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Improving patient treatment, satisfaction at a small hospital Monroe County Hospital is a critical access hospital located in Forsyth, Georgia. It is a 25-bed facility comprising an emer- gency department (ED) and medical-surgical unit that cares for inpatient and rehabilitation patients. The ED sees just over 8,500 patients annually from six counties in middle Georgia. This hos- pital has been providing access to high quality health services to the citizens of Monroe County since 1954 when the hospital au- thority was founded (monroehospital.org/about/history-and-mission. cms).

In 2016, this facility became a strategic partner of Navicent Health based in Macon, Georgia. In 2018, Monroe County Hos- pital became DNV GL accredited and was on track to become ISO 9001:2015 certified this spring. In 2019, the team embarked on the high-performance journey in the spirit of continuous im- provement. As part of the certification process, the leadership team set out to identify and eliminate any and all types of waste plaguing the hospital’s operational environment.

These initial efforts focused on delays in the emergency de- partment wait times. This is significant because such delays un- favorably impact quality of care, revenues and customer satisfac- tion levels when patients leave without treatment. The ultimate goal was to provide safer and more effective care to all patients.

The team was sponsored by the CEO, who is an IISE-trained Black Belt, along with other leaders. The project was initiated in January 2019 and concluded December 2019. But outcomes are still monitored and adjustments made as needed to ensure “wins” are sustained long term. The team used a standard DMA- IC methodology to define the problem, measure the current state, analyze the data, improve the noted issues and control the changes long term. Moreover, many cross-functional stakeholders were included in the process to ensure the improvements were maxi- mized, sustained and culturally adopted.

The process, project and outcomes Define. Extended wait times and subsequent alarm about pa- tients who leave emergency departments without treatment has become a mounting national concern. In January 2019, the proj-

Solutions in practice by Chasatie Whitley, Casey Fleckenstein, Lorraine Smith, Hershel Kessler and Casey Bedgood

case study

May 2021 | ISE Magazine 49

case study

ect team developed and implemented a method to decrease wait times and thus the number of patients who left with- out being treated (LWOT). According to the Community Health Needs Assessment of 2016, access to care was iden- tified as a need in our community. The team interpreted that the low ED volume, increased wait times and increased LWOT rates indicated that patients were seeking emergen- cy treatment elsewhere in our region. This decreases their access to care within the community and unfavorably im- pacts revenues.

The focus of the project was on reducing LWOTs in the emergency room. These patients are an issue for a variety of reasons. First, delays in care represent waste and result in patients seeking treatment at alternate care sites. This inhibits access to care, reduces quality of care and nega- tively impacts patient satisfaction and revenues. Moreover, if customers cannot receive services when, where and how they desire them, the hospital’s reputation will be less than favorable.

The goal of the project was to initially reduce LWOTs monthly to the national benchmark of 2% or less (Medicare. gov, 2018). Long term, the ideal goal was zero LWOTs each day. Unfortunately, the rate for Monroe County Hospital was over 2% on average in 2018. Also, the team focused on increasing patient satisfaction levels to the national bench- mark. The initial goal was 75% favorable each month.

It’s important to note that if goals are not consistently achieved, volumes, quality of care, customer satisfaction and revenues will continue to decline. Moreover, the pub- lic’s perspective of the organization would be further im- pacted.

Measure. The main key performance indicators chosen by the team were monthly LWOT rates and patient satis-

faction scores (percent favorable). The desired trend is to achieve fewer LWOTs and higher patient satisfaction scores each month. Both metrics were measured monthly over a year before the project began. Post project, the results were measured monthly for over a year as well to ensure the sus- tainment of wins. Figure 1 shows performance to goal for both metrics before the project showing that patient sat- isfaction scores were meeting goal only 20% of the time. The LWOT scores were only meeting goal 47% of the time pre-project for the same time period.

Analyze. To analyze the current state, the team started with a high-level process map (i.e., SIPOC; shown in Figure 2, Page 50). The team used the SIPOC to identify the suppli- ers, inputs, process, outputs and customers of the ED process. The suppliers represented various stakeholders ranging from leadership to front-line staff. These stakeholders would be crucial in addressing the waste and inefficiencies. The inputs related to items such as people, training, data, equipment and more. The outputs were very straightforward: clinical care, quality, revenue and customer satisfaction.

FIGURE 1

Pre-project KPI graphs (actual versus goal) Performance metrics before the project showed that patient satisfaction scores and patients leaving without treatment numbers were below the goals set.

Leaders must measure, track and know

their organization’s numbers. Data is

like a sheet of music that will tell you

exactly where the problem is when you

know how to interpret it.

50 ISE Magazine | www.iise.org/ISEmagazine

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A deeper dive was considered to determine both internal and external customers. Far too often, teams focus on the trees and not the whole forest. It was noted that the cus- tomers of the process included patients, families, regulatory agencies, county governments, competitors and others.

In simplest of terms, the team noted emergency delays as the No. 1 driver of patients leaving without treatment and customer dissatisfiers. Moreover, cultural opportunities, communication and ED physical layout were cited as causes of the inefficiencies. Other techniques, such as data analysis using histograms and control charts, indicated issues with consistently following an efficient process, which ultimate- ly led to customer dissatisfiers, LWOTs and lost business.

Improve. To improve the situation, the team engaged the emergency department’s physician group to complete an operational assessment related to the department’s flow. During these activities, it was noted that influences among people (i.e., culture), place, process and communication produced an elevated LWOT rate and negative patient ex- perience. Additionally, the board authority, quality man- agement system and front-line staff were engaged to gain buy-in for countermeasures. The focus was on educating these stakeholders to emphasize the importance and effects of a reduced LWOT rate for the time period.

After identifying the current conditions and targets, and engaging our stakeholders, the team started a small-scale pilot project. During the pilot, the emergency department was reduced from six treatment rooms to four due to hos- pitalwide renovations. Staff were trained on the imple- mentation of direct bedding and triage protocols. After the staff demonstrated competency and compliance with such protocols, creating movement throughout the emergency department was introduced. This included using overflow and discharge waiting areas to accommodate patients de-

spite the reduction of treatment areas. Staff then demon- strated mastery of skills and flow processes by moving to a new area as we progressed in renovation phases.

Finally, the staff moved from a four-bed to a nine-bed treatment area and demonstrated retention of learned abili- ties. These changes transformed the process, flow and sub- sequent KPI scores for over a year post-project.

The team realized significant improvements in both LWOTs and patient satisfaction post improvements (see Figure 3, Page 51). LWOTs were reduced by 27%. Test of hypothesis was used to analyze the results. The team’s hy- pothesis stated that process changes in the emergency room throughput would reduce LWOTs and improve patient satisfaction. The null hypothesis states there is no change while the alternative hypothesis states improvement was achieved.

The results revealed that T test (2.67) was greater than 1 Tail T Table (2.46) for the LWOT data analysis. Thus, null hypothesis was rejected and the alternative hypothesis ac- cepted. The process improvements reduced LWOTs at the 99% confidence level.

The team also realized a 20% increase in patient satisfac- tion scores. Test of hypothesis was also used to test the pa- tient satisfaction data. The null hypothesis states there is no change while the alternative hypothesis states improvement was achieved. The results revealed that T test (1.85) was greater than 1 Tail T Table (1.7). Thus, we reject the null hypothesis and accept the alternative hypothesis for patient satisfaction scores. The process improvements increased pa- tient satisfaction scores at the 95% confidence level.

Control. To control the changes and improvements, the team focused on internal audits, data tracking and direct communication techniques. Internal audits, for example, are conducted monthly with a focus on process noncompli-

FIGURE 2

Project SIPOC Defining the suppliers, inputs, processes, outputs and customers addressed by the LWOT project.

May 2021 | ISE Magazine 51

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ance. These teams journey to the gemba, where the work happens, to assess if processes are being followed consistent- ly. If issues are noted, the respective leaders must initiate a corrective action plan immediately for resolution. Then, teams reaudit to ensure corrections were successful.

Second, the team tracks data monthly for all KPIs against national benchmark goals. If goals are not attained, the data is communicated to senior leaders, the board and quality management system for magnification and resolution.

Finally, both vertical and horizontal communication techniques are used to ensure all stakeholders are apprised of and track the current environment. If changes are need- ed, the goal is to make interventions in real time when possible.

Lessons learned There are several pearls the team learned from the project. First, the voice of the customer is always a great starting point for any improvement project. Always focus on the customer and be able to answer: What do they want, need and expect from the organization? If gaps exist, teams should focus on measuring, validating and correcting the gaps.

Second, leaders must measure, track and know their or- ganization’s numbers. Data is like a sheet of music that will tell you exactly where the problem is when you know how to interpret it. The team learned that it’s better to initiate data-driven interventions sooner than later.

Third, the gemba should always be a focal point when solving process-related issues. Go to where the work is be- ing done, talk to those closest to the process to understand the issues and incorporate those at the gemba in the solution process.

Finally, there is no substitute for a good process. Good

processes or lack thereof can make or break an organiza- tion, particularly in healthcare. The team learned that starting with a sound, data-driven process, measuring the process outcomes regularly, auditing the process routinely (not just the activities being performed) and real-time cor- rections of nonconformities are paramount in meeting and exceeding customer requirements. 

Chasatie Whitley, BSN, RN, CEN, is process owner for Navi- cent Health.

Casey Fleckenstein, BSN, RN, is nurse director and an IISE- trained Lean Six Sigma Green Belt for Navicent Health.

Lorraine Smith, MBA, MT(ASCP)SH, is CEO, executive sponsor and an IISE-trained Black Belt. Contact her at Lorraine. Smith@ atriumhealth.org.

Hershel Kessler, DO, is emergency department medical director for Navicent Health.

Casey Bedgood, MPA, CSSBB, is the system accreditation op- timization officer at Navicent Health and an IISE-trained Lean Green Belt, Six Sigma Green Belt and Six Sigma Black Belt. He was an adviser and Black Belt sponsor for this project. He is an IISE member.

FIGURE 3

Postproject KPI improvements Results show significant improvements in the number of patients leaving without treatment (down 27%) and increased patient satisfaction.

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