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1-Fully Trained Team
2-Customers identified + Critical to Quality
3-Team Charter The Full trained Team
1-Mass General Hospital CEO "Champion"
2-Quality Manager "Black Belt"
3-Head of Cardiothoracic surgery "Green Belt "
4-Cardio thoracic consultants , resident "Orange Belt"
5-Scrub Nurses "Yellow Belt"
6-Technician and dieticians "Yellow Belt' Team Charter:
Business Case : increase Cost of Health Care Services in USA
Project Title : Walking personnel through CABG Care Path
Project Description :Development of Standardized Critical Path easy to be followed by all Cardio Surgery Staff Objectives :
1-increase Awareness of Critical Path importance .
2-increase number of trained Residents .
3-Decrease post operative Complication to Zero percentage
1-100 % participation of CardioThoracic Surgery Staff
2-Other Departments is not included Milestones
5-Conrtol 15/5/2013 Measure phase Problem location occurrence
1-Half of the total extra costs were generated on the 1st day in the operating room and SICU
2-Operating Room running cost 2000 $ per hour.
3-SICU per day is 3 to 4 times the cost of a regular patient floor. Plan for Data Collection:
-Revenue : 733,000 $
-Expenditure : 727,000
-Mean LOS : 11,38 Days
-Revenue : 900,000 $
-Expenditure : 500,000 $
-Mean Los : 9.5 Days plan for data collection:
what to measure : length of stay
Definition :the period from admission to Discharge .
who : Accountat
when :with each bill
where : From discharge Summary
Quantity : Days Bench Marking Beth israel M G H Prioritization Matrix The analyze phase
-Brainstorming on possible causes using fishbone diagram.
-Test possible X’s with scattered diagram.
-Make comparisons. This is Analysis A garden owner with harmful grass arising …
If he cuts it off it will grow again after some time and may be in faster mood …. But …. If he extirpated it out of it’s deep roots .. Will be difficult ….But ,,,, will never grow again. Incomplete forms Lack of standardized performance Done with every
case Lack of physiotherapists Surgeon Physical therapist Admission Increased cost of CABG Fish Bone Diagram A X-ray Surgical prep/wait for surgery Transport to surgery Patient admitted to MAS /CABG High level flow diagram As- Is A Other hospital bed Home Rehabilitation hospital Medical Floor Ellison 8 Transport to floor bed Transport to SICU High level flow diagram -Surgeons.
-Enough & up to date instruments /devices.
-SICU bed numbers.
-Extra blood units.
-Transportation of patient. Vital few after prioritization
1- the surgeons start operations late.
2- there are no enough instruments & devices to perform multiple CABG’s at a time.
3- SICU no enough number of beds available.
4- loss or damage of blood units not used in the surgery. Data collection plan The team work started a brain storming session to formulate theories of over cost of CABG . 2 Method of analyzing theories
5 why’s ?
Eg. Why does surgeon start operation late?
Because the last operation ended late
Why the last operation ended late?
Because of late delivery of suture material Because of disarrangement of the nurse with operation room stores.
Why there is disarrangement ?
Because there is no check out list for suture material
Or think other way for same Question …
Because he took much time this day to find parking
Why he took much time for parking ?
There is no enough space in the parking Data collection plan I-increase the area of the hospital parking and to specify places for surgeons .
-All why’s questions should go for same sequence for every item of the
vital few’s, then reprioritization of useful many.
i.e conventional problem solving stops asking WHY when the answer is a WHO . Blaming a “WHO “instead of “WHY” will not uncover the deeper & system wide sources and causes of problems. Data collection plan After the data has been collected in measure phase, analyzing can be done by using :-
-Scattered diagrams .
Why time order is important ??
Process condition can change over time. If you ignore time related patterns your conclusions may be false Analyzing the data Time plot Koski greg. -Arvind Agnihotri
-Director of cardiac quality improvement Michael N. Andrawes reduce
ALOS Patient's Guidance and support standardize ACA protocol post ap Dr David torchina Flow Chart Barriers -Surgeon Compliance -Staff afraid to lose their jobs -Variability in case presentation Solutions -Sessions for awareness of path's importance -by decreasing cost no one will lose the job -putting flexible path e care Assesment Module -Automated Care plans
-Alarm System The process was held by 2 surgical
teams of CABG surgery and the result was Pilot Test IF you are the first,
you’ll operate first Join Us
Care path Improve Control phase Tools
1 -flow chart
3-pareto charts We selected the pareto chart 1- Before and after Analysis
3- completed documentation of results
4-learning and recommendation result After the improve phase Auditing -Auditing team will audit the process every tow weeks for three months.
-Then once every 6 months. Future 6 sigma projects
1-Increase number of Beds in the Cardiothoracic Unit.
2-Training of the Juniors on CABG care path.
3-Decreasing Blood products used in CABG The previous Vital Few Customers identified :
1-Cardio thoracic Consultants
3-Cardio thoracic nurses 4-Dietician
5-Technican 6-Medical Assistant
8-physical therapist External:
4-families prolonged precedure patient education