5 Projects, 5 Hospitals: Using DMAIC for Rapid Quality Improvement

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Clinical PI

Chris Vanni
Regional Manager Performance Improvement
Sisters of Saint Francis Health Services, Inc.

Jamie El Harit RN
Business Transformation Specialist
Sisters of Saint Francise Health Services, Inc

With the new CMS MS-DRG system affecting reimbursement rates for preventable "never-events," learn how a group of five hospitals decided to commission their Lean Six Sigma teams to affect and share rapid change to improve quality care and financial viability in relation to 5 of these never-events.

In February 2008, the Northern Indiana Region of Sisters of Saint Francis Health Services, Inc. commisioned the Perfomance Improvement Manager to help minimize the impact of the new CMS MS-DRG payment structure that goes into effect in OCtober 2008. The NIR is made up of five separate hospitals, each with their own Lean Six Sigma project facilitators. The concept was born to use each of the hospital sites as the pilot site for one of the following conditions: Objetcs unintentionally left in surgery, Catheter associated urinary tract infections, catheter associated bloodstream infections, Decubitus ulcers and Injuries due to falls within the hospital. Each hospital would commission their own Lean Six Sigam team made up of front-line staff and unit process owners to work through the DMAIC process and then implement their solutions. Upon implementation, the projects would rotate to another hospital site until all five hospitals had implemented all five projects. The need was for the rotation to be completed by the October 1 deadline. Various tools were used during each project progression including: VOC Analysis, SWOT diagrams, Effort/Impact Matrices, FMEA. Each project will be discussed including the DMAIC process, what improvements were ultimately implemented as well as pilot hospital results. Also for discussion will be the mechanics of how the implementations were shared site to site, including difficulties and lessons learned.