Six Sigma at Academic Medical Hospital

The following presentation was developed by Jane

McCrea, Black Belt of the ED Wait Time Project at
Academic Medical Hospital.

The presentation follows the DMAIC methodology.

Six Sigma--DMAIC

Define: Define and scope problem. Identify potential

benefits and critical to quality (CTQ) factors.
Measure: Identify the key internal process that
influences CTQ characteristics and measure the
defects generated relative to the identified CTQs.
Confirm measurement system reliability. Know voice of
customer. End result: team can successfully measure
the defects generated for a key process affecting the
CTQ.
Analyze: Identify root causes of defects. Use statistical
data tools to identify key process inputs that affect
process outputs. End result: explain variables that are
likely to drive process variation the most.
Improve: Determine and confirm optimal solution
(statistically re-analysis). Identify the maximum
acceptable ranges of key variables. End result: modify
the process to stay within the acceptable ranges.
Control: Ensure that modified process now enables the
key variables to stay within the maximum acceptable
ranges using tools such as metric dashboards and
accountability reporting.

ED Wait Time
six sigma
The Way We Work

Project
ProjectDescription
Description

Reduce
Reduceand
andconsistently
consistentlymaintain
maintainpatient
patient
wait
waittimes
timesfrom
fromtriage
triagestart
startto
tofirst
firstphysician
physician
interaction
at
established
thresholds.
interaction at established thresholds.
EXPECTED
EXPECTEDBENEFITS
BENEFITS
Customer:
Customer:Critical
Criticalto
toQuality
Quality(CTQ)
(CTQ)
Reduce
Wait
Time
Reduce Wait Time
Internal:
Internal:Critical
Criticalto
toQuality
Quality(CTQ)
(CTQ)
Improve
ImprovePatient/Staff
Patient/StaffSatisfaction
Satisfaction
Enhance
EnhancePatient
PatientOutcomes
Outcomes
Increase
IncreaseED
EDcapacity
capacityand
and
operational
efficiency
operational efficiency

Arrival
Arrival

Triage
Triage

Register
Register

Lobby
Lobby

Define

Champion
Champion
Dr.
Gerry
Dr. GerryElbridge
Elbridge
Sponsor
Sponsor
Dr.
Terry
Dr. TerryHamilton
Hamilton
Black
BlackBelt
Belt
Jane
McCrea
Jane McCrea
Green
GreenBelt
Belt
Dr.
James
Wilson
Dr. James Wilson
Foundations
FoundationsTeam
Team
Nancy
Jenkins,
Bill
Nancy Jenkins, BillBarber,
Barber,
Georgia
Williams,
Steve
Georgia Williams, SteveSmall
Small

Tx
TxRoom
Room

Nurse
Nurse

MD
MD

Measure

What
Whatwas
wasthe
theVoice
Voiceof
ofthe
theCustomer?
Customer?

Acceptable Lobby Wait Time

Patient
PatientSurvey
Survey
N
=
30;
Priority
N = 30; PriorityIIIIPatients
Patients
Random:
all
days,
Random: all days,all
allshifts
shifts

14
12
< 10

10

10 - 20

20 - 30

30 - 60

> 60

2
0
< 10

10 - 20

20 - 30

30 - 60

Patient
PatientSurvey
SurveyResults
Results
Wait
Time
Expectations:
Wait Time Expectations:
10-20
10-20minutes:
minutes:43%
43%
20-30
20-30minutes:
minutes:23%
23%

> 60

Lobby Wait Satisfaction Rating

Patient
PatientSurvey
SurveyResults
Results
Wait
WaitTime
TimeSatisfaction
Satisfaction
Very
VerySatisfied:
Satisfied:37%
37%
Very
VeryDissatisfied:
Dissatisfied:37%
37%

12
10

V. Sat.

S. Sat.

Neutral

S. Dissat.
V. Dissat.

2
0
V. Sat.

S. Sat.

Neutral

S. Dissat. V. Dissat.

Baseline Measurements
An observational prospective manual time study
yielded baseline measurements for the total wait time

Triage
Triage Start
Start to
to
MD
MD Start
Start

20

60

100

140

180

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

Measure

What
Whatdid
didwe
wemeasure?
measure?

Y:
Y: ##of
ofMinutes,
Minutes,from
fromTriage
TriageStart
Startto
toFirst
FirstPhysician
PhysicianInteraction
Interaction
Specification
SpecificationLimit:
Limit: 37
37minutes
minutes
Specification
SpecificationValidation:
Validation:Internal
Internalexperts
experts&&data,
data,External
External
benchmarks
benchmarks
Defect:
Defect: Wait
Waittime
time>>37
37minutes
minutes
Unit:
Unit: One
Onepriority
priorityIIIIpatient
patientvisit
visitwith
withone
onedefect
defectopportunity
opportunityeach
each
Measurement
MeasurementSystem:
System: Patient
PatientSurvey,
Survey,Manual
ManualData
DataCollection,
Collection,
Chart
ChartReview,
Review,Quality
QualityReports,
Reports,Registration
Registration&&Staffing
StaffingReports
Reports
Impact
Impacton
onBusiness:
Business:

25
25min.
min.Line
Lineof
ofSight
SightReduction
ReductionPer
PerPatient
PatientResulting
Resulting==Capacity
Capacity
Opportunity
Opportunity

Improved
ImprovedPatient
PatientSatisfaction,
Satisfaction,Reduced
ReducedComplaints,
Complaints,Enhanced
Enhanced
Outcomes
Outcomes

Improved
ImprovedStaff
StaffSatisfaction
Satisfaction&&Reduced
ReducedTurnover
Turnover

Improved
ImprovedDaily
DailyED
EDOperational
OperationalEfficiency
Efficiency

Key
KeyTakeaway:
Takeaway:40%
40%Wait
WaitReduction
Reduction&&Operating
OperatingMargin
MarginGains
Gains

What critical Xs were tested as being root causes of the problem?

Environment

People

ED patient volume

Analyze

Staffing levels

ED patient acuity

Experience & skill level

Influx of squad patients

Resident specialty

Referral volume

Family needs

OR volume

Role clarification

Hospital patient volume

Match of skill sets and assignments

ED tx room limits/facility constraints

Variation of practice
Triage process

Availability of diagnostic equipment

Registration/Chart prep process

Availability of trams, pumps, etc.

Charting procedures

Non-optimization of Tracking system

Communication

Inadequate IS system for tracking/trending

No Physician Prescription Writing system

Availability of supplies

Volunteer/greeter utilization

Clinics schedules

Utilization of minor emergency unit

Ancillary services levels

No integrated, on-line charting system

Specialty testing delays

ED used as admission unit
ED discharge practice

Machines

Materials

Hospital discharge process/timing

Consult responsiveness/practices
Use of ED for boarding
Segmentation/delineation

Sequential care vs. parallel processes

Improvement implementation/maintenance ownership

Methods

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

Measure

23
&&18
23variables
variables
18time
timestamps
stamps
nd
Analyzed
via
2
.
wave
of
data
nd
Analyzed via 2 . wave of datacollection
collection
Patient Volume-Related: 10
Patient Volume-Related: 10
Staffing Volume-Related: 5
Staffing Volume-Related: 5
Staffing Mix-Related: 5
Staffing Mix-Related: 5
Misc: 3
Misc: 3

Improve
What
Whatcritical
criticalXs
Xswere
weretested
testedas
asbeing
beingroot
rootcauses
causesof
ofthe
theproblem?
problem?
23
23variables
variablesselected
selected&&analyzed
analyzed
through
throughsecond
secondwave
waveof
ofdata
datacollection
collection
Census-Related: 10
Census-Related: 10
Staffing Related: 5
Staffing Related: 5
Coded: 5
Coded: 5
Miscellaneous: 3
Miscellaneous: 3

What
Whatroot
rootcauses
causeswere
wereconfirmed
confirmedand
andtested
testedin
inthe
thepilot?
pilot?
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 Protocols

Streamlined Order Entry & Results Retrieval Process

Pilot Design
Fishbone diagramming, data collection and statistical
analysis determined the Critical Xs (contributing
factors) as key components for the randomized pilot.
1. Patient Flow
Direct-to-bed flow; Relocation to semi-private
space
2. Care Team Communication
Zoning; Communication board; Clinical protocols
3. Streamlined Order Entry & Results Retrieval
Uses central clerk

What
Whatwere
werethe
thepilot
pilotfactors
factorsand
andresults?
results?

Improve

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 Protocols
Streamlined Order Entry & Results Retrieval Process

Lobby
Target
15 min.

Study 2
N = 129

Pilot
N = 172

MD
Target
8 min.

11.2 min.

8.9 min.

42%

34.9%

Wait
Time

34.5 min.

12.6 min.

Wait
Time

% Defect

51.2%

22.8%

% Defect

Study 2
N = 129

Pilot
N = 172

PILOT RESULTS
Lobby
WT
Study 1
N =30

Lobby
WT
Study 2
N = 129

Lobby
WT
Pilot
N = 158

MD WT
Study 1
N = 30

MD WT
Study 2
N = 127

MD WT
Pilot
N = 172

31.2

34.5

12.6

16.1

11.2

8.9

Standard
Deviation

26.65

16.02

11.69

18.70

46.76

16.68

% Defect

56.7%

51.2%

22.8%

55%

42%

34.9%

Z-Score

1.33

1.47

2.25

1.37

1.71

1.89

Mean WT
(minutes)

(Attribute)

Improve

PILOT CONCLUSIONS
Moods Median Test
P-value
95% C.I.

Lobby WT
Study 1 to Pilot

0.001

2.7 to 31.8

Lobby WT
Study 2 to Pilot

0.000

4.8 to 13.2

MD WT
Study 1 to Pilot

0.016

1.0 to 16.0

MD WT
Study 2 to Pilot

0.772

-2.00 to 3.00

Lobby WT N

MD WT N

Study 1

30

30

Study 2

129

127

Pilot

158

172

Pilot lobby wait times

were better than the
established 15 min.
target, the defect rate
tumbled, and the C.I.
validated statistical
significance.
Results for MD wait
times were statistically
significant in one of two
Moods median tests.
Positive trending was
demonstrated in the
comparison of Study 2 to
the Pilot.
Stakeholders supported
department-wide, multipatient population
implementation.

Control

What
Whatare
arethe
thebuilding
buildingblocks
blocksof
ofControl?
Control?

Guidelines
Guidelines&&Assigned
AssignedResponsibility
Responsibility

New
NewStandard
StandardOperating
OperatingProcedure
Procedure

Detailed
DetailedWho,
Who,What
Whatand
andWhen
Whenplan
plan
Data
DataReview,
Review,Reporting
Reporting&&Accountability
Accountability

Quarterly
Quarterlymanual/automated
manual/automateddata
dataanalysis
analysis

Monthly
Monthlyreports
reportsand
andcontrol
controlcharts
charts

Use
Useof
ofCorrective
CorrectiveAction
ActionLog
Logper
perguidelines
guidelines

Monthly
Monthlyreports
reports

Scheduled
Scheduledreporting
reportingto
toexecutive
executiveleadership
leadership

Quarterly
Quarterlyreview
reviewto
toowner
ownerpeers
peers&&executives
executives
Communication
Communication&&Recognition
Recognition

Monthly
Monthlyupdates
updatesto
todept.
dept.communication
communicationcenter
center&&newsletter
newsletter

Monthly
Monthlyupdates
updatesat
atstaff,
staff,faculty
faculty&&resident
residentmeetings
meetings

Incorporation
Incorporationof
ofstaff
staffrecognition
recognitionfor
forongoing
ongoingpositive
positiveresults
results