Six Sigma at Academic Medical HospitalSix Sigma at Academic Medical Hospital

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D M A I C

The following presentation was developed by Jane The following presentation was developed by Jane McCrea, Black Belt of the ED Wait Time Project at McCrea, Black Belt of the ED Wait Time Project at

Academic Medical Hospital.Academic Medical Hospital.

The presentation follows the DMAIC methodology.The presentation follows the DMAIC methodology.

Six Sigma--DMAICSix Sigma--DMAIC

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D M A I C

Define:Define: Define and scope problem. Identify potential Define and scope problem. Identify potential benefits and critical to quality (“CTQ”) factors.benefits and critical to quality (“CTQ”) factors.

Measure:Measure: Identify the key internal process that Identify the key internal process that influences CTQ characteristics and measure the influences CTQ characteristics and measure the defects generated relative to the identified CTQs. defects generated relative to the identified CTQs. Confirm measurement system reliability. Know voice of Confirm measurement system reliability. Know voice of customer. customer. End resultEnd result: team can successfully measure : team can successfully measure the defects generated for a key process affecting the the defects generated for a key process affecting the CTQ.CTQ.

Analyze:Analyze: Identify root causes of defects. Use statistical Identify root causes of defects. Use statistical data tools to identify key process inputs that affect data tools to identify key process inputs that affect process outputs. process outputs. End resultEnd result: explain variables that are : explain variables that are likely to drive process variation the most.likely to drive process variation the most.

Improve:Improve: Determine and confirm optimal solution Determine and confirm optimal solution (statistically re-analysis). Identify the maximum (statistically re-analysis). Identify the maximum acceptable ranges of key variables. acceptable ranges of key variables. End resultEnd result: modify : modify the process to stay within the acceptable ranges.the process to stay within the acceptable ranges.

Control:Control: Ensure that modified process now enables the Ensure that modified process now enables the key variables to stay within the maximum acceptable key variables to stay within the maximum acceptable ranges using tools such as metric dashboards and ranges using tools such as metric dashboards and accountability reporting.accountability reporting.

Project DescriptionReduce and consistently maintain patient wait times from triage start to first physician interaction at established thresholds.

ED Wait Timesix sigma

The Way We WorkChampion

Dr. Gerry Elbridge Sponsor

Dr. Terry Hamilton Black Belt

Jane McCrea Green Belt

Dr. James WilsonFoundations Team

Nancy Jenkins, Bill Barber,Georgia Williams, Steve Small

Define

EXPECTED BENEFITSCustomer: Critical to Quality (CTQ)•Reduce Wait TimeInternal: Critical to Quality (CTQ)•Improve Patient/Staff Satisfaction •Enhance Patient Outcomes•Increase ED capacity and operational efficiency

Arrival Triage Register Lobby Tx Room Nurse MD

Patient Survey Results •Wait Time Satisfaction

Very Satisfied: 37%Very Dissatisfied: 37%

Patient Survey Results •Wait Time Expectations:

10-20 minutes: 43%20-30 minutes: 23%

Patient Survey •N = 30; Priority II Patients•Random: all days, all shifts

Acceptable Lobby Wait Time

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< 10 10 - 20 20 - 30 30 - 60 > 60

< 10

10 - 20 20 - 30

30 - 60

> 60

Lobby Wait Satisfaction Rating

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V. Sat. S. Sat. Neutral S. Dissat. V. Dissat.

V. Sat.

S. Sat.

Neutral

S. Dissat.

V. Dissat.

MeasureWhat was the Voice of the Customer?

Baseline Measurements Baseline Measurements An observational prospective manual time study An observational prospective manual time study

yielded baseline measurements for the total wait time yielded baseline measurements for the total wait time

Triage Start to Triage Start to MD StartMD Start

Mean: 62.5 min. Mean: 62.5 min. Std. Dev: 39.66Std. Dev: 39.66 Z-Score: 1.79Z-Score: 1.79 Defect Rate: 38.6% Defect Rate: 38.6% USL: 37.1 min.USL: 37.1 min.

20 60 100 140 180

What did we measure?

Key Takeaway: 40% Wait Reduction & Operating Margin Gains

Y: # of Minutes, from Triage Start to First Physician Interaction Specification Limit: 37 minutes Specification Validation: Internal experts & data, External

benchmarks Defect: Wait time > 37 minutes Unit: One priority II patient visit with one defect opportunity each Measurement System: Patient Survey, Manual Data Collection,

Chart Review, Quality Reports, Registration & Staffing Reports Impact on Business: 25 min. Line of Sight Reduction Per Patient Resulting = Capacity

OpportunityImproved Patient Satisfaction, Reduced Complaints, Enhanced

OutcomesImproved Staff Satisfaction & Reduced TurnoverImproved Daily ED Operational Efficiency

Measure

Staffing levels

Experience & skill level

Resident specialty

Volunteer/greeter utilization

Family needs

Role clarification

Match of skill sets and assignments

Variation of practice

Availability of supplies

Availability of diagnostic equipment

Availability of trams, pumps, etc.

Non-optimization of Tracking system

Inadequate IS system for tracking/trending

No Physician Prescription Writing system

No integrated, on-line charting system

ED patient volume

ED patient acuity

Influx of squad patients

Referral volume

Clinics schedules

OR volume

Hospital patient volume

ED tx room limits/facility constraints

Quality of measurement

Are we measuring the right things?

What do we do with what we measure?

Need to do more than “track”

Feedback systems to quality auditing

Need for Improved flow sheet format

Lack of on-line charting system for

automated monitoring

 

Triage process

Registration/Chart prep process

Charting procedures 

Communication Utilization of minor emergency unit

Ancillary services levels

Specialty testing delays  ED used as admission unit

ED discharge practice

Hospital discharge process/timing

Consult responsiveness/practices

Use of ED for boarding Segmentation/delineation

Sequential care vs. parallel processes

Improvement implementation/maintenance ownership

23 variables & 18 time stamps Analyzed via 2nd. wave of data collection

Patient Volume-Related: 10 Staffing Volume-Related: 5

Staffing Mix-Related: 5 Misc: 3

Environment People Materials

Measure

Methods

Machines

What critical X’s were tested as being root causes of the problem?

Analyze

Patient Flow Direct-to-bed flow & bedside registration Patient relocation to semi-private space when appropriate Flow Facilitator

Care Team Communication Modified Zoning Communication Board Clinical ProtocolsStreamlined Order Entry & Results Retrieval Process

 

What critical X’s were tested as being root causes of the problem?

Improve

What root causes were confirmed and tested in the pilot?

23 variables selected & analyzed through second wave of data collection Census-Related: 10 Staffing Related: 5 Coded: 5 Miscellaneous: 3

Pilot DesignPilot Design Fishbone diagramming, data collection and statistical Fishbone diagramming, data collection and statistical

analysis determined the Critical X’s (contributing analysis determined the Critical X’s (contributing factors) as key components for the randomized pilot. factors) as key components for the randomized pilot.

1.1. Patient Flow Patient Flow Direct-to-bed flow; Relocation to semi-private Direct-to-bed flow; Relocation to semi-private

spacespace 2.2. Care Team CommunicationCare Team Communication

Zoning; Communication board; Clinical protocolsZoning; Communication board; Clinical protocols

3.3. Streamlined Order Entry & Results RetrievalStreamlined Order Entry & Results Retrieval Uses central clerkUses central clerk

What were the pilot factors and results? ImprovePatient Flow Direct-to-bed flow & bedside registration Patient relocation to semi-private space when appropriate Flow FacilitatorCare Team Communication Modified Zoning Communication Board Clinical ProtocolsStreamlined Order Entry & Results Retrieval Process

Lobby Target 15 min.

Study 2N = 129 Pilot

N = 172

Wait Time 34.5 min. 12.6 min.

% Defect 51.2% 22.8%

MDTarget 8 min.

Study 2N = 129 Pilot

N = 172

Wait Time 11.2 min. 8.9 min.

% Defect 42% 34.9%

Lobby Lobby WTWT

Study 1Study 1N =30N =30

Lobby Lobby WT WT

Study 2Study 2N = 129 N = 129

Lobby Lobby WTWTPilotPilot

N = 158 N = 158

MD WTMD WTStudy 1Study 1N = 30 N = 30

MD WTMD WTStudy 2Study 2N = 127 N = 127

MD WTMD WTPilotPilot

N = 172N = 172

Mean WTMean WT(minutes)(minutes)

31.231.2 34.534.5 12.612.6 16.116.1 11.211.2 8.98.9

StandardStandard

DeviationDeviation 26.6526.65 16.0216.02 11.6911.69 18.7018.70 46.7646.76 16.6816.68

% Defect% Defect 56.7%56.7% 51.2%51.2% 22.8%22.8% 55%55% 42%42% 34.9%34.9%

Z-ScoreZ-Score(Attribute)(Attribute)

1.331.33 1.471.47 2.252.25 1.371.37 1.711.71 1.891.89

PILOT RESULTSPILOT RESULTS

P-valueP-value 95% C.I.95% C.I.

Lobby WTLobby WTStudy 1 to PilotStudy 1 to Pilot

0.0010.001 2.7 to 31.82.7 to 31.8

Lobby WTLobby WTStudy 2 to PilotStudy 2 to Pilot

0.0000.000 4.8 to 13.24.8 to 13.2

MD WT MD WT Study 1 to PilotStudy 1 to Pilot

0.0160.016 1.0 to 16.01.0 to 16.0

MD WT MD WT Study 2 to PilotStudy 2 to Pilot

0.7720.772 -2.00 to 3.00-2.00 to 3.00

PILOT CONCLUSIONSPILOT CONCLUSIONSMood’s Median Test Mood’s Median Test

Pilot lobby wait times Pilot lobby wait times were better than the were better than the established 15 min. established 15 min. target, the defect rate target, the defect rate tumbled, and the C.I. tumbled, and the C.I. validated statistical validated statistical significance.significance.

Results for MD wait Results for MD wait times were statistically times were statistically significant in one of two significant in one of two Mood’s median tests. Mood’s median tests. Positive trending was Positive trending was demonstrated in the demonstrated in the comparison of Study 2 to comparison of Study 2 to the Pilot.the Pilot.

Stakeholders supported Stakeholders supported department-wide, multi-department-wide, multi-patient population patient population implementation. implementation.

Lobby WT N MD WT N

Study 1 30 30

Study 2 129 127

Pilot 158 172

Improve

Control What are the building blocks of Control?

Guidelines & Assigned ResponsibilityNew Standard Operating ProcedureDetailed Who, What and When plan

Data Review, Reporting & AccountabilityQuarterly manual/automated data analysisMonthly reports and control charts Use of Corrective Action Log per guidelinesMonthly reportsScheduled reporting to executive leadershipQuarterly review to owner peers & executives

Communication & RecognitionMonthly updates to dept. communication center & newsletter Monthly updates at staff, faculty & resident meetingsIncorporation of staff recognition for ongoing positive results