This document provides a summary of projects completed by Karen Carswell and Kamal Babrah to achieve Lean Six Sigma Black Belt certification. It describes work done with the North Bay Nurse Practitioner Led Clinic to improve primary care access, efficiency, and process improvement. The summary includes defining issues around access to care, analyzing root causes using tools like value stream mapping and fishbone diagrams, implementing solutions like group intake and standard work, and tracking metrics to measure improvements in access, wait times, and data quality.

1. Lean Six Sigma Black Belt
Project Portfolio
Karen Carswell / Kamal Babrah
3/5/2015
Submittedprojectportfolio,requiredtoachieve LeanSix SigmaBlackBeltcertification.Summaryof workdone withthe
NorthBay Nurse PractitionerLed Clinictoimprove PrimaryCare access,efficiencyandprocessimprovement.

2. Project I.D./Name: North Bay Nurse Practitioner Led Clinic NBNPLC Team Lead: Miranda Weingartner
Start Date: April 2013 Team Members: Shannon, Danielle, Nicole, Leeanne
Planned End Date: December, 2014
Approval: EZ Sigma – Rod Morgan, Master Black Belt HQO QI Specialists: Karen Carswell & Kamal Babrah
Define Issue/Problem and Describe Current State:
Background
Traditionally, physicians have provided the majority of primary care services, and unfortunately many Ontarians have not been
able to access a family doctor. In order to meet this demand, Ontario is now able to offer a new type of clinic called Nurse
Practitioner-Led Clinics. These are led by nurses who have additional training as Nurse Practitioners (NP’s) and who are
trained to keep clients healthy for as long as possible.
North Bay Nurse Practitioner Led Clinic (NBNPLC) offers individual client centered care, and works with their clients to
establish health goals, and then help them meet these goals. These can be for things like losing weight, living a more active
lifestyle, managing stress, controlling blood pressure, receiving vaccinations, quitting smoking, feeling depressed or anxious,
or having a check-up. Services are offered in English or French, depending on the client need. They provide services to those
who do not have a healthcare provider and who wish to become a client of their clinic. They offer team based care, meaning
that they offer the services of nurse practitioners, nurses, a physician, a dietitian, a social worker, and a pharmacist. A
laboratory is on-site so clients may also have blood work done at the clinic.
NBNPLC was fully operational as of September 2012 and has a panel of 1902 clients and team of 4 FTE providers. Since
being fully operational, intake of new referrals is on average 28 clients per month.
Current State
Shortly after being fully operational, there was a great deal of staff turnover due in part to changes in FTE status of the
providers and having an interim executive director. Access to a provider and continuity of care was reduced due to
inconsistency in provider supply. Supply from PTE providers did not match the demand of the clients. To improve continuity
of care and better match provider supply to client demand, there was a move to change the status of all providers to full time.
As a result, the supply became more consistent over the full work week and better matched provider supply to client demand.
NBNPLC tracks access to care using the indicator of Third Next Available (TNA). TNA is the sum of the days between the
time a client requests an appointment and the time of the third next available appointment. Beginning in April 2014 they
started to notice an increase in TNA for two of the four providers.

3. Portfolio of Opportunities for Improvement using the 8 Wastes
The new Executive Director and the team became concerned with access to care in April 2014. The following identified areas
of opportunities for improvement is a compilation of processes that the team worked on to address their access and efficiency
issues. They felt that the process was not efficient during the intake process and during the client visit. Using the 8 wastes,
the team was able to identify areas for further analysis:
1) Wasted Time: With the creation of a value stream map, the team was able to identify the steps of the client
experience that were non-value added to the client. Cycle time was used as an indicator to measure improvements in
the non-value added wasted time during the client visit. Cycle time for a client visit was measured as 43 minutes with
12 minutes of non-value added wait time. The team was meeting their target of >50% face to face time with the client
and wanted to maintain this ratio but reduce the overall cycle time. This would allow each provider to maintain the
value add time to the client but increase their supply by one additional appointment per day per provider.
2) Delays in Time to Complete Administrative Tasks: The team identified two opportunities for day to day efficiency
which impact indirect client care, they included examining administrative work and interruptions throughout the day.
Administrative work related to client care was scheduled for providers on two time slots during each week. Client
complaints in delays for completing paperwork (i.e. prescription renewal referrals, client forms etc.) motivated the
team to understand the root cause of this delay. In addition, unplanned interruptions throughout the day reduced the
time available for client care and increased the amount of administrative work at the end of each day .
3) New Client Intake Wait Time: In order to improve the wait time for new client intake, the team decided to change
their intake process to a group intake as compared to individual client intake. The team hypothesized that group
intake of new clients would improve the wait time for initial visits for new clients and help to reduce the wait list for new
clients. The team was also interested in understanding the voice of the customer for this new approach to intake.
4) Extra Processing: With the use of a process map, opportunities for improvement were identified for the scanning
process.
5) Process Defects: With improvements in access, the team was having difficulty understanding why they were not able
to provide access to their providers was not occurring within 7 days of their clients being discharged from the hospital.
6) Data Collection Defects: An additional identified opportunity for this team and was related to data that was not being
captured consistently for cancer screening (colorectal, cervical, breast). NBNPLC reports cancer screening data to
the Ministry of Health and executive director was interested in brainstorming the causes of their inability to access
reliable data from their EMR, which was resulting in rework. A Kaizen event was held with a cross functional team to
create a standard process for capturing cancer screening data.
Analyze and Identify Root Causes/issues:
Each of the following items correspond to the above listed wastes.
1) Value Stream Map – A VSM was created to illustrate cycle time of a client visit. A client sample size of 27 was used
to create the VSM. Average cycle time for a client visit over these samples was measured as 43 minutes with an
average of 12 minutes of non-value added wait time. Since the ratio of face to face time (72%) and client wait time
(28%) was within their target of >50%, the team identified the areas of check-in and time during the provider visit as
opportunities to reduce cycle time and therefore increase provider supply.
SIPOC – After the value stream mapping, a SIPOC chart was created using the following boundaries for analysis;
from the moment a client is referred to the NBNPLC to the end of their initial visit with the provider.

4. Provider /
Supplier
Input Process Output Beneficiary / Recipient
Providers of
resources
Resources
required by
process –
specifications
High level
description of
activities
Deliverables of the
process step
Recipient
requirements on
output
Who receives
the output
Client, 3rd party
on behalf of
client
Schedule, EMR,
Admin staff
Request for
Clinical action -
Time allocated
Any Reception
Client receives
appointment, request
for action received
Available time,
timely
appointment
Clinician
Medical Admin,
other Clinician
Scheduler, Chart,
health card,
demographic form,
Office room
Pre-admin / Client
arrival
Front Reception
Chart Prep & Pull,
Reminder call, Chart
review.
Client check in - info
verification, socio
demo
Notification of
appointment,
Planned and
Prepared
appointment.
Clinician, Client
and CHC
Clinician(s) Chart, EMR,
results, clear
directives, available
exam room &
equipment
Action on
request(s) - Client
seen by Clinician
Assessment,
Treatment, Plan
formulated
Reason for visit
or action
understood and
addressed
Client, 3rd party
on behalf of
client
Medical Admin,
other Clinician
EMR / scheduler,
printer, clear
process, access to
resources/
paperwork /
process
Post Admin /
Front Desk
Reception
Plan, next steps, next
appointments
Request/ action
addressed - clear
plan, next steps.
e.g. Rx, booking
slip, letter, form
completed,
referral
Client, 3rd party
on behalf of
client
2) 5 Whys – The 5 Whys tool was used to understand the root cause of delays in the completion of administrative work.
Why are there delays in completing administrative work (i.e. WSIB forms)?
Providers were unable to complete administrative work during the client visit so work was set aside (batched) and
completed at a later time.
Why?
Providers completed administrative work only during two half day designated each week for
administrative work.
Why?
Scheduling design dictates the process of batching administrative work.
Proposed solution: Revaluate how administrative time is scheduled.
Interruption Study – The providers tracked the type and frequency of unplanned interruptions each day and tracked
the type of administrative tasks and the time needed to complete these tasks. This helped them to determine how
much administrative time was needed each week for each provider and led to change ideas related to just in time
work. This also provided them with some guidance for contingency planning for how much administrative time
providers would require to catch up on these tasks after an absence due to vacation or other leave. Daily huddles with
a checklist were implemented to minimize interruptions throughout the day, by creating a short meeting every morning
to discuss emergent issues the majority of these interruptions became unnecessary. (See Appendix A for huddle
checklist)
3) New Client Group Intake vs. Individual Intake
The team wanted to understand the impact of the group intake process that was implemented in April 2013 on the
size of the wait list for new client intake. Since being fully operational in September 2012, the new client wait list has
reduced from 2000 clients to a wait list of 841 clients. Prior to April 2013, the average number of client intake visits
was 28 per month. After implementation of group intake process, the average number of client intake visits per month
remains consistent at 28 per month. This data was considered to be positive by team because the rate of intake has
remained unchanged but they have still received the benefit of creating additional supply in the provider schedule.
Refer to Results Verification section for improvement analysis details.

5. 4) Process Map – The analysis of the clinics process to scan documents into their client files in their EMR involved
creating a current state process map. They collected data to determine the length of time required for scanning
documents in two locations (reception and board room). The picture below is a portion of the current state process.
The team determined that on average scanning takes 3.47 minutes longer per document in the boardroom as
compared to the reception area. After using a 2 sample t test, it was determined that there is no significant difference
in the scanning time based on location.
2-Sample t Test:receptionvs boardroom
Sample reception boardroom Est for Diff -8.46
N 5 5
95% Low er
Bound -23.9447
Mean 9.16 17.62
95% Upper
Bound 7.0247
Std Dev 3.4861 11.9738 Test of diff =0 vs <>0
SE Mean 1.559 5.3548 DoF 4
T -1.5169
P Value 0.2039
Even though there was no significant difference in the time to scan documents based on location, the process map
exercise helped the team to identify opportunities to streamline this process by removing unnecessary steps, hand
offs and duplication of effort, no matter the location of the document scanning.
5) Fishbone Diagram – In order to dig deeper and understand why the team was having difficulty providing access to
their clients within 7 days of being discharged from the hospital, the team used a fishbone diagram to identify the root
causes (See Appendix B for Fishbone Diagram). Using expert clinician opinion to decide on the few key root causes,
the team identified communication between providers and non-compliance of clients attending their scheduled
appointments as the two key root causes. Nurse practitioners in primary care (as with NBNPLC) are required to have
a collaborating physician for tasks that are out of scope and often these physicians are not co-located with the NPs.
This relationship at times causes confusion from the hospital perspective and often the North Bay Regional Health
Centre would notify the collaborating physician of client discharge information, unbeknownst to the NP.
6) Kaizen Event – To better understand the root cause of the cancer screening data collection defects the team decided
to hold a Kaizen Event. The Kaizen event agenda, held on November 12, 2014, (See Appendix C for Kaizen Agenda)
outlined the purpose of developing a new standard cancer screening data collection process. The Six Thinking Hats
tool (See Appendix D for Debono’s Six Thinking Hats Tool) was used to generate creative thinking amongst the cross
functional team, encouraging them to think outside of their usual roles. The tool allowed the team to discuss
contentious issues about how and where data should be collected and by whom, in a safe environment, as they were
‘playing their assigned roles’. The output of the day was a flow map that details a new standard approach for cancer
screening data collection (See Appendix E for Cancer Screening Data Collection Process Map).
Desired Future State:

6. Outcome Measure Baseline
(Year 1-2012)
Target Actual
2013
Actual
2014
Average # New Client Intakes per month
- Reported Annually
25 30 22 33
New Client Wait time to intake in Days
- Reported Annually
309 Reduce the backlog on w aitlist, then determine
reasonable target. Desire a reduction
compared to baseline over time.
290 105
Process Measure Baseline
(2013)
Target Actual To Date
(Dec 2014)
TNA 7 0 4
Cycle time Unavailable 35 43
Face to face time Unavailable >50% of cycle time 72%
Solutions:
# Issue/Opportunity Short Term/Rapid Trial Metrics Longer Term
(May require approval)
Metrics
1 Wasted Time
During Client Visit
30 minutes client
appointment will be
reduced to 20 minutes
 Cycle Time – maintain
>50% face to face
time
Standardizing
process to do indirect
administrative care
during client visit
(real time)
 Time, in
minutes, at end
of each to
require to
compete
administrative
task for that day
2 Delays in Time to
Complete
Administrative
Tasks
Morning Huddles to
reduce daily
interruptions
 Huddle Time-Target of
<15 minutes
 # of daily interruptions
3 Client Wait Time for
Intake
Group Intake  Wait in Days for new
intake appointment
 Avg. # of Intakes per
month
Reduce Backlog of
Intake Wait List
 # of Clients on
Wait List
4 Efficient Scanning
Process
Shift from batching to
real time process
 # of client reports
waiting to be scanned
in the EMR at the end
of each day
Standard scanning
process – flow map
 Audit – % of
Staff Adhering
to standard
process
5 Follow up within 7
Days of Discharge
Work with Hospital
partners to create a
process of discharge
notification to NPs
 # No Shows for Follow
up Appointments
 TNA
Data sharing –
notifications to come
directly to EMR
6 Kaizen- Cancer
Screening
Standardize process of
data collection in EMR
 Audit - # of defects in
data collection
Resolution Action Plan:
 Wasted Time during Client Visit - 30 minutes client appointment will be reduced to 20 minutes – One NP is currently
trialing different approaches to ensure that 20 minutes of the 30 minute appointment is face to face time with the client
and that 10 minutes is used for administrative tasks associated with that client. This will ensure that administrative
tasks are completed within the client time each day. This is reflected in her personal action plan, (see Appendix F for
the NP’s Tree Diagram), which also addresses work life balance. Once her trial is completed successfully, they plan to
test it with a second provider with the long term goal of standardizing it and spreading it to all providers. This provider
will complete her trial by March 2015.
 Delays in Time to Complete Administrative Tasks - Morning Huddles to reduce daily interruptions have been
implemented and are working effectively, the team is very receptive to these short, focused meetings. The team has
taken it a step further and now during that 15 minute meeting (see Appendix A for Huddle Checklist) they also review
all new change ideas and prioritize them on an impact/effort tool and assign a lead. (see Appendix G for Impact/Effort
Tool) The leads provide updates on all currently assigned PDSAs for change ideas.

7.  Client Wait Time for Intake - Group Intake was implemented in April 2013, it was well received by the clients. They
have collected client feedback after each group session. In summary of the survey results, clients were
overwhelmingly positive with the group intake format, but on reflection the team felt that the survey tool was too open
ended and not sensitive enough to pick up the areas of opportunity for improvement.
The team plans to engage clients in the redesign of the survey to better understand areas to ask more focused
questions. Also, they are considering the use of a Likert scale for some elements to provide a scale and to assist with
prioritization of issues.
The clinic is currently understaffed and until they have a full complement of NPs on staff they have stopped new client
intakes. This will have an impact on both the average # of new client intakes per month and the average # of days
wait time to client intake.
The staffing issue may also impact the total number of New Clients on the wait list for intake. This will add to the
existing backlog. We recommend that the team consider contingency planning and mitigation strategies to address
this backlog. This responsibility will be deferred to the Executive Director to consider the budget for the upcoming year
to see is other resources may be funded.
 Efficient Scanning Process – The team has implemented a new streamlined process, which has become their
standard practice. (See Appendix H for Scanning Process Map) This shift from batching to a same day real time
process has resulted in less frustration for all staff members and far fewer incidents of clients arriving for
appointments with the team unprepared because they cannot locate test results or referral reports.
 Follow up within 7 Days of Discharge - Work with Hospital partners to create a process of discharge notification to
NPs is ongoing. Some short term solutions have been put in place. The team now has the ability to login to hospital
information to search each day for client discharges, but they would like to continue to explore the option of data
sharing and having this information sent directly to their EMR each day.
 Cancer Screening Data Collection – After the Kaizen Event the team reviewed the change ideas and their action
plan and struck a working group to develop a standard process. (See Appendix E for Process Map of Cancer
Screening Data Collection) The team is currently providing staff education on the new process to review where and
how the cancer screening data is captured in the EMR. Once training is complete this will become standard practice.
Results Verification and Benefits:
The outstanding concern for the team is the need to reduce the wait time to initial client intake. Although the number
of client intakes per month has remained consistent, the goal for the team was to reduce the average client wait time
for acceptance to the clinic. To accomplish this goal they will have to address the current backlog on the Wait List.
31
51
24 23
28
32
8
17
24
21
13
23
36
28
15 14
18 19
35
67
52
22
15 16
27
52
65
9
0
10
20
30
40
50
60
70
80
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
#ofPatients
Month
Count of Patient Intakeby Month
WaitList: 2000
WaitList: 841

8. Median wait pre Median wait post % of Decrease in Med wait
361 148 59%
Normality Test:pre groupintake
Mean 308.8 Std Dev 202.3253 N 10
AD 0.3915 P Value 0.3086
Normality Test:postgroupintake
Mean 171.0833 Std Dev 118.3542 N 12
AD 0.4382 P Value 0.2437
2-Sample t Test:pre groupintake vs postgroup intake
Sample pre group intake post group intake Est for Diff 137.7167
N 10 12
95% Low er
Bound -18.9787
Mean 308.8 171.0833
95% Upper
Bound 294.4121
Std Dev 202.3253 118.3542 Test of diff =0 vs <>0
SE Mean 63.9809 34.1659 DoF 13
T 1.8987
P Value 0.08
At a quick glance, the median wait time for acceptance to the clinic pre group intake and post group intake reflected a
decrease of 59% in wait time. After analysis of the two groups, both groups have normally distributed data and when
comparing the two groups using a 2 sample t test, there is no difference between the means of the two samples. This data
helped the team to understand that there was no difference with the average length of wait post implementation of the group
intake process. The team was initially surprised by this data and dug deeper to identify, that until the existing backlog of 841
clients waiting for intake was eliminated, the data may not reflect an improvement. Eliminating the backlog of client intake
became an additional opportunity for improvement. Also, the staffing levels of providers was identified as a possible variable
impacting the average wait time to client intake. More data will be required to fully understand this relationship.
Median:361
April 2013:
Group Orientation

9. Sustaining Actions:
The team will utilize the following strategies to ensure the gains achieved will be held:
Sustaining Action
Visual Management  Impact/effort tool is displayed in a common area and reviewed daily during huddle
Standardization  A standard document to record communication during a huddle has been implemented
 Daily huddles will be scheduled into the provider calendars by reception on a daily basis
 Scanning process map
 Cancer screening data collection process map
Error-proofing  Implementation of audits for cancer screening data collection process and scanning
process
Metrics  Monthly reporting of metrics include: TNA, no shows, supply and demand, wait time for
new client intake, client intake wait list, cycle time.
Reports  Review of key metrics by team on a monthly basis and quarterly basis by the Board.
 Ongoing training for staff for standard processes
Systems
Management
 Internal cross functional QI team meets once per month in order to create capacity by
embedding and sustaining QI within the organization.
 Meet regularly with external partners to discuss QI opportunities for improve integration,
transitions and communication
Spread  Develop a strategy to capture regular measurements on all providers
 In order to encourage a culture of sharing, display results in a transparent and easily
accessible way.
 Identify and target those providers displaying largest opportunity for improvement.
Listing of Appendices
Appendix A: Huddle Checklist
Appendix B: Fishbone Diagram
Appendix C: Kaizen Agenda
Appendix D: Six Thinking Hats Tool
Appendix E: Cancer Screening Data Collection Process Map
Appendix F: Tree Diagram
Appendix G: Impact/Effort Tool
Appendix H: Scanning Process Map