Improving Waiting Time In Vaccination Room Using Lean Six .

Improving waiting timein vaccination roomusing Lean Six SigmamethodologyDr/ Mohamed Adel El FaiomyDr/ Ayatullah Amr Muhamad Shabana2012SAUDISENAYAMINISTRY OF HEALTHPRIMARY HEALTHCARE CENTER

background informationBackground informationELsenayea primary healthcare centre is one of thelargest primary healthcare centers in Khamis region inKSA it provides preventive, curative and healthpromotion services to more than 29000 population,due its large catchment area it serves more than 300customer per day so the waiting time is very importantto calculate and to improve

1-Define phase A) Identify the projectTo select the most appropriate project we review the data onpotential project against specific criteria & after evaluation ofthese projects we decided to work on the problem ofprolonged waiting time in vaccination room because it meetthe criteria of selecting a project as follow: Chronicity of the problem as it is a persistent problem Significant because it has a favorable outcome It is of manageable size as it can be completed in lessthan six months Improve the level of competition It has potential impact on Retaining customer Attracting new customer Reducing the cost of poor quality Enhancing employee & customer satisfaction. B) Prepare problem statment & goals The problemWaiting time before entering vaccination room is too long(average 25.4 minute) between 21st of March to 21st of

April 2012 which lead to external customer dissatisfactionand internal customer pressure. The goal is to reduce average waiting time in thevaccination room to meet customer expectations which is10 minutes.PROJECT TEAM CHARTER1- Problem statementWaiting time before entering the vaccination room is toolong (average 25.4 minute) between 21st of March to 21stof April 2012 which lead to external customerdissatisfaction and internal customer pressure.2-bussiness caseAbout 30 children are vaccinated daily. The delay invaccination negatively affects the customers satisfaction,organizational reputation in the catchment area of thePHCC, disciplinary actions from higher authorities inresponse to customer complaints and puts more pressureon internal customers .3-Goal statement

to reduce average waiting time in the vaccination room tomeet customer expectations which is 10 minutes.4-Project scopeThe process starts by the parent ordering his child’s familyhealth record & end by the child entering the vaccinationroom.5- Select teamSponsor (PHCC director)Green belt [Quality professional Dr Mohamed Adel Elfaiomy]Green belt [Quality professional dr Ayatullah Amr Shabana]Team member [medical supervisor]""[general practitioner]""[head of nurse]""[vaccination nurse]""[medical record clerk]“ “[well baby clinic nurse]6-Project planDefine phaseMeasure phaseAnalyze phaseImprove phase10/3/2012 to 10/4/201211/4/2012 to 30/4/201201/5/2012 to 9/5/201210/5/2012 to 23/6/2012

Control phase23/6/2012 to 30/6/2012Voice of customers: 4 focus groups were done with 57 parents from the60 surveyed cases to estimate the upper specificationlimit for the process, and the mean of customer srequirements was 10 minutes. An AD HOC team was formed from all the processowners to estimate the minimal time for the processusing the above mentioned flow chart, and it was 5minutes, which we the team considered as the lowerspecification limit.CTQsCustomer needsLeast waiting timeDriversLeast cycletime in vitalsigns roomLeast cycletime inexamination roomLeast cycletime invaccinationprocessCTQsStandardproceduresfor prevaccinationprocessInternal metricsTime for prevaccinationprocess

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2-Meassure phaseThe measure step identifies the symptom of the problem &establishes base line measurement of current and recentperformance.It also maps the process that is producing the problem inorder to understand how the current process actuallyoperates.High level flow chart of the current process

Data collection plan:variablewaitingtime infile roomoperational defenitionit starts since the parent askfor his child's medicalrecord till the file reachesthe well baby roomit starts since the file reachthe room till the child nameis called in well baby roomdatasourcewaitingtime datacollectionsheetwaitingtime datacollectionsheetwaitingtime inwell babyroomit starts since the file reachthe room till the child nameis called in pediatric clinicwaitingtime inpediatricclinicwaitingtime datacollectionsheetdata collection methodthe medical record clerckregister the time when theparent ask for the file andrecord it in the collectionsheetthevaccination nurse record thetime when the child entersthe room and before hetakes the vaccinationthe nurse supervisor collectthe data from data collectionsheetthe medical record clerckregister the time when theparent ask for the file andrecord it in the collectionsheetthevaccination nurse record thetime when the child entersthe room and before hetakes the vaccinationthe nurse supervisor collectthe data from data collectionsheetthe medical record clerckregister the time when theparent ask for the file andrecord it in the collectionsheetthevaccination nurse record thetime when the child entersthe room and before hetakes the vaccinationthe nurse supervisor collectthe data from data collectionsheetwho willcollect datawhen datawill becollectednursesupervisorbetween 21march and 28marchnursesupervisorbetween 21march and 28marchnursesupervisorbetween 21march and 28march

it starts since the file reachthe room till the child nameis called in vaccination roomwaitingtime datacollectionsheetwaitingtime invacinationroomnumberof staffworkingin eachroomstaff actually working inevery room involved in theprocessstaffchecksheetthe medical record clerckregister the time when theparent ask for the file andrecord it in the collectionsheetthevaccination nurse record thetime when the child entersthe room and before hetakes the vaccinationthe nurse supervisor collectthe data from data collectionsheetnumber of staff actuallyworking in each room iscollected by the nursesupervisornursesupervisorbetween 21march and 28marchnursesupervisorbetween 21march and 28march

Step 3 Analyze phase*Analyze phase seeks to discover root causes of the majorcontributes to the problem. Theories are generated by mean ofbrainstorming; the list of theories is organized by mean of causeeffect diagram so the team can discern the specific theories of rootcauses. Finally, theories of root causes are tested and causes areidentified.Test theory :After gathering data about phases of waiting time the team used Scatterdiagram to find the cause of prolonged waiting time through correlationSo we have four theories to test using scatter diagram:1. The delay because of waiting at file room2. The delay because of waiting at well baby room3. The delay because of waiting at pediatrician room4. The delay because of waiting at vaccination room

Correlations: file waiting time; total waiting time by minutesPearson correlation of file waiting time and total waiting time by minutes 0.712S c a tte r p lo t o f to ta l w a itin g tim e b y m in u te s v s f ile w a itin g tim et o t a l w a it in g t im e b y m in u t e s706050403020100123456f ile w a it in g t im e78910

Correlations: well baby waiting time; total waiting time by minutesPearson correlation of well baby waiting time and total waiting time by minutes 0.891S c a tte r p lo t o f to ta l w a itin g tim e b y m in u te s v s w e ll b a b y w a itin g tim e80t o t a l w a it in g t im e b y m in u t e s70605040302010001020w e ll b a b y w a it in g t im e3040

Correlations: pediatrician waiting time; total waiting time by minutesPearson correlation of pediatrician waiting time and total waiting time byminutes 0.668S c a tte r p lo t o f to ta l w a itin g tim e b y m i v s p e d ia tr ic ia n w a itin g tim80t o t a l w a it in g t im e b y m in u t e s70605040302010005101520p e d ia t r ic ia n w a it in g t im e253035

Correlations: vaccination room waiting time; total waiting time by minutesPearson correlation of vaccination room waiting time and total waiting time byminutes 0.725S c a tte r p lo t o f to ta l w a itin g tim e b y m i v s v a c c in a tio n r o o m w a itin gt o t a l w a it in g t im e b y m in u t e s706050403020100024681012v a c c in a t io n r o o m w a it in g t im eAnd from the above graphs we found positive correlationbetween increased total waiting time and waiting time inwell baby roomAt the end of analysis phase:We found that the highest correlation was at the phase of waiting at well baby room

Step 4 Improvement phase1- choose remedy.the team sit together after analyze phase and by brainstormingthe team agreed upon a remedy which is :redesigning the process of pre vaccination to be in one roomonly to avoid waiting time between steps2- Design remedy.After the team reviewed the goals and determined therequired resources from people-money-time-material,the team decided the following remedy:"Using lean technique to make the whole process done inone room."So we will calculate and sum the area of the three rooms and transferthe whole process to the vaccination room after arranging it usinglean technique, so that the parent and child will only wait one timebefore getting the service.The team defines a tree diagram to identify the role of each memberin the new project.

The tree diagram

3- Prove effectiveness:Before an improvement is finally adopted, it must be proven effectiveunder operating condition.pilot test is designed to start working in the new room for 1 weekfrom 9th of may 2012 to 16th of may 2012 and calculating waiting timein this period.I C h a r t o f w e ll b a b y w a itin g tim e1401W a it in g t im e30U C L 2 8 .7 320X 1 1 .0 4100LC L - 6 .6 5161116212631364146O b s e r v a t io nThis control chart showing waiting time before wellbaby room (the red X) before applying the remedy

This is the control chart showing waiting times beforeapplying the remedy showing:1. 53 out of 60 observations are above the upperspecification limit which is 10 minutes accordingto VOC, with percentage 88.3%.2. The mean is 25.42

This is the control chart showing waiting times afterapplying the remedy showing:1. All observations are within the specification limits.2. The mean is 7.555- ImplementationAfter the one week pilot and calculating waiting timeand according to the improvement proven by thecontrol chart we decided to implement this remedyusing the attached tree diagram

The new flow chart

Step 5 ControlImplementation 3 activities for control:1- Design effective quality controls.2- Foolproof the improvement.3- Audit the controls.A) Design controlTo ensure that the breakthrough is maintained, the qualityimprovement team needs to develop effective quality control byfeedback ionsNot okRegulateprocessCustomerspecifications(upper andlower controllimits)