22nd Quality Management Conference

M h4
March 4-5,
5 2010
Improvements Through People, Processes, and
Performance

Becoming the Test Tube: Inspiring Change with Six Sigma

Presented by:
Carolyn Sweetapple, RN, CPA, MBA, Six Sigma Master Black Belt
Krasnoff Quality Management Institute
Great Neck, New York
Copyright © 2009, Krasnoff Quality Management Institute slide # 1
 North Shore-LIJ Health System
Nation’s third largest, non-profit, secular healthcare system
Rockland

Westchester

Bronx Suffolk
Manhattan

Nassau
Key:
Queens Health System Hospital
Brooklyn
Staten
Island

¾ 14 Hospitals*
¾ 18 Skilled Nursing Facilities* ¾ 38,000 Employees ¾ $5 B annual operating budget
¾ More than 5,000 hospital and ƒ Largest employer on LI ¾ 5.4 M Population Served
skilled nursing facility beds ƒ 9th largest in NYC ¾ 237,900 Discharges
¾ Home Care, Hospice ¾ More than ¾ 111,000 Ambulatory Surgeries
¾ Core Lab, Ambulance Transport ƒ 7,000 physicians ¾ 495,000 Emergency Visits
¾ Research Institute ƒ 10,000 nurses
ƒ 1,230 residents & fellows
ƒ 200 Scientists, $36 M in Grants
* Includes affiliates

Copyright © 2009, Krasnoff Quality Management Institute slide # 2

Our story begins with the
Voice of the Customer

Angry,
g y dissatisfied physicians.
y
Does this look familiar?

Copyright © 2009, Krasnoff Quality Management Institute slide # 3

Hospital Administration’s Response

 Buy technology
 Quick fix
 Quiet the physicians
 On to the next crisis
Copyright © 2009, Krasnoff Quality Management Institute slide # 4
Why I love this project…

• Technology without process change

will not be the ultimate solution
solution.
• Voice of the customer - get to the core
of what really is critical to quality for
the customer
customer.
• Overcoming resistance must be
planned - it will not naturally evolve.
You must have a change management
plan.
• Use of Lean methodology to identify
process opportunities and Six Sigma
methodology to design improvements.
• Sustainability requires attention.

Lessons Learned
Copyright © 2009, Krasnoff Quality Management Institute slide # 5
 DEFINE

Stakeholder Strongly Moderately Neutral Moderately Strongly

Against Against Supportive Supportive

Patient X
Project goal:
Physician X
Reduce lab testing
Nurses X X
Turnaround time.
Phlebotomists X X
Chem Techs X X
Developed charter,
Lab Clerk X X
Team, identified
Unit Personnel X X
R i t
Resistance early.
l
Ancillary X
Departments
Administration X

• Stakeholder Analysis revealed that lab staff not

supportive of project.
• A change management plan was needed.

Copyright © 2009, Krasnoff Quality Management Institute slide # 6

 How Are We Managing Change?

4.2
4.1
4 Before After
4.18
Monthly staff presentations
Monthl Define
39
3.9
3.8

Surveys pre and post. 3.7

3.6
3.76
3.5

Whatt are your ffeelings

Wh li about
b t
4.5
the Laboratory Six Sigma 4

Project before and after the

3.5 4.5
3
3.5
presentation? Analyze
y 2.5
2
1.5
1

• Strongly Apprehensive (1) 0.5

0

• Moderately Apprehensive (2)

• Neutral
Ne tral (3)
• Moderately Supportive (4)
4.5
4
3.5 4.4
• Strongly Supportive (5) Control 3
2.5
3.6
2
1.5
1
0.5
0

Copyright © 2009, Krasnoff Quality Management Institute slide # 7

 MEASURE
Problem Measurement
and Data Gathering:
Baseline data did not reveal a significant
turnaround time problem.
So why were the doctors so dissatisfied?

Priority USL Actual Std dev DPMO SIGMA

STAT
(order 102 113 49
472,000 1.5
entry to minutes minutes minutes
resulted) Two populations:
Routine Stat and Routine
(received 60 59 27
to 369 000
369,000 18
1.8
minutes minutes minutes
resulted)

Lesson learned:
Validate VOC with
Baseline data
Copyright © 2009, Krasnoff Quality Management Institute slide # 8
 What Does The Customer Want?

Voice of the Customer

(Physician Survey)
CTQ Tree

How quickly do you expect to get results on: BLOOD

STAT Labs: _____________________
DRAWN
TIMELY
Routine Chemistry Labs: ___________

Timed Labs: ______________________ QUICKER

LABS
TURN
When does the clock start ticking for you? PROCESSED
AROUND
Do you have difficulty getting your Routine Chemistry Labs? Yes /No TIMELY
TIME
Do yyou have difficultyy getting
g g Panic Value Labs? Yes / No

Do you have difficulty getting STAT Values? Yes / No

RESULTS
What time do you make rounds?
AVAILABLE
What would be a Win for you? TIMELY

Copyright © 2009, Krasnoff Quality Management Institute slide # 9

 So when we looked at time of day
results that were available ….

We did not meet the customer specifications 91% of the time!

Now this makes sense.

Baseline ( 1 week in June 2004) USL

DPMO= 911,000 0.1 SIGMA

x = 9:08 a
a.m.
m s = 17 minutes
n = 529 USL = 8:00 a.m.
0.15 0.25 0.35 0.45 0.55

Copyright © 2009, Krasnoff Quality Management Institute slide # 10

 ANALYZE
Identifying Independent Variables
That Determine CTQ Behavior:
Becoming the Test Tube

Results
Specimen
p Received Specimen
p validated
Od
Order and
drawn in Lab processed
available

Walk the Process!

“Staple Yourself to an Order”
Order
Harvard Business Review - 1992
Benson P. Shapiro, V. Kasturi Rangan, and John J. Sviokla
Copyright © 2009, Krasnoff Quality Management Institute slide # 11
 Routine Priority Time Value Analysis
“II Am The Test Tube
Tube”

nit
Add an X in one category for each step

ou
nt
Add duration of each step

e
tio

tim
ing

s
me

ult
ica
Do Not enter anything

ge
ion
e

es
t ti
un
tim

r
ifu

ze
ss

yr
uo
mm
p

el

aly
ntr
aw
tu

ce

rif
liq
av

Co

An
Se

Ac

Ce

Ve
Dr
Total %Total

Tr

Al
Process Step 1 2 3 4 5 6 7 8 9

Representative Time (minutes) 16.00 8.00 12.00 2.00 5.00 35.00 31.00 22.00 4.00 135.0 100%

Value Added 6.00 5.00 10.00 13.00 15.00 4.00 53.0 39.3%

Nonvalue Added 82.0 60.7%

Prep/Set-up 16.00 16.0 11.9%

Travel 8.00 8.0 5.9%

Wait time for nursing staff 6.00 6.0 4.4%

Communication to unit 2.00 2.0 1.5%

Specimen
p q
queue time 25.00 18.00 7.00 50.0 37.0%

Total 135.0 100.0%

Copyright © 2009, Krasnoff Quality Management Institute slide # 12

 Routine Priority
Peak Volume Times Staffing
Chemistry Volume vs. Staffing

80 5
60 4

m techs
em tests

3
# of chem

# of chem
40
2
20 1
0 0

00

00

00

00
0

0
0

30

60

90

12

15

18

21
Time of day

Volume of chem tests # of chem techs

Before:
Unbalanced
scheduling/workload
Copyright © 2009, Krasnoff Quality Management Institute slide # 13
 Staffing Solution

Developed
p Staffing
g Plan based on Chemistry
y Workload

Chemistry Volume vs. Staffing

80 6
70 5

chs
sts

60 Volume of chem
# off chem tes

# off chem tec

50 4 tests
40 3 Current Staffing
30 2
20 Proposed Staffing
10 1
0 0
0
0
0
0
00
00
00
00
00
00
00
0
20
40
60
80
10
12
14
16
18
20
22

Time of day
Copyright © 2009, Krasnoff Quality Management Institute slide # 14
 Stat Detail Process Map
(Notification to Draw)
fax rcv'd

STAT
ordered in
LIS

label placed
on STAT
board

phleb paged
Label given to phleb

phleb initials on Drawing Routine

blood orders
STAT board

delay
Drawi routine blood in TAT NO Do I draw STAT Do I answer NO
orders
immediately? the page right
away?
delay in
TAT
YES

Draw STAT YES

Draw STAT
phleb calls back

NO NO
phleb initials on
Do I bring STAT Do I bring STAT STAT board
to lab delay to lab
immediatley? in TAT immediatley?

YES YES
delay in Finish Drawing Routine
Do I draw STAT blood orders
TAT
immediately? NO

YES
Rountine and
STAT specimens
to lab Draw STAT
Draw STAT

Do I bring STAT
Do I bring STAT delay in to lab
to lab TAT immediatley?
immediatley?
NO NO

YES

YES

Rountine and
STAT specimens
to lab

Copyright © 2009, Krasnoff Quality Management Institute slide # 15

 Cause and Effect Diagram
Stat Delays
Order Entry to Blood Drawing

Transport Volume Communication

Timing of Draws RN unavailable
No beeper
Detours N available
No il bl phlebo
hl b B
Beeper N Working
Not W ki
Phleb location unkno
Too many unnecessary Overhead paging not
Rehab patient in OT/
Staffing in phleboto Other depts want pt.
Elevator Problems
RN starting IV
lack of phleb suppli Pt. Not availble
Order Entry to
Slow phlebotomist Draw Delays
Unavailable Patient
Specimen integrity
Unco-operative
Unco operative Patie Order needed to draw Recall pprocess
Test Clarification N
Isolation Patient Orders not coordina No Patient ID band
Prioritization of St
Difficult Draw Late orders Wrong Room number
Patient Order Process

Copyright © 2009, Krasnoff Quality Management Institute slide # 16

 Baseline Stat Priority
Regression & Process Capability
The regression equation is
Total = 0.530 + 0.880 Notify phleb + 1.18 Draw

Predictor Coef SE Coef T P

Statistically Significant
Constant 0.53042 0.07567 7.01 0.000 & 69% of Variation
Notify p
Draw
0.8802
1.1783
0.1710
0.1063
5.15
11.09
0.000
0.000
Explained
S = 26.328 R-Sq = 70.1% R-Sq(adj) = 69.1%

Notification & USL

Within
Deployment Overall

Baseline
DPMO=722,000 Sigma 0.9
x = 68.4 minutes
s = 40.8 minutes
0 50 100 150 200 250
n = 36 minutes USL = 42 minutes

Copyright © 2009, Krasnoff Quality Management Institute slideR4.17

# 17
 IMPROVE

Brainstorm solutions for :

Process for notification of phlebotomists
Process for deploying phlebotomists
Narrow down possible solutions using control/impact matrix
But how do you know you have the right solution?

In Out
Draw Staff Communication
Geographic vs Stat
RN'ss Draw
a Blood
ood
Dedicated Phleb Increase Lab
Stats's drawn by uni
Why Stat?
Floor Calls Directly to Staff
Floor dedicated LTA
Increase Lab Staff

Qualify Stat
High Phleb vs Lab
Dedicated Stat LTA Beepers vs Spectralink Pneumatic Tube
Decrease Stat Draw Time Runners vs no Runner
LTA communicates to G
Geographic
hi LTA Assig
A i
Lab Staff aids LTA w
Wireless phones for
Beeper for Stat LTA
Ward Clerks pick up Order Entry on Floors
Pneumatic Tube Stat Label Printer o
Stat Orders handed
Order entry on floor
Improve TAT on Routi Robotic Implementation
Runners for Stats Triage Stat
Direct Floor to LTA
Wireless access to L Flag on Chart
Ward Clerks Transpor
Dedicated Stat phonr Barcoded Patient's

Process Transport Clinical Qualify STATs Ward Clerks

Low Transport

Copyright © 2009, Krasnoff Quality Management Institute slide # 18

 Design Of Experiment

Factorial Design

FACTORS
FACTOR NAME OPTION 1 OPTION 2

A. Floor Calls Phleb Lab

B. Assignment Geographic Dedicated

C. Communication p
Beeper Spectralink
p

D. Runner no yes

Randomized & Replicated

Copyright © 2009, Krasnoff Quality Management Institute slide # 19
 Stat Solutions

Developed Geographically Designated Phlebotomist

Schedule Based on Number of Phlebotomists Working
Deployed by Beeper from the Lab

ic k
a ph te d er r alin
r gr ic a ep
t
ec o
oo eo ed e Sp ye
s
Fl b
la g d b n
23.0
TAT RECD
D

21 5
21.5

20.0

18.5

17.0

Deployment Assignment Communication Runner

Design of Experiments

Copyright © 2009, Krasnoff Quality Management Institute slide # 20

 Design Of Experiment

BOXPLOTS

50 50

40 40
AT RECD

AT RECD
30 30

20 20
TA

TA
10 10

0 0
beeper spectralink phleb lab
Communication Deployment

Copyright © 2009, Krasnoff Quality Management Institute slide # 21

 Stat Priority
Order Entry to Results Verified
Baseline Post Implementation
DPMO=472,000 1.5 SIGMA DPMO=261,000 2.1 SIGMA
x = 113
113.28
28 minutes s = 49
49.04
04 minutes x = 82
82.94
94 minutes s = 38
38.85
85 minutes
n = 36 USL = 102 minutes n = 134 USL = 102 minutes

USL USL

0 50 100 150 200 250 50 100 150 200 250

Mood median test

Chi-Square = 9.02 DF = 1 P = 0.003

Stacked N<= N> Median Q3-Q1 ---+---------+---------+---------+---
Baseline Y 10 26 97
97.5
5 71
71.8
8 (
(---------+-----------)
+ )
Post Y 75 59 68.0 64.3 (----+-------)
---+---------+---------+---------+---
64 80 96 112
Copyright © 2009, Krasnoff Quality Management Institute slide # 22
 Routine Chemistry
Received to Result Verified
Baseline Post Implementation
DPMO=369,000 1.8 SIGMA DPMO=245,000 2.1 SIGMA
x = 59.18 minutes s = 26.82 minutes x = 48.97 minutes s = 24.26 minutes
n = 788 USL = 60 minutes n = 770 USL = 60 minutes
USL USL

0 50 100 150 200 250 300

0 50 100 150 200 250 300
Mood median test
Chi-Square = 24.87 DF = 1 P = 0.000
when N<= N> Median Q3-Q1 -----+---------+---------+---------+-
Baseline 360 428 47.0 44.0 (-------+---------)
Post- Ro 449
9 321 39
39.0
0 31
31.0
0 (
(--+----)
)
-----+---------+---------+---------+-
40.0 44.0 48.0 52.0

Copyright © 2009, Krasnoff Quality Management Institute slide # 23

 Routine Chemistry
Results Completed Prior to 8:00 AM
Baseline ( 1 week in June 2004) Post Implementation (1 week in July 2004)
DPMO= 911,000 0.1 SIGMA DPMO= 598,000 1.2 SIGMA
x = 9:08 a.m. s = 17 minutes x = 8:19 a.m. s = 27 minutes
n = 529 USL = 8:00 a.m. n = 530 USL = 8:00 a.m.

USL USL

0.15 0.25 0.35 0.45 0.55 0.15 0.25 0.35 0.45 0.55

Mood’s Median

Chi-Square = 145.88 DF = 1 P = 0.000

Date N<= N> Median Q3-Q1 ------+---------+---------+---------+
June 171 358 0.3819 0.0361 (--+)
July 368 162 0.3417 0.0715 (
(--+-)
)
------+---------+---------+---------+
0.345 0.360 0.375 0.390
Copyright © 2009, Krasnoff Quality Management Institute slide # 24
 CONTROL

Ensuring Sustainable Results:

Results were sustained for five years

Changes imbedded in departmental processes

Owners continue to monitor with control charts

and intervene if trends are observed

Copyright © 2009, Krasnoff Quality Management Institute slide # 25

 The story ends where it began…
Voice of the Customer

“The ramifications of this project reach far beyond the

turnaround time issues of the laboratory. I can easily see
th relationship
the l ti hi tto quality
lit off care ffor our patients
ti t and
d th
their
i
physicians, alleviation of wasted nurse’s time, and shortened
length of stay
stay.”

Michael R. Delman MD, FACP, FACG

SVP for Medical Affairs and Quality Management
Southside Hospital

Copyright © 2009, Krasnoff Quality Management Institute slide # 26