Leonard Perry, Ph.D., MBB, CSSBB, CQE
Scripps Clinic, Scripps Green Hospital Grand Rounds
Wednesday, Dec. 1, 2010
Bio – Leonard A Perry, PhD
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Increasing your
QI IQ using PI
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Scripps Clinic/Scripps Green Hospital
Grand Rounds
Leonard Perry, Ph.D., MBB, CSSBB, CQE
December 1, 2010
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Leonard Perry, Ph.D. is an Associate Professor and Chair of
the Industrial & Systems Engineering at the University of San
Diego and President of Innovative Quality Systems, LLC.
Dr. Perry’s current research and consulting efforts focus on
system improvement via quality improvement methods
especially in the area of applied statistics, statistical process
control, and design of experiments. He researches, consults,
instructs and collaborates on numerous quality improvement
projects in biotech, healthcare, defense and traditional
manufacturing organizations.
He is a Certified Six Sigma Master Black Belt, ASQ Certified
Quality Engineer and a Director of the Lean Six Sigma
program at the University of San Diego.
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Mistakes: To Error is Human
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Healthcare Errors: Just the Facts…
Have you ever done the following:
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Driven to work and not remembered it?
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Driven from work to home when you meant to
stop at a store?
A 1999 Institute of Medicine report estimated that as many
as 44,000 to 98,000 people die in U.S. hospitals each year
as the result of medical errors – more than deaths caused
by car accidents, breast cancer, or AIDS.
Eighteen types of medical errors account for 2.4 million
extra hospital days and $9.3 billion in excess charges each
year
Institute of Medicine, To Err Is Human: Building a Safer Health System,
Washington, DC, National Academy Press; 1999.
Run a red light?
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Nodded your head to directions and then asked
yourself: “What did she ask me to pick up?”
A study conducted from 2002 to 2007 in 10 North Carolina
hospitals found “about 18 percent of patients were harmed
by medical care, some more than once, and 63.1 percent of
the injuries were judged to be preventable.”
Study Finds No Progress in Safety at Hospitals, NY Times, 2010.
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Quality Improvement:
Process Variation
99% - Is it Good Enough?
Scripps
Mission and Values
99.99966% Performance
• 200,000 wrong drug
prescriptions each year
• 680 wrong prescriptions per
decade
• 5,000 incorrect surgical
operations per week
• 88 incorrect operations per year
• >15,000 newborn babies
accidentally dropped per year
• 5 dropped each year
• 2,000 lost articles of mail per
hour
• 2 short or long landings at most
major airports each day
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Mission
 Scripps strives to provide superior health services in a caring
environment and to make a positive, measurable difference in the
health of individuals in the communities we serve.
 We devote our resources to delivering quality, safe, cost effective,
socially responsible health care services. We advance clinical
research, community health education, education of physicians and
health care professionals and sponsor graduate medical education.
 We collaborate with others to deliver the continuum of care that
improves the health of our community.
Values
 We provide the highest quality of service
 We demonstrate complete respect for the rights of every individual
 We care for our patients every day in a responsible and efficient
manner
• less than 6 lost articles of mail per
day
• less than 1 short or long landing
every eight years
The Market Demands a Higher Standard of Excellence
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Leonard Perry, Ph.D., MBB, CSSBB, CQE
Scripps Clinic, Scripps Green Hospital Grand Rounds
Wednesday, Dec. 1, 2010
What is Performance Improvement?
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PDCA – Plan-Do-Check-Act
Performance Improvement (PI) is a process for
enhancing employee and organizational performance that
employs an explicit set of methods and strategies.
PI is a continuously evolving process that uses the results
of monitoring and feedback to determine whether progress
has been made and to plan and implement additional
appropriate changes. (Johns Hopkins (jhu.edu)
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Performance improvement is the concept of measuring
the output of a particular process or procedure, then
modifying the process or procedure to increase the output,
increase efficiency, or increase the effectiveness of the
process or procedure. ... (Wikipedia.org)
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PDCA refers to the cycle of activities
advocated for achieving process or system
improvement.
The cycle was first proposed by Walter
Shewhart, one of the pioneers of statistical
process control and popularized by his
student, quality expert W. Edwards Deming.
The PDCA cycle represents one of the
cornerstones of continuous quality
improvement (CQI).
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Performance Improvement - Overview
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Performance Improvement (PI)
Methodology – PDCA Outcomes
... select the problem, clearly
and related to customer...
Define
Plan
...statistical analysis;
look for root causes...
Form an improvement team including key stakeholders
PLAN
Measure
... Implement improvements;
Remove variation and defects ...
Validate problem statement and goals with stakeholders
Analyze
Develop "As Is" value stream Analyze process flow and map to confirm process flow identify waste
DO
Improve
Prioritize potential solutions Create a Control Plan for including cost benefits.
solution
Determine sources of variation across process
Identify, evaluate, and select, Continue to monitor and best solution
stabilze process
Determine process performance / capability
Analyze data collected for trends, patterns, and relationships.
Develop, optimize and Implement pilot solution
Perform root cause analysis
Collect data for "As‐Is " process Prioritize root causes
Develop "To Be" value stream map
Validate pilot solution for potential improvements with feedback from key stakeholders
Collect bas eline data if exists
Check/Act
...be sure it doesn’t come back;
apply and share successes
CHECK/ACT
Control
Create a plan for collecting data Develop a high level process Validate the measurement map (SIPOC)
systems
Do
Select New Problem
...measure what you care about;
know your measure is good...
Develop a Project Charter with the Project Focus, Key Metrics, and Project Scope
Determine "Voice of Customer" as it relates to the project
Develop SOP's and process maps for implemented solution
Transition project to process owner
Communicate project success & challenges to create opportunities for system wide adoption.
Facilitate change management
Create a communication plan with action items
Perform benchmarking research within Scripps and "Best Practices" in Industry
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Scripps: Performance Improvement (PI)
Certificate Program
Performance Improvement - Tools
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Performance Improvement (PI)
Methodology
Project Selection &
Management
Project Charter, Scope &
Metrics
SIPOC, Process Mapping
Voice of Customer (VoC)
Value Stream Mapping
Data Analysis in Excel using
Pivot Tables & Charts
Data Collection Plan &
Sampling
Validate Measurement
Systems
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Cause & Effect (Fishbone)
Diagrams, 5 Whys
Descriptive Statistics
Quality Improvement Tools
Correlation and Regression
Prioritization and Selection
Matrix
5S
Poka Yoke (Mistake Proofing)
& Visual Controls
Failure Mode Effects
Analysis/Risk Management
Process Control Planning
Control Charts (SPC)
Change Management
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Program Overview
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Provide advanced PI education to enhance the skills of the individuals
creating and leading PI projects at Scripps
Standardize PI education across the system so that similar tools and
language are used
Program Faculty
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10 day performance improvement certificate program tailored for Scripps
Program Objectives
Dr. Leonard Perry, Professor, Industrial & Systems Engineering,
University of San Diego
Executive Support
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Executive Cabinet attended PI Training for Leadership
Involved in Projection Selection
Assisted in Participant Selection
Final Report Out
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Leonard Perry, Ph.D., MBB, CSSBB, CQE
Scripps Clinic, Scripps Green Hospital Grand Rounds
Wednesday, Dec. 1, 2010
Performance Improvement Training:
Current Participant Summary
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Executive Training on PI Methodology (Feb10)
Cohort I (Spring/Summer 2010)
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9 PI Projects
23 Participants
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16 PI Projects
47 Participants
Robin Morrisey, Barbara Bates, Tamara Winkler, Brien Ackerly
Improve the Completeness and Timeliness of the Focused Nursing
Assessment Process
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Lynelle Posner, Brenda Flores
Identifying Hyperglycemia in Hospitalized Patients
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Michele Hausman, Shane Thielman
Medication Reconciliation for Home Health Patients
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Claudia Baker, Chris Sterling
Decrease Unnecessary Expense Associated with Patient Rental Equipment
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7 PI Projects
24 Participants
Cindy Wiesner, Chris Nicholson
Match Supply and Demand for CT and MRI services
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Elena Cresap, George Lewis
Reference Laboratory Testing (Outsourced)
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Christina Bloom, Nina Galvan, Debra McQuillen
Decrease Variation in SCMC Patient Scheduling
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Total
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Improving Productivity & Labor Efficiency in IR
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Cohort II (Summer/Fall 2010)
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PI Projects – Cohort I
Jeff Mc Comas, Marisa Lydon, Dennis Dewri
Decreased ED Length of Stay through Utilization of Ready to Move
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Steve Miller, Susan Tye, Cynde Van Wyk
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PI Projects – Cohort II
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Project Charter - SINAP
PLAN blem,
pro
ct the
... sele arly and
r...
cle
stome
d to cu
relate
TEAM MEMBERS
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Design of Standardized System-wide Initial Nursing Assessment Process
Martha Ackman, Carol Hill, Cindy Steckel, Eileen Wolfard
Reduce Pull Time from ED to Med Surg Floor
Lee Roberts, Kenneth Campbell, Nakeisha Dreher, Debra Lambert
Point of Care Testing in the Primary Care Office Setting
Joyce Hite, Kristy Jaques
Stakeholders
Mary Ellen Doyle, RN, CNE
Martha Ackman, RN, Stroke Prog Coord
Team Member
Jan Zachry, RN, Chief Nurse Exec
Executive Champion
Carol Hill, RN, Sr. Director Pt Care Serv
Team Member
Tamara Winkler, RN Dir PI
PI Mentor
Cindy Steckel, RN, Admin Dir, Clin Serv
Team Lead
Jeff McComas, RN
Eileen Wolfard, RN, PI Proj Mgr
Team Member
Marisa Lydon
Problem Statement
Optimizing CV ICU Bed Allocation
Susie Pangcog, Janet Cane, Judy Davidson
Scope
Reducing Linen Expense at Scripps Green Hospital
Marlene Castillo, Michelle Horton, Cindy Ban
This project will focus on creating a new, standardized SW
Initial Nursing Admission Assessment process from the
focused assessment through the initiation of the care plan.
>The project deliverables will include a) redesign of the
process for more accurate, useful, non-duplicative content to
be standardized and implemented systemwide, b)
identification of CE capability/limitations/opportunities for
improvement in documentation of the process.
Reducing Turnover Time – General Surgery/Main OR
Allan Heryet, Dana P. Launer, MD, Kimberlee Roberts
Cohort 1 team
Cohort 1 team
Objective
The objectives of this project are to lead a systemwide end
user RN staff work group to a) evaluate the barriers/risk points
identified by the phase I group process mapping, and b)
Design a new process which addresses those issues, fits
within the workflow of the RN, and supports an accurate,
effective, timely, and complete assessment and care plan.
The RN Initial Nursing Admission Assessment has generally
been a fragmented process, more so since March 2009,
following the implementation of the EMR. Additionally, the
accuracy and completeness of the assessment has been
inconsistent, providing incomplete data for managing the
patient's stay and establishing an optimal and individualized
plan of care. The process is not standardized within facilities
nor across the system.
Decrease Approval Time on NonThreshold Capital Project
Mike Uzitas, Linh Huynh, George Ochoa, Teresa Smith, Kathy Meglasson
Project Sponsor and
Executive Champion
Bedside RN staff Clin Doc group
Primary Metric(s)
Completeness of the Initial Nursing Assessment
Secondary Metric(s) Amount of duplicate information obtained
Accuracy of NAARS
Usefulness of NAARS
Timely documentation of physical assessment
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Cost Benefit Analysis
Success in Quality
Expected Costs
Description
Unit
“Process changes, like a new computer
system or the use of a checklist, may help a
bit,” he said, “but if they are not embedded in
a system in which the providers are
engaged in safety efforts, educated about
how to identify safety hazards and fix them,
and have a culture of strong communication
and teamwork, progress may be painfully
slow.”
Cost
Development of Education
2 Hours X 1 Expert RN X
script/goals/competency assessment
$50/HR
Education expense - negotiable depending on
what is rolled into this intiative
1 Hour per RN x 400 RN X $43/H
Additional hardware needs at select facilities
$100
$17,200
Mercy & Green
Expected Costs
$17,300
Benefits
Description
Cost avoidance of public reporting of HAPU
Recognition of CAPU at time of admission
Maintained revenue by not having a HAPU
(since it was documented on admission)
NAARS completion time savings 2nd to
elimination of documentation requirements
Improved patient satisfaction 2nd to
decreased repetition of questions/process
Value added time with patient/
remove non value added time
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Unit
Savings
$50000 per incident X 1 per
facility X 5 facilities
$250,000
$50,000
$10000 X 1 per facility
7 minutes X # admissions
ss!
Pricele
Staff satisfaction
Estimated Procurement Savings
$ 300,000
Projected Project Savings
$ 282,700
Dr. Mark R. Chassin, President of the Joint Commission
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Leonard Perry, Ph.D., MBB, CSSBB, CQE
Scripps Clinic, Scripps Green Hospital Grand Rounds
Wednesday, Dec. 1, 2010
Performance Improvement: Success Factors
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Executive Support
Executive Support
Permanent and Temporary Resources
Process Management and Measurement
Project Selection and Alignment
Training
Communication
Visible, consistent support and an active role in
communication and reward.
Assuring linkage of Performance Improvement to
corporate strategies.
Requiring the use of facts and data to support actions at
all levels of decision-making.
Creating accountabilities, expectations, roles and
responsibilities for the organization.
Conducting and attending regular reviews to assure and
verify progress.
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Performance Improvement: Resources
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Process Management and Measurement
Process Owners
Quality Director / Quality Department
Representative
Project Sponsors
Champions
Project Leaders
Team Members
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Process Management:
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Managers must take ownership of processes in
order to understand process capability
Process Measurement
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In order to fully understand a process you must
define and measure the important performance
metrics.
"You can't manage what you can't measure."
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IHI – System Measures
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Final remarks on data…
“If we are going to make decisions based on opinion,
I prefer my own”.
Jack Welch
“In God we trust; all others must bring data.”
W. Edwards Deming
Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results.
IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement, 2007.
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Leonard Perry, Ph.D., MBB, CSSBB, CQE
Scripps Clinic, Scripps Green Hospital Grand Rounds
Wednesday, Dec. 1, 2010
Project Selection
Project Selection and Alignment
Sweet Fruit
Continuous Quality Imp.
Advanced Tools
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Selection Criteria
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Bulk of Fruit
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Process Management
Intermediate PI Tools
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Low Hanging Fruit
Process Simplification
Basic PI Tools
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Alignment
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Ground Fruit
Resources needed
Likelihood of success
Support or Buy-in
Timing
Scope
Impact on business strategy, competitive position
Impact on external customers and requirements
Logic & Intuition
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Performance Improvement Training:
Current Participant Summary
Project Charter
An agreement that:
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Defines the purpose of
the project
Clarifies what is
expected of the design
team
Identifies team and key
stakeholders
Keeps team focused
and aligned with
organizational priorities
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Executive Training on PI Methodology (Feb10)
Cohort I (Spring/Summer 2010)
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Cohort II (Summer/Fall 2010)
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9 PI Projects
23 Participants
7 PI Projects
24 Participants
Total
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16 PI Projects
47 Participants
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Communication
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Summary
Advocating and using a "common language" around
Performance Improvement when discussing project
work.
Communicating pertinent facts about Performance
Improvement in every company meeting.
Regular written communications on Performance
Improvement news and successes.
Development and dissemination of communication
aids to management.
Creation and communication of a Human Resources
plan to support Performance Improvement roles.
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Performance Improvement Training:
Participant Feedback
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Focusing on the problem
Scope, scope, and then scope again
Right People at the Right Time
Data, Data, Data…
Looking for the “Needle in the Haystack”
Common Language & Tools
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Leonard Perry, Ph.D., MBB, CSSBB, CQE
Scripps Clinic, Scripps Green Hospital Grand Rounds
Wednesday, Dec. 1, 2010
Change…
Character cannot be developed in ease and
quiet. Only through experience of trial and
suffering can the soul be strengthened, vision
cleared, ambition inspired, and success
achieved.
You will never change your life until you
change something you do daily
John Maxwell
Helen Keller
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Scripps PI Resources
Questions?
Contact Information:
Leonard Perry
[email protected]
619.675.4444
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