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Achieving Physician Buy-in for Performance Improvement:
Leveraging 6 Sigma Management SystemLeveraging 6 Sigma Management Systematat
OSF Saint Francis Medical CenterOSF Saint Francis Medical Center
Tim C. Miller, M.D.Tim C. Miller, M.D.Vice President, CMO & Director of Academic AffairsVice President, CMO & Director of Academic Affairs
&&
Tom ThomasTom Thomas6 Sigma Black Belt6 Sigma Black Belt
WCBF’s 7WCBF’s 7thth Annual Lean, Six Sigma and Process Improvement in Healthcare Summit Annual Lean, Six Sigma and Process Improvement in Healthcare Summit
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Achieving Physicians Buy-in for Achieving Physicians Buy-in for Performance ImprovementPerformance Improvement
OBJECTIVESOBJECTIVES
A.A. Traditional PI and the Physician CultureTraditional PI and the Physician Culture
B.B. New Order of PI for PhysiciansNew Order of PI for Physicians
C.C.Credibly Engaging Physicians & ResidentsCredibly Engaging Physicians & Residents
D.D.Experiences, Results, & Lessons LearnedExperiences, Results, & Lessons Learned
18771877
20072007
• 570 Beds
• 27,000 Discharges
• 520 Attending Staff
• 944 Total Credentialed Providers
• Academic Medical Center
OSF Saint Francis Medical CenterOSF Saint Francis Medical Center
Peoria, Illinois
Traditional Traditional Performance Improvement Performance Improvement
andandThe Physician CultureThe Physician Culture
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Traditional Physician CultureTraditional Physician Culture
Traditional Physician Training:
• Is Independent, Autonomous, Scientific
• Is Focused on the Individual Versus System Thinking
• Maximizes Individual Competence Rather than Team-based Learning
• Is Concerned with Individual Patient Safety and Outcomes
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Traditional HealthcareTraditional HealthcarePerformance ImprovementPerformance Improvement
• Attempts to benchmark facilities with similar service lines...
Our hospital is different. • Impossible to achieve exceptionally high levels of
quality... Patients are non-compliant, co-morbidities… My patients are different.
• Poor data, validity suspect...We can’t trust the data.
• Complexity of human diseases compared to assembly-line “widgets”…
We will never be able to attain 6-Sigma levels.• Driven by bottom line or external market
conditions... It’s all about the money.
Creating a New OrderCreating a New Orderof Performance Improvement of Performance Improvement
with Physicianswith Physicians
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• Since the first IOM Report, there has been a public outcry for immediate and comprehensive improvement in healthcare quality and safety.
• CMS, Joint Commission, and other regulatory agencies and payers have responded by raising the performance bar to new levels with significant consequences for performance failure.
• These conditions are challenging the old order of relationships.
BurningBurningPlatformPlatform
Critical Shift in HealthcareCritical Shift in Healthcare
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Learning from ManufacturingLearning from Manufacturing
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ADMISSIONS - 34,160 TotalADMISSIONS - 34,160 Total
(Payor Source)
0 2 4 6 8 10 12
Commercial
Self-Pay
Managed Care
OSF
BC
Caterpillar
Medicaid
Medicare
Thousands~ FY 2006~ FY 2006
10.65
6.546
4.392
3.86
2.854
2.34
2.128
1.39
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Improvement MethodologiesImprovement Methodologies
MethodologyWars
IHICollaboratives6 Sigma
Lean &Kaizan
TQM/CQI
EBM
Nursing Research KEEP
IT
SIMPLE
!
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Ad
equ
ate
Hu
man
R
eso
urc
es
Living Our Values Every Day
OSF Mission
Imp
rove
Cap
acit
y
Imp
rove
d P
atie
nt
Saf
ety
Imp
rove
d S
ervi
ce
Imp
rove
d C
ost
an
d
Rei
mb
urs
emen
t
CommunitySafetyQualityServiceValue
6 Sigma6 SigmaThe Unifying Framework for ImprovementThe Unifying Framework for Improvement
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• The organizational commitment and involvement that engages and further develops its people - starts with CEO
• Improving performance by improving key processes
• Focusing highly skilled, highly trained people on your highest priorities
Attributes of Attributes of The 6 Sigma Culture The 6 Sigma Culture
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• Data-driven, fact-based decision making
• Rigorous alignment of actions with strategy
• Aligned with evidence based practice
• Measuring clinical outcomes and continuous performance reporting
Attributes of Attributes of The 6 Sigma CultureThe 6 Sigma Culture
Build and Maintain CredibilityBuild and Maintain Credibility
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Operations First
Demonstrate use of 6 Sigma to address MD complaints with operations!
Target key operations processes that frustrate physicians to demonstrate the improvement power of 6 Sigma
Y = f (x)
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Strategy:Strategy: Best Quality Best Quality
September 5, 2007; Page D1September 5, 2007; Page D1
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Strategy: GrowthStrategy: Growth• CT Scanner utilization
– CFH 35% increase in from 52% to 70%– Main Campus 26% increase
• General Radiology Throughput – 37% improvement cycle time IP arrive to complete
• OP Radiology – 50% reduction in delays and cancellations
• Interventional Radiology (IR) Patient Throughput – 3.7 additional CT cases per day– 6.3 additional IR cases per week– Decreased direct cost of procedure 26.2% and 25.7%
respectively
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Strategy: GrowthStrategy: Growth• Operating Room Utilization
– 24% improvement of SFMC OR from 63% to 78%– 71% improvement CFH Ambulatory OR from 35% to
60%
• Capacity Project Portfolio– 44% improvement in Patient diversions from 102 to
57– IT Enabled Bed Management Process Improvement– Admission Process Improvement– Capacity Management Process
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Listen, Leverage, & Engage MD ChampionsListen, Leverage, & Engage MD Champions
• Where Are MD Concerns About Quality?
• Create Solid Wins Early
• Don’t Make Lack Of Baseline Data A Deal Breaker
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6 Sigma Relationship to EBM6 Sigma Relationship to EBM
6 Sigma doesn’t create clinical evidence – it helps us use it consistently
6 Sigma Targets Reducing Variation And Elimination Of Errors to Reliably Deliver Quality Care In A Safe Environment
Y = f (x)
SFMC Project ExamplesSFMC Project Examples
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Reducing Ventilator Acquired PneumoniaReducing Ventilator Acquired Pneumonia
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Strategy: Best QualityReducing BSI
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2Q
FY
03
3Q
FY
03
4Q
FY
03
1Q
FY
04
2Q
FY
04
3Q
FY
04
4Q
FY
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1Q
FY
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2Q
FY
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4Q
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2Q
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4Q
FY
07
Quarter
Cen
tral
Lin
e D
ays
0
10
20
30
40
50
60
70
BS
I E
ven
ts
CL Days
BSI
4Q07 Based on 2 Months Reported
REDUCING BSI
25
Quarter
Individual V
alue
4QFY072QFY074QFY062QFY064QFY052QFY054QFY042QFY044QFY032QFY03
12
10
8
6
4
2
0
_X=1.97
UCL=3.70
LCL=0.24
BSI RateInfections per 1000 Central Line Days
KickoffRN Bundle
Red Rule
Clinical Projects & Outcomes Clinical Projects & Outcomes Reducing Blood Stream InfectionsReducing Blood Stream Infections
6-Sigma6-SigmaPhysician InvolvementPhysician Involvement
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6-Sigma Projects Portfolio6-Sigma Projects Portfolio
~ February 2007~ February 2007
18
46
41
67
6
0 20 40 60 80
Capacity/Growth
Service
FinancialImprovement
ClinicalQuality/Safety
Community ofCaregivers
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6 Sigma Projects Completed6 Sigma Projects Completed
0 10 20 30 40 50 60
Capacity/Growth
Service
Financial Improvement
Clinical Quality/Safety
Community of Caregivers
MD Involvement No MD Involvement
~ February 2007~ February 2007
4
48
30
29
12
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6-Sigma Active Projects6-Sigma Active Projects
~ September 2007~ September 2007
0 5 10 15 20
Capacity/Growth
Service
Financial Improvement
Clinical Quality/Safety
Community of Caregivers
MD Involvement No MD Involvement
2
19
11
17
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6-Sigma6-SigmaAcademic IntegrationAcademic IntegrationResident InvolvementResident Involvement
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6-Sigma6-SigmaOTHER GME ALIGNMENTOTHER GME ALIGNMENT
• Member of “Sentinel Event” Teams
• Member of “Near Miss” Teams
• Coordinate New Projects with Clinical/Academic Strategies
• TAL (Teaching, Administration and Leadership) video
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Engaging PhysiciansEngaging Physicians
I heard that you are a certified 6 Sigma Black Belt Zombie. Is that true?
He didn’t seem dangerous, Dr. Smith.
I’m an assertive and innovative professional, experienced in lean, six sigma and process improvement in healthcare.
I just sat through a 3-hour project review meeting.
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• Project Example: Quality Quest and Evidence-Based Standards
• Quality Quest is a strategic partnership between OSF HealthCare System and Caterpillar Inc.
• Goal: Improving the quality and efficiency of healthcare delivery and improve health in the tri-state area.
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To establish the consistent application of evidence-based care standards for Central Illinois tri-county area health providers.
Project GoalProject Goal::
• Identify, evaluate, and recommend evidence-based guidelines/protocol sets
• Recommend endorsement and adoption process to gain acceptance and use
• Identify implementation and maintenance support requirements• Identify operational processes and relationships
Deliverables:Deliverables:
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• 17 community physicians representing all 4 major hospitals at all levels and types of service
• 2 executive level nurses
• 1 change agent expert
• 1 6 Sigma Black Belt
Who did we bring to the table?Who did we bring to the table?
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• Healthcare is local
• Respect
• Process & Environment
• Opportunity to be a part of the change
• Talents & Expertise
• SBAR
How did we get them there?How did we get them there?
““WWe are going to ask you to do some tough thingse are going to ask you to do some tough things…”…”
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Articulate the Burning PlatformArticulate the Burning Platform
What will m
ake you
uncomfortable
enough that you will
want to be a part o
f
the change?
In the future, everybody will have 15 minutes of quality health care.
State Ranking on Quality Dimension
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• Constantly articulate the vision
• Establish aggressive agendas & timelines
• Extensive sub-team work
• Scientific approach
• Take-aways (WIFM)
How did we keep them there?How did we keep them there?
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Clear goalsExposed and validated concernsLeveraged a physician championDetailed project plan with all meetings
scheduled before kick-offSpecific tasks linked to specialtyChange management principlesCommunication
What we did right…What we did right…
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What did we do wrong?What did we do wrong?
ØTeam too large to function as a group
ØAvoid tedious tasks (i.e. creating surveys)
ØBenefit of meeting 1-on-1 with team
members
ØTimelines (i.e. Resident Hand Off Project)
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4 Major hospitals
represented by 17 physicians
and 2 of the communities largest payers
CAME TO AN AGREEMENT
on 1 set of Evidence Based Standards guidelines
for the Tri-County area
IN JUST 90 DAYS
Project Outcome…Project Outcome…
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Involving Physicians Involving Physicians “Rules of the Road”“Rules of the Road”
• Establish and Maintain Credibility Aggressive Agenda No Agenda, No Meeting Send Materials for Pre-meeting Prep Provide Key Articles from Scientific
Journals Provide Bibliography or References for
Further Reading• Respect MD Time and Be Flexible with
Participation Methods
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Engaging PhysiciansEngaging Physicians“If physicians participate on teams, communicate their needs and help design improvement strategies, it is more likely that their concepts will become an integral part of the improvement plans.
Physicians should not act as innocent bystanders in process improvement but must actively participate and support teams in performing the hard work that goes along with it.”
~ Lee Adler, D.O. (iSixSigma Magazine)
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““Why don’t clinicians engage Why don’t clinicians engage with quality improvement?”with quality improvement?”
Editorial: J. Health Serv Res Policy Vol 3 July 2007
• Limited understanding of QI methods
• Suspicious of differing definitions of clinical quality
• Belief that high quality care is already present – especially locally
• Waste of scarce personnel and resources
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Finally ...Finally ...
6 Sigma Works6 Sigma Works Operations Must Go First Operations Must Go First Data Credibility is EssentialData Credibility is Essential We Must Include the MDsWe Must Include the MDs
- Find and Develop MD Champions- Find and Develop MD Champions
- Meet Them Where They Are- Meet Them Where They Are
Communicate & Celebrate Success!Communicate & Celebrate Success!