Manhattan hospital shows viability of Six Sigma improvement

A Manhattan hospital used Six Sigma to identify breakdowns in their emergency CT workflow, increasing patient throughput after addressing communication breakdowns and software incompatibilities. Lennox Hill Hospital's experiences with the process improvement method were documented in an article published in the Journal of the American College of Radiology.

Perched on the Upper East Side of Manhattan, Lennox Hill was experiencing a surge in ED visits—a trend familiar to most of the nation’s hospitals. While some believe the increase to be temporary—a function of people learning how to use health insurance for the first time under the ACA—the strain on fixed resources remains.

CT is useful in emergency medicine primarily due to its speed and ability to image internal injuries and head trauma, two chief concerns when a patient comes to the ED after an event such as a car accident. Lennox Hill has three CT scanners but none on the same floor of the ED, which led to lengthy transport times. 

Inefficiencies like that contribute to an average time-to-scan of almost 2.5 hours, an unacceptable number according to co-authors Devon A. Klein, MD, MPH, Assistant Professor of Radiolology at Hofstra Northwell School of Medicine, and Vandanda Khan, Radiology Program Manager at Lennox Hill Hospital. 

“We recognized there was great process variation and our operation structure required modification to meet our objectives,” the authors wrote. “However, owing to the previously unorganized approach to studying the problem, the areas of ‘waste’ had yet to be identified.”

A task force convened a Six Sigma Lean Kaizen event to accurately chart the process from ordering the scan in EMR to the exam's completion. Representatives from the emergency department, nurses, transportation, radiology reception and imaging technologists came together to identify each step.

The team pinpointed several key barriers to patient throughput, including communications breakdown between different providers and non-clinical staff, limitations of the patient waiting areas, and the abuse of dedicated patient transport elevators.

“Communications failure was likely the issue with the greatest direct impact in delaying throughput,” said Klein. “After the Kaizen event, several points in the communication chain were identified and key personnel were now selected to escalate communication in the event of a breakdown.”

While some barriers—like not have a CT scanner on the ED floor—were clearly visible to clinicians, others were obscured and went unnoticed until the disparate group of Lennox Hill employees were brought together.

“IT incompatibilities between different services and even within the same service were least visible prior to the investigation,” said Klein. “In fact, high level providers in the ED were unaware that lower level clinical providers did not have access to the same information.”

Patient throughput improved after implementation of solutions, reducing time-to-scan to just over two hours. Redesigning the CT waiting area allowed staff to quickly ascertain how many patients were waiting, in addition to increasing overall capacity.

The authors were careful to note that the improvements experienced after using Six Sigma were independent of the time-to-scan benefits that accompanied the installation of a new CT scanner within the ED. However, placing a CT scanner right where it's needed is easier said than done, according to Klein.

“Space is a limited commodity in an urban hospital, and in a building of its age, finding a location that could accommodate the CT scanner required relocation of different services and reconfiguration of the emergency room entrance,” he said. “As a result many moving parts had to fall into place before we could install and eventually use the new CT scanner for patient care.”

Price is another concern: A new CT scanner costs well over $1 million, a staggering sum for smaller imaging providers. For practices with neither the budget nor floor space to drastically overhaul their systems, looking toward workflow improvements like Six Sigma can provide a multitude of benefits.