David O'Koren / Senior Consultant
Project Masters Inc.
Project Masters has been helping hospitals
apply the process improvement techniques that are in widespread
use in industry to their healthcare business with impressive
results. These tools have been used in many hospital processes
in areas such as Surgery, Laboratory Services, Nutritional
Services, Pharmacy, Hospital Admissions, etc. Results from
some of those improvements included reducing the time to
get laboratory results. In the Food Processing Center (FPC)
meals were prepared in large batches for several campuses.
Applying the Lean Principles increased the productivity
of the cooks, reduced inventory and reduced lead time (how
far in advance each campus had to place its orders with
the FPC).
This case study deals with one such improvement
initiative within a hospital. Results include increasing
patient satisfaction, decreasing the time it takes to see
an Emergency Department doctor from an average of 182 minutes
to a 2-month average of 143 minutes, and lowering Out-Patient
Length of Stay (LOS) in the Emergency Department from a
baseline of 336 minutes to a 2-month average of 288 minutes.
All of this was done without increasing the number of doctors,
staff or rooms.
Case Study -Increasing Patient Satisfaction
in the Emergency Department
A hospital was getting some of the lowest
emergency department patient satisfaction scores of any
hospital in the country. Gallup Patient Satisfaction scores
were in the range of 1 to 10 percentile. Although the emergency
department was helping patients and saving lives, their
patients were not happy with their experience in the emergency
department. The hospital had tried training its staff to
show more concern for the patients. They tried to do more
things to make the patients more comfortable (warm blankets,
ice chips, meal coupons, etc.) However, nothing seemed to
have a positive impact on the scores.
Using the DMAIC (Define, Measure, Analyze,
Improve, and Control) Process, the first step was to identify
the scope of the process: who are the Customers and what
do the Customers expect? The Emergency Department had about
35 beds with which to handle the 150 to 200+ patients per
day that they saw. From looking at the hospital's data,
it became very apparent that over 80% of the emergency room's
Customers were outpatient. That is, they came to the Emergency
Department to see a doctor and then they went home. They
expected only the best possible treatment and they wanted
it quickly. However, it was taking over 3 hours, on average,
to see a doctor and they could expect to be in the emergency
department for four to five hours once they arrived. Even
with warm blankets and meal coupons, the three hour wait
to see a doctor was never pleasant as the patients were
not feeling well to begin with and had to sit next to people
that seemed even sicker. Patients would regularly call an
ambulance to take them to the emergency department thinking
it would get them to see a doctor sooner. Or they would
present with "chest pains" hoping to get treatment
faster. When none of this worked, they became even more
dissatisfied.
The next step was to actually see what the
patient sees by measuring the process. The hospital assembled
a cross-functional team to work with the consultants. The
team used several Lean tools including Patient Process Flow,
Value Stream Mapping, and Full Work Analysis. Once the current
state of the process was understood, the team collected
data on the cycle times, change over times, defect rates,
patient volumes, and other pertinent data. Many great suggestions
and ideas were discovered during this stage and were recorded
for later use.
An analysis was performed using all the data.
Ideas were collected that resulted in a consensus on the
best improvements to make. To determine whether the ideas
were really going to be improvements, a pilot was run to
prove the benefits. Since the team was made up of a good
cross-section of the emergency department, they had enough
staff with the right skills to run their own track for a
few hours. As some of the team worked the pilot, other team
members would take data on the proposed process. The consultant
then led the team through data analysis and discussion to
make even more improvements, given their new knowledge from
the pilot.
All of the improvements were then documented
in an "Education Packet" to help educate the rest
of the Emergency Department staff or any new hire. Every
person in the department and some of the ancillary processes
were educated in their new role including doctors, nurses,
technicians, and administrative staff. Communication sessions
were held with other departments in the hospital to explain
what the team had found, how they would be changing their
process, and what results they expected. Since change is
not easy, the team was used to "coach" the rest
of the staff for the first 3-weeks to ensure that the new
changes would stay in place and to catch and correct any
issues that were created by the new process.
Sustaining the new process was accomplished
by creating a "Lean Committee" that would advise
the Emergency Department Director on what issues were being
encountered and to make suggestions on how to overcome these
issues. In addition, the consultants devised an audit that
could be done by the Emergency Department on a regular basis
to see if they were sustaining the gains made by the implementation
team and to define a path for further improving the process.
The Emergency Department has held their gains.
They reduced the average Door-To-Physician time from 182
minutes to 143 minutes. Outpatient LOS dropped from 336
minutes to 288 minutes. Patient Overall Satisfaction increased
substantially. No new staff was added. The team expects
even better results, as they are able to implement some
of the longer-term improvement opportunities in the next
month. Their goal is Door-to-Physician time of 45 minutes,
Out-patient LOS of 120 minutes, and Patient Satisfaction
greater than 80th percentile.
The biggest benefit that the hospital has
gained is that they now have people trained in improvement
techniques that can be applied to any process in the hospital.
Improving the Emergency Department helped to expose other
opportunities. Admission Holds can clog the Emergency Department
and cause extensive wait times. As a result, this hospital
has chartered a new team to use some of the same techniques
on the admission process. In addition, patients who leave
without seeing a doctor are a defect to the Emergency Department.
This has been a great opportunity to apply the Six Sigma
tool set.
Project Masters has the knowledge and
experience to help your hospital improve its processes.
We combine the right techniques of Lean, Six Sigma, and
Project Management to get the best results quickly. We are
committed to training your staff to understand the improvement
techniques so that they can continue to apply them to other
processes. We leave sustainable improvements in place, along
with the metrics to determine whether the hospital is sustaining
its gains.
Background of the Improvement Techniques
In the late 1800's, Frederick Taylor began
to study processes to improve how quickly they could be
accomplished. Frank Gilbreth (and later his wife Lillian)
built on Taylor 's work, but instead of looking exclusively
at the time a step in the process would take, they looked
at the motions that were used to perform the process. Henry
Ford used both of these techniques to design the first assembly
lines, which produced automobiles quicker and cheaper, making
them affordable to more people. Ford shared his techniques
with Tiaichi Ohno and Shingeo Shingo who worked for Toyota. Over the next fifty years, Toyota created and refined
the techniques to make Toyota one of the most revered and
profitable auto companies in the world. James Womack and
Daniel Jones began to research why Toyota was having such
phenomenal success and, with the help of their research
team, coined the term "Lean Thinking" to describe
how Toyota continually improved its operations to do more
with fewer resources.
During World War II, Dr. W. Edwards Deming,
Dr. Shewart and Joseph Juran worked for Bell Labs. They
began to use statistics to predict the outcome of a process.
They used these techniques to improve the productivity
of the factories that were making supplies for the war.
After World War II, the United States was the only major
producer left that had not been destroyed by the war.
Deming and Juran went to Japan to assist in rebuilding
and to teach using statistics to develop better processes.
With no real competitors, the United States began to forget
how to use these improvement tools and soon Japan was
taking over markets in autos, electronics, and other industries.
In the 1980's, Dr. Mikel Harry worked for Motorola. He
discovered that processes that were thought to be in statistical
control were actually making many more defects over a
long period of time. He empirically discovered that a
process has a tendency to shift its mean by plus/minus
1.5 standard deviations over longer periods of time. He
theorized that a process must be controlled so that six
standard deviations (Six Sigma) fit within the specifications
for the process to ensure that the process always produced
a good product (3.4 defects per million). Dr. Harry designed
a program for Motorola that taught how to improve processes
using both the standard tools that Deming and Juran had
been teaching and higher-level statistical tools such
as Designed Experiments, Analysis of Variance and others.
Six Sigma became not only a measurement, but also a goal,
a philosophy and a methodology to eliminate errors.
Lean Principles and Six Sigma techniques work
together and build on each other. Lean looks at the time
it takes to perform the process. Its tools concentrate on
reducing the cycle time of the process. Six Sigma's emphasis
is on the number of errors or defects a process makes and
how to eliminate those defects. As defects are eliminated
with Six Sigma, the process gets faster. As the cycle time
of the process is reduced with Lean, the process has less
time to create defects.
Although these techniques were developed
in manufacturing processes, it quickly became apparent that
they could be used to improve any process. Frank Gilbreth,
in his book Motion Study from the early 1900's, said that
his techniques could be used to improve any process and
gave some examples of administrative processes where it
was applied. Since then, many companies have successfully
applied these techniques to improving service processes.
