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Osama Khalil

on 22 January 2013

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Transcript of MGH CABG

MEASURE ANALYZE DEFINE Project Charter IMPROVE Together for quality group Presented by: Osama Yehia Bothaina Thabet Eman Awad Ebaa Ebrahim Belal Mohammad Hani Rahmatallah
Since 1811, Massachusetts General Hospital has been committed to delivering standard-setting medical care. Throughout the decades, the hospital has had a consistent commitment to advancing that care through pioneering research and educating future health care professionals.
Introduction Prioritization Clip! CABG Increasing the cost.
Inaccurate information system.
Staff resistance.
Payment methods.
length of stay.
Implementation of the newly created path for CABG.
An optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure, designed to minimize delays and resources utilizations and at the same time maximize the quality of care. Care Path One may argue that in any cases, doing nothing is always a solution. However, with increased cost pressure and competition, MGH must do something; it must rethink its way of curing its patients, its way of doing business. 
Success in the healthcare industry are focus on costs of services, average length of stay (which also has a high impact on costs) and quality (often measured through mortality rates).
So, We are tried to lower the cost by finding Solutions for the length of stay of the patients who undergo CABG surgeries.

Kotter's 8-Step
Change Model Change becomes a must COMMUNICATE
to buy in 4 5 ENABLE
Action DMAIC Methodology Primary objectives Project name: Reduction of ALOS of CABG patients in the cardiac surgery department of MGH.
Department: Cardiology department.
Process: Length of stay in CABG surgeries.
Start Date: 1/12/2012Reduction of ALOS of CABG patients in the cardiac surgery department of MGH.
End Date: 31/5/1013 Team Members
Black belt: Quality expert from ASQ.
Green belt: Dr.David Torchiana, Dr. Richard Bohmer.
Orange belt: Surgeons, Anaesthesiologists, residents.
Yellow belt: Cardiologists and physiotherapists such as Brian Roy.
White belt: Patient educators such as Mimi O’ Donell
MGH’s critical need to reduce cost of medical services especially in the areas that have greatest resource utilization like the CABG procedure.
Most of the problems in the CABG area result from individual variations between CABG surgeons and lack of communication and coordination between different departments that involved in the management of CABG patient. Unnecessary delay during any step in that procedure will affect CABG patient LOS and increase cost of the procedure.
Many patients stay longer in the hospital and often receive more tests and expensive medication than they actually need. Problem Statement
To reduce the CABG patient’s length of stay 20-30% within 6 months from 9 down to 7 days.
To reduce the cost of CABG surgeries 20% within 6 months. Goal Statement
CABG surgeries either inpatient or on emergency basis from preoperative assessment till postoperative assessment.
Out of Scope
Other C.V.S. surgeries. Scope Vital few internal customers
• 7 cardiac surgeons.
• Anesthesiologists.
• Physiotherapists.
• O.R personnel.
• Social workers.
• Patient educators. Vital few external customers
• CABG patients and their families.
• Third party payers for CABG DRGs 106, 107, 546.
• Society.

•Delayed admission.
•Delayed diagnosis “emergency”.
•Delayed billing.
•Developed complications.
•Delayed clearance. CTQ’S
•Accurate scheduling.
•Standardized procedures.
•Efficient Information & Accounting Systems for analysing individual pieces of data.
• Consistent implementation of CABG pathway allow optimal sequencing and timing of interventions by all healthcare givers to minimize delays and resources utilization with maximum quality of care. CTS
•Length of stay.
•Complications (medical, surgical).
•Availability of beds in Ellison 8.
•Social Problems.(availability of someone at home).
•No of hours spent in O.R.
•No of days spent SICU.
•O.R cost. CTC'S VOP SIPOC Diagram Questionnaire

Patient Name.........................................................


Date of Admission.................................................

Date of Discharge..................................................

What is your total length of stay?......................

Do you think you could have got discharged earlier?....................................................................

If yes, how many days earlier?............................

Do you feel any delay happened at any stage during your stay?...................................................
If yes, please tick the process that got delayed and specify the delay in hours.

-Post Operation
-Discharge Service Delay In Hours VOP Data Collection Sheet
Define: 1/12/2012-31/1/2012 by C.E.O.& Drs. Trochiana& Bohmer .
Measure: 1/2/2013-28/2/2013 by ASQ expert.
Analyze: 1/3/2013-20/3/2013 by orange belt team members.
Improve: 21/3/2013-30/4/2013 by the team members.
Control: 1/5/2013-31/5/2013 by the team members. Project
Time Frame Primary objectives  -To define the KPOV - Key Process Output variables that need to be measured.
 -To develop data collection plan
 -To collect data
 -To determine current performance (baseline performance). Current financial state  
Current resources available for CABG surgery:
3 OR, 1 recovery floor (Ellison 8), 1 SICU and 7 cardiac surgeons.
Requirements for preparation and postoperative care for CABG procedure: 
Admission of patient 1 day prior to surgery.
Patient spends 4-8 hrs. in surgery.
Patient stays 1-3 days in SICU.
Patient stays 4-10 days in Ellison 8.
Patient’s LOS in CABG procedure is 14 days.
Average LOS in MGH during the last quarter of 1994 was approximately imroved to 9 days.
Approximately 80% of MGH’s CABG patients are on DRG 106, 107 and 546 clusters.
About 20,187,874 and 7,245 are available for resource utilization and total bed days, respectively, for the CABG area alone. The CABG area has the highest resource utilization in the hospital. With respect to the CABG procedure payment plan: 
● 1 hour in the OR costs $2000.
● 1 blood unit in OR costs$150.
● 1 day's stay in the SICU costs 3-4 times as much as one day in the regular rooms.
Estimated Sigma level for the hospital is 3.5 sigma. Measures related to critical to cost (CTC): Measures related to MGH’s benchmarking: 
New England Deaconess hospital had 378, 10 days and 0.52for number of stays, average LOS and Charlson Index, respectively, in DRG 107 cluster in 1992 and 1993. These values indicate that NEDH has the best practice in CABG procedure among all Harvard University affiliated teaching hospitals.

Beth Israel hospital comes the second after NEDH with 235, 9.63 days and 0.6 in number of stays, average LOS and Charlson Index, respectively, for DRG 107 cluster in 1992 and 1993. To analyze all possible causes.
To shortlist major suspected causes (vital few).
To verify root causes. Primary objectives The team conducted a fish bone diagram as a method of root cause analysis to describe the causes of increased ALOS in the simplest form. Cause and effect diagram No standard process
for emergency Procedures No accurate
information system Time spent on waiting lab.
and radiology results Poor communication
among care givers Belief that pathways may
hasten downsizing Not all cardiac surgeons put their
patients on the pathway Staff Social situation at home Scattered info. On discharge planning Lack of weekend admissions
to rehabilitation facilities Availability Determination Delay of Rehabilitation services Developed medical complications Delay in discharge Improper patient education Limited transfer time
, no later than 6:00pm No currently designated floor
for patient overflow Beds unavailability Ellison 8 Insufficient drugs and
first aid materials X-ray and pharmacy delays Timing of ventilator wean
and extubation Poor communication of schedule SICU Lack of staff Lack of preoperative instructions Transport delays to both the OP and SICU Delay time between surgeries Unorganized OR schedules Variable start times for first cases Day of surgery Increased ALOS Amount of surgeries performed
by the residents Beds unavailability on Ellisson 8 Pareto Analysis It is a graphical tool used to describe the relationship between two variables through the pattern of their intersecting points.

Most often a scatter diagram is used to prove or disprove cause-and-effect relationships. Scatter Diagram CONTROL Primary Objectives

To standardize improvement plan to sustain the gains of the improvement.
To close this improvement project. Indicators Criteria ?
Which stage? POKA YOKE Preoperative
No admission to OR before physical assessment and training in addition to surgical and anesthesia evaluations.(Proven in the patient’s record).
Routine call to the patient to remind him of the precautions with repeat back from the patient. Provision of the care path to the patient in a form of a simplified check list to participate in accurate implementation of the care path and in the same time close the gap between both doctors and patients’ expectations.
Assigning a check list coordinator to ensure that care givers don’t proceed to the next step in the care path without signing each item in the check list.
Providing high tec. Monitors in OR and SICU which can provide feedbacks, alarm when something goes wrong and may support a corrective action.
Adopting the policy of face to face hands off communication instead of telephone orders and if the performing doctor was unavailable especially postoperative so read or repeat back is a must. Operative The surgeon who performed the surgery is the only one who indicates discharge readiness to reduce rate of re admissions. Postoperative "When in distress
, everyman become our neighbor" Primary Objectives
To identify and evaluate possible improvement solutions.
To confirm possible improvement solutions towards optimized performance.
The implemented solution also needs to be measured in order to ensure there is an improvement. POSSIBLE IMPROVEMENT SOLUTIONS
Brainstorming sessions were conducted and all the team members proposed the ideas for improvement and possible solutions for the different problems discovered in the analyze phase.
From the high level flow diagram, we have identified 6 main stages through which the CABG patient passes by. In the improve phase we proposed solutions for each stage and started implementing them in a pilot study. Before surgery
Day of surgery
During operation
Ellison 8
in addition to overall Organization culture The six stages
Standard procedure for booking and scheduling operating rooms.
OR schedules are organized according to staff capabilities and number of rooms available.
Maintain OR rooms for emergency cases.
Print and provide patient instructions to the patients and their families to understand hospitalization process. Preoperative
Recruit new porters and medical assistants.
Add sufficient number of wheel chairs and stretchers.
Specify certain elevators for patients transfer to and from OR Plan for patient discharge from his first day of admission with some.
Standardized checklist to verify the presence of relevant documentation required. Day of surgery
Insist on timely start of OR schedule and audit for any delays .
Residents training within specific timeframe.
Implement a standardize procedure to Reduce variation and control operation time. During operation Increase the number of SICU staff.
OR schedule should be communicated on daily basis to the SICU.
Inventory critical level.
computerized (ATD) system.
portable X-ray .
Advanced monitors which can interfere in patient management .
Transfer on patient readiness. SICU Prioritization Matrix

Scoring: 5 = High 3=Medium 1 = low
Reallocate and use other hospital beds for CABG patients.
Determine patient's need for rehabilitation.
Patient's education.
Keep the patient and his family always informed with his progress. ELLISON 8 Discharge plan is conducted at earlier stages.
Prepare patient discharge summary from the day before. DISCHARGE
Empower all team members: participate follow the standardized care path .
Leadership’s commitment.
Staff Education.
Team approach.
Utilize indicators for key processes and monitor compliance in all steps of the process.
Multiple disciplinary investigation team .
Celebrate success; everyone should be aware of improvement. ORGANIZATION CULTURE
A pilot study was conducted over a period of 1 month. After conducting training to the all responsible staff and instructions were given to staff to adopt the care path for all CABG patients, average length of stay for all patients, and the percentage of patients on the path and off the path was calculated and showed a reduction from 9 to 7 days leading to belief in CABG pathway as a salvage from increased cost due to ALOS. Pilot test and Data collected after improvement From the previous study it becomes clear although we may face resistance which is completely normal but our driving forces can lead a new level of equilibrium and subsequently a significant change. FORCE FIELD ANALYSIS Reduction of ALOS of CABG patients in the cardiac surgery department of MGH. "Prevention of errors is NOT hard to do"
It is just hard to sell" philip crosby "A six sigma project is a problem scheduled for solution" Juran "NO one has to change.
Survival is optional" Deming "Innovate or evaporate" Bill Saporito "If you can not measure it,
you do not know what
you are talking about." Lord Kelvin "Six sigma is the most important training
thing we've ever had. Is's better than going to Harvard Business School, It teaches you
how to think differently" Jack Welch Quality Tips Quality Tips Quality Tips Quality tips Quality Tips Quality Tips THANK YOU INTRODUCTION MGH revenues in research and other purposes were $177,409 and $ 179,042 for 1993 and 1994 respectively, showing a slight increase by $1633 in 1994 while this value was $13062 in 1993.
Total operating revenues were $732,634 and $733,852 for 1993 and 1994 respectively. These values show a slight increase by $1218 in 1994 while it was $40669 in 1993. MGH revenues declined in 1994.
The hospital’s expenditure in salaries and related compensation was decreased by $16507 in 1994while it increased by $ 9968 in 1993 which is a good indicator of financial salvage during 1994. MGH’s expenditure in supplies and other expenses was $200,453 and $188,762 in 1994 and 1993 respectively, showing a slight increase in expenditure by $11673 in 1994 while it increased by $16037 in 1993. This is a good indicator of the hospital’s success in decreasing expenditure in these areas in 1994.
There was an increase of MGH’s expenditure in research and other specific expenses by $4276 in 1994 while it was $7899 in 1993. MGH decreases expenditure in this area during 1994.
Total operating expenditures increased by $5099 during 1994 which is 5 times less than that for 1993.MGH successes in decreasing expenditure during that year.
MGH’s surplus in 1994 was $14,174. It is almost 14 times more than that in 1993. •To identify the focus areas or key performance measures.
•To setup a project charter and deploy a project team. Postoperative Triggers of the Problem Triggers of the Problem Dr. Osama
All my
team members

With respect to the success of the pilot study to reduce ALOS, our team recommends the comprehensive implementation of the care path plan across all CABG patients. Also, It is believed that if all the suggested improvements are implemented, the ALOS would be further reduced thus sigma level and customer satisfaction could be improved.

It is also proposed that the post implementation performance shall be continuously measured to evaluate and sustain the improved performance and to ensure that the care path and other improvement solutions became embedded in MGH DNA and it became business as usual

The project report was submitted to the management and the management is considering the implementation.
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