PURPOSE: A retrospective study was conducted to evaluate the outcomes of a Six Sigma (SS) performance improvement project focused on compliance with Joint Commission (JCAHO) Community-acquired Pneumonia (CAP) Core Measures.
METHODS: From August 2004 to December 2006 a multidisciplinary team at a large community hospital developed a Six Sigma performance improvement initiative to ensure that each patient with CAP had each JCAHO Core Measure of care met. Six Sigma is a performance improvement system that utilizes data and statistical analysis to measure and improve operational performance and practices. Utilizing SS methodology, critical processes and key stakeholders in patient care were identified.When deviations from the SS performance improvement protocol occurred, timely feedback was provided to care providers. Descriptive statistics were used for data analysis of Core Measures, length of stay (LOS), and mortality. Control charts were used to monitor variation in LOS and CAP admission order use.
RESULTS: 670 CAP patients were admitted during the baseline period of fiscal year 2003; 1550 CAP patients were admitted during the study period. Following implementation of the SS program, compliance scores for each JCAHO Core Measure improved from 70% to >90%. CAP order usage improved from 40% to 73% (p=0.000), an 82.5% increase, with a statistically significant reduction in mean LOS from 5.9 days to 5.1 days (p=0.000), a 13.56% reduction. The decreased LOS was associated with greater than $300,000 in cost savings. In-hospital mortality rates decreased from 6.7% in 2003 to 3.5% in 2006 (p=0.004), a 47.8% reduction.
CONCLUSION: Standardizing CAP care through implementation of a Six Sigma performance improvement program improved compliance with JCAHO CAP Core Measures and led to a reduction in hospital length of stay, health-care costs, and in-patient mortality.
CLINICAL IMPLICATIONS: CAP is one of the most common causes of hospitalization and death in the USA. Through a Six Sigma program focused on achieving 100% compliance with JCAHO Core Measures, not only did compliance with the Core Measures improve, but significant decreases in cost of care and mortality were achieved.
DISCLOSURE: Karen Gamerdinger, No Financial Disclosure Information; No Product/Research Disclosure Information