Running head: SUNNY STATE HOSPITAL CASE STUDY 1
Sunny State Hospital System Emergency Department
Lean Six Sigma Case Study
Cheryl Koznetski
Liberty University
MGMT645 – B01
SUNNY STATE HOSPITAL CASE STUDY2
Introduction
The premise of the paper is to review a case study of the emergency department (ED) at
Sunny State Hospital in Miami, Florida. The case study covers the current state of quality
healthcare services within the ED. The hospital’s chief administrator, Denise Roman, is in the
process of identifying and closing gaps using the Six Sigma methodology. Several gaps in
process and resources relating to an overcrowded waiting room, longer than average wait times,
patient dissatisfaction, and poor financial performance are present. The analysis will include
identifying where the quality gaps exist, what should remain or change in the processes, and a
recommendation put forth on how the author can improve the quality of healthcare in the ED to
improve patient care and financial performance.
Emergency Room Quality Problems
Worldwide, ED’s have the reputation of overcrowding and excessive wait times (Improta
et al., 2018). Such delays lead to an increase in mortality rates, inefficient use of resources, and
an increase in both patient and employee dissatisfaction (Improta, et al., 2018). “Overcrowding,
treatment delays, reduction in quality and safety of care and inefficient use of available resources
are considered patient flow obstacles in the ED” (Cooke et al. 2004, Campbell, Sinclair, and
Canadian Association of Emergency Physicians Flow Management contributors 2004;
Richardson and Mountain 2009; Pines et al. 2011; Lecky et al. 2014, as cited in Al Owad et al.,
2018, p. 1059, para. 7) The ED at Sunny State Hospital has quality problems relating to patient
flow-through from the time of entry to receiving medical care. The facility operates with 60 beds
and serves an average patient load of 350 per day (McGraw-Hill Create, 2020). The high
volume of patients using the ED include low-income individuals without health insurance, using
the ED as first point of care, taking advantage of the law that ED’s are unable to turn away
uninsured patients (McGraw-Hill Create, 2020). This increase in patient visits often causes the
waiting room to fill to capacity. Wait times are 73 minutes which is significantly above the
regional industry average of 30 minutes. The ED would benefit from hiring two new nurses,
expanding the waiting room area, or adding another exam room, however, the cost of expansion
estimates at $500,000, therefore, approval is difficult (McGraw-Hill Create, 2020). The quality
problems present within the ED show in several areas throughout the processes and facilities.
The Bible tells us in Psalms 90:12 (ESV), “So teach us to number our days that we may get a
heart of wisdom”.
Areas Containing Quality Gaps
Several areas throughout the ED process contain quality gaps. The design of the facility
introduces a confusing entrance point by offering two entry door locations, Door 1 and Door 2.
Door 2 enters opposite the registration desk making it difficult for some patients finding the
SUNNY STATE HOSPITAL CASE STUDY3
registration desk. During the registration process, clerks collect patient information and
manually enter the data into the system. Data entry may result in delays if information is
missing, or the desk is busy. The clerk must walk to the waiting area and bring the registrant
back to the desk if additional information is necessary for the data collection sheet. Patient
charts are manual and physically placed in an outbox awaiting a triage nurse assignment. In the
triage area, patients repeat the symptoms to the nurse, the nurse evaluates and assigns a room on
the basis of acuity level, room availability, and the nurses best judgement. If testing
requirements are present, the nurse enters the order into the informatics system and must obtain
necessary testing supplies from the storage closet in the nurse’s station. The lab tech collects
testing samples every fifteen minutes, but in some cases the nurse may walk the sample to the
lab. The physician does not meet with the patient until conference with the nurse, test results are
available, and personal judgement according to acuity level assignment. In most cases the
patient has to repeat the symptoms again to the physician.
The quality of service contains many non-value-add activities which require streamlining
to become more efficient. The Lean Six Sigma methodology underway is a good start in
defining the gaps and recommending strategic sustainable changes to increase stakeholder
satisfaction. The Sunny State Hospital ED will benefit from a process and throughput re-design.
Production System Re-Design
A re-design of the current ED processes at Sunny State Hospital is necessary to achieve
efficiencies in wait times, improvement of patient and employee satisfaction, and an increase in
financial performance. The first step is to assess current state, collect data, involve ED staff and
all hospital stakeholders, conduct time studies, and identify the best improvement opportunities.
Luke 14:28 (ESV) teaches “For which of you, desiring to build a tower, does not first sit down
and count the cost, whether he has enough to complete it?”. It is important to note bottlenecks in
the ED can be due to internal ED inefficiencies or due to other department dependency delays.
The area’s most in need of improvement pertain to space utilization, registration, technology,
roles and responsibilities, and communications.
To improve patient entry and registration, the elimination of Door 2 is necessary. All
patients must enter the ED through Door 1, as the location is directly in front of the registration
desk. Patient information data collection sheets must undergo a review by the clerk for
completeness prior to the patient returning to the waiting area. The entering of patient
information into an electronic health records management system must occur as soon as the clerk
finishes review. This information serves as the basis for the triage process to begin. The use of
electronic information boards within the waiting room and nurse’s station will assist with
notification of patient readiness.
Clearly defining and assigning roles within the ED will improve worker satisfaction and
deliver more improvement to patient care. Utilizing highly skilled physicians within the triage
process will facilitate faster patient evaluations, acuity assessments, testing orders, consultation,
and quick discharge for non-urgent patients. Having secure supply carts in triage and patient
rooms will eliminate waste and speed up the lab processing times. All information pertaining to
a patient’s medical records must be electronic and integrated across the hospital departments and
easily accessible. Physicians seeing patients should have all information ready and available
from registration and triage, eliminating the need for patients to continually repeat themselves.
Lastly, communication is key across the ED as a whole. All resources should participate in daily
updates especially at shift change to inform incoming staff of the current status. Sharing
information is critical and significantly reduces delays in the flow process.
SUNNY STATE HOSPITAL CASE STUDY4
Quality Changes and Retention
Improving the quality of care within the Sunny State Hospital ED requires changes in
most areas of service. . “And let us not grow weary of doing good, for in due season we will
reap, if we do not give up” (Galatians 6:9, ESV). The layout is sufficient after the elimination of
the second entrance door. The registration desk is easily accessible, triage is across from the
waiting area and patient rooms are also in close proximity. The location of the lab requires
batching of samples for pick-up. Batching delays the processing time and is a non-value-added
process. An improvement to the lab process would be to establish a dedicated ED lab service
providing timely access to results and reports without batching (Elamir, 2018). Electronic
information boards should display notification of lab results and reporting, providing information
in a timelier manner. These notifications would serve as a prompt for the attending nurse to
retrieve the results and notify the physician. The challenges present in the ED pertain to process
and technology inefficiencies and not an understaffing issue in most of the cases.
Conclusion
The Sunny State Hospital ED faces the same challenges as other ED’s worldwide. ED’s
continually struggle with long wait times, overcrowding in waiting areas, patient and employee
dissatisfaction, and poor financial performance. Using the Lean Six Sigma methodology, Sunny
State has an opportunity to improve the quality of care by implementing strategic sustainable
changes to gain efficiencies. The main areas for improvement identify as registration, triage,
technology, roles and responsibilities, and communications. Issues plaguing the ED are both
internal and external to the department. The elimination of non-value-add activities will improve
patient throughput by streamlining and removing waste from the processes. In order to be
successful, all stakeholders must engage, accept, and participate in the design for a better
outcome. Hospital ED’s are the first line of treatment and are the face of the hospital. Patient
experiences and satisfaction are vital to the financial performance of the entire organization.
SUNNY STATE HOSPITAL CASE STUDY5
References
Al Owad, A., Samaranayake, P., Karim, A., & Ahsan, K. B. (2018). An integrated lean
methodology for improving patient flow in an emergency department - case study of a
saudi arabian hospital. Production Planning & Control, 29(13), 1058-1081.
https://doi.org/10.1080/09537287.2018.1511870
Elamir, H. (2018). Improving patient flow through applying lean concepts to emergency
department. Leadership in Health Services (2007), 31(3), 293-309.
https://doi.org/10.1108/LHS-02-2018-0014
English Standard Version Bible. (2021). ESV.org.
Improta, G., Romano, M., Di Cicco, M. V., Ferraro, A., Borrelli, A., Verdoliva, C., Triassi, M., &
Cesarelli, M. (2018). Lean thinking to improve emergency department throughput at
AORN cardarelli hospital. BMC Health Services Research, 18(1), 914-914.
https://doi.org/10.1186/s12913-018-3654-0
McGraw-Hill Create (2020). Project Quality Management. Upper Saddle River, NJ: McGraw-
Hill Education
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