GROUP A

Dr: Mirna Morqos Effects of applying Six Sigma

Dr. Mohamed Yakob methodology (DMAIC) in improving ID
Dr. Mohamed Shamaa process and reducing Transfusion
Dr. Ahmed Safwat Errors In Shefaa Al-orman Oncology
Dr. Abdalla Megahed Hospital
Dr. Mohamed Ramadan
• 1- Organization Profile        • 5- Problem Statement    • 9- Project Charter Details
• 2- Scope of Service • 6- Team Effectiveness • 10- Measure Stage
• 3- Mission, Vision and Values • 7- Objective of the Project • 11- Data Collection
• 4- Introduction • 8- Define Stage • 12- Pie Chart

• 13- Pareto Chart • 16- Analyze Stage • 19- Conclusion

• 14- KPIs' • 17- Control Stage • 20- Appendix
• 15- Improve Stage (Action • 18- Accreditation
Plan)
 Organization Profile
ORGANIZATION DATA  ORGANIZATION DESCRIPTION  
Organization Name: Shefaa alorman Oncology Floors  Departments 
Hospital 

Location: Luxor- New Tieba City  Basement kitchen - laundry - cafeteria – Warehouses- IT –
mortuary
Organization Type: NGO Hospital Ground Floor Laboratories - pharmacy - Purchasing - human
resources - outpatient clinics - emergency - social
workers - Radiotherapy - diagnostic radiology -
Number of buildings: 1 nuclear medicine – Admission office - call center -
public relations - infection control- accounts
department - contract department.
Opening Date: 27/5/2016 First Floor Inpatient departments - intensive care -Daycare unit
- medical records - central sterile services
department - occupational health safety - internal
Serviced Area: Qena - Luxor - Aswan - auditing.
New Valley - Red Sea-
sohag Second Floor Inpatient departments - blood bank - pathology -
operations – endoscopy- Biomedical.
Number of floors: Basement+ three floors

Number of Beds: 150 beds

Number of Employee: 1200

 a. Anesthesiology f. Radiotherapy Department.
b. Medical Oncology Department: g. Clinical Pharmacy Department.
I. Hematology cancers:) Lymphomas “all h. Radiology Department.
types” and Leukemias “acute & i. Laboratory Department.
chronic”). j. Pathology Department
II. Solid Tumors (all types and all body k. ICU department
systems). l. Endoscopy Department
c. Emergency Department.
d. Surgery Department:
Scope of III. Breast cancer surgeries
IV. Urologic cancer surgeries

Service V. Gyna-oncology Surgeries

VI. Head and neck cancer surgeries
VII.GIT
  cancer surgeries
VIII.Bone and Soft tissue cancer surgeries
IX. Thoracic cancer surgeries
e. Pediatric Oncology Department (Solid
tumors and Hematology cancers for Ex):
X. Acute lymphoblastic leukemia.
XI. Acute myeloid leukemia.
XII.Hodgkin's lymphoma
XIII.Non-Hodgkin’s lymphoma
XIV.Nephroblastoma
XV.Neuroblastoma
 Mission Values Vision
. Patient Satisfaction To be the leading Oncology
 Providing Top quality service
. Accountability hospital in Middle East and
according to highest
. Commitment Africa for treating cancer.
international standards to
. Compassion
people of Upper Egypt for
. Motivation
awareness, early detection,
. Ethics and Integrity
research and treatment of
. Continuous Performance
cancer.
Improvement
. Education
. Contribution to
Community
. Confidentiality
Introduction 

Hospital quality improvement (QI) is a set

of activities are designed to continuously
Therefore, there are five components for
analyze and monitor the quality of
healthcare quality improvement are
hospital's processes and it's aimed to
including,  problem identification, Setting
standardized processes in order to
goals and determine the aim and
improve the patient experience and
measures used,  analyze,  assess the
outcome achieved, increase efficiency of
measures, Improve and finally control. 
care, improve patient safety, and increase
Shefaa Alorman‘s Funds. 
 Six Sigma Team and Methods used to bring teams together
Title Role/Responsibilities
Medical director Champions/Sponsors
Nursing director The Project leader
Deputy of Lab director Member and training
Lab technician Member and collect data
ER Nurse Member
OPD Nurse Member
ICU Nurse Member
Quality Coordinator Coordinator , analyze data and internal audit

Lab Reception Recorder

Six Sigma Methodology:
I. Define Phase :
  In this stage the project team :
1. Identify the project
2. listen to the Voice of customer(Nurse/Phlebotomist)
and Patient),
3. Make the project charter
4. Verify the  project objective. 
 Problem Statement 

     Improper patient identification processes in the healthcare industry result in major errors such
as, Medication errors, transfusion errors, testing errors, and wrong patient procedures. Between
June 2022 to July 2022, the laboratory department of Shefaa alorman Oncology Hospital
reported that there are 1 case of Incorrect blood components transfused (IBCT),  25 incidences
(out of 1000) and near misses prior to blood transfusion related to Patient misidentification,
missing sample labels, and wrong blood in the tube (WBIT) with WBIT rate 2.5%.  Therefore,
the problem was an increase in transfusion errors and the sigma level has been calculated:
Defects: 25/2(Opportunities)*1000(Product)*1 million, DPMO= 12,500. The Sigma level is
3.70.  
 • Project title: Effects of applying Six Sigma methodology (DMAIC)
in improving ID process and reducing Transfusion Errors In Shefaa
alorman Oncology Hospital
• Objective: To improve the patient identification process and reach to
5 sigma level by the end of January 2023.
• Rationale: Enhanced patient safety, Utilization management. 
• Expectations: The impacts of project outcomes on increased ID
Project charter   process compliance, decrease transfusion errors, and improve patient
safety.
• Timeline: 
1. Define Phase: August 2022
2. Measure Phase: September 2022
3. Analyse Phase: October 2022
4.  Improve Phase: November 2022
5. Control Phase: from November 2022 to January 2023.
 This project aims to improve the patient identification process in
order to decrease transfusion errors and improve patient safety by
identifying and analyzing the causes that lead to transfusion errors
and investigating solutions to reach the expected sigma level which is
5 sigma DPMO: 233. By the end of January 2023.   

Project       
     Hence, the Six Sigma methodology was implemented following

Objective the DMAIC cycle to identify process gaps and measure performance
improvement. 

     The problem reported by the head of the laboratory department

can be stated in 1 case IBCT,  25 incidences Report of  rejected
samples related to Identification problems
    
 II. Measure Phase :

In this stage  First, we made a flowchart for the

current process in order to
  identify process gaps. the current view of the
process showed many gaps and defects leading to
identification errors as reported which affects
patients’ safety. Hence the project team starts to
collect data and analyze it. 
Data were collected from June 2022 to July 2022
period From the laboratory rejection log (25
rejected samples and include the following
information: 
1.Date and time of Sample rejected  
2. MRN 
3. Patient Name                                       
4. Department                                  
5. Sampling Personnel                 
6. Cause of Rejection
     This data was collected to measure the process
performance through those  Key performance
indicators

Process measures :
1. Compliance with patient identification process
(Clinical Audit)  Checklist

Outcome Measures:
1. Rate of wrong blood in tube/month
2. Number of adverse blood transfusion reactions
Process measure
KPI:
Outcome
measure
KPI:
Outcome
measure
KPI:
 Analyze Phase
     Based on the data Collection there were two
types of errors that occurred in sampling that led to
transfusion errors (IBCT) or (WBIT) those types
included sampling Misidentification or missing
sample labels. 
Moreover, there were two definitions of wrong
blood in the tube (WBIT). 
First one: the blood sample was taken from the
intended patient but labeled with the wrong patient
information.  
Second one: the blood sample was taken from the
wrong patient and labeled the sample with the
intended patient information. 
 Analyze Phase

Improve Phase :
Analyze

By analyzing the fishbone

diagram, it has been concluded
that there are four main
categories of causes of
problems: 
1. System process issues.
2. Registration. 
3. Human factor issues.
4. Technology issues.
 Pareto Chart

• The circle in the diagram

represents 80% of the problem
and the rest of the causes were
20% of the problem. Pareto
highlighted each cause
frequency in numerical terms.  
 Types of Errors
IBCT
Pie Chart of types of
errors [Figure 1] 
4%

2nd Type WBIT

31%

• Highlighted that there were 1 IBCT case

• 8 cases 2nd type WBIT
• 17 cases 1st type WBIT. 
1st Type WBIT
65%

IBCT 1st Type WBIT 2nd Type WBIT

 Improve Phase
• Action Plan
Action Plan
Problems Actions Persons Responsible End Date
Poor handling or disposal - Barcoding patient
wristband ,Portables printers to
-
-
IT Department
CNO
NOV - 2022
of lables generate labels at the bedside to
facilitate accurate patient
identification and collection
Non compliance with ID - The Nurse must make sure that the
patient is wearing the correct bracelet
- CNO
- Quality Department
NOV - 2022
process before sampling . - IT Department
- Ask patient to State her / his full
name and date of birth
- Raise awareness by posters and
flyers reminding nurses to take labels
into the room to follow identification
process
- use of bar coding device scanners to
decode the patient’s wristband
Action Plan
Problems Actions Persons Responsible End Date
Rushing - Training Staff
- Correct Time management and
- Training Department NOV - 2022
scheduling .

Labeling samples away - Ongoing staff in_ service training and

competency assessment are
- Training Department
- IT Department
NOV - 2022
from patient important aspects of reducing - CNO
specimen labeling errors.
- Encourage the labeling of containers
used for blood and other specimens in
the presence of patient
- using of a bedside barcode labeling
system to easily scan for nurses and
doctors to reduce the errors and
ensure patient safety
Lack of two samples - Avoid having specimens from
multiple patient at the same time
- Training Department NOV - 2022
confirmation - Training Staff
Action Plan
Problems Actions Persons Responsible End Date
Batched technique - Avoid having specimens from
multiple patient at the same time
- Training Department NOV - 2022

Mislabeling - Reject unlabeled samples

- The Nurse must make sure that the
- Lab & Blood Bank Departments
- CNO
NOV - 2022

patient is wearing the correct bracelet

before sampling .
- Ask patient to State her / his full
name and date of birth
- Use of bar coding device scanners
to decode the patient’s wristband
 Future Flow Charts

1.Patient Identification Flow Chart

2.Blood Transfusion Flow Chart
3.Blood Collection Flow Chart
Control Phase
 Control Spreadsheet

Control Measured How Measured Where Standard Who analyzes What variable done
(KPIS)

1. Compliance of No. Of Patients ER / OPD/ ICU. Greater than or Quality Internal Audit
patient received proper equal 90% Department and inspection
Identification ID/Total No .Of checklist
process inspected
Patients per
month*100

2. Rate of wrong No. Of Rejected All setting less than 1%. Laboratory Implement
blood in tube samples related department. Department rejection criteria
Per month to wrong blood
in tube / Total
No. Of samples
per month*100
Control Measured How Measured Where Standard Who analyzes What variable done
(KPIS)

3. Number of ( No. Of Adverse ER / OPD/ ICU. Reach zero Blood Bank Blood
Adverse blood blood cases transfusion
transfusion transfusion Checklist form
reactions reactions in/
Total No. Of
blood
transfusion
cases per
month) *100. ER
/ OPD/ ICU.
 Run Chart

Improve Phase :
 Accreditation: How the project abides by GAHAR
accreditation standards
• It is one of National Safety Requirements (NSR): NSR.01 Patient identification
EOC.05 The hospital tracks, collects, analyzes, and reports data on the patient’s identification
process.
 EOC.06 The hospital acts on improvement opportunities identified in its patient identification
process.
• compliance with DAS.15 Laboratory pre-examination:
EOC.04 Preparation of specimen collection and labeling requirements are implemented.
• Compliance with DAS.16 Specimen reception, tracking and storage
EOC.02 All staff involved in receiving specimens are aware of the policy requirements.
EOC.04 . Records for specimen rejection and specimens referred to other laboratories are
maintained and include all data mentioned in the intent.
• Compliance with DAS.31 Ordering of blood and blood products
Eoc.05 Blood sample label and blood transfusion request are completed with all required data
and cross-checked before issuing blood or blood components
 Conclusion:

In conclusion ,we studied a problem of patient identification as it 's a major concern related to
patient safety .we applied six sigma methodology with it phases :define ,measure ,analyze ,improve
and control (DMAIC).we tried to best use of quality tools in every phase .finally we calculated the
sigma level at the start of the project and the targeted sigma level.

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PRESENTATION TITLE

Appendix:

https://diagnostics.roche.com/nl/en/news-listing/2019/Five-key-performance-indicators-for-healthcare-
organisations.html

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Thank you
Shefaa Alorman Oncology Hospital