Thibodaux

Using Six Sigma to Reduce Pressure UlcersUsing Six Sigma to Reduce Pressure UlcersThibodaux Regional Medical CenterThibodaux Regional Medical Center

Darcy Prejeant & Sheri EscheteDarcy Prejeant & Sheri EscheteAugust 20, 2007August 20, 2007

What has contributed to What has contributed to our success?our success?

Ongoing LeadershipOngoing Leadership

Allocating Full Time Allocating Full Time Resources to PIResources to PI

Involving PhysiciansInvolving Physicians

Having Process Owners Having Process Owners Own Own TheirTheir Projects Projects

Making a CommitmentMaking a CommitmentMaking a CommitmentMaking a Commitment

Six SigmaChampion

CEO

Quality CouncilET & MBBs

2 MasterBlack Belts

12 Six Sigma Green Belts

Performance Performance Improvement Improvement

45 Lean & DIG Leaders

ET SponsorET Sponsor

350+ Team MembersProcessOwners

ProcessOwners

Executive TeamExecutive Team

Community HospitalCommunity Hospital

185 Beds185 Beds

850 Team Members850 Team Members

Master Black BeltsMaster Black Belts

Keeping PI AliveKeeping PI Alive– Train new LeadersTrain new Leaders

– Organize projectsOrganize projects

– Assist in deploying Assist in deploying projectsprojects

– Serve as a resourceServe as a resource

– Assist Process Owner to Assist Process Owner to monitor successmonitor success

– Report to Executive Report to Executive TeamTeam

PhysicianPhysician Paradigm Paradigm ShiftShift

““TRMC TRMC administration has administration has been doing it right… been doing it right… we need to learn we need to learn from them.”from them.”

This has opened the This has opened the door to engage door to engage physiciansphysicians

Physician InvolvementPhysician Involvement

Process Owners Process Owners Now Own TheirNow Own Their Project Project

Has Has primary responsibilityprimary responsibility for the outcome of the processfor the outcome of the process

Implement the solutions Implement the solutions identifiedidentified

Continue to monitor and Continue to monitor and evaluate results to achieve or evaluate results to achieve or exceed goalexceed goal

Communicate continual Communicate continual progress to Master Black Beltsprogress to Master Black Belts

Give final report outsGive final report outs

Goal: Eliminate nosocomial Stage 3 and Stage 4 pressure ulcers and reduce Stage 2 pressure ulcers from 4.0 to <1.6 skin breaks/1000 patient days per quarter.

Goal: Eliminate nosocomial Stage 3 and Stage 4 pressure ulcers and reduce Stage 2 pressure ulcers from 4.0 to <1.6 skin breaks/1000 patient days per quarter.

Project Description/Scope: CQI data suggests an increase in nosocomial pressure ulcers on in-patient units (MS2 & 3, ICU, SDU, and Rehab). Includes in-patients with length of stay >72 hrs.

Project Description/Scope: CQI data suggests an increase in nosocomial pressure ulcers on in-patient units (MS2 & 3, ICU, SDU, and Rehab). Includes in-patients with length of stay >72 hrs.

Title: Nosocomial Pressure UlcersPillar: Quality

Title: Nosocomial Pressure UlcersPillar: Quality

“The Skin Savers”“The Skin Savers”

MeasureCurrent PerformanceCurrent PerformanceCurrent PerformanceCurrent Performance

Based on historical data:Based on historical data:

Overall ProcessOverall Process Zst =Zst = 2.73 2.73

Sub-processes :Sub-processes : Braden Scale freq Braden Scale freq ZstZst = 1.12 = 1.12 Proper Bed Proper Bed Zst Zst = 0.48= 0.48 Q2H turning Q2H turning ZstZst = -0.37 = -0.37

Based on historical data:Based on historical data:

Overall ProcessOverall Process Zst =Zst = 2.73 2.73

Sub-processes :Sub-processes : Braden Scale freq Braden Scale freq ZstZst = 1.12 = 1.12 Proper Bed Proper Bed Zst Zst = 0.48= 0.48 Q2H turning Q2H turning ZstZst = -0.37 = -0.37

What did we learn?What did we learn? Although the overall Z score for nosocomial pressure ulcers is relatively good, the sub-processes have a great deal of opportunity for improvement, which will positively impact the overall process.

What did we learn?What did we learn? Although the overall Z score for nosocomial pressure ulcers is relatively good, the sub-processes have a great deal of opportunity for improvement, which will positively impact the overall process.

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Customer Priority 1 8 4 10 2 10 2 8 9 5 3 8 7

Process Step Process Input Total

1 Patient Admitted HIS Admit Module 10 0 0 0 0 0 0 0 0 0 0 0 0 102 Admit Assess-Braden Scale HIS Admit Assessment 0 10 10 7 0 8 9 2 2 0 0 0 5 3573 Braden Scale (Admit) 0 10 0 9 0 7 9 6 3 0 0 0 7 3824 Professional Judgement 0 10 10 0 5 8 10 0 0 0 0 0 7 2795 Initiate Prevention Protocol Braden Scale result 0 10 0 9 0 8 10 8 0 0 0 0 5 3696 Staff Compliance 0 8 0 10 0 10 0 0 0 8 0 8 10 4387 Prevention Protocol 0 0 0 10 0 10 0 0 7 0 0 8 8 3838 Treatment Protocol on Chart Manual Placement on Chart 0 0 0 0 10 5 0 0 0 0 0 0 4 989 Initiate Treatment Protocol Staff Compliance 0 0 0 9 8 10 0 0 0 8 0 0 10 316

10 Treatment Protocol 0 0 0 4 0 10 0 7 3 7 0 0 7 30711 ET RN Notified via Clinical Alert HIS Documentation 0 0 0 0 0 0 10 0 0 0 0 0 10 9012 ET RN Physical Assessment HIS Documentation 0 0 0 0 0 0 0 9 9 0 0 8 9 28013 ET RN Professional Judgement 0 0 0 0 0 0 0 10 10 0 0 8 9 297

14ET RN Verifies Prevention/Treatment Protocol

Chart Verification 0 0 0 0 8 7 0 6 10 0 0 0 5 259

16 Daily Dept. Skin Assessment HIS Daily Skin Assess 0 0 0 8 0 10 10 0 8 10 7 8 10 47717 CNA Reports Skin Condition 0 0 0 9 0 10 0 0 0 8 0 0 6 27218 Wound Assessment Daily Skin Assess. Findings 0 0 0 6 0 10 10 9 0 10 10 6 10 45019 HIS Wound Assess 0 0 0 0 0 0 0 8 4 0 5 0 5 15020 Repeat Braden Scale (7days) Braden Scale (Repeat) 0 0 0 10 0 10 10 5 0 0 0 10 8 39621 Professional Judgement 0 0 0 0 0 8 9 0 0 0 0 10 6 22022 Skin Policy Defined Frequency 0 0 0 0 0 7 9 0 0 5 0 10 6 23523 Patient Discharged Consistency of Care 0 0 0 9 3 10 0 0 6 9 0 5 10 405

Cause & Effect DiagramCause & Effect Diagram

Measure

Braden Scale, Prevention & Treatment Protocols, and Daily skin assessments are the major factors affecting the current process.

Braden Scale, Prevention & Treatment Protocols, and Daily skin assessments are the major factors affecting the current process.

LOS and Admit Braden Scale for Patients at Risk of NPU

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LOS BS

Scatterplot of LOS vs Patient Category, BS vs Patient Category

Category 1 = No NPUAve. LOS = 6.47

Admit Braden Scale = 12.3

Category 2 = NPUAve. LOS = 10.43

Admit Braden Scale = 16.6

What did we learn? Admit Braden Scale is higher for pts who develop NPU

than for those who do not develop NPU. Patients are NOT at risk upon admit,

but as their condition changes, they are not identified as being at risk.

What did we learn? Admit Braden Scale is higher for pts who develop NPU

than for those who do not develop NPU. Patients are NOT at risk upon admit,

but as their condition changes, they are not identified as being at risk.

Analyze

Analyze Braden Scale PerformanceBraden Scale Performance

Category 1 = No NPU : :

Bad = 8Bad = 8 Good = 51Good = 51

%Defective = %Defective = 13.613.6

Category 2 = NPU:

Bad = 11Bad = 11 Good = 20Good = 20

%Defective = %Defective = 35.535.5

• Chi-Square Test: B.S Bad, B.S Good

– B.S Bad B.S Good Total

• 1 11 20 31

• 6.54 24.46 • 3.033 0.812

• 2 8 51 59 • 12.46 46.54• 1.594 0.427

• Total 19 71 90

• Chi-Sq = 5.866, DF = 1, P-Value = 0.015

Chi-Square Conclusion:Chi-Square Conclusion: There is a statistical difference! There is a statistical difference!

Frequency of Braden Scale performance does have an affect on Frequency of Braden Scale performance does have an affect on the development of nosocomial pressure ulcers. the development of nosocomial pressure ulcers.

Chi-Square Conclusion:Chi-Square Conclusion: There is a statistical difference! There is a statistical difference!

Frequency of Braden Scale performance does have an affect on Frequency of Braden Scale performance does have an affect on the development of nosocomial pressure ulcers. the development of nosocomial pressure ulcers.

Binary Logistic RegressionAnalyzeEvent: Development of Nosocomial Pressure Ulcer

Reference Level: No Defects

Process Coefficient Odds ProbabilityOdds Ratio

No Defects -0.5222 0.59 0.37

Braden Scale Defects

2.54322 7.55 0.88 12.72

Bed Defects 1.56220 2.83 0.74 4.77

Q2 Turn Defects

-2.16870 0.07 0.07 0.11

What did we learn?

Most significant “X” is the Braden Scale Defect:

- Odds of development 7.5 to 1 - Likelihood of NPU = 88%

- 12.72 times more likely to develop NPU

What did we learn?

Most significant “X” is the Braden Scale Defect:

- Odds of development 7.5 to 1 - Likelihood of NPU = 88%

- 12.72 times more likely to develop NPU

Solutions Implemented• Braden Scale

– Increased frequency of performance – Q5D

– Added descriptions to BS assessment in HIS

• Prevention/Treatment Protocol

– Prompts added to HIS

– Revised protocol to include more details

– Task list for PCTs

– Posted turning schedule

• Education

– Skin care covered in RN orientation by ET RN

– Annual global competency on BS interpretation

– ET RN accountability tracking tool for non-compliance

Improve

Reduced pressure ulcer rate by 79%Reduced pressure ulcer rate by 79%

Project Benefits

4.03

3.52

1.18

1.99

2.822.53

0.85

4 4 4 4 4 4 4 43.75

0.0

0.5

1.0

1.5

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2.5

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3.5

4.0

4.5

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TargetActualBaseline

Nosocomial Pressure Ulcers Decreased LOSDecreased LOS

Increased awareness Increased awareness of skin issuesof skin issues

$300,000 cost $300,000 cost avoidanceavoidance

Improved overall Improved overall quality of carequality of care

Ongoing Efforts Led by Process Owner

New incontinence protocol New skin care product line New pressure ulcer staging system Complete pressure relief on heels Specialty beds on new unit Increased BS frequency – Q3D

Continuous efforts on skin care issues are Continuous efforts on skin care issues are necessary for maintaining quality performance.necessary for maintaining quality performance.