Six Sigma Anticoagulation Improvements: Virtua Health

Process Step

Deficiency

Intervention

Anticipated Benefit

Preheparin lab studies

Inconsistency among nurses and physicians on holding heparin until results received

Clarification with physicians; default is do not wait for labs with hold option for physician

Decreased variation in nursing practice

Infusion pumps

Occasional incorrect setting leading to dosage error

Programmable pumps with drug personalities and maximum drip rate settings

Avoidance of extreme overdosage due to pump-setting errors

Use of unfractioned heparin

Complex process with complexity-related failures

Substitute low-molecular heparin

Fewer complexity-related errors

The control phase includes creation of visible metrics used by process owners to ensure gains are sustained. Study authors note their work “is not a research methodology, and the findings of this project should not be interpreted in the same light as a rigorous clinical research paper. The focus of this paper is to describe an approach for identifying opportunities for improvement and taking action that leads to results that matter to patients in a framework that is achievable in the typical community hospital setting.”30

Toyota Production System

The Pittsburgh Regional Healthcare Initiative (PRHI) is a collaborative effort by institutions and individuals that provide, purchase, insure, and support health care services in Southwestern Pennsylvania. The initiative aims to achieve “perfect patient care” in six counties in the Pittsburgh Metropolitan Statistical Area with the following goals:

  • Zero medication errors

  • Zero health care–acquired (nosocomial) infections

  • Perfect clinical outcomes, measured by complications, readmissions, and other patient outcomes in the following areas:



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