Focus on process slashes average cycle time by 37%

Staff overcome instinct to blame personnel levels

It may seem logical to blame your overcrowding problems on understaffing, but as the ED staff at the 302-bed North Shore University Hospital at Forest Hills in Queens, NY, found out, that may not always lead you to the root of your problems. Learning that lesson, and finding the real cause of their problems, enabled them to slash their average cycle time from 187 minutes to 118 minutes.

At the outset of a Six Sigma project to address the issue of excessive patient wait times in the ED, "Every-one involved stated that the ED was understaffed," recalls Kevin G. Tuttle, MBB, MHA, the Six Sigma Master Black Belt who oversaw the project on-site. (Six Sigma Master Black Belts are quality leaders responsible for Six Sigma strategy, training, mentoring, deployment, and results.)

"The [Six Sigma] team also thought staffing was a major issue with the project," Tuttle says.

Tuttle and North Shore partnered with Waukesha, WI-based GE Healthcare, a $14 billion unit of General Electric Co., "so that GE could train North Shore in the Six Sigma methodology," he says. GE Healthcare offers services to address productivity and better enable health care providers to diagnose, treat, and manage patients with conditions such as cancer, Alzheimer’s, and cardiovascular diseases.

Tuttle, who is with the Center for Learning and Innovation at the hospital’s parent organization, North Shore-Long Island Jewish Health System in Lake Success, NY, demonstrated to them that more nurses, physicians, and registrars were not the answer. "We started to measure the data, and what we saw was there were gaps in the process that had nothing to do with staff," he adds. "We could have had 14 more ED people, but the process was broken and not where it should be."

The Six Sigma team included the assistant director of the ED, Jim Halfpenny, DO, who, in Tuttle’s words, was "our lifeline to the clinical staff." The team, which also included two staff nurses and the ED charge nurse, broke down the process into several steps, or buckets:

  • Arrival to triage. When patients came through the door, they filled in a form with their name and chief complaint. A time clock was stamped.
  • Triage to registration. The nurse took the triage slip, saw the patient, then time-stamped the triage form in the upper right hand corner.
  • Arrival to seen by physician. The patient then went to the registration booth. When registration was complete, the form was time-stamped once again.
  • Seen by MD to discharge. After registration, the patient and chart went to the physician. When the chart went to the back, it also was time-stamped.
  • Arrival to discharge.

All of the time clocks were synchronized with the ED computer system. "That’s basically how we measured the whole process," says Tuttle. This required purchasing three additional time clocks at a cost of less than $500, he notes.

After completing a measurement system analysis, the data were reviewed by the team. A primary issue that surfaced was how the registrar was working and the batching of charts by the registration staff. When they were busy, the registration staff gathered three or four before bringing them back. In addition, which physician was on duty seemed to be a major cause of variation in the process. Here were some solutions:

  • Time-stamping was used to reduce the delay problem caused by batching. "By time-stamping the charts, you could easily identify which registrar was batching charts," Tuttle explains.
  • Registrars were retrained on how to use laptops for bedside registration, because they had not been using them. Backup printers were installed directly in the ED so they would be available whenever needed.
  • Before, when patients were triaged, the triage nurse would complete a seven-page assessment form. "We reasoned, why can’t they just fill out the top form?" he continues. (The form basically notes the complaint and records vitals.) The triage form was incorporated into the nursing assessment form, Tuttle explains, and the triage nurse was instructed to complete the triage section of the form only —not the entire nursing assessment.
  • During triage, the nurses also would draw blood. Now, a threshold has been established by the charge nurse and ED physicians: If there are more than seven patients waiting to be seen, there are no blood draws; the patient is triaged and brought right to the back of the ED.
  • The shortened triage form was an effective solution to a common ED problem, notes Eric Carter, a Six Sigma Master Black Belt and a consultant with performance solutions at GE. "A lot of hospitals ask 60 questions or more, which delays the process," he notes. "What they came up with is good solution and would make a difference in other EDs as well."
  • Scripts for standardizing patient communication (to be used by the registrars) were developed and addressed questions such as how long they might wait. "This not only reduced cycle time, but increased satisfaction," says Tuttle.
  • Discharge instructions sheets, which used to be written on the charts, now are entered electronically into a database and printed as needed. "Thus, they are always legible, and patients don’t have many questions," he points out.

Another key lesson learned is the value of having someone like Halfpenny on the team. "Given their preconceived notions, getting physician and nurse buy-in was critical," Carter notes. "For that, you need to have the people closest to the process itself on your team."

Finally, he advises, let your team find its own solutions. "I always have some good solutions in the back of my head," Carter concedes, "But you must let the team [members] figure it out for themselves. They will not let their own idea fail."


For more on the North Shore Six Sigma project, contact:

  • Eric Carter, Performance Solutions, GE Healthcare, Waukesha, WI. Phone: (860) 663-3655. E-mail:
  • Kevin G. Tuttle, MBB, MHA, North Shore — Long Island Jewish Health System Center for Learning and Innovation, 1979 Marcus Ave., Suite E130, Lake Success, NY 11042. Phone: (516) 396-6159. E-mail: