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Lean Six Sigma DMAIC Project(Example)Green Belt Project Objective:To Reduce Clinic Cycle Time(Intake & Service Delivery)Last Updated: 1‐15‐14Team:The SpeedersTom Jones (Team Leader)Steve MartinArt FranklinAmy KiddBob VillaLinda Hill (Sponsor)012017Mary JeffersonJimmy Smits

Backgroundy The Community Health Organization (CHO)Leadership Team determined that Clinic Cycle Time(Intake & Service Delivery) needed improvement.y This objective was driven by patient satisfaction surveyresults from throughout the service area.y The Executive Director assigned Tom Jones as theTeam Leader, and requested Mr. Jones to assemble across-functional company-wide team to develop aProject Charter and confirm the need for improvement.y The team decided to use the DMAIC methodology andLean Six Sigma tools to address this issue.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-22121

Theme Selection MatrixThe team evaluated cycle time in the context of the 5 greatest issuesidentified in the strategic planning SWOT process.Date: June, 2013Theme Selection MatrixImportanceNeed toImproveOverallScoreFacility Cleanliness3412Employee Lost Time Incidents5315Employee Absenteeism339Clinic Cycle Time (Check-in toCheck-out)5525Customer Service Responsiveness5210Potential ThemesScale:1 Negligible2 Somewhat3 Moderate4 Very5 ExtremeThe team selected “Reduce Clinic Cycle Time” as its theme because cycletime was a driver of patient satisfaction, retention, and referral. Cycle Timewas also a strategic objective and Key Performance Indicator on the SeniorLeadership Scorecard.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-22122

Project CharterGreen Belt Team Project ect Name (Theme): To Reduce Clinic Cycle Time (Current Actual 70 Minutes)Problem / Impact: Clients expect to be treated within a reasonable time. Longer than necessaryLength of Stays (LOSs) cause Client dissatisfaction and loss of trust in theclinic’s ability to meet their health care needs.Expected Benefits: Reduce Arrival to Checkout (Intake & Service Delivery) Times: Reduced # ofClient Complaints; Increase Client SatisfactionOutcome Indicators:Proposed Target(s):Timeframe:Strategic Alignment:In Scope:Authorized By:Sponsor(s):Team Leader:Team Members:Process Owner(s):Mgmt. Review Team:Completion Date:Review Dates:Key Milestone Dates:Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-2212Q2 - Average # of Minutes to Serve Clients (from Arrival to Checkout)Target 39 minutesJuly 2013 through December 2013Supports CHO Strategic PlanClients within CHO AreaLinda HillLinda HillTom JonesSteve Martin, Art Franklin, Mary Jefferson, Amy Kidd, Jimmy SmitsLinda HillDr. Kildare and Linda HillDecember 31, 2013Monthly and Final Review in November 2013.See Action Plan3

Project Planning WorksheetNote: In some cases a team may choose to use a Project Charter and a separateProject Planning Worksheet with DMAIC schedule as follows.Project Planning Worksheet – Page 1 of 2ThemeReduce Clinic Cycle Time 31 minutes by 12/31/13 (77.5% of Gap)Problem Statement(Summarize)73.7% of Clients served that were taking longer than 30 minutes requiredCBC Lab WorkTeam Work LocationMiami, FLTeam NameThe SpeedersDuration6/13/13(mm/yy) throughTeam MembersTeam Leader(mm/yy)Sponsor:Linda HillTom Jones2nd Team LeaderN/ATeam Member 1Amy KiddTeam Member 2Team Member 3Team Member 4Team Member 5Team Member 6Team Member 7Steve MartinArt FranklinBob VillaMary JeffersonJimmy /10 10:00a79710346/17 3:00p56/24 2:00p657/21:00p67/9787/23 NoonTeam InfoSubject matter experts from variousdisciplines invited throughout meetingschedule.Att.#7/30 6:00p4178/10 4:00p418118/17 3:00p5128/24 7:00a35138/31 8:00a9:00a7149/47/16 11:00a7156169/18 5:00pCopyright 2017 ets, inc. - www.etsfl.com – (321) 636-2212TimeDateAtt.#10/12 2:00p72510/31 9:00a7261911/15 9:00a4272012/3 10:00a52872112/19 4:00p7299:00a722309/11 4:00p62331524324TimeDateTimeAtt.

Project Planning WorksheetOutline of ActivitiesNote: In some cases a team may choose to use a Project Charter and aseparate Project Planning Worksheet with DMAIC schedule as follows.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-22125

Reason for Improvementy Project Name: Reduce Clinic Cycle Time (Intake &Service Delivery)y Situation:– 11 Clinics in Service Area– Average Cycle time 70 minutes– Industry Best 30 minutes– Customer Satisfaction 68%– Customer Complaints 3.7/100 encounters– Strategic Issue related to patient satisfaction, revenue, andFederal funding– 20% of patients leave before being seenCopyright 2017 ets, inc. - www.etsfl.com – (321) 636-22126

Reason for ImprovementStakeholders and NeedsStakeholdersCustomer / PatientNeedsQuality Medical ServicesTimely Medical ServicesAccurate Billing for ServicesCompany / SeniorLeadership TeamRetain Existing Patients (Maximize Revenue)Add New Patients (Revenue Growth)Maximize Funding Potential (No Penalties)EmployeesMeaningful WorkCareer OpportunitiesFair Pay and BenefitsRecognitionCopyright 2017 ets, inc. - www.etsfl.com – (321) 636-22121.7

Costs of Poor QualityStakeholderPainAnnualized “Costs”Customer / PatientLow Satisfaction68% SatisfactionCustomer / PatientComplaints3.7/100 EncountersCustomer / PatientLeaves Without Being 20% LWOBSSeen (LWOBS)CompanyLost Patients 1.5 Million RevenueCompanyFinancial Penaltiesfrom Funders 900,000 in PenaltiesEmployeesRework10% Rework 2.5Million per Year in WastedLabor ExpenseCopyright 2017 ets, inc. - www.etsfl.com – (321) 636-22128

Line Graph2.GOODShortTermTarget39Minutes70GapIndustry Best300ASONDJFMAM2013JJASOND2014Theme: Reduce Clinic Cycle Time 31 minutes by12/31/13 (77.5% of Gap).3.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-22129

DMAIC ScheduleA schedule for completing the five DMAIC steps was developed.Outline of Activities4.The Sponsor signed off on the project’s purpose, scope, and significance.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-2212105.

Flow Charty The teamdeveloped aflow chart.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-221211

Eight (8) Categories of Waste (Muda)The team applied the 8 Wastes to the process with anemphasis on cycle time.y Defective parts, services & reworky Over-productiony Waitingy Non-utilized talent & wasted knowledgey Transportingy Inventoryy Motiony Excess processingCopyright 2017 ets, inc. - www.etsfl.com – (321) 636-221212

8 Wastes8 WastesPotential Causes of Waste1.Defects & Reworky Patients show up late for appointments.y Walk-ins are accepted and worked into the patient flow.y Must call-back patients many times to reach them.2.Over-productionRequiring patients to change gown when not necessary.3.Waitingy Patient waits for blood draw and lab work.y Patients without appointments are mixed with those that haveappointments.y Exam rooms are not available.y Patient must wait for nurse.y Clinician not informed immediately when nurse completes exam.y Patient must wait to be checked out.y Patients must wait in line at cashier.4.Non-Utilized Talent &Wasted Knowledgey Only clinicians are allowed to order lab work.y Physicians required to complete routine paperwork.5.TransportingMust move equipment between exam rooms.6.InventorySupplies and equipment are ordered based on the calendar ratherthan demand.7.MotionDesk top computers not positioned in exam rooms to provideconvenient access by physician or nurse.8.Excess ProcessingUnnecessary tests may be performed on the patient.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-221213

Checksheet (Used to collect & analyze data)A checksheet was developed to collect data on patient flow throughthe clinic for 100 patients. Clinic Services SummaryNote: Checksheets may be used in all DMAIC steps.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-2212146.

Histogram - Stratification7.# of ClientsThe team collected a random sample of 100 clinic clients served duringJuly 2013. The team analyzed the data many ways and found The team looked closer at these 91 clients served.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-221215Patient Flow ReportWhen: June 2013Where: Miami, FLWho: J. Smits x 313

Pareto Chart – Stratification ContinuesThe team stratified the 91 clients which took longer than 30minutes many ways and found Clinic ClientsServed DuringJuly 2013taking longerthan 30 minutesfrom Check-into Check-outand involvingLab Work.9197.8%94.5%n 917.100%89.0%75676075%73.667 (73.6%) Clientshad Complete BloodCount (CBC) LabWork Performed4550%30Target: 75%Reduction in CBCLab Work Delays25%17CBC Lab14UA (w/oMicroscopic)532Quantitative Bhcg(Pregnancy)GC/ChlamydiaDNA ProfileCk-Mb Profile0%Type of Lab WorkWe set a target to reduce the percentage of CBC Lab clients taking 8.longer than 30 minutes from check-in to check-out by 75%.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-221216

Problem Statement and Targety Problem Statement: 73.6% of clients served that weretaking longer than 30 minutes from Check-in to Checkout required CBC Lab work.y Target: We will reduce the percentage of CBC Labclients taking longer than 30 minutes from Check-in toCheck-out by 75%.9.10.y If the target is achieved, the team determined that it couldachieve the short term target of 39 minutes AverageCycle Time on the Theme Indicator in the Define step.y The team looked closer at these 67 clients.y The Sponsor signed off on the project’s focus and target.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-22121711.

Cause and Effect (Fishbone) DiagramThe team completed Cause and Effect Analysis and found 12.PeopleMethodsLimited # of people trained and/or authorized to draw bloodCPolicy on who is allowed todraw blood out of dateLab Work ordered byClinician after ExamAClinician is planned tosee Client after Vitalsand RN AssessmentRN and Clinician availablestaff often less than neededto meet demandDPolicy for securing temporaryback-up staff not clearEnvironmentExisting Policy only allowsClinician to order Lab WorkSupplies for drawing bloodare limited and not easilyaccessible to allBProcedures for stocking suppliesand equipment needed fordrawing blood not well definedEquipment / MaterialsProblem StatementCBC Lab clientsserved duringJuly 2013 takinglonger than 30minutes fromCheck-in toCheck-out. Potential Root CauseThe team next looked to verify the 4 identified PotentialRoot Causes.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-22121813.

Probable Cause Verification MatrixThe team collected data to verify causes and summarized itsfindings on a Verification Matrix.Potential Root CauseHow Verified?Root Cause orSymptomA. Existing Policy only allowsClinician to order Lab WorkTeam reviewed current Policy andguidelines and verified Policy only allowsClinician to order Lab Work.Root CauseAB.Procedures for stockingsupplies and equipmentneeded for drawing bloodnot well definedTeam reviewed current guidelines andverified that no clear Policy exists.Root CauseBC.Policy on who is allowed todraw blood out of dateTeam reviewed current guidelines andfound Policy is current and matchescompany standardsSymptomCRoot CauseDD. Policy for securingtemporary back‐up staffnot clearCopyright 2017 ets, inc. - www.etsfl.com – (321) 636-2212Team reviewed current guidelines andfound there is no written Policy on whento secure back‐up staff to meet staffingneeds.19

Probable Cause Verification Matrixy A checksheet was developed and 100 samples were takento determine the frequency of occurrence of each selected 14.cause. This enabled the team to estimate the impact of eachroot cause on the gap. Three (3) primary causes wereverified by the team.15.y Root Cause A present 35% of the time 23 patients;y Root Cause B present 22% of the time 15 patients;y Root Cause D present 19% of the time 13 patients;Total 51 patientsEstimate: 51 67 76% which approximates the targetin the Measure step of a 75% reduction.y The sponsor signed off on the verified root causes andimpact on the gap.Copyright 2017 ets, inc. - www.etsfl.com – (321) 636-22122016.