S. L. Furterer, Lean Six Sigma Case Studies in the Healthcare Enterprise, DOI: 10.1007/978-1-4471-5583-6_3, © Springer-Verlag London 2014
hospital-wide view of the processes, the team created the Emergency Services Value Chain. This Value Chain consisted of providing emergency services to patients that came to the ED and were either discharged after assessment, testing, and medical care and disposition, or were admitted to the hospital due to their crit- ical condition. The Emergency Services Value Chain is shown in Fig. 3.1.
The Emergency Services Value Chain consists of the following activities:
• Triage: Assess patient condition and acuity.
• Register: Collect patient personal, demographic, and insurance information.
• Treat: Nurse and physician stabilize the patient, provide treatment, and order diagnostics tests.
• Test/Diagnose: Perform lab and radiology diagnostic tests.
• Disposition: Determine patient disposition (discharge or admit to hospital).
• Transport: Move patient to room if admitted.
• Discharge or Admit: Discharge patient from ED, or admit patient to hospital.
We used the DMAIC (define, measure, analyze, improve, control) problem solving methodology to improve the throughput, measured by patient (LOS) and the percent of patients who leave without being seen (LWBS) treated. A truly cross-functional team was engaged on the project. The team represented clinical and nonclinical team members from the ED, administration, the hospital floors, Information Technology, Case Management, Environmental Services, Radiology, and Lab Services.
The average patient ED LOS was reduced by 86 minutes and 21 % within the first month of the piloted improvements, while the standard deviation was reduced by 43 minutes and 19 % in the same time period. This showed statistically signifi- cant improvement with a p value of zero.
Define Phase
The Hospital and ED Throughput Improvement Project was kicked off in May 2009. This project was identified as a strategic project for the hospital. The chief executive officer (CEO) and the chief operating officer (COO) identified the project team participants by selecting key Vice Presidents and Directors in the organization that represented the critical cross-functional areas in the Emergency Services Value Chain.
Fig. 3.1 Emergency services value chain
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The author, a certified Six Sigma Master Black Belt was assigned as the Lean Six Sigma project leader and facilitator for the project. As the project lead, she worked with the CEO and COO to understand the desired scope of the project.
The CEO and COO wanted a very quick turnaround time in reducing the LOS.
The project time frame to piloting the improvements was reduced from a proposed five months to just three months.
The Lean Six Sigma DMAIC problem solving approach was combined with the concepts of Theory of Constraints and Systems Engineering to identify the critical constraints impeding ED patient flow. The goal was to implement improvements that could quickly improve patient flow, and then form additional Lean Six Sigma teams that targeted the critical constraints.
The following steps were executed in the Define Phase:
1. Develop project charter 2. Perform stakeholder analysis
3. Perform initial voice of customer (VOC) and identify critical to satisfaction (CTS)
4. Select team and launch the project 5. Create project plan.
Develop Project Charter
The team reviewed the initial draft of the project charter in the first team meeting.
The project charter is shown in Fig. 3.2, Project Charter.
Project Charter
This project is focused on improving patient throughput in the ED. About 40 % of the patients seen through the ED are admitted to the hospital, versus 60 % that are seen are discharged.
The Emergency Department had been experiencing delays in moving the patients through the ED in a timely manner. They recently built a larger ED to be able to bet- ter handle anticipated patient volume, and better manage patient flow. However, the patient LOS was still not meeting expectations of ED physicians, nurses, staff, and administration. For January through April 2009 patients, it took an average of 5.8 hours for a patient to be seen, treated, tested, and discharged and an average of 8.7 hours for a patient to be seen, treated, tested, and admitted to the hospital. There were excessive delays and an average 6.5 % of the patients left without being treated or seen by an emergency department physician (EDP), due mainly to long delays in the ED.
The primary stakeholders are the ED Patients, Medical Associates (Doctors, Nurses, Technicians), and Ancillary Services (lab, radiology, pharmacy, transpor- tation) that provide care to the patients. Secondary stakeholders are emergency
Define Phase
medical services (EMS), Registration, Admitting Physicians and Consultants, Regulatory Agencies, and Hospital Administration.
The goals of the project were to improve ED throughput time to 3 average hours for discharged patients and 5 average hours for admitted patients. There could be an improvement in patient satisfaction and quality of care due to the syn- ergistic relationship between throughput, quality, and satisfaction.
The scope includes the ED processes starting from patient arrival, triage, test and diagnosis, treatment, transporting the patient, to finally disposition and dis- charge or admit to the hospital. This project also included identifying the major constraints to throughput, the root causes, and improvement recommendations.
Projected Financial Benefits include improved revenue, increased volume (reduc- tion of Left Without Being Seen (LWBS)), increased volume through increased per- formance, and reduced costs through improved efficiency (time per patient).
Perform Stakeholder Analysis
The primary stakeholders are the ED Patients, Medical Associates (Doctors, Nurses, Technicians), and Ancillary Services that provide care to the patients, Fig. 3.3. The primary stakeholders have a critical stake in the success of the pro- ject, and the processes to be improved. The ED patients are those that come to the ED either as walk-ins, or are brought in by ambulance. The Medical Associates include the ED clinical staff, including the physicians, physician assistants,
Project Overview: This project is focused on improving patient throughput in the ED.
Problem Statement: The Emergency Department is experiencing delays in moving the patient through the ED in a timely manner. There are excessive delays and a high percentage of patients left without being seen.
Customer/Stakeholders: ED Patients, Medical Associates (Doctors, Nurses, Technicians, Transportation), Administration, EMS, Inpatient areas, diagnostic departments.
What is important to these customers – CTS (Critical to Satisfaction): Patient Satisfaction, Quality of Care, Throughput Time, Waiting time.
Goal of the Project: Improve ED throughput time to 3 average hours for discharged patients and 5 average hours for admitted patients.
Scope Statement: The scope includes the ED processes starting from patient entrance, to triage, treat, transport, test/diagnose, disposition and discharge/admit.
Projected Financial Benefit (s): Improved revenue; increased volume (reduction of Left Without Being Seen (LWBS)), increased volume through increased performance; reduced costs through improved efficiency (time per patient).
Fig. 3.2 Project charter
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nurses, and medical technicians. The Ancillary Services staff includes Radiology, Transportation, Lab, and Pharmacy who provide services for the ED patients.
The secondary stakeholders are involved in the process, but at a less critical level than the primary stakeholders. The secondary stakeholders, shown in Fig. 3.4 are: EMS who bring the patients to the hospital via ambulance, Registration who registers the patients, Admitting Physicians and Consultants who admit patients to the hospital from the ED, Regulatory Agencies who provide standards for compli- ance, and the hospital’s Administration who administer the hospital.
Suppliers-Inputs-Processes-Outputs-Customers
The suppliers-inputs-processes-outputs-customers (SIPOC) is used to ensure the scope of the project is well understood, and is shown in Fig. 3.5. It is also a check and balance for the customer and stakeholder analysis. Any customer and supplier should also be identified as a project stakeholder.
The high-level process steps are the triage, patient registration, treat, diagnose/
test, disposition, transport, and discharge or admit. The patients come into the ED either by EMS or by private vehicle. The patients request ED care, and some are referred by their primary care physicians to go to the ED. In triage, the initial acuity of the patient is assessed. The patients are also registered in the medical information system by registration personnel. The nurse will see the patient and ensure that they are stabilized. The physician or physician assistant will also see the patient, and determine the disposition. Lab and imaging diagnostic tests are ordered and performed on the patients. The patient may be further treated based on the results of the tests. The physician determines whether the patient will be discharged from the ED, or admitted to the hospital. The patient is then either dis- charged or admitted.
Stakeholders Who They Are? Potential Impacts/Concerns
ED Patients Patients that go through the Emergency Department.
Includes patients who are seen and discharged, admitted, or who leave without being seen
Quality of Care Low waiting time Patient Satisfactions
Medical Associates Physicians and Physician Assistants, Nurses, and Medical Technicians who provide care for ED patients.
Efficient processes Patient Satisfactions Patient Throughput Patient Capacity Ancillary services Support Staff, Environmental
Services, Lab, Radiology, Pharmacy
Efficient use of resources Patient Satisfaction Patient Throughput Fig. 3.3 Stakeholder analysis—primary stakeholders
Define Phase
Stakeholders Who They Are? Potential Impacts/Concerns
EMS Emergency Medical Services
who transport patients to the ED from outside the hospital
Quality of Care Low waiting time Patient Satisfaction
Registration Register the patient Correct registration
Accurate billing Regulatory Agencies Regulatory Agencies who
define regulatory criteria. Quality of Care Revenue Integrity Administration Administration of the Hospital Efficient processes Patient Satisfaction Patient throughput Fig. 3.4 Stakeholder analysis—secondary stakeholders
Fig. 3.5 Suppliers-Inputs-Processes-Outputs-Customers (SIPOC)
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Perform Initial Voice of Customer and Identify Critical to Satisfaction
The Critical to Satisfaction Criteria for this project are:
• Patient throughput time measured by LOS;
• Patient Satisfaction assessed by the percent of patients leaving without treatment;
• Quality of Care measured by quality of care measures;
• Patient waiting times, such as waiting to be seen by the EDP, waiting to be tri- aged, waiting for tests or test results, waiting for transportation, and waiting to be admitted or discharged.
Select Team and Launch the Project
The cross-functional team was identified and formed. The following areas were included as team members:
• ER nurses and physicians
• Admitting and registration
• Compliance
• Imaging, Lab Diagnostics
• Floor, unit nursing
• Chief Nursing Officer
• Information Technology
• Decision Support/Finance
• Pharmacy
• Environmental Services
• Administration.
Rules of Engagement:
The following rules of engagement were embraced by the project team:
• Be present and be committed at the meetings.
• Look at issues, not people; not to be defensive.
• Be open to new ideas.
• Think outside of the box.
• Help each other work together as a team.
• Be respectful for people to finish their thoughts.
• Focused structure: agendas, outcomes, and parking lot issues.
• Limit our time; keep our meetings to the time; and finish meetings.
• Fix the process, do not fix blame.
The rules of engagement are critical to ensure the smooth running of the team meetings, so that the team can stay on topic, and change management can begin.
Define Phase
Create Project Plan
The aggressive project milestones are shown in Fig. 3.6. The project was started at the end of May, and the initial pilot improvement ideas were designed by mid July.
The pilot period started on July 22nd. The pilot activities continued for several months, and the control plan was implemented in November. The project scope was much broader than was feasible to fully implement in only two months as ini- tially proposed.
Measure Phase
The Measure Phase included the following activities:
1. Define the current process
2. Define detailed Voice of Customer (VOC)
3. Define the voice of process (VOP) and current performance 4. Validate measurement system.
Fig. 3.6 Initial project milestones
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Define the Current Process
The first step in the Measure phase was to map the current process by creating detailed process maps of the current processes in the Emergency Services Value Chain. The patient arrival, triage assessment, and assigning an ED bed is shown in Fig. 3.7. There were several additional process maps that were also generated, including, lab test processing, radiology diagnostic testing, registration and admit- ting, patient transportation, and hospital bed assignment for patients admitted to the hospital from the ED.
Define Detailed Voice of Customer
The internal VOC was gathered during the weekly team meetings as the team developed the current state process maps and later identified the performance tar- gets and goals. There was no direct collection of ED patient voice of customer beyond the existing patient survey process, and collection of patient complaints on as needed basis.
Measure Phase
Emergency Room Process
EMSPatientEmergency Room Staff
Security Shows patient how to sign into
Kiosk
Transport patient via ambulance to
ER Start
Start
Enter patient info into Kiosk Walk into
ER
Security or Nurse calls patient and sends to ER room
Move patient to ER room
A
ER Room Available?
Enter patient info into Kiosk Delay
No
Triage patient Acuity
1?
Move patient With lower acuity to hallway
ER Room Available?
Triage patient ER Room
Available?
Triage Room available?
Security or Nurse calls patient and sends to Triage
room Yes
No
6/8/09 Version 1.0
Move patient To ER room No
Yes No
Yes Yes
Acuity 2: 1st available bed Acuity 3: Bed by
time of arrival Acuity 4: Minor
care beds
Wait for ER room
Fig. 3.7 Current state process map
Define the Voice of Process and Current Performance
The VOP and current performance was an extensive data collection experience.
The data collection plan was developed by the team, and shown in Fig. 3.8. The goal is to measure the Critical to Satisfaction criteria identified in the Define phase, including patient throughput time, patient wait time, and patient satisfaction.
The operational definitions were developed for each metric.
The purpose of the first set of metrics was to measure the overall ED patient throughput time, and then the detailed process times.
Process Throughput and Time Metrics
The Patient LOS is the time from when the patient arrives at the ED (signs in at the Kiosk) to when they leave the ED, either being discharged and leaving in a private vehicle or being moved by patient transport to the hospital to be admitted. The
Critical to Satisfaction
(CTS)
Metric Data
collection mechanism
(survey, interview, focus group,
etc.)
Analysis mechanism
(statistics, statistical tests, etc.)
Sampling plan (sample size,
sample frequency)
Sampling instructions (who, where, when, how)
ED Patient Throughput Time:
Admitted from ED;
Discharged;
LWBS
Time from when patient arrives at ED to when they leave:
Total LOS;
Triage time:
EDP time
ED Bed Board System
Minitab: Basic statistics; confidence intervals; throughput time calculations
January through April 2009 data
Verify and validate data with team and subject matter experts.
Patient Wait Time at visit
Wait time for ED; Disposition to Leave ED
ED Bed Board System
Minitab: Basic statistics; confidence intervals; throughput time calculations
January through April 2009 data
Verify and validate data with team and subject matter experts
Left without being seen
Percent of LWBS ED Bed Board System
# patients LWBS / Total # Patients
January through April 2009 data
Verify and validate data
Lab time;
Diagnostic time; Admit time; Register time
Lab time;
Diagnostic time;
register time;
admit time
Within departments (system and manual)
To Be Determined Jan through Apr 09
Verify and validate data
Fig. 3.8 Data collection plan
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time when the patient arrives is captured in the ED Bed Board when the patient signs in at the Kiosk in the ED waiting room. The nurse selects a field on the ED Bed Board when the patient physically leaves the ED, which is logged in the elec- tronic ED Bed Board system. This ED Bed Board system tracks the major process steps and records the time of each step. It also provides alerts if the patients are waiting in any one step beyond identified target times. The following times are measured:
ED Patient Throughput Time (Length of Stay) Time from arrival to leaving the ED.
Wait for ED Physician The time from patient arrival to when the physician first sees the patient.
Triage Time The time from patient arrival to when the nurse completes the tri- age assessment and defines the patient acuity level.
Time to ED Bed The time from when the patient arrives to when they are placed in an ED Bed.
Time from Bed to Physician The time from when the patient is placed in the ED Bed to when the physician first sees them.
EDP Visit Time The time from when the EDP initially sees the patient to when they determine the disposition (whether to discharge or admit the patient). The EDP visit time includes the time to receive the diagnostic (typically lab and radiol- ogy) tests and results.
Lab Turnaround Time Time from when the lab order is placed to when the results are available to the EDP.
Radiology Turnaround Time Time from when the radiology tests are ordered to when the results are available to the EDP.
Disposition to Leave ED The time from when the EDP provides the patient dis- position (discharge or admit) to when they leave the ED.
Disposition to Receive Admitting Orders The time from when the physician provides the disposition to admit to the time when the nurse receives the admitting orders from the admitting physician.
Admit Orders to Assign Bed The time from when the nurse receives the admit orders to when they assign the hospital bed.
Assign Bed to Leave ED The time from when the hospital bed is assigned to when the patient leaves the ED.
Disposition to Discharge The time from when the patient receives the admitting orders to when they leave the ED.
Figure 3.9 shows a Gantt chart of the process steps and relative times of each step in the current baseline performance.
To assess the baseline process performance, we collected data from the ED Bed Board electronic system for data from January through April. We validated the data and removed any data inconsistencies, such as process times that were not selected at the appropriate process step that would cause negative time values.
The second set of metrics collected was the patient volume metrics and the per- cent of patients leaving the ED without being treated.
We tracked the number of ED visits on a daily basis, as well as the percent of patients that were admitted to the Hospital from the ED. The other statistic that we
Measure Phase
tracked was the Percent of Patients leaving the ED without being seen or treated by an EDP. The patient volume metrics are discussed in the next section.
Patient Volume Metrics
ED Visits The number of patients that came to the ED on a daily basis
ED Admissions The number of patients that were admitted to the hospital from the ED
LWBS The Percent LWBS patients is the number of patients LWBS divided by the Total ED visits for that time period.
The baseline metrics are shown in Fig. 3.10. The baseline metrics showed that the team had a tough road in front of them to get to the desired metrics of 3 and 5 hours for discharged and admitted patients, respectively. The current baseline was 5.8 hours for discharged patients and 8.7 hours for admitted patients. For all patients combined, the baseline LOS was 6.9 hours.
We created histograms of the LOS for all patients using Minitab®. The histo- gram is shown in Fig. 3.11. The histogram for LOS for admitted patients is shown in Fig. 3.12, and the histogram for LOS for discharged patients is shown in Fig. 3.13.
The histograms illustrate non-normal distributions with fairly long tails indicating a few patients with quite long length of stays. These are typically patients that are held in the ED when critical care beds are not available in the hospital due to increased vol- umes. The standard deviation for the admitted patients was 3.1 hours and for discharged patients was 3.0 hours. The standard deviation across all patients was 3.1 hours.
Validate Measurement System
We reviewed the electronic data in the ED Bed Board to validate the data collected electronically in the ED. We observed the processes to understand how the data are collected, and whether they are consistent and represent the process times.
Fig. 3.9 Baseline ED process time line