Post on 21-May-2015
Linking Six Sigma and LEAN toLinking Six Sigma and LEAN toOrganizational StrategyOrganizational Strategy
Kevin G. Tuttle Director of Operational Performance Solutions
Six Sigma Master Black Belt
Source: U.S. Census Bureau
Population Statistics
North Shore-Long Island Jewish Health SystemNorth Shore-Long Island Jewish Health SystemService AreaService Area
2
125 Miles
SuffolkNassau
Queens
Kings
Manhattan
StatenIsland
Richmond Queens Nassau Suffolk Total
2000 Total Population (000's omitted) 443 2,229 1,335 1,419 5,427
Population Per Square Mile 7,521 20,835 4,980 1,523 3,973
COUNTYPOPULATION 2000
(000 OMITTED)
1 Los Angeles County, CA 9,519
2 New York City (5 boroughs) 8,008
3 NS - LIJ SERVICE AREA 5,427
4 Cook County, IL 5,377
5 Dallas County, TX 2,219
6 Westchester County 923
7 Fulton County, GA 816
8 Baltimore City County, ML 754
9 Suffolk County, MA 689
11 Washington D.C. 572
12 Orleans Parish, LA 485
Facilities
4,840 Hospital & LTC Beds
–3 Tertiary Care Hospitals
–2 Specialty Care Hospitals
–9 Community Hospitals
–2 Long-Term Care Facilities
–3 Regional Trauma Centers
–2 Area Trauma Centers
–1 Burn Center
9 Home Health Agencies
Research Institute
Core Laboratory
Center for Emergency Services
Operating Statistics
215,408 Inpatient Discharges
22,380 Births
113,990 Ambulatory Surgery Cases
422,908 Emergency Room Visits/Admissions
625,399 Home Care Visits
1,053,229 Adult & Pediatric Clinic/Faculty Practice Visits 1,600 Community Education Programs & Services
3Source: Internal Operating Statistics; Owned & Sponsored Hospitals Only
Staff
30,500 Employees; 7,000 Nursing Professionals
5,000 Active Physicians & Dentists; 800 Full-time
6,000 Volunteers & Auxiliary
1,179 Residents & Fellows in 89 Accredited Programs
1,347 Medical Student Rotations
Key Operating Characteristics – SummaryKey Operating Characteristics – Summary
WHY DOES SIX SIGMA WORK?WHY DOES SIX SIGMA WORK?
• Begins with active leadership support Executives establish vision, challenges and objectives Provide focus, leadership and commitment
Relies on dedicated resources of highly skilled and focused individuals
Champions select projects, track and quantify resultsBlack Belts lead and perform improvement projectsGreen Belts (process experts) perform and support projects
Customer focusedListens to the “Voice of the Customer”Projects based on “Critical to Quality” (CTQ) definitions
Continued
Focuses on solutions to real business problemsSystematic method of improvement across business functions
Links processes to bottom-line financial results
Rapid project completionClear definition of success
Project completion (3-6 months)
Sound data-driven statistically validated approach
Uses change management techniques to implement and sustain changes
ENABLER FOR CULTURAL CHANGEENABLER FOR CULTURAL CHANGE
Six Sigma can: • Change the culture • Change the operating philosophy of a
company
It becomes “the way we do our job”!
It becomes “the way we do our job”!
Today there are thousands of organizations employing Today there are thousands of organizations employing Six SigmaSix Sigma
Period ofDesign
Period ofRefinement
Period ofResults
Period ofCompetitiveAwareness
Period ofTechnology
1985 – 1992 1993 - 1994 1994 - 1996 1996- 1997 1997 - 1998
TI
ABB Allied Signal
Motorola
GeneralElectric
Bombardier
GeneralElectric(Capital)
NokiaPhonesSiebe, plc
Sony
Crane
Polaroid
Avery Dennison
Shimano
1999 - 2000
Dupont
AmericanExpress
Ford
CNH
Period ofAcceptance
TRW
Toyota
2000-2003
Mt. CarmelHospital
Common-WealthHealth
NS-LIJHS
EVOLUTION OF SIX SIGMA ...EVOLUTION OF SIX SIGMA ...
VirtuaHealthSystem
……
THE SIX SIGMA PROCESS:THE SIX SIGMA PROCESS:
• Six Sigma begins with an understanding of the “customer’s” needs, requirements, and values (The Voice of the Customer).
• Once the customer’s needs and values are defined, Six Sigma identifies those factors that are critical to customer satisfaction.
• The processes that are involved in these “critical to..” factors are then analyzed and measured.
Six Sigma is about solving business problems by improving process.
• Solution known projects are led by project managers
•Solution unknown projects are led by the six sigma black belts
Projects are the heart of Six Sigma
•Selecting projects is a non-delegable leadership role
•Projects need one or more measurements that quantify themagnitude of the problem, can be used to set project
goals & monitor progress
Leadership
Responsibilities:Break down the multitude of issues, problems , challenges,
&opportunities into manageable projects & identify those that
can be addressed using the six sigma methodology.
Objective:Create a pipeline of projects
Role:Breakdown political barriers
Six Sigma Project Criteria
•Align with objectives and business plans
•Voice of Customer/ Critical to Quality (CTQ)
•Consistent with principles of Six Sigma …Elimination of process defects
•Concentrate on “Chronic” issues/opportunities ..... not “problem of the day”
•Justify the investment
Project Selection Questions
What Corporate objective is supported by this project?
What Sector objective is addressed by this project?
What customer will benefit from this project?
How will that customer benefit from this project?
Can the project be completed in 2-4 months (4-6 months for a project associated with Black Belt training )?
Could the process improvements be handled adequately using basic methods and techniques?
Is the more structured 6approach and the methodology required desirable for this project?
Will this project require application of all phases of Six Sigma?
More Project Selection Questions
Is the defect defined?
Does the baseline data exist?
Is the process improvement offered greater than 40%?
What improvements are expected from this project?Are projected savings greater than or equal to $175K per year?
Will this project lead to improvements with little or no capital?
Is there a similar project already underway or proposed at another location?
-Do the differences warrant a separate project?
-What are the plans for coordination?Can this project be led by a Black Belt in training?
Can you identify the team members to start this project?
SIX SIGMA GOALS:SIX SIGMA GOALS:
• The goal of Six Sigma is to reduce the variance and control processes in order to assure compliance with the “critical to” specifications
• Six Sigma aims at virtually error free performance by focusing on defect reduction, cycle time reduction, and cost savings
• Most companies report that they operate at the 3-4 Sigma level. But most actually operate at 2-3 Sigma
THE COST OF POOR QUALITY THE COST OF POOR QUALITY “ICEBERG”“ICEBERG”
Lost Opportunity(intangible)
(tangible)
Additional (hidden) costs of poor quality
Traditional (apparent) costs of poor quality
Lost management time
Maintenance cost
Lost customer loyalty
Long cycle times
Employee morale, productivity, turnover
Overtime
Lost credibility
Rework cost
Prevention
Appraisal
Failure (Litigation)
SIX SIGMA ROLES AND RESPONSIBILITIESSIX SIGMA ROLES AND RESPONSIBILITIES
• Owns vision, direction, integration, results
• Leads change
• Project owner• Implements solutions• Agent manager
• Full time• Trains and coaches Black
Belts
• Full time• Facilitates problem solving• Trains and coaches Project
Teams
• Part-time• Project-specific
All employees
• Understand vision• Apply concepts to
their job and work area
• Part-time• Helps Black
BeltsMaster Black Belts
Black Belts
Green Belts
Project Team Members
Champions
Executives
BLACK BELT ROIBLACK BELT ROI
• The typical Black Belt improvement project requires 4-6 months to complete and results in a return from $75,000 to upwards of $150,000
• Black Belts can conduct 3- 4 projects/annually
• The annual benefit per Black Belt exceeds $500K
Center for Learning and InnovationCenter for Learning and Innovation
LearningLearningInitiativesInitiatives
OperationalOperationalPerformancePerformance
SolutionsSolutions
NursingNursingInstituteInstitute
ScholarScholarPipelinePipeline
InnovativeInnovativeSolutionsSolutions
Foundations
Enrichment
Core Management
Leadership/ExecutiveEducation
Clinical ExecutiveEducation
Service Excellence
(emp./pt/MD)
OrganizationalDevelopment
LeadershipDevelopment
Change Facilitators(CAP, FTD)
Black BeltGreen Belt
Lean Leader
Lean/Six Sigma
Deployment
System-wideOPS
Education
Education
SimulationLabs
Situational Modeling
Research
Education &Workforce
Development
NursingEmpowerment
StudentAchievement
JuniorAchievement
Internships
AdministrativeResidency &Fellowship
Coaching &Mentoring
Baldrige Process
Retention &Recruitment
CorporateCorporatePartnershipsPartnerships
Technical Technical EducationEducation
EEG Technician
Perfusionist
O.R.Technician
UniversityUniversityAffiliationsAffiliations
General Electric
Ritz Carlton
Harvard
Cornell
NYU Hofstra Farmingdale
RespiratoryTechnician
Georgetown
Labor/ManagementPartnership
PhysicianPhysicianLeadershipLeadership
InstituteInstitute
PhysicianOrientation
PhysiciansResourceNetwork
Office ManagerProgram
LeadershipCertificateProgram
ComputerCourses Critical Care
R.N.
Adelphi
Patient SafetyPatient SafetyInstituteInstitute
North Shore – Long Island Jewish Health SystemNorth Shore – Long Island Jewish Health System
Six Sigma InstituteSix Sigma Institute
• Six Sigma methodology is taught and deployed throughout the Health System, assisting in the achievement of the System’s Strategic Goals
• The Institute became self sufficient in July 2004
• Currently the Institute has:– 24 Black Belts
– 127 Green Belts
– 2 Master Black Belts
– 400 Change Facilitators
– 80 completed Six Sigma Projects
THE BENEFITS OF SIX SIGMA…THE BENEFITS OF SIX SIGMA…
• Leadership development
• Problem solving at the front-line
• Increased efficiency
• Increased productivity
• Increased customer satisfaction
• Increased accountability at all levels
North Shore University Hospital in Manhasset is a tertiary care facility that is one of the cornerstones of the health system, as well as an academic campus for the New York University School of Medicine. It was named the nation’s top hospital by AARP’s Modern Maturity magazine. The hospital has 731 beds and a staff of 2,700 specialist and subspecialist physicians. It offers the most advanced care in all medical specialties, including open-heart surgery, neurosurgery, urology, and maternal-fetal medicine. The hospital also excels in intensive care for medical, surgical, newborn, and pediatric patients
What is the Y?Y = Total time required for a patient to leave the ED once a bed is assignedThe Y value will be measured in minutes
What is the Y?Y = Total time required for a patient to leave the ED once a bed is assignedThe Y value will be measured in minutes
What are the data sources? How will the data be collected? Admission Log SheetsData Collection Tool (new)
What are the data sources? How will the data be collected? Admission Log SheetsData Collection Tool (new)
What is our goal?The goal is to transport patients to assigned beds with a maximum time (USL) of 45 minutes, and a target time of 30 minutes.
What is our goal?The goal is to transport patients to assigned beds with a maximum time (USL) of 45 minutes, and a target time of 30 minutes.
Project Description / Problem Statement: It currently takes 65 minutes for an ED patient with an assigned bed to be transported out of the ED. The standard deviation is 49 minutes.
Project Description / Problem Statement: It currently takes 65 minutes for an ED patient with an assigned bed to be transported out of the ED. The standard deviation is 49 minutes.
Project Scope: Improve time and streamline tasks that occur between bed assignment and patient transport. Out of Scope: Multiple concurrent bed assignments
Project Scope: Improve time and streamline tasks that occur between bed assignment and patient transport. Out of Scope: Multiple concurrent bed assignments
S I P CO
ED REP
ED NURSE
ED CHARGE
PATIENT
RECEIVE BED ASSIGNMENT
FAX REPORT
MEDICALRECORD
PATIENT READY
CHARGERN NOTIFIED
FAX REPORT
COORDINATEPATIENT
TRANSPORT &EQUIPMENT
PATIENTLEAVES
ED
-
FAX CONFIRM
PATIENT LEAVES ED
ED ROOMCAPACITY
ED NURSE
NURSINGUNIT
PATIENT & FAMILY
CHARGE NURSE
SIPOC
What is the mean of our process? What is the standard deviation?Mean = 65 minutesSt. D. = 49 minutes
What is the mean of our process? What is the standard deviation?Mean = 65 minutesSt. D. = 49 minutes
What is our process capability DPMO = 658,948 Yield = 31%Sigma score = 1.0
What is our process capability DPMO = 658,948 Yield = 31%Sigma score = 1.0
Two-Sample T-Test and CI: Dur, Area
Two-sample T for Dur
Area N Mean StDev SE MeanGold 134 61.7 46.2 4.0Red 133 42.3 45.7 4.0
Difference = mu (Gold) - mu (Red )Estimate for difference: 19.4495% CI for difference: (8.37, 30.51)T-Test of difference = 0 (vs not =): T-Value = 3.46 P-Value = 0.001 DF = 264
Ho: There is no difference in the time it takes for the medical record to be completed between Gold and Red
Graphical Analysis: Summary slideGraphical Analysis: Summary slide
Hypothesis Test P-Value ConclusionThere is no difference in TAT between Red & Gold 2 Sample T-Test 0.002 Significant - Reject HoThere is no difference in TAT for Shifts in Red ANOVA 0.053 Possible Significance - Accept HoThere is no difference in TAT for Shifts in Gold ANOVA 0.174 No Significance - Accept HoThere is no difference in TAT caused By Shifts ANOVA 0.022 Significant - Reject HoThere is no difference in TAT caused by Day ANOVA 0.001 Significant - Reject HoSTART TO MEDICAL RECORD COMPLETEThere is no difference between Gold & Red 2 Sample T-Test 0.001 Significant - Reject HoThere is no difference between Shifts ANOVA 0.037 Significant - Reject HoThere is no difference between Day of the Week ANOVA 0.258 No Significance - Accept HoThere is no difference between Gold & Red/day of the week Test for Eq. Var. 0.4 No Significance - Accept HoThere is no difference between Shifts/day of the week Test for Eq. Var. 0.109 No Significance - Accept HoThere is no difference between Gold & Red/Shift Test for Eq. Var. 0.003 Significant - Reject HoMEDICAL RECORD COMPLETE TO PATIENT TRANSPORTThere is no difference between Gold & Red Mood's Median 0.583 No Significance - Accept HoThere is no difference between Shift Mood's Median 0.339 No Significance - Accept HoThere is no difference between Day of the Week Mood's Median 0.058 Possible Significance - Accept Ho
What is our improvement strategy? How will we implement the change?
Our improvement strategy is to re-educate the staff concerning MR Completion and to augment responsibilities. •Reps are responsible for Medical Record Completion via Checklist•SCA’s can transport patients & ensure clothing sheet completion•Transporters can ensure clothing sheet completion
What is our improvement strategy? How will we implement the change?
Our improvement strategy is to re-educate the staff concerning MR Completion and to augment responsibilities. •Reps are responsible for Medical Record Completion via Checklist•SCA’s can transport patients & ensure clothing sheet completion•Transporters can ensure clothing sheet completion
What are some potential solutions? How can we change the process?
Shift some responsibilities of the Medical Record Completion process from the Charge Nurse to the Rep. We will also look at expanding the role of the SCA and Transporter.
What are some potential solutions? How can we change the process?
Shift some responsibilities of the Medical Record Completion process from the Charge Nurse to the Rep. We will also look at expanding the role of the SCA and Transporter.
What X’s (inputs) are causing most of our variation?
Medical Record CompletionRed versus Gold
What X’s (inputs) are causing most of our variation?
Medical Record CompletionRed versus Gold
Diagnosis Service
Blood work documented
EKG on chart
CXR documented
H/P Property sheet complete
ED AttendingSignature
Medical Record Cover Sheet
How will we conduct a confirmation run or pilot? What is our statistically significant sample size?
A Confirmation was run from Thursday, November 18th through Saturday, November 20th. This run focused on admitted patients from the hours of 11AM through 2AM. The same boundaries for in scope and out of scope that were used in Measure/Analyze were applied.
How will we conduct a confirmation run or pilot? What is our statistically significant sample size?
A Confirmation was run from Thursday, November 18th through Saturday, November 20th. This run focused on admitted patients from the hours of 11AM through 2AM. The same boundaries for in scope and out of scope that were used in Measure/Analyze were applied.
Is our measurement system adequate for our X’s?
Yes. To measure the time difference between Red and Gold, we used the Admit Log Sheets, which were deemed adequate earlier in the process. To measure the MR time, we used the MR Checklist. Since our total process time has been reduced, this tool has been effective.
Is our measurement system adequate for our X’s?
Yes. To measure the time difference between Red and Gold, we used the Admit Log Sheets, which were deemed adequate earlier in the process. To measure the MR time, we used the MR Checklist. Since our total process time has been reduced, this tool has been effective.
Mean = 65Std. Dev = 49
Mean = 40Std. Dev = 26
I and MR Chart
Before (September) After (January)
Improvement Implementation Begins
Long Island Jewish Medical Center shares the title of clinical and academic hub of the North Shore-Long Island Jewish Health System. It is an 827-bed voluntary, non-profit tertiary care teaching hospital serving the greater metropolitan New York area. The 48-acre campus is 15 miles east of Manhattan on the border of Queens and Nassau Counties. LIJ comprises three divisions: Long Island Jewish Hospital, Schneider Children’s Hospital and The Zucker Hillside Hospital for behavorial healthcare. Long Island Jewish Hospital is a 452-bed tertiary adult care hospital with advanced diagnostic and treatment technology, and modern facilities for medical, surgical, dental and obstetrical care. It features the Heart Institute; Pain and Headache Treatment Center; comprehensive pulmonology programs for asthma, emphysema and sleep disorders; The Center for New Life with private labor-delivery-recovery suites and a high-risk pregnancy program; and the Institute of Oncology.
Project Scope : Admitted patients with bed assignments 7 days a week between the hours of 12 noon and 12 midnight.
Project Scope : Admitted patients with bed assignments 7 days a week between the hours of 12 noon and 12 midnight.
Project Description / Problem Statement:It takes 149 minutes or more for an ED patient with a bed assignment to physically occupy that bed.
Project Description / Problem Statement:It takes 149 minutes or more for an ED patient with a bed assignment to physically occupy that bed.
Potential Benefits:decreased ED overcrowdingdecreased diversion hours decreased walk-outs increased Press Ganey Scores increased patient satisfactionincreased staff morale and retention.
Potential Benefits:decreased ED overcrowdingdecreased diversion hours decreased walk-outs increased Press Ganey Scores increased patient satisfactionincreased staff morale and retention.
What is the Y?
Y = Time in minutes from dirty, unoccupied bed assignment to patient arrival in clean bed.
What is the Y?
Y = Time in minutes from dirty, unoccupied bed assignment to patient arrival in clean bed.
What are the data sources?
Bed Coordinator/Access Rep Patient Admit Tracking (PAT) logsInvision ADT dataBedTracking Bed History Report
What are the data sources?
Bed Coordinator/Access Rep Patient Admit Tracking (PAT) logsInvision ADT dataBedTracking Bed History Report
What is our goal?
Reduce the time from bed assignment to occupied bed to 75 minutes for all admitted ED patients.
What is our goal?
Reduce the time from bed assignment to occupied bed to 75 minutes for all admitted ED patients.
High Level Process Map:High Level Process Map:
D/C ENTERED(INVISION)
DIRTY BEDSIGNAL ONELEC BB &
BED ASSIGNEDTO ER ADMISSION
REPORT FAXED TO
PT UNIT
ELECTRONIC NOTIFICATIONOF CLEAN BED
TO ED
TRANSPORTPT TO ROOM
HOUSE-KEEPINGPAGED
What are the specification limits?The USL based on the voice of the customer is 83 minutes.
What are the specification limits?The USL based on the voice of the customer is 83 minutes.
Continuous Data
IWhat is the mean of our process? What is the standard deviation? (n=249)
MEAN 149 STANDARD DEVIATION 81
What is the mean of our process? What is the standard deviation? (n=249)
MEAN 149 STANDARD DEVIATION 81
What is our process capability
SIGMA SCORE - .75
What is our process capability
SIGMA SCORE - .75
Continuous Data
What do we want to know? What does our process capability
plot look like?
What do we want to know? What does our process capability
plot look like?
5004003002001000-100
USLUSL
Process Capability Analysis for TAT in min
PPM Total
PPM > USL
PPM < LSL
PPM Total
PPM > USL
PPM < LSL
PPM Total
PPM > USL
PPM < LSL
Ppk
Z.LSL
Z.USL
Z.Bench
Cpm
Cpk
Z.LSL
Z.USL
Z.Bench
StDev (Overall)
StDev (Within)
Sample N
Mean
LSL
Target
USL
778197.42
778197.42
*
794914.40
794914.40
*
730923.69
730923.69
*
-0.26
*
-0.77
-0.77
*
-0.27
*
-0.82
-0.82
86.6989
80.6487
249
149.422
*
*
83.000
Exp. "Overall" PerformanceExp. "Within" PerformanceObserved PerformanceOverall Capability
Potential (Within) Capability
Process Data
Within
Overall
]
THE TEAM USED OUR FISHBONE DIAGRAM TO BRAINSTORM ALLTHE VARIABLES (X’S) WE THOUGHT WOULD EFFECT OUR TAT
Assign time
Arrival time
TAT in minutes
Dirty/In progess
In Progress/clean
Hskpg. process time
Bed Coordinators
Charge RN/ER
Housekeeping aide
Unit recept/f loor
Unit recept/ED
Staff RN/ER
PCA's for transport
Primary RN/Floors
Batching D/C's
Batching admits
Batching assigns
Diversion
Increased volume
Gridlock
Patients not ready
Pts held/pending lab
ADT(INVISION)
Pre-admit tracking
Bedtracking
Admit report fax pro
Bed Assign pages
Escalation pages
Non value add calls
Linen
Moniters
Wheelchairs
Computers
Fax machines
Portable O2
O2 regulators
Med bag
Measurement
Personnel
Environment
Communication
Equipment
Environment
Cause-and-Effect Diagram
Looking for the “X” Type of Test P Value
TAT vs shift (normal data) Anova P=0.256
TAT vs assigner Anova P=0.230
TAT vs track( service) Anova P=0.591
TAT vs floor Anova P=0.863
TAT vs holding (admit pts w/o beds)
Anova P=0.602
TAT vs process time (housekeeping)
Anova P=0.459
TAT vs day Anova P=0.047
TAT vs shift (transformed data)
Anova P=0.348
TAT vs floor Anova P=0.000
TAT vs track Anova P=0.000
TAT vs floor Moods Median P=0.020
Hypothesis Testing
THE INPUTS THAT CAUSED MOST OF OUR VARIATION
DAY OF THE WEEKTRACK(MED,SURG,TELE)FLOOR
THE INPUTS THAT CAUSED MOST OF OUR VARIATION
DAY OF THE WEEKTRACK(MED,SURG,TELE)FLOOR
What is our goal? What will success look like?
Decrease TAT by 50% (75 min) Decrease SD by 50% (40min)
Increase Sigma level to 1.0
What is our goal? What will success look like?
Decrease TAT by 50% (75 min) Decrease SD by 50% (40min)
Increase Sigma level to 1.0
In Our Control
Out Of Our Control
C
O
N
T
R
O
L
IMPACT
High Medium Low
Prioritization Of Xs – Control/Impact Matrix
•Housekeeping response to dirty, assigned beds
•Housekeeping supervisors response to escalation pages
•Staff productivity- staffing constraints
•Work re-design
•Invision/ Teletracking server down
•Cath lab receives priorityfor tele beds
•Volume and acuity
•Limited number of tele beds
•Current OR scheduling process
•Batching admissions
•Sick calls
•Batching discharges •Batched assignments
•Case manager/bed coordinator rounds•Process for assigning ED pts tele beds•Communication•Non value adding phone calls•9 hour R/O Coronary Syndrome•Transport
Equipment:•Tele monitors•Portable O2
•Location of faxes on pt. units
•Patient not ready
SMOOTH FLOW + COMMUNICATION = TAT
BEST PRACTICE
What are some potential solutions? How can we change the process?
Low TAT on 5no and 8so told us they were doing something different
What are some potential solutions? How can we change the process?
Low TAT on 5no and 8so told us they were doing something different
• EARLY BUY IN
• REDUCE CYCLE TIME
• ELIMINATE NON VALUE ADDED TASKS
• REDUCE HANDOFFS
• AVOID ZIGZAGGING MOTIONS
• A PLAN TO RE-DESIGN THE ADMISSION FAX REPORT
SYNCRONIZED FLOWSTREAMLINE THE ED ADMISSION FAX
ED FAX REPORTPROCESS
Bb
Bed coordinator Assigns bed
ED charge nurse Receives bed assign on Computer and beeper
ED charge nurse Initiates fax and givesTo primary RN
Bed coordinator Assigns bed
ED Charge nurse initials fax
Primary nurse completes and returns fax to charge nurse
Charge nurse gives chart to UR for bursting
UR calls floor to see if bed clean
Pre FTD Post FTD
ED charge nurse
Ambulance triage
ED charge nurse staffing
problem
ED charge nurse
Trauma/CAC
UR receives assign on
computer /has access to clean
bed status
ED charge nurse pt family
crisis
ED charge nurse
beeped with
assign
UR initiates fax, gives to
primary
Fax completed, returned to
UR/chart burst
Fax sent to floor
Fax sent to floor
Pt ready for transport
Pt ready for transport
Verify fax received
DEVELOP A MORE EFFICIENT REPORT
LIJ ED ADMISSION CHECKLIST AND REPORT SHEET
Admit Room #_________Time Report faxed_________ *ED verify fax received
Form Completed by/Time______________/______
ED Chief Complaint:_______________________Med Allergies: none ____________ □ List Attached Admitting Diagnosis(s):_____________________Attending_____________ Service________ Code Status: Unknown Full DNR/DNI Advance Directive Family Present Safety Needs: Fall Risk Hearing/Vision Impaired Interpreter Required Metal in body Isolation Type__________ Neutropenic Constant observation 1:1 Cervical Spine Precautions in Place (Do not remove C-collar without a written order) History: ______________________________________________________________________
Vitals time of transport: T_______B/P_________Pulse______RR______SpO2______% O2_______L/min Pain Scale Level: _____(0-10) Labs (Completed and due: none CBC______ CK-MB______ SMA-7 ______
Blood cultures ______ ABG ______ PT/PTT______ Type______ UA______ Urine C&S______
Patient From: Home Assisted Living Nursing Home Other Assessment: Cardiac: Chest Pain ___/10 Rhythm__________ Respiratory: Lung Sounds________________________ Neuro: A & O Confused Combative Restraints GI: Vomiting Diarrhea NPO Since_________ Unable to Assess GU: Voiding Foley Incontinent Dialysis Unable to Assess Musculoskeletal: Outside Normal Limits___________________________ Skin: Pressure ulcer Stage_______ Other No breakdown Clothing/Personal Belongings: With patient Given to family To security
Patient Label
THIS IS WHERE THE OLD REPORT GOES
“ Old” “NEW”
DEVELOPED BY THE SENDERS AND RECEIVERS
UNIT RECEPTIONIST ROUNDS• BE PRO-ACTIVE• MANAGE YOUR INPUT AND OUTPUT
PUT DISCHARGES IN AS THEY OCCUR
PILOT ED CASE MANAGER• FACILITATE MOVEMENT• IDENTIFY PTS TO BE DC’D FROM TELE• IDENTIFY PTS WHO CAN BE DISCHARGED
SYNCRONIZED FLOWDECREASE BOTTLENECKS
Thank You for Trusting Us To Take Care of You!
Please Bring This Notice to the Nursing Station As You Leave. Name: ________________________ Room: ________________________ Date: _________________________
BATCHING
RE-INFORCE COMPLIANCE WITH TIMELY, ACCURATE INFORMATION
COMMUNICATIONMISTAKE PROOF THE PROCESS
ENTERING ADMISSIONS AND DISCHARGES IN INVISIONGUIDE FOR UNIT RECEPTIONISTS
You should enter the patient in Invision as soon as the patient arrives on the floor. When this is done Invision automatically enters the time at that moment (default).If you are unable to enter the information when the patient arrives because you are busy doing something else, enter the time on your handwritten census. You can put it in Invision later.When you go into Invision later to enter the admission, the correct time of arrival must be manually entered on the transfer screen. That field is located at the lower right corner of the screen. Discharges must be put in Invision as soon as the patient leaves the floor. This is important so that housekeeping is paged as each patient leaves and not in batches and so that an empty bed goes into the system for a sick patient who needs it. I have read this information and understand it.Signature
MOVED ELECTRONIC PLASMA SCREEN BED BOARDTO THE “BED HUDDLE” ROOM
• KEEPS EVERYONE ON THE SAME PAGE
OFFER TECHNICAL ASSISTANCE AND REFRESHER INSERVICE FOR ED STAFF USING TELE-TRACKING TECHNOLOGY
ROLL OUT MINI BEDBOARDS ON 4 MORE UNITS
COMMUNICATIONMAXIMIZE USE OF TECHNOLOGY
Continuous DataCONTROL
5004003002001000-100
USLUSL
Process Capability Analysis for TAT in min
PPM Total
PPM > USL
PPM < LSL
PPM Total
PPM > USL
PPM < LSL
PPM Total
PPM > USL
PPM < LSL
Ppk
Z.LSL
Z.USL
Z.Bench
Cpm
Cpk
Z.LSL
Z.USL
Z.Bench
StDev (Overall)
StDev (Within)
Sample N
Mean
LSL
Target
USL
778197.42
778197.42
*
794914.40
794914.40
*
730923.69
730923.69
*
-0.26
*
-0.77
-0.77
*
-0.27
*
-0.82
-0.82
86.6989
80.6487
249
149.422
*
*
83.000
Exp. "Overall" PerformanceExp. "Within" PerformanceObserved PerformanceOverall Capability
Potential (Within) Capability
Process Data
Within
Overall
5004003002001000
USLUSL
Process Capability Analysis for TAT in min
PPM Total
PPM > USL
PPM < LSL
PPM Total
PPM > USL
PPM < LSL
PPM Total
PPM > USL
PPM < LSL
Ppk
PPL
PPU
Pp
Cpm
Cpk
CPL
CPU
Cp
StDev (Overall)
StDev (Within)
Sample N
Mean
LSL
Target
USL
707213.06
707213.06
*
725202.52
725202.52
*
648936.17
648936.17
*
-0.18
*
-0.18
*
*
-0.20
*
-0.20
*
58.6289
53.4255
376
114.968
*
*
83.000
Exp. "Overall" PerformanceExp. "Within" PerformanceObserved PerformanceOverall Capability
Potential (Within) Capability
Process Data
Within
Overall
ANALYZE CONTROLMean 149
SD 80
Sigma score -.75
Mean 115
SD 59
Sigma score 1
[Insert Control charts if applicable. Ex- I&MR, X-bar, R, C, U, P]
Control 8 weeks of improvement
400300200100Subgroup 0
400
300
200
100
0
-100
Indi
vidu
al V
alu
e
Mean=115.0
UCL=275.2
LCL=-45.31
400
300
200
100
0
Mo
ving
Ra
nge
R=60.26
UCL=196.9
LCL=0
I and MR Chart for TAT in min
North Shore University Hospitalat Manhasset
Department of Radiology
Lean CT
Report-Out
November 7, 2005
CT Lean at NSUH @ Manhasset
• Purpose: Evaluate the daily patient throughput on the two 1st floor CT scanners. Monday-Friday (8am-12mid)
• Goal: Increase average daily patient throughput by 20%. (increase patient volume from 45 to 54 patients daily)
• Benefits: Decrease LOS, decrease scheduling delays, increased patient and physician satisfaction
Kickoff Pre-work Sustain Kaizen
Team Strategy for Kaizen Day 1
1. Focus on “Lean” Tools
• Value Stream Mapping (Detailed Process Map)
• Execute 5S (Sort, Simplify, Shine, Standardize, Sustain)
2. “Try-storming” various patient scheduling solutions –
• Balanced schedule by procedure type
• “Pull”-scheduling system
Patient Scheduling
Staffing PatternsTechnologists
ExtraneousPhone Calls
Oral Contrast Prep/Delivery
Transport Staffing
Transport Tickets
Patient Education
CT Throughput
RequisitionWork flow /
Process
Drivers to CT Throughput
Kaizen Impact Highlights - Workspace
After KaizenBefore Kaizen
Operation Problem Actions Taken Results
Work environment
• Cluttered workspace in CT Room A.
• No designated work space for Lead Technologist.
• Coordinated some of the 5S activities yielding positive changes to work environment.
• Kaizen team collaborated with Engineering, Environmental Services and IS to complete projects.Cleaned and re-organized the area.
Created designated work space for CT Lead Tech including new computer, wall-mounted shelves and file holders. Relocated RMS computer for optimal use by tech staff Clean, functional work area
Kaizen Impact Highlights – Workflow
After Kaizen
Operation Problem Actions Taken Results
• Obtained one printer capable of printing the two types of forms (requisitions & transport notice)
• Relocated printer to a more central location (for techs & transporters) in Room B
Workflow / travel distance
Average CT tech travel distance to requisition printer = 6,480 feet / day (324 miles per year!)Average Transporter travel distance to transport notice printer = 432 feet / day (21.6 miles per year!)Before Kaizen
Eliminated need to travel down hallway multiple times during the shift, substantially reducing distances traveled by techs & transporters (>300 miles per year).
Improved work flow with less hallway traffic
CT Room A
CT Room B
Main Desk
En
tran
ce
CT R
eg
istratio
n
CT TransportCT Tech Room A
CT Tech Room B
CT Room A
CT Room B
Main Desk
En
tran
ce
En
tran
ce
CT TransportCT Tech Room ACT Tech Room B
En
tran
ce
CT R
eg
istratio
n
Kaizen Impact Highlights - Scheduling
After KaizenBefore Kaizen
Operation Problem Actions Taken Results
• Implemented new schedule (excel format) adding additional patient slots.• Instituted process for faxing of schedule to floors and transfer to Outlook to provide visibility of schedule within and outside the CT Department.
Created additional patient slots with better utilization of scanners around special procedures Implemented “pull” scheduling process resulting in increased throughput and improved TAT Modified patient procedure types served by each scanner to facilitate optimal patient flow
• Manual schedulingprocess (hand written) revised continuously in attempt to meet demand.
• No schedule visibility for CT clerical staff and hospital nursing units.
Patient Scheduling (Rooms A and B)
COMPLETED
C.T. Outlook Schedule Time Line
Lean/Kaizen Improvements
• 5 S’d work area for a more productive work environment• Removed >300 miles a year in requisition printer travel• Implemented "pull" system of in-patient scheduling• Developed an electronic schedule with additional in-patient slots• Created visibility of patient schedule to nursing units, CT techs, and front-desk CT clerical staff • Reduced phone calls to techs• Identified need for additional transporter • Instituted early morning oral contrast delivery routine• Implemented evening shift oral contrast preparation • Construction and re-organization of reception area to include new refrigerator for distributing outpatient contrast
(reduces non-value added time for technologist)
dows-
o o
utp
twthtmf
25
20
15
10
5
0
Boxplot of CT outpatient vol vs Day of the week
dows-
o o
utp
twthtmf
25
20
15
10
5
0
Boxplot of CT outpatient vol vs Day of the week
Null Hypothesis: There is no statistical difference in the number of outpatientcases performed vs Day of the week p=.323
Before After
DOW
Out
wthtmf
25
20
15
10
5
0
Boxplot of Outpatient volume by Day of the Week
DOW
Out
wthtmf
25
20
15
10
5
0
Boxplot of Outpatient volume by Day of the Week
Hypothesis= There is no difference in outpatient volume between days of the weekP=.000 Reject the null hypothesis
dow
s-o in
pts
wthtmf
55
50
45
40
35
30
25
20
Boxplot of CT inpatient vol vs Day of the week (sept-oct)
dow
s-o in
pts
wthtmf
55
50
45
40
35
30
25
20
Boxplot of CT inpatient vol vs Day of the week (sept-oct)
Alternate hypothesis: There is a statistically significant difference in inpatientVol vs day of the week p=.029 (Friday & Wednesday)
Historical
Day of week
In
wthtmf
55
50
45
40
35
30
25
20
Boxplot of CT inpatient vol vs Day of the week (June-Oct)
Day of week
In
wthtmf
55
50
45
40
35
30
25
20
Boxplot of CT inpatient vol vs Day of the week (June-Oct)
If you go back historically it is still significant for FridaysP=.002
Current
4 hr case
1501209060300-30
TargetUSL
Process Data
Sample N 1439StDev(Within) 12.4193StDev(Overall) 23.0302
LSL *Target 16USL 24Sample Mean 20.7976
Potential (Within) Capability
CCpk 0.21
Overall Capability
Z.Bench 0.14Z.LSL *Z.USL 0.14Ppk
Z.Bench
0.05Cpm 0.11
0.26Z.LSL *Z.USL 0.26Cpk 0.09
Observed PerformancePPM < LSL *
PPM > USL 362751.91PPM Total 362751.91
Exp. Within PerformancePPM < LSL *
PPM > USL 398258.48PPM Total 398258.48
Exp. Overall PerformancePPM < LSL *
PPM > USL 444704.11PPM Total 444704.11
WithinOverall Befor
e
After
Average TAT= 20.7 hrs
Average TAT = 13.1 hrs
1251007550250-25
USLProcess Data
Sample N 1466StDev(Within) 8.70782StDev(Overall) 16.1318
LSL *Target *USL 24Sample Mean 13.1148
Exp. Within PerformancePPM < LSL *PPM > USL 105641.02PPM Total 105641.02
WithinOverall
Process Capability of TOTAL TAT
1251007550250-25
USLProcess Data
Sample N 1466StDev(Within) 8.70782StDev(Overall) 16.1318
LSL *Target *USL 24Sample Mean 13.1148
Exp. Within PerformancePPM < LSL *PPM > USL 105641.02PPM Total 105641.02
WithinOverall
Process Capability of TOTAL TAT
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Pro
ced
ure
vo
lum
e
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
In-Patient CT Procedure Volume2004 vs. 2005
In patient 2004 In patient 2005
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Pro
ced
ure
vo
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e
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
In-Patient CT Procedure Volume2004 vs. 2005
In patient 2004 In patient 2005
LEAN Improvements Implemented
0
100
200
300
400
500
600
700
Vo
lum
e
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Out-Patient CT Procedure Volume2004 vs 2005
Outpatient 2004 Outpatient 2005
0
100
200
300
400
500
600
700
Vo
lum
e
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Out-Patient CT Procedure Volume2004 vs 2005
Outpatient 2004 Outpatient 2005
Out-Patients scheduled on Mondays
Post Kaizen Highlights and Work Plan• Added 8 out-patients to Monday schedule
• Add additional out-patients to Friday schedule
• Reduced in-patient TAT from 20.7 hrs. to 13.1 hrs.
• Improved average daily patient throughput by from 45 to 50 patients with less variation
• Presentation at Nursing Leadership meeting
• Continue to monitor and measure data/metrics and improve TAT and patient throughput volume
• Maintain optimum daily staffing model to sustain improvement (3 technologists and 2 transporters)
• Report TAT and daily CT patient/procedure volumes @ Monthly Radiology Operations Meeting
DOW 4 628.8 157.2 12.04 0.000
Error 29 378.8 13.1
Total 33 1007.5
S = 3.614 R-Sq = 62.41% R-Sq(adj) = 57.22%
Individual 95% CIs For Mean Based on
Pooled StDev
Level N Mean StDev ---------+---------+---------+---------+
f 7 14.714 3.402 (----*-----)
m 6 3.667 2.066 (-----*-----)
t 7 14.571 4.353 (----*-----)
th 7 14.286 3.684 (-----*----)
w 7 15.857 3.934 (-----*----)
---------+---------+---------+---------+
5.0 10.0 15.0 20.0
Pooled StDev = 3.614
Fr
Mo
Sa
Su Th Tu We
0
5000
10000
15000
Day ordered
TA
TTurn Around Time by Day Test Ordered
(means are indicated by solid circles)
Hypothesis= There is no difference in Turn Around Time based on the day test OrderedP=.000Reject the null hypothesis
Analysis of Variance for TAT
Source DF SS MS F P
Day orde 6 130060041 21676673 16.24 0.000
Error 1652 2.205E+09 1334568
Total 1658 2.335E+09
Individual 95% CIs For Mean
Based on Pooled StDev
Level N Mean StDev -------+---------+---------+---------
Fr 246 1096 1668 (--*---)
Mo 230 742 823 (---*--)
Sa 126 1669 2177 (----*----)
Su 162 1149 1003 (----*---)
Th 281 664 971 (---*--)
Tu 327 773 842 (--*--)
We 287 720 645 (--*--)
-------+---------+---------+---------
Pooled StDev = 1155 800 1200 1600
TAT_
Fr
TAT_
Mo
TAT_
Th
TAT_
Tu
TAT_
We
0
1000
2000
3000
4000
5000
6000
7000
Boxplots of TAT_Fr - TAT_We(means are indicated by solid circles)
Hypothesis= There is no difference in turn around time for tested order on Mon -FriP=.000Reject the null hypothesis
Analysis of Variance
Source DF SS MS F P
Factor 4 29599374 7399843 6.97 0.000
Error 1366 1.450E+09 1061857
Total 1370 1.480E+09
Individual 95% CIs For Mean
Based on Pooled StDev
Level N Mean StDev ---+---------+---------+---------+---
TAT_Fr 246 1097 1668 (------*-----)
TAT_Mo 230 742 823 (------*------)
TAT_Th 281 664 971 (-----*-----)
TAT_Tu 327 773 842 (-----*----)
TAT_We 287 720 645 (-----*-----)
---+---------+---------+---------+---
Pooled StDev = 1030 600 800 1000 1200
OverviewThe Center for Emergency Medical Services provides quality Emergency Medical Services as it relates to pre-hospital emergency care and inter-facility medical transportation. The CEMS utilizes a state of the art Computer Aided Dispatch System for the purpose of tracking all ambulance transports and vehicles within the department. We provide quality education to both the EMT and Paramedic.
The CEMS is comprised of 3 Clinical Divisions. These divisions are: Inter-Facility, NYC-911 and Paramedic First Responders. We also act as the Health System Emergency Management Command Center.The Inter-Facility Transport Division started in 1993 when 2 vehicles were dispatched from a small office in the emergency department of NSUH-Manhasset. Since then we have grown to a fleet of 38 Basic and Advanced Life Support Vehicles. Currently we average approximately 2300 inter-facility transports per month.
The NYC 911 Division has 8 Basic and Advanced Life Support units that complement the FDNY-EMS fleet of vehicles. The NYC division responds to approximately 1550 transport requests monthly. The Paramedic First Response Division has 6 Advanced Life Support Paramedics riding in specially equipped vehicles to assist the Volunteers in Suffolk County. They respond to approximately 400 requests for assistance monthly.
Alignment with Strategic Plan:Operational PerformanceQualityWorkforce Development
Alignment with Strategic Plan:Operational PerformanceQualityWorkforce Development
Project Scope:Start: Call is receivedStop: Claim is paid911 and Inter-facility
Project Scope:Start: Call is receivedStop: Claim is paid911 and Inter-facility
Project Description / Problem Statement: On average, it takes 24 days from the time the call is received to the time the claim is billed.
Project Description / Problem Statement: On average, it takes 24 days from the time the call is received to the time the claim is billed.
Potential Benefits: Increased revenue, increased compliance with documentation.
Potential Benefits: Increased revenue, increased compliance with documentation.
Issues:
•Incomplete PCR’s•Incomplete insurance information•Open positions in registration•Inconsistent communication between Westbury and EMS
High Level Process Map Current Process
Call received and dispatched
Transfer patient
Paper work checked
Paper work scanned
Scrubbing and Pricing
Registration
Bill Dropped in Westbury
Total = 24 Days
2 hours
2 days
8 days
7 days
6 days
1 day
Solutions:
Clinical:
•Re-education of all staff on: e-PCR’s – how to write it Insurance – what is required
•Obtain insurance information at time call is booked•FTO Program•HOLD PEOPLE ACCOUNTABLE – everyone from management to road staff
**Consistent and correct information flow between all levels of staff**
Solutions:
Non Clinical:
•Insurance information obtained by clinical staff before registration process•Scanning 911’s off site•Continuing education for registration staff•Consistent number of registration/scanning staff•Cross train all registrars•Updated tools – books, software, etc.•Interaction between registration with all other facilities•Additional scanners for offsite locations•Incentives for employees
Solutions:
Non Clinical:
•Administration involvement – listen to suggestions, be open minded•ADHOC report – based on date of registration for totals•Communication between Westbury and EMS regarding denials•Bill all calls (courtesy calls), patients will not be balanced billed•Revise job description/requirements for registrars•Reconciliation of PCR’s to number of calls received•Dedicated employees at EMS/Westbury to track accounts (ie: correct payment amount)
Solutions:
Non Clinical:
•Access to CERNER Master Patient Index•Interface between Scan Health and Invision•Policies and Procedures for billing/registration•Credit card machine
High Level Process Map New Process
Call received and dispatched
Transfer patient
Paper work checked
Paper work scanned
Scrubbing and Pricing
Registration
Bill Dropped in Westbury
Total = 6 Days
2 hours
2 days
2 days
1 days
0 days
1 day
Questions