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Efficiency, Organizational -- United States. Summary "By using theories of Six Sigma and Lean methodology, this text presents solutions to fundamental problems in healthcare. This text breaks the system down into three fundamental areas: primary care, hospitals, and managed care. The author identifies the four critical issues that affect healthcare as it relates to efficiency and cost by addressing the specific issues. The book discusses the application of IT in healthcare as a tool of improvement, and how to select the best project for improvement.

Case studies are included to illustrate successes"--Provided by publisher. Contents Machine generated contents note: 1. Testing Changes 7. What Is the Significance of the Project? What Is the Cost of Poor Quality? Notes Includes bibliographical references and index. View online Borrow Buy Freely available Show 0 more links Set up My libraries How do I set up "My libraries"? Campbelltown Campus Library. Hawkesbury Campus Library. Parramatta South Campus Library.

None of your libraries hold this item. Found at these bookshops Searching - please wait We were unable to find this edition in any bookshop we are able to search. These online bookshops told us they have this item:. Tags What are tags? Add a tag. The authors conducted a time-motion study to measure each step in the process to determine factors impacting the overall process. El-Banna [ 28 ] presented a case study in which he built a simulation model of the discharge process at a private hospital in Amman, Jordan.

He focused on insured patients in all three departments of the hospital female, male, and pediatrics. He then optimized the model with a designed experiment and response surface model. He found that insurance and pharmacy operations were critical in the process. The author reported that the patient discharge time was decreased to be less than 50 minutes, which increased customer satisfaction, increased the number of admissions and turnovers on the rooms, and increased the hospital's profitability.

The study identified five critical issues causing delays in the timely handover of the discharge summary to the patients. The issues were failure to utilize information technology to generate and verify the patient information, job rotation, lack of decentralized discharge summary preparation process, failure to empower the assistant physician or surgeon to proof read the rough discharge note prepared by the editor for review, and failure to link all the computers located in all the departments with ERP software so that accurate and up-to-date information about the patients can be gathered without delay.

These issues were further explored and subjected to root cause analysis using brainstorming techniques. Rossi et al. Large delays in turnover of patient rooms and inconsistent cleaning practices were occurring because of a lack of knowledge about cleaning roles and responsibilities and because of a lack of communication between the services.

Table 1 summarizes the articles that have addressed the discharge process, highlighting the different tools used. Summary of tools used in existing work applying Six Sigma to hospitals' discharge process. Notably, in the case studies presented in these articles, only one used simulation as a tool and none included stakeholder analysis. This work attempts to present a comprehensive approach that includes tools that can detect problems and failures, tools that measure current and future performance and tools that help generate new solutions.

This work also uses stakeholder analysis. Regardless of its technical justification, any change effort needs sufficient support and involvement from key stakeholders. The ability to mobilize commitment often makes the difference between a success and a good idea that failed [ 33 ]. Stakeholder analysis identifies the stakeholder groups, their roles, how they are impacted, and their concerns related to the process [ 9 ].

A stakeholder is anyone impacted by the project; however, the project sponsor and project manager need to identify the key stakeholders needed to support, promote, and sustain the project and its improvement. Stakeholder analysis enhances the ownership of the project's success including sustaining the improvement among the stakeholders and improves communication [ 34 ]. The main aim in performing a stakeholder analysis is to understand the stakeholders' attitudes toward change and potential reasons for resistance. The next step is to develop activities, plans, and actions that can help the team to overcome resistance and barriers to change.

It is used to help ensure that the entire organization will accept and be comfortable with the improvement initiative and the changes that it is proposing. All stakeholders are analyzed to try and identify any issues or concerns that they may have with the new improvement strategies. You can then develop a strategy to address these potential barriers so that the targeted processes and areas can be changed effectively.

This public nongovernmental hospital provides high-quality services to patients of more than 48 nationalities from around the world. The hospital is famous for its provision of diagnostic, therapeutic, and healthcare services to different types of cancer patients with different needs. In , approximately 8, patients were discharged from the hospital.


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Delays in discharging patients affected the hospital operations and impacted the overcrowded ED throughput since many patients in the ED await to be admitted to the hospital. The BB ensured that each improvement tools were used appropriately during each phase. The BB also verified that the project's solutions were correct and complete. The project BB and Champion described and scoped the project. They also met with selected team members, explaining the project objectives and importance, discussing their roles, and listening to their feedback. The team decided to focus on medical and surgical patients.

Preliminary data analysis showed that medical patients had longer discharge times than did surgical patients, who have planned discharges, and for this reason, surgical patients were excluded from this study. Process mapping was essential for understanding the process. The SIPOC analysis included the macro process steps and identified all of the suppliers and customers involved in the process. Developing the SIPOC analysis provided the team with an understanding of the project's major components and boundaries.

The patient discharge process was defined as the set of activities that started with a specialist's signature on the discharge order and ended with a patient leaving the room. The team prepared a project charter, which was approved to proceed to the next step. The key measure in this phase was the time of all the activities starting from the physician's signature on the discharge form and ending when the patient left the room.

To create a detailed process flowchart, team members shadowed patients and gathered real-time data observations through the eyes of patients and their families. Since we are dealing with cancer patients, most patients were accompanied by their family members during the discharge process. The figure presents one of the many scenarios that a discharged patient may experience. The process begins after the doctors finish their rounds and decide which patients are to be discharged. The nurse waits for the doctor to write the prescription for medication and then faxes it to the pharmacy, where the medication is prepared.

After some time, the doctor writes the discharge order, which allows the medical records department to start working on the patient's file. A porter then takes the file to the accounting department on the ground floor, and the medical records department instructs the PF to pay the patient's bill and generates the clearance sheet indicating that the patient has no outstanding bills. After the medication is ready at the pharmacy and the porter has arrived, the medication is delivered to the nurses' station.

Six Sigma Requires Five Steps for Quality Improvement

The nurse contacts the clinical pharmacist, who provides counseling to the patient regarding the medication. If the doctor has forgotten a medication, an add-on prescription is written, and the process repeats. Before closing the inpatient file, extra medications that were prescribed to the patient but not used during the hospital stay must be returned to the pharmacy. For narcotics, the physician also writes an outpatient controlled drug prescription, which the nurse delivers to the PF, who then submit it to the pharmacy.

This step may occur early or late in the discharge process, depending on the physician.

Essentials for the Improvement of Healthcare Using Lean & Six Sigma - Semantic Scholar

When supplies are issued after the inpatient file has been closed, the PF need to go to the outpatient clinic to create an outpatient file to buy the supplies. For the removal of a central IV line, the nurse contacts the venous access device team.


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When patients require equipment such as an oxygen generator, the nurse contacts a social worker, who suggests places where the family can buy the needed equipment. Some patients request sickness reports for medical leave purposes, these reports are then signed by the physician in charge. The data were collected using approved and pretested data collection methods. Data on the discharge process were collected for a period of one month.

The data collected included activities and durations. Observations regarding the activities were also noted. Of the discharges that took place, a sample of 41 patient discharges were closely shadowed. The selection was random from different floors. Each day 2 or 3 patients were shadowed. Three discharges were cancelled due to errors in measurements, leaving us with 38 patient discharges. We calculated the mean and standard deviation of the sample, minutes and 67 minutes, respectively. However, since we had 38 discharges, we decided to end the data collection and move forward to data analysis.

Initial analysis of the data identified two populations, as shown in Figure 4. The first population represents patients who go through the standard discharge process, which includes medication preparation, clinical pharmacist counseling, and accounting. The second population represents patients with extra needs prescribed equipment, supplies, or add-on medications. We define discharges belonging to the first population as standard discharges and discharges belonging to the second population as complex discharges.

An individual control chart was drawn to identify the presence of special-cause variations in the discharge process, as shown in Figure 5. The typical discharge process takes about three hours. The out-of-control points marked in red in the figure are data points belonging to the second population. To analyze observations of the process through the eyes of the patients, patients were classified according to their needs, as shown in Figure 6.

The average time spent on each activity was recorded, and a sample of these results is shown in Figure 7. The duration between writing the discharge order and the medication order is about 38 minutes. A process capability analysis was performed to assess the performance of the discharge process. The main purpose of a capability study is to determine whether a process is capable of meeting certain requirements [ 36 ]. Capability analysis involves the calculation of the percentage of defects in the process and their corresponding sigma quality level SQL.

Observations noted while shadowing patients data collection followed by brainstorming sessions were used to examine potential reasons behind long discharge durations. A summary of the findings is presented using a cause-and-effect diagram Figure 9. Some root causes identified in the figure actually were observed and some were identified as potential trying to holistically encompass the causes.

For example, in one rare case, the discharge process was delayed because of late arrival of the patient family. Unnecessary variation in the discharge process and a lack of standardization led to two important undesirable outcomes: increased discharge time and decreased quality, where mistakes were likely to occur and people were likely to forget. Discharge orders, medication orders, and supplies and equipment orders were made in different sequences and at different times.

Additionally, a prescription was sent to the pharmacy for preparation, but then later during the discharge process, another prescription order was sent to the pharmacy for the same patient for another medication, causing the discharge process to take longer than necessary. Furthermore, a lack of preplanning for the discharge process and issues with the hospital layout were also among the root causes of the problem.

A major cause of the long discharge process was poor communication between the different stakeholders treating physicians, consultants, nurses, pharmacy staff, and the accounting department. Because the discharge process is a highly people-dependent process, it was imperative to observe the complexity of the communication in the discharge process.

A communication complexity diagram is shown in Figure For example, the medical records communicate with the porter, who in turn communicates with the accounting department. Communication between the accounting department back and forth with the PF and the PF with the nurse is also shown. These partial communications, highlighted in red and numbered 1—6, represent part of the communication cycle emphasizing the complex and multiplex details of the overall discharge process. Observed delays caused by lapses in communication were noted in organizing the radiotherapy session, the inpatient chemotherapy regimen, the necessary diagnostic lab tests, and the diagnostic radiology imaging.

Delays caused by hospital security-PF-accounting department communications sometimes occurred because of PF challenging the fees added for companions. PF often denied having companions stay with the patient overnight, claiming that they had visitors who were incorrectly counted as companions when they visited after the last security rounds and refusing to pay the charges. In these cases, PF challenged the charges and requested a revision.

The improvement efforts included many facets. Changing how discharge occurs for both groups of patients will have a major impact on patient flow and the effective use of bed capacity. This can mean the difference between a system where patients experience long delays and one where delays are minimal.

continuous quality improvement in healthcare six sigma

The effective management of system-wide processes that support patient flow, such as admission, assessment and treatment, patient transfer, and discharge, can minimize delays in the delivery of care [ 37 ]. To support the improvement efforts and address the lack of standardization, checklists were proposed as a way to standardize the processes and ensure that all medications are prescribed together, thus eliminating the unnecessary delay caused by adding new medications to a patient's medication list.

A thorough review of all medications should be an essential part of discharge planning. Effective discharge planning can ensure that medications are prescribed correctly. Diligent discharge planning has been associated with positive outcomes, including higher patient satisfaction [ 38 ]. However, despite the fact that it clearly increases the well-being of patients and caregivers, discharge planning is often not given the attention it deserves. Indeed, inefficient planning often adds to patients' and caregivers' stress. Effective discharge planning is crucial for ensuring timely discharge and making sure that the hospital's limited resources are used most effectively.

Under the best of circumstances, the discharge planner should begin his or her evaluation when the patient is admitted to the hospital. Furthermore, it is recognized that all departments involved in the discharge of a patient, from the pharmacy to the transport services, must collaborate to reduce overlap, waste, and frequent frustrations [ 39 ]. The role of discharge planning coordinator may be assigned to administrative staff, rotating-shift nurses, or full-time coordinator nurses.

Three main roles are assigned to the coordinator: communication, multidisciplinary teamwork, and assessment. The inclusion of such a coordinator leads to successful process improvement efforts in non-physician-centered processes without interrupting physician care [ 40 ]. The discharge process was modeled using ProModel 6. To build a complete simulation model, the simulation starts with the patient's arrival at the hospital for treatment and progresses through the receipt of treatment.

Then, the discharge process is initiated, as shown in Figure We focus here on the discharge process. Figure 12 presents a detailed process flowchart describing the simulation model from patient arrival to discharge. In ProModel, a process is initially defined by an entity and a location at which the operation is performed as shown in Figure The operation defines the procedure performed in the process and the routing , which defines the outcome entity of the operation and where it is sent.

Detailed code was developed to simulate each step in the discharge process. For illustration, a sample of the simulation code developed is shown in Figure The figure explains the tracking of the patient's file. The flow in the accounting is done by the patient's family. Then the accounting process takes N 1.

The process results in the clearance entity in the accounting department, moving the patient's file to the third floor in the routing. Verification was initially performed by visualizing the animation of the simulation model flow, entity by entity. All stakeholders' PF, doctors, nurses, and porters movement in the hospital was checked to verify the correctness of the simulation model. Figure 15 shows a snapshot of the simulation model while running in the different floors.

The simulation model was then validated by comparing the output of the model to the actual discharge process in the hospital. We looked at both the number of discharges and the average duration of the discharge process. The model was run for a simulated period of time equal to one month. Because of the stochastic behavior of the system, a single run would be insufficient to draw an actual estimate from simulation model. Instead, replications were performed, and the average of these runs was evaluated.

The simulated average time for the replicates of the discharge process was The results for one replication were an average time of The average discharge time observed in the collected data was The error between the real collected data and data from the simulation model is calculated using the following formula:.

After the simulation model was verified and validated, we identified several activities that contributed substantially to increasing the duration of the discharge process. These activities included medication preparation in the pharmacy, waiting for the porter, and the preparation of supplies and equipment. In addition, activities related to physicians, such as late rounds and the fact that physicians do not write prescriptions for medication at the same time as the discharge order, were also important factors adding to the duration of the discharge process.

Before approaching the hospital management with recommendations for improvements, the simulation model was run to study how improving each activity would affect the discharge process time. The improvements are visualized in a Pareto chart Figure This means that the pharmacy would take 30 minutes for medication preparation instead of an average of 88 minutes. In the Pareto chart, it can be seen that this improvement would reduce the total discharge time by an average of about 36 minutes. Because the pharmacy also waits for the porter's arrival to transport the medication to the patient, even when the medication is ready, we suggested making another porter available, which would save 8.

Another suggested solution was eliminating both waiting at the pharmacy and the high variation in porter transportation by assigning the role of transporting the medication to the clinical pharmacist, thus eliminating the nurse's phone call and waiting during delays in the pharmacist's arrival; this would result in a minute reduction, on average, in the total discharge duration. Announcing the need for equipment one day earlier would lead to an average reduction of 4.

Additionally, if supplies were brought to the floor instead of requiring the patient to go to the outpatient clinic, this would save 7. A process capability analysis was also performed after improvement, as shown in Figure The Z bench is equal to 1. The SQL value increased from 0. A control plan was put in place to ensure that the improvements would continue in the future. The goals here were to ensure that the processes continue to work well, produce the desired output results, and maintain quality levels.

All organizations experience resistance to change. Furthermore, Yih [ 25 ] has argued that this resistance is often viewed as insurmountable in healthcare organizations. This gloomy view arises because physicians—one of the most important and most highly constrained resources in hospitals—are mostly autonomous in the management structure and thus immune to incentives typically available in other organizations.

Because of the autonomous nature of their profession, it is difficult for physicians to accept standardization, especially when it goes against their own interests [ 41 ]. Physicians do not feel comfortable adopting a standardization initiative unless there is transparent evidence of its impact on patient outcomes [ 42 ]. As shown in Table 2 , physicians have high levels of influence and impact on the control process steps, but their interest in these issues is low. We recommend involving physicians in the analysis and development of solutions, whether through participation in the improvement team or workshops and meetings presenting and discussing quality improvement issues.

Six Sigma Applications In Healthcare

Other stakeholders such as pharmacy workers, the accounting department, and medical records staff members should collaborate in the proposed methods to sustain and control the improvements, for example, using an electronic discharge system. These stakeholders have low-to-moderate interest in leading or initiating any change process and medium impact on the process control and improvement.

Patients' family members who usually participate in the discharge process are contacted by the discharge planning coordinator in a one on one meeting, their role in executing an effective discharge process is explained, and any special arrangements are discussed and taken care of.

Change is always unsettling, even when all the parties involved are committed to the outcome. Taking the time to brief the stakeholders ensures cooperation and reduces stress during and immediately following the improvement event [ 43 ]. A responsible, accountable, consulted, and informed matrix was utilized to improve communication, convey information about responsibilities, and identify any gaps or redundancies associated with stakeholders' responsibilities, as shown in Table 3. If all of the stakeholders understand this matrix and take the proper actions accordingly, communication between these people will improve, reducing the waste of time and thus benefiting the patient.

Control charts were used to monitor the ongoing performance of the key variables. After implementing all of the improvements in the process, a decrease in the mean duration of the discharge process was observed, as seen in Figure 20 , which shows the control chart before and after improvement. The lower and upper control limits of the individual values and the moving range also showed a reduction, indicating a more stable process.

Early indications of success: IMR chart of discharge time before and after improvement.