Six Sigma CAP initiative reduces mortalities

Enables staff to make required process changes

A Six Sigma performance improvement project in community-acquired pneumonia (CAP) at Mercy Medical Center has decreased mortality rates from 6.7% in 2003 to 3.5% in 2006, or a 47.8% reduction.

The program also reduced the mean length of stay (LOS) from 5.9 days to 5.1 days and saved more than $300,000. In order to achieve these improvements, staff raised compliance scores for each Joint Commission core measure for CAP to between 70% and 90%.

The results were measured in 670 CAP patients who were admitted during the baseline period of fiscal year 2003, and the 1,550 CAP patients who were admitted during the study period. The staff at Mercy Medical in Des Moines, IA, credit their success to the standardization of treatment and the statistical identification of the appropriate processes to target.

"Six Sigma was the P.I. methodology our hospital had adopted," explains Karen Gamerdinger, RN, MSN, pulmonary case manager. However, while there were many such projects implemented in the hospital, "we were the first," she adds.

Targeting core measures

The CAP core measures targeted, says Gamerdinger, were:

  • Oxygenation assessment within 24 hours;
  • Blood cultures before antibiotic dose;
  • Antibiotics within four hours of arrival at the hospital;
  • Antibiotic regimen consistent with guidelines;
  • Screening and administration of influenza and pneumococcal vaccine;
  • Smoking cessation advice or counseling for those who smoke or did so in the previous year.

"Those were the core measures at the time of the study," clarifies Neil Horning, MD, medical director of the pulmonary care improvement team. "They continue to be adjusted by The Joint Commission."

The pulmonary care improvement team, he continues, included himself and Gamerdinger, the facility's Six Sigma Master Black Belt, the chief nursing officer, the ED medical director, ED and floor nurses, a representative from the finance department, and a pharmacist.

A focused intervention

One of the main benefits of Six Sigma, says Horning, was that it enabled the team to conduct a "focused intervention."

"It gave us a couple of important tools to be able to really dive in and look at what was going wrong and at what the critical processes were; to measure statistically where we could make important changes; what kind of interventions could help; and who the important people were who could make this happen and get back to us," he explains.

In this case, the most important place identified was the ED, and the person was the director. With his assistance, says Horning, "we were able to get data back more quickly, we moved faster, and we knew where we were and were not making improvement — what we should and should not be doing."

What else led them to the ED? "One of the main reasons was the ED director knew that 80% of our patients came through the ED, and four of the six core measures had to be met before they left. So that was the key," Gamerdinger explains.

"From our baseline analysis, we found that in those patients who had pneumonia admission standard orders their LOS was almost a full day less," she adds. "Switching from IV to oral medication also had a strong correlation with [shorter] LOS."

Revising orders

Accordingly, the team revised the ED orders to incorporate the appropriate guidelines and to make sure they were initiated in the department. "Prior to this, our compliance had only been 40%," says Gamerdinger. "Having the medical director from the ED function as a process owner meant he was able to give timely feedback to the doctors who were deficient."

Educating the physicians about the new orders also was critical, says Horning. "We let them know the orders were available, made them easy to locate, and tried to make them as easy as possible to use," he says. "We worked with the ED physicians to change the orders, and make some requested adjustments."

Before these orders, physicians had a number of different choices about things that could happen on the floor, he adds. "There were almost too many choices; the form was too cluttered, and we had tried to pack too many things in," he says. "All you really had to do was to make the diagnosis and to order the correct antibiotic."

When it was discovered through chart audits (control charts were used to monitor variation in CAP admission order use) that a specific physician was not using the form, Gamerdinger would send an e-mail to the ED director telling him which patients had gone through without proper orders. "She developed a pretty simple chart for them so they could see at a glance the percentage of use by each doctor," notes Horning. The director would then go directly to the physician and point out their performance.

To track other results, descriptive statistics were used for data analysis of core measures, LOS, and mortality.

Getting docs on board

As with many QI projects, getting physicians on board was a challenge. "Some physicians have a problem with standardized forms no matter what they are, although that is a minority," notes Horning. "Compliance was lower at the beginning because some doctors didn't know about them and their easy availability."

Letters were sent out to the doctors telling them about the new form, and the ease of availability soon became evident. In the ED, the new form was made part of all standardized admission order forms. "On the floors where [CAP] patients were admitted frequently, they were in the chart at room-side," says Horning. "We also brought them to the doctors' offices."

In addition, the medical executive committee and the administration made it clear they expected the form to be used for every patient. "Once we had data we were able to take them to the medical staff and administration; after we showed them the data, they endorsed the use of that order form for all patients with CAP," Gamerdinger explains.

In addition, says Horning, "Six Sigma was a hospital-wide QI initiative, so that gave some weight and importance to our project. The implication was that this was important to the administration, and that it should happen correctly."

He adds that using Six Sigma processes is not by itself a guarantee of success. "Six Sigma is used in a lot of hospitals — without success in some," he notes. "What's important here is that this was a QI initiative where the administration presented it as something they believed would improve quality of care — that it was not just a cost-saving initiative. Also, in some hospitals, it is used in a punitive way, but not in ours. The attitude was, 'Let's all pull together and make things more efficient for everyone at the hospital.'"

[For more information contact:

Karen Gamerdinger, RN, MSN, Pulmonary Case Manager, Neil Horning, MD, Mercy Medical Center, Des Moines, IA. Phone: (515) 643-2497. Fax: (515) 643-5830. E-mail:]