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26 Aug 2012
Roulla Nau
George
Washington
University

A CASE STUDY ON
QUALITY AND
PROCESS
IMPROVEMENT

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AT SICKLEY HOSPITAL CENTER

Tridib Borkakoty

CONTENTS

Objectives of the quality improvement plan

The theoretical bases that support the QI plan

Process Analysis

The types of staff and process improvements needed to implement the QI effort 5

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Implementation

Mechanisms to evaluate the plan

References

Appendix

Objectives of the quality improvement plan:

The primary goal of the plan presented here, is to improve patient satisfaction at the ED
by reducing the time a patient has to wait before receiving treatment. To achieve this
goal, the objectives of this plan are to
a. Management commitment for action to initiate and monitor the Q/PI efforts.
b. Make all employees focused on patient satisfaction.
c. Analyze and improve every process that delays treatment.
The theoretical bases that support the QI plan:
There are many evidences present in the case study which suggest that the
management of the Sickley Hospital has not been following any of the fourteen
management points of Dr Deming. Instead, they follow management style that Dr

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Deming considers harmful to an organization. Currently the ED and the Lab

departments function as if they are two different entities. The Lab techs are now only
responsible for processes within the Lab (Management by objective). They are not
concerned if the report quickly gets to the physician and patient treatment starts.

The

system of ranking employees, by conferring the employee-of-the-month reward, is also

affecting the morale of the employees. The frustrations among the employees are
evident in their interactions with each other. It is an obstacle to co-operation among the
employees. The Chief Physician designation in the ED is also creating ranks among
physicians. Thirdly, there are evidences of tampering (Management by Results). The
organization learning is single loop in nature. Whenever there is an error in a process,
employees take action to correct it but there are no attempts to correct the underlying
causes of the error.
The proposed QI Plan supports introduction of the concept of 4 th generation
management to improve the quality and performance of the ED department. Managers
need to work around the three corners of the Joiner triangle to focus on quality, all in one
team and develop scientific process. Some of the 14 points for management as
suggested by Dr Deming can be applied here are 1. Improve every process, 2. Institute
leadership of people: 3. Drive out fear, 4. Break down barriers: 5. Permit pride of
workmanship: 6. Encourage education:

7. Top management commitment and action:

Process Analysis:
From the analysis of control chart 2 and control chart 3 (see appendix), prepared from
the given data, we find that the average time for STAT test turn around time (TAT) for

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Hemoglobin and Potassium are approximately 24 and 36 minutes respectively. They

match with the CAPs definition of TAT and the standard time requirement for such tests.
However, on further analysis of the control charts, it is observed that both STAT test
process for hemoglobin and potassium are unstable. There are several incidents when
the TAT values are way higher than the upper control limit. Since TAT data considers is
calculated from the time the specimen is collected to the time results are made available
in the LIS (Laboratory Information System), an unstable process indicates that there are
special cause of variations exist within the laboratory process.
Though the LAB TAT average is only 24 and 36 minutes for hemoglobin and potassium,
there are significant time delays between
a) STAT test order is placed and LAB receives the blood samples.
b) LAB reports are available at the LIS and it is made available to the physicians.

The types of staff and process improvements needed to implement the QI effort:
The top management of the Sickley Hospital is responsible to initiate QI plans. It is the
task of the management to remove the obstacles that prevent people from doing their
jobs correctly. It needs to commit for action and overhaul itself.
The management needs to instill All-One-Team concept. Performance of the ED can not
be improved without co-operation from other departments. Employees from ED, LAB, IT
and all other departments must have patient care as their primary goal. They need to
co-operate across departments to make sure that patients in the ED get medical care as
fast as possible.

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To avoid delay between placing order by physicians and lab receiving the blood sample,
ED should have own staff to draw blood samples and co-ordinate with Lab. The process
to get reports from lab to the physicians needs to be improved to avoid any unnecessary
delay.

The time required for these two processes are currently not available. The

department of quality is to record these data for further analysis of these processes.
Implementation:
a. As part of overhauling the management, the quality department is to be headed by a
senior level manager having experience in quality control measures.
b. Immediately remove the employee ranking system. There will be no employee-of-themonth recognition with immediate effect. There will be also no Chief Physician
designation in ED.
d. All ED nurses will be trained to collect blood sample. Information about the quantity
and other requirement will be provided to them. They will collect blood samples at the
same time when a physician places order. [refer to flow chart 1 in appendix]
e. An LIS system to be installed at the ED. The Nurse will update the LIS with the order
information. The IT department is to resolve issues with data transfer between LIS and
HIS. Once it is resolved, ED nurses can start using HIS system again.
e. Lab technician will page central nursing station when test results are available in the
LIS. ED nurse can directly access report from LIS.
f. To improve the unstable process at the LAB we need to employ Special Cause
Strategy. Currently there is not data available on individual sub-processes in the lab. Lab
team should breakup the processes used for testing and keep record of time required for
each process. The lab director to review data frequently to detect any special causes

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quickly. Immediate measure should be taken to prevent any delay caused by special
causes. Frequent reviewing of data will help to understand what was different that
caused the delay. Once the special cause of variations are known, long term measures
can be taken to improve the unstable process.
Mechanisms to evaluate the plan:
The Quality department will monitor the patient wait time starting from registration to the
time the patient starts receiving treatment. The time will be recorded for the three
separate events - from physician ordering lab test to the start time of lab process, the
total time taken by the lab and then the time between laboratory reports is available to
the time when patient receives treatment.

These data will be reviewed by the

management after a month to check for stability in the process and carry out further
PDCA cycle.

References:
1. Case Study : Case Study: Whos to Blame? ED-Lab Tension Rising
2. Brian L. Joiner. (1994). Fourth Generation Management, 4th Edition
3. W Edwards Deming. (1994). The New Economics for, Industry, Government and
Education, 2nd Edition

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APPENDIX

-9Physician orders STAT test and

gives it to the nurse

Nurse refers to the information

on blood test requirement and
accordingly collects required
quantity of blood from patient.

Lab acknowledge receipt in

LIS

Lab processes sample and

results are entered in LIS

Label the blood sample

Lab technician to page ED
nursing station that report is
ready
Update LIS with order
information and page Lab

Send Sample to Lab

ED nurse prints report from

LIS and takes it to the
physician

Patient gets treatment

Chart 1 Flow chart to improve Stat Lab test process

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Chart 2 Control Chart for STAT Hemoglobin test TAT

Chart 3 - Control Chart for STAT Potassium test TAT