Heart failure deaths cut 50% using Six Sigma process

Six Sigma, DMAIC used

Patient deaths from heart failure were decreased by 50%, readmissions reduced by 12%, and complications reduced by 77%, as a result of a quality improvement initiative at Texas-based Valley Baptist Health System.

Six Sigma principles and the organization's own DMAIC (Define, Measure, Analyze, Improve, and Control) methodology were used to redesign standard operating procedures, in order to comply with national standards for heart failure.

Valley Baptist staff reviewed 300 medical records and created an aggregate score for each measure. Next, the team identified the greatest variances in the process and barriers to uniformity.

Resulting improvements included staff and physician education, a process to identify heart failure patients on admission, and documentation tools and reminders to facilitate compliance. 

In the near future, the organization is hoping to be able to incorporate the data into its newly upgraded electronic medical record, so that documentation is required and not optional as a patient with heart failure is being treated.

Physicians on Valley Baptist's cardiac care committee were key drivers in developing the new procedures. From October 2005 to August 2006, the improvements affected 626 heart failure patients. "The improvements are projected to affect as many as 7,000 patients over the next 10 years," says Tomas A. Gonzalez, MD, MBA, senior vice president and chief quality officer. "This means less people dying and less people coming back to the hospital."

Maintaining gains

In 2005, 100% compliance with heart failure core measures was achieved, and this result has been sustained over time. "One of the toughest challenges is always to maintain the gains," says Gonzalez. "In 2007, we were ranked the No. 1 hospital in the entire country in compliance with the core measures for heart failure in the Premier/CMS demonstration project. To maintain the gain, we have several approaches which work in parallel."

Each unit is measured on its compliance on a monthly basis. "If you don't measure something, you don't know how you are performing and you definitely will not know how to improve it," says Gonzalez.

The quality professional's role is to promote awareness, facilitate meetings and brainstorming for solutions, maintain the Six Sigma methodology, data collection and analysis, and compile performance scorecards. "Their role is to guide the quality improvement strategy and maintain the goal, but their role is not to impose a solution," says Gonzalez. "The solutions are developed by the frontline caregivers — the nurses and physicians."

Data are gathered daily and analyzed monthly on the four core measures related to heart failure management: measurement of left ventricular function documented; ACE inhibitor given or the contraindication documented; smoking cessation counseling documented; and complete discharge instructions documented. 

Internal auditors and monthly compliance reports are very specific when it comes to nurse and physician compliance.

"We name names — we make it very personal," says Gonzalez. "The data are specific to each individual nurse and physician. Each person has a rating — we can tell you how Nurse A has performed over the past two years. We can tell you if Nurse B is failing to comply with the standard. We can tell you if Physician C is getting it right every time, or if Physician X is struggling to document."

[For more information, contact:

Tomas A. Gonzalez, MD, MBA, Senior Vice President & Chief Quality Officer, Valley Baptist Health System. Phone: (956) 389-1530. Fax: (956) 389-1531. E-mail: tomas.gonzalez@valleybaptist.net.]