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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.

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six sigma at academic medical hospital
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
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.
slide3

Define

MD

Nurse

Tx Room

Register

Arrival

Lobby

Triage

ED Wait Time

Champion

Dr. Gerry ElbridgeSponsor

Dr. Terry Hamilton

Black Belt

Jane McCrea

Green Belt

Dr. James Wilson

Foundations Team

Nancy Jenkins, Bill Barber,

Georgia Williams, Steve Small

six sigma

The Way We Work

Project Description

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

  • EXPECTED BENEFITS
  • Customer: Critical to Quality (CTQ)
  • Reduce Wait Time
  • Internal: Critical to Quality (CTQ)
  • Improve Patient/Staff Satisfaction
  • Enhance Patient Outcomes
  • Increase ED capacity and operational efficiency
slide4

Baseline Measurements

An observational prospective manual time study

yielded baseline measurements for the total wait time

  • Triage Start to
  • MD Start
  • Mean: 62.5 min.
  • Std. Dev: 39.66
  • Z-Score: 1.79
  • Defect Rate: 38.6%
  • USL: 37.1 min.

20 60 100 140 180

slide5

Measure

What was the Voice of the Customer?

  • Patient Survey
  • N = 30; Priority II Patients
  • Random: all days, all shifts
  • Patient Survey Results
  • Wait Time Expectations:
    • 10-20 minutes: 43%
    • 20-30 minutes: 23%
  • Patient Survey Results
  • Wait Time Satisfaction
    • Very Satisfied: 37%
    • Very Dissatisfied: 37%
slide6

ED Wait Time Project

Define

MD

Nurse

Tx Room

Register

Arrival

Lobby

Triage

Reduce level II emergency department patient wait times (WT) by 40% from point of triage start to initiation of physician assessment.

  • Mean: 62.48
  • St. Dev: 39.66
  • Z-score: 1.79
  • Defect Rate: 39%

Expected Benefits: Critical to Quality Factors

  • Improved patient/staff satisfaction
  • Enhance patient outcomes by expediting care
  • Increase ED capacity & operational efficiency

Reg. End to

Tx Room Start

“Lobby Wait”

Nurse End to MD Start

“MD Wait”

slide7

Measure

What did we measure?

  • 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 Opportunity
  • Improved Patient Satisfaction, Reduced Complaints, Enhanced Outcomes
  • Improved Staff Satisfaction & Reduced Turnover
  • Improved Daily ED Operational Efficiency

Key Takeaway: 40% Wait Reduction & Operating Margin Gains

slide8

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

Environment

People

Materials

Analyze

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

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

Triage process

Registration/Chart prep process

Charting procedures 

Communication

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

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

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

Measure

Machines

  • 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

Segmentation/delineation

Sequential care vs. parallel processes

Methods

Improvement implementation/maintenance ownership

slide9

Improve

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

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

What root causes were confirmed and tested in the 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

slide10

Pilot Design

Fishbone diagramming, data collection and statistical analysis determined the Critical X’s (contributing factors) as key components for the randomized pilot.

  • Patient Flow
    • Direct-to-bed flow; Relocation to semi-private space
  • Care Team Communication
    • Zoning; Communication board; Clinical protocols
  • Streamlined Order Entry & Results Retrieval
    • Uses central clerk
slide11

Improve

What were the pilot factors and results?

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

slide14

PILOT CONCLUSIONS

Mood’s Median Test

  • 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 Mood’s median tests. Positive trending was demonstrated in the comparison of Study 2 to the Pilot.
  • Stakeholders supported department-wide, multi-patient population implementation.
slide15

Control

What are the building blocks of Control?

Guidelines & Assigned Responsibility

  • New Standard Operating Procedure
  • Detailed Who, What and When plan

Data Review, Reporting & Accountability

  • Quarterly manual/automated data analysis
  • Monthly reports and control charts
  • Use of Corrective Action Log per guidelines
  • Monthly reports
  • Scheduled reporting to executive leadership
  • Quarterly review to owner peers & executives

Communication & Recognition

  • Monthly updates to dept. communication center & newsletter
  • Monthly updates at staff, faculty & resident meetings
  • Incorporation of staff recognition for ongoing positive results