Lean Six Sigma Approach to Improving Interventional

CASE STUDIES IN CLINICAL PRACTICE MANAGEMENT

Lean Six Sigma Approach to Improving Interventional Radiology Scheduling Joshua D. Dowell, MD, PhD, Mina S. Makary, MD, Mathew Brocone, MD, James G. Sarbinoff, JD, Ivan G. Vargas, SSBB, Mrinalini Gadkari, MD, MBA INTRODUCTION Interventional radiology (IR) suites are highly congested, with IR departments providing care for thousands of outpatients every year. The lead time for scheduling patients for outpatient procedures oftentimes ranges from 2 business days to 2 weeks at our institution, which can be below expectations for patients and referring physicians. Failure to meet scheduling time requirements may result in treatment delays and diminished care quality, as well as lower patient and employee satisfaction scoring. Effectively managing outpatient procedure scheduling can produce improvements in medical outcomes, patient satisfaction, and access to service [1]. The purpose of this prospective study was to use Lean Six Sigma methodology to evaluate the lead time from outpatient order acquisition to scheduled procedure, and to identify and develop strategies to decrease the process time. ACTION A quality improvement initiative was adopted to improve workflow efficiency and lead times using the DMAIC methodology. DMAIC, a core tool for the Lean Six Sigma quality strategy, is an acronym for Define, Measure, Analyze, Improve, and Control. This was developed for

industrial process improvement with the goal of reaching a level of quality of six standard deviations above the average, which is equivalent to 3.4 defects per million opportunities [2-5]. Initially designed to improve efficiency in industry, Lean Six Sigma methodology implores collecting and evaluating baseline data, as well as integrating personnel communication to identify waste and reduce variation. These concepts were applied to outpatient procedural scheduling at our institution to improve scheduling workflow and throughput, as well as patient and referring physician satisfaction. This prospective quality improvement case study was performed with institutional review board approval and evaluated the scheduling process for all IR outpatient procedures ordered through the electronic medical record (Epic, Madison, Wisconsin), fax, or direct communication by referring physician offices. The study team included interventional radiologists, a radiology fellow and resident, scheduling staff, quality improvement specialists, and graduate students. The study team was led by two physicians trained as Six Sigma Black Belts. Meetings were held to develop a baseline understanding of the existing practice, followed by

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observance of current scheduling practices. Subsequent weekly meetings explored and modified the process. The individual elements of the DMAIC core methodology (Fig. 1) were assessed for each step during patient procedure scheduling. The DMAIC process was started in January 2014 and incrementally implemented over 5 months. To understand the baseline process, the scheduling process was mapped from order acquisition to scheduled procedure. A time-stamp observation study was performed on 60 requests over 2 weeks. Time stamps were analyzed to identify scheduling flow constraints and areas for potential interventions. Interventions were evaluated and adjusted based on feedback from stakeholders. An electronic preprocedure checklist was created by institutional information technology support through the electronic medical record (Epic, Madison, Wisconsin) from July 2014 until the fall of 2015. The electronic checklist was implemented in January 2016 with training of scheduling staff over a 2-month period.

Define the Problem In any IR division, including ours, at a large tertiary medical center, there are continuous requests by referring

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Define the problem

Decide what and how to measure.

Analyze the process

Identify areas to improve

Sustain any improvements

D

M

A

I

C

Define

Measure

Analyze

Improve

Control

Fig 1. The DMAIC core methodology, an acronym for Define, Measure, Analyze, Improve, and Control, is used to better understand and evaluate the process under study.

physicians for IR interventions. This high demand, coupled with finite resources, leads to bottlenecks occurring in the scheduling process, causing delays in patient treatment. These inefficiencies ultimately may lead to increased patient length of stay, a negative impact on patient outcomes, increased health care costs, and reduced overall patient satisfaction. Tools used to define and identify all relevant elements of the process improvement include the voice of the customer, the voice of business, the voice of the process, and the voice of the employee (Table 1). Additional considerations are outlined in the SIPOC diagram (Suppliers, Inputs, Process, Outputs, Customers) (Fig. 2). This diagram details the interactions of these parties. The aforementioned

methods utilize various perspectives to define the problem targeted for improvement.

Measure the Problem The scheduling time was defined as the time from when an order is received in the “depot” until it is officially scheduled in the electronic medical record by the scheduling staff. This was identified as the target measure that would determine the success of the quality improvement process. Tools used to quantify and measure the various elements of the scheduling time included a Cause Map (Fig. 3) and Failure Mode and Effect Analysis (FMEA) (Table 2). A Cause Map (Fig. 3) is a method that breaks down the causes of the problem into value-adding tasks (VAT) and non-value-adding tasks

(NVAT), with the goal of streamlining the VAT and eliminating/ reducing the time required for the NVAT. FMEA (Table 2) is a systematic technique for failure analysis to identify resultant effects on system operations.

Analyze the Process The scheduling process was reviewed and critically analyzed by the study team to brainstorm potential inefficiencies and/or barriers to timely outpatient procedural scheduling. A Value Stream Map (VSM) tool was used to identify scheduling flow constraints and areas for potential interventions. The scheduling process was mapped from order acquisition to scheduled procedure over a 2-week period. A time-stamp observation study from acquisition to procedure was

Table 1. Relevant elements of process improvement Stakeholder Who?

Voice What do they want from us?

Customer: Patients

Want to improve scheduling time

Employee: (Scheduling) nurses Business: IR physicians

Want to streamline scheduling so it is less time-consuming Want to streamline scheduling to expedite care and efficiency

Key Issue(s) What do they want from us? Identify the issue(s) preventing us from satisfying entity. Patients want an easier scheduling process, without delays to set up procedures Many processes and steps involved in scheduling each patient Help with the scheduling process to limit their administrative oversight

Critical Requirement Summarize key issues and translate them into specific and measurable requirements. To decrease scheduling time by 50%

By decreasing scheduling time by 50%, will have more time for other tasks To decrease scheduling time by 50%

IR ¼ interventional radiology.

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Suppliers • Referring physicians • Patients • Vendors of surgical equipment

Inputs • Patient information including diagnosis codes, medications etc. • Nurse’s time • IR Physicians

Outputs

Process 1. Order received from referring physician

2. DMC reviews order

3. DMC fills out IR scheduling checklist

4. Checks OR availability

8. Calls patient with date/ time of procedure

7. Assigns anesthesia to the case (if needed)

6. Assigns IR surgeon to case

5. Selects OR based on procedure

Customer

Input Metrics

• Patient • Referring physician

•Medication list accuracy/completeness •Complications and comorbidities •Completeness of procedure order

• Patient • Referring physician

•Medication list accuracy/completeness •Complications and comorbidities •Completeness of procedure order •Number of interruptions

Process Metrics

• Scheduled Procedure

Customers •Patients •Referring physicians •OSU staff (physicians, nurses, techs etc.)

&

Output Metrics

• Rework at each step

• Amount of time it takes to schedule correct procedure

• Rework at each step

• Amount of time it takes to schedule correct procedure

Quality

Speed

Fig 2. SIPOC (Suppliers, Inputs, Process, Outputs, Customers) diagram to define and identify all relevant elements of the process improvement project. DMC ¼ disease management coordinators; IR ¼ interventional radiology; OR ¼ operating room; OSU ¼ Ohio State University.

performed on a total of 60 requests. The time stamps were analyzed and a VSM was created detailing each step in the scheduling process, including time spent and needed resources. After

completion of the VSM (Fig. 4), a group discussion to include all stakeholders was organized to discuss the VSM, as well as the strengths and weaknesses of the process.

Improve the Process To improve the scheduling process, the study team brainstormed potential practical interventions to expedite and streamline the required

Fig 3. Cause Map detailing reasons for high interventional radiology (IR) outpatient scheduling process time. The value-adding and non-value-adding tasks are listed at bottom left. Project goals include eliminating/reducing time required for non-valueadding steps (blue boxes) and streamline the value-adding tasks (green boxes). B.T. ¼ blood glucose testing; IR ¼ interventional radiology; VIR ¼ vascular and interventional radiology. Journal of the American College of Radiology Dowell et al n Case Studies in Clinical Practice Management

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Table 2. Application of Failure Mode and Effect Analysis technique Failure Mode 1) Interruptions 2) Patient medical condition 3) Patient no-show causing rework 4) Physician schedule conflict 5) Room availability 6) Unable to reach patient

Severity* 10 9 9 8 8 10

Detection Probability Rate† 5 4 3 2 2 1

Occurrence Probability Rate† 9 4 4 5 5 4

Risk Priority Number (RPN) 450 144 108 80 80 40

*Severity scored from 1-10 with 10 ¼ most severe. † Probability rate scored 1-10 with 10 ¼ highest probability.

procedures for scheduling based upon the findings of the VSM (Table 3). A list of 10 solutions was created and elaborated upon by the study team (Table 3). A Solution Priority Calculator tool was then used to determine the highest-yield interventions among the 10 suggested interventions by rating each solution in terms of its impact on the process, scheduling time, cost-benefit, and its feasibility for completion (each item rated from 1 to 5, with 5 having the

greatest impact) (Fig. 4). The selected interventions designed to tackle controllable barriers to an efficient operation were evaluated and adjusted based on feedback from stakeholders. The most promising interventions included those to be implemented to minimize waste and variation.

Control the Process In collaboration with the medical center’s electronic medical record

support staff, a preprocedure workflow checklist was designed and implemented to reduce unnecessary paperwork, streamline the scheduling process, and optimize order entry. The checklist was created to standardize work for scheduling nurses and also to integrate procedural nurses to improve communication. After implementation of the process, the entire scheduling staff was trained in the new scheduling procedures; they will be monitored

Fig 4. Value Stream Map used to identify scheduling flow constraints (bottlenecks) and areas for potential interventions.

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Table 3. Brainstorming solutions generated by study team Brainstorming interventions to improve and streamline IR outpatient scheduling Ask for a specific contacting time from patient Use an electronic preprocedure checklist Establish and provide education on instructions for referring physician offices Create standard of work Establish standard operating procedure for emergency add-on procedures Continually track scheduling throughput Optimize order entry function of electronic medical record Enhance communication with referring physician offices Provide physician schedule and daily assignments earlier Reduce unnecessary paperwork IR ¼ interventional radiology.

periodically by the study team to assess for improvement.

Data Analysis Two-sample t tests were performed to compare the differences of continuous data. All statistical analysis was performed using the JMP Pro 12.0.1 software package (SAS Institute Inc, Cary, North Carolina). OUTCOMES Interventions were evaluated and adjusted based on feedback from stakeholders: removal of bottlenecks in scheduling flow, elimination of NVAT, and alignment of staff work to accommodate times of high ordering census. Lead time from

when the outpatient procedural order was received to when the procedure was scheduled measured 4.3 days (median, 1.8 days) with 6.7 orders received daily, for a takt time of 225.7 minutes and a value-added time of 55.1 minutes (Fig. 4). Chart review, patient contact, procedure to be performed, and data entry were all identified as critical value-adding processes. Lead time was not influenced by weekday (P ¼ 0.6) or the scheduling nurse (P ¼ 0.8). A detailed Cause Map (Fig. 3) and FMEA chart (Table 2) were created to identify VAT and the resultant effects on system operations. Solutions were then brainstormed for the problem (Table 3). The Solution Priority Calculator

(Table 4) identified an IR-specific electronic checklist as most beneficial to have the greatest impact upon several identified areas for improvements, as well as an influence upon other identified possible solutions. This was designed in collaboration with all stakeholders and developed in coordination with institutional information technology support through the electronic medical record. In the presented quality improvement study, Lean Six Sigma principles were prospectively utilized to understand and possibly improve the outpatient procedure scheduling process in an academic IR division. These principles not only may be used to identify areas for improvement in scheduling for outpatient IR procedures, but may ultimately improve both workflow and patient, as well as employee, satisfaction. Critical strategies for improvement in the presented study were process mapping, engagement of staff, and elimination of nonvalue-adding steps. These results are similar to those of Zhang et al, who applied the DMAIC process to improve bottlenecks and the efficiency of central venous access services at their academic IR service

Table 4. Application of Solution Priority Calculator

1 2 3 4 5 6 7 8 9 10

Solution Description Use electronic checklist Reduce unnecessary paperwork Provide physician schedule early Optimize order entry function Continually track scheduling Create standard of work Ask for specific contacting time Enhance referral office communication Set up referral instructions Establish SOP for emergency add-on

Solution Priority Calculator Process Time Cost-Benefit Impact Impact Impact 5 5 5 4 4 4 1 5 5 2 2 5 1 2 5 5 3 3 2 2 2 3 2 3 3 3 1 2 2 2

Technical Feasibility 4 4 4 4 5 1 5 2 3 2

P Total (Rating) 500 256 100 80 50 45 40 36 27 16

Priority, time, and cost-benefit impact scored with rating 1-5 with 5 ¼ greatest impact. SOP ¼ standard operating procedures.

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[1]. The authors were able to improve their access service throughput by reducing lead time from 100 to 86 minutes, leading to approximately 13% reduction in wait time [1]. In conclusion, ease of scheduling, timely scheduling of procedures after referral, and improving patient/referrer satisfaction are all vital to the growth of an IR practice. By using Lean Six Sigma principles, areas for improvement in each of these areas can be identified, and changes can be implemented to

further streamline clinic or scheduling processes.

ACKNOWLEDGEMENTS The authors thank Michael Bertke, MBA, Vishal Bhatt, MBA, Yuwen Guan, MBA, and Shuang Jin, MBA for their contribution through the Fisher School of Business at the The Ohio State University to this manuscript.

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REFERENCES 1. Zhang L, Runzheimer K, Bonifer E, et al. Improving efficiency of interventional service

by Lean Six Sigma. J Am Coll Radiol 2015;12:1200-3. Sutphin P, Reis S, McKune A, et al. Improving inferior vena cava filter retrieval rates with the define, measure, analyze, improve, control methodology. J Vasc Interv Radiol 2015;26:491-8. Antony J, Downey-Ennis K, Antony F, et al. Can Six Sigma be the “cure” for our “ailing” NHS? Health Serv 2007;20:242-53. DuPree E, Martin L, Anderson R, et al. Improving patient satisfaction with pain management using Six Sigma tools. Jt Comm J Qual Patient Saf 2009;35: 343-50. Makary MS, Shah SH, Warhadpande S, et al. Design-of-experiments approach to improving inferior vena cava filter retrieval rates. J Am Coll Radiol 2017;14: 72-7.

Joshua D. Dowell, MD, PhD, is from Northwest Radiology, St. Vincent Health, Indianapolis, Indiana; the Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio; and DV Solutions, Powell, Ohio. Mina S. Makary, MD, and Mathew Brocone, MD are from the Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio. James G. Sarbinoff, JD, and Ivan G. Vargas, SSBB are from DV Solutions, Powell, Ohio. Mrinalini Gadkari, MD, MBA is from the Fisher School of Business, The Ohio State University, Columbus, Ohio. The authors have no conflicts of interest related to the material discussed in this article. Joshua D. Dowell, MD, PhD: Northwest Radiology, St. Vincent Health, 5901 Technology Center Drive, Indianapolis, Indiana 46278; e-mail: [email protected].

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