Six Sigma Green Belt project

Indian Statistical Institute, Delhi Centre

(a multi-specialty hospital)
 Project Title

Reduction of delays in the in-

patient discharge process

Project submitted by
Shoumya Roy Choudhury
 About Sitaram Bhartia Institute of
Science and Research

SBISR is a 70-bed multi-specialty hospital recognized for

its outstanding medical faculty, innovative care
programs, high ethical standards, and patient-friendly
ambience. SBISR is in the forefront of developing clinical
programs that use a structured team approach to deliver
care as per international guidelines. SBISR provides a
work environment that is characterized by teamwork,
continuous learning, and respect for the individual.
Mission statement
To become a national benchmark for clinical and research
excellence

Envisioned future
We will be a prolific medical center that will be known for its
commitment to practicing evidence-based medicine and providing
world-class care. We will have established research programs that
will focus on gaining a better understanding of the health care needs
in our communities and developing practical solutions for addressing
those needs. We will be seen as pioneers who have successfully
taken up those health care challenges that may otherwise have
remained poorly addressed. We will have collaborative
arrangements with leading institutions from around the world and be
in the forefront of providing training to health professionals. Donor
agencies and individual philanthropists will recognize our work by
generously supporting our initiatives. We will be widely
acknowledged as an institution that serves as a symbol of
excellence in our society.
 Values
Our core values are
• Caring for people
• Continuous learning and improvement
• Institution building
• Honesty and integrity
DEFINE PHASE
 PROJECT CHARTER

Reduction of delays in the in-patient Project commenced

Project Title discharge process on 21-Aug-08

Project Type Reduction of time variation Project completed on 16-Oct-08

Project Gurpreet Chauhan, Chief Process Audit and

Champion Administrative Officer data analysis Vishal Mehta

Green Belt Shoumya Roy Choudhury

Problem Statement

An analysis of the discharge process indicated that the delays happened due to delay in handover at
the inter-departmental transition points. The average time taken to complete each task is lesser than
the total time elapsed in a department (entry and exit times in the dept)

Goal Statement

To decrease the time taken to complete and handover to the next step in the process
 CTQs of the project
The CTQs of the project are given below

Customer CTQ ----> Able to physicially leave the room within two hours of discharge
announcement by the consultant physician

Internal CTQ -------> Reduction of delays in each individual step of the discharge
process

Project CTQ -------> Reduction of total time taken to discharge a patient

 How is the
The time taken in each step of the discharge
situation
process is more than required for
handled? completion
What the Customer meant?

Why is the
need felt?
Patient wishes to leave the hospital quickly
Voice of Customer table and SIPOC

Where is the
need felt?
In the patient's room
When is the
need felt? After the discharge has been announced by
the consultant
What is the
Need? To reduce the delays in each individual task of
the discharge process
What Customer The discharge process takes a long time and
said? there are delays in the intermediate steps
in the process
Who is the
Customer? Patient who is admitted in the in-patient
Sl. No. department

1
 Voice of Customer (cont.)
(1) Source: Please see excel sheet "PEQ Analysis 01-Jul-08 to 30-Sep-08"
(2) Discharge-related patient feedback ("Comments/Remarks" column) is highlighted in
yellow

(3) There are a total of 24 questions on the PEQ (patient experience questionnaire)
(4) Ques No. 24 is "How satisfied were you with the discharge process (clearance of bills,

medication information, time taken etc.)?"

(5) The average score on Ques No. 24 of the PEQ for each of the three months is given
below

Month Average score Ranking

Jul-08 4.19 23

Aug-08 3.85 24

Sep-08 3.85 24
MEASURE PHASE
 Data Collection
Data Collection Plan
What to collect Time taken to discharge a patient admitted in the in-
patient department Note the "reasons for delay"

Record time at Step B "Announce discharge of patient Time recorded by discharge

(consultant)" coordinator
How to collect
Record time at Step N "Enter bill number in patient file
and hand over discharge summary to Attendant Time recorded by discharge
(nurse)" coordinator

All the discharges for a 12-day period (initial) 112 data points
How many All the discharges for a 12-day period (after
implementation of changes ) 76 data points

Please see excel sheet "PRIMARY DATA and analysis.xls"

 SAMPLE DATA - Discharge time for an IPD patient (after change)

summary to pt (nurse)
Discharge announced

Total discharge time

Whether On Schedule or
Case Registration No

Reasons for delay

Date of discharge

Hand over disch

at (consultant)
Patient Name

Patient type
(minutes)
Room No
Sl. No

Late
Mrs SUMAN VISHWAKARMA 189287 109-F 19-Sep-08 4:38 PM 4:42 PM General On
1 4 Schedule

Mr AMBAR NARULA 189298 223-A 19-Sep-08 7:20 PM 7:22 PM General On

2 2 Schedule

Mr ANKUR GUPTA 140328 201-B 20-Sep-08 9:19 AM 10:44 AM General On

3 85 Schedule

4 Mrs RENU YADAV 171640 217 20-Sep-08 9:23 AM 11:27 AM 124 General Late

Mr SOMNATH MALIK 187927 109-F 20-Sep-08 12:00 PM 12:58 PM General On

5 58 Schedule

Ms LEELA GUPTA 188671 106 20-Sep-08 9:48 AM 11:34 AM General On

6 106 Schedule

Mr DEBASHISH BINDHANI 189218 201-D 20-Sep-08 3:40 PM 3:40 PM General On

7 0 Schedule

Ms SUMAN JOSHI 189238 109-A 20-Sep-08 2:30 PM 3:37 PM General On

8 67 Schedule

Mr KARAN VIR SEHGAL 189306 223-B 20-Sep-08 2:16 PM 3:39 PM General On

9 83 Schedule
ANALYZE PHASE
 Process flow diagram for discharge of IPD patient (general)

C Thursday, October 30, 2008

Step C
Step B
Step A Complete charge-sheet entries (incl
Announce the N
Start requisitions for blood, investigations,
discharge of patient
medicine, and consumables)

Step D
R Prepare handwritten
discharge summary
Step E
Send handwritten IPD
W-N
charge-sheet to IPD
Step F billing section
W-N Send discharge summary to
medical documentation dept

Step G
EIB Prepare final IPD
Step H
bill
EMD Type discharge
summary

Step J Step I
R Check the typed discharge AIB Call patient for payment
summary and sign and settlement of IPD bill

Step K
Step L ATT Make full payment of
W-MD Submit the signed discharge outstanding IPD bill
summary to Staff Nurse amount

Step N
Enter bill number in patient file
N and hand over discharge
summary to Attendant (along with
post-discharge instructions)
Step O
End
Abbreviations
C – Consultant (physician, surgeon)
R – Resident Doctor (of relevant speciality)
N – Staff Nurse assigned to the patient
Step M W-N – Ward-boy of nursing dept (shifting
ATT
Submit IPD Bill number to of patient; internal docum ent delivery)
assigned Staff Nurse W-MD – Ward-boy of m edical
docum entation dept
EMD – Executive Medical Docum entation
EIB – Executive IPD Billing
AIB – Associate IPD Billing (front desk)
ATT - Attendant
 Monday, October 27, 2008
Delay in discharge of an IPD patient
Process Communication
Ward-boy not available
Patient / Attendant to deliver (i) h/w DS to MD
dept; (ii) h/w IPD charge-sheet
to IPD billing; (iii) completed DS to
Nurse did not check progress assigned nurse
record (in pt file) for
instruction of discharge
Attendant not informed by IPD
about giving bill number
to assigned nurse resulting in delay
Delay in checking
Resident waits till completion
the IPD bill
of morning rounds with
sr consultant
Resident doctor did not
Attendant not available inform assigned nurse
when called; arrives late
Mandatory visit from
to billing section
dietician / physiotherapist not
completed

Delay in discharge
of IPD patient

Delay in calling attendant to the

Only one PC available
IPD billing section due to
for discharge processing
many patients waiting in
More than 10 simultaneous line (for admission/discharge)
discharges (can happen at
full occupancy)

Equipment Ward-boy serving

other patients

Staffing shortage
(Ward-boy)

Assigned nurse allotted

Nursing procedure incomplete more than 3 patients
(eg. emptying of glucose
bottle, etc)

Increase in
Clinical reasons workload

Page 1
Causes for delay in the discharge process
Primary causes
• Lack of communication at the transition points in
the process
• Unanticipated increases in workload for the
employees who are involved in discharge
processing
• Shortage of equipment involved in discharge
processing
(please refer to the cause-and-effect diagram in the
next slide)
Calculation of DPU, DPMO, and Sigma Level
(before making the process change)
A total of 85 discharges were observed in the period Sept 3, 2008 to Sept 11, 2008
Number of times discharges were “Late”
Defects per unit = -------------------------------------------------------
Total number of discharges observed

= 33 / 112 = 0.2946

Number of opportunities for error = 4

(a) Error in discharge summary
(b) Error in demographic data
(c) Error in IPD charge-sheet data entry (error in IPD bill)
(d) Delay in discharge (Late)

Defects per opportunity = 58 / (85 X 4) = 0.07367

Defects per million opportunity = 0.07367 X 1,000,000

(DPMO) = 73660.71

|Z| = | (-) 1.45|

(based on nearest value i.e. 0.0735)

Therefore, Sigma Level (σ) = 1.45 + 1.50

of discharge process before
change = 2.95
 Control Charts (before change)

• Xbar-R chart for the period BEFORE the change was

implemented
• Period – Sept 3, 08 to Sept 15, 08
• Refer - Attached excel sheet “Xbar-R chart (data before
change).xls”
 Discharge time (minutes)

100.00
150.00
200.00
250.00
300.00
350.00

0.00
50.00
03-Sep-08

04-Sep-08

CL
UCL

05-Sep-08

06-Sep-08

07-Sep-08

08-Sep-08
XbarR Chart R

09-Sep-08

Date of discharge 10-Sep-08

11-Sep-08

12-Sep-08

13-Sep-08
158.92
318.47

15-Sep-08
 Discharge time (minutes)

103.66
123.66
143.66
163.66
183.66
203.66

3.66
23.66
43.66
63.66
83.66
03-Sep-08

04-Sep-08

CL

LCL
UCL

05-Sep-08

06-Sep-08

07-Sep-08

08-Sep-08
XbarR Chart X

09-Sep-08

Date of discharge 10-Sep-08

11-Sep-08

12-Sep-08

13-Sep-08
29.24
106.00
182.76

15-Sep-08
IMPROVE PHASE
 Initiative to reduce delays in the discharge
process

• Appointed a “discharge coordinator” to ensure

fast and efficient communication at the transition
points of the process
• The DC handled increases in workload by
lending a helping hand to overstretched
employees
• Two computers were allotted to the IPD billing
section for discharge processing
• The resident doctor prepared a draft discharge
summary one day in advance so that it takes
lesser time on day of discharge
Calculation of DPU, DPMO, and Sigma Level
(after making the process change)

A total of 75 discharges were observed in the period Sept 3, 2008 to Sept 11, 2008
Number of times discharges were “Late”
Defects per unit = --------------------------------------------------
Total number of discharges observed

= 12 / 76 = 0.15789

Defects per opportunity = 23 / (45 X 4) = 0.03947

Defects per million opportunity = 0.03947 X 106

(DPMO) = 39473.68

|Z| = | (-) 1.76|

(based on nearest value i.e. 0.0392)

Therefore, Sigma Level (σ) = 1.76 + 1.50

= 3.26
 Interpretation – DPMO and Sigma

There has been a 46% reduction in the DPMO from

73,660 to 39,473 after the implementation of the
initiative. This translates to a sigma level improvement
from 2.95 to 3.26
 Control Charts (after change)

• Xbar-R chart for the period AFTER the change was

implemented
• Period – Sept 20, 08 to Sept 30, 08
• Refer - Attached excel sheet “Xbar-R chart (data after
change).xls”
 XbarR Chart R

250.00
UCL 232.71

200.00
Discharge time (minutes)

150.00

CL 116.12

100.00

50.00

0.00
20-Sep-08 22-Sep-08 24-Sep-08 25-Sep-08 26-Sep-08 27-Sep-08 29-Sep-08 30-Sep-08
Date of discharge
 XbarR Chart X

140.00

UCL 124.90
120.00

100.00
Discharge time (minutes)

80.00

CL 68.81

60.00

40.00

20.00
LCL 12.72

0.00
20-Sep-08 22-Sep-08 24-Sep-08 25-Sep-08 26-Sep-08 27-Sep-08 29-Sep-08 30-Sep-08
Date of discharge
 Interpretation of Xbar-R chart
• The R-chart for the data before the change indicates that
the process is out-of-control
• Indication – Five of five consecutive points are beyond
the 1-sigma limits
• The R-chart that is drawn for the data after the change.
All the points are within the control limits and no pattern
can be observed
• Since the R-chart indicates that process variability is in
control, the Xbar-chart is constructed. All the points are
within the control limits and out-of-control condition is not
observed
• Thus the process which was out-of-control earlier, is in-
control after the changes have been implemented
CONTROL PHASE
 Improved process Control

Appointed a "discharge coordinator" to

Created position of "discharge coordinator" coordinate the communication activities and
with primary responsibility of managing the smoothen workload in the discharge
discharge process for each patient process

Purchase of one additional computer for

discharge processing Desktop PC purchased and installed

Prepare a draft discharge summary one

day in advance (in cases where discharge
date is known) Included in the updated process flow
 Acknowledgement

(i) Gurpreet Chauhan, Chief Administrative Officer

(ii) Bindu Menon, Sr. Executive – Patient Services
(iii) Vishal Mehta, Asst. Manager - Quality
(iv) Medical Documentation department
(v) Nursing department
(vi) Patient Services department
(vii) Control chart software www.qimacros.com