1. Six Sigma at Academic Medical Hospital
The following presentation was developed by Jane McCrea, Black Belt of the ED Wait Time Project at Academic Medical Hospital.
The presentation follows the DMAIC methodology.

2. Six Sigma--DMAIC
Define: Define and scope problem. Identify potential benefits and critical to quality (“CTQ”) factors.
Measure: Identify the key internal process that influences CTQ characteristics and measure the defects generated relative to the identified CTQs. Confirm measurement system reliability. Know voice of customer. End result: team can successfully measure the defects generated for a key process affecting the CTQ.
Analyze: Identify root causes of defects. Use statistical data tools to identify key process inputs that affect process outputs. End result: explain variables that are likely to drive process variation the most.
Improve: Determine and confirm optimal solution (statistically re-analysis). Identify the maximum acceptable ranges of key variables. End result: modify the process to stay within the acceptable ranges.
Control: Ensure that modified process now enables the key variables to stay within the maximum acceptable ranges using tools such as metric dashboards and accountability reporting.

3. ED Wait Time Define Project Description
six sigma
The Way We Work
Champion
Dr. Gerry Elbridge Sponsor
Dr. Terry Hamilton
Black Belt
Jane McCrea
Green Belt
Dr. James Wilson
Foundations Team
Nancy Jenkins, Bill Barber,
Georgia Williams, Steve Small
Project Description
Reduce and consistently maintain patient wait times from triage start to first physician interaction at established thresholds.
EXPECTED BENEFITS
Customer: Critical to Quality (CTQ)
Reduce Wait Time
Internal: Critical to Quality (CTQ)
Improve Patient/Staff Satisfaction
Enhance Patient Outcomes
Increase ED capacity and operational efficiency
Arrival
Triage
Register
Lobby
Tx Room
Nurse MD

4. What was the Voice of the Customer?
Measure
What was the Voice of the Customer?
Patient Survey
N = 30; Priority II Patients
Random: all days, all shifts
Patient Survey Results
Wait Time Expectations:
10-20 minutes: 43%
20-30 minutes: 23%
Patient Survey Results
Wait Time Satisfaction
Very Satisfied: 37%
Very Dissatisfied: 37%

5. Baseline Measurements
An observational prospective manual time study
yielded baseline measurements for the total wait time
Triage Start to
MD Start
Mean: 62.5 min.
Std. Dev: 39.66
Z-Score: 1.79
Defect Rate: 38.6%
USL: 37.1 min.
The Upper Specification of 37.1 is shown as a yellow vertical line.The z Score is the number of Sigma above mean.The rectangle at the bottom of the graph is the 95% Confidence Level for mean

6. Key Takeaway: 40% Wait Reduction & Operating Margin Gains
Measure
What did we measure?
Y: # of Minutes, from Triage Start to First Physician Interaction
Specification Limit: 37 minutes
Specification Validation: Internal experts & data, External benchmarks
Defect: Wait time > 37 minutes
Unit: One priority II patient visit with one defect opportunity each
Measurement System: Patient Survey, Manual Data Collection, Chart Review, Quality Reports, Registration & Staffing Reports
Impact on Business:
25 min. Line of Sight Reduction Per Patient Resulting = Capacity Opportunity
Improved Patient Satisfaction, Reduced Complaints, Enhanced Outcomes
Improved Staff Satisfaction & Reduced Turnover
Improved Daily ED Operational Efficiency
Key Takeaway: 40% Wait Reduction & Operating Margin Gains

7. What critical X’s were tested as being root causes of the problem?
Environment
People
Materials
Analyze
ED patient volume
ED patient acuity
Influx of squad patients
Referral volume
Clinics schedules
OR volume
Hospital patient volume
ED tx room limits/facility constraints
Staffing levels
Experience & skill level
Resident specialty
Volunteer/greeter utilization
Family needs
Role clarification
Match of skill sets and assignments
Variation of practice
Availability of supplies
Triage process
Registration/Chart prep process
Charting procedures 
Communication
Availability of diagnostic equipment
Availability of trams, pumps, etc.
Non-optimization of Tracking system
Inadequate IS system for tracking/trending
No Physician Prescription Writing system
No integrated, on-line charting system
Quality of measurement
Are we measuring the right things?
What do we do with what we measure?
Need to do more than “track”
Feedback systems to quality auditing
Need for Improved flow sheet format
Lack of on-line charting system for
automated monitoring
Utilization of minor emergency unit
Ancillary services levels
Specialty testing delays 
ED used as admission unit
ED discharge practice
Hospital discharge process/timing
Consult responsiveness/practices
Use of ED for boarding
Measure
Machines
23 variables & 18 time stamps
Analyzed via 2nd. wave of data collection
Patient Volume-Related: 10
Staffing Volume-Related: 5
Staffing Mix-Related: 5
Misc: 3
Segmentation/delineation
Sequential care vs. parallel processes
Methods
Improvement implementation/maintenance ownership

8. Improve
What critical X’s were tested as being root causes of the problem?
23 variables selected & analyzed
through second wave of data collection
Census-Related: 10
Staffing Related: 5
Coded: 5
Miscellaneous: 3
What root causes were confirmed and tested in the pilot?
Patient Flow
Direct-to-bed flow & bedside registration
Patient relocation to semi-private space when appropriate
Flow Facilitator
Care Team Communication
Modified Zoning
Communication Board
Clinical Protocols
Streamlined Order Entry & Results Retrieval Process

9. Pilot Design
Fishbone diagramming, data collection and statistical analysis determined the Critical X’s (contributing factors) as key components for the randomized pilot.
Patient Flow
Direct-to-bed flow; Relocation to semi-private space
Care Team Communication
Zoning; Communication board; Clinical protocols
Streamlined Order Entry & Results Retrieval
Uses central clerk
Important link here: Larry Bossidy, former GE exec and CEO at Allied and Jack Welch

10. What were the pilot factors and results?
Improve
What were the pilot factors and results?
Patient Flow
Direct-to-bed flow & bedside registration
Patient relocation to semi-private space when appropriate
Flow Facilitator
Care Team Communication
Modified Zoning
Communication Board
Clinical Protocols
Streamlined Order Entry & Results Retrieval Process
Lobby Target
15 min.
Study 2
N = 129
Pilot
N = 172
Wait Time
34.5 min.
12.6 min.
% Defect
51.2%
22.8% MD
Target
8 min.
Study 2
N = 129
Pilot
N = 172
Wait Time
11.2 min.
8.9 min.
% Defect
42%
34.9%

11. PILOT RESULTS
Lobby WT
Study 1
N =30
Study 2
N = 129
Pilot
N = 158
MD WT
N = 30
N = 127
N = 172
Mean WT
(minutes)
31.2
34.5
12.6
16.1
11.2
8.9
Standard
Deviation
26.65
16.02
11.69
18.70
46.76
16.68
% Defect
56.7%
51.2%
22.8%
55%
42%
34.9%
Z-Score
(Attribute)
1.33
1.47
2.25
1.37
1.71
1.89
Important link here: Larry Bossidy, former GE exec and CEO at Allied and Jack Welch

12. PILOT CONCLUSIONS 0.001 2.7 to 31.8 0.000 4.8 to 13.2 0.016
Mood’s Median Test
Pilot lobby wait times were better than the established 15 min. target, the defect rate tumbled, and the C.I. validated statistical significance.
Results for MD wait times were statistically significant in one of two Mood’s median tests. Positive trending was demonstrated in the comparison of Study 2 to the Pilot.
Stakeholders supported department-wide, multi-patient population implementation.
P-value
95% C.I.
Lobby WT
Study 1 to Pilot
0.001
2.7 to 31.8
Study 2 to Pilot
0.000
4.8 to 13.2
MD WT
0.016
1.0 to 16.0
0.772
-2.00 to 3.00
Important link here: Larry Bossidy, former GE exec and CEO at Allied and Jack Welch
Lobby WT N
MD WT N
Study 1 30
Study 2
129
127
Pilot
158
172

13. Improve

14. What are the building blocks of Control?
Guidelines & Assigned Responsibility
New Standard Operating Procedure
Detailed Who, What and When plan
Data Review, Reporting & Accountability
Quarterly manual/automated data analysis
Monthly reports and control charts
Use of Corrective Action Log per guidelines
Monthly reports
Scheduled reporting to executive leadership
Quarterly review to owner peers & executives
Communication & Recognition
Monthly updates to dept. communication center & newsletter
Monthly updates at staff, faculty & resident meetings
Incorporation of staff recognition for ongoing positive results