HCD Case Study – 28 Case Studies related to Healthcare Process Improvement with Culture Changes

1. Increasing the Percentage of Heart Failure Patients Who Receive Heart Failure Discharge Instruction

by DeFeo, Joe; Ralston, J. Er

Abstract: A not-for-profit healthcare system found that adherence to clinical quality observed metrics for inpatient heart failure discharge instruction was consistently below national standards. Working toward a goal of increasing the observed rate of compliance from 45.3% to at least 90% by January 2008, the improvement team used the Six Sigma DMAIC (define, measure, analyze, improve, control) approach and Pareto analysis to identify potential failures and the vital factors contributing to the problem.Strategies developed to counter the vital Xs and improve the process included standardizing the discharge process across all nursing units, standardizing the most effective type of discharge instruction, improving the knowledge level of heart failure discharge instruction elements unit-by-unit with one-on-one training, and standardizing and simplifying the heart failure discharge instruction process. Based on a three-month pilot, the project succeeded in reaching its goal of a 90% compliance rate with heart failure discharge instruction.

2. Achieving Zero Percent Antibiotic Administration Rate Errors & Eliminating Surgical Sentinel Events

by Sower, Victor E.

Abstract: An internal study at Columbus Children’s Hospital found that in 2004 only 64 percent of patients with acute appendicitis received the correct antibiotic at the right time. The hospital took a systems approach to root cause analysis, launching “Operation Takeoff,” which involved revising policies, redesigning and standardizing processes, and building in redundancies. The project was eventually expanded to address all forms of errors associated with surgical procedures. In the first year of Operation Takeoff, 98.2 percent of acute appendicitis patients received antibiotics correctly, a 1.8 percent error rate, and there were no surgical errors and only two near misses.

3. Reduction in Gross Accounts Receivable By Reducing Delays In Documentation, Coding and Billing

by Helgeson-Britton, Pam

Abstract: At SMDC Health System in Duluth, Minnesota, dollars in accounts receivable (A/R) had increased in the discharged, not final billed (DNFB) portion of active A/R over 12 months. By reducing delays in documentation, coding, and billing, gross A/R could be reduced by two gross days revenue outstanding (GDRO). Tools used to understand the problem and evaluate improvements included brainstorming techniques, the 5 Whys, and a PICK chart. As a result, lead time was improved 44% from 8 days to 4.6 days. This resulted in a reduction in gross days revenue outstanding by 2.75 days, improving cash on hand by over $5 million. The financial benefit on interest income annually was $152,831.

4. A Process to Recover Additional Revenue for Home Care Plan Oversight

by Devos, Denis J.

Abstract: Mercy Physician Community PHO saw an opportunity to recover more revenue for patients’ home care by performing a more thorough review of the treatments and chart notes and physician orders and charging against additional codes. Introducing a new worksheet for capturing data as part of the billing process resulted in estimated annual new revenues of $20,860.

5. Reduction in Length of Stay for Heart Failure & Shock Patients Admitted To A Medium-Sized Hospital

by DeFeo, Joe; Ralston, J. Er

Abstract: A medium-sized acute care hospital sought to decrease the amount of time that DRG 127 patients (heart failure & shock) spent in care. The hospital’s average length of stay (ALOS) was 5.18 days, 1.08 days longer than the geometric mean length of stay, 4.1 days. The improvement team identified seven root causes as the vital few driving the extended stay time: congestive heart failure (CHF) standard orders not used, delay between discharge order to time patient leaves floor, patient stay included a weekend, patient becomes deconditioned because of lack of activity, practices were not based on Gold Standards, patients held after meeting InterQual discharge criteria, and inpatient holding process was not being standardized. The pilot project defined solutions for each root cause, successfully reducing the average length of stay at the hospital by nearly 50%, from 5.18 days on average to just 2.6. The baseline of stay continues to remain at an average of 3.6 days, well below the Centers of Medicare & Medicaid geometric mean average of 4.1 days.

 6. Planning and Implementation of a Multidimensional Hand-Hygiene Program – Reduce the Risk of Healthcare Associated Infections (HAI) at Rapid City Regional Hospital (RCRH)

by Boersma, Beth; Keegan, J. M.

Abstract: Rapid City Regional Hospital implemented a multidimensional hand-hygiene program to improve hand-hygiene adherence in accordance with The Joint Commission (TJC) Patient Safety Goal #7: Reduce the risk of healthcare associated infections (HAI). Root cause analysis uncovered three primary reasons for non-compliance: takes too much time; dry, cracked hands from too much washing and use of soap; and a non-supportive culture. Solutions included making alcohol hand rubs and hospital-approved lotion more available, providing education and encouragement, establishing an infection control hotline to report non-compliance, and holding physicians accountable. Hand-washing compliance increased from 57% to 91%, resulting in a 21% reduction in HAI and dollar savings of $291,450.

7. Using Advanced Process Simulation Methodology to Plan for a Major Facility Renovation – Surgical Suite at The Children’s Hospital of Wisconsin (CHW)

by Kolker, Alexander

Abstract: Children’s Hospital of Wisconsin (CHW) is in the planning stages for a major facility renovation of its surgical suite to increase capacity; patient, physician, and staff satisfaction; and efficiency of surgical services. Principles of management science and operations research helped address the issue of capacity analysis and patient flow in the complex surgical facility. Discrete events computer simulation methodology helped predict if the current number of beds and operating rooms and their allocation for the various surgical services would be enough to meet the projected patient flow demand from 2009 to 2013. Using computer simulation of a number of feasible scenarios, the team determined the best possible allocation of available resources (operating rooms and beds) to meet the accepted criteria and estimated the implementation cost of different options. Projected return on investment is 7% over a 15-year period, and positive cash flow in year one.

8. Reducing the Time Female Patients Spend Waiting for Diagnostic Mammogram Results

by DeFeo, Joe; Ralston, J. Er

Abstract: To reduce stress and anxiety for its patients, a small nonprofit hospital set the goal of decreasing the amount of time that women had to wait to receive mammogram results. The team used the Six Sigma define, measure, analyze, improve, control (DMAIC) process to identify key areas for improvements.

9. Improving Access to Urgent Skin Screening Appointments – University of Texas M.D. Anderson Cancer Center Cancer Prevention Center

by Rohe, Duke K.

Abstract: Cancer Prevention Center (CPC) patients at the University of Texas M.D. Anderson Cancer Center were unable to schedule skin screening appointments in a timely manner. Because of the extended wait time for appointments, patients were going elsewhere for care. The center launched a project to decrease the wait time for urgent appointments by 10 percent and bring patients in for urgent care in fewer than seven days.

10. Improving the “Thinning” of Medical Records at University of Texas M. D. Anderson Cancer Center

by Rohe, Duke K.

Abstract: The University of Texas M. D. Anderson Cancer Center launched a project to decrease the amount of time it took for clinicians to locate patient information. The team focused on three goals: reducing the number of charts that were incomplete at patient discharge, making “thinned” documents available online within 24 hours, and improving timeliness of decision making based on availability of scanned documents.

11. Improving e-Prescription Use by Patients

by Devos, Denis J.

Abstract: Although Mercy Physician Community PHO had been using e-prescriptions for one year, up to 50% of patients were still calling the doctor’s office for prescription refills when they should have been calling their pharmacies. An improvement project sought to decrease this percentage by identifying and addressing two root causes: 1) lack of training or diligence at the pharmacies, and 2) lack of awareness among patients, coupled with leniency of staff out of motivation to be patient-focused.

12. Reduction of Door-to-Balloon Time to 90 Minutes or Fewer for STEMI Patients – Rapid City Regional Hospital (RCRH)

by Handcock, Randee; Keegan, J. M.

Abstract: Rapid City Regional Hospital was not meeting the national standard (reduced from 120 to 90 minutes in 2006) for timely intervention and reperfusion for patients with ST Segment Elevation Myocardial Infarction (STEMI). A project to meet the national standard identified and addressed the following root causes: inconsistent applications for protocols for STEMI, lack of order sets and group-page alerts for STEMI, capability for EKG field transmission, perceived lack of need for improvement/change.

13. Improving the Pre-Empted Medication Error Reporting System, St. Charles Hospital, Port Jefferson, NY

by LeDoux, Kathleen

Abstract: Beginning in 2004-2005, a team at St. Charles Hospital, Port Jefferson, NY, began to explore ways to recognize and improve the reporting of pre-empted errors. While traditional reporting via the formal occurrence reporting system was encouraged, other venues for recognition and reporting were considered. Determining that certain categories in the clinical interventions performed by pharmacy and the MAR (medication administration record) communications generated by nursing could appropriately be recognized as pre-empted medication errors, the team launched a project to: 1) provide a process to ensure the correctness of the MAR on a daily basis, 2) accurately capture clinical interventions performed by the pharmacy staff, and 3) simplify the process to communicate MAR corrections from the nursing staff to the pharmacist.

14. Reduction of the Incidence of Hospital-Acquired Pressure Ulcers – A Case Study from a Medium-Sized, Not-for-Profit Hospital

by DeFeo, Joe; Ralston, J. Er

Abstract: A medium-sized, not-for-profit hospital had hospital-acquired ulcers developing at an 18% incidence rate. Compared to the national benchmark of 7%, the amount of pressure ulcers occurring at this level was costly and unacceptable. Identifying and addressing root causes led to a 13.1% reduction in incidences in 18 months and a 72% reduction in costs. By the conclusion of the project, the incidence rate had dropped to 2.1 percentage points below the national average.

15. Discovering the “Cost of Current Quality” (COCQ) in a Family Medicine Practice

by Valentine, Michelle

Abstract: When asked to identify the most difficult, problematic, and least-liked process in the practice, St. John’s Family Medical Associates staff named the processing of patient forms (work-comp forms, disability forms, school physical forms, etc.) as the most troublesome. To reduce the physician and staff time required for completion of patient forms, improve throughput time, reduce staff stress resulting from dealing with dissatisfied patients, and demonstrate the value of process improvement tools in a medical practice, an improvement team created a value stream map of the current process, identifying waste, redundancies, and delays, or the “Cost of Current Quality.” Practice staff then received instruction in the use of process improvement tools for waste reduction and dramatically improved the process. The net return on investment of the effort was $90,000, and staff and physicians were eager for more improvement.

16. Addressing High Nurse Turnover at Bronson Methodist Hospital in Kalamazoo, Michigan

by Sower, Victor E.

Abstract: Bronson Methodist Hospital in Kalamazoo, Michigan, sought to reduce nurse turnover and become best in class, developing a stable and committed workforce. Root cause analysis identified leadership and a competitor that paid higher salaries as major contributors to turnover. The project team addressed root causes by benchmarking organizations recognized for workforce excellence and conducting leadership development training. The team also used the Baldrige Criteria for Performance Excellence to help make the workforce development plan part of organizational strategy. Results include improvements in employee opinion survey results and potential cost savings of $420,000 to $840,000 annually.

17. Reducing Instrumentation in Major Operating Room Sets for Abdominal Colectomiesand Proctectomies – University of Texas M. D. Anderson Cancer Center

by SoRelle, Paul C.

Abstract: One major instrument set had been routinely provided for all major abdominal/pelvic cases at the University of Texas M. D. Anderson Cancer Center’s Department of Surgical Oncology. However, many instruments were not used in the surgeries. Because of the great number of instruments in a set, there is a greater chance of counting errors, which can lead to retained foreign objects. The center launched a project to reduce the number of instruments in major operating room sets by at least 50 percent over a four-month period for abdominal colectomies (removal of a portion of the colon) and proctectomies (resection of the rectum).

 18. Reduction in the Amount of Unused Patient Supplies at Discharge – North Shore University Hospital-Manhasset Cardiothoracic Critical Care Unit

by Riebling, Nancy B.

Abstract: As per Joint Commission and Centers for Medicare & Medicaid Services infection control standards, as well as the hospital’s infection prevention and control goals, all unused CTU patient supplies are discarded after patient discharge or transfer. An initial cost assessment of the unused and discarded supplies in the CTU at North Shore University Hospital-Manhasset yielded an average cost of approximately $66.11 per patient discharge. A Six Sigma waste reduction project was launched to reduce the defect of unused supplies discarded upon discharge.

19. A Quality Improvement Project to Inform Chiropractic Clinical Decision Making 

by Metz, Douglas

Abstract: Chiropractors have used X-ray examinations as a common practice in the diagnosis of musculoskeletal and spine-related conditions; however, evidence indicates X-ray exams are not necessary in the vast majority of cases. American Specialty Health (ASH) implemented a quality improvement project to educate doctors and manage the reimbursement for unnecessary X-ray exams. Key causal drivers identified by root cause analysis included lack of evidence-based guidelines, lack of evidence-based education for practitioners, lack of practitioner knowledge and commitment to evidence-based practices, and lack of practitioner buy-in about changing entrenched healthcare decision making. Practices implemented to address root causes included guidelines development, practitioner education, utilization management oversight, credentialing and practice protocol oversight, and quality management oversight. Results include reducing the number of unnecessary X-ray exams from a baseline of 72% of patients receiving an x-ray exam to a current state of 9%, without negatively affecting the quality or outcomes of treatment provided. The 13-year project has won national awards for changing doctor behavior while maintaining a safe and highly satisfied patient population.

 20. Reduction in the Percentage of Open Patient Encounters at the SMDC Clinic in Duluth, Minnesota

by Helgeson-Britton, Pam

Abstract: In the ambulatory setting, clinic practice management is integrated with the electronic health record. Providers determine the codes and diagnoses for patient visits and are responsible for documenting care. When documentation is not entered in a timely manner, it affects timely billing and patient care. It is the action of completing and closing the patient encounter that causes the coding to post the charges for the visit. When an encounter is left open, no revenue is realized for that visit. As SMDC Health System implemented provider-based billing at the Duluth Clinic, it was even more imperative to force the timely release of the charges from closed encounters, as UB04 billing did not allow for line-item billing but required all charges to be posted before billing. Previous efforts to address this problem resulted in a one-time cleanup, but old practices resurfaced and the problem returned to former levels. No formal monitoring occurred and the focus was departmental versus system monitoring. A project team focused on the process of closing encounters.

21. Review of IDR Inventory Control Processes and Implementation of Procedures to Minimize Discrepancies 

by Young, Karen

Abstract: At a large university health system, inventory distribution and receiving (IDR) rates fell to 32 percent below the minimum customer requirement of 98 percent. There was no clearly defined inventory control procedure. An independent audit revealed a significant discrepancy in the inventory recorded in the general ledger and the actual IDR inventory on hand. The auditors recommended that management review processes related to IDR inventory control and implement procedures to decrease opportunities for future discrepancies.

 22. Improvement in Treatment Documentation at SMDC Rehabilitation Locations, Duluth, Minnesota, Region

by Helgeson-Britton, Pam

Abstract: Paper-based documentation systems existed at 5 out of 10 SMDC Health System rehabilitation locations, resulting in inefficient interprovider communication, inconsistent processes, waste, and compliance risk. The lead time to complete the documentation from initial visit to discharge was more than 31 days. Initial patient evaluations were dictated and transcribed. The documentation often did not meet Medicare documentation compliance standards because the standards were not widely understood or practiced. SMDC launched a project to eliminate paper treatment documentation, reduce its Medicare documentation compliance error rate, establish a centralized location for all therapy documentation, and reduce physician complaints regarding inadequate reporting from the current baseline of three times per month to less than one time per month.

23. Use of Process Improvement Tools and Concepts to Increase Aggregate Mean/Index Door-to-Balloon Time – In Acute Myocardial Infarction (AMI) Cases

by DeFeo, Joe; Ralston, J. Er

Abstract: A large nonprofit hospital was struggling to meet the Centers for Medicare and Medicaid Services’ (CMS) new standard for door-to-balloon time, which was reduced from 120 minutes to 90 minutes in July 2006. Using the numbers from the third and fourth quarters of 2006, the hospital’s aggregate mean/index rate for the door to balloon time within 90 minutes was only 47 percent. The team identified the potential root causes of the delayed door-to-balloon time by using the Six Sigma define, measure, analyze, improve, and control (DMAIC) process and by analyzing process maps, cause and effect diagrams, baseline measurements, failure mode & effect analysis (FMEA), and voice of the customer. Removing the waste discovered by the team allowed the hospital to meet its 90-minute target. After the pilot was implemented, the door-to-balloon compliance rate increased to 82 percent, while the sigma level increased from 1.62 to 2.4.

24. Reduction in Claims Denials for High-Tech Imaging (HTI) at SMDC Health System Center for Therapy

by Helgeson-Britton, Pam

Abstract: SMDC Health System Center for Therapy was experiencing a higher-than-usual level of claims denials from a number of insurers for high-tech imaging tests (CT and MRI). The claims were being denied because SMDC had not obtained prior authorization for the tests. This resulted in approximately $45,000 in claims denials over a six-month period. A project was launched to reduce denials of claims for high-tech imaging tests ordered by non-SMDC providers by 85 percent.

 25. Reducing Delays Due to Inadequate or Incorrect Patient Preparation at Waterford Medical Associates – The “Dream Book”

by Casey, John J.

Abstract: At Waterford Medical Associates, patients were not being properly prepared by medical assistants for common medical procedures. This resulted in wasted time and missed opportunities to see additional patients. The practice launched a project to decrease by 75 percent the time lost due to inadequate or incorrect patient preparation.

 26. Development of an Enterprise-wide Information System to Meet Strategic Goals and Operational Needs

by Sower, Victor E.

Abstract: North Mississippi Health Services sought to develop a progressive enterprise-wide information system to be nurtured and grown to meet the organization’s strategic goals and operational needs. Patient records needed to be accessible at any facility in the system, regardless of where the patient first entered the system, in order to avoid the creation of duplicate records. Each facility in the system needed to have the same information system functionality as any other. A single information system for the entire health system met this goal.

 27. Development and Implementation of a New Process for Handling Add-On Lab Orders

by Helgeson-Britton, Pam

Abstract: At SMDC Health System’s Duluth Clinic-Ashland, additional lab tests ordered by providers were not communicated to the laboratory in a standardized, efficient manner. Once a sample had been drawn and tested, the electronic health record system did not recognize the addition of another lab test to it. The clinical assistant or physician had to contact the lab by phone or e-mail to add a test. Many times the lab was not notified of the added test. This occurred approximately 37 percent of the time and resulted in additional work, wasted time, and decreased customer satisfaction. A project was launched seeking to submit 99 percent of all add-on lab orders correctly at Duluth Clinic–Ashland through the use of an efficient, effective process.

 28. The Use of Process Engineering In a New Digital Imaging Solution and Radiology Information System – Planning, Vendor Selection, and Installation

by Boutet, Mike

Abstract: A major university teaching hospital sought assistance and leadership in planning, vendor selection, and installation of a new digital imaging solution (PACS) and radiology information system (RIS) for its clinical radiology department. A project was launched to identify return on investment and design and implement a measurable business transformation and workflow process re-engineering. Cross-functional teams were used to identify potential savings and operational efficiencies. For the first year of the project, $2,300,000 in savings were identified.