
82.9%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y= % Accuracy of Identified elements per claim
Ju
ne
M
ay
A
pr
il
ch
M
ar
Fe
br
ua
ry
Ja
nu
ar
y
be
r
ec
em
D
N
ov
em
be
r
r
O
ct
ob
e
be
r
pt
em
Se
B
as
el
in
e
4/
1/
05
0.0%
Medical Records TAT (VB-B)
Gary Lampi
FY 2006
91.0%
100.0%
90.0%
78.3%
80.0%
68.6%
70.0%
89.5%
94.5%
86.6%
73.2%
87.6%
60.0%
50.0%
40.0%
39.5%
30.0%
19.0%
20.0%
10.0%
12.0%
Ju
ne
ay
M
A
pr
il
ar
ch
M
Fe
br
ua
ry
Ja
nu
ar
y
ec
em
be
r
D
N
ov
em
be
r
r
O
ct
ob
e
be
r
m
pt
e
Se
B
as
el
in
e
3/
7/
05
0.0%
Y = Date / time of physician dictation to the date / time the completed report is posted
in the chart
USL= 12 hrs
Target = 8 hrs
MDS Accuracy (Golden Palms)
James Eastham
FY 2006
6+ Sigma
100.00%
100.0%
100.0%
100.0%
90.00%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
Y = % accuracy of Minimum Data Set coding at Golden Palms
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
ob
er
0.15%
Se
pt
em
be
r
Ba
se
lin
e
6/
10
/0
3
0.00%
Forms Management (VB-H)
James Eastham
FY 2006
6+ Sigma
100.0% 100.0%
100.0%
98.0%
90.0%
80.0%
100.0%
100.0%
97.6%
92.0%
98.5%
86.0%
94.4%
77.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
ob
er
r
em
be
Se
pt
Ba
se
lin
e
3/
1/
04
0.0%
Y = TAT from the time print request arrives in Materials Management to the time the
completed print job is received by the requesting department
USL= 6 days
Outpatient Services Integration (VB-H)
Gary Lampi
FY 2006
100.00%
89.4%
89.3%
89.4%
90.00%
86.2%
80.00%
69.7%
75.4%
70.00%
60.00%
78.3%
72.7%
60.60%
53.6%
50.00%
43.7%
40.00%
30.00%
20.00%
10.00%
Ju
ne
ay
M
pr
il
A
ar
ch
M
Ja
nu
ar
y
Fe
br
ua
ry
D
ec
em
be
r
r
m
be
ov
e
N
ct
ob
er
O
be
r
Se
pt
em
B
as
el
in
e
2/
1/
04
0.00%
Y = Patient arrives at Outpatient Registration until an outpatient procedure begins
USL = 60 min
Patient Registration Accuracy (VB-H)
Gary Lampi
FY 2006
100.0%
91.0%
84.0%
90.0%
90.6%
87.5%
86.6%
80.0%
87.6%
88.5%
90.3%
84.0%
84.8%
70.0%
60.0%
59.2%
50.0%
40.0%
30.0%
20.0%
10.0%
Y= % Accuracy of Identified elements per claim
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
o
be
r
r
Se
pt
em
be
Ba
se
lin
e
6/
10
/0
3
0.0%
6+ Sigma
DRG Assurance of Accuracy (VB-H)
Gary Lampi
FY 2006
100.0%
100.0%
100.0%
100.0%
90.0%
97.0%
97.5%
98.0%
95.0%
99.3%
100.0%
98.1%
80.0%
70.0%
75.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = % Accuracy of DRGs (Medicare charts only)
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
ob
er
Se
pt
em
be
r
Ba
se
lin
e
6/
10
/0
3
0.0%
Nursing Assessment Cycle Time
Gloria Tobin, CNO
FY 2006
100.0%
97.3%
94.0%
96.7%
97.4%
90.0%
90.9%
88.6%
83.3%
94.7%
89.3%
80.0%
70.0%
60.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Ju
ne
ay
M
Ap
ril
ar
ch
M
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
r
m
be
No
ve
ct
ob
er
O
be
r
Se
pt
em
Ba
se
lin
e
6/
10
/0
3
0.0%
Y = Time patient is admitted to the floor from the ED to the time the nurse completes
initial nursing assessment in IDX
USL = 180
ED - Floor Admissions
Gloria Tobin, CNO
FY 2006
100.0%
90.0%
77.3%
80.0%
71.0%
76.7%
74.1%
75.0%
75.9%
70.0%
70.0%
71.6%
60.0%
66.7%
50.0%
63.5%
43.0%
40.0%
30.0%
20.0%
10.0%
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
Oc
to
be
r
Se
pt
em
be
r
Ba
se
lin
e
3/
1/
04
0.0%
Y = TAT in minutes of ED doctor disposition for admitted patients to exit from ED
USL = 120
Abbreviations
Gloria Tobin, CNO
FY 2006
6+ Sigma
100.0%
90.0%
99.7%
99.5%
99.6%
100.0%
6 Sigma
99.9998%
99.96%
99.9%
99.6%
99.9%
99.8%
80.0%
70.0%
60.0%
50.0%
55.5%
40.0%
30.0%
20.0%
10.0%
Y = % compliance with SOP regarding the use of inappropriate abbreviations.
Ju
ne
Ma
y
Ap
ril
Ma
rc
h
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
mb
er
No
ve
mb
er
Oc
to
be
r
em
be
r
Se
pt
Ba
se
lin
e3
/1 /
04
0.0%
Pneumonia Core Measures
Gloria Tobin, CNO
FY 2006
100.0%
90.0%
80.0%
70.3%
70.0%
55.0%
60.0%
59.3%
50.0%
32.3%
40.0%
30.0%
Y = Compliance with all 7 Core Measures
Ju
ne
M
ay
A
pr
il
M
ar
ch
Fe
br
ua
ry
16.0%
Ja
nu
ar
y
N
ov
em
be
r
ct
o
be
r
12.0%
O
Se
pt
20
04
FY
em
be
r
5.0%
0.0%
D
ec
em
be
r
21.0%
10.0%
B
as
el
in
e
35.4%
27.0%
20.0%
40.6%
Inpatient Identification Process (MBU)
Gloria Tobin, CNO
FY 2006
6+ Sigma
100.0%
100.0%
100.0%
100.0%
90.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
96.8%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y1 = % of patients with an identification band on upon admission to the MBU
Y2 = time it takes for an identification band to be placed or replaced on a patient
USL = 30 Minutes
e
Ju
n
Ma
y
ril
Ap
Ma
rc
h
Fe
br
ua
ry
ar
y
Ja
nu
be
r
De
ce
m
be
r
No
ve
m
er
Oc
to
b
be
r
em
Se
pt
Ba
se
lin
e3
/1/
04
0.0%
Inpatient Identification Process (Ancillary)
Lorenzo Olivarez
FY 2006
6+ Sigma
100.0%
100.0%
99.99%
96.8%
90.0%
100.0%
100.0%
100.0%
100.0%
99.9%
100.0%
100.0%
100.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y1 = % of patients with an identification band on prior to a laboratory procedure
Y2 = time it takes for an identification band to be placed or replaced on a patient
USL = 30 Minutes
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
br
ua
r
Fe
nu
ar
y
m
be
ec
e
D
ov
e
N
Ja
r
r
m
be
r
ob
e
O
ct
ep
te
S
B
as
e
lin
e
4/
1/
m
be
r
05
0.0%
Surgical Preparation- Inpatients
Gloria Tobin, CNO
FY 2006
100.0%
88.9%
90.0%
80.5%
80.0%
71.8%
78.1%
87.9%
90.1%
92.4%
88.3%
81.3%
77.9%
70.0%
60.0%
59.8%
50.0%
40.0%
30.0%
20.0%
10.0%
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
Oc
to
be
r
Se
pt
em
be
r
Ba
se
lin
e
6/
10
/0
3
0.0%
Y = Percent compliance with proper surgical preparation for patients from Inpatient
Units to Holding Area
Surgical Preparation-Day Surgery
Gloria Tobin, CNO
FY 2006
100.0%
6+ Sigma
100.0%
100.0%
90.0%
97.4%
95.8%
98.5%
96.1%
97.9%
99.5% 99.1%
99.2%
80.0%
70.0%
78.8%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
o
be
r
r
em
be
Se
pt
Ba
se
lin
e
6/
10
/0
3
0.0%
Y = Percent compliance with proper surgical preparation for patients from Day Surgery
department to Holding Area
Pain Management
Gloria Tobin, CNO
FY 2006
100.0%
90.0%
89.9% 91.6%
87.2% 86.4%
84.2% 83.3% 86.2%
78.7%
89.3% 94.6%
80.0%
70.0%
72.6%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = % of patients assessed and reassessed with a pain level equal to 3 or greater,
adheres to the pain assessment policy
Ju
ne
M
ay
A
pr
il
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
D
ec
em
be
r
N
ov
em
be
r
be
r
ct
o
O
em
be
r
Se
pt
B
as
el
in
e
3/
1/
04
0.0%
Pharmacy Turnaround Time
Gloria Tobin, CNO
FY 2006
93.7%
93.0%
100.0%
95.5%
94.0%
94.4%
92.3%
95.2%
90.0%
92.5%
91.3%
80.0%
89.8%
70.0%
60.0%
50.0%
40.0%
49.0%
30.0%
20.0%
10.0%
Y = Time from medication order placed in IDX to the time the order is verified by
pharmacist
USL = 45 Minutes
Ju
ne
ay
M
pr
il
A
ar
ch
M
Ja
nu
ar
y
Fe
br
ua
ry
D
ec
em
be
r
r
m
be
ov
e
N
ct
ob
er
O
be
r
Se
pt
em
B
as
el
in
e
5/
30
/0
2
0.0%
Interdisciplinary Communication
Christopher H. Hansen, M.D.
FY 2006
6+ Sigma
100.0%
86.2%
90.0%
92.1%
96.9%
95.1%
97.8%
100.0% 100.0%
100.0%
99.7%
99.7%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = Evidence of interdisciplinary communication in care planning
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
De
ce
m
be
r
No
ve
m
be
r
O
ct
ob
er
3/
17
/0
6
Ba
se
lin
e
Se
pt
em
be
r
1.9%
0.0%
On Time Discharge
Christopher H. Hansen, M.D.
FY 2006
6+ Sigma
101.4%
100.0%
83.3%
80.0%
60.0%
52.5%
40.0%
35.9%
20.0%
Ju
ne
M
ay
pr
il
A
ch
M
ar
y
ar
y
nu
ar
Ja
Fe
br
u
D
ec
e
m
be
r
be
r
ov
em
N
ct
ob
er
O
m
be
r
Se
pt
e
/0
5
7.0%
B
as
e
lin
e
6/
13
/0
5
-1
0/
30
0.0%
Y = % of patients discharged (leaves room) by 12:00 noon, measured by: time of day
Goal: 40% of patients discharged by 12:00 noon
USL: 12:00 noon
Ancillary Departments Results Availability
Lorenzo Olivarez
FY 2006
6+ Sigma
99.6%
100.0%
100.0%
90.0%
88.0%
80.0%
86.0%
70.0%
60.0%
89.0% 93.0%
99.2% 98.9%
96.3%
81.0%
64.3%
50.0%
40.0%
30.0%
20.0%
10.0%
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
br
ua
r
Fe
nu
ar
y
m
be
ec
e
D
ov
e
N
Ja
r
r
m
be
r
ob
e
O
ct
pt
e
Se
B
as
e
lin
e
3/
7/
m
be
r
05
0.0%
Y = Cycle time: from when the test is complete to when the results are available for
the physician in the medical record
USL = 24 Hours
Heart & Vascular Cath Lab Capacity
Lorenzo Olivarez
FY 2006
100.0%
90.0%
77.8%
80.0%
73.7%
70.0%
57.7%
60.0%
56.3%
50.0%
40.0%
30.0%
20.0%
26.9%
10.0%
Ju
ne
M
ay
Ap
ril
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
No
ve
m
be
r
De
ce
m
be
r
O
ct
ob
er
Se
pt
em
be
r
Ba
se
lin
e
9/
30
/0
5
0.0%
Y = Physician out of lab to following procedures “time out”; all to-follow cases
USL = 45 Minutes
ED Charges
Lorenzo Olivarez, CFO
FY 2006
97.0% 98.5% 98.4%
95.0% 95.1% 95.5%
100.0%
90.0%
80.0%
80.3%
70.0%
92.0% 92.0% 89.0% 90.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
ne
Ju
ay
M
Ap
ril
ar
ch
M
br
ua
ry
Fe
ar
y
em
Y = % of accurate charges in ED
Ja
nu
be
r
r
De
c
No
v
em
be
er
ob
O
ct
pt
Se
Ba
s
el
in
e
11
em
/1
/
be
r
04
0.0%
OR Turnaround Time-All To Follow Cases
Shane Spees, CEO
FY 2006
90.0%
80.0%
76.6% 75.1%
74.4%
79.9%
77.1% 73.9%
81.0% 80.6% 78.2%
76.4%
70.0%
60.0%
56.7%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = Surgeon Out to Surgeon in; all to follow cases
USL = 60 Minutes
e
Ju
n
M
ay
pr
il
A
ch
M
ar
ry
br
ua
Fe
ar
y
nu
m
ec
e
D
Ja
be
r
be
r
m
ov
e
N
O
ct
ob
er
r
m
be
ep
te
S
B
as
el
in
e
2/
27
/0
3
0.0%
CT Turnaround Time to ED
Shane Spees, CEO
FY 2006
6+ Sigma
100.0%
98.7%
100.0%
92.7%
99.4% 99.4% 97.9% 98.5% 98.6% 98.5%
90.0%
91.9%
80.0%
70.0%
60.0%
50.0%
40.0%
45.2%
30.0%
20.0%
10.0%
Y = Order entry to preliminary report delivered
USL = 120 Minutes
Ju
ne
ay
M
pr
il
A
ar
ch
M
Ja
nu
ar
y
Fe
br
ua
ry
ct
ob
er
N
ov
em
be
r
D
ec
em
be
r
O
be
r
Se
pt
em
B
as
el
in
e
2/
27
/0
3
0.0%
Emergency Department Hold Time
Rebecca Harper, CNO
FY 2006
94.4%
94.9%
100.0%
94.8%
90.0%
97.4%
87.0%
80.0%
89.7% 88.7% 88.0%
94.1%
93.8%
70.0%
60.0%
50.0%
40.0%
46.6%
30.0%
20.0%
10.0%
Ju
ne
ay
M
A
pr
il
ch
ar
M
Ja
nu
ar
y
Fe
br
ua
ry
be
r
ec
em
D
be
r
ov
em
N
ob
er
O
ct
be
r
Se
pt
em
B
as
el
in
e
3/
31
/0
5
0.0%
Y = Time from admission order received in ED until time patient leaves the ED for
destination
USL = 360 Minutes
Radiology Turnaround Time
Leslie Bingham, COO
FY 2006
95.0%
100.0%
90.0%
91.3%
90.7% 90.4%
80.0%
6+ Sigma 100.0%
93.4% 93.2% 92.4% 90.4%
92.7%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
29.0%
10.0%
Ju
ne
M
ay
A
pr
il
M
ar
ch
Fe
br
ua
ry
Ja
nu
ar
y
N
ov
em
be
r
D
ec
em
be
r
O
ct
ob
er
Se
pt
em
be
r
B
as
el
in
e
2/
24
/0
5
0.0%
Y = Time the order is received in the Radiology department to the time the final
report is posted in the patient’s chart
USL = 24 Hours
Patient Identification (Labor & Delivery)
Leslie Bingham, COO
FY 2006
6+ Sigma
100%
100.0%
100.0%
90.0%
99.6%
99.7%
100.0%
100.0%
100.0%
100.0%
99.6%
100.0%
93.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Y = % of patients with an identification band placed upon admission to L&D
USL 30 Minutes (if found off)
ne
Ju
M
ay
pr
il
A
M
ar
ch
y
br
ua
r
Fe
nu
ar
y
m
be
ec
e
D
ov
e
N
Ja
r
r
m
be
r
ob
e
O
ct
pt
e
Se
B
as
e
lin
e
5/
5/
m
be
r
05
0.0%
ICU Care Management
Rebecca Harper, CNO
FY 2006
100.0%
88.5%
90.0%
77.1%
74.4%
80.0%
70.0%
72.9%
81.7%
79.5%
76.0%
83.3%
73.7%
60.0%
50.0%
57.9%
40.0%
30.0%
20.0%
10.0%
Y = ICU length of stay from “Time In” to Time Out” in hours.
USL = ICU LOS < 50% assigned LOS determined by the final DRG
ay
M
A
pr
il
ch
ar
M
Fe
br
ua
ry
Ja
nu
ar
y
be
r
ec
em
D
be
r
ov
em
N
O
ct
o
be
r
be
r
em
Se
pt
B
as
el
in
e
2/
24
/0
5
0.0%
Respiratory Care Services
Juan Mancillas, M.D./VP Medical Affairs
FY 2006
100.00%
90.5%
97.4%
90.00%
93.7% 89.4%
80.00%
70.00%
76.0%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
Ju
ne
ay
M
il
pr
A
ar
ch
M
ct
ob
er
N
ov
em
be
r
D
ec
em
be
r
Ja
nu
ar
y
Fe
br
ua
ry
O
r
be
em
ep
t
S
B
as
el
in
e
I1
/0
5/
0
511
/1
5
/0
5
0.00%
Y = Timeliness of subsequent treatment (measured in minutes): a defect = any
treatment > 30 minutes before or after scheduled treatment time
USL = 30 minutes
LSL = 30 minutes
Surgical Case Time Management
Leslie Bingham, COO
6+ Sigma
FY 2006
100.0%
100.0%
90.0%
97.2%
92.1%
89.5%
80.0%
70.0%
60.0%
50.0%
40.0%
50.6%
30.0%
20.0%
10.0%
Y = Surgeon out from procedure to “time out” of “to follow” procedure
USL = 60 minutes
Ju
ne
ay
M
A
pr
il
ch
ar
M
Ja
nu
ar
y
Fe
br
ua
ry
B
as
el
in
e
11
/3
/0
512
/0
4/
05
Se
pt
em
be
r
O
ct
ob
er
N
ov
em
be
r
D
ec
em
be
r
0.0%
Medication Administration TAT - First Dose
Leslie Bingham, COO
FY 2006
95.0%
100.00%
97.1% 86.0%
90.00%
80.00%
68.1%
70.00%
60.00%
50.00%
40.00%
30.00%
34.5%
20.00%
10.00%
B
as
el
in
Y = Order time stamp to documented administration time.
USL = 180 minutes
Ju
ne
ay
M
il
A
pr
ch
ar
M
Ja
nu
ar
y
Fe
br
ua
ry
r
be
em
ec
D
N
ov
em
be
r
ob
er
O
ct
r
te
m
be
Se
p
e
11
/0
5/
0
51
1/
18
/0
5
0.00%
Six Sigma Performance Summary
FY 2006 to Date
• VBMC – Brownsville
–
50% Performance with 7 of 14 Initiatives have achieved 6 Sigma
• VBMC – Harlingen
–
31% Performance with 10 of 32 Initiatives have achieved 6 Sigma
• VBHS – Corporate
–
65% Performance with 11 of 17 Initiatives have achieved 6 Sigma
• VBHS
–
44% Performance with 28 of 63 Initiatives at 6 Sigma