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1-1 Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
Managing Patient Throughput by Process Improvement to Improve
Quality and Control Cost
Maria MadrigalMaria MadrigalBlack BeltBlack Belt
Sigma Breakthrough TechnologiesSigma Breakthrough Technologies
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-2
Your TakeawaysYour Takeaways
You will take away from this presentation:− In-depth knowledge of the Six Sigma and Lean
methodologies of process improvement
− An example of how Six Sigma and Lean concepts can work together in helping hospitals solve problems and increase revenues
− Understanding of how two hospitals found outstanding results by using these concepts
− Useful ideas on beginning these types of initiatives in your healthcare facility
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-3
IntroductionIntroduction
Before we get started, we want to hear from YOU!− What would make this 45 minutes worthwhile of your time?
− What initiatives in your facility prompted you to attend this conference?
− What tools are you hoping to return with?
− Do you want to be entertained? Educated? Both?
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-4
A MeasurementA Measurement
2 308,5373 66,8074 6,2105 2336 3.4
SigmaLevels
Parts per Million Defective
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-5
Practical MeaningPractical Meaning
99% Good 99.99966% Good
Postal System
20,000 Lost Articles of Mail / Hr
Airline System
Two Short/Long Landings / Day
Medical Profession
200,000 Wrong Drug Prescriptions / Yr
7 Lost Articles / Hr
1 Short / Long every 5 Years
68 Wrong Drug Prescriptions
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-6
The Hidden Process YieldThe Hidden Process Yield
ShrinkageShrinkage(waste)(waste)
>95% >95% Customer QualityCustomer Quality
RedoRedoHidden Process
NOTOK
Yield At Measurement
OperationOperationInputsInputs MeasureMeasure FinalFinal‘Yield’‘Yield’ =
OK
Final Yield ignores the hidden process. Final yield performance is a function of post measurement.
65% 65% is notis not 95% 95% ... why not?... why not?
Process1 2 3
90%90%YieldYield
90%90%YieldYield
85%85%YieldYield =
FPY/RTY 81 % 69 %
95%95%YieldYield
4
65 %
>95%>95%‘Yield’‘Yield’
Final Measurement
Process Variation Causes A "Hidden Process"Increased Cost – Lost Capacity
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-7
Rolled Throughput in HealthcareRolled Throughput in Healthcare
ShrinkageShrinkage(waste)(waste)
>95% >95% Customer QualityCustomer Quality
RedoRedoHidden Process
NOTOK
Yield At Measurement
XX--RayRayPatient presentsPatient presentsfor xfor x--rayray
ResultsResults FinalFinal‘Yield’‘Yield’ =
OK
Final Yield ignores the hidden process. Final yield performance is a function of post measurement.
65% 65% is notis not 95% 95% ... why not?... why not?
Process1 2 3
90%90%XX--RayRay
90%90%
Correct TestCorrect Test85%85%
ResultsResults =FPY/RTY 81 % 69 %
95%95%ReturnedReturned
4
65 %
>95%>95%‘Yield’‘Yield’
Final Measurement
Process Variation Causes A "Hidden Process"Increased Cost – Lost Capacity
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-8
Variation Causes DefectsVariation Causes Defects
LSL USL
Poor Support of Robust Product
Functionality
Process Capability
No standard process for
staff membersInadequate
StaffingNeeds
Variation in Medical Supplies
No Metrics
Way off Target
Out of Spec.
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-9
Time
Perf
orm
ance
Breakthroughs inProcess Performance
GOOD
BAD
3 Sigma (CpK = 1)
6 Sigma (Cpk = 2)
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Changing the Decision Making ProcessesChanging the Decision Making Processes
Decision MakingGrowth Path
Types of ProblemsYou Will Normally Solve
1. Intuition, gut feel, I think …..
2. We have Raw Data and look at it
3. We make graphs / charts of the data
4. We use advanced statistical toolsto evaluate the data
Simple
Complex
How Many Times Have Your Heard This ? “I Think The Problem Is…”
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-11
Overall ApproachOverall Approach
Practical ProblemPractical Problem Statistical ProblemStatistical Problem
Statistical SolutionStatistical SolutionPractical SolutionPractical Solution
y f x x xk= ( , ,... , )1 2
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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The Funneling Effect
Optimized Process
30+ Inputs
8 - 10
4 - 8
3 - 6
Found Critical X’s
Controlling Critical X’s
10 - 15
All X’s
1st “Hit List”
Screened List
MEASURE
ANALYZE
IMPROVE
CONTROL
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Triage TeamTriage TeamA.K.A. “Muda Busters!”A.K.A. “Muda Busters!”
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Accelerated Change Event, “ACE”Accelerated Change Event, “ACE”
Time Period
Team Given Clear Objectives
Team Composition
Support
Timeline
• Lead time reduction • Cost reduction• Yield enhancement• Meet customer demand
• 1/3 are process specialists from area• 1/3 are people related to the area • 1/3 are those from outside of area
• 5 Days Ground Rulesg Cannot damage the customerg Cannot permanently “harm”
internal operationsg Use creativity before capital
AM
PM
MON TUE THU FRIWED
TRAINING
CURRENT STATEMAP
CONCEPT & DETAILDESIGN
“TAKE ACTION”
IMPLEMENTIMPROVEMENTS
REFINE
Stabilize / MeasureIMPROVEMENTS
REFINE CHANGESPREPARE PRESENTATION
PRESENTATION& CELEBRATION
“TAKE ACTION” 14
DESIRED STATEGAP ANALYSIS
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-15
What is Lean?What is Lean?
Lean is the identification and elimination of “Waste” with in a process
Waste is define as anything that adds cost but Does not add value to the process.
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-16
TYPES OF WASTETYPES OF WASTE
PEOPLE
TYPESOF
WASTE
Processing
Motion
Waiting
FixingDefects
Making TooMuch
MovingThings
Inventory
QU
ALITY
QUANTITY
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-17
Lean Tools UsedLean Tools Used
Value Stream Mapping
SIPOC
Spaghetti Mapping
Shift Transition Score Card
Flow Analysis
Time / Value Mapping
5S
C & E Matrix
Kanban
Visual Workplace
Consensus Building
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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ACE Events Focus on ACE Events Focus on Non ValueNon Value--Added Activity To Reduce Lead Time Added Activity To Reduce Lead Time
Reducing value-added (VA) activities usually results in only minor gainsReducing Non Value-added (NVA, aka Waste) usually results in major lead time reductions without adding resources or capital
Typical company VA NVA Original lead time
Traditional cost reductions VA NVA
Minor improvement
VA NVA Major improvement
Don’ t make capital investments on improving VAs until the NVAs achieve equilibrium with the VAs
ACE waste reduction
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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The Value Stream MapThe Value Stream Map
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Reducing Length of StayReducing Length of Stay
Team’s Actions Potential Time Savings
2 minTaking specimen to lab
30 minWait to be tasked
30 minWait to be seen by MD
2 minTriage paper to Reg/MD
5 minPt waiting to be triaged
2 minRN/tech to take vital signs
2 minRN/tech start blue form
5 minCentral Location for Stretchers and Wheelchairs
Total Potential Savings of 1’18”
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-21
Changes In MTCChanges In MTC
Change: − Clear criteria at Meeter/Greeter
and in MTC as to which patients can be transferred directly to MTC
Benefits:− Reduction in ALOS for MTC
− Reduction in load on ER Triage
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Changes In MTCChanges In MTC
Change: − Standardize daytime registration & Fast Track after 11pm
Benefits:− Reduction in patient ALOS
− Cuts registration from 2-3 hours to 15 minutes
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Changes In MTCChanges In MTC
Change: − Visible performance tracking metrics
MTC volume
ALOS for discharged
ALOS admitted patients
5s scores
Benefits:− Sustain the gains
− Pride of ownership
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-24
Changes In MTCChanges In MTCChange: − 5s in MTC (everything has a place, everything in its place)
Move nurse station computers to central areaRelocate crash carts, eye-trays, Pixus, glove dispensers, slit lamp, fridges, linenRemove unnecessary itemsMend exam lightPaintedOmnicells redesigned, removed unused inventory and repositionedIncreased accessibility to & visibility of crash carts
Benefits:− Reduced travel time− Improved patient / visitor safety− Increased workspace efficiency− Decreased inventory− Increased patient throughput− Reduce patient ALOS
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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BeforeBefore
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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AfterAfter
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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MTC Tech Travel To SplintMTC Tech Travel To Splint
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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MTC ALOS ImpactMTC ALOS Impact
Before After (conservative)
Process Steps 45 40
VA Time (mins) 48-123 46-121
NVA Time 100-926 95-712
Historical MTC ALOS = 7’30”
End of the week MTC ALOS = 3’04”
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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QuotesQuotes
“We have More ‘Blue’ than anything” (blue being waste in the current process”
“Everything that we’re talking about we’ve been trying to change for 2 years”
“I think there are a lot of us that are working against ourselves”
“It usually takes 6 months to move a computer, we’ve moved 3 today”
“It usually takes 2 months to move an Omnicell, we did it in hours”
“These teams could put a man on the moon”
“We’ve achieved more this week than we have in the last year!”
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Lean + Six SigmaLean + Six SigmaLeanLean
Waste EliminationStandard WorkFlowCustomer PULL
Six SigmaSix Sigmaσ Variation Reductionσ Scrap / Rework Eliminationσ Process Optimizationσ Process Control
SPEED STABILITY & ACCURACY
LEAN + SIX SIGMA = A POWERFUL UNIONLEAN + SIX SIGMA = A POWERFUL UNION
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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113-bed hospital located in Central Texas
35 miles south of Austin; 45 miles north of
San Antonio. Out migration has always been
a problem
57.7% of inpatient admissions come through the Emergency Department
Factual InformationFactual Information
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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VOC, VOB and Problem StatementVOC, VOB and Problem Statement
Q3 02 Q4 02 Q1 03 Q2 03
2.732.952.902.97
0
0.5
1
1.5
2
2.5
3
3.5
4 Only 27% Patients reported being “Very Satisfied”.Where do unsatisfactory delays occur?− 81 % stated before being taken
to a treatment room.− 56 % stated before being
treated by a physician.
Facility had been concerned over customer satisfaction ratings with wait times in the ED. It was thought that people from the community were heading to area hospitals in Austin and San Antonio to receive
care (with shorter waiting times)
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-33
Metrics IdentifiedMetrics Identified
ALOS (Average Length of Stay)− Goal to see a 5% reduction in ALOS
Triage to ER Bed− Goal of reducing turnaround time by 20 minutes
LWBS (Left Without Being Seen)− Goal to reduce LWBS to under 2%
Patient Satisfaction− Measured Gallup poll scores in these areas:
ED Overall SatisfactionWait TimeHelpful and Courteous StaffED EfficiencySpeed of Service
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Data CollectionData Collection
LOS (minutes) Triage to ER bed
220.0
200.0
180.0
160.0
140.0
120.0
100.0
80.0
60.0
40.0
20.0
0.0
Median = 34 minutes
Mode = 25 minutes
Freq
uenc
y
300
200
100
0
Std. Dev = 29.73 Mean = 42.3N = 1023.00
Cycle Time from Triage to Bed Using Six Sigma tools, we
began collecting data on variables in the process. We
found that the average waiting time for a patient to be placed in a bed was over
42 minutes!
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Data CollectionData Collection
Tl Length of Stay (LOS) in minutes
675.0
625.0
575.0
525.0
475.0
425.0
375.0
325.0
275.0
225.0
175.0
125.0
75.0
25.0
Median = 128 minutes
Mode = 55, 90, and 95 minutes
Freq
uenc
y
300
200
100
0
Std. Dev = 88.84 Mean = 149.6N = 1285.00
ALOSWe also found that the
Average Length of Stay for our ED patients was 2.5
hours.
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Using Lean Tools to Drive ResultsUsing Lean Tools to Drive Results
Lean Tools, such as 5S, allowed us to organize the medical
supply closets in the ED. Labels were created, excess inventory returned and par levels adjusted
to provide a savings of over $32,000.00.
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Result 1: Triage to ER BedResult 1: Triage to ER BedOld Process New Process
Average of 19 MinutesAverage of 43 Minutes
Over 50% reduction in overall cycle time!
Observation
Indi
vidu
al V
alue
2532251971691411138557291
150
100
50
0
-50
_X=19.2
UCL=48.7
LCL=-10.4
October Direct April
Triage to ER Bed
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-38
Result 2: Average Length of StayResult 2: Average Length of Stay
6005004003002001000
Median
Mean
145140135130125120
A nderson-Darling Normality Test
V ariance 7618.62Skewness 1.32885Kurtosis 2.54811N 2587
Minimum 1.00
A -Squared
1st Q uartile 80.00Median 123.003rd Q uartile 183.00Maximum 680.00
95% C onfidence Interv al for Mean
139.31
56.75
146.04
95% C onfidence Interv al for Median
120.00 127.00
95% C onfidence Interv al for StDev
84.97 89.73
P-V alue < 0.005
Mean 142.68StDev 87.28
95% Confidence Intervals
Summary for LOS
Old Process New Process
Variation of 29 MinutesVariation of 87 Minutes
Over 60% reduction in overall variation!
18016014012010080
Median
Mean
140135130125120
A nderson-Darling Normality Test
V ariance 883.18Skewness -0.152343Kurtosis -0.856168N 31
Minimum 76.00
A -Squared
1st Q uartile 108.00Median 126.003rd Q uartile 157.00Maximum 178.00
95% C onfidence Interv al for Mean
116.71
0.56
138.51
95% C onfidence Interv al for Median
119.40 137.52
95% C onfidence Interv al for StDev
23.75 39.72
P-V alue 0.140
Mean 127.61StDev 29.72
95 % Confidence Intervals
Summary for June
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
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Result 3: Left Without Being Seen (LWBS)Result 3: Left Without Being Seen (LWBS)
Reduction from 2% to 0.84%!
60% Reduction in LWBS
Observation
Indi
vidu
al V
alue
554943373125191371
4
3
2
1
0
_X=0.84
UCL=1.950
LCL=-0.270
Before After
2
2
226
6
1
I Chart of Rate by Label 2
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-40
End NotesEnd Notes
Before Project:
− ER was ranked anywhere from 7 to 10 out of the Multi-State region of 17
− No goals to become the “2nd
to None” ED
− No formal data collection process to prove where the problems were coming from
− We knew we had problems, however lacked a clear roadmap
After Project:
− 2nd to None ED-pushing into national top quartile customer satisfaction ratings
− Moving to become the benchmark (leading) ED
− LWBS = $181,800.00 savings
− Reducing Average Length of Stay to allow for increase of 95 patients per month
− Medical supplies returned and par level adjustments =$32,923.70
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-41
End NotesEnd Notes
Before Project:
− ER was ranked anywhere from 7 to 10 out of the Multi-State region of 17
− No goals to become the “2nd
to None” ED
− No formal data collection process to prove where the problems were coming from
− We knew we had problems, however lacked a clear roadmap
After Project:
− 2nd to None ED-pushing into national top quartile customer satisfaction ratings
− Moving to become the benchmark (leading) ED
− LWBS = $181,800.00 savings
− Reducing Average Length of Stay to allow for increase of 95 patients per month
− Medical supplies returned and par level adjustments =$32,923.70
Rev. A Printed 5/2/2006© 2005 by Sigma Breakthrough Technologies, Inc.
1-42
Questions & CommentsQuestions & Comments