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6 LEAN SIX SIGMA APPROACH

Article  in  International Education Journal · June 2016

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Research Paper Medical Science E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016

A
LEAN
SIX
SIGMA
APPROACH
TO
REDUCE
WAITING
AND

REPORTING
TIME
IN
THE
RADIOLOGY
DEPARTMENT
OF
A

TERTIARY
CARE
HOSPITAL
IN
KOLKATA
1 2
Dr (Brig). A. P. Pandit | Ms. Tanima Debmallik
1
MD(HA) DNB(H&HA), Prof, Symbiosis Institute of Health Sciences, PUNE-411004.
2
MBA (HHM), Symbiosis Institute of Health Sciences, PUNE-411004.

ABSTRACT
A Lean Six Sigma (DMAIC) approach was taken to study the issue of the imaging services cycle turnaround time (TAT) of the Radiology Department of a Tertiary care
Hospital Kolkata. By conducting a Gemba Walk interview (Annexure 1) and Time motion study (Annexure 2), the entire process was mapped and areas causing delay
were identified in the defining and measuring stage. Pareto analysis yielded the root causes of delay in the analysing stage. In the intervention stage practical
approaches were undertaken to increase patient orientation and preparedness for the scan thereby decreasing pre-test waiting time and streamlining of operations. The
reporting process ultimately aided in reduced pre-test and post-test waiting times.

KEYWORDS: Lean Six Sigma, Pre-test waiting time, post-test report generation time.

INTRODUCTION Ÿ Identify causes of delay.

PROJECT CHARTER (BUSINESS CASE)
The Tertiary care hospital in Kolkata is a 500 bedded multi-speciality tertiary Ÿ Propose recommendations and implement them.
care hospital with an advanced department of Imaging and Interventional Radi-
ology catering to both Inpatients as well as Outpatients. The Hospital has an oper- Ÿ Statistically find the effectiveness of the implementations.
ating system that has set parameters for all hospital operations and processes that
need to be completed within a certain amount of time. Based on this a balanced PROJECT SCOPE:
scorecard is created by the organization and different scores portray the overall The project attempted to find the bottlenecks in the process of scanning and
performance of the hospital and the areas that need improvement. reporting of CT scan and MRI for outpatients only as the data pertains to only out-
patient percentages since it was a critical parameter according to the manage-
On studying the Tertiary care hospital data of Jun to Aug 2015, it was found that ment and administration. The project had in its scope the mapping, identification
one of the major areas requiring improvement was the “Services on Time” sec- and measurement of bottlenecks in the process, suggestions and recommenda-
tion. In the data scorecard, the parameter for CT and MRI scan report generation tions of changes that was to be made and their implementation and impact assess-
time was 2 hours from the time the patient left the scan room. The target set was ment. The project did not have in its scope the above stated points for Inpatients.
that, at least 90% reports of CT and MRI must be generated within this time
period of 2 hours. However, the data collected in May 2015 showed that the per- REVIEW OF LITERATURE:
centage of reports generated within 2 hours is only 51.1% and the overall “Ser- Sigma is a Greek letter of the alphabet used to describe variability, or in mathe-
vices on time” score was 44.4%. matical terms, standard deviation. Six Sigma offers a way of measuring the per-
formance capability of existing systems or processes. It is a statistical unit of mea-
This delay in the generation of reports was leading to an increased post scan wait- sure that reflects the likelihood that an error will occur. Six-sigma relies on rigor-
ing time for the patient and hence the patient satisfaction was seen to decrease. In ous statistical methods, and implements control mechanisms, in order to tie
most cases the reports were given to the patients only one day after the test com- together quality, cost, process, people, and accountability. It begins with an
pletion. This was not conducive for many outpatients who had come to the hospi- understanding of customer requirements, and values. The six-sigma goal is to
tal from places outside Kolkata and also West Bengal, as their lodging and travel- reduce both variance and control processes in order to assure compliance with
ling charges increased due to the waiting time. Also, the billing process for Insur- the critical specifications.1
ance patient could not be completed and they were not discharged unless com-
pleted scan plates were provided to the TPA. For this aforesaid reporting delay, Six Sigma was originally a concept for company-wide quality improvement
the discharge process of these patients also became prolonged. introduced by Motorola in 1987. It was further developed by General Electric in
the late 1990s.2
The major bottlenecks in the entire process from the time the patient entered the
Radiology department and submitted the test requisition till the time the patient From emergency room to boardroom, six-sigma can reduce variability and waste
received the report from the reception were identified, quantified and addressed by translating to fewer errors, better processes, improved patient care, greater
so that the overall delay could be reduced leading to more streamlined operations patient satisfaction rates, and happier, more productive employees. To achieve
and increased efficiency. these goals, the DMAIC must be implemented. The DMAIC is a five-step
improvement cycle with the aim to continuously reduce errors: Define the pro-
PROBLEM STATEMENT ject by identifying problems, clarifying scope, defining goals, measure the cur-
The pre-test and post-test (Report Generation) waiting time for CT scan and MRI rent performance against requirements, gather and compare data, refine prob-
in the Imaging and Interventional Radiology Department of Tertiary care Hospi- lems/goals, analyse by developing hypotheses, identifying sources and gaps.
tal Kolkata was noticed to be above the set parameters leading to less number of Improve by conducting experiments to eliminate root cause, testing solutions,
reports generated on time and decreased patient satisfaction due to prolonged measuring results, standardizing solutions, implementing new processes by
waiting times. designing creative solutions to fix and prevent problems. To control the perfor-
mance of the process by institutionalizing improvements and putting a mecha-
AIM: nism for ongoing monitoring in place
To reduce pre-test and post-test waiting time in the Radiology Department of a
tertiary care hospital in Kolkata using a Lean Six Sigma approach. At its core, Six-Sigma revolves around the following key concepts:
1. Critical to quality: Attributes most important to the patient.
OBJECTIVES:
Ÿ Study the applicability of Lean Six Sigma in the healthcare industry. 2. Defect: Failing to deliver what the patient wants. In terms of impact to the
patient, a defect in the delivery of healthcare can range from relatively minor
Ÿ Map the entire process flow with time tags from patient entry till report gen- to significant. Ina worst-case scenario, the defect can be fatal, as when a med-
eration from the Radiology Department. ication error results in the patient's death.

Ÿ Identify areas of delay. 3. Process capability: What the healthcare process can deliver.

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International Education & Research Journal [IERJ] 21

Research Paper E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016
4. Variation: What the patient sees and feels. mising errors. Of all the phases making up the process, reporting (from end of
examination to end of reporting) and distribution (from the report available to
5. Stable operations: Ensuring consistent, predictable processes to improve administrative staff to report available to the patient) accounted for 90% of pro-
what the patient sees and feels. cess variability. It was also found that a voice recognition system was much faster
than a Dictaphone for faster report delivery. The change made was adoption of
6. Design for Six sigma: Designing to meet patient's needs and process capa- the voice recognition system and optimization of scheduling of the staff to
bility. achieve a better understanding of the internal operations and have a more total
quality approach. 7
7. Lean Six Sigma: integration of Lean Thinking (that means speed and better
flow of the processes by eliminating waste) and Statistical Thinking (that
means understanding data, process and variation in processes). The department of Radiology at Akron Children's Hospital, US, had embarked
on a Lean Six Sigma mission as part of a hospital wide initiative to show
Appropriately implemented, Six Sigma clearly produces benefits in terms of increased customer satisfaction, reduce employee dissatisfaction and frustration,
better operational efficiency, cost-effectiveness and higher process quality.3 and decrease costs. Three processes that were addressed were reducing the MRI
scheduling back-log, reconciling discrepancies in billing radiology procedures,
Till date, six sigma projects in healthcare industry have focused on direct care and implementing a daily management system. Keys to success are that manag-
delivery, administrative support and financial administration. Most projects in ers provide opportunities to openly communicate between department sections
the healthcare industry are based on increasing capacity in X-ray rooms. to break the barriers. Executive leaders must be engaged in Lean Six Sigma for
the company to be successful. 8
Ÿ Reducing avoidable emergency admissions;
To increase capacity and raise patient satisfaction, Carle Clinic in Illinois needed
Ÿ Improving day case performance; to improve cycle time for CT exams.

Ÿ Improving accuracy of clinical coding; The solutions proposed were- Using Six Sigma and change management tools,
Carle Clinic uncovered the most critical factors impacting the exam scheduling
Ÿ Improving patient satisfaction at emergency room (ER); process and implemented these changes:

Ÿ Reducing turnaround time in preparing medical reports; Ÿ Administered contrast solution earlier so patient is prepared for exam on
time
REASULTS EXPECTED ON APPLICATION OF SIX SIGMA IN HOSPI-
TALS Ÿ Used MRI IV start room to prep CT patients
Ÿ Reducing bottle necks in emergency departments;
Ÿ Reducing cycle time in various inpatient and outpatient diagnostic areas; Ÿ Expanded tech availability with chart, requisition and file room improve-
Ÿ Reducing number of medical errors and hence enhancing patient safety; ments
Ÿ Reducing patient falls;
Ÿ Reducing errors from high-risk medication; All these had the following results-
Ÿ Reducing medication ordering and administration errors; Ÿ Increased CT capacity by six exams per day
Ÿ Improving active management of personnel costs;
Ÿ Increasing productivity of healthcare personnel; Ÿ Achieved better predictability in the process
Ÿ Increasing accuracy of laboratory results;
Ÿ Increasing accuracy of billing processes and thereby reducing the number of Ÿ Increased satisfaction
billing errors;
Ÿ Improving bed availability across various departments in hospitals; Ÿ Financial potential approximately $390,000 annually
Ÿ Reducing number of post-operative wound infections and related
woundproblems; Process improvement and workflow adjustments using Six Sigma and other
Ÿ Improving MRI exam scheduling; tools can have a measurable impact on cost and quality of services.9
Ÿ Reducing lost MRI films;
Ÿ Improving turn-around time for pharmacy orders; Li Zhang, PhD, from the department of diagnostic radiology at the University
Ÿ Improving nurse or pharmacy technician recruitment; Hospital of Giessen and Marburg in Germany, and colleagues noticed that IR
Ÿ Improving operation room throughput; suites are consistently viewed as “bottlenecks in patient flow” that can cause
Ÿ Increasing surgical capacity; delays in treatment and lead to longer hospital stays for patients. By applying
Ÿ Reducing length of stay in(ER); Lean Six Sigma, they found that mean cycle time had decreased 28%, from 75
Ÿ Reducing ER diversions; minutes to 53 minutes. The cycle time of steps performed by the radiologist
Ÿ Improving revenue cycle; decreased over 20%, from 29 minutes to 23 minutes.
Ÿ Reducing inventory levels;
Ÿ Improving patient registration accuracy; These changes in cycle time led directly to a change in lead time, which then led
4
Ÿ Improving employee retention. to less waiting time for patients and referring physicians.10

In recent years, however, Lean Six Sigma (LSS), which incorporates the MATERIALS AND METHODOLOGY:
speed and impact of Lean with the quality and variation control of Six Sigma, The Lean Six Sigma methodology used to approach the problem is DMAIC (De-
has emerged as a favourite. fine, Measure, Analyse, Improve and Control). The different steps and tools used
in each step have been described-
Radiology is a major source of revenue generation within healthcare. Insuring
the referral base for a specific radiology department and service area is an impor- STAGE 1- DEFINING THE PROCESS
tant component to providing a consistent revenue stream for a healthcare facility. During the Define phase of a DMAIC (Define, Measure, Analyse, Improve and
The important components to maintaining the referral base include 1) timely Control) project, the researcher is responsible for clarifying the purpose and
patient scheduling, 2) timely reporting of results to physicians, and 3) providing scope of the project and for getting a basic understanding of the process to be
an expected level of technology.5 improved. It involves the mapping of the process which is done using the tool Pro-
cess Mapping which is a qualitative process.
According to a patient satisfaction survey done in an Imaging and Diagnostic
facility in Texas, it was found that the percentage of satisfaction was only 30%. STAGE 2 - MEASURE
On probing into the matter it was found that this was because the waiting time for The “measure” stage of DMAIC is the second stage after the process under study
patient was very high. The targeted area that needed to reduce the cycle time was has been defined. Here measuring means quantifying or measuring the defects or
the registration area. However with interdepartmental collaboration, patient errors or delays associated with the process. There are various tools that have
tracking systems and Radiologist's support, the patient satisfaction percentage been used to measure the bottlenecks associated. The “M” (Measure) in DMAIC
was increased to 98-99%. Hence waiting time must be aimed to be reduced in the is about documenting the current process, validating how it is measured, and
imaging and Interventional Radiology department for increased patient satisfac- assessing baseline performance.
tion.6
Finally, the baseline sigma level for the overall defect rate is estimated using a
In a similar project which was aimed at optimizing the process of reporting and sigma conversion chart, providing a relative indicator of how close the current
delivering radiological examinations with a view to achieving 100% service process is to delivering zero defects. A Six Sigma process has a sigma level of
delivery within 72 hours to outpatients and 36 hours to inpatients, a Six Sigma six, and for all practical purposes is considered a defect-free process over the
approach was adopted, which adopts a systematic approach and rigorous statisti- long run, provided that adequate controls are in place to maintain capability.
cal analysis to analyse and improve processes, by reducing variability and mini-

22 International Education & Research Journal [IERJ]

Research Paper E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016
The tools used are Operational definitions and Time Motion study of the entire
process.

STAGE 3- ANALYSE
The data collected in the measuring stage is analysed in this stage using the tools
Pareto Analysis, Fishbone analysis.

STAGE 4- IMPROVE
In this stage the recommendations are described and implemented.

STAGE 5- CONTROL
In the control stage, the effectiveness of the implementations are statistically
tested.

OBSERVATIONS AND RESULTS:

DEFINE STAGE Tool 1- PROCESS FLOW MAPPING
The Process Flow chart provides a visual representation of the steps in a process.
A Process Map is detailed flow diagram of the process using symbols that dig fur-
ther into the nuances of a process to get a better understanding of it in terms of –

Ÿ Which steps precede which ones

Ÿ Who are the responsible personnel
Ÿ Where the process begins and ends
Ÿ The flow of events

The purpose is to visually represent the process as it is in reality. The key to get-
ting a clear preview of the process is to actually observe it and interview the
responsible personnel in the actual work environment. This is a valuable learning
experience and I could quickly gain insight about the actual flow.

The process in Radiology Department takes the following stepwise pathway:

Ÿ Patient enters the Radiology Department either from one of the OPDs or
from outside.

Ÿ For all tests except MRI, billing is done at the Reception. On paying the Figure1- Swim line process chart for operations in the Radiology
required amount of money through cash or card, the patients' test requisition CT/MRI Section
number and patient details sheet is generated along with the billing invoice.

Ÿ The patient takes this Invoice and Requisition and goes to the Nursing station
in the Patient screening area where the Consent form is filled by him. This
consent form and requisition document is given to the nurse who gives it to
the Technician in the console room.

Ÿ On arrival of the patient the technician updates patient status to “patient

arrived” in the HIS.

Ÿ The patient is screened for proper clothing and food intake and based on that
pre test preparation is initiated by the nurse and the technician.

Ÿ Once the patient is prepared (dress changed, water intake proper, channel-
ling for contrast studies- for CT), patient is put onto the scan bed in the scan-
ning room and settled there in the proper posture with the proper aids as
required by the test.

Ÿ The technician comes to the console room and performs the test.

Ÿ After patient physically leaves the scan room, technician sends the Requisi-
tion and Consent to the Radiologist.

Ÿ Radiologist sees the scan through PACS and Info View and does the report-
ing on paper.

Ÿ This paper is sent to the MT room for typing.

Ÿ Medical Technician types and enters in the HIS and sends back the typed
final version for Radiologist's signature.

Ÿ Radiologist signs off and the final report is collected by the technician. The
plates are also collected by the technician.

Ÿ The CD of the scan images, the signed off report and the scan plates are
sorted out by the technician. Figure 2- The above image shows the process flow in details from the com-
mencement of the scan till the reports being sent to the reception for col-
Ÿ The final report envelope is sent to the reception for collection. lection.

Ÿ In case of a MRI scan, the billing is done after the patient physically leaves MEASURE STAGE TOOL 1- OPERATIONAL DEFINITIONS WITH
the scan room. DATA COLLECTION PLAN
One of the major milestones in a Lean Six Sigma or Six Sigma project is the draft-
Ÿ The process flow is only for Outpatients. The inpatients process flow is ing of the data collection plan along with the operational definitions. The Data
beyond the scope of this project and hence has not been mapped. Collection Plan is said to be a documented procedure for standardized and effi-
cient data collection of the process. An operational definition, when applied to
Ÿ A Swim line process flow chart gives a pictorial representation of the above data collection, is a clear, concise detailed definition of a measure. The need for
stated process. operational definitions is fundamental when collecting all types of data.

International Education & Research Journal [IERJ] 23

Research Paper E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016
The following table shows the Operational Definitions and the Data Collection Plan-
Metric Definition Collection source Interdependencies
1. Requisition The date and time when the OPD patient HIS, Reporting room/ Consoles 1.On HIS data
enters the Radiology department and pays for 2. Unless Requisition is obtained,
the test and requisition number is generated technician cannot begin the test even if
and reflected in the HIS patient is waiting.
2. Prep time/ Waiting time Time between requisition end and before Structured observation as given Tests like CT require prep time of 60
patient moves inside the test room. in annexure mins average.
This time is often prolonged due to
delay in previous patient to physically
move out of the test room.
3. Patient goes inside scan room The point in time when patient physically Structured observation as given Patients who can walk move faster,
enters the scan room in annexure patients seriously ill or in wheelchairs
need assistance and take more time.
4. Scan starts The scanning process starts Structured observation as given
in annexure
5. Scan ends The scanning process ends Structured observation as given
in annexure
6. Patient leaves Patient physically moves out of the scan room Structured observation as given
in annexure
7. MT receives the report MT receives the report after it has been done Structured observation as given
by the Radiologist for typing it in annexure
8. Typing commencing and completion The time at which typing by MT starts and Structured observation as given
ends in annexure and HIS
9. Signoff Typed, corrected report signed off by the Structured observation as given
Consultant Radiologist in annexure
10. Post test waiting time The duration of time after patient physically Analysis of data collected from The longer the final report generation
leaves the scan room till his/her report is the structured observation. takes, the longer is this time duration.
generated.
11. Report generated The time when report is typed, signed off by Reporting room from Info Vision
the Radiologist and is ready. software that records reporting
time.
12. Delivered at reception The time at which the report is sent to the Structured observation as given
reception after assembly by technician in annexure

The following table depicts the overview of Data Collection Plan that is common for all metrics being measured-
CRITERIA DETAILS ABOUT THE CRITERIA
Sample size A convenient sample of 200 total outpatient CT/MRI cases.
Sampling frequency From 23rd June 2015 to 4th August 2015
Sampling strategy 100 outpatient cases- For Time motion study from patient requisition to the time report is made ready by the MT and sent to
reception.
100 outpatient cases- for post implementation studies.
Measurement method HIS aided and self-measured real time observations. The metric wise measurement method is stated in the next table.
Observations recording tool Initially all observations are recorded in a structured questionnaire format ( Gemba walk sheet) and then entered in MS Excel for
analysis.

In the Time motion study, the aim was to determine the time required for performing each step as depicted in the process map in the previous Defining stage and find out
the areas that require the lean treatment. With the help of the Time Motion study, the following observations were made.

OBSERVATIONS
Based on the data collected through the Time Motion Study using Gemba Walk Questionnaire, the following data has been collected-

STEP SOURCE OF DATA AVERAGE TIME REQUIRED

Test Requisition time Radiology HIS This is the starting point T1

Patient enters scan room Physical observation This is T2

PRE TEST PREP TIME T2-T1 41 mins

Scan starts Physical observation/plate time T3
Scan ends Physical observation/plate time T4

TOTAL SCAN TIME T4-T3 15 mins

Patient leaves the room Physical observation 5 mins (T5)

Report made ready by MT Radiology HIS T6

POST TEST REPORTING TIME T6-T5 99 mins

24 International Education & Research Journal [IERJ]

Research Paper E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016
CALCULATION OF DEFECTS PER MILLION OPPORTUNITIES
AND BASE LEVEL OF SIGMA

Figure 3- This figure summarizes the time taken for performing different
steps as defined in the process flow map.

The Post-test waiting time was also broken up into different steps to collect data
on time required by each step and the following is the data collected.

AVERAGE TIME
STEP SOURCE OF DATA
REQUIRED

Radiologist receives the This is the starting point

Physical observation
Requisition T1
Report written by the
Physical observation This is T2
Radiologist reaches the MT
RADIOLOGISTS
T2-T1 53mins
REPORTING TIME
MT Typing commences Physical observation T3
MT Typing completed Radiology HIS T4
From the above Observations, it was clear that the major areas that required maxi-
TOTAL TYPING TIME T4-T3 12.7 mins
mum time were the Pre-test waiting time and the Post-test report generation time.
MT Typing completed Radiology HIS T4 By calculating the Base Sigma level for both the waiting times, based on the num-
ber of times patients had to wait beyond set parameters of time it was observed
Final signoff by that the Sigma Level was 2.6- 2.7 whereas the target value should be 6. Hence
Physical observation T6
Radiologist there is room for improvement in this entire process once the causes of delay are
RADIOLOGISTS identified.
T6-T4 13.2 mins
SIGNING OFF TIME
IDENTIFYING THE CAUSES OF DELAY
Final signoff by In this section we found out which were the causes that contributed to 80% and
Physical observation T6 above in increasing the pre-test and post-test waiting times, using Pareto Analy-
Radiologist
sis
Reports, plates assembled
by technicians and sent to Physical observation T7 PARETO ANALYSIS FOR CAUSES OF PROLONGED PRE TEST
reception for collection WAITING TIME (WAITING TIME)
TECHNICIANS
ASSEMBLING AND
T7-T6 75 mins
MAKING FINAL
REPORT READY

From the above Pareto Chart it was analysed that the main reasons for delay were
the clothes changing process that happened because of the wrong make of clothes
being worn by patients while coming for the CT scan and food intake at the
wrong time. It was required by the patient to wear simple cotton clothes with less
or no buttons and no sequin work. However this was not followed and the reason
for that was that the patient was not informed about it. Also for all contrast studies
it was required that, the patient to be on fasting for 4-6 hours prior to the test.
Hence if the patient came at 9 am and was prescribed to do a contrast study but
just had his/her breakfast, then he had to wait for 4 hours in the waiting area
before the test was done on him. This was mostly because proper information
was not given to patient party about these prerequisites of performing a CT scan.
80% delay was caused due to the two above stated reasons as could be seen from
the Pareto chart. Hence if these can be targeted and reduced, majority of the delay
could be removed.

International Education & Research Journal [IERJ] 25

Research Paper E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016
PARETO ANALYSIS FOR CAUSES OF PROLONGED POST TEST STAGE 4 – IMPLEMENTATION
WAITING TIME (REPORTING TIME) Based on the data given in the previous pages, two new ideas were implemented-
1. A Written Communication System for patients- This was done to increase
NUMBER OF CUM.FR %CUM.F the patient information regarding how to prepare for the tests so that patient ori-
CAUSES OF DELAY CASES EQ REQ entation increases and pre-test waiting time was also saved. A printed sheet (An-
nexure 2) containing the detailed test preparation and general instructions were
Radiologist performing
given to the patients at the time of billing. Standees containing the same informa-
procedure 13 13 32.5
tion were put up in all OPDs.
PACS server down 10 23 57.5
Requisition and patient 8 31 77.5 2. Clustered Seating Arrangement- The Medical Technologists(MT) were
details not sent to Radiologist placed in one room marked REPORTING ROOM and the Radiologists were
immediately after scan seated in their respective rooms. Hence the technician after the scan completion
completion, they are allowed had to take the requisition form to the Radiologist, who would do the report, and
to accumulate then this report would go to the Reporting room for typing by the MT and then
again after typing completion would have to be brought to the Radiologists room
Technician does not collect 7 38 95.0 for corrections and final signoff. The new seating arrangement proposed a Clus-
signed off reports and plates tered seating. The arrangement was made to create two clusters- CLUSTER 1
on time and CLUSTER 2.
Radiologist does the report
but it does not reach MT CLUSTER 1- It was beside one of the USG rooms. It had catered for 3 Radiolo-
room on time 2 40 100.0 gists and 2 MTs (2 Shifts).

CLUSTER 2- The same previous Reporting room consisting of 1 MT and 1 Radi-

ologist.

RESULTS OF IMPLEMENTATIONS-
After the implementations were made, the following results were observed-
1. Average Pre-test waiting time before implementation= 41 mins

2. Average Pre-test waiting time after implementation= 18 mins

NULL HYPOTHESIS- there is no significant difference between the pre-test

waiting time before and after the implementation.

ALTERNATE HYPOTHESIS- there is significant difference between the pre-

test waiting time before and after the implementation.

CALCULATIONS USING MS EXCEL-

Anova: Single Factor
From the above Pareto Chart, it was analyzed that the major causes of delay in the SUMMARY
reporting waiting time were the Radiologists were engaged in procedures (CT
Guided Biopsy, etc.) which in turn caused an accumulation of reports that needed Groups Count Sum Average Variance
to be done by them and thereby caused delay of the entire process. Column 1 101 1853 18.34653 167.6287
The other main cause was the PACS server being down and thereby not allowing Column 2 101 4237 41.9505 1207.488
the Radiologist to make the report without the plates being printed which again
delayed the entire reporting cycle. ANOVA

Altogether it was observed that the reporting cycle was not streamlined and the Source of Variation SS df MS F P-value F crit
personnel involved were not assigned specific responsibilities as to when the req- Between Groups 28135.92 1 28135.92 40.92152 1.1E-09 3.888375
uisition and patient details were to be taken to the Radiologist and when and who
was responsible for collection of reports to be typed and completed reports that Within Groups 137511.6 200 687.5581
are signed off to be collected from the Radiologists room. Total 165647.5 201
Table F Value- 3.84
Calculated F value- 40.9

Since the calculated value was higher than the ANOVA table value (Annexure 3),
we reject the null hypothesis.

Hence there was significant difference between the two pre -test waiting times.
Hence the implementation of establishing a written communication to the
patients regarding test preparation showed a positive result.

Figure 5- A Fishbone Diagram to show the causes of delay.

Causes were grouped into major categories, which were classically defined as
the 6 Ms: Man , Methods (processes), Machines (technology), Materials (raw
materials, information, and consumables), Measurements (inspection), and Figure 6- This figure graphically shows the difference in the pre-test wait-
Milieu/Mother Nature (environment). ing times before and after the implementations.

26 International Education & Research Journal [IERJ]

Research Paper E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016
1. Average post-test report generation time before implementation= 99 mins Kolkata. Two areas were the bottlenecks for the entire process flow of the depart-
ment. The areas identified were the Pre-test waiting time period when the patient
2. Average post-test report generation time after implementation=51 mins has paid for the test and received the requisition document and he or she is wait-
ing for the test to commence; and the other area was the Post-test waiting time
NULL HYPOTHESIS- there was no significant difference between the Post- period when the patient is waiting for the test report. Based on the data collected
test Report generation time before and after the implementation. it was seen that the overall Sigma level for the process from the patient entering
the department till the time his test report was generated was low (2.6-2.7) when
ALTERNATE HYPOTHESIS- there was significant difference between the the general accepted value for any industry is 6. Hence it is concluded that there is
Post-test Report generation time before and after the implementation. room for improvement. On analysing the causes of delay it was found that the
lack of information given to the patient regarding preparations for the test was the
Anova: Single Factor major cause of delay and increased pre-test waiting time. The major contributor
SUMMARY for increased post-test waiting time was the non-streamlined process flow of the
department and repetitive steps performed. These were small issues giving rise to
Groups Count Sum Average Variance delayed overall operations. The solutions adopted hence were simple to under-
Time after Impl. 100 5131 51.31 1377.852 stand and follow. Also they were one time changes. The Written communication
system was an unmanned process that successfully reduced the Per-test waiting
Time before Impl. 100 9982 99.82 4272.533 time by 23 minutes and the Clustered Seating arrangement got the Radiologist
and other people who were key personnel of the entire process flow closer and
ANOVA reduced redundant steps and successfully reduced the Report generation time by
48 minutes.
Source of Variation SS df MS F P-value F crit
Hence it can be inferred that small but effective steps can make a positive impact
Between Groups 117661 1 117661 41.64707 8.23E-10 3.888853 in any department if the key problem area is well identified and worked upon.
Within Groups 559388.2 198 2825.193
Total 677049.2 199 REFERENCES
1. Riebling, N. (2005), “Six sigma project reduces analytical errors in an automated lab”,
Table value of F=3.88 Clinical Issues, June, pp. 20-3
Calculated value=41.6 2. Breyfogle, F. W. (2003) “ Implementing Six Sigma—Smarter solutions using statistical
methods” (2nd ed.). New York: Wiley.De Koning, H., & De Mast, J. (in press). A ratio-
nal reconstruction of Six Sigma’s breakthrough cookbook.International Journal of
Since the calculated value was higher than the ANOVA table value (Annexure 3), Quality and Reliability Management, 23(5).
we rejected the null hypothesis. 3. “An overview of six sigma applications in healthcare industry.” Mehmet Tolga Taner
and Bu¨lent Sezen Gebze Institute of Technology, Kocaeli, Turkey, and Jiju Antony,
Hence there was significant difference between the two Post-test report genera- Caledonian Business School, Glasgow, UK
tion times. Hence the implementation of Clustered seating showed a positive 4. Antony, J., Antony, F. and Taner, T. (2006), “The secret of success”, Public Service
result. Review: Tradeand Industry, Vol. 10, pp. 12-14
5. “Implementing Lean Six Sigma Methodologies in the Radiology Department of a Hos-
5.Reports generated within set time period before implementation= 51% (May pital Healthcare System”. Jamie Workman-Germann, Purdue University, Regenstrief
2015) Center for Healthcare Engineering,2007, pp. 5
6. “Increasing patient satisfaction seen in reduced wait times”. Kelly Bilodeau, The
6.Reports generated within set time period after implementation= 95% (July "Mammography Regulation and Reimbursement Report." Exerpt published in
2015) Auntminnie.com
http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=70345
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ogy department.” Cavagna E, Berletti R, Schiavon F, Scarsi B, Barbato G, La Radiol-
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8. “A Lean Six Sigma journey in Radiology.” Ronald V. Bucci,PhD, Anne Musitano,
Rph,B.Pharm; Radiology Management, A Journal of AHRA, The Association for Medi-
cal Imaging Management. May-June 2013, Vol 3, pp. 27-32
9. “Applying Six Sigma to improve diagnostic imaging.” Carolyn Pexton, Case Study
published in isixsigma.com
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diagnostic-imaging/
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ter, July 2015, Published in Radiologybusiness.com
http://www.radiologybusiness.com/topics/practice-management/quality/lean-six-
sigma-method-leads-improved-care-german-ir-suite

Figure 7- This figure graphically shows the difference in the post test
report generation times before and after the implementations.

Figure 8- This figure graphically shows the difference in the percentage of

reports generated on time (Within 2 hours of patient leaving the test
room as defined in FOS) before and after the implementations.

CONCLUSION
The objective was to identify the areas that take up the maximum amount of time
in the Radiology Department of a super speciality Tertiary care Hospital, in

International Education & Research Journal [IERJ] 27

Research Paper E-ISSN No : 2454-9916 | Volume : 2 | Issue : 6 | June 2016
ANNEXURE 1

A Lean Six Sigma approach to reduce waiting and reporting time in the Radiology Department a Tertiary care Hospital in Kolkata

DATE CASE REQUISITION TIME PREP TIME GOES IN SCAN STARTS SCAN OVER PATIENT GOES OUT REPORT MADE/VERIFIED IN
PHYSICALLY HIS

Gemba Walk Time Motion Study Part 1

Patient name TEST order time entry into test exit from test (t1) ack time & date (t2) TAT (t2-t1)

MRINMOY GHOSH CT 09:43 10:15 11:15 10:24 00:00

USHA THAKUR MRI 11:12 11:15 11:22 11:21 00:00

Time Motion study Part 2 Sample

Time Motion study Part 3 Sample

receiving of report by typing typing correction TAT (Typing completion

final signature delivered at counter dr. name
medical technologist commencing completion completed - exist from test)

Time Motion study Part 4 Sample

Radiologists report Typing completion Collection and Typing Pretest

In mins In mins Mins Mins Mins Post test Data System
writing time to signature sorting time waiting time

05:05 305 00:14 14 00:30 30 00:16 16 00:32 32 05:31 381

ANNEXURE 2

A Lean Six Sigma approach to reduce waiting and reporting time in the Radiology Department a Tertiary care Hospital in Kolkata

28 International Education & Research Journal [IERJ]

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