E6S-102 LSS to Help Prevent Veteran Blindness - Johanna Ficatier - Glaucoma Treatment Compliance

Intro:  Welcome to the E6S-Methods podcast with Jacob and Aaron, brought to you by E6S Industries, your source for expert training, consulting, and leadership in business performance and continuous improvement methods, like Lean and Six Sigma. In this episode number 102, we interview Johanna Ficatier, Master's Student and Lean Six Sigma Green Belt from UNC, Charlotte, on her research in applying Lean Six Sigma tools to aid US V.A. doctors to improve the treatment of glaucoma to veterans of the United States' armed forces.  Here we go. http://bit.ly/E6S-102; http://bit.ly/E6S-iTunes

Johanna Ficatier


Research Assistant in the Department of Systems Engineering and Engineering Management at the University of North Carolina at Charlotte.

Johanna holds a Bachelor’s degree in International Business with Minor in Industrial Engineering. She has worked in Japan in the Industrial Equipment and Machine Tools Industry in the positions of Mechanical Design Engineer and as the Global Engineering Coordinator, where she successfully managed several process improvement projects.

She also holds a Lean Six Sigma Green Belt and she is currently enrolled in the Master of Science in Engineering Management.

Her research interest is in improving Healthcare Systems through application of Systems Engineering methods such as Lean Six Sigma, as well as optimization and simulation methods.

I            Introduction

a.       Situation: Before having recourse to surgery, adherence to the treatment is critical to the evolution of glaucoma. Non-compliance behavior therefore needs to be understood and identified in order to offer help and support to the veterans and improve patient care.

b.      Metrics

i.      Non-compliance: more than 48% patients

1.      not conforming to the recommendations made by the provider , as “the extent to which a patient acts in accordance with the prescribed interval and dose of a dosing regimen.” (Cramer et al., 2008).

a.       timing

b.      dosage

c.       frequency.

2.      Possible "Compliance" Measures

a.       Electronic monitoring

b.      Prescription Refill Rate (actual less than 80%)

i.      data readily available

ii.      Refill rate also seems to align with the literature which talks about Medication Possession Ratio (MPR) as a possible measure (Friedman et al., 2007).

1.      MPR > 80% considered "compliant." Meaning 80% of actual days medication coverage relative to prescribed number of days.  (Cate et al., 2013).

c.       Project Description: The goal of this project is to improve the quality of care for Glaucoma patients, by improving the follow-up treatment process.

i.      Problem Statement: In the current process, low compliance (adherence to prescribed medication) appears to be the most concerning problem. Influential factors for non-compliance need to be identified and analyzed.

ii.      Goal Statement: By identifying the influential factors, the goal is to help medical doctors to identify patient non-compliance to glaucoma treatment and its root causes, and then take the appropriate measures.

d.      In Scope: This study focuses on the two first research questions:

i.      What are the main factors influencing non-compliance behavior?

ii.      How can non-compliance behavior be identified and assessed quantitatively?

II         Background on Glaucoma

a.        Neurological disorder

b.      Primary Open-Angle Glaucoma (POAG) (90%)

c.       Often associated with increase of Intra-Ocular Pressure (IOP), may damage the optic nerve

d.      Reduces vision from the side

e.       Can lead up to blindness (irreversible)


This picture describes the intraocular fluid flow in the eye of a Glaucoma patient. We can observe that because of a blockage of the drainage canal in the cornea (the clear “window” in front of the pupil), the intraocular fluid cannot flow outside of the eye and thus create an intraocular pressure increase (blue arrows in the image), which, at terms, by transferring the pressure through the retina (the big non-visible part of the eye, the red part in this picture) can damage the optic nerve (nerve carrying visual information to the brain) (at the very right of the image)

III      Literature review

IV      Methodology

V      Data analysis: In collaboration with Salisbury VAMC. Approved by VA Salisbury IRB and privacy officers

a.       Retrospective chart review from the patient database in Charlotte-Piedmont Area, NC

i.      20 input variables, both categorical and continuous

ii.      120 data points

b.      Random split sampling method: 80 data points for calibration (model building), 40 data points for model validation

VI      Results

a.       6 Statistically significant factors, based on the regression model

b.      Depression and disability did not match the original hypothesis 

i.      Believe that those patients given extra attention and care

ii.      Assume a 3rd party supports medication management - higher compliance

c.       Using the 40 validation data points

i.      Mean Squared Error (MSE) 0.0203 à Good forecasting accuracy.

ii.      The correlation coefficient between measured and computed compliance: 0.42 à Promising linear relation.

iii.      t-test P value = 0.965, Chi-Square P value = 1 à no statistically significant difference between original and computed values


VII   Conclusion

a.       In order to identify the factors influencing non-compliance behavior, Factor Analysis then Stepwise Regression Analysis were performed on 120 data points from a local hospital.

b.      Key Factors (non-compliance)

i.      Duration of Glaucoma,

ii.      Severe Stage

1.      1: mild (Glaucoma diagnosed, but no visual field defect),

2.      2: moderate (visual field defect, but without influence on daily activities),

3.      3: severe (visual field defect limiting ability to perform daily activities)

iii.      Recorded depression history,

iv.      Service connected % (disability level for Veterans)

1.      dependence to external services, with 100% being totally disabled and dependent.

v.      Recorded mental disorder

vi.      Number of missed appointments

c.       Future Research:

i.      Further Analysis with more data points (250)

ii.      Predictive modeling à development of a non-compliance prediction model

VIII                      Any other questions I forgot to ask?

IX      How can the listeners contact you?

a.       Connect on Linkedin,

b.      or email: johannaficatier@hotmail.com

Outro: Thanks for listening to episode 102 of the E6S-Methods Podcast. Stay tuned for episode 103, where Jacob continues to go agile with an explanation of the inner workings of SCRUM.  If you would like to be a guest on the podcast, contact us through our website.  Join our mailing list!  Subscribe to past and future episodes on iTunes or stream us on-demand with Stitcher Radio.  Don't forget to leave a review and share us with a friend.  Find outlines and graphics for all shows and more at www.E6S-Methods.com. “Journey Through Success - If you're not climbing up, you're falling down.”