Six Sigma in Healthcare: Redefining the Emergency Room Process

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Six Sigma in Healthcare Redefining the Emergency
Room Process

• Christopher Valerian, DO, MMM
• Vice President, Medical Affairs
• Bon Secours Canterbury Partnership for Care
• St Mary Hospital, Hoboken, NJ

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Project Definition

• Part of the overall redesign of the Emergency
  Department flow
• Clinical problem areas identified
• Appendectomy agreed upon
• Clinical protocols defined
• Six Sigma methodology applied

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Project Definition

• Problem Statement
• Cases presenting to ED with acute abdominal pain
  experience a delay in diagnosis of appendicitis
  resulting in over use of services, misdiagnosis
  and a delay in surgical intervention
• Project Scope
• Patients presenting to ED with ultimate diagnosis
  of appendicitis

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Project Goals/Deliverables

• Project Goal
• 1)  Improve the time from presentation to ED with
  an surgical abdomen to diagnosis of
  appendicitis.
• 2) Early interventions of surgeons while patients
  are still in ED.
• Key Deliverables
• 1)   Incision time within 6 hours of registration
  for patients with appendicitis.
• 2)   Decreased average cost/case.
• 3)   Appropriate use and duration of antibiotics.
• 4) Decrease LOS for diagnosis of appendectomy
  from 4 to 2 days
• Financial and Operational Benefits
• Improve clinical outcome (ie less perforations,
  complications).
• Reduce average cost/case by 20 which equals an
  annual savings of 118,000.
• There is reproducibility for abdominal pain in
  general, which would yield a greater savings.

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Data Collection/Analysis

• Retrospective chart review performed
• Minitab software program utilized for data
  analysis
• Process analyzed by multidisciplinary team
• Protocols developed by team

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Number of Hours to Surgery did not Effect LOS
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Perforations did Effect LOS
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Solutions Identified

• Standardize protocol for surgeon involvement in
  case
• Standardize lab/radiology utilization per case
• Implement new triage process to see patients
  sooner

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Solution Implementation

• Implement new Abdominal pain protocol that
  involves standardized testing and notification of
  surgeon.
• Incorporate protocol into new triage process for
  the Emergency room.

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Process Control Plan
Response Plan
Process Controls

• 100 chart audit of all appendectomies
• Clinical indicators (LOS, time, antibiotic use,
  etc.) monitored and reported out to the team and
  PI committee.

• Variance from accepted results to be reported out
  at team/department level.
• Individual physicians informed of outliers and
  counseled.
• Results presented and recommendations made at
  Care Management committee.

Training Plan
All medical directors and medical leadership
informed through 1 on 1 conversations. Medical
staff informed through mailings. Nursing/staff
educated at the department level on an ongoing
basis.
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Results
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Results
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Project Benefits
Soft Benefits
Financial (Hard) Benefits

• 23 reduction of average costs (153,000
  annualized savings)
• Average LOS decrease by 25 (4.5 to 2.7 days)

• Reduction of time from registration to incision
  from 21 hours to 10 hours (48 reduction)
• Standardized protocol developed for evaluation of
  abdominal pain
• These 2 factors combined, translate into better
  clinical quality

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ED ProcessFrom Arrival to Seen by Physician
Begin
End
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New Triage System

• Quick Registration Process
• Medical Doctor is the 1st person a patient sees
• MD, RN and PCA assess patient together in triage
  area
• Ability to discharge non-emergent patients from
  triage
• Bedside registration
• Registration is now back end of process

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Further Successes

• New Process minimizes wait times to treatment
• Registrations completed at bedside
• Better Service to Patients ED Staff

• Eliminated Initial Waiting
• EMTALA Compliant Process
• Improved Patient Satisfaction Scores
• Number of Patients that Left Without Being Seen
  (LWBS) has decreased from 85/month to lt10/month
• Increased volume 10 - 12

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Questions?
?