Health Organizational Case Study

Case Studies

Real-world examples of how quality can make a difference in the delivery of healthcare.

Using DMAIC to Improve Nursing Shift-Change Assignments
In this case study involving an anonymous hospital, nursing department leaders sought to improve efficiency of their staff’s shift change assignments. Upon value stream mapping the process, team members identified the shift nursing report took 43 minutes on average to complete. Using DMAIC and other quality tools, team members improved the process’ sigma level from 0.7 to 3.3. Read the online case study presentation or download Using DMAIC to Improve Nursing Shift-Change Assignments(PDF).
February 2016

Using Control Charts in a Healthcare Setting
This teaching case study features characters, hospitals, and healthcare data that are all fictional. Upon use of the case study in classrooms or organizations, readers should be able to create a control chart and interpret its results, and identify situations that would be appropriate for control chart analysis. The case is best suited for MBA operations courses and modules, particularly those focused on operations/process improvement. It also could be used in a hospital setting at a facility that has embraced a continuous improvement philosophy. the online case study presentation or download Using Control Charts in a Healthcare.(PDF)
December 2015

Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor
When St. David’s HealthCare first adopted the Baldrige criteria, leaders viewed it as an improvement framework to shape a culture of quality and performance excellence. Once immersed in the framework, leaders used it as a tool to help align and improve the work of the organization and key performance measures. The organization’s emergency departments served as a prime example of improving key metrics, as wait times were significantly shortened to meet competitive challenges. In 2014, St. David’s HealthCare earned the nation’s top honor for performance excellence, the Malcolm Baldrige National Quality Award. Read the online case study presentation or download Aligning, Improving Key Measures Net Texas Healthcare Organization Baldrige Honor (PDF).
August 2015

Lack of Reported Medication Errors Spurs Hospital to Improve Data Focus, Patient Safety
A quality improvement project at Medcare Hospital in Dubai centered on unreported medication errors. A cross-functional team used the FOCUS-PDCA model to determine root causes and identify potential improvements. Upon implementing a variety of low-cost solutions, staff members felt more comfortable in reporting errors, thus providing valuable information for building safer systems. Read the online case study presentation or download Lack of Reported Medication Errors Spurs Hospital to Improve Data Focus, Patient Safety (PDF).
June 2015

Polish Dialysis Center Employees Use Visual Management to Increase Safety, Improve Organization of Medical Facility
The Regional Nephrology Centre (RNC) Dializa in Poland uses efficient and effective methods of lean philosophy to ensure patient safety and a high-quality level of medical services. The RNC was experiencing problems related to workspace organization, use of utility rooms, and treatment space shared among patients. Staff used visual management (VM) lean methods such as 5S, gemba, and kaizen to improve organization and efficiency of hospital space. Read the online case study presentation or download Polish Dialysis Center Employees Use Visual Management to Increase Safety, Improve Organization of Medical Facility (PDF).
March 2015

Systematically Improving Operating Room Patient Flow Through Value Stream Mapping and Kaizen Events(PDF, 450 KB)
In this case study, learn how Thomas Jefferson University Hospitals in Philadelphia, PA, used value stream mapping to identify and execute seven lean projects within the perioperative department over four years. October 2013

Doctors, Nurses Overcome Workplace Hierarchies to Improve Patient Experience Scores in Phoenix ER
Using the DMAIC approach and Pareto analysis, a vision team of physicians and nurses at Banner Health in Arizona sought to improve patient experience scores within the emergency room while reducing litigation risks. By instituting a number of process improvements, leaders were able to decrease the likelihood a patient files a complaint prior to ER discharge by 89 percent. October 2013

Six Hospitals Combat Regional Emergency Department Congestion With Lean(PDF, 371 KB)
Representatives from six urban hospitals in the Canadian province of British Columbia that partner to serve mental health and addiction patients worked together to curb emergency department congestion by deploying a single care model across all sites. More than 80 staff from the hospitals assisted with this effort by employing lean tools, obtaining benchmarking data, and standardizing work activities. Recognizing that the technical side is only one piece of the puzzle, leadership and the project team turned to a formal set of critical success factors to engrain the change into the culture. November 2012

Journey to Perfect: Mayo Clinic and the Path to Quality
Part of an initiative to explore the “Next Generation of Quality Leadership,” this case study will describe the development of the Mayo Clinic’s culture of quality and how leaders drove a system-wide transformation using a unique quality model that included aspects of continuous improvement, the Baldrige criteria, lean, and Six Sigma. July 2012

Imaging Core Lab Takes Quality Beyond Regulatory Requirements with ISO 9001
Medical Metrics Inc. (MMI), had an existing quality management system structured to meet FDA regulations, but it was missing a framework to help drive organizationwide improvement. MMI worked with an external consultant to create an integrated management system—a fusion of regulatory requirements with the ISO 9001 framework—and received certification to the standard in less than seven months. Read the online case study presentation or download Imaging Core Lab Takes Quality Beyond Regulatory Requirements with ISO 9001 (PDF).
June 2012

Critical Success Factors Lead to Second Baldrige Award (PDF, 119 KB)
After its flagship hospital received a Baldrige Award in 2006, North Mississippi Health Services deployed the Baldrige Criteria throughout the entire organization. Focusing on its five critical success factors, the system received the Baldrige in 2012.

Trading Accreditation for Performance Excellence Model (PDF, 386 KB)
To move forward on its journey to excellence, Spectrum Care searched for the right quality framework and discovered the New Zealand Business Excellence model. At the same time, the organization concluded that its accreditation process failed to provide a significant challenge, so it returned its “certification” to the auditing body. Using an organization-wide approach, Spectrum Care applied the new framework to all service areas and activities. The organization earned a Silver Award from the New Zealand Business Excellence Foundation in 2010.
February 2012

Department of Defense Tools Help Hospital Foster a Culture of Patient Safety(PDF, 536 KB)
Abington Memorial Hospital created a culture of patient safety and improved communication among staff using the TeamSTEPPS™ program. Created by the Department of Defense and the Agency for Healthcare Research and Quality, TeamSTEPPS™ is a teamwork system based on lessons learned from “high reliability organizations,” such as military operations, aviation, and community emergency response services.
October 2011

ASQ Certification: My Competitive Advantage in a Tough Economy (PDF, 361 KB)
This recent college graduate jumpstarted his career in healthcare by obtaining the CQIA and CSSBB certifications. Within two years after landing his first job, he received two promotions and tripled his salary.
September 2011

Reducing Wait for MRI Exams Gives Akron Children's Hospital Competitive Edge
The Radiology Department in this northeastern Ohio hospital used Lean Six Sigma to reduce wait times for MRI exams by days and weeks. Following the improvement project, the hospital earned $1.2 million in first-year incremental revenue.
April 2011

Healthcare Provider Formalizes Improvement Framework, Captures State Honors (PDF, 720 KB)
ChildServe adopted the Baldrige/IRPE (Iowa Recognition for Performance Excellence) framework to structure its process improvement journey, earning a bronze-level IRPE award in 2010 with its first application.
August 2011

A Better Way to Perform Portable X-rays
A cross-functional team at Aurora St. Luke’s Medical Center used lean tools to develop a new procedure for performing portable x-rays. Process improvements have reduced workers' compensation costs, increased productivity, and improved patient safety. Read the online case study presentation or download A Better Way to Perform Portable X-Rays (PDF).
March 2011

Barnes-Jewish Hospital Enhances Quality Patient Care by Embracing Lean (PDF, 530 KB)
The organization-wide lean curriculum at Barnes-Jewish Hospital combines an education program for all employees with focused improvements in value streams.
November 2010

Taking Process Improvement Beyond the Quality Department (PDF, 326 KB)
Since adopting the Baldrige criteria as a framework for process improvement in 2005, Genesis Health System has earned two statewide bronze-level performance excellence awards and one silver award.
June 2010

Quality Engrained in Culture at Iowa Hospital (PDF, 250 KB)
The plan-do-study-act (PDSA) cycle, data-based decision making, and lean methodologies are part of the quality culture at Guttenberg Municipal Hospital. In 2008, the hospital received a Silver Award in the Iowa Recognition for Performance Excellence program.
June 2009

Rural Hospital Thrives With Continuous Improvement and Innovation (PDF, 210 KB)
High patient satisfaction resulted from a culture change at Wright Medical Center. They shifted to a more open communication model and a pillar system that focuses on six areas of performance improvement. The hospital is now a destination of choice for healthcare in north central Iowa, with some of the highest patient satisfaction scores in the nation.
April 2009

Streamlined Enrollment Nets Big Results for Healthcare Leader
Kaiser Permanente Colorado used Lean Six Sigma to evaluate and improve Medicaid enrollment processes. A three-month project resulted in a 45 percent gain in Medicaid membership while increasing Medicaid revenue by more than $1 million annually.
January 2009

Great Ormond Street Hospital for Children: Ferrari’s Formula One Handovers and Handovers From Surgery to Intensive Care (PDF, 136 KB)
Great Ormond Street Hospital for Children (GOSH) benchmarked its handoff from cardiac surgery to the intensive care unit against pit stop techniques of the Ferrari Formula One race car team. Process improvements resulted in increased patient safety and decreased error rates.
August 2008.
Excerpted from chapter 10 of Benchmarking for Hospitals: Achieving Best-in-Class Performance Without Having to Reinvent the Wheel, by Victor E.Sower, Jo Ann Duffy, and Gerald Kohers.

Community Health Network Reduces Deadly Infections Through Culture of Reliability  (PDF, 223 KB)
Community Health Network (CHN) has achieved stunning results in reducing cases of ventilator-associated pneumonia (VAP) using specific bundles of care. Four of the network’s critical care or coronary care units have reported no cases of VAP for at least two years, and one unit has eliminated all cases of this deadly infection since December 2003.
June 2008

Emergency Department Prescribes Lean for Process Improvement (PDF, 179 KB)
When the Mercy Medical Center emergency department used lean techniques to improve process flow, patient satisfaction scores rose from the 30th to the 95th percentile. Value stream mapping helped identify and eliminate non-value-added steps.  
May 2008.

St. Luke’s Hospital Breaks Out of the Pack to Improve Patient and Physician Satisfaction (PDF, 238 KB)
Since implementing its Baldrige-based “breaking out of the pack” strategy, St. Luke’s Hospital has improved patient satisfaction scores from the 49th to the 90th percentile. The hospital was named a Press Ganey Success Story recipient in 2007 and a Silver Award winner in the Iowa Recognition for Performance Excellence program.
March 2008.

Prescription for Community-Based Healthcare Includes ISO 9001 (PDF, 270 KB)
The Community Anticoagulation Therapy Clinic demonstrates how ISO 9001 principles can provide a framework for a community model of care delivery and patient safety. Customer and provider surveys demonstrate 100% satisfaction with the clinic, which uses a controlled document system based on ISO 9001, internal and external auditing, and preventive and corrective action plans.
February 2008.

Pocono Medical Center: Faster Lab Results Using Six Sigma and Lean(PDF, 188 KB)
A Six Sigma/Lean project helped a laboratory develop a solution for delivering blood test results to doctors by 6 a.m. for critical care patients and by 7 a.m. for all other patients.
October 2006.

Bringing Order to Orders at the Nebraska Medical Center
(PDF, 118 KB)
The Nebraska Medical Center used Six Sigma to improve the completeness and availability of physician orders for patients; the project occurred within a Six Sigma program that has returned about $7.5 million in savings.
July 2006.

Dutch Hospital Implements Six Sigma (PDF, 61 KB)
A Six Sigma implementation at Red Cross Hospital in Beverwijk, the Netherlands, shows that even small projects can make a big difference.
Six Sigma Forum Magazine, February 2005.

Surmounting Staff Scheduling Challenges at Valley Baptist Health System(PDF, 53 KB)
A project on staff scheduling led to an overall reduction in the hourly cost of overtime and agency use, translating to $460 thousand in potential savings.
ASQ Six Sigma Forum, September 2003.

FMEA—the Cure for Medical Errors (PDF, 116 KB)
St. Joseph’s Hospital in West Bend, Wisconsin, has used failure mode and effects analysis to create a healthcare facility aimed at reducing errors and promoting patient safety and satisfaction through design.
Quality Progress magazine, August 2003.

Heroes Wear Scrubs Too (PDF, 54 KB)
After the collapse of the World Trade Center, teamwork helped emergency department staff at NYU Downtown Hospital meet a demand far greater than this small hospital normally handles.
News for a Change, April 2002.

1. Increasing the Percentage of Heart Failure Patients Who Receive Heart Failure Discharge Instruction

by DeFeo, Joe; Ralston, J. Er

Abstract: A not-for-profit healthcare system found that adherence to clinical quality observed metrics for inpatient heart failure discharge instruction was consistently below national standards. Working toward a goal of increasing the observed rate of compliance from 45.3% to at least 90% by January 2008, the improvement team used the Six Sigma DMAIC (define, measure, analyze, improve, control) approach and Pareto analysis to identify potential failures and the vital factors contributing to the problem.Strategies developed to counter the vital Xs and improve the process included standardizing the discharge process across all nursing units, standardizing the most effective type of discharge instruction, improving the knowledge level of heart failure discharge instruction elements unit-by-unit with one-on-one training, and standardizing and simplifying the heart failure discharge instruction process. Based on a three-month pilot, the project succeeded in reaching its goal of a 90% compliance rate with heart failure discharge instruction.

2. Achieving Zero Percent Antibiotic Administration Rate Errors & Eliminating Surgical Sentinel Events

by Sower, Victor E.

Abstract: An internal study at Columbus Children’s Hospital found that in 2004 only 64 percent of patients with acute appendicitis received the correct antibiotic at the right time. The hospital took a systems approach to root cause analysis, launching “Operation Takeoff,” which involved revising policies, redesigning and standardizing processes, and building in redundancies. The project was eventually expanded to address all forms of errors associated with surgical procedures. In the first year of Operation Takeoff, 98.2 percent of acute appendicitis patients received antibiotics correctly, a 1.8 percent error rate, and there were no surgical errors and only two near misses.

3. Reduction in Gross Accounts Receivable By Reducing Delays In Documentation, Coding and Billing

by Helgeson-Britton, Pam

Abstract: At SMDC Health System in Duluth, Minnesota, dollars in accounts receivable (A/R) had increased in the discharged, not final billed (DNFB) portion of active A/R over 12 months. By reducing delays in documentation, coding, and billing, gross A/R could be reduced by two gross days revenue outstanding (GDRO). Tools used to understand the problem and evaluate improvements included brainstorming techniques, the 5 Whys, and a PICK chart. As a result, lead time was improved 44% from 8 days to 4.6 days. This resulted in a reduction in gross days revenue outstanding by 2.75 days, improving cash on hand by over $5 million. The financial benefit on interest income annually was $152,831.

4. A Process to Recover Additional Revenue for Home Care Plan Oversight

by Devos, Denis J.

Abstract: Mercy Physician Community PHO saw an opportunity to recover more revenue for patients’ home care by performing a more thorough review of the treatments and chart notes and physician orders and charging against additional codes. Introducing a new worksheet for capturing data as part of the billing process resulted in estimated annual new revenues of $20,860.

5. Reduction in Length of Stay for Heart Failure & Shock Patients Admitted To A Medium-Sized Hospital

by DeFeo, Joe; Ralston, J. Er

Abstract: A medium-sized acute care hospital sought to decrease the amount of time that DRG 127 patients (heart failure & shock) spent in care. The hospital’s average length of stay (ALOS) was 5.18 days, 1.08 days longer than the geometric mean length of stay, 4.1 days. The improvement team identified seven root causes as the vital few driving the extended stay time: congestive heart failure (CHF) standard orders not used, delay between discharge order to time patient leaves floor, patient stay included a weekend, patient becomes deconditioned because of lack of activity, practices were not based on Gold Standards, patients held after meeting InterQual discharge criteria, and inpatient holding process was not being standardized. The pilot project defined solutions for each root cause, successfully reducing the average length of stay at the hospital by nearly 50%, from 5.18 days on average to just 2.6. The baseline of stay continues to remain at an average of 3.6 days, well below the Centers of Medicare & Medicaid geometric mean average of 4.1 days.

6. Planning and Implementation of a Multidimensional Hand-Hygiene Program – Reduce the Risk of Healthcare Associated Infections (HAI) at Rapid City Regional Hospital (RCRH)

by Boersma, Beth; Keegan, J. M.

Abstract: Rapid City Regional Hospital implemented a multidimensional hand-hygiene program to improve hand-hygiene adherence in accordance with The Joint Commission (TJC) Patient Safety Goal #7: Reduce the risk of healthcare associated infections (HAI). Root cause analysis uncovered three primary reasons for non-compliance: takes too much time; dry, cracked hands from too much washing and use of soap; and a non-supportive culture. Solutions included making alcohol hand rubs and hospital-approved lotion more available, providing education and encouragement, establishing an infection control hotline to report non-compliance, and holding physicians accountable. Hand-washing compliance increased from 57% to 91%, resulting in a 21% reduction in HAI and dollar savings of $291,450.

7. Using Advanced Process Simulation Methodology to Plan for a Major Facility Renovation – Surgical Suite at The Children’s Hospital of Wisconsin (CHW)

by Kolker, Alexander

Abstract: Children’s Hospital of Wisconsin (CHW) is in the planning stages for a major facility renovation of its surgical suite to increase capacity; patient, physician, and staff satisfaction; and efficiency of surgical services. Principles of management science and operations research helped address the issue of capacity analysis and patient flow in the complex surgical facility. Discrete events computer simulation methodology helped predict if the current number of beds and operating rooms and their allocation for the various surgical services would be enough to meet the projected patient flow demand from 2009 to 2013. Using computer simulation of a number of feasible scenarios, the team determined the best possible allocation of available resources (operating rooms and beds) to meet the accepted criteria and estimated the implementation cost of different options. Projected return on investment is 7% over a 15-year period, and positive cash flow in year one.

8. Reducing the Time Female Patients Spend Waiting for Diagnostic Mammogram Results

by DeFeo, Joe; Ralston, J. Er

Abstract: To reduce stress and anxiety for its patients, a small nonprofit hospital set the goal of decreasing the amount of time that women had to wait to receive mammogram results. The team used the Six Sigma define, measure, analyze, improve, control (DMAIC) process to identify key areas for improvements.

9. Improving Access to Urgent Skin Screening Appointments – University of Texas M.D. Anderson Cancer Center Cancer Prevention Center

by Rohe, Duke K.

Abstract: Cancer Prevention Center (CPC) patients at the University of Texas M.D. Anderson Cancer Center were unable to schedule skin screening appointments in a timely manner. Because of the extended wait time for appointments, patients were going elsewhere for care. The center launched a project to decrease the wait time for urgent appointments by 10 percent and bring patients in for urgent care in fewer than seven days.

10. Improving the “Thinning” of Medical Records at University of Texas M. D. Anderson Cancer Center

by Rohe, Duke K.

Abstract: The University of Texas M. D. Anderson Cancer Center launched a project to decrease the amount of time it took for clinicians to locate patient information. The team focused on three goals: reducing the number of charts that were incomplete at patient discharge, making “thinned” documents available online within 24 hours, and improving timeliness of decision making based on availability of scanned documents.

11. Improving e-Prescription Use by Patients

by Devos, Denis J.

Abstract: Although Mercy Physician Community PHO had been using e-prescriptions for one year, up to 50% of patients were still calling the doctor’s office for prescription refills when they should have been calling their pharmacies. An improvement project sought to decrease this percentage by identifying and addressing two root causes: 1) lack of training or diligence at the pharmacies, and 2) lack of awareness among patients, coupled with leniency of staff out of motivation to be patient-focused.

12. Reduction of Door-to-Balloon Time to 90 Minutes or Fewer for STEMI Patients – Rapid City Regional Hospital (RCRH)

by Handcock, Randee; Keegan, J. M.

Abstract: Rapid City Regional Hospital was not meeting the national standard (reduced from 120 to 90 minutes in 2006) for timely intervention and reperfusion for patients with ST Segment Elevation Myocardial Infarction (STEMI). A project to meet the national standard identified and addressed the following root causes: inconsistent applications for protocols for STEMI, lack of order sets and group-page alerts for STEMI, capability for EKG field transmission, perceived lack of need for improvement/change.

13. Improving the Pre-Empted Medication Error Reporting System, St. Charles Hospital, Port Jefferson, NY

by LeDoux, Kathleen

Abstract: Beginning in 2004-2005, a team at St. Charles Hospital, Port Jefferson, NY, began to explore ways to recognize and improve the reporting of pre-empted errors. While traditional reporting via the formal occurrence reporting system was encouraged, other venues for recognition and reporting were considered. Determining that certain categories in the clinical interventions performed by pharmacy and the MAR (medication administration record) communications generated by nursing could appropriately be recognized as pre-empted medication errors, the team launched a project to: 1) provide a process to ensure the correctness of the MAR on a daily basis, 2) accurately capture clinical interventions performed by the pharmacy staff, and 3) simplify the process to communicate MAR corrections from the nursing staff to the pharmacist.

14. Reduction of the Incidence of Hospital-Acquired Pressure Ulcers – A Case Study from a Medium-Sized, Not-for-Profit Hospital

by DeFeo, Joe; Ralston, J. Er

Abstract: A medium-sized, not-for-profit hospital had hospital-acquired ulcers developing at an 18% incidence rate. Compared to the national benchmark of 7%, the amount of pressure ulcers occurring at this level was costly and unacceptable. Identifying and addressing root causes led to a 13.1% reduction in incidences in 18 months and a 72% reduction in costs. By the conclusion of the project, the incidence rate had dropped to 2.1 percentage points below the national average.

15. Discovering the “Cost of Current Quality” (COCQ) in a Family Medicine Practice

by Valentine, Michelle

Abstract: When asked to identify the most difficult, problematic, and least-liked process in the practice, St. John’s Family Medical Associates staff named the processing of patient forms (work-comp forms, disability forms, school physical forms, etc.) as the most troublesome. To reduce the physician and staff time required for completion of patient forms, improve throughput time, reduce staff stress resulting from dealing with dissatisfied patients, and demonstrate the value of process improvement tools in a medical practice, an improvement team created a value stream map of the current process, identifying waste, redundancies, and delays, or the “Cost of Current Quality.” Practice staff then received instruction in the use of process improvement tools for waste reduction and dramatically improved the process. The net return on investment of the effort was $90,000, and staff and physicians were eager for more improvement.

16. Addressing High Nurse Turnover at Bronson Methodist Hospital in Kalamazoo, Michigan

by Sower, Victor E.

Abstract: Bronson Methodist Hospital in Kalamazoo, Michigan, sought to reduce nurse turnover and become best in class, developing a stable and committed workforce. Root cause analysis identified leadership and a competitor that paid higher salaries as major contributors to turnover. The project team addressed root causes by benchmarking organizations recognized for workforce excellence and conducting leadership development training. The team also used the Baldrige Criteria for Performance Excellence to help make the workforce development plan part of organizational strategy. Results include improvements in employee opinion survey results and potential cost savings of $420,000 to $840,000 annually.

17. Reducing Instrumentation in Major Operating Room Sets for Abdominal Colectomiesand Proctectomies – University of Texas M. D. Anderson Cancer Center

by SoRelle, Paul C.

Abstract: One major instrument set had been routinely provided for all major abdominal/pelvic cases at the University of Texas M. D. Anderson Cancer Center’s Department of Surgical Oncology. However, many instruments were not used in the surgeries. Because of the great number of instruments in a set, there is a greater chance of counting errors, which can lead to retained foreign objects. The center launched a project to reduce the number of instruments in major operating room sets by at least 50 percent over a four-month period for abdominal colectomies (removal of a portion of the colon) and proctectomies (resection of the rectum).

18. Reduction in the Amount of Unused Patient Supplies at Discharge – North Shore University Hospital-Manhasset Cardiothoracic Critical Care Unit

by Riebling, Nancy B.

Abstract: As per Joint Commission and Centers for Medicare & Medicaid Services infection control standards, as well as the hospital’s infection prevention and control goals, all unused CTU patient supplies are discarded after patient discharge or transfer. An initial cost assessment of the unused and discarded supplies in the CTU at North Shore University Hospital-Manhasset yielded an average cost of approximately $66.11 per patient discharge. A Six Sigma waste reduction project was launched to reduce the defect of unused supplies discarded upon discharge.

19. A Quality Improvement Project to Inform Chiropractic Clinical Decision Making 

by Metz, Douglas

Abstract: Chiropractors have used X-ray examinations as a common practice in the diagnosis of musculoskeletal and spine-related conditions; however, evidence indicates X-ray exams are not necessary in the vast majority of cases. American Specialty Health (ASH) implemented a quality improvement project to educate doctors and manage the reimbursement for unnecessary X-ray exams. Key causal drivers identified by root cause analysis included lack of evidence-based guidelines, lack of evidence-based education for practitioners, lack of practitioner knowledge and commitment to evidence-based practices, and lack of practitioner buy-in about changing entrenched healthcare decision making. Practices implemented to address root causes included guidelines development, practitioner education, utilization management oversight, credentialing and practice protocol oversight, and quality management oversight. Results include reducing the number of unnecessary X-ray exams from a baseline of 72% of patients receiving an x-ray exam to a current state of 9%, without negatively affecting the quality or outcomes of treatment provided. The 13-year project has won national awards for changing doctor behavior while maintaining a safe and highly satisfied patient population.

 20. Reduction in the Percentage of Open Patient Encounters at the SMDC Clinic in Duluth, Minnesota

by Helgeson-Britton, Pam

Abstract: In the ambulatory setting, clinic practice management is integrated with the electronic health record. Providers determine the codes and diagnoses for patient visits and are responsible for documenting care. When documentation is not entered in a timely manner, it affects timely billing and patient care. It is the action of completing and closing the patient encounter that causes the coding to post the charges for the visit. When an encounter is left open, no revenue is realized for that visit. As SMDC Health System implemented provider-based billing at the Duluth Clinic, it was even more imperative to force the timely release of the charges from closed encounters, as UB04 billing did not allow for line-item billing but required all charges to be posted before billing. Previous efforts to address this problem resulted in a one-time cleanup, but old practices resurfaced and the problem returned to former levels. No formal monitoring occurred and the focus was departmental versus system monitoring. A project team focused on the process of closing encounters.

21. Review of IDR Inventory Control Processes and Implementation of Procedures to Minimize Discrepancies 

by Young, Karen

Abstract: At a large university health system, inventory distribution and receiving (IDR) rates fell to 32 percent below the minimum customer requirement of 98 percent. There was no clearly defined inventory control procedure. An independent audit revealed a significant discrepancy in the inventory recorded in the general ledger and the actual IDR inventory on hand. The auditors recommended that management review processes related to IDR inventory control and implement procedures to decrease opportunities for future discrepancies.

 22. Improvement in Treatment Documentation at SMDC Rehabilitation Locations, Duluth, Minnesota, Region

by Helgeson-Britton, Pam

Abstract: Paper-based documentation systems existed at 5 out of 10 SMDC Health System rehabilitation locations, resulting in inefficient interprovider communication, inconsistent processes, waste, and compliance risk. The lead time to complete the documentation from initial visit to discharge was more than 31 days. Initial patient evaluations were dictated and transcribed. The documentation often did not meet Medicare documentation compliance standards because the standards were not widely understood or practiced. SMDC launched a project to eliminate paper treatment documentation, reduce its Medicare documentation compliance error rate, establish a centralized location for all therapy documentation, and reduce physician complaints regarding inadequate reporting from the current baseline of three times per month to less than one time per month.

23. Use of Process Improvement Tools and Concepts to Increase Aggregate Mean/Index Door-to-Balloon Time – In Acute Myocardial Infarction (AMI) Cases

by DeFeo, Joe; Ralston, J. Er

Abstract: A large nonprofit hospital was struggling to meet the Centers for Medicare and Medicaid Services’ (CMS) new standard for door-to-balloon time, which was reduced from 120 minutes to 90 minutes in July 2006. Using the numbers from the third and fourth quarters of 2006, the hospital’s aggregate mean/index rate for the door to balloon time within 90 minutes was only 47 percent. The team identified the potential root causes of the delayed door-to-balloon time by using the Six Sigma define, measure, analyze, improve, and control (DMAIC) process and by analyzing process maps, cause and effect diagrams, baseline measurements, failure mode & effect analysis (FMEA), and voice of the customer. Removing the waste discovered by the team allowed the hospital to meet its 90-minute target. After the pilot was implemented, the door-to-balloon compliance rate increased to 82 percent, while the sigma level increased from 1.62 to 2.4.

24. Reduction in Claims Denials for High-Tech Imaging (HTI) at SMDC Health System Center for Therapy

by Helgeson-Britton, Pam

Abstract: SMDC Health System Center for Therapy was experiencing a higher-than-usual level of claims denials from a number of insurers for high-tech imaging tests (CT and MRI). The claims were being denied because SMDC had not obtained prior authorization for the tests. This resulted in approximately $45,000 in claims denials over a six-month period. A project was launched to reduce denials of claims for high-tech imaging tests ordered by non-SMDC providers by 85 percent.

25. Reducing Delays Due to Inadequate or Incorrect Patient Preparation at Waterford Medical Associates – The “Dream Book”

by Casey, John J.

Abstract: At Waterford Medical Associates, patients were not being properly prepared by medical assistants for common medical procedures. This resulted in wasted time and missed opportunities to see additional patients. The practice launched a project to decrease by 75 percent the time lost due to inadequate or incorrect patient preparation.

26. Development of an Enterprise-wide Information System to Meet Strategic Goals and Operational Needs

by Sower, Victor E.

Abstract: North Mississippi Health Services sought to develop a progressive enterprise-wide information system to be nurtured and grown to meet the organization’s strategic goals and operational needs. Patient records needed to be accessible at any facility in the system, regardless of where the patient first entered the system, in order to avoid the creation of duplicate records. Each facility in the system needed to have the same information system functionality as any other. A single information system for the entire health system met this goal.

27. Development and Implementation of a New Process for Handling Add-On Lab Orders

by Helgeson-Britton, Pam

Abstract: At SMDC Health System’s Duluth Clinic-Ashland, additional lab tests ordered by providers were not communicated to the laboratory in a standardized, efficient manner. Once a sample had been drawn and tested, the electronic health record system did not recognize the addition of another lab test to it. The clinical assistant or physician had to contact the lab by phone or e-mail to add a test. Many times the lab was not notified of the added test. This occurred approximately 37 percent of the time and resulted in additional work, wasted time, and decreased customer satisfaction. A project was launched seeking to submit 99 percent of all add-on lab orders correctly at Duluth Clinic–Ashland through the use of an efficient, effective process.

 28. The Use of Process Engineering In a New Digital Imaging Solution and Radiology Information System – Planning, Vendor Selection, and Installation

by Boutet, Mike

Abstract: A major university teaching hospital sought assistance and leadership in planning, vendor selection, and installation of a new digital imaging solution (PACS) and radiology information system (RIS) for its clinical radiology department. A project was launched to identify return on investment and design and implement a measurable business transformation and workflow process re-engineering. Cross-functional teams were used to identify potential savings and operational efficiencies. For the first year of the project, $2,300,000 in savings were identified.



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