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Breyfogle (15) observes that much interest has been developed in the applications of lean six sigma statistical techniques to process improvement. Traditionally, this technique was reserved for the manufacturing firms but it has gained fame in the service industry where its application has yielded positive results. The lean six sigma principles can be applied in healthcare organisations to improve their financial and operational performance. Since six sigma examines quality as defined by customer, I used it to solve the problems in the discharge process at Nancy medical center where there has been numerous complains about delay.
Nancy medical centre is an outpatient/inpatient profit making hospital. The inpatient accommodates a capacity of 100 patients at a go. The hospital which operates on a 24-hour basis has key departments like the laboratory, radiology and a state of art laboratory which serves the surrounding clinics. The newly invented physiotherapy department has seen its bed occupation rise from 80% to 100% most of the times. The hospital has a total of 200 employees both the medial staff and non-medial staff. Since this is a small hospital, it has a small organisational structure as simple too.
In my project, I created a lean six sigma for a discharge process in Nancy health center hospital. The process followed in planning and developing the plan is fictional and so the details about the hospital. We have noted with concern that the discharge process in our hospital is usually a lengthy and inefficient process to the disappointment of patients and their families. There were delays in the handling of the new patients from admitting, the emergency department and the registration desk. Through the customers complain feedback system received so many complains about the delay in the discharge process.
Though there are other complains about delay in other department for this project, I will however concentrate on the discharge and the main goal reduction of time intervals between when the discharged order details for a patient was keyed in to the computer to the time when the room was available for the another incoming. Since I have already known there is a problem, I will select a team that is multidisciplinary from all departments and this will act as the black belt as recommended by six sigma proponents.
During the planning stage, the team divided the discharge process into four sections:
- From the discharge order details keyed in the computer to the time when the patient signed it.
- From discharge instruction to patient going out.
- From patient signing out to the room preparation for the next patient.
- From cleaning the room to the discharge details keyed in the computer thus showing the bed is vacant for the next patient.
The hospital is committed to excellent customer service; therefore, the team will concentrate on the process number one and two which touches on the customer. The goal is to find ways so as to ensure the first process was completed in 45 minutes. To be addressed is the time when bed was cleaned and when the discharge was keyed into the computer. This is to ensure the admitting desk has the correct information to avoid situation where the patients are either turned away or have to wait for long in the emergency room.
Mapping was done first as recommended (Breyfogle 51). During mapping, it was realised that there lacked standard procedure for discharge and this could be one reason there were delays. This variation in discharge process was noted because the nurses failed to reach a consensus when asked to draw a map.
The team, therefore, drew a representative map so as to provide a foundation on which to apply the lean six sigma components. The lean six sigma elements were combined with the representative map and were applied to understand which of the above steps were causing delay in the discharge process. The existing process had aspects which were classified as value adding, non-value added and those which enable values. After the above process, the team was able to identify rework loops, non-value added steps, communication flows, and staff movement. This analysis showed that we could not do without the steps but there some non-value added components of time and rework which needed adjustments if the discharge was to be sped up.
Assuming the data were collected revealed the sub process from discharger order entry to patient leaving took 184 minutes; the standard deviation will be 128 minutes. We also assumed that the sub process from the time the patient left to the time the discharge was keyed in the computer, it took 36 minutes thus the standard deviation is 36 minutes too. Remember, the goal was to make 45 minutes and therefore as we compare this with the first process, it has yielded only 7% but the second sub process is preferred with 25% of the targeted time of 5 minutes.
According to Kooy and Pexton (26), lean-six-sigma is used to determine the critical drivers that cause waste and variation. From this, we identified the process to have the following segments:
- The secretary makes a discharge order entry in to the computer;
- The nurse begins to work on the discharge process;
- The nurse then keys in the detail of the discharge into the computer
- After the computer entry is complete, the nurse obtains the signature from the patient.
We used Mood Median as proposed by Kooy and Pexton, (35) to test the various hypotheses to come up with the following factors which were causing waste and variation.
It was found out that around 21 cases needed clarification from the physician before the nurse made the entry into to the computer. This clarification added a significant amount of time such that the median of the process increased from 12 minutes to 45 minutes if a case needed clarification.
It was also found out that if a case needed handling by more than one nurse the median increased from 9 minutes to 73 minutes. The process which was in place required that primary nurse entered the details of discharge into the computer and then printed out the discharge. He/she then placed the print out in the discharge bin and would signal the second nurse who would review the discharge together with the patient so as to obtain a signature. Sometimes, the first nurse was so overwhelmed that he/she forgot to signal the second nurse and, in that situation, the patients who was delayed up to an hour.
The third waste and variation drive was found out to arise if the patient required after care services. For example, if there were equipment to be ordered, maybe from physiotherapy department, the median cycle noted an increase of 121 minutes in the ongoing process, up to 160 minutes when this after care was required.
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From the above analysis, we can see that the process suffered because of rework and no visual signals were available to facilitate handoff.
After identifying the variations the following steps which represent the new standard, operating process will be applied; this is the improvement step as proposed by Breyfogle (Breyfogle 88):
- The secretary enters the discharge order;
- Unit secretary notifies the concerned first nurse via phone to take over the process;
- First nurse analyses the order and writes down the assessment notes;
- The same nurse also keys in information into the computer system;
- The next step is printing the information and any instructions necessary.
- At this stage, the patient signature is obtained after confirming with the patient.
The above steps ensured only value adding steps were followed and it removed bottlenecks like reworks. Patients were to be assessed the day before discharge to identify those who required after care services so that their equipment will be made ready before hand. To ensure the success, daily meeting will be conducted to coordinate the activities and it will involve the charge nurse, first nurse and any other person involved in the discharge process. From this daily meeting, the physician could clarify any anomalies and thus the numbers of cases reduced. The idea to have the primary nurse handle all task eliminated the handoff bottlenecks which was previously causing delays.
During the research, the team discovered that there was always a delay in updating the information on the computer when the patient left or if a patient was moved from one unit to another. To solve this problem, a session was conducted between the unit secretaries and the transporters (they move patient from one unit to the other, e.g. ICU to general ward) to find the best way to improve the entry into the computer process. It was discovered the problem arose because no signal was given when the patient left or was moved.
To solve this problem, a small slip fro discharge was designed. It was to contain details like the patient name, room number, and time of call for discharge. The process stated with the transporter who picked up the patient and went of the secretary desk so that he can obtain the time. He then writes the time on the card and hands over the slip to the secretary who is the second person in the process.
In order to maintain improvement, Frabotta (58) suggest that one should use the change acceleration process and employ an ongoing tracking system. These two tactics were employed simultaneously so that improvement can be sustained. The change acceleration process proposed by Frabotta (58) involved conducting a meeting with the parties concerned so as to increase understanding as to why the improvement was necessary, to provide the initial date and also establish available sections that had room for further improvement (World Health Organization 12).
The tracking system will include three components:
- A daily report to the previous day discharges including the discharge times and the person responsible (nurse and secretary);
- A tracker to capture performance was to ensure each individual was accountable by using mean and standard deviation to measure;
- A control chart to track the means and standard deviation would be introduced.
Let us assume that the process is in control and re-measure the components.
From the above information, we can see that the steps from the time the discharge order was placed to the time the patient was free to leaves sub-process labeled 1 show an improvement in the mean , this is equivalent to 74% decrease in the standard deviation. The second sub-process which is labeled 2 that shown the time from when the patient left to when the first nurse keyed in the details in computer shows an improvement of 90% in the mean and 58% in the standard deviation (Glied 23).
The challenges faced were in the implementation process. First of all, getting the staff to understand why they needed to fill in the time chart. The staff also took time to adjust that they had to attend meetings every morning. The primary nurses also complained that they were being overworked. However, after training on the importance of following the standard procedure, great success was achieved.
In conclusion, we can say that the lean six sigma process is an important process in the service industry and it helps to improve efficiency by identifying and eliminating bottle necks that cause variation and waste time. The above process is a success since no additional finances will be required. In fact, money will be saved because if the customers are satisfied, the inpatient capacity will be 100%.
Breyfogle, Wall. Implementing Six Sigma: Smarter Solutions Using Statistical Methods. New York, NY: John Wiley & Sons, 1999. Print.
Frabotta, Dick. “Six Sigma set for growth”, Managed Healthcare Executive. New York, NY: John Wiley & Sons, 2002. Print
Glied, Sherry. “Health Care Financing, Efficiency, and Equity.” National Bureau of Economic Research, 2008: LZ01. Print.
Kooy, Mill and Pexton Collins. Using Six Sigma to Improve Clinical Quality and Outcomes, Washington: Medical Systems Healthcare Services, 2002. Print.
World Health Organization. World Health Report 2000 – Health systems: improving performance. Geneva: WHO, 2002. Print.
For the purpose of privacy, personal details were not requested from the patients at the hospital.
- How old are you?
- How long have been coming to this hospital?
- Do you leave around?
- If no the answer is no, how far do you leave from here?
- What makes you choose this hospital?
- How is there process?
- Kindly estimate how long you spend at there admission desk during your first admission.
- Do you think it was fast enough than other hospitals that you have been before. If the answer is no, kindly estimate the time you took from your previous hospital.
- At what stage do you feel there is much delay within this hospital?
- What is your comment on the discharge process within this hospital?
- Kindly give a recommendation on what you feel has to be improved within this system.