Healthcare Six Sigma

Project
ED Wait Times and Service Quality
Michael J Floriani

Project Overview
A recent report from the Centers for Disease Control and Prevention indicates that
over the past decade, trips to the emergency department (ED) increased twenty
percent, while the number of available emergency centers fell by fifteen percent.
Another study from the American Hospital Association (AHA) indicated that sixtytwo percent of hospitals feel they are at, or over operating capacity. That number
jumps to ninety percent when considering Level 1 Trauma Centers and larger (300+
beds) hospitals.
These statistics are frighteningly familiar to many hospitals and patients. The
pressures are mounting and a faltering economy has swelled the ranks of the
uninsured those who often rely on the local ED for primary care. Countless
emergency departments are literally on life support as they try to cope with the
following:

Capacity issues
Workforce shortages

Preparing for, or responding to emergency threats such as bioterrorism and SARS,

only increases the strain on the system. In hospitals across the U.S., emergency
departments face a similar story of delays and dissatisfaction from both patients
and clinicians.
Some hospitals, however, are finding new ways to overcome the challenges and are
creating safer and more efficient environments. Through a combination of Six
Sigma and Lean, hospitals are targeting critical aspects of patient flow, patient
access, service-cycle time, and admission/discharge processes. A growing number
of hospitals are taking steps to identify and remove bottlenecks or inefficiencies in
the system. As a result, they are seeing a positive impact on patients, staff, and the
bottom line.
By using the principles in the Villanova Six Sigma Black Belt course, the objectives
of the project are:

Decrease door to doctor time

Decrease the patients total length of stay (LOS)
Decrease the number of patients who leave the ED without being seen as a
result of being tired of waiting.

Last year, the hypothetical hospital received 43,800 patients into its emergency
department with 6.3% leaving without treatment essentially because of their
dissatisfaction with the wait time.

The nations emergency care network must be strong not only to maintain its
ability to serve basic community needs, but also to ensure it will have the necessary
capacity and processes in place to respond quickly during a crisis.

Project Charter (Define)

The project charter of this Six Sigma/Lean healthcare project establishes the first
phase of the DMAIC process by defining the problem and other key elements to
motivate the team and ensure the project meets the stakeholders needs.
Additionally, it establishes buy-in of the project.
The project charter is composed of various elements; however, the key elements
include:

Business Case
o The sponsor must know what the project is about and how it impacts
the strategic objectives of the organization. This business case
statement should be limited to one to two sentences.
Problem Statement
o The sponsor must be sold on why we need to do this project and needs
a short, to-the-point compelling reason why we need to do this. It is in
the problem statement, we 'sell' the need for the project with specific
and measurable data.
Goal Statement
o This includes the target improvement for this project and target date.
o Six Sigma projects should target the project for an initial 50%
improvement as a best practice.
Project Scope
o The project scope identifies the boundaries of the project to include
what is and is not included as part of the project. Assumptions and
constraints may also be included in the scope statement which affect
the budget or project team.

The following project charter deliverable has been established for this healthcare
case:

Business Case
o Paoli Hospitals emergency department is facing increased patient
volumes, constrained capacity and employee shortages as it moves
towards a Level 1 Trauma Center.

Excessive delays and length of stays negatively impact patient

outcomes and satisfaction requiring us to initiate this project to
improve key ED metrics.
Problem Statement
o Since 2009, patients who left the emergency room without waiting due
to delays, accounted for 6.3% of a total 43,800 ED visits. This 50%
higher than desired increase resulted in 2,759 balked visits, lost
hospital revenue, negative hospital reputation and poor emergency
room preparedness.
Goal Statement
o The project will commence June 1, 2010 and meet all objectives six
months prior to the hospital becoming a Level 1 Trauma Center,
currently planned for June 2011 and result in increased patient
satisfaction and improved financial performance.
o Goals for the project include 1) Improving door to doctor time by
50%, 2) Decreasing total LOS by 20% and 3) Reduce unseen patients
by 75%.
o A project plan will be provided to management by June 15 outlining
tasks involved, risk plan and communication plan. Weekly status
reports will be distributed and a mid-phase and final phase
implementation plan will be presented to executive management.
Project Scope
o Registration process, ED flow process, lab process and discharge
process will be included in this project.
o Included in this scope is the time from patient entry to the ED, either
by foot or by emergency transport, and ends when the patient is
officially discharged by the physician.
o Outside of the scope is the admission process for patients admitted
due to severity of illness.
o Not included are delays attributed to patients, patient families or other
members outside of hospital personnel.
o

Baseline Sigma (Measure)

The baseline sigma establishes the original state sigma before any process
improvement initiative is implemented.
Because the defect, the number of potential patients leaving the hospitals ED, is
attribute data (only one possible defect per opportunity a two state condition in
which the patient either stays or leaves ), the opportunity to calculate uses the
value 1 for opportunity; hence:
Units:
Hospital ED visits which, according to the case, are 43,800 visits per
year.
Defects: 6.3% or 2,759 people leaving the hospital ED without being seen by a
doctor.

DPMO or DPMU result in same because of the 1 opportunity and therefore the
formula and result is
2759/(1*43,800) = .062991 or 63,000 DPMO. This equates to 3.03 Sigma with
1.5 shift.
SIPOC (Define)
The following SIPOC represents a high-level identification of the current state
process to observe the major process elements. This includes the 1) Suppliers 2)
Inputs 3) Processes 4) Outputs and 5) Customers associated within this project.
The SIPOC begins by identifying the key steps within the process by listing five to
seven process elements. Once identified, other areas are listed associated with
the projects SIPOC.
Further breakdown of sub-processes can be achieved later within this project;
however, the purpose of the SIPOC. The SIPOC diagram helps to identify the
process outputs and the customers of those outputs so that the voice of the
customer can be captured.

Suppliers
Patient
Triage Nurse

Registration
Clerk
Nurse
ED
Doctor/Hospitali
st

Emergency Room SIPOC

Inputs
Process
Outputs
Medical
Records
Patient
Symptoms

Patient Arrival
to ED
Triage patient

Discharge
Documents
Prescriptions

Rx Information

Register Patient

Physician Notes

Insurance Data

Assign Patient
to Room
Assign
Physician

ED Activity Log

ED Activity Log

Room Data

Physician
Examines
Patient
Physician
Orders Tests
Physician
Treats Patient
Physician
Discharges
Patient

Empty ED
Room

Customer
Patient
ED
Doctor/Hospitali
st
ED Manager
Orderly/Nurse/Ai
d
Lab Personnel

Pareto Diagram (Analyze)

The principle is based on the unequal distribution of things in the universe. It is
the law of the "significant few versus the trivial many." The significant few things
will generally make up 80% of the whole, while the trivial many will make up
about 20%.
The purpose of a Pareto diagram is to separate the significant aspects of a
problem from the trivial ones. By graphically separating the aspects of a
problem, a team will know where to direct its improvement efforts. Reducing the
largest bars identified in the diagram will do more for overall improvement than
reducing the smaller ones.
Based on information provided by those who entered the hospital, the following
reasons were stratified for leaving:
Got tired:
6
Not necessary: 4
People Waiting: 4
Doctor Treatment:
Staff Treatment: 2
Environment: 2
Went Elsewhere:
Ignored Me:
1
Too Expensive: 1
Had to Leave: 1

3
1

From the above data, the project team should focus, at most, on the first six
reasons while accepting others as the useful many. This information is
substantiated from the Pareto Chart below.

Expected Variation (Analyze)

During the past month, the patient wait times were logged and are noted within
this document. All figures are in minutes with a wait time operational definition
of the patient entering the ED facility until brought into an ED room. All values
are rounded to the nearest minute.
24
17
18
28

27
28
27

18
24
22

11
17
27

22
8
17

27
21
40

17
26
22

23
23
18

17
17
17

5
31
18

From the thirty-one observations, the following results are provided:

Average wait time:

21.1935484 minutes
Standard Deviation: 6.9013011
Range of Expected Variation
o Lowest Point: 0.4896451
o High Point:
41.8974517
Histogram to determine Normal Distribution or Assignable-cause variation
is normally distributed as shown on the following histogram by the bell
curve.

Patient Wait Times

12
10
8
6

Frequency

4
2
0
5

12

19

26

33

More

Minutes

Stem and Leaf Diagram (Analyze)

The Stem and Leaf diagram preserve the actual data values compared to the
histogram which categorizes values into bins. To get a visualization of the
variation in wait times over the past seventy days, it can be determined by this
diagram, if assignable cause variation exists.
The values over the past seventy days are indicated within this document as
shown below:
16
16
17
37
47
32
48

9:::
8:::
7:::
6:::
5:::
4:::
3:::
2:::
1:::

5
0
1
3
0
4
2
0
0

2
5
4
0
4
5
0
1

5
0
5
7
0
3

1
6
8
0
4

21
18
75
15
17
13
47

11
47
38
17
20
49
19

16
26
17
65
15
17
48

16
44
48
45
50
49
63

17
22
10
18
51
14
80

6
49
48
47
48
52
46

48
47
20
71
47
50
95

47
20
50
35
21
46
48

20
64
16
44
82
51
58

1
6

2
7

8
7

1
5

1
5

2
6

6
6

0:::

The above Stem and Leaf diagram shows that this data is not normally
distributed. As a recommendation, the project team should focus on wait times
of forty minutes and more. The number of wait times is fairly evenly distributed
at the point of >= 40 minutes and <40 minutes.
Design of Experiment (Improve)
The Design of Experiments (DOE) approach has been recommended to hopefully
realize an improvement considering variables that impact wait times. The
project team brainstormed five possible reasons for the delay to include the
following:
1.
2.
3.
4.
5.

Staff size
Order of treatment
Treatment method
Tracking software
Waiting room temperature

Using a statistical software package for Fractional Factorial Designs, the effects of
the five factors can be achieved in as little as eight experiments with no interactions
of these factors.
The factors or each experiment were:
A
B
C
D
E

Level (-)
8
FIFO
Iterative
Product A
68 Degrees

Staff Size
Order of Treatment
Treatment Method
Tracking Software
Waiting Room Temp

Level (+)
16
By Priority
All at Once
Product B
75 Degrees

The breakdown of the experiments is as follows:

Trial #

Staf

Order

Method

Software

Temp

1
2
3
4
5
6
7
8

1
-1
1
-1
-1
1
1
-1

1
-1
1
-1
1
-1
-1
1

-1
-1
1
1
1
-1
1
-1

-1
1
1
1
-1
1
-1
-1

-1
1
-1
-1
1
1
-1
1

(Y) Wait
Time
9
7
25
28
26
8
28
6

To determine the correlation, average wait times must be taken for various
conditions. For the first experiment for staff size, the average wait time for a staff
size of 8 and 16 was as follows:

Staff Size of 8:
Staff Size of 16:

(7+28+26+6)/4 = 16.75
(9+25+8+28)/4 = 17.50

Charting these results in the following:

Treatment

Staf Size
30

30

20

20

10

10

Method

Software

30

30

20

20

10

10

Temperature
30
20
10
0

Since the objective is Less is Better relative to wait times, the following should be
achieved:

1. Immediately make an adjustment to room temperature from the 68 degree

setting to achieve a more comfortable setting. This has the most significant
impact, based on the DOE data, for a reduction in wait times.
2. Begin prioritizing patients as this has reduced the average wait time.
3. While the average wait time has decreased slightly using product B, this
should be used as the other software may contribute to not effectively
tracking patients; thus, increasing wait times. This software should be
evaluated to ensure it prioritizes patients.
Scatter Diagram (Improve)
The following data and Scatter Diagram are used to determine the correlation
between the volume of patients and the impact on the number of patients that
leave without treatment (LWT). This was believed by the project team, and as
such, the data identifies the correlation.
Number in for
treatment per
specific day
172
132
130
206
199
223
201
169
135
200
189
110
203
189
224
197
188
125
199
194
207

Leave without
treatment
incidents
4
6
2
4
6
4
8
7
5
3
7
8
6
5
8
4
8
2
6
8
7

9
8
7
6
5
4

Linear ()

3
2
1
0
100

120

140

160

180

200

220

240

Correlations of 1.0 to -0.7 indicate a strong negative association while a

correlation of -0.7 to -0.3 indicates a weak negative association. The correlation
of -0.3 to +0.3 indicates little or no association and +0.3 to +0.7 weak positive
association. A +0.7 to +1.0 indicates strong positive association.
The Scatter Diagram does not indicate any correlation with a correlation
coefficient of .2256432 (very weak) and is positive.
XmR Chart (Control)
The earlier Stem and Leaf diagram indicated a bi-modal condition; therefore the
project team identified the source of this condition and eliminated one of the
sources and optimized accordingly. The two sources were 1) some patients were
first-time visitors and 2)some of the patients were return visitors.
Order
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Order
10
17
29
39
55
64
28
6
5
3
39
46
35
30
6

16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

32
33
11
20
13
9
14
12
30
56
62
73
54
10
9

The project team changed the process so that first-time visitors were processed
ahead of time; thus, reducing their wait time in the waiting room. This
dramatically decreased the overall average wait time. Part of the control
strategy is to employ the use of an on-going capability study; however, one must
first determine the process is in statistical control. To do this, an XmR Chart of
new wait times has been established in order of occurrence. This data is
shown above.
The Upper Control Limit (UCL) and Lower Control Limit (LCL) are indicated which
shows that continuous improvement is necessary.
18
16
14
12
10
8
6
4
2
0

Mean
UCL
LCL

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