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Health facility professionals must know pre-cisely which pieces of equipment requirepreventive maintenance or routine inspec-

tion, which work orders are outstanding, and whichassets are near the end of their useful lives.To help, the staff at Virtua, a health care system

based in Marlton, N.J., is using new technology andpractices to improve the process for preventive, rou-tine and predictive maintenance for more than

10,000 assets at its four acute care hospitals.The multigenerational plan will allow manage-

ment to maintain regulatory compliance, meet cus-tomer expectations around equipment repairs, andbudget appropriately for big-ticket facility items. Implementation has been organized into three

phases: preventive, routine and predictive mainte-nance. While all three phases have involved intro-ducing new technology to the facilities staff, the

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Using Six Sigma to implement a work-request system

BY DAVE OWENS

routine-maintenance phase has involvedintroducing a new electronic work order-request system to Virtua’s more than8,000 employees and, most importantly,getting them to use it.

A broken systemIt was clear that the existing mainte-nance-request process was broken. Plac-ing requests was complicated and incon-sistent because there were so many dif-ferent ways to do it — phone, email,pager, log book or “tell the facilities staff.”In addition, staff spent a great deal oftime managing and delegatingrequests, investigating andresponding to complaints andtracking open work orders. The manual nature of the

process made metrics for keyindicators difficult to collect andcompare across divisions. Froman internal customer’s perspec-tive, the process was inefficientand a burden. A nursing leader’sfeedback summed up the gener-al attitude about the process.She said it was difficult for staffto place a request; it was hard tofollow up on a request once onewas placed; it seemed to takedays to complete a request; andmultiple requests sometimes

were required for the same issue. The maintenance initiative focused on

designing a process that streamlined rou-tine work order submissions for requestssuch as clogged toilets, stained ceilingtiles, broken equipment and even projectwork (e.g., painting and renovations). Management recognized that improv-

ing routine maintenance would involvechanging not only the technical processof submitting requests but also the behav-ior of thousands of staff. They chosedesign for Six Sigma (DFSS) tools andmethodology so they could include staff

in the process of creating and implement-ing the standardized, enterprisewide rou-tine maintenance program.

Major DFSS stepsThe five major DFSS steps — define,measure, analyze, design and verify —were applied to the project in the follow-ing ways:

Defining the challenge. The firstphase of the DFSS process focused onbuilding a team and defining the project.The project was sponsored by a hospitalchief operating officer and the vice presi-dent for support services. The team con-sisted of facilities directors, operationsdirectors, the system safety director, ITbusiness analysts, human resources, anHVAC vendor and facilities staff.Three of the team’s initial tasks includ-

ed identifying industry best practices,scoping the project and assessing chal-lenges they needed to address. The teamconducted a comparative analysis toidentify best practices from organizationsboth within and outside the industry,including process strengths, requirementsand lessons learned. The scope includedequipment already supported by facilitiesmanagement at the organization’s fouracute care facilities and one of the sys-tem’s ambulatory-based facilities.The team identified two major chal-

lenges — managing change and account-ing for the differing levels of clerical sup-port staff within the facilities depart-ment at each hospital. The teamidentified key stakeholders at each loca-tion and tried to assess their potentialresistance to change. While most stake-holders were not opposed to change, theteam learned they would have to help

move the primary customers(i.e., clinical and non-clinicalstaff, and physicians) to amore supportive mindset.Regarding clerical staffinglevels, the team was con-cerned that people would beless likely to submit a rou-tine request electronicallyand more likely to continuecalling clerical staff withinthe facilities department toverbally place a request.The team decided to take await-and-see approach tothis issue. If the use of cleri-cal staff impacted the adop-tion rate, the team woulddevelop corrective action.

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Tommy Doss, a plumber located at Virtua’s Marlton, N.J., facility, responds to an automated work order that requires his attention.

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Jonathan Morad, maintenance mechanic at Virtua Marlton, resolves a room-temperature issue moments after receiving the request.

Measuring customer needs. The nextphase consisted of identifying the cus-tomers’ needs and deciding which met-rics were deemed critical to quality. The team developed a survey with five

questions focused on timeliness, notifica-tion preferences and communicationaround delays. The results showed that atleast 65 percent of customers preferred tosubmit requests and receive updates elec-tronically. In addition, customers workingin patient care areas wanted a time-sensi-tive mechanism they could use when anurgent or a patient-related request need-ed attention.

Analyzing and designing. Inthe analyze and design phases,the DFSS team created processmaps to show each step in thenew routine. The goal was to setup a process that incorporatedcustomers’ expectations and wasefficient for the facility staff.The team focused on develop-

ing a process that provided anelectronic method for routinerequests, included a method forplacing expedited urgentrequests and integrated an elec-tronic feedback mechanism. The team spent a day design-

ing the new process, whichallowed customers to submitroutine requests via Virtua’sintranet and submit urgentrequests by phone to a facility staff member who thenwould enter the request into thesystem elec tronically andaddress it immediately.The team decided to pilot the

plan enterprisewide instead ofat one facility because the elec-tronic requests would be initiat-ed from Virtua’s systemwideintranet. Also, starting the pilotsystemwide would reduce con-fusion among front-line staff, especiallythose who travelled between facilities.The team created a scorecard to deter-

mine effectiveness of the new processand gauge the success of the pilot. Met-rics included the percentage of requestsmade by Web versus phone, the time ittook to acknowledge a request, and thetimeliness of work completion. A commu-nication plan was developed to educatestakeholders across all facilities. It includ-ed educating staff at manager meetings,distributing weekly notices and instruc-tions in organizationwide electronic

newsletters, conducting departmentrounds, making presentations at townhall meetings and putting placards in allcafeterias leading up to the change. The pilot lasted four weeks. Initially, 54

percent of routine-maintenance requestswere made electronically, far short of theteam’s goal of 80 percent and an indica-tion that the process was not hardwired. Additional analysis showed that the

electronic method was adopted moreslowly in facilities with more clerical sup-port within the facilities department. So,when a nonurgent request was phonedin, the facilities staff captured the

request, entered it electronically, educat-ed the caller about the new system andencouraged the caller to use it. During the pilot, 100 percent of

requests were acknowledged within 45 minutes. This performance met thecustomer’s expectation. In fact, becausethe system was electronic, the personmaking a request received immediateconfirmation of the submission and infor-mation about tracking its progress. Withrespect to timeliness, 81 percent of thework orders opened were closed duringthe four-week pilot. This surpassed the

goal of closing 80 percent of work orderswithin 30 days.

Managing mixed results. When aDFSS project comes to a close, a controlplan is put in place to monitor and hard-wire the new process. In the case of thisproject, the control plan included stan-dard reports that are reviewed and actedupon monthly by the facilities council(consisting of the vice president for sup-port services, the system safety directorand facility directors from all campuses). A follow-up was conducted to deter-

mine the sustainability of the pilotresults. Between May 2009 and February

2010, more than 18,500 rou-tine-maintenance requestswere placed across the system.The acknowledgment- andwork order-completion targetsfor these requests wereachieved. However, use of theWeb-based system for routinerequests significantly laggedthe target.The team scrutinized data

and observed that the lowestutilization rate was at the orga-nization’s ambulatory center.The most likely reason wasbecause the majority of thebuilding’s occupants are non-Virtua employees in officespace rented by health care-based community organiza-tions. Although a portal wasbuilt for this group to allowaccess to the system, adoptionhas been slow. The two largest facilities —

the ones with the most clericalstaff in the facilities depart-ments — displayed the nextlowest utilization rates. Theteam spoke with employeesthere and found they contin-ued to ask facilities staff to

place routine requests instead of enteringthem electronically simply because staffwere readily available. The team also learned that another fac-

tor contributing to the low electronic-sub-mission rates was the way environmentof care (EC) rounds were documented.These monthly safety rounds are com-pleted by a representative from eachdepartment who submits routine-requestwork orders via paper to the facilitiesstaff, leaving a facilities clerical staffmember to enter the information elec-tronically into the new system.

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After implementation of the new system, maintenance team members can respond more quickly to routine and urgent requests.

As a result, the team will be imple-menting a way for the department safetyrepresentatives to capture the EC infor-mation electronically and submit it to theroutine-maintenance request system viaan electronic work order. In addition, the team is working with

the maintenance-request system’sadministrator to create an automaticallygenerated report that the administratorand the project sponsors can use tomonitor the electronic request rate real-time. Furthermore, the team is studyingthe facility with the highest utilizationrate to replicate the best practice that ispresent there.

Keys to successThe control phase of the project contin-ues as the team works to build on theproject’s overall successes. Several keyfactors have made the system viable andrevealed opportunities for improvement.First, the project received support at all

levels of the organization. Second, therepresentatives from facilities manage-ment were very committed to the success

of the new process. Third, informationtechnology support was critical. And,finally, the DFSS methodology providedthe structure needed to build standardiza-tion and implement process changeacross the organization.After implementation of the new

process, the facilities team and customersnoted significant benefits.“The new system has had multiple

benefits,” says Rick Houck, director ofplant engineering at Virtua’s Marlton,N.J., facility. “Because the previousprocess was manual and had multipleinputs, we were challenged by howquickly we could complete requests.Now my team can complete requests intwo hours because we have a consistentway of receiving them.”Houck adds that the new system allows

him to shift staff between projects androutine-maintenance work, depending onthe current needs of his customers. The ability to track and trend com-

plaints also has improved. “We are nowable to tell when, and if, a work orderwas placed and can work with our

employees to make sure that everyonefollows the correct process to place awork order,” Houck says. “In addition, theability for our system to ‘close the loop’with the customer has proven to be bene-ficial as customers don’t have to wonderif their request was completed. Theyknow exactly when it was done.”

Customer focusPreventive maintenance, routine work-order requests and predictive mainte-nance can be streamlined through the useof new technology, but these softwarepackages are hardly “plug-and-play.”Rather, new technology should be used

in conjunction with a process-improve-ment tool like Six Sigma that encouragesstaff involvement and, most importantly,a focus on the health care facility’s inter-nal customer base. HFM

Dave Owens is a Six Sigma black

belt working in operations improve-

ment at Virtua in Marlton, N.J. He

can be contacted via e-mail at

dowens@virtua.org.

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