Six Sigma is a training and leadership program that enables clients to achieve “breakthrough performance and profitability by [taking advantage of] expertise in process improvement and data-driven problem solving,” claims the Six Sigma Academy (Scottsdale, Ariz) Web site. Founded in 1994, the program boasts such clients as General Electric Co, McKesson, Toshiba, and Honeywell.

In the hopes of improving workflow and patient throughput, the Nebraska Medical Center (Omaha) began implementation of Six Sigma in December 2002. As a 735-bed nonprofit hospital, the center is the largest teaching hospital in Nebraska with both academic and private practice physicians. One of the first Six Sigma projects for the organization was in the Interventional Radiology (IR) department, where such invasive procedures as chemoembolization, fluoro-guided biopsies, and ureteral stent placements are performed.

A Six Sigma project team-including the lead nurse scheduler, lead technologist, and department manager-was assembled to address patient throughput problems. Physician involvement was initiated early with ongoing input and information sharing for process improvements.

The team followed a five-phase process: define, measure, analyze, improve, and control (DMAIC). The project team defined physicians who referred patients into the IR department as their primary customer. It was quickly realized that current volumes supported by the department didn’t fully meet the needs of referring physicians. Patients were lost to other healthcare systems that could accommodate the additional patients within the community, resulting in uncaptured revenue and loss of market share.

During the measure phase, the project team measured the cycle time of each step to determine where to best focus improvement efforts. Reducing holding room (HR) time quickly became evident as an area of opportunity. A patient’s HR time averaged 151 minutes with a standard deviation of 242.4 minutes (February 4?19, 2003). Upon further examination, however, many more problems were identified. First, patient flow coordination from the HR into one of three procedure rooms was problematic because of different equipment in the rooms. Often, the nurse scheduler was pulled to function as the department appointment scheduler as well as the person coordinating patient flow. The duality of tasks created problems for timeliness in appointment scheduling with the referring clinics and flow of patients through the HR.

Additionally, labs could be identified as abnormal after a patient arrived into the HR. The patient would then spend additional time within the HR or the patient could be sent to an alternate location (eg, the inpatient area) to receive treatment, with the radiology schedule juggled to accommodate the patient after the patient’s condition had been medically corrected. If the condition was corrected in the HR, it impacted the HR’s limited space where alternate patients scheduled next would be prepped.

Also, information on the scheduling slip was not always complete when the patient arrived into the HR. This predicament would result in the interventional radiologist calling the referring physician for additional information, which created time delays.

To tackle these issues, the project team used Six Sigma’s “lean” approach, which methodologically looks at waste reduction in processes and doing more with less while focusing on the customer. During the measure phase, the project team completed detailed process maps outlining specific steps that occurred within the HR. Color coding was applied to the map for contrasting areas of rework from the ideal patient flow. The team also focused on process standardization and simplification by asking four questions:

1) How can the scheduling form be standardized to obtain relevant and complete information?

Interventional radiologists, technologists, and nurses within the department met to discuss the necessary information for the scheduling form. After determining the relevant items, the department agreed upon how the form should be filled out. The group also spent time determining the order of item placement and how much space was needed for the requested information. The form went from a quarter-page square to a half page in size for better capture of information needed, and some items were obtained earlier at the time of scheduling.

Department collaboration on the form was useful not only for standardization, but it also provided a better tool for the nurses when they were on-call during off-hours at home. Additional items were added to the form that did not previously exist to serve as a prompt for probing additional information.

2) What steps within the HR can be removed or modified to simplify patient flow?

This chart illustrates the high-level process of the Interventional Radiology department at the Nebraska Medical Center.
This chart illustrates the high-level process of the Interventional Radiology department at the Nebraska Medical Center.

If a case required preapproval by an interventional radiologist before being placed on the department schedule, the required labs could vary because often, the interventional radiologist was not assigned until the day of the case. Therefore, the interventional radiologists agreed upon which labs would be required for department procedures for providing consistent expectations. Standardization of labs allowed for clarification to the clinics and resulted in greater process consistency. The labs and procedures also were placed into a matrix, which was given to the high-volume referring clinics.

Additionally, the interventional radiologists reached agreement regarding information that could be collected from the patient via a form given in the waiting room (eg, listing home medications and dosages). The form was modeled after a version that one of the interventional radiologists had used at a prior hospital. With patients providing information in advance, it helped speed the process for staff and gave the patient a value-added task while waiting. The department staff was able to review the information with the patient upon entering the HR.

Detailed process mapping indicated that medical procedure consents often were obtained after the patient arrived in the HR. However, some patients were within the hospital inpatient system already and could be accessed for consent the night before. And the day prior, residents began obtaining consent on those who were inpatient, could answer questions, and ensure in advance that necessary labs had been completed. A one-page checklist was developed with the IR section chief physician and added to the resident orientation packet. It outlined items to verify on patients who already were within the hospital during preprocedure rounds.

3) What items impacting the HR can be standardized or simplified?

Interventional radiologists’ attendance at meetings was reviewed with the section chief. It was determined that some of the regularly scheduled meetings did not require all interventional radiologists to be present. Particularly with morning meetings where duplication could be reduced, it allowed for more cases to be done within the department and better patient flow for first-case-of-the-day procedures.

Standardization of the IR paging process affected the time patients would spend in the HR through better paging coordination. This change also increased interventional radiologist satisfaction.

4) Who can best perform the various functions within the HR based upon their area of expertise?

Because the department lead nurse often was placed into a dual role of scheduler and HR coordination, it often created frustration. The scheduling function occurred in a different location than the procedure area. Attempting to do both tasks-and do both well-proved to be a difficult challenge. Focusing on scheduling prevented optimal patient flow within the department, and focusing on the HR resulted in complaints about the time it took for clinics to schedule appointments. The scheduler often felt placed in a no-win situation.

To overcome the duality of tasks, the role of the room coordinator was examined. The evaluating team determined that a technologist, rather than a nurse, could best perform the room coordination role. Because rooms had slightly different equipment, the technologists-who understood the equipment required for procedures-were in a better position to determine the best patient placement. This modification also simplified the tasks for department nurses.

The change in who was dedicated to the HR coordination role allowed for proactive emphasis on case start time with the interventional radiologists. Because one individual provided only the coordination function, interventional radiologists could be better notified when the patient was ready for the procedure room. Additionally, labs could be identified earlier in the process as missing or needing patient correction, because the responsibility became part of the room coordinator, who was dedicated to one area only. With the shortage of nursing staff within the department, changing the role to a technologist ensured the scheduler was not asked to cover the HR coordination as well. It also allowed the scheduler to focus time on the information needed and a nursing assessment when clinics called to schedule.

Benefits Realized

Changes made during the Six Sigma implementation had a significant impact on the amount of time patients spent in the HR. The amount of time a patient spent in the HR after the improvements averaged 32.7 minutes, with a standard deviation of 37.71 minutes (March 17?24, 2003). Follow-up monitoring during the control phase showed sustained improvements, with the patient HR time averaging 31.02 minutes and a standard deviation of 24.86 minutes (October 29?December 16, 2003).

Lean techniques applied within the IR department resulted in improved processes and an ability to better meet customer expectations. As a result of the project, referring clinics were successfully able to feel the impact of changes for improved patient flow. The changes also facilitated more collaboration and teamwork between nurses, technologists, and interventional radiologists within the department. Not only were the changes significant, but, postproject, the department has been able to successfully sustain the gains made in the HR.

Jennifer Volland is a consultant with the Juran Institute (Omaha, Neb) and the clinical leader of Juran Institute’s Healthcare practice. Prior to joining the Juran Institute, Volland was a Six Sigma master black belt at the Nebraska Medical Center; GE facilitated the Six Sigma initiative at the center.