1. Thibodaux Using Six Sigma to Reduce Pressure Ulcers Thibodaux Regional Medical Center Darcy Prejeant & Sheri Eschete August 20, 2007

2. What has contributed to our success? Ongoing Leadership Ongoing Leadership Allocating Full Time Resources to PI Allocating Full Time Resources to PI Involving Physicians Involving Physicians Having Process Owners Own Their Projects Having Process Owners Own Their Projects

3. Making a Commitment

4. Six Sigma Champion CEO Quality Council ET & MBBs 2 Master Black Belts 12 Six Sigma Green Belts Performance Improvement 45 Lean & DIG Leaders ET Sponsor 350+ Team Members Process Owners Process Owners Executive Team Community Hospital 185 Beds 850 Team Members

5. Master Black Belts Keeping PI Alive Keeping PI Alive – Train new Leaders – Organize projects – Assist in deploying projects – Serve as a resource – Assist Process Owner to monitor success – Report to Executive Team

6. Physician Paradigm Shift “TRMC administration has been doing it right… we need to learn from them.” “TRMC administration has been doing it right… we need to learn from them.” This has opened the door to engage physicians This has opened the door to engage physicians Physician Involvement

7. Process Owners Now Own Their Project Has primary responsibility for the outcome of the process Has primary responsibility for the outcome of the process Implement the solutions identified Implement the solutions identified Continue to monitor and evaluate results to achieve or exceed goal Continue to monitor and evaluate results to achieve or exceed goal Communicate continual progress to Master Black Belts Communicate continual progress to Master Black Belts Give final report outs Give final report outs

8. Goal: Eliminate nosocomial Stage 3 and Stage 4 pressure ulcers and reduce Stage 2 pressure ulcers from 4.0 to <1.6 skin breaks/1000 patient days per quarter. Goal: Eliminate nosocomial Stage 3 and Stage 4 pressure ulcers and reduce Stage 2 pressure ulcers from 4.0 to <1.6 skin breaks/1000 patient days per quarter. Project Description/Scope:  CQI data suggests an increase in nosocomial pressure ulcers on in-patient units (MS2 & 3, ICU, SDU, and Rehab).  Includes in-patients with length of stay >72 hrs. Project Description/Scope:  CQI data suggests an increase in nosocomial pressure ulcers on in-patient units (MS2 & 3, ICU, SDU, and Rehab).  Includes in-patients with length of stay >72 hrs. Title: Nosocomial Pressure Ulcers Pillar: Quality Title: Nosocomial Pressure Ulcers Pillar: Quality “The Skin Savers”

9. Measure Current Performance Based on historical data:  Overall Process Zst = 2.73  Sub-processes :  Braden Scale freq Zst = 1.12  Proper Bed Zst = 0.48  Q2H turning Zst = -0.37 Based on historical data:  Overall Process Zst = 2.73  Sub-processes :  Braden Scale freq Zst = 1.12  Proper Bed Zst = 0.48  Q2H turning Zst = -0.37 What did we learn? What did we learn? Although the overall Z score for nosocomial pressure ulcers is relatively good, the sub-processes have a great deal of opportunity for improvement, which will positively impact the overall process.

10. Cause & Effect Diagram Measure Braden Scale, Prevention & Treatment Protocols, and Daily skin assessments are the major factors affecting the current process.

11. LOS and Admit Braden Scale for Patients at Risk of NPU Category 1 = No NPU Ave. LOS = 6.47 Admit Braden Scale = 12.3 Category 2 = NPU Ave. LOS = 10.43 Admit Braden Scale = 16.6 What did we learn? Admit Braden Scale is higher for pts who develop NPU than for those who do not develop NPU. Patients are NOT at risk upon admit, but as their condition changes, they are not identified as being at risk. Analyze

12. Braden Scale Performance : Category 1 = No NPU : Bad = 8Good = 51 %Defective = 13.6 Category 2 = NPU: Bad = 11Good = 20 %Defective = 35.5 Chi-Square Test: B.S Bad, B.S Good –B.S Bad B.S Good Total 1 11 20 31 6.54 24.46 3.033 0.812 2 8 51 59 12.46 46.54 1.594 0.427 Total 19 71 90 Chi-Sq = 5.866, DF = 1, P-Value = 0.015 Chi-Square Conclusion: There is a statistical difference! Frequency of Braden Scale performance does have an affect on the development of nosocomial pressure ulcers. Chi-Square Conclusion: There is a statistical difference! Frequency of Braden Scale performance does have an affect on the development of nosocomial pressure ulcers.

13. Binary Logistic Regression Analyze Event: Development of Nosocomial Pressure Ulcer Reference Level: No Defects ProcessCoefficientOddsProbability Odds Ratio No Defects-0.52220.590.37 Braden Scale Defects 2.543227.550.8812.72 Bed Defects1.562202.830.744.77 Q2 Turn Defects -2.168700.07 0.11 What did we learn? Most significant “X” is the Braden Scale Defect: - Odds of development 7.5 to 1 - Likelihood of NPU = 88% - 12.72 times more likely to develop NPU What did we learn? Most significant “X” is the Braden Scale Defect: - Odds of development 7.5 to 1 - Likelihood of NPU = 88% - 12.72 times more likely to develop NPU

14. Solutions Implemented Braden Scale –Increased frequency of performance – Q5D –Added descriptions to BS assessment in HIS Prevention/Treatment Protocol –Prompts added to HIS –Revised protocol to include more details –Task list for PCTs –Posted turning schedule Education –Skin care covered in RN orientation by ET RN –Annual global competency on BS interpretation –ET RN accountability tracking tool for non-compliance Improve

15. Reduced pressure ulcer rate by 79% Project Benefits  Decreased LOS  Increased awareness of skin issues  $300,000 cost avoidance  Improved overall quality of care

16. Ongoing Efforts Led by Process Owner  New incontinence protocol  New skin care product line  New pressure ulcer staging system  Complete pressure relief on heels  Specialty beds on new unit  Increased BS frequency – Q3D Continuous efforts on skin care issues are necessary for maintaining quality performance.