Six Sigma Case Cart Project Final Report Jan. 2011

Six-Sigma Project Report

Six Sigma Project Final Report Jan. 2011.doc 1

Hospital Surgical

Case Cart Completion

Six-Sigma Project

By Dan Johnson

Final Report

January 2011



TABLE OF CONTENTS

Executive Review……………………………………………………………...3

1. Overview; Project Selection

1.1 Background Information…………………………………….…………..4

1.2 Problems and Symptoms………………………………………………...5

2. Define

2.1 Goals and Expected Results……………………………………………...6

2.2 Framework………………………………………………………………10

2.3 Assumptions ……………………………………………………….……17

3. Measurement

3.1 Study, Late Case Carts, Missing Items, Case Delays……………….…18

3.2 Statistical Results and Sigma Level Calculation……………..………..23

4. Analysis

4.1 Cause and Effect…………………………………………….…………..24

4.2 Pareto………………………………………………………………...…..24

4.3 Action Item List……………………………..…………………………..26

5. Improvement…………………………………………………………………27

6. Control

6.1 Process, Standardized Work…………………………...……………….30

6.1 Metrics…………………………………………………………………....30

7. Conclusion and Outlook

7.1 Sigma Calculation……………………………………………….………33

7.2 Savings Summary………………………………………….……………34

Appendix: Process Flow



Executive Review

This hospital‟s Surgical Services and associated Operating Room (OR) and Sterile

Processing and Distribution (SPD) are faced with many strategic growth decisions that

provide both challenges and rewards. While there are many positive attributes within the

Sterile Processing Department, surgical staff, hospital administration and the surgeon‟s

committees have made keenly known their concern and dissatisfaction with the delays

and time wasted due to lack of complete and ready surgical case carts, or case supplies.

The hospital hasn‟t established a Lean or 6-sigma based process improvement

methodology, however C-level executives are aware of the power of the approaches in

facilitating improvement and therefore sanctioned a process improvement project focused

on these concerns. For purposes of external publication, the facilities name and location

is omitted and will simply be referred to as “the hospital” or similar designation.

A team was assembled under my direction and consisted of eight individuals,

participating as necessary over the course of the project. One of the team members is

concurrently pursuing a green belt certification, although not through Aveta. The team

applied the DMAIC methodology to the process of supplying the Operating Room (OR)

with supplies and equipment required in the performance of surgical procedures (cases)

with the intent of improving the number of cases for which all supplies are available at

the time of need. The team drew upon some Lean knowledge, as well during the

implementation phase. The project report is presented in alignment with the DMAIC 6-

sigma phases.

In the Define phase, we drew up a project charter, specified and quantified our goals and

determined a method to track savings. We continued with a project plan and high-level

task list outlining each team member‟s responsibilities. A rough process map was

developed to ensure our understanding of the process and to provide a framework for

improvement activities.

An early discovery during the Measurement phase showed that the reporting capability in

the OR limited the use of historical information for measurement or performance

analysis, therefore the team was required to conduct detailed observations to understand

the true nature of the delays being reported by the OR. During this phase we also began

soliciting suggestions from SPD and OR personnel. A SIPOC and a HOQ were

developed to assist the team in better understanding the relationships of the inputs and

outputs to the process, its vendors and customers.

During the Analyze phase Ishakawa charting was used to understand cause and affect

relationships. This lead to brainstorming of the possible root-causes and ultimately was

used to populate an Action Item List that is still in use to facilitate and monitor the

ongoing process changes. A significant change brought about by the team involved

completing a spaghetti diagram of the supply pick process; the results which included the

implementation of a 2-bin kanban system and reorganization of the supplies storage area

to align with the pick ticket sequence. During this phase the team reviewed the data

collected during the observation period and quantified the scope of the incomplete case



cart issues. Note: case carts refer to the system of picking and delivering all supplies and

instruments needed for the performance of a surgical case.

The Improvement phase allowed the team the opportunity to implement a large number

of the process improvement items detailed in their Action Item List and to begin

measuring their impact. Detailed process flows were developed to help in the change

process and to enlist buy-in from the technicians responsible. While many items remain

to be accomplished the team focused on those that would have the greatest or most

immediate impact to the process with the intent of quickly improving the satisfaction

levels of the OR surgical personnel. A series of metrics closely aligned with the key data

from the Measurement phase was installed at the same time, so impact could be

quantified from the onset.

The series of metrics mentioned before is now used daily to track and trend performance

against an established baseline. This provides the Control element for the processes and

allows for the quantification of impact as well as ensuring that the gains made will be

sustained.

1. Overview; Project Selection

1.1. Background Information

The hospital is one of a network of hospitals located in the southern US. The hospital

offers general healthcare and wide variety surgical services including reconstructive,

cardiovascular, urology, etc, utilizing 29 OR suites. Approximately 22% of its surgical

caseload is in the fields of orthopedics and spine, both heavily supply and instrument

intensive. The case volume for 12 calendar months ending July 2010 was about 33,000,

split nearly equal in-patient to out-patient, although the trend for the past few years has

been increasing the out-patient percentage. The OR conducts business typically from 7:30

am to 5:00 pm Monday through Friday, but often extends late into the evening. Saturday

cases are not considered scheduled, but several routinely occur each weekend.

A key support service to the OR caseload is the reprocessing of surgical instrumentation

and the assembly and distribution of Case Carts (customized kitting of supplies and

instruments) by the Sterile Processing Department (SPD). The SPD is responsible for the

cleaning, reassembly and sterilization of surgical instruments following a case and in

preparation for those instruments to be reused. The SPD is also tasked with

supply/inventory control and preparing case carts for use in the OR. The SPD operation

runs 24-7.

Quality is thought of in the relative terms of Clean and Sterile, Complete and On-time

and is quickly becoming a focus within hospitals as accrediting agencies begin to look

more closely at this part of the operation than ever before. Recently the noise level from

surgeons and the hospital‟s surgical staff about the state of affairs regarding incomplete

case carts and instruments sets had increased to the point of administrative concern. It

was generally felt that something needed to be done, but efforts internal to the SPD had



proved fruitless and the department was taking a serious rap for its poor quality and

delivery reliability, though no supporting numbers were presented.

The hospital doesn‟t have an established process improvement methodology, but

executives are acutely aware of improvements made in other hospitals using Lean or 6-

Sigma methodologies, or a combination and believe that the 6-sigma approach may be a

powerful tool to detect and reduce errors in the process. While not setting themselves up

with a process improvement department they did agree to support the team approach to

addressing these issues. That the process involved here is more service than production

oriented it seems a challenge to utilize many of the 6-sigma statistical tools. However, it

is their hope that the DMAIC provides the blueprint for solving and eliminating the

problems they now face.

1.2. Problems and Symptoms

It is important to separate the noise from the real issues. Many of the same stories of case

delays (late starts) are heard time and again throughout the hospital hallways. Weekly

review after weekly review raised many of the same concerns. The OR record keeping

system contains some information related to reasons for delays. However the system is

inconclusive as it allows only a single reason code to be entered for case delay and while

this is considered to be the primary reason there may be multiple factors and reality is

that input often serves the person recording the code. The team initially created a Pareto

from the OR data to begin to understand the opportunities rough order of magnitude. See

Figure 1.

Figure 1. OR Case Delay by Reason Code

0.00% 5.00% 10.00% 15.00% 20.00% 25.00%

XRAY TECH/CARM UNAVAILABLE

SURGICAL CHECKLIST NOT COMPLETE FROM SENDING UNIT

OUTSIDE SERVICE PROVIDER DELAY

EQUIPMENT MALFUNCTION

BIOMED DELAY IN CHECKING EQUIPMENT

SCRUB PERSON NOT READY

BED NOT AVAILABLE ON FLOOR

BED NOT AVAILABLE ON ICU

TRAUMA BUM

NEEDS TRANSLATOR

PATIENT NOT NPO

ADDITIONAL MD CONSULT REQUESTED

ASSISTANT NOT AVAILABLE

PROCTOR NOT AVAILABLE

UNANTICIPATED MULTIPLE LINES

CONSENT DOES NOT MATCH SCHEDULE

NOT ENOUGH STAFF TO START CASE

PACU SATURATED

PATIENT WAITING FOR FAMILY

PATIENT REQUESTED TO SPEAK TO MD

PATIENT DIRECT ON A VENT/ISOLATION

DIFFICULT IV START

ADDITIONAL TESTS REQUESTED BY SURGEON/ANESTHESIA

ANESTHESIA NOT AVAILABLE

XRAYS NOT DONE/UNAVAILABLE

C SECTION BUMP

PATIENT DELAYED IN OPSU

H&P DICTATED NOT TRANSCRIBED

CONSENT INCOMPLETE/INACCURATE

PHARMACY MEDS NEEDED

BLOOD BANK DELAY

SCHEDULING CONFLICT

INSTRUMENTS NOT ORDERED

EMERGENCY BUMP

DIFFICULT INTUBATION

NO MD ORDERS

EKG NOT DONE/AVAILABLE

PATIENT DELAYED IN ADMITTING

PHYSICIAN REQUEST CHANGE IN LINE UP

EQUIPMENT NOT AVAILABLE

ROOM NOT SET UP PROPERLY

IMPLANTS NOT AVAILABLE

TRANSPORT TEAM DELAY

LABS NOT AVAILABLE

SURGEON DELAYED IN OTHER ROOM

OTHER

H&P NOT DICTATED-WRITTEN IN HOLDING

EQUIPMENT/INSTS NOT REQUESTED WHEN SCHEDULED

INSTRUMENTS NOT STERILE

PATIENT LATE TO HOSPITAL

ANESTHESIA LATE

OTHER

PREFERENCE CARD DISCREPANCY

OTHER

OTHER

SURGEON LATE

PREVIOUS CASE OVER SCHEDULED TIME

OR Recorded Case Delay by Reason CodePercentage



Note that the highlighted reasons are each related to the proper availability of supplies or

instruments needed for the case. While no single reason recorded would lead a team to

tackle it as the top offender, the aggregate of all related to supplies supports the concern

of the hospital administration. This chart indicates that approximately 13% of delayed

cases are so by virtue of missing supplies or instruments. The story is compelling enough

to move forward with a project and ultimately drove the project more than adequate ROI

analysis and comparison to other opportunities.

2. Define

2.1. Goals and Expected Results

Prior to assemblage of a 6-sigma team the Green Belt candidate and I developed a charter

and had it approved and sponsored by the Sr. VP Perioperative Service. See Figure 2.1.

The primary goal of the team is to decrease the number of surgical case carts that are

delivered to the OR incomplete. The goal is further broken down into 1st and 2

nd Cases

and all other cases. The thought behind this is two-fold. First, getting a good start to the

day helps ensure surgeon satisfaction. Second, the availability of some instrument sets is

impacted by the timing of their use in cases earlier in the day. The lack of adequate

instrumentation may be a focal point of the team during the project. The business case for

this improvement is that improved service and delivery of complete case carts reduces the

hours spent by both OR and SPD personnel in later searching for the missing items and

may result in the recapture of enough OR time to provide availability for additional

revenue generation.

As well as the OR Pareto shown in Figure 1, a Project Evaluation and Cash Flow

projection is developed along with a set of base data and savings projection. The base

and savings projection are compiled through the course of the Define and Measurement

phases and is finalized upon completion of the base data analysis. See Figures 2.2, 2.3

and 2.4.

The cash flow projection is predicated on the estimated FTE weeks that specific team

members will be utilized across the course of the project. Salary considerations are

expected to be about $76,900 over 3 months and we plan to have a couple of team

dinners and minor project expenses. The sponsor wasn‟t concerned about capturing costs

associated with hospital conference rooms as some are nearly always available for the

team meetings and working sessions. Overall ROI is anticipated to be 4.4 to 1, assuming

all hard and soft-savings targets are hit.



Figure 2.1 6-Sigma Project Charter

Six-Sigma Project Charter / Client Hospital

Product or Service

Impacted

Case Cart OR Delivery Expected Project Savings ($) $ 350,000

Facilitator Dan Johnson Business Unit CSP/OR

Champion Ms. Jackson Phone Number for Facilitator 602-448-5704

Start Date 8/10/10 Target Completion Date 11/30/10

Element Description Team Charter

1. Process: Case Cart Assembly and Delivery Need to reduce the overall number of case carts

delivered incomplete to less than 25% and 1st and 2

nd

cases to less than 5% by end of November 2010

2. Project Description:

what is the

“Practical Problem”

Problem and goal statement (project‟s purpose)

Case Cart delivered to the ORs missing trays

and supplies. Wet case carts

Eliminate the causes of case carts being delivered

incomplete and wet.

3. Objective:

Improvement is sought in 1) ensuring that all

„available” items are picked to the case cart,

Project

Y’s

Baseline

GOAL

Unit of

Measure

units

2) “items unavailable‟ at time of pick are

recorded and follow-up accomplished,

1st and

2nd

case

comple

tion

82 95 # Case

Carts

%

3) Reasons for “items unavailable” documented

and used for next steps.

Overall

case

comple

tion

60 75 # Case

Carts

%

OR

Delay

(Mins /

Day)

194; 1st 2

nd

cases

274 all

others

54

171

# Delay

Mins

#

Savings Metrics will include OR Delay minutes

per case resulting in increased OR utilization

and OR Staff minutes used tracking the missing

items.

OR

Staff

Time

(Mins /

Day)

324; 1st 2

nd

cases

456 all

others

90

285

# Staff

mins

#

4. Business Cases:

Expected financial improvement, or other

justification.

Improved service to the OR and decreased OR Starts

delayed due to incomplete cases carts. Will decrease

labor hours spent on location and recovery.

5. Stakeholder Team

members:

Names and roles of team members? CSP Case Cart Tech(X2) – M. Hendersen, J. Maliford

OR Staff – J. Rodriguez, C. Nestman (Greenbelt)

CSP Leadership – R. Sanchez

6. Project Scope: Which part of the process will be investigated

and excluded.

Case Cart Assembly, Transport and Staging.

Storage Location Control

Completeness of reporting

7. Benefit to External

Customers:

Who are the final customers, what are their key

measures, and what benefits will they see?

Patients, OR Staff and Surgeons; Improved delivery

performance, improved OR Start Times

8. Schedule: Give the key milestones/dates.

Project Kick-off,

Define, Set Goals,

Proc Map & AIL

Review

August 10, 2010

M- Measurement, Metrics validation, Success

Metrics

“M” Completion August 25,2010

A- Analysis “A” Completion September 18, 2010

I- Improvement “I” Completion September 25, 2010

C- Control “C” Completion October 10,2010

Note: Schedule appropriate Safety Reviews. Safety Reviews October 10, 2010

Project Completion November 30,2010

9. Support Required: Will any special capabilities, hardware, trials,

etc be needed?

Meeting room, LCD Overhead, Flip Charts



Figure 2.2 Project Evaluation

Score Interpretation

10 Sponsorship

10 External Customer

3 Shareholder

3 Employee or Internal Customer

3 Other (supplier, environment, etc.)

4.75 - Total Benefit

3 Availabilty of resources other than team

3 Scope in terms of Black Belt effort

10 Deliverable

3 Time to Complete

3 Team

10 Project Charter

10 Value of Six Sigma Approach

59.225 Total



Figure 2.3 Base and Savings

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Figure 2.4 Cash Flow Projections

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

Project Week

Project Cash Flow ProjectionCase Cart Completion Project

Cum Projected Savings Cum Project Cost Planned Out-of-Pocket

Approximate Annual Savings: $350,000Project Cost: $78, 781ROI: 4.4 to 1

2.2. Project Framework

A high-level task plan (fig. 2.5) laid out the team members primary responsibilities and

tasks for the project and was later detailed in the Project Gantt Chart for schedule

adherence and reporting (fig. 2.6)



Figure 2.5 Task Plan High Level Task and Responsibility

Responsibility Date Due Complete

Charter

___ Indentify Opportunity Dan Johnson 25-Jul

___ Identify Sponsor Dan Johnson 25-Jul

___ Estimate Savings Dan Johnson 29-Jul

___ Draft Charter Dan / Ms. Jackson 2-Aug

___ Sponsor project review (weekly) Dan / Ms. Jackson 2-Aug

Define

___ Team selection Dan / Ms. Jackson 3-Aug

___ Complete Charter Dan Johnson 4-Aug

___ Team Training Dan Johnson, Green belt ( Cory Nestman) 12-Aug

___ Review existing documentation Dan Johnson, Cory nestman 15-Aug

___

Define objectives and develop

plan Team 8-Aug

___ Develop Plan Gannt Chart Cory Nestman 10-Aug

___

Present objectives and plan to

management Cory Nestman 10-Aug

___ Map As-Is process Team 15-Aug

___

Review and redefine

problem/opportunity Team 20-Aug

___ Sponsor sign-off Ms. Jackson 22-Aug

Measure

___ Identify CTQs Cory Nestman 15-Aug

___

Collect data on event tasks and

cycle time Team 22-Aug

___

Determine and validate

measurement system Dan Johnson, Cory Nestman 25-Aug

Analyze

___

Prepare baseline graphs on event

tasks and cycle time Dan Johnson, Cory Nestman 25-Aug

___

Analyze impacts on tasks and cycle

times Dan Johnson, Cory Nestman 5-Sep

___

Evaluate time and value, risk

management Team 5-Sep

___ Benchmark other companies Malik 10-Sep

___ Discuss team's preliminary findings Team 12-Sep

___

Consolidate team's findings and

analysis (additional brainstorming) Team 16-Sep

Improve

___

Present recommendations to

process owners and operators Team 18-Sep

___

Review recommendations and

formulate beta Team 18-Sep

___ Prepare Beta Dan Johnson, Cory Nestman 21-Sep

___ Run beta (test improved process) Team 24-Sep

___ Analyze beta and results Dan Johnson, Cory Nestman 24-Sep

___ Present final presentation Team 25-Sep

___

Present final recommendations to

management team Team 28-Sep

Control

___ Develop Control Metrics Dan Johnson, Cory Nestman 21-Sep

___ Develop metrics collection tool Cory Nestman 21-Sep

___ Roll out improved process Team 29-Sep

___ Roll out metrics Team 29-Sep

___

Monitor process monthly, using

control metrics Team 10-Oct

TASK



Figure 2.6 Project Gantt Chart



The SIPOC is used to focus the team‟s scope of work. Figure 2.7 illustrates this project‟s

SIPOC ensuring that the team doesn‟t try to resolve issues with the entire instrument and

supply flow from between the SPD and the OR. For example, while purchasing and

warehouse distribution certainly have an impact on the availability of supplies, it is

considered outside the scope of this project. The focus will be on the interrelationship

between the SPD and the OR and the staff‟s ability to accomplish the task of completing

case carts and delivering them on time to the OR.

Figure 2.7 Case Cart SIPOC

SIPOC Help

Surgeon's offices Call to OR Planners Surgical Schedule OR Planners and Team Leaders

OR Planners OR Surgery Scheduling System Or Schedule for Reference Case Pick Technicians

Surgeon's officesSurgery Equipment, Instruments

and Supplies req'd

Pick Lists

Priority / Conflict Management

OR Planners

Case Pick Technicians

CSP ManagementCase Pick Technicians Schedule

and assignmentPick assignments to technicians OR Staff

OR; Post use Decontamination cart washCase Carts clean and staged

ready for useCase Pick Technicians

Cardinal HSS Warehouse / distributionComplete Case Carts; Ready for

surgical useOR Staff

OR and Vendors (Loaners) CSPComplete Case Carts; Ready for

surgical useOR Staff

Priority Needs List CSP Staff

Case Pick Techs Completed and signed pick list OR Staff

Case Pick Techs Complete Case CartsOn time case starts, satisfied

customers OR, Doctors, Patients

Metrics Metrics

-Surgeon's scheduling

Timeliness

-Surgery Schedule

Timeliness and accuracy

-Surgeon's Need's

accuracy

-Needs List Percentage

-CSP Absentee rate -Case Cart Completion

Rate

-CSP case Pick Technician

skills set

-OR On-time Starts

-Cardinal and HSS

distribution Fill Rates

-Vendor delivery

performance (Timeliness

and accuracy)

-Case Cart Completion

Percentage

Completeness acknowledged and

accounted for by tech

SIPOC DIAGRAM

Case Cart Completion Improvement Project

► ► ► ►Supplier Input Process

Print Surgery Schedule

Print Preference Cards / Pick Lists

Assign CSP Resources to Pick

Obtain Clean, Dry Case Carts

Pick Soft Goods and Document on

Preference Card

Pick Instrumemts and Document on

Preference Card

Output Customer

Sign Pick List and Surgery Schedule

Deliver to the OR



Along with the SIPOC a House of Quality was used to correlate and weight the various

customer requirements with the functional “Hows” of the process. This tool with the

later used fishbone helped the team to identify and quantify specific issues and eventually

determine the tasks required to address the problems. Figure 2.8 is the HOQ developed

and being two layers is spread over the next several pages.

Figure 2.8 House of Quality



The team assembled and produced an initial Process Flow to ensure that they understood

the process and breakdowns that occurred. This was built and displayed as a working

model on a roll of kraft brown paper, a portion of which is shown in figure. 2.8. This

methodology kept the team involved since the flow continued to be a work in process and

didn‟t feel like an end product.

Critical to Quality was assessed and the following was determined to be the key metrics.

Quality

Sets missing Instruments

Case Carts Missing Supplies / Instruments

Schedule

Case Carts Missing Supplies / Instruments

Cost

Missing Item Recovery Time

Revenue Potential

Case Pick Time



Figure 2.8 Process Flow

2.3. Assumptions

The Pareto of case delay cause codes reviewed in section 1.2 is inherently flawed due to

its subjective nature. The system that the OR staff uses to capture delay reasons is first

limited to a single input, while there may be numerous contributing factors to the delay,

or additional reasons that as stand-alone would have caused a delay. This puts the staff

member in the position of need to identify a „primary‟ reason for the delay. The

subjective nature is also heightened by the perception that a staff member may wish to

use a delay reason to “protect or incriminate” individuals. For this, the team determined

that it must conduct an in-depth study of the delay reasons.

While there have been threats from surgeons to leave the hospital and take their business

elsewhere and while their patience is limited, none have taken this option, but do make

life miserable for the staffs.

Case Cart assembly begins at about 5:00 pm the afternoon prior to the scheduled cases,

after the schedule has been finalized by the OR office staff. The case carts are assembled



in accordance with the surgery schedule, but the schedule is subject to change for a wide

variety of reasons.

The perception of what is late seems to be in constant debate. The OR staff will record

late case carts depending on whom and when the pre-case audit is done. This varies from

the time that the case is ready to commence to hours prior to case start. For purposes of

the team‟s study, late is defined as “1/2 hour prior to need in the room, potentially

prompting a case delay”

The amount of instrumentation is not unlimited. This is true and impacts the availability

of instruments for cases later in the day, as those same sets may be in use in earlier cases.

The ability to see that need and prioritize the “quick turn‟ of those sets is an important

step in the process. Standard supplies should never be an issue, if the replenishment

system is used and working correctly. Special order supplies may be a cause of delay,

but doesn‟t impact this study as they are outside the norm and out of the control of the

SPD staff.

Case carts delivered complete and on time remain complete. This is not a true

assumption as OR staff is known to cannibalize other case carts for supplies and

instruments when they feel a need or want to have extra “just in case”.

For purposes of savings calculation a standard value of $40 per OR minute is used. This

is based on the financial office‟s input that an hour of surgery in the OR puts $2,400 to

the bottom line.

3. Measurement

3.1. Study; Late Case Carts, Missing Items, Case Delays

Based on the initial process flow developed the team set out to quantify the process and

the effects of incomplete and late case carts to the OR. Part of the reason for the

approach taken was to fill the void of case delay reasons contained within the OR data.

The team observed and documented the timing and completeness of case carts for a

period of 27 days and conducted interviews with the surgery staff to determine the actual

reasons for case delay. Figure 3.1 contains the summary data from the study.



Figure 3.1 Base Data Development

Ca

se

Min

ute

s D

ela

ye

d S

um

ma

ry D

ata

Min

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From the data collected we tracked daily a number of key defect measurables including:

number of case carts incomplete

# Items missing from case carts

# Items missing per Case

Total Delay Minutes

# / % Instrument Sets missing instruments

Use of Attribute Control Charts:

Since all existing data points were used and the subgroups contained data from each

scheduled surgery for the day the sample size was inconsistent, varying from 90 to 105

across 27 subgroups. In the control charts (p) average sample size of 98 was used. NP

and C charts were not used due to sample size variance.

Used a false LCL to show methodology. In reality, there is no LCL as any item not

delivered could cause an unacceptable case delay.

U chart was used to show the number of items missing

There is a mix both in terms of types of cases being and 8 different technicians

responsible for the assembly of Case Carts. Note that in nearly all samples the technician

responsible isn‟t documented.

The p chart indicates a process out of control as it alternates data points up and down,

although over the center line.

The charts below contain the daily results the team found significant.

Incomplete case carts ranged between 15.7% and 40.8% daily with a mean of 26.6%. Each of

these incomplete case carts represents a potential case delay. Actual case delay is a function of



many other variables, including the critical nature of the specific item missing from the case. For

purposes of this study, that detail was not factored. Actual number of cases delayed due to

incomplete case carts was 85. This chart and data was later used to set up the first control chart

and the upper and lower control limits were calculated and included on this chart. During the

improvement phase this data was correlated to the individual tech and deficiencies in standard

process, training and motivation were addressed.

Items missing per ranged from .43 to 1.238 (.8) per total daily case count with a mean of .804

items per case. Factored against only those cases missing items the mean is 3.003 items per case

with a range of 1.19 (2.26 to 3.45). This correlation caused the team to consider that once a case

has a missing item, the technician picking the case failed to focus on completing as much of the

case as possible.



The two charts correlating the number of items missing to the delay time demonstrated that the

average case delay was 18.1 minutes and 6 minutes per missing item. There was a noticeable

increase following Labor Day that we attributed to unusual staff shortages and a delay in the

receipt of a supply shipment. A phenomenon noted was that contrary to expectation, days with

more items missing didn‟t necessarily result in longer case delays. This, presumably, is due to

an „all hands on deck‟ approach when items are missing. It did, of course, result in more staff

time to locate the multiple items.



As mentioned earlier, during the observation process the team noted the high number of

instrument sets not included in the case carts because the sets themselves were incomplete. Data

was collected from the SPD‟s instrument management system to get a picture of how prevelent

this issue was. The Missing instrument chart shows that over the course of 4 months an average

of 18% of all instruments sets assembled were incomplete. This became a major focus for

improvement.

Incomplete Case Carts Statistical Results

Over 27 days, between August 16 and September 15 there were 2648 surgery

cases conducted

o Daily case volumes ranged from 90 to 105

Of these 1620 (61.1%) were 1st or 2

nd cases for the room for the day

704 (26.6%) cases were picked incomplete

o 292 of these impacting 1st or 2

nd cases (11.3% of total cases)

85 (3.2%) cases were actually delayed due to incomplete case picks

Average OR case delay due to incomplete cases carts; 18.1 minutes

o Results in an mean delay to all cases of 4.8 minutes

Given $40 per OR minute lost the opportunity is $61.042 per month

66424 Items were required for the cases

2129 (3.2%) Items were missing

3.2 Sigma Calculation

Opportunities for Defect: 66424

Defects: 2129

DPMO: 32052

Failure Rate: .321

Accuracy Rate: .968

--------------------------------------

Sigma Level: 3.35



4. Analysis

4.1 Cause and Effect

Upon completion of the observations and base development, the team conducted a

brainstorming session utilizing the Ishakawa Cause and Effect diagram to detail the

variety of reasons for the incomplete case carts. Each entry was then weighted, after

lengthy discussion, to determine which had the highest likelihood of impact. See Figure

4.1.

Figure 4.1

Case Cart Completion Brainstorming Session Fishbone Diagram (the 6 M's)

E E U

Priority 1,2,3 N R E

2 I Lack of priority / Conflict management 3 U Audit vs. OR Feedback 2 I Block scheduling

1 H Picklists incomplete, inaccurate, extra items 1 S Individual Measurement 3 L Existing Carts not adequate

3 C Implants not listed on Count sheet 3 A Method of Accurate Measure 3 I Late reprocessing

Problem Description:

1 A Soft-goods need to be in T-Doc? 2 E No Consistent Definition of"Complete" 1 M

Case Carts sent M M

to OR Incomplete 3 M 3 M Out-of-Service Sets 1 M Different methods of documenting pick

2 A 2A Carry-Over Sets 1 E Lack of Job Expectation

1 N Lack of Knowledge - Location 1 T Loaners not available on time 1 T Quick Reference needed?

2 Lack of Knowledge - Material 1 E 1 H Lack of follow-up

1 Sets not put-away in right location 2 R 1 O

1 Staff indifference to assignment 3 I 1 D Lack of standardized process

2 Staff inexperience 1 A Loaners not available in time for processing

1 L Incomplete / Inaccurate Pref. Cards

Instruments not available at pick time

Interruptions to Pick (Phone & Delivery)

Impacts focus accuracy

Soft goods not available at pick time

"Called-For"sets not

returned to CSP

Sets "Called For"

in other Rooms

"Called for" Sets, not used, not

returned to CSP

Use of Priority List,

Inconsistent

Management follow-up

4.2 Pareto Revised

The reason code results from the team‟s observations were then entered into a new

pareto, figure 4.2 and compared to the initial results from the OR data system. While the

numbers were greater, the rating of the items didn‟t differ significantly.



Figure 4.2

0 10 20 30 40 50 60 70 80 90 100

Existing Carts not adequate

Soft goods not available at pick time

Staff inexperience

Inconsistent Management follow-up

Block scheduling

"Called for" Sets, not used, not returned to CSP

Different methods of documenting pick

Audit vs. OR Feedback

Carry-Over Sets

Implants not listed on Count sheet

Lack of Job Expectation

Lack of priority / Conflict management

Late reprocessing

Out-of-Service Sets

Sets "Called For" in other Rooms

Use of Priority List,

No Consistent Definition of"Complete"

Quick Reference needed?

Lack of standardized process

Lack of Knowledge - Material

Lack of Knowledge - Location

Individual Measurement (Accountability)

Method of Accurate Measure

Staff indifference to assignment

Sets not put-away in right location

Picklists incomplete, inaccurate, extra items

Interruptions to Pick (Phone & Delivery) Impacts focus accuracy

Loaners not available in time for processing

Instruments not available at pick time

Case Cart Incomplete# Times Reason Code Assigned

Source: Case cart Incomplete, 6-Sigma Tracker. Dates August 15, 2010 - Sept 14, 2010

These breakouts were then further defined into actionable steps and were entered into the

team‟s Action Item Log. The log eventually contained over 160 entries and remains in

use at the time of this writing. A portion of the Action Item Log is shown in figure 4.4.

Key actions taken by the team will be reviewed in the upcoming Improvement section.



Figure 4.4 Project Action Item List – Sample Page Effect: Case carts are not 100% complete, accurate and available on time

Category Cause Subcause Recommendation

Staffing Staff indifferentNot a value alignment Use dedicated staff for case

picking

Staffing Staff indifferent

No feeling that they are being measured,

watched or held accountable for case cart

defects

Use dedicated staff for case

picking

Staffing Staff indifferent

No negative impact to them while working in

case (by the time they do relief everything is

fixed)


picking

Staffing Staff inexperiencedNot all staff has scrubbed all cases therefore

they are not familiar with all supplies & trays


picking

Staffing Staff inexperiencedDescriptions on work sheets are not always

clear & user friendly

Have existing staff highlight

routine problem items &

allocate staff to fix daily

Staffing Staff inexperienced

No place for staff to reference locations for items Pick cases using pick lists &

ensure all items have location

list

Staffing Staff inexperiencedNo place for staff to reference where locations

are in relation to the core (master location list)Post master list of locations

Staffing Staff inexperienced

No existing process diagram or work instructions

for how cases are to be picked. Make work instruction & share

process flow with staff

Staffing Staff inadequate

Staff for case picking not dedicated. PM staff

used prior to 2:30pm when they get pulled to do

lunch relief


picking

Staffing Staff inadequateCases are booked after 5pm when staff is more

limited and/or in roomsUse dedicated staff for case

picking

Staffing Staff inadequateStaff picks the cases they are familiar with and

can do fastUse dedicated staff for case

picking

Case Carts &

environment

Existing case carts not

adequate

Items for case are placed on open carts (with 3

procedures per shelf) due to lack of availability of

carts

Use dedicated closed case

carts on each case

Case Carts &

environment


adequate

Case carts are not numbered or identified as

SJHC with numbering system

Label each cart with SHJC ID

number and reference back to

manufacture's SR #

Case Carts &

environment


adequate

Case carts have gotten lost or removed over the

years see above reason.

Label each cart with SHJC ID

number and reference back to

manufacture's SR #

Case Carts &

environment


adequate

Case carts are not being cleaned between each

use unless they are used for soiled transport to

SPD


carts on each case

Case Carts &

environment


adequate

No other system (totes or bins) available to

contain smaller cases such as eye cases.


carts on each case but make

an exception for eyes and put

three per cart.

Case Carts &

environment


adequate

Case carts are not closed therefore present

challenge with separation of clean and dirty


carts on each case

Case Carts &

environment


adequate

Case carts are not being maintained wheels

need lubricant Using SJHC cart ID number, set

up PM system with Biomed to

have carts inspected annually.

Monitor and report.



The opportunity to observe the Case Cart process caused us to revise the process flow a

number of times. The end result was a cleaner, streamlined version of the process and it

is included in the appendix. This exercise prompted the team to recognize that the case

cart process is highly variable and statistically out of control and generated a need for not

only improved processes but also standardized practices, which they developed in the

way of Work Instructions for each of the key components.

One of the top reasons for case carts not being completed was the SPD‟s inability to

complete instruments sets on time. While staffing appropriately across the day to handle

the incoming workload was an issue to be addressed, a significant factor was that the staff

had developed the habit of not putting up incomplete sets, making them unavailable and

not adequately communicating this to the OR. During the observation period a second

set of metrics and trending was initiated to begin to understand the magnitude of this

problem. A review of several months‟ data of sets missing instruments was captured

from the SPD‟s instrument tracking system. It was determined that for the period

extracted 18% of the sets put up were incomplete. The OR staff had complained often

enough that the SPD staff determined not to send the incomplete sets with the case cart,

further extenuating the problem. This became the focus of a major improvement

initiative which we will cover shortly.

While the availability of supplies would not have seemed to a major issue, it was

discovered that some case cart assemblers were not addressing all the supply needs.

Reasons ranged from:

They thought the supplies were actual stored in the OR

Were unfamiliar with the supply layout to

Supplies not listed with locations on the pick tickets

If one item is missing, less focus came to picking all the remaining items.

This then lead to another major improvement initiative by the team and began with a

spaghetti diagram detailing the typical paths taken by the case assemblers to pick all

supplies.

5. Improvement

This is where the proverbial rubber meets the road. Beginning with the brainstorming,

process flow review and Paretos used in the measurement and analyze phases of the

project the team constructed an action plan that eventually grew to over 160 separate

items covering the following areas:

Staff experience , skills, training, motivation

Case Cart condition and size

Space for storage, picking and staging

Standardized procedures and work instructions

Pick sequence and flow

Pick list updates

Completion of instrument sets



Availability of loaner and consignment sets

It‟s important to the team to set and follow a structured approach or risk losing

themselves in the myriad possibilities and tasks. Many of the improvement tasks

identified are beyond the team‟s scope and will remain for the SPD leadership to continue

to facilitate or move to another improvement initiative.

A Test of Change approach was used to introduce process changes. The team determined

the change, its method of measurement to see whether the change resulted in

improvement, then communicated to the SPD and OR staffs the change and how it would

be implemented. Critical to the team‟s thinking was to over communicate in order to

gain buy-in.

Using the tools the team set to determine a priority for the solutions, establish the

improvement method, define the implementation steps and communicate.

It is clear that standardization of process and practice is key to any sustainable

improvement. First steps included cleaning up the process flow and using it to

demonstrate the opportunities and the revised or new elements to the SPD staff,

developing a set of Standard Work Instructions detailing the „hows and whys‟ of each

associated task. For the Case Cart Technicians these include instrument set put-away,

pick sequence and documentation. Standard Work Instructions were also developed for

the SPD Instrument Set Assembly process. The document took the form of a step-by-

step manual with photos correlated to each step. The process steps were reviewed with

each staff member during training sessions and are visibly posted in the work space for

quick reference. The simplified process flow is included in the appendix.

As part of the effort to complete instrument sets it was deemed necessary to identify the

critical instruments in each set. This information is then entered into the SPD‟s

instrument management system and guides the assembly technician to not complete the

assembly if a critical instrument is missing, but to complete it if a non-critical instrument

is missing. This should result in fewer sets being left unavailable for use in a case. An

additional step added to this work sequence is a required supervisor sign-off for any set

assembled incomplete. While this is contrary to Lean thinking, it was determined to be

pragmatic and necessary in the short-term to ensure awareness and adherence to the

process. The identification of critical instruments is a painstaking chore, accomplished by

OR personnel, so it will be a work-in progress for some time.

A result of the focus on instrument set completion highlighted the negligence of the SPD

management to effectively replace instrument that were lost or damaged. A significant

expenditure needed to be made in order to elevate the inventories to the point that a daily

impact could be made. The team sponsor agreed that the expenditure had been needed for

some time and measures were put in place to monitor the needs going forward, so the

cost associated are not included in the cost-benefit analysis or savings projections for the

project.



Process changes in the Case Cart Assembly process includes re-layout of the supplies

inventory from a product-family based to alignment with the pick ticket sequence and the

addition of stores location on the pick ticket printout. A Quick Reference Locator was

also produced and made available in various supply areas. This later change addresses

needs that occur more often after the case carts have been picked, for add-on or

emergency cases or when unforeseen needs arise.

In addition to the change in the stores layout a 2-bin Kanban was installed. In this system

each item‟s inventory is evenly split between two compartments. The items are picked

from the „active‟ compartment. Once this is empty, pickers select from the second or

backup compartment. Empty compartments or containers are replenished. For small

items, bins are used as the kanban signal. For larger items cards are used.

The realignment of the stores, integration of the kanban system and inclusion of item pick

locations has resulted in a pick time reduction of an average of two minutes, from 18 to

16 per case. At 98 cases per day the savings equates to 196 minutes each day.

Kanban Pictures

Swinging Compartment Door

With the above key process changes the team still needed to address the control and

compliance issues within the Case Cart assembly process itself. Consistency is important,

but it comes at a cost. Introduced were the requirements that the picking technician

record each pick ticket they assemble. While not a fix, it was hoped that the requirement

would raise awareness. Case carts required, by timing, to be sent to the OR incomplete



required a supervisor‟s sign-off and a communication call to the OR control desk. This

helped preemptively set in motion any schedule change or recovery action needed.

Highlighted in the brainstorming session was the need for cross-training. The department

suffered when primary Case Cart Assemblers were absent, especially if more than one.

Other areas within the SPD had similar issues. It was determined to begin a cross-

training program and soon to begin a position rotation that would allow for staff to gain

competency in all areas. It is beyond the scope of this team to provide the train or set up

the schedules and this will be left to the department management. They are documented

on the project action item list for future follow-up.

Daily controls and metrics were introduced to track case cart and instrument set

completion rates. These are displayed daily at a department level and fed into a Quality

Dashboard at an individual as well as department level. Note: The dashboard is now

expanding to track quality, productivity and service across the entire SPD.

6. Control

Controls are integral to the success of any implementation ensuring compliance to

practices and standards, monitoring improvement progress and sustaining the gains. First

and foremost are the Standard Work Instructions highlighted before and training provided

to gain understanding and compliance.

Among the controls implemented was the Case Cart Audit mentioned in the prior section.

This audit provided near real-time feedback from the OR to the SPD. The results were

posted daily in the Incomplete Case Carts Daily-Monthly Control Chart. Figure 6.1

shows the actual charts for the months of October and November.

For purposes of this exercise, both Upper and Lower Control Limits were calculated, but

the team and staff recognizes that the target for incomplete case carts is zero. In the two

months since initiating the project steady progress has been made. The last two weeks of

November shows the incomplete carts steady at about 16.4 % versus 26.6 during the

observation period. Still work to do, but showing a 38% improvement.



Figure 6.1 Incomplete Case Carts Control Chart

The second control chart installed is a daily tracker of instrument sets assembled

incomplete. Figure 6.2 contains the charts from October and November and demonstrates

significant improvement. November versus the base period shows an improvement from

18% to 9.9% of Instruments Sets assembled incomplete for a 45% improvement. This

trend is expected to continue as many eyes are focused, now, on the problem.



Figure 6.2 Incomplete Instrument Sets Control Chart

Additionally, a daily report was established to actively monitor case delays recorded to

incomplete case carts. While the OR recording methodology hasn‟t changed and

therefore the inherent inconsistencies still exist, the renewed awareness and diligence by

the OR staff, coupled with improved review from OR management may provide better

insight. For the month of November the OR statistics reported versus the base period:

OR Stats Base November Imp %

Total Cases 2648 2725

# Incomplete Case Carts 702 26.5% 447 16.4% 38%

# Caused Delayed Cases 85 3.2% 68 2.5% 22%



7. Conclusion and Outlook

The 6-sigma methodology proved a useful approach to identifying, quantifying and

providing a framework to address the many issues related to incomplete case carts at this

hospital. Using the DMAIC roadmap the SPD can increase its accuracy and therefore

dependability in customer service.

While we have not yet met our goals, it is believed that with continuing perseverance that

they may be over the next 4 to 8 months. We‟ve seen our metrics improve:

Incomplete Case Carts down from 26.6% to 16.4 %, a 38% improvement

Incomplete Instruments Sets, while not an initial goal, became a significant factor

in incomplete case carts: down from 18% to 9.9%, a 45% improvement.

Sigma level

Sigma Calculation Base November

Opportunities for Defect: 66424 69387

Defects: 2129 1370

DPMO: 32052 20625

Failure Rate: .321 .197

Accuracy Rate: .968 .980

---------------------------------------------------------

Sigma Level: 3.35 3.56



Base Data Normalized to November Actuals and Savings Projection Summary

# Cases Incomplete

Incomplete

Resulting

in OR Delay

Delayed

Cases

Delay

OR Lost

Minutes

per Case

Delay OR

Lost

Minutes

per Day

Cost per

OR

Minute

Cost Daily

Delay Lost

OR Min

OR Staff

Minutes

per Case

OR Staff

Minutes

per Day

Cost per

Staff

Minute

(Burdened)

Cost Daily

Staff Min

Total Delay

Cost per

Day

Daily Avg. % # # % # Min Min $ $ Min Min $ $ $

1st & 2nd Cases 60 82% 49 11 15% 1.6 18 29 40$ 1,166$ 30 324 0.63$ 205$ 1,372$

Remaining Cases 38 60% 23 15 10% 1.5 18 27 40$ 1,094$ 30 456 0.63$ 289$ 1,383$

Total Daily 98 73% 72 26 3.1 56.52 2,261$ 780 494$ 2,755$

25480 18720 6760 816 14695 587,808$ 202800 128,440$ 716,248$

Base 27 Day Month 2648 1944 702 85 1526.04 61,042$ 21060 13338 74,380$

November 2725 447 68

Impact at Base 722 87

Improvement and Savings Impact 275 19 18 346.42 40$ 13,857$ 30 8262 0.63 5,205$ 19,062$

Direct Project Savings Annualized 166,279$ 62,464$ 228,743$

Addition Soft Savings

SPD Case Cart Pick Time

# Case

Carts

Daily

Base

Assm.

Mins

Nov. Assm.

Mins Improvement

Saved

Mins /

Day

Std Prod

FTE

Min/Day

Equiv.

FTEs

Mean FTE

Payroll

(Annual) Savings

Subtotal 98 18 16 2 196 390 0.5 32,000$ 16,082$ 16,082$

11.1%

# Sets

Daily

Base

Missing

Nov.

Missing Improvement

SPD

Mins per

set

Saved

Mins /

Day

Std Prod

FTE

Min/Day

Equiv.

FTEs

Mean FTE

Payroll

(Annual) Savings

910 164 121 43 25 1075 390 2.8 32,000$ 88,205$

18% 13% 26.2%

OR Mins

per set

Saved

Mins /

Day

Std Prod

FTE

Min/Day

Equiv.

FTEs

Mean FTE

Payroll

(Annual) Savings

Subtotal 12 516 390 1.3 43,000 56,892$ 145,097$

Subtotal Soft Savings (not verified) 161,179$

Potential Total Project Savings 389,922$

SPD/OR Time recovered due to

improved set completion

Baseline

Complete

Average Annual @ 260

surgical days

Using the base data for comparison to the results in November we can ascertain that we are on

track to save $228,743 annually. While the impact on staff minutes spent searching for missing

items is nearly on track, it‟s difficult to tell if the lost OR time will be sufficiently recovered.

Shown also are soft savings calculated based on the reduction in time to pick and assemble case

carts and reduction in the time SPD uses search for instruments from incomplete sets. These lines

are excluded from the Direct Project savings for two reasons; first they are difficult to verify on a

consistent basis and no labor has actually been reallocated from the department and second, they

were not part of the original savings projections. However it is important to recognize the

impact that the 6-sigma team had relative to the entire process. It is too early to definitively state

that the project will result in the savings projected, however at the time of this writing all

indicators are moving in the right direction and the gains made are being sustained.



Appendix

Six Sigma Case Cart Project Final Report Jan. 2011

Documents

Transcript of Six Sigma Case Cart Project Final Report Jan. 2011