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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.

Measure: Identify the key internal process that influences CTQ characteristics and measure the defects generated relative to the identified CTQs. 5 4 3 2 1 0 D M A I C . End result: explain variables that are result: likely to drive process variation the most. End result: team can successfully measure result: the defects generated for a key process affecting the CTQ. Improve: Determine and confirm optimal solution (statistically re-analysis). 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.Six Sigma--DMAIC Sigma--DMAIC Define: Define and scope problem. Know voice of customer. Analyze: Identify root causes of defects. End result: modify result: the process to stay within the acceptable ranges. Identify the maximum reacceptable ranges of key variables. Confirm measurement system reliability. Identify potential benefits and critical to quality (“CTQ”) factors. Use statistical data tools to identify key process inputs that affect process outputs.

James Wilson Foundations Team Nancy Jenkins. Terry Hamilton Black Belt Jane McCrea Green Belt Dr. Georgia Williams.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. Gerry Elbridge Sponsor Dr. Steve Small Arrival Triage Register Lobby Tx Room Nurse MD . Bill Barber. 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.

Dissat.30 30 . Sat.60 > 60 Patient Survey •N = 30. V. V. Priority II Patients •Random: all days. S. Sat. . Dissat. Neutral S.60 > 60 < 10 10 . Dissat.20 20 . Sat.What was the Voice of the Customer? Measure Acceptable Lobby Wait Time 14 12 10 8 6 4 2 0 < 10 10 . 8 6 4 2 0 V. 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. Dissat. S.30 30 . Sat. Neutral S.20 20 .

20 60 100 140 180 .5 min.79 Defect Rate: 38. Dev: 39. Std.66 Z-Score: 1.6% USL: 37.1 min.Baseline Measurements An observational prospective manual time study yielded baseline measurements for the total wait time Triage Start to MD Start Mean: 62.

Quality Reports. 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. Registration & Staffing Reports Impact on Business: 25 min.Measure What did we measure? Y: # of Minutes. Enhanced Outcomes Improved Staff Satisfaction & Reduced Turnover Improved Daily ED Operational Efficiency Key Takeaway: 40% Wait Reduction & Operating Margin Gains . Manual Data Collection. Chart Review. Reduced Complaints. Line of Sight Reduction Per Patient Resulting = Capacity Opportunity Improved Patient Satisfaction.

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. etc. wave of data collection Patient Volume-Related: 10 Staffing Volume-Related: 5 Staffing Mix-Related: 5 Misc: 3 . pumps.What critical X’s 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. Non-optimization of Tracking system Inadequate IS system for tracking/trending No Physician Prescription Writing system No integrated. parallel processes Improvement implementation/maintenance ownership Methods 23 variables & 18 time stamps Analyzed via 2nd.

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 .

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

51.2% 22.6 min. Study 2 N = 129 Pilot N = 172 8.9 min.8% % Defect 42% 34. Study 2 N = 129 Pilot N = 172 12.5 min. Wait Time 11.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.9% . Wait Time % Defect 34.2 min. MD Target 8 min.

68 34.8% 2.37 11.25 16.9 16.2 46.89 Standard Deviation % Defect Z-Score (Attribute) .33 34.6 11.71 8.70 55% 1.9% 1.5 16.65 56.2% 1.69 22.02 51.76 42% 1.2 26.47 12.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 31.1 18.7% 1.

Improve .

0 to 16.I.PILOT CONCLUSIONS Mood’s 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.2 1.8 4.016 0.001 0. and the C. 0. Positive trending was demonstrated in the comparison of Study 2 to the Pilot.00 Lobby WT N Study 1 Study 2 Pilot 30 129 158 MD WT N 30 127 172 .000 0. multimultipatient population implementation. Stakeholders supported departmentdepartment-wide. Pilot lobby wait times were better than the established 15 min.00 to 3. target.0 -2.I.772 2.8 to 13. the defect rate tumbled. validated statistical significance. Results for MD wait times were statistically significant in one of two Mood’s median tests.7 to 31.

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. What and When plan Data Review. communication center & newsletter Monthly updates at staff. faculty & resident meetings Incorporation of staff recognition for ongoing positive results .Control What are the building blocks of Control? Guidelines & Assigned Responsibility New Standard Operating Procedure Detailed Who.