In a joint session, staff from Seattle Children's and Children's Hospital of Wisconsin shared performance improvement methods that have shown success at each hospital. The overarching message from both institutions is that there is no one-size-fits-all improvement methodology -- no tool fits all problems -- and that knowing and combining tools is the best way to achieve continuous quality and performance improvement.
From Seattle Children's, President and COO Pat Hagan and Administrative Director Stephanie Axelrod shared that "It's Not Easy Being Lean." The hospital brought together three ideologies on process improvement to come up with their own continuous performance improvement ideas. They see continuous performance improvement (CPI) as "a philosophy, a management system, with a set of tools that changes how we do our work."
Hagan exhorted listeners to make sure that when talking about improvement, they avoid Japanese words which can create confusion and misunderstanding, and that they avoid the word "lean," which has developed negative connotations -- especially for people who may already feel that they are try to do too much with too little.
Seattle Children's CPI Philosophy
- Focus on the patient and family
- Support faculty and staff in their work
- Take a long term view
The hospital's strategy: create a thought revolution. Engage everyone in a patient-focused philosophy that produces no waiting and no harm. These are the ultimate objectives, though taking the long term view, it may take a long time to get there.
Says Hagan, "improvement only comes out of engagement." Employees have to have the psycological commitment to make CPI happen. Out of engagement, quality, cost, delivery and safety goals can be met which results in putting patients and families first.
CPI results at Seattle Children's: revenues up, costs down, inpatient admissions up, and a lot of other positive results of traditional measurables. However, at the same time, the hospital has also reduced infection rates, increased patient and family satisfacion, and maintained employee engagement.
The hospital is also preparing for the economic recovery. One practical application is "no layoffs;" don't get rid of the people that you've trained because you will need them soon.
By the numbers
Stephanie Axelrod shared some of Seattle Children's quantitative results from CPI, including an estimated $200 million is capital cost avoidance from achieving higher average occupancy rates instead of building more space; $20 million in capital cost avoidance from using CPI priniciples to streamline a new ambulatory care center; and internal cost savings of approximately $650,000 from "CPIdeas" suggestions from staff since the program started in March 2009. Axelrod also shared numerous examples of specific areas of quality and safety improvement from throughout the hospital.
Blending methodologies at Children's Hospital of Wisconsin
From Children's Hospital of Wisconsin, Ramesh Sachdeva, MD, vice president of quality aand outcomes, shared on various quality improvement methodologies and gave examples and merits of each of four methods: Plan, Do, Study, Act (PDSA);Lean; Six Sigma; Management Sciences. Ultimately, Children's Hospital of Wisconsin is interested is how the various methodologies can be combined and used simultaneously to even greater effect.
- Plan, Do, Study, Act -- The NACHRI-led PICU CA-BSI Collaborative is an ideal use of PDSA methodology, showing tens of millions of dollars and dozens of lives saved.
- Lean -- Theresa Mikhailov, MD, assistant professor of pediatrics in critical care division, shared how lean was used in the ICU to clean up and organize the supply rooms to radically improve access to necessary resources. After success in the ICU, the same methods are being used throughout the hospital to standardize supply rooms. nurse carts, supply carts, and other similar storage areas.
- Six Sigma -- Christine Gall, director of the National Outcomes Center at Children's Hospital of Wisconsin, shared how Six Sigma was used to improve the rates that asthma home management plans of care were being provided to patients and parents. The team was brought together with the right people to define the problem; needed measurement steps were established; ongoing challenges were analyzed; improvement stategies were put in place, and ultimately the staff were engaged in the process to create buy-in and sustainability. The hospital saw success rates go from less than 10 percent to approximately 90 percent in providing asthma home management plans to patients and families.
- Management Sciences -- Tom Rice, MD, medical director of the PICU, shared how a management sciences methodology was successfully used to facilitate optimal PICU staffing to maximize safety and outcomes along with bed expansion of 20 percent in the PICU. The methodology was used to identify staffing needs for the three floors of the new PICU to maximize safety and outcomes -- this resulted in the implementation of a new physician staffing model for evenings and weekends since April 2009. In six months, preliminary information shows that discharge delay times have continued to improve as has patient care. Management science methodologies is also being used in the hospital to evaluate patient flow and staffing across the critical care continuum, including the PICU and operating rooms.
Choosing the right strategy for each problem
Says Sachdeva, combining quality improvement methods is both an art and a science. In his experence, PDSA is a preferred method to improving clinical practice; lean is a preferred method to improve quality and reduce waste; Six Sigma is preferred for process improvement and reducing variation within projects. At the end of the day, these three are all reactive approaches -- ways to improve an existing system. The question comes up: why do we have systems that need to be improved? Why don't we just build them right from the start? It appears that management sciences is a proactive approach towards system optimization.
Visit the Annual Meeting session page on the NACHRI Web site for additional information, slides and handouts from this joint presentation.
