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Application of Lean Six Sigma tools to minimise length of stay for

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Article  in  International Journal of Six Sigma and Competitive Advantage · April 2011

DOI: 10.1504/IJSSCA.2011.039716

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156 Int. J. Six Sigma and Competitive Advantage, Vol. 6, No. 3, 2011

Application of Lean Six Sigma tools to minimise

length of stay for ophthalmology day case surgery

Nabeel Mandahawi*
Industrial Engineering Department,
The Hashemite University,
Zarqa, 13115, Jordan
E-mail: nabeelma@yahoo.com
*Corresponding author

Omar Al-Araidah
Industrial Engineering Department,
Jordan University of Science and Technology,
Irbid, 22110, Jordan
E-mail: alarao@just.edu.jo

Ahmad Boran
Public Health Department,
Jordan University of Science and Technology,
Irbid, 22110, Jordan
E-mail: boran@just.edu.jo

Mohammad Khasawneh
Department of Systems Science and Industrial Engineering,
State University of New York at Binghamton,
Binghamton, New York, USA
E-mail: mkhasawn@binghamton.edu

Abstract: This article presents a process improvement study conducted at a

local hospital based on a customised Lean Six Sigma methodology.
Specifically, the define, measure, analyse, improve, control (DMAIC) project
management methodology and various Lean tools have been utilised to
streamline processes and enhance productivity of a hospital’s ophthalmology
department. Special emphasis is given to day case surgeries based on patients’
complaints. Thorough investigations revealed various improvement
opportunities at different stages of the day case surgery process, some of which
have been adopted by the hospital’s top management. The expected
improvements revealed an approximate potential reduction of 48% in patients’
length of stay at the hospital.

Keywords: healthcare quality; Lean tools; Six Sigma; define, measure,

analyse, improve, control; DMAIC methodology; ophthalmology.

Copyright © 2011 Inderscience Enterprises Ltd.

 Application of Lean Six Sigma tools to minimise length of stay 157

Reference to this paper should be made as follows: Mandahawi, N.,

Al-Araidah, O., Boran, A. and Khasawneh, M. (2011) ‘Application of Lean Six
Sigma tools to minimise length of stay for ophthalmology day case surgery’,
Int. J. Six Sigma and Competitive Advantage, Vol. 6, No. 3, pp.156–172.

Biographical notes: Nabeel Mandahawi is an Assistant Professor in the

Department of Systems Science and Industrial Engineering at the Hashemite
University. He received his PhD in Industrial Engineering from University of
Texas at Arlington since 2005. His research has an interdisciplinary emphasis
that links human factors in manufacturing, quality and operation management.

Omar Al-Araidah is an Assistant Professor of Industrial Engineering at Jordan

University of Science and Technology (JUST). He received his PhD in
Decision Sciences and Engineering Systems from Rensselaer Polytechnic
Institute, New York, in 2005. His research emphasises links between the
multidisciplinary areas of industrial engineering.

Ahmad Boran is an Assistant Professor in Occupational Health and Safety at

the medical school in Jordan University of Science and Technology. He
received his Master degree in Occupational Health from London University and
his PhD from the Institute of Occupational Health at Birmingham University,
UK. He works as a Consultant for many international organisations such as
WHO, ILO, and German GTZ, He also worked as Head of Train the Trainer
Programme at the UN Training Centre, Italy. He has conducted many
workshops in occupational health and safety, ergonomics, creativity and
innovation and leadership in seven countries.

Mohammad Khasawneh is an Associate Professor in the Department of

Systems Science and Industrial Engineering at the State University of New
York at Binghamton. He received his PhD in Industrial Engineering from
Clemson University, South Carolina, in August 2003. His research has an
interdisciplinary emphasis that links human factors in manufacturing, quality
and simulation.

1 Introduction

Facing the global financial crisis that started in the last quarter of 2008, businesses
worldwide have been striving to survive where cash flow has become a major concern
and loyalty of customers has been significantly affected by prices. Reducing cost,
improving quality and building a powerful bond with customers emerged as major
players in today’s global market. Healthcare, similar to manufacturing and other service
sectors, has been challenged by the global competition in prices and quality in addition to
the increase in demand compared to the scarcity of available recourses. The Institute of
Medicine (IOM) reported that the current healthcare system needs fundamental changes
with respect to safety and quality problems (Institute of Medicine, 1999, 2001). Since
then, various initiatives have been launched to improve current healthcare processes and
systems by minimising unnecessary process duplications, long waiting times, and
customer delays. This is achieved by identifying process redundancies and wastes (Van
den Heuvel et al., 2006).
Over the years, researchers have tried different theories to improve the efficiency and
effectiveness of processes, such as total quality management (TQM), quality control,
158 N. Mandahawi et al.

theory of constraints (TOC), Lean philosophy, Six Sigma, and many others. For example,
while going lean focuses on smoothing and accelerating flow by eliminating wastes, Six
Sigma focuses on improving quality by reducing variation (Sampson, 2004). However,
using either one of them alone has limitations. Specifically, Six Sigma eliminates defects
but does not address the question of how to optimise the process flow. On the other hand,
going lean excludes the use of Six Sigma’s DMAIC cycle as a management structure to
achieve process capabilities needed to be truly Lean. Consequently, these two tools could
complement each other, wherein DMAIC’s roadmap could be used as a general
framework for process improvement while simultaneously embedding lean tools within
each phase (Van den Heuvel et al., 2006). For instance, a value stream map (VSM) helps
management identify and quantify value and non-value added activities before and after
improvement. To identify value, both patients (i.e., external customers) and healthcare
professionals or staff (i.e., internal customers) are consulted. Generally, patient
requirements include smooth admission, short length of stay, on time operations, zero (or
minimum) clinical errors, and a smooth or timely discharge, to name a few. On the other
hand, staff requirements include better schedules, enough capacity, better
communications, and safe working environments.
Many healthcare organisations reported several positive results indicative of the
applicability of Lean and/or Six Sigma within the healthcare industry (American Society
for Quality, 2009). Recent investigations include reducing lead-time (Al-Araidah et al.,
2010), process redesign (Van Lent et al., 2009), reducing patients’ length of stay
(Bisgaard and Does, 2009), improving efficiency (Arbos, 2002), enhancing patient and
staff satisfaction (Dickson et al., 2009), reducing clinical errors (Raab et al., 2006),
minimising waiting time (Yu and Yang, 2008), process improvement for both the
radiology department and medication administration processes (Lioyd and Holesnback,
2006), as well as reducing patients’ length of stay and waiting time at an emergency
department using both design for Six Sigma and discrete event simulation (Mandahawi et
al., 2010). Furthermore, Van den Heuvel reported different examples where Lean and/or
Six Sigma are used as tools to tackle present healthcare challenges through different
projects at a Red Cross hospital (Van den Heuvel et al., 2005a, 2005b, 2006). Works by
Lioyd and Holesnback (2006), Cherry and Seshadri (2000), Pan et al. (2008), Hamzeh
(2008), Yu and Yang (2008), King et al. (2006), Mari (2007) and Raghavan et al. (2010),
were also in support of the applicability of the aforementioned tools in the healthcare
industry.
In this paper, Lean and Six Sigma philosophies and tools are integrated to streamline
processes and enhance productivity at a local hospital. The hospital consists of 200 beds,
28 resident doctors, 55 specialists, 150 nurses/staff members, and 38 external or
outpatient clinics. The study focuses on increasing patient satisfaction through better
management of available capacity and information for the ophthalmology department’s
daily surgeries. The rest of the paper is organised as follows: Section 2 presents an
overview of the DMAIC methodology, Section 3 describes the case study and Section 4
presents the concluding remarks.

2 The DMAIC model

DMAIC is a systematic Six-Sigma project management practice inspired by Deming’s

plan, do, check, and act (PDCA) cycle. The process consists of the five phases as
 Application of Lean Six Sigma tools to minimise length of stay 159

illustrated in Table 1. The Define phase concentrates on forming the team, defining the
project’s goals, mapping the process, identifying customers, and identifying the high
impact characteristics or the critical to quality (CTQs). The Measure phase consists of
defining and executing a data collection plan for the key measures (CTQs) of the current
process. Data collected in the Measure phase are analysed in the Analyse phase to
identify the root causes behind the gap between the current performance and the goals
identified in the first phase. The Improve phase focuses on finding solutions to enhance
performance. The Control phase concentrates on creating and implementing monitoring
and response plans for sustaining improvements. Moreover, the Control phase also
includes the documentation and publication of operating standards and procedures.

Table 1 The five phases of the DMAIC methodology

Objectives Outcomes Tools

• Determine purpose • An identification of the scope of the • Voice of
and scope problem customer (VOC)
• Obtain background • A clear statement of the intended • Brainstorming
information about improvement and how to measure it
Define

the process and its

customers
• Determine CTQs • A high level process map that • Pareto analysis
includes suppliers, inputs, process,
• Project charter
output, and customers (SIPOC)
• SIPOC analysis

• Collect data about • Data to pinpoint the location of • High level

the current practice the problem and the rate of process map
occurrence (blue prints)
Measure

• Baseline data on how well the process • Time study

meets customers’ needs
• An understanding of how the current • Pareto analysis
process operates
• Value stream
mapping
• Identify losses • A more focused problem statement • Cause and effect
diagram

• Identify and • Information about the few activities • Priority matrix

verify root causes that has the largest impact on the
outcomes of the process
Analyse

• Identify • Identification of value added, support, • Pareto analysis

improvement and non-value added activities
opportunities
• Identification of the gap between • Value stream
current practices and Benchmarks mapping

• Statistical
analysis
160 N. Mandahawi et al.

Table 1 The five phases of the DMAIC methodology (continued)

Objectives Outcomes Tools

• Statistical
analysis
Analyse

• Losses and gains

chart
• Gap analysis
• Benchmarking
• Develop, test, and • Planned and tested actions to • Brainstorming
implement eliminate or reduce the impact of the
solutions that identified root causes • Time study
address root • Value stream
causes mapping
• Statistical
Improve

analysis
• Process map
(blue prints)
• Priority matrix
• Losses and gains
chart
• Standardise work • Written work instructions • Control charts
procedures to and check sheets
Control

sustain the gains

• Process management procedures • Awareness and
training
• Continuous improvement plan

DMAIC utilises various effective tools to execute the quality improvement project,
including statistical analyses tools, time study, priority matrix, benchmarking,
standardised work methods, brainstorming, supplier, input, process, output, and customer
(SIPOC), Pareto analysis, cause-and-effect diagram, and value stream mapping (VSM).
For example, a SIPOC diagram is used to identify relevant elements of the supply chain
of the process under investigation. In this article, the authors utilise various tools to
identify potential wastes within current processes.
The improvement of a business process may result in a total redesign of the process
that calls for using Design for Six Sigma (DFSS) or define, measure, analyse, design, and
verify (DMADV). The redesign process may require introducing new technologies and/or
training employees to enhance productivity. Other possible improvements include
eliminating, combining, reordering, or simplifying activities in the process using lean
tools. Al-Araidah et al. (2010) subdivides actions based on the nature of the activities,
including value-added, value-enabling, and non-value added activities. While non-value
added activities are to be eliminated, value-added and support activities are combined,
relocated or simplified to save effort and time. The process of defining value and
 Application of Lean Six Sigma tools to minimise length of stay 161

identifying value-added activities requires consulting with the organisation’s internal and
external customers. On the other hand, waste refers to any activity/practice that would not
have any impact on the flow of the process if eliminated. Wastes include over-processing,
overproduction, waiting, unnecessary motion of employees/products/customers,
non-conformities, excess inventory/capacity, and reprocessing.

3 Case study

As stated earlier, this research illustrates the application of the DMAIC model at an
ophthalmology department, at a local hospital. Based on customer requirements, the
scope of the study is limited to day case surgeries (i.e., where the patient enters and
leaves the hospital on the same day). The objective is to minimise the time patients spend
in the system, measured from the time a patient enters until he/she leaves the hospital.
This includes admission, pre-operation, operation, post-operation, and discharge. The
following subsection illustrates how the DMAIC cycle is used to minimise patient cycle
time.

3.1 Define

In the define phase, the project scope and objectives, team, stakeholders, and work
schedules are clearly defined. To identify the project scope, ABC analysis is performed
based on hospital’s historical data. This analysis revealed that eye surgeries are the most
frequent among all surgeries performed at the hospital. Based on this consideration, the
reduction of patients’ time in the hospital was defined as the primary objective of this
research. Accordingly, eliminating non-value added time in day case operations
associated with eye surgeries became the focus. A team from the Ophthalmology
department’s staff, quality assurance personnel, management, and investigators was
assembled. The stakeholders identified were admission, day case, and operations
personnel, as well as patients. A project charter tool was used to combine the project data
in an organised way which also highlights the project’s phases, milestones, window,
counter balance measures, and primary and secondary measures.
To identify the scope of the project, a SIPOC diagram for day case operations is used,
as shown in Figure 1. Suppliers are external clinics, internal clinics and insurance
companies. Inputs include patients, surgery information, and communications with other
hospital departments and insurance companies (in the form of phone calls and faxes). The
process starts at the admission department, then going through pre-operation, surgery,
post-operation, and finally ending by the patient getting discharged. Outputs include
treatments, prescribed medications, documentations, and invoices to be paid. Customers
include patients, physicians and staff. Before proceeding to the Measure phase, the
project charter and the SIPOC diagram were submitted to top management for revision
and approval. At this stage, top management decided to consider all operating room
activities as a single activity and hence excluded them from further investigations.
Furthermore, the hospital’s top management, based on their experience, specified the
expected time for the cash and the insurance payment processes. The specified numbers
are the targets that the DMAIC team should work to achieve at the end of the study.
162 N. Mandahawi et al.

Figure 1 SIPOC diagram for day case operations

Figure 2 Blue prints of the day case surgery process

Admission Emergency Pre-Operation Post Operation Finance

Paper Sign Change Clothes Patient Recovery Get Invoice Data

Enter Data to PC Nurse Test Get Food Approval by

Finance Manager

Resident Dr. Test Resident Dr. Fills

Cash or Insurance Discharge Papers
Insurance

Cash
Go to Post
Operation File Papers to OR
Pay Money ER Doctor Test

Send Fax to Give Receipt to

Insurance ER Doctor Day Case
Company Approval Dept.

Discharge
Wait for Approval
 Application of Lean Six Sigma tools to minimise length of stay 163

3.2 Measure
A detailed process map is developed for the day case surgery as shown in Figure 2. The
process is divided into three main stages:
1 the admission stage, which accounts for the time from when the patient arrives until
he/she is approved to enter to the pre-operation room
2 the pre-operation stage, which includes the time required to prepare the patient to
enter the operation room
3 the post-operation process, which encompasses the time from the end of the surgery
until the patient recovers and finalises his/her paperwork.
Excluding operating room activities, the total operation time is compared to an expected
time of about 30 minutes.
Data are collected from the moment the patient enters the hospital until the moment
he/she is discharged. The time the patient spends at each department is measured over a
two-month period. Table 2 presents a sample of average process times for 33 patients and
the standard time for each process based on the management’s experience. The high
variations in time suggests that processes are unstable, which would, therefore, decrease
process reliability and predictability. Those times comprise of the following activities:
• Admission: the time the patient spends in the admission department
• Preparation: the time the patient spends in the pre-operation process
• Operation: the time the patient spends in the surgery room
• Discharge: the time the patient spends in the post-operation process and at the
finance department.
Table 2 Sample of observed time at each department

Case Payment Admission Preparation Operation Discharge

Case name
no. method time (min) time (min) time (min) time (min)
1 Avastine Cash 9 47 81 4
2 Avastine Cash 20 60 80 25
3 Avastine Cash 6 35 95 10
4 Left phaco Cash 12 45 85 65
5 Left phaco Cash 8 70 15 50
6 Left phaco Cash 8 65 90 14
7 Left phaco Cash 3 23 47 9
8 Left phaco + IOL Cash 4 55 49 44
9 PPV Cash 10 20 150 60
10 PPV Cash 9 10 120 83
11 PPV Cash 8 29 29 46
12 Right phaco Cash 4 63 50 31
13 Right phaco Cash 8 50 95 60
14 Right phaco Cash 13 32 130 5
15 Right phaco Cash 8 35 60 34
164 N. Mandahawi et al.

Table 2 Sample of observed time at each department (continued)

Case Payment Admission Preparation Operation Discharge

Case name
no. method time (min) time (min) time (min) time (min)
16 Right phaco Cash 4 10 45 23
17 Right phaco Cash 7 30 59 9
18 Right phaco Cash 8 43 35 45
19 Right phaco Cash 5 95 55 10
20 Ring Cash 25 52 160 40
21 RT. avastine Cash 6 12 43 55
22 RT. avastine Cash 6 100 20 4
Mean (cash) 8.68 44.59 72.41 33.00
St. Deviation (cash) 5.19 24.66 40.34 23.34
Target (cash) 10 25 30 30
23 Avastine insurance 25 35 80 35
24 Avastine insurance 16 53 110 25
25 Avastine insurance 25 18 84 9
26 Lasic insurance 210 10 50 20
27 Lasic insurance 60 20 45 3
28 Lasic insurance 101 31 40 8
29 Left phaco insurance 22 6 69 12
30 Left phaco insurance 22 180 45 7
31 Left phaco insurance 25 194 70 6
32 PPV insurance 11 24 95 7
33 Right phaco insurance 8 20 150 8
Mean (insurance) 47.73 53.73 76.18 12.73
St. Deviation (insurance) 60.11 67.17 33.24 9.82
Target (insurance) 30 25 30 15
Mean (overall) 26.75 47.64 73.67 26.24
St. Deviation (overall) 38.68 42.76 37.63 26.10

3.3 Analyse
As shown in Table 2, the average time in the system measured from the time a patient
enters the admission department until he/she is discharged is 158.68 minutes for cash
paying patients and 190.37 minutes for those who are insured. Those times are higher
than the expected time identified by the hospital’s top management based on their
experience, which is about 95 minutes for those with cash payments and 100 minutes for
the insured ones. Employing lean management concepts, the team investigated value
added and non-value added activities at each process. Accordingly, time studies are
conducted focusing on the wastes embedded within each sub process (i.e., department) at
each stage. Figure 3 shows the VSM of the current state.
 Insurance
Kitchen
Company

Fax

Admission Day-Case Operations Finance

Arrival Discharge
Department Department Room Department
Figure 3 Value stream map of current state

Patient Profile

Paper Sign Data Entry Payment Change Clothes Nurse Test Resident Dr. Test Approval Operation Recovery Get Food Filling Documents Go to Finance Dep.

Approval from
Approval from Cash/
Patient Info. Insurance Eye Surgery by resident Dr.
patient Insurance
Company
Value Add: 2.5 minutes Value Add: 3.4 minutes Value Add: 3.5 minutes Value Add: 30 minutes Value Add: 7.35 minutes Value Add: 3.8 minutes
NVA = 2 minutes NVA = 23.3 minutes NVA = 1.4 minutes NVA = 13.2 minutes NVA = 2 minutes NVA = 3 minutes
Value Add: 3.94 minutes Value Add: 3.96 minutes Value Add: 7.4 minutes Value Add: 30 minutes Value Add: 15.6 minutes Value Add: 3.3 minutes
NVA = 0.94 minutes NVA = 25.6 minutes NVA = 29 minutes NVA = 5 minutes

4.5 minutes 26.7 minutes 4.9 minutes 4.9 minutes 33 minutes 43.2 minutes 59 minutes 9.35 minutes 8.3 minutes 6.8 minutes Lead T ime = 220 minutes
2.5 minutes 3.94 minutes 3.4 minutes 3.96 minutes 3.5 minutes 7.4 minutes 30 minutes 30 minutes 15.6 minutes 7.35 minutes 3.3 minutes 3.8 minutes VA / T = 115 minutes
Application of Lean Six Sigma tools to minimise length of stay
165
166 N. Mandahawi et al.

The current VSM shows several types of non-value added time (NVA) embedded within
the current process flow. NVA accounts for about 48% of the total time in the system.
Furthermore, the admission and pre-operation stages account for about 63% of these
wastes. At this stage, the DMAIC team’s goal was to investigate the root causes of the
excessive cycle time. To this end, the team members brainstormed and came up with the
following root causes:

Admission
The payment process contributes to more than 92% of the registered delays in the
department. While cash payments scored low in delays, while insurance-dependent
payments contributed largely to delays. As illustrated in Figure 2, the insured patients
have to go through additional steps, out of which communicating with their insurance
companies for approvals takes the longest time. Setting the upper delay limit at 30
minutes as specified by the admissions department, the communication time for a sample
of 44 day-case admissions are collected. The sample incorporates the communication
with the insurance company and the time elapsed until a case is resolved. Figure 4
illustrates the results obtained from the study, indicating weak policies between the
hospital and those companies. Furthermore, Pareto analysis showed that two companies
were responsible for more than 66% of the registered delays. Hence, a redesign of the
communication process or procedure should be considered when dealing with those
particular companies. Moreover, the vagueness of the forms used at admissions results in
complications and a set of questions raised by patients. Therefore, simplification of these
forms should be considered in the improve phase.

Figure 4 Pareto analysis of the impact of insurance companies on delays

14

12 Conforming
non-Conforming
10
Frequency

0
A B C D E F G H
Insurance Company

Pre-operation
Pre-operation includes changing clothes, lab (or nurse) tests, and resident doctor triage,
which contributes to about 27% of the total time wasted. Table 2 shows that there is cross
variation at the per-operation room especially between the cash and the insurance
payment process. Therefore, in order to identify the main potential causes for this
 Application of Lean Six Sigma tools to minimise length of stay 167

variation and delay, a cause-and-effect diagram has been developed as illustrated in

Figure 5. The causes are identified through a brainstorming session held by the project’s
team members. Table 3 presents a prioritisation of the causes based on their relative
importance. The DMAIC team considered three criteria for evaluating these causes,
which are cycle time, customer satisfaction, and process performance. The priority matrix
results showed that the highest percentages of delays are due to one or more of the
following causes:

Figure 5 Fishbone diagram of possible causes of delay in pre-operation

168 N. Mandahawi et al.

• Resident doctor: The resident doctor is responsible for pre-checking the patient to
decide on the type of surgery needed and also for filling or updating the patient’s
profile. The study showed that measured delays are due to the absence of the resident
doctor, thereby suggesting that a full-time resident doctor should be assigned to day
case operations.

• Scheduling: The nurse contacts operations to include the patient in their schedule
after the resident doctor specifies the type of surgery. Moreover, he/she contacts the
admissions department to verify if the insurance company provides coverage for the
specified surgery. In many cases, the nurse forgets to double-check if the approval
fax was received from the insurance company. This causes delays and interruptions
at the day of surgery since the operations’ room staff have to wait for approval
before operating on the patient. If the insurance company does not cover the surgery,
the operation is cancelled, resulting in significant waste in time and resources.
Therefore, this impacts the whole schedule and calls for better coordination between
admission, day case, and operations departments.

• Bad or no feedback loops: In many cases that involve delayed cases, although on
time approval is received from the insurance company, the company’s representative
or the admission department personnel sometimes fail to inform day case and/or
operations about the approval.

• Standardisation: The mapping process reveals a lack of standardisation in

collecting, reviewing, and distributing information. Moreover, it shows that nurses in
the day case and operations departments lack established protocols for tracking
admitted patients. Therefore, by considering these factors, the hospital could
significantly decrease the variation that occurred at the pre-operation stage as shown
in Table 2.

Table 3 Priority matrix

Customer Performance of
Criteria Time variation
satisfaction the process
Final score
Item to prioritise Weight = 10 Weight = 7 Weight = 4

Patients 4 0 4 56
Resident Doctor 10 8 4 172
Nurses 8 8 4 143
Companion 8 4 0 112
Human factors 6 10 2 138
No direct feedback loop 8 6 10 182
Schedule 10 8 10 196
Filing 4 2 10 94
Ongoing QA 0 10 10 110
Policies 8 4 8 156
 Application of Lean Six Sigma tools to minimise length of stay 169

Operation room
Due to limitations imposed by top managers, the DMAIC team was not allowed to enter
into the operation room. When one observes the times patients spend in the operation
room (Table 2), it becomes clear that there is high variation in the surgical time for
specific operations, such as phacoemulsification. These variations could be due to many
reasons, such as the availability of the requested laboratory test results, the availability of
the required tools and medications, the way the operation is performed, including the
communication between the team, the number of staff, the experience level of the doctor
and the nursing staff, and others. This cross variation indicates that various types of
wastes exist inside the operation room. Computed wastes contribute to more than 72% of
the total waste. Therefore, the operation cycle time is higher than the standard time
specified by top management. Consequently, a detailed investigation of wastes within the
operations department is required to minimise the cross variation in the process.

Post-operation
Post-operation includes recovery, getting food, filling documents by the resident doctor,
and going to the finance department. These operations contribute to more than 9% of the
total wasted time. While the current layout contributes to delays through travel time,
wastes associated with documents’ filling are due to the lack of standardisation. In many
cases, the resident doctor finds out that many required documents and tests are not
available at the time of discharge. Therefore, he/she has to wait until all the required
documents are prepared and received.

3.4 Improve
Brainstorming sessions were held by the DMAIC team to generate alternative solutions to
minimise the time patients spend in the system. Each solution is evaluated with respect to
cost, ease of implementation, and probability of accomplishment upon implementation.
As a result of several meetings, the proposed solutions include the following:
• Assign a full-time resident doctor to the day case department.
• Work with insurance companies (suppliers) to shorten the times associated with
transferring information. This includes requesting that the insurance company
improve their databases to include latest information about surgeries they cover.
• Network associated departments should use a shared database to enhance near
real-time retrieval of information and improve internal communication.
• Review the forms used at the admissions department to eliminate all non-value
added information. Wastes include multiple forms, useless information, information
contained in patient’s ID and/or insurance card, and information that already exists in
the database. Therefore, redesigning those forms should focus on eliminating all
instances where a patient is asked to provide information that may be obsolete,
erroneous, or simply not needed.
• At post-operation, investigators suggest that all required documents be initialised by
the nurse and completed by the resident doctor. To achieve this, a check sheet has
been prepared since the alternatives are rather limited.
170 N. Mandahawi et al.

• To enhance flexibility and agility in scheduling at the pre-operation department, a

new scheduling process is designed and proposed. Specifically, scheduling is to be
performed by the nurse at the clinic directly after the initial diagnosis by the resident
doctor, where the nurse contacts the insurance company to verify coverage, as well
as checking the schedules of operations for approved cases.
Among the many improvement alternatives, special attention is given to
a improving current information systems and documentations
b assigning a full-time resident doctor to the day case department.

3.5 Control
A set of actions were implemented to minimise patients’ time in the system. For example,
after assigning a full-time doctor to the day case department, the preparation times for a
sample of 32 cases were collected. Results reveal that the average time a patient spends in
the preparation process drops by more than 25 minutes. Moreover, to minimise the
patients’ time at the admission department, brainstorming sessions are conducted with the
insurance companies to expedite the approval delivery process. Furthermore, meetings
are scheduled with the various departments to improve the current internal
communications system.

4 Conclusions

The paper presents a DMAIC procedure for enhancing patient satisfaction by reducing
the time he/she spends in the system. To assess the model, a case study is carried out at
the ophthalmology department at a local hospital. The scope of the study was limited to
day case surgeries, based on customer and management request. Thorough investigations
revealed various causes that contribute to significantly prolonging the patients’ time in
the system. Moreover, the data collected showed high variation in the execution times
within the various sub-processes. Through the collected data during the Measure phase
and their analyses during the Analyse phase, various improvement opportunities have
been suggested and some of these suggestions have been implemented. For example, the
presence of a full-time resident doctor at the day case department has decreased patient
cycle time from around 48 minutes to slightly over 20 minutes. Furthermore,
collaboration with insurance companies expedited the approval process and contributed
to shortening patients’ time in the system. Furthermore, improving internal
communications and standardising procedures helped in reducing the delays and
interruptions associated with the operations schedule.

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