A Six Sigma Emergency Department Case Report

Emergency Department Diversions

By Staff Writersbiz-book1

According to Daniel L. Gee MD MBA, Scottsdale Healthcare in Arizona used consultants from Creative Healthcare USA on a recent project, rather than doing a full deployment of Six Sigma in its organization, to analyze its problem of emergency department (ED) “diversions.”

Emergency Department Diversions

Diversions happen when emergency departments are too full in capacity to handle acute emergencies and a decision is made to close its doors to patients and ambulances are diverted elsewhere. The issue of closed and diverted emergency rooms is a growing nationwide phenomenon because of fewer EDs and a growing aged and uninsured population. The consultants, using Six Sigma principles, mapped the ED process and found multiple bottlenecks that have a direct effect on the probability of evoking a “diversionary” status in the emergency room.

Out of Control Bottlenecks

One bottleneck process deemed “out of control,” in Six Sigma jargon, was the issue of bed control. A process is considered “in control” when operating within acceptable specification limits. It was found that the average transfer time for a patient admitted to a hospital bed from the emergency department was 80 minutes, of which half of this time, a bed is available and waiting. The process was a significant “waste of time” and, moreover, complicated by an Administrative Nurse “inspector” locating beds on different floors.

Sig Sigma Tenants

Two tenements of Six Sigma level of quality were violated: one is that having an inspection is a correction for an inefficient process and two, the more steps involved the less is the potential yield of a process. Through this revelation, the hospital eliminated the Administrative Nurse, reduced cycle time by 10% in bed control, and improvement ED throughput with greater turnover thereby, improving revenue by nearly $600,000.

Little’s Law

The addition of a nurse inspector and waiting patients in a busy ED is an example of “Little’s Law” or sometimes referred to as the first fundamental law of system behavior. When more and more inputs are put into a system, such as more ED patients and an additional nurse employee, and when there is variation in their arrival time (no control over patient arrivals) or process variation (different people doing the same things differently), there becomes an exponential rise in “cycle time.” Productivity of the system begins to fall and inefficiency and variation creeps in.


An examination of the project types to which health care provider organizations have utilized Six Sigma methodology reveals almost any hospital or medical clinic process is a candidate.


And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is Six Sigma a real medical quality control initiative that’s here to stay; or just another passing fad?

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10 Responses

  1. Six Sigma is not a panacea. Many would like you to think that. The application of the appropriate lean engineering tool will improve performance in a process that is broken. There are a wide range of tools. Six Sigma is just the most recognizable.

    Thank you Jack Welsh.

    The medical industry needs lean engineering. Look at the Quality Section of the AHA web site and the white paper on waste elimination published by the Joint Commission.

    We have had some success applying lean technology in the long term care arena. We are convinced that the technology can transfer and shows results in the ED, the OR and in cliniics.

    Andrew Masson


  2. Andrew,

    Did you know that according to Fierce HealthFinance, on March 25, 2009, a new study has concluded the U.S. hospitals are beginning to embrace Lean and Six Sigma business management strategies to cut costs and boost productivity, despite there currently being little evidence as of yet that these strategies are effective? Yep; it’s true!

    As readers of our books, journal and the ME-P are aware, lean management focuses on removing waste from companies and processes, while delivering added value to customers. Six Sigma; meanwhile, is to reduce variations in processes, products and services.

    The study, from the American Society for Quality, included 77 hospitals. Researchers concluded that 53 percent of hospitals reported some level of Lean deployment, while 42 percent reported some level of Six Sigma deployment. Not surprisingly, given the gradual evolution of these practices in hospitals, only 4 percent reported “full deployment” of Lean, and only 8 percent full deployment of Six Sigma.

    Where hospitals had not deployed either method, reasons included a need for more resources (59 percent); lack of information (41 percent) and lack of leadership buy-in (30 percent). Another 11 percent of hospitals surveyed weren’t familiar with either strategy.



  3. Medicare is launching a four-state demonstration to determine if cash incentives will improve the quality of care and efficiency of operations in nursing homes. Nursing homes in Arizona, Mississippi, New York and Wisconsin will be asked to participate.

    Link: http://www.healthcarefinancenews.com/resource-central-research



  4. Hi Ann, Max and Andy

    Mom leaves hospital with wrong baby! Can you believe that this sort of thing “still” happens in 2009?




  5. This is the first time I’m seeing these kinds of numbers. Very interesting. It should have a profound impact of how we are further exposed to business operations I would think.

    Joe Conway


  6. Joe,

    What numbers are you talking about?
    I am very interested in SS, so please advise.



  7. SS Levels

    Six Sigma auditors are referred to by their level of accomplishment under Six Sigma guidelines. There are four levels of inspectors’ training:

    Black Belt:
    The Black Belt level is held by individuals who have been trained in the Six Sigma methodology and have experience in leading Functional Process Improvement Action


    Green Belt:
    Holders of the Six Sigma Green Belt are team members in the Six Sigma Process

    Improvement Action Teams

    Master Black Belt:
    The holder of this level of achievement acts as the organization-wide Six Sigma Program Manager. He or she, oversees Black Belts and improvement projects, while providing guidance to Black Belts as necessary. A Master Black Belt teaches other Six Sigma students and helps them to achieve higher level status.

    Six Sigma Champion:
    Usually a top executive or senior manager who “talks-the-talk”, and “walks-the-walk”, of Six Sigma. He/she is the catalyst behind the organization’s Six Sigma implementation. He/she has the ear of executive management.

    Dr. David Edward Marcinko; MBA


  8. More on Six Sigma

    Six Sigma is a performance improvement methodology using statistical analysis to reveal the root cause of defects in products, services and performance. Long used in manufacturing, its principles and techniques have been introduced into the healthcare, service, education, and other sectors with impressive results.

    In Six Sigma performance analysis for healthcare, the statistician’s bell-shaped curve becomes a representative of accounting and/or medical variation. It measures to the upper standard limits of 99.99966% as a rigorous systematic discipline that demands the use of various problem solving tools and a particular methodology to measure performance and drive process improvement.

    In fact, more and more healthcare organizations are using the measurable feedback data provided by Six Sigma to augment other ongoing quality initiatives; like the balanced scorecard [dashboard]. By validating the impact of care defects and medical improvements, as well as the use of small-scale experiments, reaching the optimal solution to a performance or outcome problem makes implementing a change more believable to the hospital, clinic, practice or healthcare organization.

    Dr. David Edward Marcinko MBA CMP™


  9. Five [5]-S Manufacturing in Heatlhcare

    Five [5]-S manufacturing is the name of a more recent workplace organization methodology that uses a list of five Japanese words [seiri, seiton, seiso, seiketsu and shitsuke].

    This list describes how items, like durable medical equipment, are stored and how the new order is maintained. The decision-making process usually comes from a dialogue about standardization that builds a clear understanding among employees of how work should be done. It also instills ownership of the process in each employee.

    There are 5 primary phases of 5S: sorting, straightening, systematic cleaning, standardizing, and sustaining.

    Additionally, there are three other newer or secondary phases sometimes included; safety, security, and satisfaction.

    The concept, like lean Six-Sigma, is gaining traction in the healthcare operational ecosystem.

    Dr. David Edward Marcinko MBA


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