Pocono Medical Center Faster Lab Results Using Six Sigma & Lean


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Pocono Medical Center Faster Lab Results Using Six Sigma & Lean

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Pocono Medical Center Faster Lab Results Using Six Sigma & Lean

  1. 1. 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 the workday. 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 acute-care services. 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
  2. 2. 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. some patients. 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 Wait Centrifuge Computer Analyst 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 Computer physician access. Waiting times between process steps are also Median 3 Median 16 Median 2 Median 0.5 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 End great variability in test processing times: The American Society for Quality ■ www.asq.org Page 2 of 4
  3. 3. 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.” Fast Payback 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- R-Sq 66.9% ists who care for patients who have been admitted by another 140 LT Start Draw to Comp Comp R-Sq (adj) 66.9% physician. Although both the lab process and the use of hospital- 120 ists ultimately help improve overall length of stay, the precise 100 impact of each has not yet been officially measured. 80 60 40 20 Figure 3 Before and After: Lab Results Delivered by 7 a.m. 0 0 10 20 30 40 50 60 70 80 90 Time to Lab Delivered Delivered % Delivered by Process Total after 7 a.m. by 7 a.m. Target Time Sigma Fitted Line Plot 294 626 920 68% 1.97 Before LT Start Draw to Comp Comp = 44.48 + 1.112 Chem 160 S 20.4845 21 999 1020 98% 3.54 After R-Sq 29.0% 140 LT Start Draw to Comp Comp R-Sq (adj) 28.9% 120 Figure 4 10 Days Before and After Redesign Results 100 for ICU, CCU, PCU 80 60 10 Days Before 10 Days After Done by 6 a.m. Done by 6 a.m. 40 No 251 No 48 20 18% 92% 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
  4. 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. http://www.asq.org/healthcaresixsigma/. The American Society for Quality ■ www.asq.org Page 4 of 4