Making the Case for Quality
Pocono Medical Center:
Faster Lab Results Using
Six Sigma and Lean
Contributed by Walter T. Hayes and Carmine J. Cerra, with Mary Williams
For years, the Pocono Medical Center’s laboratory battled to provide test results to doctors in time for
their early-morning patient rounds. Time crunches would occur, both in drawing patients’ blood and in
processing it. Physicians would begin their rounds at 6 a.m., but blood test results generally were not
ready until 9 a.m.
Walter Hayes, the hospital’s director of laboratory services, and Dr. Carmine Cerra, chief of pathology,
were seriously considering automating the lab in an effort to fix the bottlenecks. Both had learned
about Six Sigma and Lean quality improvement processes during a recent automation conference, and
they wanted to make lab automation the hospital’s first Six Sigma process.
Before beginning such a huge project, however, senior management requested that a satisfaction survey
be sent to the hospital’s 160 doctors. Based on the responses received, the executive management team
decided against jumping into an automation effort. “The doctors essentially said ‘just give us the test
results by 7 a.m. and we don’t care how you do it,’” Hayes notes.
At a Glance . . . Management asked Hayes and Cerra to focus instead on a pilot project using Six Sigma/Lean. Their
project goal was to find a way to get blood test results to doctors earlier. With board approval, Pocono
Medical Center launched the project in mid-May 2005 and finished it less than three months later. Today,
• The Pocono Medical Center
doctors have blood test results for critical care patients by 6 a.m. and for all other patients by 7 a.m.
initiated a Six Sigma/Lean
project to deliver blood test
About Pocono Medical Center
results to doctors earlier in
Pocono Medical Center is a 196-bed not-for-profit community hospital, fully accredited by the Joint
• Within about six weeks, the
Commission on Accreditation of Healthcare Organizations. Located in the Pocono Mountains in East
project team implemented a
Stroudsburg, Pennsylvania, the center employs more than 1,400 people and offers emergency and
solution. Doctors began to
receive blood test results
by 6 a.m. for critical care
Pocono Medical Center Laboratory provides clinical diagnostic services to physician offices and
patients and by 7 a.m. for
nursing homes in the area. The laboratory performs more than 300 different procedures, including
all other patients.
blood, tissue, and cell analysis, and preparation of blood for transfusion.
• Project results also extend
outside of the laboratory,
Timely delivery and accuracy of results are chief quality indicators for the laboratory, as well as
contributing to a decrease
key inputs for overall quality of patient care. Therefore, the laboratory workflow, including
in overall patient length of
pre-analytical, analytical, and post-analytical processes, has always been central to the laboratory’s
stay for the medical center.
quality management program.
The American Society for Quality ■ www.asq.org Page 1 of 4
A Scheduling Bottleneck • Collection of patient samples
• Delivery of tubes to the lab
The Six Sigma methodology—define, measure, analyze, improve, • Front-end processing
and control (DMAIC)—supplied the framework for Hayes and • Actual running of the tests
Cerra’s project. The physician satisfaction survey had already
underscored the need for delivering lab results earlier, thus pro- Analyzing Flow, Implementing Solutions
viding a project focus and objective to begin the define stage:
Williams’ team ran the data it collected from following test tubes
• Because most physicians indicated a need for test results by around the medical center through a number of statistical analyses.
7 a.m., delivering all results by that time was the primary For a full list of the tools used during the measure and analyze
focus of the project.
phases of the project, see “Statistical Tools Used.”
• Physicians with patients in the intensive care unit (ICU),
critical care unit (CCU), and progressive care unit (PCU) Statistical Tools Used
expressed a need for results by 6 a.m. The team resolved to
meet the needs of these three units and find a way to deliver • Value stream maps (current and future)
their results even earlier. • Detailed process map
• Time series plots
Hayes and Cerra lobbied the hospital’s management and board
• Control charts
for approval to proceed, and the hospital selected Mary Williams,
• Stratified frequency plots
a vice president at Rath & Strong, a Lexington, Massachusetts-
• Cause and effect diagram
based firm, to provide consulting services.
• Hypothesis tests (ANOVA, Moods Median test)
• Multiple regression
Defining the problem within the lab was easy. Lab technicians
• Matrix plot
could not forecast how many blood draws would need to be done
• Pareto charts
the next morning until the middle of the night. “Unit secretaries
• Binary logistic regression
transcribe orders all day long for the morning,” Cerra says. “On
top of that, there are many situations in the ICU that have sched- • Process capability
uled draw times. Sometimes the patient has to fast for 12 hours
before drawing, which dictates that we draw in the morning.” As the regression fitted line plots in Figure 2 show, the two
biggest drags on the process were the actual delivery of the test
The phlebotomist would wait for eight to 10 blood draws to be tubes to the lab and their analysis. “The phlebotomist would col-
done before taking them down to the lab. That, in turn, caused lect 10 to 15 patient samples and return to the lab with a basket
a backup in processing, late results, and delayed discharges for of tubes all at once. This created a huge bottleneck,” says Cerra.
The issue quickly became how to avoid the batch collections on
The Measuring Blitz
the hospital floor and batch deliveries to the lab. “It became
obvious that we needed to have continuous flow into the lab. We
It was in the measuring phase that Williams and her team helped
shouldn’t be collecting from 16 patients and then taking those
the hospital the most. “They analyzed where every tube was,
tubes to the lab,” Hayes says.
through every stage of the process,” Cerra recalls, adding that
the consultants literally followed hospital personnel and tracked Figure 1 Pocono Medical Center Laboratory
the test tubes’ paths. Process Map
“If you just do a process map, you don’t see that tube of blood
Draw Wait Deliver to Lab
sitting there or the other things that are not adding any value,” Start Median 2 Median 34 Median 5
Range 1-45 Range 0-184 Range 0-23
Williams explains. “Walt (Hayes) walked us through the process.
We walked through the hospital and the emergency room. We
talked to stakeholders and went to the front and back of the lab.”
Enter to Give to
Median 2 Median 7
Figure 1 shows the process steps Williams mapped based on her Median 2 Median 0
Range 0-28 Range 0-20
Range 2-6 Range 0-7
walk-through, including the drawing of a sample of blood, delivery
to the lab, entry into the computer, putting the tube into a centrifuge,
performing analysis work, and feeding results into the computer for Complete in
Wait Analyze Wait
physician access. Waiting times between process steps are also Median 3 Median 16 Median 2
Range 0-72 Range 0-271 Range 0.5-280
represented to help identify delays that can be addressed. Range 0.5-1
Process mapping revealed that four basic areas were causing
great variability in test processing times:
The American Society for Quality ■ www.asq.org Page 2 of 4
Williams’ team returned to the process flow and learned that one Even more dramatic improvements occurred with tests delivered to
tube—or even four tubes—of blood could be drawn in 71⁄2 min- the ICU, CCU, and PCU, the three units requesting results by 6 a.m.
utes. Completing an assessment of the total number of draws per Figure 4 provides a closer look at results for these units for 10 days
floor, and of the lab’s processing, analyzing, and delivery capac- before the redesign and 10 days afterward, showing that the per-
ity, led to a surprisingly simple solution: Designate a “runner” to centage of results delivered by 6 a.m. increased from 18 to 92.
bring test tubes from the floor to the lab every 15 minutes. A lab
“We did this really, really fast and we got our payback really, really
person is assigned to pick up tubes at key points on the hospital
fast,” Hayes says. Cerra agrees that the rewards of the project have
floor. The phlebotomist on the floor places a flasher light outside
been “tremendous” and notes, “The physicians are really happy.”
the patient room so the runner can quickly find the phlebotomist.
According to Williams, the Pocono Medical Center’s Six
Under the new model, work can keep advancing every 15 min-
Sigma/Lean project was unique in that it was completed so
utes. “The model worked surprisingly well and we didn’t have to
quickly: “We did this in about six weeks. Frequently, these types
increase our staff,” Hayes says, although one lab technologist
of projects take nine to 12 months.” She jokingly adds, “We
was promoted to senior technologist to oversee the new process.
really beat everyone over the head.”
Hayes says the project “was designed as an accelerated project.
No one was really sure that we could get it done this quickly.”
Figure 3 shows a comparison of results from before and after the
But employees and management worked hard to keep the
Six Sigma/Lean redesign of the lab collection process. For a sample
momentum strong. Having the buy-in of the medical center staff
of 920 blood results delivered before the redesign, 68% reached the
was key to fast progress. Williams calls the staff involved with
appropriate doctors by 7 a.m. For a sample of 1,020 results using the
the project “top notch,” commenting, “They were right with us
new process, the percentage delivered by 7 a.m. increased to 98%.
all the way and they did a bang-up job.”
Project results also extend outside of the laboratory. Hayes has
observed a decrease in overall length of stay, an improvement he
Figure 2 Key Drivers of Total Lead Time attributes in part to the faster lab process. Another factor in help-
ing the medical center discharge patients in a timely manner is
Fitted Line Plot
LT Start Draw to Comp Comp = 44.24 + 1.076 Time to Lab its use of hospitalists, medical doctors whose specialty is caring
160 S 13.9088 for hospitalized patients. The medical center has seven hospital-
ists who care for patients who have been admitted by another
LT Start Draw to Comp Comp
R-Sq (adj) 66.9%
physician. Although both the lab process and the use of hospital-
ists ultimately help improve overall length of stay, the precise
impact of each has not yet been officially measured.
20 Figure 3 Before and After: Lab Results Delivered
by 7 a.m.
0 10 20 30 40 50 60 70 80 90
Time to Lab Delivered Delivered % Delivered by Process
after 7 a.m. by 7 a.m. Target Time Sigma
Fitted Line Plot
294 626 920 68% 1.97
LT Start Draw to Comp Comp = 44.48 + 1.112 Chem
160 S 20.4845 21 999 1020 98% 3.54
LT Start Draw to Comp Comp
R-Sq (adj) 28.9%
Figure 4 10 Days Before and After Redesign Results
for ICU, CCU, PCU
60 10 Days Before 10 Days After
Done by 6 a.m. Done by 6 a.m.
No 251 No 48
Yes 56 Yes 534
0 Yes Yes
0 10 20 30 40 50 60 70 80 90 Total 307 Total 582
Chem Done by 7 a.m. Done by 7 a.m.
No 57 No 0
While each step drives total lead time, we see a strong relationship with 81% 100%
Yes 250 Yes 582
time to lab, and a moderate relationship with Chemistry (time analyst Yes Yes
Total 307 Total 582
receives to complete in computer).
The American Society for Quality ■ www.asq.org Page 3 of 4
Maintaining the Gains—Every Day Article Contributors
Walter T. Hayes is currently the administrative director of
Pocono Medical Center recognizes that the improved laboratory
Laboratory Services at the Pocono Medical Center in East
process will only continue to be effective as long as a number of
Stroudsburg, Pennsylvania. He holds a bachelor’s degree in
factors remain in place. A well-respected staff member must be
chemical engineering from the University of Pittsburgh and a
present to manage the process during the crucial hours of 3 a.m.
master’s degree in public administration from Cleveland State
to 7 a.m., enough phlebotomists must be on staff, and runners
University. Having started his healthcare career at the Cleveland
must consistently make their regularly scheduled rounds.
Clinic as the manager of Laboratory Computer Systems and then
manager of the Primary Laboratory Center, Hayes has held
Above all, the process must continually be measured, and meas-
administrative director positions at several other hospitals and
urements must be reported in time to take corrective action when
healthcare systems in Ohio and Virginia. He has also served as
needed. To ensure that the right measurement activity occurs, a
chair of the North East Ohio Red Cross Health Care
control plan prescribes daily review of the following measures:
Administration Advisory Board and vice chair of the Greater
• Percent of results delivered on time—troubleshooting occurs Cleveland Hospital Association’s Regional Reference Laboratory
if the outcome ever falls below 95% Alliance Project.
• Number of late tests and reason for delay—troubleshooting
Carmine J. Cerra is a practicing anatomic and clinical patholo-
occurs for all late results
gist with 24 years of experience in the laboratory environment.
• The variance of actual versus expected results for cumulative
He has been past chief of the medical staff and is the current
tubes every 15 minutes—troubleshooting occurs if the
department chair in pathology and the medical director of the lab
variance exceeds 10%
at Pocono Medical Center. A teaching assistant at nearby East
Stroudsburg University, Cerra has published through the
Because daily measurement is necessary, maintaining results
Pennsylvania Academy of Sciences. He is the chair of the
remains an ongoing effort. The laboratory process project team
Medical Staff Performance Improvement Committee.
made progress quickly using Six Sigma and Lean, but holding
the gains requires effort from the entire Pocono Medical Center
Mary Williams, a vice president at Rath & Strong, Aon
staff every day.
Consulting, assists senior-level executives, training teams, facili-
tators, and middle managers with Six Sigma, process
For More Information
improvement, and redesign. Previously, she was a vice president
with the Juran Institute, where she focused on the healthcare
• Learn more about the Pocono Medical Center at
industry. She received her B.S. from Columbia University, her
http://www.poconohealthsystem.org and the Pocono Medical
MBA from the University of the Virgin Islands, and her R.N.
Center Laboratory at http://www.pmclab.org/.
from St. John’s Hospital, New York City, and has completed
• Access more case studies, how-to articles, and other informa-
advanced studies in operations management in the service
tion about using Six Sigma in healthcare by visiting
industry at the Massachusetts Institute of Technology.
The American Society for Quality ■ www.asq.org Page 4 of 4