SIX SIGMA FOR IMPROVEMENT. Rohit Ramaswamy, PhD, MPH Gillings School of Global Public Health University of North Carolina, Chapel Hill

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1 SIX SIGMA FOR IMPROVEMENT USING LEAN and SIX SIGMA TO IMPROVE HAND HYGIENE IN A TERTIARY HEALTH CARE FACILITY Rohit Ramaswamy, PhD, MPH Gillings School of Global Public Health University of North Carolina, Chapel Hill IHI Africa Forum Durban South Africa February 20, 2018

2 INTRODUCTION MMR in Ghana decreased from 470 to 380 maternal deaths/100,000 live births between 2005 and 2013 (MGD target 185) In tertiary hospitals MMR is higher than the national average: Koforidua MMR 957 ( ) Semin Perinatol 2012;36(1):79-83 Tamale Teaching Hospital MMR 842 (2008) Ghana Med J 2011;45(3): Korle Bu Teaching Hospital MMR 840 (2012) Internal source Komfo Anokye Teaching Hospital MMR 1004 ( ) Acta Obstet Gynecol Scand 2012:91(1):87-92

3 MORTALITY AUDITS AVOIDABLE FACTORS FACTOR Delay in getting labs Unavailability of size 18 cannula Temporary failure of oxygen system Unavailability of blood Administration of wrong medication Risk factor of anemia not identified Not diagnosing pelvic abscess Discharged too early Senior person not called on time Inadequate monitoring CATEGORY Operational Operational Operational Operational Clinical Clinical Clinical Leadership Leadership Leadership

4 SYSTEMS STRENGTHENING APPROACH Clinical Excellence Operational Excellence Leadership Excellence Integrated Health Systems Strengthening Approach

5 QUALITY IMPROVEMENT AT RIDGE REGIONAL HOSPITAL

6 5 STEPS OF SIX SIGMA DMAIC Define the problem, improvement activity, opportunity for improvement, the project goals, and customer requirements. Measure process performance and refine project goal Analyze the process to determine root causes of variation, poor performance (defects). Improve process performance by addressing and eliminating the root causes. Control the improved process and future process performance. Source: ASQ

7 PLANNING A SIX SIGMA PROJECT Revisit project charter Create data collection plan Design data collection form

8 DEFINE NICU PROCESS MAP

9 DEFINE CHARTER AND DRIVER DIAGRAM 25% reduced incidence of infection episodes in NICU in 3 months Proper Sanitation Proper Diaper Change Adherence to Visiting Parent Protocol Sanitary Suction Machine Sanitary/P roper Access of IV Cannula Proper Storage of Breast Milk Sanitary Bag and Mask Minimal and Sanitary Sharing of Cots and Incubators HAND HYGIENE EDUCATION OF NICU STAFF Any Ridge employee (every house officer, new staff member of NICU, etc.) who will be working in NICU is required to complete a sanitation training using curriculum developed specific to Ridge NICU Infection control reinforcement reminder at each Tuesday all staff meeting Visual reminders placed around NICU for infection control measures CREATING CLEANING PROTOCOLS Create cleaning protocols for (1) hand washing, (2) suction machinery, (3) feeding equipment, (4) bag and mask Train all NICU staff on proper cleaning protocols CREATING CLINICAL CARE PROTOCOLS Create clinical care protocols for (1) IV cannula usage/access, (2) breast milk storage, (3) cot sharing, (4) changing of diapers, (5) changing of sheets Train all NICU staff on proper clinical care protocols FUNCTIONING EQUIPMENT Repair (1) second suction machine in isolation NICU, (2) sink in sluice room Purchase (1) replacement refrigerator for breast milk storage (2) replacement tubing for suction machine, (3) additional hand towels, (4) dryer for after hand washing, (5) additional gowns for visiting parents, (6) washing machine for NICU use ROUTINE AND UNBIASED MONITORING Create appropriate processes for monitoring each of these change packages that (1) do NOT over burden staff and (2) that allow for continuous checks (random audits) for compliance with protocols relating to identified infection drivers

10 IMPACT DEFINE IMPACT/EFFORT MATRIX HAND HYGIENE Create training curriculum, weekly CME, and visual reminders EQUIPMENT: Repairing and purchasing CLEANING Create cleaning procedures and training MONITORING: Design and Perform Compliance checks CLINICAL CARE: Create clinical protocols and training EFFORT

11 MEASURE BASELINE HAND SWABS

12 % Adherence % Adherence ANALYZE IDENTIFYING AREAS OF FOCUS Anonymous observational data was collected by NICU nurse to determine where lapses in hand hygiene protocols were occurring in the NICU. N=771 assessments were made. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 53% 74% 89% Diaper Change Feeding Examination NICU Activities Data was also stratified by shift. Night Shift had the lowest hand hygiene adherence. 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% 79% Data was stratified by NICU nurse activities. Diaper Change had the lowest hand hygiene adherence. 12/8/14-1/11/15 67% compliance 71% 67% Morning Afternoon Night NICU Shifts

13 ANALYZE REVISED AIM At least 25% increase in hand hygiene compliance in problem areas in 3 months Proper Hand Hygiene Proper Diaper Change Adherence to Visiting Parent Protocol HAND HYGIENE EDUCATION OF NICU STAFF Any Ridge employee (every house officer, new staff member of NICU, etc.) who will be working in NICU is required to complete a sanitation training using curriculum developed specific to Ridge NICU Infection control reinforcement reminder at each Tuesday all staff meeting Visual reminders placed around NICU for infection control measures CREATING CLEANING PROTOCOLS Create cleaning protocols for (1) hand washing, (2) suction machinery, (3) feeding equipment, (4) bag and mask Train all NICU staff on proper cleaning protocols

14 IMPROVE DEVELOP CHANGE PACKAGE Hand hygiene training presentation (with post test) Visual reminders posted throughout NICU Weekly reinforcement messages on hand hygiene topic areas during staff meetings Additional hand towels supplied to NICU

15 THE IMPLEMENTATION GAP IN QUALITY IMPROVEMENT - 60% of Six Sigma projects do not achieve the desired results Wall Street Journal, By 2010 only 21% of 127 Six Sigma professionals trained in a large global corporation in 2007 had completed 2 projects needed for certification.

16 Rating Percent REASONS FOR SIX SIGMA PROJECT FAILURE S olution not implemented Management Support Project selection not financially based Pareto Chart of Failure Modes No data - bad data Project scope too large Project forced into DM A IC format Training was poor O rganizational readiness and support Project too small for DMA IC rigor P oor project selection M anagement doesn' t understand 6 sigma Too little resource alocation Time to complete the project is not giv en Rating Percent C um % O ther Source: ASQ world conference Minitab Survey of 180 Six Sigma practitioners

17 IMPROVE - MODEL FOR IMPLEMENTATION What implementation outcomes are critical to achieving the improvement aims? What factors impede the achievement of these outcomes? What implementation strategies are the most appropriate to address these factors?

18 IMPROVE SYSTEMATIC IMPLEMENTATION FRAMEWORK Wandersman A, Duffy J, Flaspohler P, Noonan R, Lubell K, et al. Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation.[

19 IMPROVE IMPLEMENTATION STRATEGIES

20 CONTROL OBSERVATION PRE/POST (3 months later) Pre-Intervention Post-Intervention Variable Compliance, % Compliance, % % change P Overall <0.001 Activity Diaper Change <0.001 Feeding <0.001 Examination Location Cot <0.001 Warmer <0.001 Incubator <0.001 Shift Morning <0.001 Afternoon <0.001 Night <0.001

21 CONTROL MEASUREMENT PRE/POST (3 months later)

22 An integration of systematic implementation with quality improvement approaches is likely to enhance the quality of healthcare delivery by increasing the ability of practitioners to improve as well as to implement well Wandersman, Alia, Cook and Ramaswamy (2015) CONCLUSION