six sigma
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aksccs2102616.pptxUsing Six Sigma to Improve Patient Safety
AKSCCS2102616
Team H
Aaron Kraemer Stefan Mangroo
Company Profile
New York
Built in early 1900’s
Hospital cost 21k
Initially 26 beds
Started Six Sigma Project in 2012
Drivers For Change
Preventing “Never Events”:
Surgery at wrong locations of body
The wrong procedure done to a person
Six Sigma Project
The overall goal was to:
Improve patient safety
Improve “Time Out” protocol
(Assessment given to patients before surgery)
Core Team Consists of 3 employees each from:
Quality management
Nursing management
Nurses
(All Greenbelts in Six Sigma)
Define
The team started by establishing a baseline performance and goals for the project.
Developed 2 measures to track performance
1st measure worked because the 2nd measure was too long and cumbersome
Define Cont.
Measure
88 cases
Baseline measurements- average compliance to the safety process was 93.15%,
DPMO (Defects Per Million Opportunities)=784,091
Sigma score .71 (only 78% of were complying with all safety protocol)
Reduce DPMO score by 65%
Increase Sigma score to 3.76
Analyze
Used Cause and Effect
Diagram for the safety
Compliance
Analyze Cont.
FMEA
(Failure Mode Effects Analysis)
Tracks mitigated
risks and shows
the controls that
are in place.
Analyze Cont.
Used to identify factors that influence the performance of the process
Found that when the surgeon was late, it impacted how the staff perceived the process
Influenced by documentation
Most cases surgical teams provided inaccurate documentation
Results show communication was lacking
Improve
Identified elements to be improved
Standardization of the process flow
Acceptance and perception of the safety process by the perioperative team members
Presence of the surgeon to start the safety process
Documentation related to the safety process
Inconsistent communication throughout the surgical case
Set specific strategies to impact elements
Quick win
“good catch” form
beta blocker sticker
preprocedure checklist
SCIP checklist
Longer term changes
eliminating non-critical step requirements
- Reduced process flow from 44 to 28 steps
new paging system
Control
Process owners took ownership over the project
statistical process control (SPC)
control plan
Monthly updates to higher ups
Six Sigma Tools Used
Cause and Effect Diagram
Statistical Process Control (SPC)
Affinity Diagram
Hypothesis Testing
FMEA
KPIV AND KPOV
KPIV
Variation in:
- Time out protocols
- Surgical compliance to safety process
KPOV
- Reduced Defects per Million Opportunities in surgical cases
Results Achieved
Improved process compliance to 98.30% (from 93.15%)
Reduced the standard deviation from 6.24% to 3.70%
reduced the DPMO by 82% (from 784,091 to 136,987)
increased the sigma score from 0.71 to 2.59.
Increased the yield from 22% to 86.50%,
Reduced the variation in time of completing the safety process to 3-4 minutes
the standard deviation was reduced from 34 seconds to 10 seconds
reduced the DPMO from 34,091 to 0;
the sigma score was increased from 3.32 to 6.0.
yield was increased from 96.4% to 100%.
Lessons Learned
The frontline staff, surgeons, and anesthesiologists were critical to this projects success as they provided support counteracting the resistance from stakeholders in the organization
Maintaining constant communication with the stakeholders and organizational leadership garners continued support and sustainability of the improvement strategies
Questions?
Sources
Galli, B. J., Riebling, N., Paraso, C., Lehmann, G., Yule, M., & McGinley, P. (2013, August 13). Using Six Sigma to Improve Patient Safety in the Perioperative Process. Retrieved October 23, 2016, from http://www.psqh.com/analysis/using-six-sigma-to-improve-patient-safety-in-the-perioperative-process/
