Six Sigma at Academic Medical Hospital

5 4 3 2 1 0 D M A I C
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 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 result: 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 result: likely to drive process variation the most. Improve: Determine and confirm optimal solution (statistically re-analysis). Identify the maximum reacceptable ranges of key variables. End result: modify result: 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.

5 4 3 2 1 0 D M A I C

ED Wait Time
six sigma
The Way We Work

Define

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

Champion Dr. Gerry Elbridge Sponsor Dr. Terry Hamilton Black Belt Jane McCrea Green Belt Dr. James Wilson Foundations Team Nancy Jenkins, Bill Barber, Georgia Williams, Steve Small

Arrival

Triage

Register

Lobby

Tx Room

Nurse

MD

What was the Voice of the Customer?

Measure

Acceptable Lobby Wait Time

14 12 10 8 6 4 2 0 < 10 10 - 20 20 - 30 30 - 60 > 60 < 10 10 - 20 20 - 30 30 - 60 > 60

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%

Lobby Wait Satisfaction Rating

Patient Survey Results Wait Time Satisfaction Very Satisfied: 37% Very Dissatisfied: 37%
12 10 V. Sat. 8 6 4 2 0 V. Sat. S. Sat. Neutral S. Dissat. V. Dissat. S. Sat. Neutral S. Dissat. V. Dissat.

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

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

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

Environment
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

People
Staffing levels Experience & skill level Resident specialty Volunteer/greeter utilization Family needs Role clarification Match of skill sets and assignments Variation of practice

Materials

Analyze

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

Triage process Registration/Chart prep process Charting procedures Communication

Quality of measurement Are we measuring the right things?

What do we do with what we measure? Need to do more than track

Utilization of minor emergency unit Ancillary services levels Specialty testing delays ED used as admission unit ED discharge practice

Feedback systems to quality auditing Need for Improved flow sheet format Lack of on-line charting system for automated monitoring

Measure

Machines

Hospital discharge process/timing Consult responsiveness/practices Use of ED for boarding Segmentation/delineation

Sequential care vs. parallel processes Improvement implementation/maintenance ownership

Methods

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

Improve
What critical Xs 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

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-toDirect-to-bed flow; Relocation to semi-private semispace 2. Care Team Communication Zoning; Communication board; Clinical protocols 3. Streamlined Order Entry & Results Retrieval Uses central clerk

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

Lobby Target 15 min.

Study 2 N = 129

Pilot N = 172 12.6 min.

MD Target 8 min.

Study 2 N = 129

Pilot N = 172 8.9 min.

Wait Time % Defect

34.5 min.

Wait Time

11.2 min.

51.2%

22.8%

% Defect

42%

34.9%

PILOT RESULTS
Lobby WT Study 1 N =30
Mean WT
(minutes)

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 26.65 56.7% 1.33

34.5 16.02 51.2% 1.47

12.6 11.69 22.8% 2.25

16.1 18.70 55% 1.37

11.2 46.76 42% 1.71

8.9 16.68 34.9% 1.89

Standard Deviation % Defect Z-Score

(Attribute)

Improve

PILOT CONCLUSIONS
Moods Median Test P-value Lobby WT Study 1 to Pilot Lobby WT Study 2 to Pilot MD WT Study 1 to Pilot MD WT Study 2 to Pilot 95% C.I.
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 departmentdepartment-wide, multimultipatient population implementation.

0.001 0.000 0.016 0.772

2.7 to 31.8 4.8 to 13.2 1.0 to 16.0 -2.00 to 3.00

Lobby WT N Study 1 Study 2 Pilot 30 129 158

MD WT N 30 127 172

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