Improving the hospital discharge process with Six Sigma

8 August 2016

This report is a part of dissertation completed at Gulf Medical College Hospital and Research Centre (GMCHRC), Ajman, UAE. This report is based on the study that I have conducted on Discharge process at GMCHRC. First of all, we wish to thank Dr P. K Menon, Director Administration Research and Quality Assurance for his unlimited support, guidance, giving a through insight of the hospital and his constant virtual presence despite of his busy schedule.

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During my term in the hospital he provided me with ample opportunities to explore my areas of interest and acquire knowledge about functioning of all the departments. He has provided me with opportunities and explained the importance of data driven decision making process. He has involved me in the quality assurance process and in forming standard operation procedures for the hospital which has been a great learning experience. We thank Dr Prashanth Hedge, Chief of Medical Staff GMCHRC for his guidance with timely and benevolent comments, support and friendship.

His trust and faith in my abilities motivated me and helped me to come up with innovative ideas. We also express our sincere gratitude towards Dr Manvir Singh, Medical Director for his support and guidance during my visit to GMCHRC, which was my first insight to the functioning of a international hospital and Dr Manvir explained and gave me and insight into the qualities and responsibilities of a hospital administrator and introduced me to the world of international healthcare.

Sister Abi, Nursing Instructor for her insight into the real time process that are followed in the hospital, Sister Abi helped me understand it is very important to keep in mind what i have studied in books but it is much more important to learn on the floor, accept responsibility and to be aware of your surroundings. I would like to thank Mr.

Akbar Director Healthcare Thumbay Group, for giving me the opportunity to attend the Joint Commission International Mock Audit survey, which helped me to understand the true meaning of data driven measures for quality improvement and I was also exposed in detail to infection control practices and continuity of care of which helped me get a in depth view of hospital quality assurance process. I thank Dr Nitin, Dr Risab and Dr Ankur my fellow batch mates, during my dissertation I have learnt a form them and also because of them.

I would also like to thank my parents and family for believing in me and discussing what I have learnt during my days in the hospital, which helped me to refresh my observations and identify areas where improvements can be made. I would like to thank Dr Jalpa H Thakker, Dr Gunjan Dhawan, Dr Shihad Khader, and Dr Malavika Kathuria for sharing their time with me, which has taught me many things about my work and about life. Last but not the least I would like to thank Ar. Shikha Gosain, for supporting me emotionally due to which I have been able to perform to the best of my abilities and for reminding me of the important things in life.

Himanshu Maitra Gulf Medical College Hospital Research Centre CERTIFICATE This is to certify that Mr. Himanshu Maitra student of PGDHM 16th Batch (Hospital), Institute of Health Management Research; Jaipur has undergone his dissertation on “Improving the Hospital Discharge process with Six Sigma Methods” from Feb 9, 2013 to May 5, 2013. The candidate has successfully carried out the study assigned to him during dissertation and his approach to study has been scientific and analytical.

This dissertation and internship is partial fulfillment of the course requirements recommended for the award of Post Graduate Diploma in Hospital and Health Management. I wish him success for all his future endeavors. Dr. Ashok Kaushik Dr. P. R Sodhani Dean (Academics and Student Affairs) Professor, Dean Training IHMR, Jaipur IHMR, Jaipur Gulf Medical College Hospital is a teaching hospital, in this international institution it was very important for me to understand and adapted to the work culture in this institution. Thus it was very important for me to understand the protocols and find the gaps in operations.

This was a learning experience and especially while working with the Quality assurance department I had the opportunity to work with the JCI standards and the infection control department and the patient care process. The experience has opened various avenues for me towards quality assurance related to infection control department. AIM: To understand the working of an international institution and to get acclimatized to the working culture. To analyze the gaps and difference in health care delivery process between Ajman and UAE.

Work with the patient affairs department infection control and the quality assurance department in forming standard operating procedures to comply towards JCI standards. My primary goal during my internship at GMCHRC was to formulate Standard operating procedures for infection control and patient care process, which was great learning experience. Departments visited and Participation During internship I had the opportunity to work with various departments and understand their day to day operations and then after being assigned with the quality assurance team was asked to formulate SOPs for these departments.

The departments that I have worked with are: Patient Affairs Department During the initial period of training was posted in the patient affairs department, the management had assigned a study on discharge timing and process mapping of the discharge process. I had the opportunity to work on the admission and discharge process, interacted with the billing officer, administrative assistant and the director of patient affairs department. After various interview sessions, discussions and personal observations the process map for discharge and admission process was prepared.

Additionally with the help of the care coordinators working in the patient affairs department we were able to identify the bottle necks in the discharge process and a six sigma DMAIC study was performed to reduce the average discharge time in the hospital. Infection Control Department During the second month of internship i had the opportunity to work with the infection control team in formulating standard operating procedures to comply with JCI standards. The responsibilities included performing a gap analysis between the existing infection control processes followed and the JCI standard requirements.

This covered formulating an infection control plan for the entire hospital, SOP on Staff Health & Safety Program, SOP on the management of infectious and hazardous wastes, SOP to prevent and reduce Health care associated infections, SOP on Handling and disposal of sharps and needles, SOP on Personal Protective Equipment, SOP on Operation theatre infection control policy, Staff Training on Infection Prevention and control, SOP on construction and renovation, SOP on risk-based approach towards prevention and reduction of health care–associated infection.

This covered the care bundle approach towards the healthcare associated infections and the surveillance tools associated for measuring the data. Had the opportunity to conduct training sessions for the maintenance and the administrative staff. Quality Assurance Department: Also had the opportunity to work with the Quality assurance department and was involved in the documentation control process and forming a quality control plan for GMCHRC. The integration of the quality control plan with the entire hospital was a challenge as it required continues monitoring of the data to be collected from all the departments.

Thus along with the quality control team various checklists were prepared which were used as data collection tools to monitor these departments. But the lack of time limited the scope of work and the involvement with the change process was satisfactory. Improving the Hospital Discharge process with Six Sigma Methods Executive Summary The main purpose of this study is to describe the application of the five-phase Six Sigma Define, Measure, Analyze, Improve and Control (DMAIC) approach to streamline patient discharge process at Gulf Medical College Hospital and Research Centre (GMCHRC).

In this study key output variable (KOV) was identified as average discharge time and a list of key input variables (KIVs) were selected, any improvements in the KIVs can improve the KOV values. In the initial phase of this study process mapping of the admission and the discharge process was carried out, various interview sessions and self observations made during the study period. Once the process maps were formulated they were discussed with the departments participating in the discharge process.

The next step was to develop a repeatable and reproducible measurement standard operating procedure (SOP) for discharge time. The SOP involved finding the time the physician wrote the discharge order from handwritten orders, which usually included a time notation. For the time that the patient left the hospital, times were typed into a system. This SOP was then used to review patient records and find the average discharge time for patients at GMCHRC. The discharge times recorded were charted using the individuals moving range control chart method to find signals which were out of the upper control limit set. In the analyze phase of the study the KIVs were selected and a cause effect matrix was used to analyze the issues and possible solutions to the issues, the most easy to implement and the cost effective solutions were selected as process improvement initiatives. Early discharge planning and IT initiative (Computer on Wheels COWs) was selected. Due to the lack of time the base line data for the control phase could not be collected but the initial response to the care providers to the interventions was positive.

Literature Review The Importance of Patient Discharge Process Nagaraju (2005) defines the patient discharge process as ‘the final step of the treatment procedure during a patient’s length of stay’, and timely discharge as ‘when the patient is discharged home or transferred to an appropriate level of care as soon as they are clinically stable and fit for discharge’. According to Bateni (1995), appropriate discharge processes enable the list of available beds for admission to be kept current and accurate.

A study on the medical centers of Tehran University of Medical Sciences, Iran and Shahid Beheshti has shown that in most centers complications in the discharge process and unnecessary routines have caused discharge delay and patient dissatisfaction. Scattered information and nonintegrated database systems had resulted in increased works loads and dissatisfaction among internal and external hospital clients (Derayeh 2003). Improving the quality of the discharge process should therefore lead to an increase in patient satisfaction.

As a result patients are likely to return to a health centre where they have experienced an efficient discharge process when they next seek treatment. In turn, efficiency and productivity are increased at the hospital (Gholipor & Ghomry 2003). Conversely, available beds are a hospital’s most important resource and the length of stay in hospital is an important factor in its efficiency. The unnecessary occupation of hospital beds and rooms and consequent low hospital bed turnover rate represent a waste in health care resources, and result in heavy associated organizational costs (Porhasani 1995).

A fast discharge process can ensure early availability of patient beds, which in turn, can reduce the waiting time of patient admissions or even reduce the incidence of patient rejection due to unavailability of beds (Nagaraju 2005). Hospital discharge is an example of a systemic problem that can be characterized as a dangerous situation in which latent conditions exist such that sharp end individuals are set up to fail. While knowledge-based, rule-based, and skill-based behaviors are needed for optimal care, there are many opportunities for slips, lapses, mistakes, and adverse events.

The restructuring of the discharge process requires an understanding of the causes of the errors and use of data driven methods concepts to minimize errors by detecting them before harm occurs. There are two forms of errors occurring at the time of hospital discharge, Active and latent errors. Active errors include, for example, those occurring at the time of hospital discharge during knowledge based decision making performed at the point of care. (JCI patient safety goals) Latent errors are a result of conditions or system failures that are the consequences of failures in technical design or organization.

For instance, in many hospitals, nurses and residents are responsible for the discharge process. The harried nature of their work, as well as competing interests (e. g. , new admissions requiring attention), results in the discharge of a patient not being considered a high priority, and can lead to an incomplete discharge process. Patient discharge is also fragmented among various caregivers, including first-year residents, nurses, trainees in both fields, and support staff. (Leape LL, Breman TA, Laird N, et al) Six Sigma and Healthcare Six Sigma continues to be of interest in the corporate world.

In the field of health care, Six Sigma has been used to address numerous problems including decreasing length of stay, reducing medication errors, and improving the admissions process (Castle et al. 2005; Christianson et al. 2005). In general, Six Sigma is credited with an ability to manage and improve complicated processes. Even though patient discharge has been identified as one such complicated process (Watts and Gardner 2005), a review of the literature did not discover any hospital discharge projects utilizing the Six Sigma methodology. The Joint Commission for the Accreditation of Health

Care Organizations (JCAHO) requires hospitals to implement projects to improve their patient discharge processes. Yet, the rules are ambiguous about how to implement improvements. Several authors have studied the application of individual quality methods for data-driven systems improvement in health care. These methods have included failure mode and effects analysis (FMEA) and root cause analysis (Robinson et al. 2006). Other authors have argued that multimethod approaches are needed (Davies 2001). Six sigma is one such multimethod approach.

It also has been defined as a data-driven method for process improvement (De Mast 2007; Linderman et al. 2003). Since Six Sigma programs strive to reduce variability and defects within processes, implementing a breakthrough strategy is a logical solution for improving patient care. These defects in patient care processes can run the spectrum from minor dietary issues to patient morbidity and fatality. Harry and Schroeder define six sigma methods as disciplined methods of using extremely rigorous data gathering and statistical analysis to pinpoint sources of errors and ways of eliminating them’.

Long describes healthcare industry measures of operating in a higher sigma level environment (i. e. lower defect rate) as: patient satisfaction, physician satisfaction, educed overtime, reduced patient wait times, increased revenues, and enhanced quality of life. Tucci states that some potential barriers to implementation of Six Sigma programs in hospitals include: Nursing shortage: moving Registered Nurses (RNs) to full-time quality program positions, e. g. training to be Black Belts. Governmental regulations.

Costs: the data driven interventions are expensive and require training of the staff start-up and maintenance initial costs of executive education, employee orientation, and investment in intensive training of Black Belts and green belts. Difficulty in obtaining base-line data on process performance. Long project ramp-up times typically 6 months or more. Risk of Six Sigma programs in health care being marginally implemented to only easily measureable non patient care processes, i. e. low touch processes.

He also states that some potential benefits of implementation of Six Sigma in hospitals include: Measurement of health care performance requirements on the basis of common standards through use of statistical analysis and hypothesis testing, Six Sigma mirrors the medical fields life-threatening situation and high risk decision-making processes; Creation of shared accountability for continuous quality improvement requires development of common definitions of how an error is defined; Health care employee surveys indicate that the employees consider their work to be important and they want to improve the quality of patient care, but interestingly these same employees feel under-appreciated and left out of quality improvement programs; Implementing Six Sigma with emphasis on improving customer’s lives could engage more health care professionals and support personnel in the quality improvement process. OBJECTIVE The objective of the project was to streamline patient discharge process by application of a five-phase Six Sigma define, measure, analyze, improve, and control (DMAIC) approach and to improve process inefficiencies throughout discharge process to reduce variability in discharge cycle time. RESEARCH QUESTION

Will application of the DMAIC approach help reduce the average discharge time and improve the discharge process in the inpatient department? INTRODUCTION This study was carried out in the patient affairs department of Gulf Medical College Hospital and Research Centre. The six sigma process of Define, Measure, Analyze, Implement and Control (DMAIC) is a data driven process and its main objective is to drive costly variation from business processes. The six sigma approach consists of the five step DMAIC approach. Each step of this process is can be explained as follows: Define: Problem selection and benefit analysis Identify and map relevant processes. Identify stakeholders. Determine and prioritize customer needs and requirements.

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