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Facility uses Six Sigma to improve quality

Isolation management initiative earns recognition

New York-Presbyterian Hospital recently received top honors in two categories at the Global Six Sigma Summit & Industry Awards — "Best Achievement of Six Sigma in Healthcare" (sponsored by CIGNA Corporation), and the Platinum Award for "The Most Outstanding Organizational Achievement through Six Sigma." After a review by an independent, international panel of 14 leaders from business, industry, and government, New York-Presbyterian received the top award in the health care category and also took the Platinum Award for being the best overall of all seven category winners for using the quality methodologies to achieve major advances in patient safety, cost savings, innovation, and efficiencies. The Global Six Sigma Awards program received 65 entries from organizations based in India, Saudi Arabia, Singapore, South Africa, the United Kingdom, and the U.S. for the 2006 competition.

The 2,224-bed academic medical center is affiliated with Columbia University College of Physicians & Surgeons, and Joan and Sanford I. Weill Medical College of Cornell University.

The hospital's initial investment in Six Sigma was $8 million. In 2004, the first full year of the program, a savings of $47 million was realized from bottom-line expenses — a direct result of the Six Sigma initiatives. The 130 projects initiated that year included length of stay reduction, financial performance, and constraints in an increasing regulatory environment.

The facility's initiative in isolation management IT solutions was a key factor in its earning the awards, says Michelle Evangelista, RN, MHSA, a Six Sigma Black Belt at the facility. (New York-Presbyterian has more than 20 Black Belts on staff.) "We received a request to apply for the award, and we applied in the health care category," she recalls. "As we put together our application, we used the isolation management project as a specific example of our Six Sigma programs."

The demand for isolation beds had been growing at New York-Presbyterian in response to the hospital's ability to identify patients who required isolated environments, as well as the increasing number of patients who were colonized with resistant organisms. In 2004, contact isolation bed utilization increased 25% for MRSA (methicillin resistant Staphylococcus aureus) cases and 27% for VREF (vancomycin-resistant Enterococcus faecium bacteremia) cases at locations studied, while isolation bed capacity remained unchanged.

The isolation bed placement data analysis for November 2004 to November 2005 demonstrated a 23% improvement in first bed assignment to a private isolation room. "We have also seen improvement in the percentage of patients transferred after first bed placement for isolation purposes, as well as the percentage of patients that were cohorted [placed in a room with a roommate that meets the policy for cohorting patients], and the percentage of patients isolated in blocked bed rooms [placing the patient in a semi-private room and blocking the other bed from use by non-isolation admissions]," says Evangelista.

Using the Six Sigma DMAIC (Define - Measure - Analyze - Improve - Control) process, staff identified an opportunity to improve and then gathered the "voice" of the customers (internal or external) to fine-tune the scope of focus to ensure a greater impact.

"We did a measurement system analysis, which we think is always critical; you have to know how good your data is," says Evangelista. "We looked at the critical factors that were impacting our ability to perform optimally, and it really came down to communication and staff training. That, in turn, drove the improvement initiative."

It became clear that the facility had to have a reliable, automated methodology to identify patients who would need isolation. "This population does not arrive with acute illness — which is easy to identify — but is transferred or returned to us and have been colonized, or had infections," explains Evangelista. "They are a little harder to identify."

Fortunately, says Evangelista, the hospital has a very strong epidemiology department. Once a patient is known to be positive, a staff member can go into a database established by the epidemiology department.

The database has logic built into it and can be applied to specific organisms. Utilizing the hospital standards (based on CDC and other national guidelines), a treatment plan is then created for the individual patient according to those standards.

The database gets uploaded on a daily basis and feeds the registration system, she explains. "So, there is a field the bed assignment people can look at, and a code is generated. The patient is designated as either active or inactive. If you have been coded as active, the field is populated and the bed assignment person can see you've been colonized, and according to our rules, you require isolation."

The facility, she adds, also has a pre-admit tracking system that interfaces with the database, "So we can look at it in both ways."

To sustain and institutionalize project results, a reporting mechanism was developed in the control phase of the Six Sigma process to integrate and include isolation management measures in the hospital's Intranet site. This involved the creation of a new portal so that the epidemiology department can take this success even further. "Now that we've achieved a certain level of compliance, they will build it into their processes to monitor if they are maintaining gains or improving upon them," Evangelista says.

To date, she adds, "We have maintained this [improved] level of performance."