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QUALITY PROGRESS I FEBRUARY 2005 I 57

he Nebraska Medical Center is a 735-bed nonprofit hospital in Omaha. Made up of two merged facilities—Clarkson Hospital

and the University of Nebraska Medical Center—it is the largest teaching hospital in the state, with both academic and private practice physicians. It

began implementation of Six Sigma in December 2002, with this definition as a guide: Six Sigma is “a statistical measure of performance of a process or product; a goal that reaches near perfection for performance improvement; and a system of man- agement to achieve lasting business leadership and world-class performance.”1

The Nebraska Medical Center’s interventional radiology department was selected as one of the first areas of focus through the hospital’s project selection process. With a staff of 12 to 15 nurses, radiology technicians and physicians, this department per- forms a wide variety of invasive procedures, includ- ing placing urethral stents, transjugular liver biopsies, and procedures using fluoroscopy and chemoembolization.

In October 1997, physician loss and process inef- ficiencies were causing patient volume to decline. By 2002, it still hadn’t improved, as dissatisfied referring physicians were sending patients to other hospitals. Patients who remained were expe- riencing delays in their treatments, another prob- lem. The interventional radiology department was well aware this was hurting the medical center ’s revenue and the satisfaction of patients and refer- ring physicians.

T

In 50 Words Or Less

• The Nebraska Medical Center used quality

methods in its interventional radiology

department to turn around a decline in

patient volume.

• The result was more patients and more

satisfaction for patients, employees and

referring physicians.

Quality Intervenes At a Hospital by Jennifer Volland

Quality Intervenes At a Hospital

HEALTHCARE

Defining the Problem A Six Sigma project team was assembled to

address problems in the department’s scheduling process (see Figure 1) and increase both the num- ber of patients seen and the volume of procedures the department was conducting. Key project team members included the lead nurse scheduler, lead technologist and department manager.

The lead nurse scheduler speaks to the referring physicians and clinics to schedule patients for pro- cedures. The lead technologist and other technolo- gists are responsible for setting up the surgical area where procedures are done, running the equip- ment and assisting the interventional radiologist doing the procedure. The technologists know the supplies needed for each case and are able to pull whatever is needed for the physician while keep- ing everything sterile. The department manager is a former technologist.

Physician involvement was also initiated early in the process with ongoing input and informa-

tion sharing from the two physicians on staff. Two additional physicians joined the department after the initiation of the project and were added as valuable resources to the team.

During the first phase of the define, measure, analyze, improve, control (DMAIC) cycle, it became clear scheduling was a primary concern for refer- ring physicians. Physicians who referred a high volume of patients expressed difficulties their clin- ic staff had reaching the interventional radiology scheduler: The current process involved calling a pager first, phone calls were often placed on hold, and it sometimes took multiple attempts to set up an appointment time. Referring physicians wanted appointments scheduled in one call.

The referring physicians also had many patients who lived out of town, and once a patient left a clinic, it was often difficult to reach him or her. Setting an appointment time for the interventional radiology procedure would be much easier if it could be done while the patient was still in the office. With clinic nurses waiting for the nurse scheduler to return phone calls, it was clear easier communication was needed.

At the time, the nurse scheduler was also the lead nurse for the department, which often resulted in him or her being pulled from scheduling duties to help in the holding room, an area where the staff nurses perform pre-procedure tasks for the patients, such as starting intravenous peripheral lines, com- pleting nursing assessments and giving medications. The duality of the role created stress in the position, and other nurses in the department were often frus- trated when they needed to cover the scheduler’s role. There were ample opportunities for improving processes and increasing job satisfaction.

Along with the referring physicians and nurses in the department, the interventional radiologists and technologists also experienced frustration with scheduling. Both groups said the scheduling information form was inadequate, with informa- tion slots on the form left blank or pertinent infor- mation missing. Often the nurse scheduler knew the information from the clinic interaction, but the information was not consistently written on the form because of time constraints and the belief that some items on the scheduling form were redundant or not necessary.

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Referring physician call

Patient scheduled

Hospital arrival

Holding room arrival

Procedure room in

Procedure room out

Dictation

Report finalization

High Level Process FlowFIGURE 1

QUALITY PROGRESS I FEBRUARY 2005 I 59

Measuring the Current Process During the measure, phase the project team

members collected data on the scheduling process. They discovered it took an average of 1.4 calls to schedule an appointment. But the biggest problem was the amount of variability—it could take up to seven calls, with a standard deviation of 0.989. Additionally, scheduling an appointment took an average of 32.17 minutes, and at times up to 298 minutes, depending on the procedure (standard deviation of 59.36 minutes). There were often prior x-ray or treatment films to be reviewed or sched- ule time coordination needed with the computer- ized tomography (CT) department. It was clear too much time and effort were being spent on processes that could be streamlined.

Changes in the Scheduling Process In the analyze and improve phases, the project

team and department staff started to identify changes that could be made for process improve- ment early on. To address scheduling concerns, a Work-Out was held with seven high volume refer- ring clinics, the interventional radiology nurse scheduler and the department manager to deter- mine what they needed to streamline the schedul- ing process and make scheduling easier.

The Work-Out concept was originally developed at General Electric and consists of highly facilitated sessions.2 There are three main steps:

1. A sponsor challenges key individuals who know a process best—people who actually use the process as part of their jobs—to solve a problem.

2. This team of process experts is allowed to cre- ate solutions while being led by a facilitator trained in specific change process dynamics and team facilitation tools. This facilitator is often called a change agent.

3. At the end of the Work-Out, the sponsor returns, examines the proposed solutions and renders a decision of yes, no or needs more information.

When done right, Work-Outs have the ability to rapidly drive decision making and change through an organization to overcome everyday problems and identify critical to quality (CTQ) needs. CTQ needs are expectations by customers based on what matters most to them.3

Assembling the Work-Out team was a valuable experience for all involved. People who had never worked together were able to meet and collabora- tively address common problems. Silos that existed between the clinics and the interventional radiolo- gy department began to break down as concerns were discussed face-to-face.

From the Work-Out it was discovered communi- cation in scheduling with the department was not

the only CTQ need. Clinics were uncertain which procedures were scheduled directly through the interventional radiology department and which procedures went through centralized scheduling for other radiology departments. A quick win determined early in the Work-Out was to make available a complete list of procedures that oc- curred in the interventional radiology department. Clinics could refer to this list to know which pro- cedures were scheduled through the department and use it as a tool in training their new employ- ees.

Another CTQ need in the scheduling process was to give clinics the ability to reach an actual person when they called for scheduling. The cur- rent process involved calling a department pager number, with the scheduler returning the page to the clinic. If the scheduling nurse was with a pa- tient or in the holding room, it could be a while before the call was returned.

The number of calls to schedule was also identi- fied as a concern by the clinics. The project team was not so much concerned about the average of

Silos that existed between the clinics and the interventional radiology department began to break down as concerns were discussed face-to-face.

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1.4 calls. With the maximum number of calls at seven, they were most concerned with reducing the variability in the process.

The clinics were also uncertain of what informa- tion would be requested when scheduling was done. Different information could be asked for depending on the individual scheduler. Clinics sought consistency and awareness of what infor- mation would be required when they called so they could readily provide it.

Collaboration Leads to Improvement The Work-Out spurred further discussions and

team building opportunities for the interventional radiologists, technologists, nurses and scheduler. They examined and redesigned the scheduling slip—more informational items were added—and agreed on how the form was to be consistently filled out. Copies of the revised form were sent to the high volume referring clinics so they would know in advance the information that would be requested. The clear and complete scheduling slip also made things easier for the nurses who covered for the regular scheduler.

Another difficulty was scheduling CT scanner time, since this required additional coordination and calls. CT scans are needed for any patient undergoing a biopsy. The Nebraska Medical Center revisited this issue using its new change manage- ment methodologies. Based on the current volume of cases requiring CT scanner rooms, the CT depart- ment agreed to allocate two one-hour time slots per

day exclusively to the interventional radiology department. This change reduced the number of calls necessary to schedule time in the CT depart- ment and guaranteed available time.

Further improvement was made by the interven- tional radiology physicians reaching consensus on time allocation for procedures and lab work needed prior to procedures. This allowed for continuity of lab work requested and the amount of procedure time allocated by the scheduler. The consistency helped the scheduler know what lab work to tell the clinics was needed independent of the interven- tional radiologist, who was often not assigned until the day of the procedure.

The interventional radiologists also agreed on approval types for needed procedures. Procedures could require either front-end approval (interven- tional radiologist approval needed before scheduling an appointment), no approval or a new category— back-end approval. With back-end approval inter- ventional radiologists still needed to approve the case, but an appointment time could be given when the referring clinic called to schedule. This category was for cases that just required addition- al film review prior to patient arrival. These cases could be scheduled immediately and discussed the following day durning the department physi- cians’ morning meeting.

Since calling the pager was a concern for the clinics, the process was changed to calling a direct department phone number. If the scheduler was not at the desk, then the call was rerouted to the pager. This change streamlined the process and reduced the variability in how many calls were needed to schedule an appointment.

The responsibility of coordinating patients from the holding room into the procedure room, previ- ously held by a nurse, was given to a tech, which allowed the nurse scheduler more time for sched- uling. The tech understood the functionality of equipment in the procedure rooms and could give more attention to the job. This change ultimately decreased overall patient time spent in the hold- ing room.

As another process improvement, the team developed patient information sheets and gave them to the high volume referring clinics. These sheets outlined items that were important for the patient to know about their procedure, aiding com-

0 1 2 3 4 5 6 7 8

Average Range Standard deviation

Before changes After changes

Interventional Radiology Calls To Schedule

FIGURE 2

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QUALITY PROGRESS I FEBRUARY 2005 I 61

munication between the patient and the depart- ment. On the back of the information sheets were maps illustrating the location of the interventional radiology department for the day of the procedure.

Achieving Successful Results Although the average number of calls to sched-

ule remained unchanged, the maximum number of calls was reduced from seven to three, with the standard deviation decreasing from 0.989 to 0.52 calls (Figure 2). The referring clinics felt the change, and the department recognized additional reduc- tion in the average number of calls could be harm- ful to patients, as further collaboration between referring physicians and interventional radiologists was sometimes needed when scheduling more complex cases.

Minutes to schedule increased from 32.17 to 33.18 on average. However, with the changes in the sched- uling slip, better quality of information was obtained at the time the clinics were calling to schedule, which reduced the need for calling back for additional in-for- mation. The extra minute allowed for exchange of all necessary information during the first call, reducing the need for subsequent calls back the department.

With all the changes implemented (Table 1 and Figure 3), complaints from the referring clinics were

12-19-2002 Project start.

3-26-2003 Room coordination role changes from

nurse to technologist.

4-10-2003 Begin to modify scheduling slip

and clinic Work-Out.

4-14-2003 Begin to use

computerized tomography block time

for scheduling.

4-28-2003 Final agreement

from interventional radiologists on labs,

procedure times.

6-7-2003 Call directly to

department scheduler; call forwards to

pager if unavailable.

6-2003 Clinic visits start.

Clinics receive patient information

sheet, list of procedures.

6-25-2003 Control phase:

report out.

Project TimelineFIGURE 3

Lean

Scheduling slip re-examined and redesigned to capture pertinent information.

Agreement on how to fill out the scheduling slip.

Reduction in calls to schedule through obtaining block time from the computerized tomography department.

Interventional radiologists agree on allotted procedure times.

Interventional radiologists agree on lab work to be done for proce- dures.

Interventional radiologists agree on approval type needed for pro- cedures.

Six Sigma

Room coordination role changed from a nurse to a radiology tech.

Patient information sheets designed with maps on the back.

Work-Out

Clinics received a list of procedures done in interventional radiolo- gy.

Ability to call into a person rather than dialing a pager.

Clinics received copies of scheduling information needed.

.

Interventional Radiology Changes

TABLE 1

reduced to zero. One clinic staff member noted, “It’s much easier to reach the scheduler, and calls are re- turned sooner.” Similar comments were made by high volume referring physicians to the department. One said, “After the Six Sigma project, scheduling for procedures is going much better. I don’t have problems now.”

By using Six Sigma tools, the department was able to collaborate with referring clinics and its own staff on improving its scheduling process. Many of the changes not only improved efficien- cies, but also strengthened relationships between the department and referring clinics.

The Work-Out between the external clinics and department staff allowed individuals to meet face- to-face and begin to build relationships through better communication of what each needed to per- form his or her job well.

Job satisfaction was improved by making the position of the scheduler easier, establishing clear expectations of which lab procedures would be required and standardizing approval type and amount of time a procedure needed to be sched- uled. Not being pulled to different job functions created a win for both the nurse scheduler and the clinics impacted by the process.

Most importantly, in the fiscal year 2003-04, the interventional radiology department saw 4,649 patients, a more than 21% increase over the 3,829

patients served in the previous fiscal year that reflects improvements in patient and referring physician satisfaction and process efficiencies.

R E F E R E N C E S

1. Pete Pande and Larry Holpp, What Is Six Sigma? McGraw-Hill, 2002.

2. Ron Snee and Roger Hoerl, Leading Six Sigma: A Step-by- Step Guide Based on Experience With GE and Other Six Sigma Companies, Prentice Hall, 2003.

3. Greg Brue, Six Sigma for Managers, McGraw-Hill, 2002.

A C K N O W L E D G M E N T S

The author gratefully acknowledges from the Nebraska Medical Center: Glenn Fosdick, CEO; Steve Smith, chief medical officer; Sue Korth, outcomes and performance improvement director; the interventional radiologists; department staff; project team; Terry Paulsen, project sponsor; Pat Fryant, department man- ager; and high volume referring clinics for their dedica- tion to Six Sigma and substantial improvements made through their collaboration. Recognition is also given to GE Medical Systems, specifically Phil Kaczmarski, David Green and Carolyn Pexton, for their support and mentoring of the Six Sigma process.

JENNIFER VOLLAND was a Six Sigma Master Black Belt at the Nebraska Medical Center. She received her nursing degree from Creighton University in Omaha. She also received an executive MBA from the University of Nebra- ska in Omaha, where she is currently working toward her doctorate in public administration with an emphasis in healthcare administration and policy.

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Not being pulled to different job functions created a win for both the nurse scheduler and the clinics impacted by the process.