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Über dieses Buch

This book provides a detailed description of how to apply Lean Six Sigma in the health care industry, with a special emphasis on process improvement and operations management in hospitals. The book begins with a description of the Enterprise Performance Excellence (EPE) improvement methodology developed by the author that links several methodologies including systems thinking, theory of constraints, Lean and Six Sigma to provide an enterprise-wide prioritization and value-chain view of health care. The EPE methodology helps to improve flow at the macro or value-chain level, and then identifies Lean Six Sigma detailed improvements that can further improve processes within the value-chain.

The book also provides real-world health care applications of the EPE and Lean Six Sigma methodologies that showed significant results on throughput, capacity, operational and financial performance. The Enterprise Performance Excellence methodology is described, and also the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control) problem solving approach which is used to solve problems for health care processes as they are applied to real world cases. The case studies include a wide variety of processes and problems including: emergency department throughput improvement; operating room turnaround; operating room organization; CT imaging diagnostic test reduction in an emergency department; linen process improvement; implementing sepsis protocols in an emergency department; critical success factors of an enterprise performance excellence program.



Chapter 1. Enabling Enterprise Performance Excellence Through Strategic Business Process Architecture Modeling Techniques

We start this book with a description of an Enterprise Performance Excellence (EPE) methodology that links the Lean Six Sigma methodology discussed in Chap.​ 2 with other systems engineering methodologies that can help to optimize the entire enterprise’s processes. EPE helps to understand the organization from a cross-functional enterprise view so that the Lean Six Sigma program can be aligned with the strategic and operational plans as well as focused on key bottleneck processes within the healthcare organization. This methodology starts with understanding the value chains of the organization and functionally decomposing the business functions that provide services to the customers or patients. Following is a description of the EPE methodology.
Sandra L. Furterer

Chapter 2. Lean Six Sigma Roadmap

The purpose of this chapter is to provide a roadmap to applying the Lean Six Sigma (LSS) methodology and the key tools that can be applied when implementing LSS in healthcare processes. This chapter was originally published in Furterer (2009), and adapted for the healthcare enterprise. A little over twenty-one percent (21.3 %) of the industrial workforce is engaged in educational services and healthcare, and social assistance occupations (US Census Bureau). Service industries are the fastest growing segment of our economy and now account for almost 70 % of economic activity, and over 85 million employees (US Census Bureau North American Product Classification). Healthcare processes include both clinical and nonclinical processes, and both types can be improved using LSS methodologies and tools.
Sandra L. Furterer

Chapter 3. Hospital and Emergency Department Throughput Improvement

Visits to emergency departments (ED) are increasing and overcrowding has become a serious problem for hospitals, patients, physicians, and clinical staff. In this case study, a cross-functional team representing the ED, inpatient floors, and units including clinical, ancillary support staff, and non-clinical members applied Lean Six Sigma methodologies and tools to drastically reduce the patient length of stay (LOS) and the percent of patients Left Without Being Seen. There was a 31 % reduction in LOS which is closely tied to patient satisfaction. The percent of Left Without Being Seen was reduced from 6.5 to 0.3 %. The door to doctor time was reduced by 78 % to an average of 23 minutes. Patient Satisfaction scores increased by 24 to 89.9 % which placed this EDs department in the top 1 % of EDs nationally.
Sandra L. Furterer

Chapter 4. Operating Room Turnaround and On Time Starts Improvement

The next two chapters describe the improvements made to a community-based acute care hospital’s Operating Room environment with respect to the following areas: (1) Chapter 4. Performing turn around time between surgical cases, and improve on-time start of operating room cases. (2) Chapter 5. Improve OR location and organization of equipment, instruments and supplies.
Sandra L. Furterer

Chapter 5. Applying 5S to Improve OR Organization

This chapter describes the project that was initiated with the OR Turnaround and On-time Case Starts project from Chap.​ 4. The need for this project became painfully obvious early in the OR turnaround project. When we first toured the OR to better understand the layout and processes, we saw the challenges the OR was facing with storage and management of the OR supplies, instruments, and equipment. The hallways were cluttered with supplies, both in storage from the vendor (vendor owned and managed), as well as storage that did not fit into the Core inventory storage area, and cases that are staged for the cases for the same day. There were also beds waiting for patients to come out of surgeries, and trash bags being staged while rooms are cleaned. These challenges resulted in the need for improving the OR location and organization of equipment, furniture, instruments, and supplies. Before pictures of the OR, prior to the start of the project are shown in Figs. 5.1 and 5.2. In Fig. 5.1, the OR case cart staging area is shown. One of the OR hallways is shown in Fig. 5.2. As is evident from the pictures, the areas lack organization, labeling, and visual control, so it is difficult to find desired supplies and equipment quickly.
Sandra L. Furterer

Chapter 6. Leaning the Surgical Outpatient Screening Process in an Acute Care Hospital

Elective surgery is a surgery that is a planned, nonemergency surgery, that can be scheduled at the convenience of the patient or the physician. The surgical procedure may extend life or improve the quality of life. In the year 2000, there were over 40 million inpatient surgical procedures performed in the United States, and 31.5 ambulatory or outpatient surgeries in 1996, based on the National Center for Health Statistics of the U.S Centers for Disease Control CDC (http://​www.​healthtools.​com 2012). Typically a complete health history, physical examination, lab and diagnostic tests may be part of the preparation of the surgical patient prior to the elective surgery. Additionally, typing and screening of the patient’s blood is also performed prior to surgery (http://​www.​healthtools.​com 2012). A percentage of the patients who receive the elective surgery, may already be a patient in the hospital, and this preparation for surgery is performed under the guidance of the inpatient nurse. A patient that is not already in the hospital, but has scheduled their elective surgery is considered an outpatient from the perspective of the surgical preparation, even though the patient may be admitted after the surgery. This case will describe how the Lean Six Sigma team at an acute care hospital improved the pre-screening process for surgical outpatients applying Lean tools, with the Six Sigma DMAIC problem solving approach.
Sandra L. Furterer

Chapter 7. Appropriate Use of CT Scan in the Emergency Department

This chapter describes a case study in a community-based acute care hospital that was able to successfully reduce the Computed Tomography (CT) utilization in their Emergency Department by 8.7 % for 1 year, and 13.8 % since the prior 2-year period. The reduction was especially important because 10 % of the U.S. population gets a CT scan each year, and use of CT imaging is growing more than 10 % per year, and with it, increased long-term exposure can increase potential cancer risks. The cross-functional team applied the Six Sigma methodology and tools to define the problem, measure the current state, identify root causes, and develop medical research-based and evidence-based CT guidelines to reduce CT utilization. The information presented in this case study is not designed or intended to provide medical advice or recommendations.
Sandra L. Furterer

Chapter 8. Linen Loss Reduction in an Acute Care Hospital

This chapter describes a case study in an acute care hospital that formed a cross-functional team to apply the Lean Six Sigma problem solving methodology and tools to improve the linen processes. The goal of the project was to identify and implement process improvements that would reduce linen loss. We applied the (Define-Measure-Analyze-Improve-Control)(DMAIC) problem solving approach and within the first 6 months of implementation we improved the soil to clean linen ratio by 1.1 % and saved over $75,000 for the first year.
Sandra L. Furterer

Chapter 9. Sepsis Protocol Design Project

Sepsis is a systemic infection that is the 10th leading cause of death in the United States. The sooner that the antibiotic protocols are started, the better is the patient’s outcome. This case study applied the Lean Six Sigma methodology and tools to develop and implement Sepsis protocols in the Emergency Department of a community-based hospital to improve patients’ sepsis mortality by 9.6 %, while improving the time that the sepsis protocols were administered from the time that the patient arrived to the Emergency Department. There is still improvement to be made in the consistency of administering the sepsis protocols for suspected sepsis patients in the ED. This chapter is not intended to provide medical advice or recommendations.
Sandra L. Furterer

Chapter 10. Design of Women’s Center Service Processes

A community hospital’s Women’s Center recently moved into a new facility to respond to the exponential growth of women’s health care needs in their market area by redefining, refocusing, reconfiguring, and expanding its women’s health services line. They had an existing smaller center, with fewer services that was part of their outpatient facility. The goal of the new facility is to create a “one stop shopping” model where women can receive a comprehensive range of services conveniently, comfortably, efficiently, and with speed and ease. A similar case was originally published in Cudney and Furterer (2012) and Cudney et al. (2013).
Sandra L. Furterer

Chapter 11. Innovating the Patient Care Operating Model: Integrated Value Care

The healthcare industry and hospitals in general have been providing care from an operating model perspective in much the same way since hospitals began. Yes, the medical technology has become much more advanced: imaging technology providing an ever-advancing and amazing view inside the body without a single incision; surgical techniques with cameras and robots enabling surgeons to perform surgeries with smaller incisions and quicker recoveries are just two examples. But the basic operating model has not changed. We are still managing the flow of patients through the healthcare system with a focus on the processes and care providers within a department providing care to each patient, but largely ignoring the flow and progression of a patient to the next step in their care. Patients sit in emergency rooms, with long delays, because the model doesn’t incorporate pulling the patient through their emergency care by understanding where the patient needs to be in their next step of care in a proactive manner. The patient arrives in the emergency room, signs in, and sits down to wait. The triage nurse triages the patient and returns them to the lobby to wait with a vague priority rating of the rough order that they will be called to an emergency room. The patient is finally placed in a room, and waits for the next care provider to pick them out of a list of their other patients, in an unknown priority to assess their medical status, and push them to the next step of the process. Each care step is provided in a somewhat random order, not based on the series of activities that must be performed to make the patient well, but on them sitting in multiple queues for separate departments such as imaging, transportation, registration, scheduling, admitting, emergency physician, nurse, admitting physician, consulting physician, etc. Another example is in the inpatient operating model. The patient comes to the hospital in one of several input channels, being admitted through the emergency room, being a direct admit to registration based on a physician’s orders, being admitted based on either a planned or emergency surgery. Once the patient is admitted to an inpatient floor, which could be after a long wait in one of the input channels, the patient sits and waits again for their initial assessment. “Normal” service level requirements, typically based upon a regulatory requirement from the government, require a patient’s initial inpatient assessment to be performed within 24 hours of admission. This seems like a long time to identify an initial diagnosis, let alone design a potential path of care for the patient. The patient then waits to be “roughly” scheduled for diagnostic tests that provide more insight into their maladies. The “roughly” term is used because a diagnostic test is ordered, but there is really no inpatient schedule. The patient is put on a list for the required department, but has little or no insight into when the test will be run, other than within a rough 24 hours period time-frame. Wouldn’t it be patient-centered to provide the patient with a schedule each morning of the care, and tests that will be provided and performed for that day? In this way the family members can easily be a part of the patient’s care, without waiting for days not knowing when the patient will get their tests. Wouldn’t it also be novel to know when the patient is expected to be discharged based on standardized patient care protocols and inpatient schedules of patient care activities? The existing operating model in a hospital is inefficient and causes immense delays in patient care, when what could be minutes and hours of delays become days and weeks of delays. Is there a better way? The author believes there is a better way to manage the flow of care for a patient through the myriad activities, tests, transports, and hand-offs in a hospital, based on the principles of Lean, Six Sigma, Systems Engineering, and Business Architecture. This chapter will provide a proposal for a new and innovative value care operating model for providing patient care in a hospital setting. It is a proposal for future research and application for those brave care providers, in particular management engineering pioneers who seek to provide a better way.
Sandra L. Furterer

Chapter 12. Labor Management in Healthcare: Flaws and Best Practices

Labor Management is critical in healthcare and especially so in acute care hospitals, where 50 to 70 % of the costs are attributed to labor costs. According to the American Hospital Association labor represents more than half the cost of business in a healthcare facility ( The purpose of this article is to describe best practices of labor management, and how they can be applied to effectively manage an acute care hospital.
Sandra L. Furterer

Chapter 13. Critical Success Factors of Enterprise Performance Excellence

There are a wide variety of ways to structure an organization’s Enterprise Performance Excellence program. This chapter describes practical guidance based on the literature and the author’s experience for designing your Enterprise Performance Excellence program to help enhance the success of the program.
Sandra L. Furterer

Chapter 14. The Future and Challenge of Lean Six Sigma in Healthcare

This book provides an overview of Lean Six Sigma and the Define-Measure-Analyze-Improve-Control (DMAIC) methodology, and real-world healthcare case studies applying these methods and tools. This chapter describes a view into the future with the attempt at projecting where Lean Six Sigma for healthcare will evolve over the next decade.
Sandra L. Furterer


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