linking six sigma and lean to organizational strategy

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.


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


Low TAT on 5no and 8so told us they were doing something different


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


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



Process Data

Within

Overall

5004003002001000

USLUSL


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



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


• 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


• 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


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


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


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

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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

0

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In-Patient CT Procedure Volume2004 vs. 2005

In patient 2004 In patient 2005

LEAN Improvements Implemented

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Out-Patient CT Procedure Volume2004 vs 2005

Outpatient 2004 Outpatient 2005

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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

linking six sigma and lean to organizational strategy

Documents

sigma project criteria

sigma process

project lead

customer projects

project goals

similar project

sigma evolution

sigma work