Northwestern Memorial Hospital’s Approach to Process Improvement

Presented To

WCBF's 8th Annual Lean, Six Sigma and Process Improvement in Healthcare Summit

March 18, 2009

By

Northwestern MemorialHospital

Bob Costello, Director, Process Improvement

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Northwestern Memorial HospitalChicago, Illinois

• Second oldest hospital in Chicago (1865)

• Largest hospital in Illinois: 873 licensed beds / 46,182 admissions in 2008

• Only acute care hospital in Chicago’s central area

• Primary teaching affiliate of Northwestern’s Feinberg School of Medicine

• Average of 17% operating cash flow margin for last 20 years

• AA+ bond rating by Standard and Poor’s and Aa/AA category rating for more than 25 consecutive years

• Approximately $1 billion in revenue

Feinberg and Galter Pavilions

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NMH Has Been Recognized for Quality and Excellence

• “Most Preferred Hospital” for 14 Years

• Leapfrog Group’s “Top Hospitals List”, 2006, 2008

• UHC Top 10 for Quality and Accountability 2006-2007

• 2005 National Quality Health Care Award

• Achieved Magnet Status, 2006

• Named to “100 Best Companies for Working Women” for 9 Years

• 10 Specialties in U.S. News & World Report of Best Hospitals

• “Most Wired” for 8 Years

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NMH Is Mission Driven with a Strategic Plan that Guides the Organization

• Mission: NMH Is an Academic Medical Center Where the Patient Comes First

• Strategic Plan:– To Provide the Best Patient Experience from the Patient’s Perspective

– To Recruit, Develop and Retain the Best People who Share the Organization’s Values and Achieve Results

– To Develop the Resources to Achieve Our Mission and Vision through Exceptional Financial Performance

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Goal of Process Improvement Program

Deliver Measurable Results which Significantly Impact the Strategic Plan

• Best Patient Experience • Best People• Exceptional Financial Performance

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• 154 projects completed

• 78% reduction in avoidable severe events (since 2004)

• Over 1 million patient interactions impacted

• Over $30 million in net financial benefit

• Over 70% of completed projects achieved statistically significant improvement

Impact of Process Improvement Program Since 2002

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Core Elements of Process Improvement Program

• Chartered projects with data driven problem statements, key metrics for success, and timelines

• DMAIC framework for problem solving

• Toolbox featuring a wide array of tools, including Six Sigma, Lean, Rapid Improvement Workshops, and Change Management

• Trained process engineers and change managers on staff

• Project selection process

• Project oversight

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• Clarifies what is expected of the team

• Keeps the team focused

• Keeps the team aligned with organizational priorities

• Transfers the project from the Project Sponsor to the project team

Project Charter

The charter establishes the purpose and plan for the process improvement project

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Project NameProject NameOverview

•Linkage to BPE/BP/EFP: “Why is this a strategic project”

•Problem Statement: “What is specifically wrong with how we’re currently doing things?”

•Goal/Benefit: “By next September this will be better by this much”

•Scope: “By next September this process/area will have been affected … this process/area will not”

•System Capabilities/Deliverables:

“The problems will be solved and the goals achieved through the delivery of the following functionality”

•Resources Required: “This can only be achieved with xx system, yy people and zz dollars”

Key Metric(s)

“Here’s how you’ll know that we’ve made an impact”

“Yes, I can measure this“

“No, it does not require manual data pulls”

Executive Sponsor: Sponsor: Process Owner: Improvement Leader:

Milestones“Here’s how you’ll know I’m on track”

Description Date (mo/yr)

#1

#2

#3

Project Charter Template

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Tips for Successful Chartering

• If it sounds confusing to you, then it is … you’re not done

• Complete the problem statement first

• There is data collection in the Charter … it can take time

• Always answer the “Start - Stop” question

• Ensure your scope reflects your time horizon

• Try to avoid over 12 month projects … ideally target < 6 months

• Outcomes, outcomes, outcomes … whenever possible … studies do not impact

our patients, employees or finances

• Estimate where necessary, refine over time … something provides a guide,

nothing causes delay’s

• Like issues, like team members, like timeframes = potentially same project

• As a sponsor ask “If I was the improvement leader, would I know what to do?”

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Process Improvement Methodology (DMAIC)

DMAIC provides an easily managed, systematic process to deliver measurable results

Who are the customers and what is the problem from their perspective?

How is the process performing today and how is it measured?

What are the most important drivers of poor performance?

How do we remove the drivers of poor performance?

How do we ensure that we sustain the improved performance?

Define Measure Analyze Improve Control

To Date: Nearly 700 Managers / Staff trained in DMAIC fundamentals

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Improvement TeamsProper team establishment increases probability for success

Project Sponsor

Improvement Leader Process Owner

Improvement Team

Project Executive Sponsor

Clinical / Academic Sponsor(As Required)

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The “Toolbox”

CategorizeProblems/Barriers

Ease Implementation

Define the Problem

BrainstormProblems/Barriers

Define “Headers”for Categories

Prioritize Categories

2 10 9 1 6vo

tes

Brainstorm Potential Solutions

AssessPotential Solutions

Pa

y-o

ff

Develop Action Plans

Share Action Plans

Report-Out Action Plans

Kick-Off

Ground Rules, Introductions,

Roles, etc

Mission

What: Who: When: Resources

CategorizeProblems/Barriers

Ease Implementation

Define the Problem

BrainstormProblems/Barriers

Define “Headers”for Categories

Prioritize Categories

2 10 9 1 6vo

tes

Brainstorm Potential Solutions

AssessPotential Solutions

Pa

y-o

ff

Develop Action Plans

Share Action Plans

Report-Out Action Plans

Kick-Off

Ground Rules, Introductions,

Roles, etc

Mission

What: Who: When: ResourcesWhat: Who: When: Resources

What a WorkOut Looks Like….

Six Sigma Change Acceleration Process

Lean Rapid Improvement Workshop

Leading Change

Changing Systems & Structures

CurrentState

TransitionState

ImprovedState

Creating A Shared Need

Shaping A Vision

Mobilizing Commitment

Making Change Last

Monitoring Progress

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Process Improvement Department50+ years experience in operational consulting

• Structure: – Northwestern Memorial Hospital Employees– Peers to Management– Lead and Coach projects– Aligned with Corporate Objectives– Engaged Through Implementation

• Experience:Industries

• Providers

• Automotive

• Telecommunications

• Banking / Financial Services

• Retail

Non-Healthcare Clients

• AT&T

• Saturn (GM)

• Bankers Trust

• Sears

• Lucent Technologies

Healthcare Clients

• Cedars Sinai Medical Center

• University of North Carolina

• Baptist Memorial Health System

• American College of Radiology

• University of Pennsylvania

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Process Improvement TrainingIntroduction to Process Improvement and DMAIC  

This class provides individuals with a basic understanding of the DMAIC methodology, lean principles and change management.  Participants will learn basic tools that will help them to lead and execute improvements within their specific teams.(Time Commitment: 8 hours)

9.23.0811.18.081.20.093.17.095.19.097.21.09

Lean Principles and Tools for DMAIC  

This class gives individuals the opportunity to gain a deeper understanding of Lean principles and philosophy.  The class will cover the key principles of Lean thinking and how to identify a Lean opportunity during a DMAIC project and how to translate Lean thinking into action (value stream mapping, push vs. pull model, eight wastes, 5S, set-up reduction, kanban). (Time Commitment: 8 hours)

10.28.0812.16.082.17.094.21.096.16.098.18.09

Excel for DMAIC  

This class will teach participants to efficiently understand and analyze data using Microsoft Excel within the context of the DMAIC process improvement methodology. Topics include manipulating raw data using formulas and pivot tables, custom graphing strategies, and tactics to best tell the analytical story.(Time Commitment: 4 Hours)

10.21.0812.9.082.12.094.14.096.9.09

8.11.09

DMAIC Improvement Leader Training  

This class is designed for individuals assigned to lead a DMAIC improvement project and will provide an in-depth exposure to the tools and methods necessary to successfully lead and achieve results using the DMAIC methodology, lean thinking and change management techniques.  Application of methods along with hands-on exercises will help to ensure rapid learning, knowledge retention, and immediate application.  The expectation is for the student to lead future projects and serve as a local DMAIC resource for their department.(Time Commitment: planned 14 sessions at 4-8hrs/session; a total of 64 hrs between Oct08 and Mar09)

Training will begin in Oct08 and will continue into Mar09.

Project Selection Process

Compile Project

Requests

Launch New DMAIC Projects

Confirm Alignment with Organizational

Priorities

• Completion of NMH goals

• Linkage with Annual Quality Planning Process

• PI internal review

• Cross-Departmental Advisory Group review

• BPE Committee review

• Identify resources to lead prioritized projects– PI Leaders– Departmental staff

• Communicate status to Sponsors

PI project selection is aligned with the annual NMH & Quality goal setting processes

Refreshed Quarterly

Project Request Process

• Common process for all proposed PI projects

• Builds upon the Annual Quality Planning process

• Consistent level of detail facilitates effective project prioritization

FY08 DMAIC Project Request Form Instructions: Please complete all fields. Use the tab button or arrow keys to move easily between fields. There is no limit on the amount of text you can enter. Thank you for completing this form.

1. Contact Information

Requesting Party:

Administrative Sponsor (Director):

Requesting Department:

Phone Number:

Email:

2. Have you discussed this project request with your VP? 3. Is this project on an FY08 Quality Plan? 4. Project Name: 5. Other Departments/Units Impacted: 6. Linkage to BPE/BP/EFP (Select most relevant linkage):

BPE: Deliver the most effective care based on clinical evidence BPE: Deliver care that is safe and without error BPE: Coordinate care so that it meets each patient's unique needs BPE: Deliver care that is timely and convenient BPE: Offer advanced expertise through research and education BPE: Be the trusted source of health information for our community BP: Best People EFP: Exceptional Financial Performance Other (please specify):

(FY08 DMAIC Project Request Form continued on following page)

FY08 DMAIC Project Request Form (cont’d) 1. Problem Statement (Impetus for Project Request):

Describe in measurable terms what is specifically wrong with the current process. Example: During Q1 FY05, only 60% of inpatient bedside PICCs were placed within 24 hours.

2. Project Goals/Benefits:

Express in measurable terms the expected improvement resulting from the project. Example: 95% of PICC lines inserted within 24 hours from the time the PICC is ordered.

3. What level of support do you request from the Process Improvement (Quality)

Team? (please select one)

Coaching (Weekly DMAIC coaching in support of a Project Leader in your department) A Process Improvement Leader to serve as the Project Leader Other (please specify):

4. Target Timeframe for Project Launch:

5. Expected Project Duration:

6. Additional Comments/Notes:

Thank you for taking the time to complete this project request form. Your request will be reviewed and you will be contacted no later than October ’07 when the prioritization of FY08 DMAIC projects is complete. If you have any questions, please contact Bob Costello, Director of Process Improvement, at rcostell@nmh.org or 6-4714. Thank you.

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Project OversightProvides improved communication, prioritization and accountability

Improvement Council

• Bi-monthly sessions for all PI projects

• Chaired by Senior VP Quality & Planning

• 30+ projects per session

• Front line staff present, senior leaders attend

– Complete a standard template

– 50% presentation – 50% Q&A

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Improvement Council “Four Blocker”

• The DMAIC phase you are in

• The problem, described using key measures

• What the analysis tells us about the drivers of error (starting in Analyze phase)

• Planned and/or implemented improvements and linkage to key drivers of error (starting in Improve phase)

• The key outcome metric, expected improvement, and when we should see the outcome measure move

Project Name

Launch D Completion

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Overview Progress Since Last Update

Key Metrics Issues/Concerns/Roadblocks

• Linkage to Strategic Plan:

• Problem:

• Goal/Benefit:

• Scope:

• Deliverables:

• Resources Required

Next Steps (By Next Update)

M A I C

Last Updated: mm/dd/yyy

Exec Sponsor: Sponsor: Process Owner: Improvement Leader:

- Add Text Here - Add Text Here

- Add Text Here

- Add Text Here

““The script”The script”

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Key Organizational Focus Areas in FY08

Achieve Top Decile performance on 80% of publicly reported

quality measures

Achieve $35 Million in cost improvement and

Increase net revenue by $6 Million through revenue cycle

enhancements

Operationalize New Prentice Women’s Hospital, Increase bed

capacity, and Improve patient throughput

Achieve 95% - 100% compliance with 80% of targeted safe care

practices

Evidence-based Care Always Practices

Operating ExcellenceImproving Access for our

Patients

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Process Improvement Project Portfolio Reflects Key Focus Areas

• Door to Balloon Time Improvement • Heart Failure: Compliance with Discharge

Instructions• Pneumonia Core Measures• Surgical Care Improvement Project:

Colorectal Normothermia• Surgical Care Improvement Project : Core

Measures

• Clean Hands Improvement• Compliance with Pitocin Protocol• Falls Prevention and Patient Safety• Management of Major Obstetrical

Hemorrhage• Pressure Ulcers Phase II: Developing New

Always Practices to Reduce Prevalence

• Item Availability• Pharmacy Distribution Automation• Reducing the Use of Safety Aides• Revenue Cycle Enhancement • Surgery Scheduling Workflow

• Care of the Critically Ill Oncology Patient• Decentralized Design: Role of the Unit

Secretary in Interdepartmental Communication • Dining On Call Emergency Department Length of Stay• Optimizing Observation Care

Evidence-based Care Always Practices

Operating ExcellenceImproving Access for our

Patients

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Key Results Enabled by Process Improvement

Achieved Top Decile performance on 84% of publicly reported quality

measures

Achieved $35 Million in cost improvement and

Increased net revenue by $8.3 Million through revenue cycle

enhancement projects

Added 72 inpatient beds as a result of NPWH opening &

Feinberg re-stack enabling a 12% increase in admissions, and

Achieved throughput improvements

Achieved 95% - 100% compliance with 90% of targeted safe care

practices

Evidence-based Care Always Practices

Operating ExcellenceImproving Access for our

Patients

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Lessons Learned

• The right questions drive culture:– What is the problem you are trying to solve?

– Where is the graph which shows this is a problem?

• Select the right projects

• Put the right people on the bus for every project

• The value of a consistent framework

• Provide strong improvement tools & experienced improvement leaders and coaches

• Process improvement supports strategy…it’s not “the strategy”

• Ensure clear accountability for sustaining results

• Measure, Measure, Measure…Report, Report, Report