2012 Improving waiting time in vaccination room .docx

2012
Improving waiting time
in vaccination room
using Lean Six Sigma
methodology
Dr/ Mohamed Adel El Faiomy
Dr/ Ayatullah Amr Muhamad Shabana
S A U D I M I N I S T R Y O F H E A L T H
S E N A Y A P R I M A R Y H E A L T H C A R E C E N T E
R
background information
Background information
ELsenayea primary healthcare centre is one of the
largest primary healthcare centers in Khamis region in
KSA it provides preventive, curative and health
promotion services to more than 29000 population,
due its large catchment area it serves more than 300
customer per day so the waiting time is very important

to calculate and to improve
1-Define phase
▲▲▲ A) Identify the project
To select the most appropriate project we review the data on
potential project against specific criteria & after evaluation of
these projects we decided to work on the problem of
prolonged waiting time in vaccination room because it meet
the criteria of selecting a project as follow:
than six months
the level of competition
☻Retaining customer
☻Attracting new customer
☻Reducing the cost of poor quality

☻Enhancing employee & customer satisfaction.
▲▲▲ B) Prepare problem statment & goals
►The problem
Waiting time before entering vaccination room is too long
(average 25.4 minute) between 21
st
of March to 21
st
of
April 2012 which lead to external customer dissatisfaction
and internal customer pressure.
►The goal is to reduce average waiting time in the
vaccination room to meet customer expectations which is
10 minutes.
PROJECT TEAM CHARTER
1- Problem statement
Waiting time before entering the vaccination room is too
long (average 25.4 minute) between 21
st
of March to 21

st
of April 2012 which lead to external customer
dissatisfaction and internal customer pressure.
2-bussiness case
About 30 children are vaccinated daily. The delay in
vaccination negatively affects the customers satisfaction,
organizational reputation in the catchment area of the
PHCC, disciplinary actions from higher authorities in
response to customer complaints and puts more pressure
on internal customers .
3-Goal statement
to reduce average waiting time in the vaccination room to
meet customer expectations which is 10 minutes.
4-Project scope
The process starts by the parent ordering his child’s family
health record & end by the child entering the vaccination
room.

5- Select team
Sponsor (PHCC director)
Green belt [Quality professional Dr Mohamed Adel Elfaiomy]
Green belt [Quality professional dr Ayatullah Amr Shabana]
Team member [medical supervisor]
" " [general practitioner]
" " [head of nurse]
" " [vaccination nurse]
" " [medical record clerk]
“ “ [well baby clinic nurse]
6-Project plan
Define phase 10/3/2012 to 10/4/2012
Measure phase 11/4/2012 to 30/4/2012
Analyze phase 01/5/2012 to 9/5/2012
Improve phase 10/5/2012 to 23/6/2012
Control phase 23/6/2012 to 30/6/2012

Voice of customers:
ocus groups were done with 57 parents from the
60 surveyed cases to estimate the upper specification
limit for the process, and the mean of customer`s
requirements was 10 minutes.
owners to estimate the minimal time for the process
using the above mentioned flow chart, and it was 5
minutes, which we the team considered as the lower
specification limit.
CTQs
Customer needs Drivers CTQs Internal metrics
Least waiting time Least cycle
time in vital
signs room
Standard
procedures
for pre
vaccination
process
Time for pre
vaccination
process
Least cycle
time in

examinatio
n room
Least cycle
time in
vaccination
process
.
2-Meassure phase
The measure step identifies the symptom of the problem &
establishes base line measurement of current and recent
performance.

It also maps the process that is producing the problem in
order to understand how the current process actually
operates.
High level flow chart of the current process
Data collection plan:
variable operational defenition
data
source
data collection method who will
collect data
when data
will be
collected
waiting
time in
file room
it starts since the parent ask
for his child's medical
record till the file reaches
the well baby room

waiting
time data
collection
sheet
the medical record clerck
register the time when the
parent ask for the file and
record it in the collection
sheet the
vaccination nurse record the
time when the child enters
the room and before he
takes the vaccination
the nurse supervisor collect
the data from data collection
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
well baby
room
it starts since the file reach
the room till the child name
is called in well baby room
waiting
time data

collection
sheet
sheet the
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
pediatric
clinic
is called in pediatric clinic
waiting
time data
collection
sheet

sheet the
sheet
nurse
supervisor
between 21
march and 28
march
waiting
time in
vacination
room
is called in vaccination room
waiting
time data
collection
sheet

sheet the
sheet
nurse
supervisor
between 21
march and 28
march
number
of staff
working
in each
room
staff actually working in
every room involved in the
process
staff
checksheet
number of staff actually
working in each room is

collected by the nurse
supervisor
nurse
supervisor
between 21
march and 28
march

Step 3 Analyze phase
*Analyze phase seeks to discover root causes of the major
contributes to the problem. Theories are generated by mean of
brainstorming; the list of theories is organized by mean of
cause-
effect diagram so the team can discern the specific theories of
root
causes. Finally, theories of root causes are tested and causes are
identified.
Test theory :
After gathering data about phases of waiting time the team used
Scatter
diagram to find the cause of prolonged waiting time through
correlation
So we have four theories to test using scatter diagram:-
1. The delay because of waiting at file room
2. The delay because of waiting at well baby room
3. The delay because of waiting at pediatrician room
4. The delay because of waiting at vaccination room

Correlations: file waiting time; total waiting time by minutes
Pearson correlation of file waiting time and total waiting time
by minutes =
0.712
10987654321
70
60
50
40
30
20
10
0
f ile w a it in g t im e
t

o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i n u
t e s v s f i l e w a i t i n g t i m e

Correlations: well baby waiting time; total waiting time by
minutes
Pearson correlation of well baby waiting time and total waiting
time by minutes
= 0.891
403020100
80
70
60

50
40
30
20
10
0
w e ll b a b y w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b

y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i n u
t e s v s w e l l b a b y w a i t i n g t i m e
Correlations: pediatrician waiting time; total waiting time by
minutes
Pearson correlation of pediatrician waiting time and total
waiting time by
minutes = 0.668
35302520151050
80
70
60

50
40
30
20
10
0
p e d ia t r ic ia n w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b

y
m
in
u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i v s
p e d i a t r i c i a n w a i t i n g t i m
Correlations: vaccination room waiting time; total waiting time
by minutes
Pearson correlation of vaccination room waiting time and total
waiting time by
minutes = 0.725
121086420
70
60
50
40

30
20
10
0
v a c c in a t io n r o o m w a it in g t im e
t
o
t
a
l
w
a
it
in
g
t
im
e
b
y
m
in

u
t
e
s
S c a t t e r p l o t o f t o t a l w a i t i n g t i m e b y m i v s
v a c c i n a t i o n r o o m w a i t i n g
And from the above graphs we found positive correlation
between increased total waiting time and waiting time in
well baby room
At the end of analysis phase:
We found that the highest correlation was at the phase of
waiting at well baby room

Step 4 Improvement phase
1- choose remedy.
the team sit together after analyze phase and by brainstorming
the team agreed upon a remedy which is :
redesigning the process of pre vaccination to be in one room
only to avoid waiting time between steps
2- Design remedy.
After the team reviewed the goals and determined the
required resources from people-money-time-material,
the team decided the following remedy:-
"Using lean technique to make the whole process
done in
one room."
So we will calculate and sum the area of the three rooms and
transfer
the whole process to the vaccination room after arranging it
using
lean technique, so that the parent and child will only wait one
time
before getting the service.
The team defines a tree diagram to identify the role of each
member
in the new project.

The tree diagram
3- Prove effectiveness:-
Before an improvement is finally adopted, it must be proven
effective
under operating condition.
pilot test is designed to start working in the new room for 1
week
from 9
th
of may 2012 to 16
th

of may 2012 and calculating waiting time
in this period.
464136312621161161
40
30
20
10
0
O b s e r v a t io n
W
a
it
in
g
t
im
e
_
X=11.04
UCL=28.73

LCL=-6.65
1
1
I C h a r t o f w e l l b a b y w a i t i n g t i m e
This control chart showing waiting time before well
baby room (the red X) before applying the remedy
This is the control chart showing waiting times before
applying the remedy showing:-
1. 53 out of 60 observations are above the upper
specification limit which is 10 minutes according
to VOC, with percentage = 88.3%.
2. The mean is 25.42
This is the control chart showing waiting times after
applying the remedy showing:-
1. All observations are within the specification limits.

2. The mean is 7.55
5- Implementation
After the one week pilot and calculating waiting time
and according to the improvement proven by the
control chart we decided to implement this remedy
using the attached tree diagram
The new flow chart
Step 5 Control
Implementation 3 activities for control:
1- Design effective quality controls.
2- Foolproof the improvement.
3- Audit the controls.

A) Design control
To ensure that the breakthrough is maintained, the
quality
improvement team needs to develop effective quality control by
feedback loop.
ok
Not ok
Measure
actual
performance
Compare

to
specificatio
ns
Regulate
process
Customer
specifications
(upper and
lower control
limits)
To build a feedback loop, the team will need to
1- Measure the end results or the outcome of the improved
process
must be measured to be between upper and lower specification
limits
(5 min and 10 min) by random samples taken every week using
the
following data collection plan.
variable operational defenition
sample

size
data
source
data collection method who will
collect data
when data
will be
collected
waiting
time
before
vaccination
it starts since the parent ask
for his child's medical
record till the child name is
called in vaccination room
5% of
cases in
the
week
waiting
time data
collection
sheet
the medical record clerk

sheet
the vaccination nurse record
the time when the child
enters the room and before
he takes the vaccination
the data from data
collection sheet
nurse
supervisor
Starting from
23 June 2012
Waiting
time in
vaccination
room
It starts from entry of child
till he is out
5% of
cases in
the
week
Vaccination
room
register

The room nurse register the
time when child enters the
room and when he leaves
the room and record it in
collection sheet
Room nurse
Starting from
23 June 2012
The act of comparing actual performance to specifications will
be the
role of quality professional:-
taken to control the process according to control plan:
B) Audit the control
Clear documentation of control is done
What done Who
acts

Who
analyze
Upper
and
lower
control
limits
Where
measured
How
measured
Control
variable
5 why
technique to
know the
reason for
variation
Team meeting
to suggest
error proof
solution
Team
leader
Quality
professional

Between
5 min
and 10
min
Files room
Vaccination
room
since the
parent ask
for his
child's
medical
record till
the child
name is
called in
vaccination
room
Waiting
time for
pre
vaccination
process
5 why
technique to
know the
reason for
variation
Team meeting
to suggest

error proof
solution
Team
leader
Quality
professional
Less
than 10
min.
Vaccination
room
Since the
child
enters the
room till he
leaves
Waiting
time in
vaccination
room
Example of A3 (lean management ) model
Example:
Toyota is known for its continued commitment to improving
operational performance. How does a company with close to
350,000 employees consistently, rapidly improve? With a Lean
thinking tool called the A3 process. See how the A3 process and

problem solving approach helps organizations practice
continuous improvement.
The A3 process and problem solving approach helps
organizations practice continuous improvement.
What is the A3 Process?
The A3 process is a problem solving tool Toyota developed to
foster learning, collaboration, and personal growth in
employees. The term “A3” is derived from the particular size of
paper used to outline ideas, plans, and goals throughout the A3
process (A3 paper is also known as 11” x 17” or B-sized paper).
Toyota uses A3 reports for several common types of work:
· Solving problems
· Reporting project status
· Proposing policy changes (policy meaning rules agreed upon
and enforced by the group)
Why Use an A3 Process?
In most organizations, on most teams, we aren’t collaborating as
strategically as we could be. We leave meetings with ideas half-
baked. We often move hastily to begin working on
implementing a solution, without aligning around important
details. Projects move slowly due to rework and duplicate
effort, two symptoms of a lack of alignment.
The A3 process allows groups of people to actively collaborate
on the purpose, goals, and strategy of a project. It encourages
in-depth problem solving throughout the process and adjusting
as needed to ensure that the project most accurately meets its
intended goal.
The A3 process prescribes to the famed quote by Abraham
Lincoln: “Give me six hours to chop down a tree and I will
spend the first four sharpening the axe.” The A3 process helps
an organization sharpen its proverbial axes by fostering
effective collaboration, bringing out the best problem solving in
teams.
Collaboration between talented people is critical for innovation
and speed. Using the A3 process to foster collaboration can help
organizations and teams invest their time, money, and

momentum most effectively.
Steps of the A3 Process?
There are nine (well, ten) steps in the A3 process.
0: Identify the problem
Since the purpose of the A3 process is to solve problems or
address needs, the first, somewhat unwritten, step is that you
need to identify a problem or need.
1: Capture the current state of the situation
Once you align around the problem or need you’d like to
address, then it’s time to capture and analyze the current state
of the situation. Toyota suggests that problem solvers:
· Observe the work processes firsthand and document your
observations.
· Gather around a whiteboard and walk through each step in
your process. You can use fancy process charting tools to do
this, but stick figures and arrows will do the job just as well.
· If possible, quantify the size of the problem (e.g., % of tickets
with long cycle times, # of customer deliveries that are late, #
of errors reported per quarter). Graph your data if possible;
visualizations are really helpful.
2: Conduct a root cause analysis
Now that you see your process, try to figure out the root cause
of the efficiencies. You can ask questions like:
· Where do we suffer from communication breakdowns?
· Where do we see long delays without activity?
· What information are we needing to collaborate more
effectively/smoothly?
Document these pain points, then dig deeper. The 5 whys is a
helpful tool for conducting a thorough root cause analysis. The
basic idea is that you begin with a problem statement, and then
you ask “Why?” until you discover the real reason for the
problem. You may or may not have to ask why exactly five
times – this is simply an estimate.
3: Conduct a root cause analysis
Countermeasures are your ideas for tackling the situation; the
changes to be made to your processes that will move the

organization closer to ideal by addressing root causes.
Countermeasures should aim to:
· Specify the intended outcome and the plan for achieving it.
· Create clear, direct connections between people responsible
for steps in the process.
· Reduce or eliminate loops, workarounds, and delays.
4: Define your target state
Once you’ve selected your countermeasures, you are able to
clearly define your target state. In the A3 process, you
communicate our target state through a process map. Be sure to
note where the changes in the process are occurring so they can
be observed.
5: Develop a plan for implementation
Now that you’ve defined your target state, you can develop a
plan for how to achieve it. Implementation plans should
include:
· A task list to get the countermeasures in place
· Who is responsible for what
· Due dates for any time-sensitive work items
Most teams choose to document their implementation plan in
their A3.
6: Develop a follow-up plan with predicted outcomes
A follow-up plan allows Lean teams to check their work; it
allows them to verify whether they actually understood the
current condition well enough to improve it. A follow-up plan is
a critical step in process improvement because it can help teams
make sure the:
· implementation plan was executed
· target condition was realized
· expected results were achieved
These first six steps are captured in the A3 report. Most teams
use a template for their A3.
7: Get everyone on board
The goal for any systemic improvement is that it improves every
part of the system. This is why it’s vital to include everyone
who might be affected by the implementation or the target state

in the conversation before changes are made.
Building consensus throughout the process is usually the most
effective approach, which is why many teams choose to include
this at each critical turning point in the A3 process. Depending
on the scope of the work, it might also be important to inform
executives and other stakeholders who might be impacted by the
work.
8: Implement!
Now it’s time for implementation. Follow the implementation as
discussed, observing opportunities for improvement along the
way.
9: Evaluate results
In far too many situations, the A3 process ends with
implementation. It’s critical to measure the actual results and
compare them to your predictions in order to learn.
If your actual results vary greatly from what was expected, do
research to figure out why. Alter the process as necessary, and
repeat implementation and follow-up until the goal is met.
1. Personal Mastery :Tell us your experience when leading a
group of people to coordinate work. How did you approach the
task, what specifically did you do, what was the response to my
efforts, describe in detail the outcome and if you would do
anything differently?
Success story: Challenge-Context- Action-Result (CCAR)
Model
Position: Patient Advocate- Dental ranked #1 in customer
service complaints
Challenge: How to best reward and recognize employees in
order to improve quality of care for our Veterans and improve
their outcome.
· The goal is to increase morale, improve patient experience,
and business outcomes.

I caught you caring initiative – to reinforce extraordinary
customer service behavior through peer or Veteran recognition.
This contains two folds
· Increased attention to the contribution of co-workers.
· Enhance collaboration and teamwork.
Focus Area/ Piolet Clinic: Dental
I shared my vison with the top administrators in the Dental
Clinic-Operative Care Line team. I met weekly with these
officials and presented key components to increase customer
satisfaction and build morale in the Dental section. I created a
PowerPoint presentation from data produced by the VEO
showing dental ranking #1 in customer service complaints. I
successfully argued that launching the Caught you caring
initiative/campaign that will boost the morale, improve patient
satisfaction, and the veteran experience. My Vision for ICYC
initiative includes recognizing individuals who demonstrates
our hospital values, the values expressed by our
patients/community, and our vision to deliver excellent
customer service. I proposed, lobbied for, and succeeded in
including the ICYC initiative as part Dentals award/recognition
segment in quarterly meetings.
My ability to communicate my expectations of the ICYC
initiative allowed me to garner the support of upper
management administrators. The Dental clinic employees rallied
and provided positive feedback on how this initiative made
them feel recognized and this award drives the dental team to
provide the best customer service to our Veterans. Management
backing was key in obtaining support from executive leadership
and the award ceremony was a success and vital to increasing
customer satisfaction.
Within the next 6 months I would like to establish the ICYC as
an important program that give us the opportunity to recognize
an individual who demonstrates compassion, care and
contributes to delivering an excellent care experience. The goal
is to recognize the employee with the most compliments every
quarter. That employee will get to select a gift or compensatory

time, get to take a professional headshot photo, be recognized in
employee newsletter.

2012 Improving waiting time in vaccination room .docx

Recommended

Recommended

More Related Content

Similar to 2012 Improving waiting time in vaccination room .docx

Similar to 2012 Improving waiting time in vaccination room .docx (20)

More from eugeniadean34240

More from eugeniadean34240 (20)

Recently uploaded

Recently uploaded (20)

2012 Improving waiting time in vaccination room .docx