SigmaMed Solutions Process Improvement Success
I. Restructuring of a Hospital Quality System
Problem and Opportunity
The hospital quality system consisted of ad hoc reporting of roughly 50 metrics. Most
were high level regulatory compliance metrics; almost none were aimed at monitoring
performance for cost, quality, or safety. They were not driving process improvement,
and therefore most of the measurement effort was being wasted.
Gap Analysis
A study of the quality system showed several root causes of ineffective measurement and
inadequate process improvement action:
 There was no clear linkage between the metrics used and the hospital’s need for
meaningful process improvement.
 Metrics were aimed at “counting defects”, usually from time consuming audits.
The staff didn’t understand the linkage between the defects and the process root
causes driving the defects.
 Staff had very limited statistical understanding. They often reacted on process
noise rather than valid process signals. They also had limited data presentation
skills, so even good data was hard to understand.
 There was little benchmarking or goal setting. Staff didn’t understand whether
“80%” right was good enough. Some processes were running at less than 50%
effective.
 There were too many, generally ineffective, process improvement projects in
place.
Lean Sigma Approach
Several parallel approaches were taken to improve effectiveness of the quality system.
 Proposal of and agreement at the Board level for a more effective set of system
measures.
 Training of staff in root cause analysis, basic statistics, Six Sigma, Lean, and
process benchmarking.
 A shift from defect counting to understanding the process “vital signs” that were
leading indicators of defects.
 Development of standard data presentation methods, stop-lighting of metrics, and
mandatory root cause analysis of metrics short of goals.
 Mentoring individual department heads in specific data collection and process
improvement techniques, with a focus on solving the most critical problems first.
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Facilitating Kaizen or other improvement events to permanently improve
processes.
Results
After 6 months of training, mentoring, and hands-on work, the quality system showed
marked improvement:
 Managers and Directors had clear, understandable presentations and data.
 They had determined benchmarks
 They used stoplights to show problem areas.
 They could triage process performance into buckets of: “stay the course”, “watch
and wait”, or a critical few “process improvement project required/justified”
 For process improvement projects, they had a roadmap and the tools to make real
progress.
 There was a prioritized process improvement project list for the organization.
 The system became self-sustaining and continuously improving.
II. Surgical Flow Improvement and Process Redesign in
Central Sterile Processing
Problem and Opportunity
A hospital surgery unit was experiencing late case starts and in-case delays.
Lean Sigma Approach
A thorough analysis of case data and a survey of staff were made by a SigmaMed
Solutions consultant. There were a number of causes for delays, but the major factor was
errors in completeness or integrity of the sterile packaging for surgical sets from Central
Sterile Processing. A team of sterile processing staff, an outside sterile processing
resource, and key process customers was assembled for a Kaizen event. Key findings
and improvements included:
 A spaghetti diagram showed disjointed and inconsistent flow of used and sterile
sets between two floors of the hospital. There were two sterile processing areas,
and the one closest to the surgical unit was re-purposed to handle rapid turnover
of sets (e.g. hand sets) when needed for an upcoming case. The main sterile
processing unit was re-purposed for larger orthopaedic sets and endoscopy sets.
 Modeling of set usage showed that given the sterilizer cycle time, hand sets could
not be turned over quickly enough to meet the usual case demand. A small
amount of capital was used to purchase a few items to complete 2 additional hand
sets.
 Sets were occasionally incomplete, either with instruments missing or incomplete
packaging. Job aids with pictures and checklists for completed sets were posted
at assembly workstations.
 Sterile wrappers were frequently found to be torn when the set was retrieved from
inventory. Root cause was the way sets were put into the storage shelving.
Shelves were redesigned to avoid stacking the wrapped sets on top of each other.
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Supplies and spare instruments were missing or hard to find, causing delays in set
assembly before sterilizing. A 5S reorganization of both sterile areas put
frequently used supplies and instruments within reaching distance of the set
assembly benches.
Checklists were implemented to make sure that all sterilizer documentation was
complete and sterility indicators were present.
Results
Case delays due to errors in set assembly were virtually eliminated. Process performance
went from more than 10% incomplete sets to 5-Sigma performance (4 sets out of 1000
with errors). Flashing of single instruments in the OR was reduced to less than 1% of
cases; the only real use for flash sterilization was for late-arriving vendor accessory
supplies or dropped instruments.
III. Process redesign for Radiology Exam Scheduling and
Payor Reimbursement
Problem/Opportunity
Radiology appointment service level for CT and MRI exams was very good, with short
wait times until the next available appointment. Reimbursement denials, however, were
high, and co-pays and self pay payments were difficult to collect in full. The opportunity
was to collect more money while keeping the service level high.
Gap Analysis
The team performed a root cause analysis of underpayment. Key gaps were identified:
 Many physician orders for CT and MRI were incorrect. Physicians often
didn’t’ specify the diagnosis correctly and usually didn’t include an ICD-9
code. They also frequently ordered the wrong exam for the diagnosis. This
caused denials from insurance companies.
 Patients weren’t informed of their copay or self-pay responsibilities. That led
to high patient dissatisfaction when the bill arrived.
 There was no reliable and consistent communication method between the
insurance verification staff and the radiology scheduling staff.
Lean Sigma Approach
SigmaMed Solutions facilitated an interdisciplinary team and provided training on Lean
Sigma process improvement methods. The end to end process was redesigned by a team
consisting of admissions, radiology, and insurance verification staff. A Lean process
flow was mapped out that included:
 Providing physicians with “cheat sheets” so that many more exams were correctly
ordered.
 Building a checklist into the radiology EMR so that the radiology scheduler could
collect complete insurance and exam order information on the first call to
schedule the exam. Appointment requests without complete information were
penciled in but not confirmed until all information was available.
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Insurance verification staff were given access to the electronic radiology
schedule. Exams that required pre-authorization or significant co-pays were
tentatively scheduled and flagged in orange on the schedule. Insurance
verification used the orange items on the schedule as their worklist.
Insurance verification called patients and informed them of copays. Admissions
had the information on copays and collect them day-of-service.
Results
The result was an immediate reduction of 30% for insurance denials, and a 50% increase
in copay collection. Service levels remained constant. The team has continued to apply
Lean principles to their process, and they are showing continued, self sustaining, process
performance improvement.
IV. Medication Administration Process Redesign
Problem/Opportunity
Medication administration errors on an in-patient unit had caused a number of “near
miss” events. Documentation of medication administration was only about 75% correct.
Nurses found the process and equipment to be frustrating to use.
Gap Analysis
The process had numerous barriers to success and safety:
 All medications for the unit were stored in a central medication room. The room
was small and had a door with a keypad lock. There was a single EMR terminal
and a single Pyxis medication dispenser in the room. That meant that nurses had
to queue up to get medications out of the system.
 Most patient supplies were stored in the medication room and dispensed through a
supply Pyxis. That added to congestion in the room and required a separate
biometric log in, looking up the patient, and several keystrokes to remove even
low-value supplies.
 Nurses had to walk long distances to give medications to patients at the end of the
hall.
 EMR documentation computers were scattered through the department. Many of
the portable “computers on wheels” had dead batteries or functional issues.
Nurses were supposed to wheel the computers into the patient rooms to document
the medication administration, but a door threshold in each room made it difficult
to wheel the top-heavy computers into the room without tipping them over.
 Given those frustrations, nurses usually returned to the main unit desk to do
document the medications given. There was a long walk back to the unit desk,
and nurses were frequently interrupted. They often forgot to document or
documented incompletely. Incomplete documentation resulted in a number of
double dosing medication errors.
 Refrigerated medications like antibiotic IV bags were put in the refrigerator in no
particular order. That resulted in two near miss events where the correct drug was
given to the wrong patient.
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Lean Sigma Approach
With problem solving help from SigmaMed Solutions, the nursing team, IT, and facilities
came up with a number of problem solutions:
 We reviewed the regulations for securing controlled substances. As long as the
drugs were in a Pyxis dispensing machine, there was no need for a locked door.
The keypad lock on the central medication room was removed, and facilities
changed the door to a “close only on fire alarm door”.
 We removed about 2/3 of the supply Pxyis machine and put low value items like
water cups, disposable bedpans, and wound care items in a simple shelf and bin
system. We also did a 5S reorganization of the central medication room.
 We added 2 satellite Pyxis medication dispensers in strategic spots down the hall.
We also added the shelf and bin system for the low value items next to the Pxyis
to save nurse walking time.
 We made minor upgrades to the wireless network and gave the nurses laptops that
they could take to the patient rooms. There was no extra cost for the laptops
because they were purchased at the time of the EMR installation—they just
wouldn’t work well with the old wireless network. We also added a shelf next to
each bed so that there was a convenient place to put the laptop and medications.
 We reorganized the medication refrigerator so that there was a bin for each patient
with a temporary label. Pharmacy put the right IV bags in the right bin.
Results
We monitored the results for six months. For very modest investment, improvements
were dramatic:
 No medication “near misses” or sentinel events.
 Documentation correctness went up to over 90%. Still not good enough, but a
good foundation to do a second round of process improvement.
 Nurses saved an estimated ½ hour per day per nurse from reduced queuing in the
central med room and reduced walking back to the med room.
V. Urgent Care Clinic Patient Flow Redesign
Problem and Opportunity
An urgent care center had been built into a storefront and designed without much
consideration for patient flow. There was a single admissions desk for check-in, check
out, and payment. Patients had to queue up to be served, and there was no way to triage
urgent patients until they reached the front of the line. Patients with upper respiratory
illness were standing in close proximity to patients with other problems. Patients were
frequently struck by the main exit door from the exam room area. There was no way for
the front desk staff to see patients in the waiting area to monitor them for signs of
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distress. There were also HIPAA concerns with all patients standing close to each other
and the admissions/discharge desk.
Lean Sigma Approach
A SigmaMed Solutions consultant trained the department Director on “spaghetti
diagrams”. The admissions staff sketched out a flow that separated incoming and
outgoing patients and added a second window for check out and payment.
Results
The separation of incoming and outgoing patients improved the flow, reduced queuing
for incoming patients, and made it possible for the front desk staff to monitor patients in
the waiting area for worsening conditions. An ideal solution of having a separate
storefront entrance and exit for patients had to be postponed due to the capital cost of
installing an additional door in the glass storefront. Findings from this study were used to
design a new urgent care center with optimum patient flow.
Outpatient Pharmacy Workflow Improvement
Problem and Opportunity
A hospital outpatient pharmacy was having patient dissatisfaction issues with long wait
times for prescriptions. The pharmacist and pharmacy tech workflow appeared to be
chaotic.
Lean Sigma Approach
A SigmaMed Solutions consultant helped the pharmacy team identify problems with
flow. The team came up with two key problems:
 Many orders were missing critical information when the customer called in or
came to the order window. Problems with the order weren’t resolved until the
prescription was filled resulting in frustrating customer delays and pharmacy staff
interruptions. The team created a checklist to triage whether the customer had all
the information necessary to fill a prescription. Complete requests were
immediately filled. Incomplete requests due to illegible or unsigned prescriptions
or incomplete insurance information were handled by one of the pharmacy techs
at a separate desk in a back room. The order wasn’t filled until all of the order
details were complete. The customer with the incomplete order was informed of
the delay and the reason for the delay and given an estimated time for completion.
 The pharmacy flow was analyzed with a spaghetti diagram. Pharmacy staff were
wasting considerable time and steps to accommodate the equipment layout for
filling prescriptions. Simple modifications to the filling line such as relocating a
printer and a telephone reduced the wasted effort and time.
 Prescriptions for discharging patients from the inpatient floor were picked up by
the pharmacy as soon as it opened. That allowed the pharmacy to fill those
prescriptions when the pharmacy was less busy vs. having several discharged
patients all show up at the same time.
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Results
Customer satisfaction results were significant with only small changes to workflow.
Prescriptions with complete information could be filled in as little as 15 minutes. Many
discharged inpatients only had to wait a few minutes to pick up their prescriptions.
Customers who were informed upfront that there was a delay were more tolerant of
waiting for the order to be corrected.
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