Six Sigma success story: Reducing variations is key
Averages do not give an accurate picture
If you had reduced the mean door-to-doctor time in your ED from 64.3 minutes to 39.8 minutes (a 38.1% improvement) in seven months, you’d probably be pretty happy. But for Maureen Kelly-Nichols, RN, MSA, the ED nurse director at Providence Hospital in Southfield, MI, that was not the key measure of success in her recent Six Sigma project.
Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects in any process. In the most recent project, the most meaningful statistic for Kelly-Nichols was the standard deviation in wait time, which was reduced from 44.7 minutes to 27.7 minutes — a 38% improvement.
Standard deviation, she explains, illustrates the variability around the process you are seeking to improve. "Averages are not a good way to assess your performance," she asserts. "If you have [a good average wait time and] a patient who waits 10 minutes, [that person is] happy, but the one who waits 90 minutes is not."
In terms of wait times, it’s important to identify the "upper spectrum" — how long a wait patients are willing to tolerate — and then strive to keep all patients below that spectrum, Kelly-Nichols says. "We did a voice of the customer’ survey and found they were willing to accept 60 minutes to see a physician," she adds.
When they started, 70% of the patients were seen between 20 minutes and 110 minutes, says Ben Miles, MBA, Six Sigma Master Black Belt at St. John Health, the system to which Providence belongs. Master Black Belts are quality leaders responsible for Six Sigma strategy, training, mentoring, deployment, and results. "Once we got done, for 70% of the patients, it was between 20 minutes and just over one hour," he says.
They let the data drive their decision making, says Kelly-Nichols, noting that is an important lesson for ED managers to learn. "What you think is the problem isn’t necessarily correct," she says.
Six Sigma helps keep ED managers on the right track because of its core DMAIC (define, measure, analyze, improve, control) method. "It does take a lot of discipline, because you want to move to right to the solution," Miles notes. "We wanted to go on our intuition and say we didn’t need to measure the process, but when we did, we had a few Aha!’ moments. Some of the things we did not think would be critical were the chief drivers of variability." Those drivers turned out to be:
- whether the patient was a fast-track patient;
- whether there was a bed available;
- whether the patient had an X-ray performed.
Miles advised that the first process to bring under control (and the subject of this seven-month project) should be the fast-track patients, as they almost exclusively were the purview of the ED.
The problem with express care is that it wasn’t, Kelly-Nichols says. "The patients were waiting two to three times longer than the average patient, because they were less acute. We tend to treat the sickest patients first." Clearly, no one was going to treat the acute patients more slowly, so the express process had to be sped up. The area used to open at 11 a.m., but there was no formal physician coverage until 1 p.m.; until that time, it was staffed by a nurse and floating physicians from other departments. Now when the area opens at 11 a.m., there is a board-certified ED physician, a nurse, and a physician extender — usually a nurse practitioner. "At times, we will also float a nurse in there, which is almost a shifting, not an added [full-time equivalent]," she says.
"One thing that precluded getting the patients to express care as quickly as we would like was registration," Miles notes.
The registrar has been moved, and registration is now done at the bedside. "When you walk in the door, we do a quick assessment of vitals, but full registration is done at the bedside," Kelly-Nichols adds.
A final factor was improving ergonomics to aid work flow. "We moved a computer [to make it more accessible] and a refrigerator to make flow smoother," she says. "We’ve moved our meds to where we have more counter space and gone to automatic medication dispensing." As a result of the project, the ED has reduced its left-without-being-seen rate to less than 1%, even though volume is higher than it ever has been. Kelly-Nichols says volume is up 5% this year, to 63,000 annual visits. "What we’ve done is change the whole philosophy in express care. The staff strive for quick, efficient care and quality care." (For another success, see box, below.)
|
Improving X-ray process helps reduce variability Research conducted as part of a Six Sigma project to improve door-to-doc times at Providence Hospital in Southfield, MI, revealed three factors — whether a person was a fast-track patient, a bed was available, or a patient received an X-ray — were responsible for 94% of the variation in door-to-doc times. Six Sigma is a disciplined, data-driven methodology for eliminating defects in any process. The team has turned its attention to X-rays as wave two of the project. They studied the process from the time the X-ray was ordered: when it was ordered, when the patient went to X-ray, and how long it took to get read back, says Maureen Kelly-Nichols, RN, MSA, the ED nurse director. "We really dug deep, and since we made the project data-driven, not personal, the radiology staff came right on board," she adds. The ED team observed the radiologists and learned about how they read film, when they went to lunch, the way things were ordered — even how they faxed information. "We found that over 95% of the X-rays ordered were STAT — so nothing was really STAT," recalls Ben Miles, MBA, Six Sigma Master Black Belt at St. John Health, the system to which Providence belongs. "We know all X-rays are important, but we developed more rigor around what was truly STAT and deploying our resources in a more concerted fashion to treat the sickest patients first." Some of the changes were not so esoteric. A new fax machine was purchased to help speed up the process, for example. To date, more than 10 minutes have been shaved off the average time to process and X-ray, but even more important from a Six Sigma perspective, variability in the process decreased by more than 30%. |
For more information, contact:
- Maureen Kelly-Nichols, RN, MSA, ED Nurse Director, Providence Hospital, 16001 W. Nine Mile Road, Southfield, MI 48075. Phone: (248) 849-3298. E-mail: [email protected].
- Ben Miles, MBA, Six Sigma Master Black Belt, St. John Health Corporate Services Building, 28000 Dequindre, Warren, MI 48092. Phone: (586) 753-0953. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content