The Journey to Hospital Operational Excellence: Achieving Process Improvement at Presbyterian Hospital

The Emergency Department (ED) at Presbyterian Hospital in Charlotte, N.C., located in one of the fastest growing regions in the country, is often stretched beyond capacity. Patient volume in the 43-bed ED has jumped 34 percent in the past four years, and more than 86,000 people are expected to seek care there during 2008.

Root Cause

Back in 2006, the Presbyterian ED recognized the obstacles before them—too many patients and too little patience among a stagnant staff, many of whom were discouraged and negative to change. With the volume steadily increasing and no additional rooms in sight, patient throughput issues had become more apparent. Earlier hospital-wide attempts to make quality improvements were generally unsuccessful.

Following the arrival of a new department director, John Schooley, in May 2006, managers began attending regular off-site retreats to identify the issues and barriers that existed to providing excellent patient care and a great place to work. The retreat’s action plans spawned several random quality control and process improvement efforts, but they had little success because the staff was not engaged and the data needed to make process improvements was not readily available.

Looking to Lean Six Sigma for Process Improvement

To help the ED leaders facilitate the process improvement work, variation reduction and the needed culture change, the hospital imbedded me as the operational improvement and Lean Six Sigma advisor within the department in late 2006. My time was dedicated to helping make the ED a better place to work and to receive care through Six Sigma and also to use Six Sigma to generate virtual capacity in order to handle the growing volumes.

My initial efforts were spent obtaining the necessary data to guide process improvement efforts before engaging the staff. Together with ED leadership, we reviewed data from the previous months and years looking for trends and patterns. Baseline data was established for benchmarking, as well as value stream maps, to determine where to focus efforts to improve patient flow and reduce length of stay—two things that would help the overcrowded ED and the frustrated staff.

The Data Collection Process

The ED leadership and I used statistical processes to produce a series of correlation studies in early 2007 to determine what was driving the high rate of patients who left without being seen (this was at the time about 7 percent), aside from simply a high volume of patients in the ED.

After considering many correlations—including things that seemed to make sense and things that did not—we finally realized that the number of patients sitting in the waiting room at 3 p.m. every day actually was the greatest correlation to the left-without-being-seen rate. As intuitive as it might sound, that correlation was important because it allowed the team to focus the first improvement efforts on being more productive during the first shift so the flow of the next shifts would be improved as patient volume increased during the day. Arrival-to-room time was tracked as a key performance indicator.

I slowly began to engage staff members in process improvement by asking them what they felt caused their delays each day. I collected all that data and created Pareto charts, allowing daily challenges to be analyzed and prioritized. The results included answers such as the inability to handle the incoming volumes, radiology department turnaround times and insufficient staffing. The interview process also allowed for the development of a trusted relationship between ED staff and myself, perhaps the most important piece of this successful process improvement effort.

Knowledge Sharing for Lean Six Sigma

Rather than being resistant to change, the staff was beginning to come to the table, helping to propose ideas and solutions and then implementing the changes. By design, process improvement teams included staff members who wanted to embrace change and also those who were resistant but were among the social leaders within the organization. Soon staff members began to urge each other to embrace the efforts to make changes.

The ED staff started looking at the patient flow process in segments—from door to room, room to doctor, doctor to disposition, disposition to discharge. Process improvement teams systematically went down a list of projects, taking on one at a time that would make the biggest impact, then watching for sustainable results. The teams utilized the Plan-Do-Study-Act (PDSA), a four-step process for problem solving generally used in quality control, to analyze their efforts. If there were no sustainable results, they readdressed the project until they found the right solution.

There were 10 major projects, along with other smaller continuous improvement efforts, that were undertaken during 2007. Incremental changes began occurring over several months along with a couple major breakthroughs. More projects continue in 2008, along with the introduction of 5S throughout the department to support Lean improvement efforts.

Achieving Continuous Improvement

The staff’s new willingness to accept process improvement changes was essential to the department’s evolving continuous improvement culture. Staff members also began to understand the value of data to help guide change. They watched it, monitored it and got excited when it moved in the right direction. Color-coded charts showing how many patients left each day without being seen; data in the form of control charts, Pareto diagrams and mind maps were posted in break rooms and hallways in the emergency services area, along with patient satisfaction scores and other charts and graphs. The ED is now a visual department.

As the workplace culture in Emergency Services has changed through continuous improvement, so has the level of care that patients receive. The average patient walkout rate was cut by almost half, from 7 percent to 3.9 percent during the last six months of 2007. Accordingly, patient satisfaction scores also jumped. Employee turnover was cut by more than 50 percent, from 43 percent in 2006 to 18 percent in 2008.

The number of patients who seek emergency care at Presbyterian Hospital is expected to continue increasing. Construction is underway on a 31-bed addition to the hospital’s ED, and the existing 43 beds are being renovated. The multi-year building projects will create even more opportunities for change. But with a strong foundation in process improvement, leaders and staff members in Emergency Services are better prepared to deal with these and other future challenges.