Transcript Six Sigma ED Wait Time Project Presentation UVA

Six Sigma at Academic Medical Hospital
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The following presentation was developed by Jane
McCrea, Black Belt of the ED Wait Time Project at
Academic Medical Hospital.
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The presentation follows the DMAIC methodology.
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Six Sigma--DMAIC
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Define: Define and scope problem. Identify potential
benefits and critical to quality (“CTQ”) factors.
Measure: Identify the key internal process that
influences CTQ characteristics and measure the
defects generated relative to the identified CTQs.
Confirm measurement system reliability. Know voice of
customer. End result: team can successfully measure
the defects generated for a key process affecting the
CTQ.
Analyze: Identify root causes of defects. Use statistical
data tools to identify key process inputs that affect
process outputs. End result: explain variables that are
likely to drive process variation the most.
Improve: Determine and confirm optimal solution
(statistically re-analysis). Identify the maximum
acceptable ranges of key variables. End result: modify
the process to stay within the acceptable ranges.
Control: Ensure that modified process now enables the
key variables to stay within the maximum acceptable
ranges using tools such as metric dashboards and
accountability reporting.
ED Wait Time
six sigma
The Way We Work
Project Description
Reduce and consistently maintain patient
wait times from triage start to first physician
interaction at established thresholds.
EXPECTED BENEFITS
Customer: Critical to Quality (CTQ)
•Reduce Wait Time
Internal: Critical to Quality (CTQ)
•Improve Patient/Staff Satisfaction
•Enhance Patient Outcomes
•Increase ED capacity and
operational efficiency
Arrival
Triage
Register
Lobby
Define
Champion
Dr. Gerry Elbridge
Sponsor
Dr. Terry Hamilton
Black Belt
Jane McCrea
Green Belt
Dr. James Wilson
Foundations Team
Nancy Jenkins, Bill Barber,
Georgia Williams, Steve Small
Tx Room
Nurse
MD
Measure
What was the Voice of the Customer?
Acceptable Lobby Wait Time
Patient Survey
•N = 30; Priority II Patients
•Random: all days, all shifts
14
12
< 10
10
10 - 20
8
20 - 30
6
30 - 60
4
> 60
2
Patient Survey Results
•Wait Time Expectations:
10-20 minutes: 43%
20-30 minutes: 23%
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< 10
10 - 20
20 - 30
30 - 60
> 60
Lobby Wait Satisfaction Rating
Patient Survey Results
•Wait Time Satisfaction
Very Satisfied: 37%
Very Dissatisfied: 37%
12
10
V. Sat.
8
S. Sat.
6
Neutral
4
S. Dissat.
V. Dissat.
2
0
V. Sat.
S. Sat.
Neutral
S. Dissat. V. Dissat.
Baseline Measurements
An observational prospective manual time study
yielded baseline measurements for the total wait time
Triage Start to
MD Start
20
60
100
140
180
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Mean: 62.5 min.
Std. Dev: 39.66
Z-Score: 1.79
Defect Rate: 38.6%
USL: 37.1 min.
Measure
What did we measure?
 Y: # of Minutes, from Triage Start to First Physician Interaction
 Specification Limit: 37 minutes
 Specification Validation: Internal experts & data, External
benchmarks
 Defect: Wait time > 37 minutes
 Unit: One priority II patient visit with one defect opportunity each
 Measurement System: Patient Survey, Manual Data Collection,
Chart Review, Quality Reports, Registration & Staffing Reports
 Impact on Business:
 25 min. Line of Sight Reduction Per Patient Resulting = Capacity
Opportunity
 Improved Patient Satisfaction, Reduced Complaints, Enhanced
Outcomes
 Improved Staff Satisfaction & Reduced Turnover
 Improved Daily ED Operational Efficiency
Key Takeaway: 40% Wait Reduction & Operating Margin Gains
What critical X’s were tested as being root causes of the problem?
Environment
People
ED patient volume
Materials
Analyze
Staffing levels
ED patient acuity
Experience & skill level
Influx of squad patients
Resident specialty
Referral volume
Volunteer/greeter utilization
Clinics schedules
Family needs
OR volume
Role clarification
Hospital patient volume
Match of skill sets and assignments
ED tx room limits/facility constraints
Variation of practice
Triage process
Availability of diagnostic equipment
Registration/Chart prep process
Availability of trams, pumps, etc.
Charting procedures
Non-optimization of Tracking system
Communication
Inadequate IS system for tracking/trending
No Physician Prescription Writing system
Availability of supplies
Utilization of minor emergency unit
Ancillary services levels
No integrated, on-line charting system
Specialty testing delays
ED used as admission unit
Quality of measurement
Are we measuring the right things?
What do we do with what we measure?
Need to do more than “track”
Feedback systems to quality auditing
Need for Improved flow sheet format
Lack of on-line charting system for
automated monitoring
Measure
ED discharge practice
Machines
Hospital discharge process/timing
Consult responsiveness/practices
Use of ED for boarding
Segmentation/delineation
Sequential care vs. parallel processes
Improvement implementation/maintenance ownership
Methods
23 variables & 18 time stamps
Analyzed via 2nd. wave of data collection
 Patient Volume-Related: 10
 Staffing Volume-Related: 5
 Staffing Mix-Related: 5
 Misc: 3
Improve
What critical X’s were tested as being root causes of the problem?
23 variables selected & analyzed
through second wave of data collection
 Census-Related: 10
 Staffing Related: 5
 Coded: 5
 Miscellaneous: 3
What root causes were confirmed and tested in the pilot?
Patient Flow
 Direct-to-bed flow & bedside registration
 Patient relocation to semi-private space when appropriate
 Flow Facilitator
Care Team Communication
 Modified Zoning
 Communication Board
 Clinical Protocols
Streamlined Order Entry & Results Retrieval Process
Pilot Design
Fishbone diagramming, data collection and statistical
analysis determined the Critical X’s (contributing
factors) as key components for the randomized pilot.
1. Patient Flow
 Direct-to-bed flow; Relocation to semi-private
space
2. Care Team Communication
 Zoning; Communication board; Clinical protocols
3. Streamlined Order Entry & Results Retrieval
 Uses central clerk
What were the pilot factors and results?
Improve
Patient Flow
 Direct-to-bed flow & bedside registration
 Patient relocation to semi-private space when appropriate
 Flow Facilitator
Care Team Communication
 Modified Zoning
 Communication Board
 Clinical Protocols
Streamlined Order Entry & Results Retrieval Process
Lobby
Target
15 min.
Study 2
N = 129
Wait
Time
34.5 min.
% Defect
51.2%
Pilot
N = 172
MD
Target
8 min.
Study 2
N = 129
Pilot
N = 172
12.6 min.
Wait
Time
11.2 min.
8.9 min.
22.8%
% Defect
42%
34.9%
PILOT RESULTS
Lobby
WT
Study 1
N =30
Lobby
WT
Study 2
N = 129
Lobby
WT
Pilot
N = 158
MD WT
Study 1
N = 30
MD WT
Study 2
N = 127
MD WT
Pilot
N = 172
31.2
34.5
12.6
16.1
11.2
8.9
26.65
16.02
11.69
18.70
46.76
16.68
% Defect
56.7%
51.2%
22.8%
55%
42%
34.9%
Z-Score
1.33
1.47
2.25
1.37
1.71
1.89
Mean WT
(minutes)
Standard
Deviation
(Attribute)
PILOT CONCLUSIONS
Mood’s Median Test
Lobby WT
Study 1 to Pilot
Lobby WT
Study 2 to Pilot
MD WT
Study 1 to Pilot
MD WT
Study 2 to Pilot
P-value
95% C.I.
0.001
2.7 to 31.8
0.000
4.8 to 13.2
0.016
1.0 to 16.0
0.772
-2.00 to 3.00
Lobby WT N
MD WT N
Study 1
30
30
Study 2
129
127
Pilot
158
172
 Pilot lobby wait times
were better than the
established 15 min.
target, the defect rate
tumbled, and the C.I.
validated statistical
significance.
 Results for MD wait
times were statistically
significant in one of two
Mood’s median tests.
Positive trending was
demonstrated in the
comparison of Study 2 to
the Pilot.
Stakeholders supported
department-wide, multipatient population
implementation.
Improve
Control
What are the building blocks of Control?
Guidelines & Assigned Responsibility
New Standard Operating Procedure
Detailed Who, What and When plan
Data Review, Reporting & Accountability
Quarterly manual/automated data analysis
Monthly reports and control charts
Use of Corrective Action Log per guidelines
Monthly reports
Scheduled reporting to executive leadership
Quarterly review to owner peers & executives
Communication & Recognition
Monthly updates to dept. communication center & newsletter
Monthly updates at staff, faculty & resident meetings
Incorporation of staff recognition for ongoing positive results