Lab order to results in 16 minutes? You heard right! 

Six Sigma helps ED overcome internal squabbling 

ED-laboratory relations at North Memorial Medical Center in Robbinsdale, MN, were not unlike those in many hospitals:

There was a long history of frustration over lab specimen turnaround time — but not anymore. Thanks to a successful Six Sigma initiative, turnaround time for the ED’s criteria draws (draws based on specific patient criteria that indicate lab work will be needed) has dropped from about 46 minutes to 16 minutes.

"We were frustrated by the patient delays that occurred while waiting for test results to become available, and the lab [staff] were frustrated because they felt they were doing the best they could and that we needed to be more patient," recalls Maribeth Woitas, RN, BSN, director of emergency services.

Six Sigma is a performance improvement approach pioneered by large corporations such as GE and Motorola. In the health care context, it aims at delivering near-perfect patient care.

"As we were taught it, Six Sigma is a seven-step process that enables you to study your work processes in depth to qualitatively validate where the greatest opportunities to improve exist," Woitas explains.

The seven steps are:

1. Establish the focus.
2. Examine the current situation.
3. Analyze the causes.
4. Act on the causes.
5. Study the results.
6. Standardize the changes.
7. Draw the conclusions.

It was a logical step for North Memorial to try the Six Sigma approach, because some top managers recently had attended a program at the Carlson School of Management at the University of Minnesota in Minneapolis, and already had begun a hospitalwide initiative addressing capacity management, notes Woitas. A multidisciplinary team was established in early 2003 to address lab turnaround.

In-depth analysis 

The team began its work with some in-depth data analysis of the process. "We actually broke it down into subprocesses," Woitas explains.

This was a critical part of the Six Sigma process, notes Kathy Willemsen, RN, BSN, who at the time was the ED nurse manager.

"When you get something that involves multiple steps, it is usually so overwhelming. You try to fix it all at once, and your effort ends up being nonproductive," she observes. "In our case, we were able to zero in on the one piece of the process that would give us the most bang for our buck."

And just what was that subprocess? "The piece of the process that had the most significant variation was from the time a test was ordered until the specimen was collected," says Woitas.

Because this conclusion was data-driven, it was easier to obtain buy-in from the staff. "This very objective analysis of the data removed the emotional piece and allowed us to look at the reality of the situation in a different light," Woitas observes.

It’s difficult to argue with data, she points out. "It gets everyone on the same page, focusing on improving," Woitas adds.

Focusing efforts

With the data in hand, the identified subprocess became the focus of the team’s efforts.

"We did a lot of integrative flowcharting and came up with a very simplistic, but quite novel idea," Woitas recalls.

Whenever the ED primary nurse was admitting a patient, the nurse had a set of criteria, i.e., shortness of breath in a patient older than 40, abdominal pain in a patient older than 40, hypotension, and vomiting for more than 24 hours, she points out.

If this patient met those criteria, staff knew there was a significant probability he or she needed lab work done. "We gave pagers to the phlebotomy staff, so the nurse at the bedside could page them, enter a cart number, and the phlebotomist would then begin going to the ED," Woitas says.

The phlebotomist drew a standard set of tubes, gave the specimens to the lab, then the physician saw the patient and ordered specific tests, which was entered into a computer. "But since the patient’s information had already been entered into the lab, it wasn’t that long a delay from the time the physician ordered the test until the blood was drawn," she explains.

Woitas says the team has been able reduce turnaround time by 30 minutes. Of course, when a patient doesn’t meet the criteria, staff still need to wait for a physician, "So we have aggressively worked on increasing the percentage of times we are able to do a criteria draw," she adds. At present, that percentage has increased from 31% to about 40%.

The Six Sigma process has broad applications, says Willemsen. "There are a lot of procedures in the ED that lend themselves to Six Sigma," she asserts.

"We are currently looking at opportunities to evaluate our triage system," Woitas notes.

Six Sigma also is readily adaptable to different ED environments, she adds. "This project is so easy to replicate," Woitas concludes.


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