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Client Results

A few of the transformational results we have helped clients achieve.

Improving registration process of one-day-stay and observation patients

Project

The project goals were to achieve 100% correct patient assignment for One Day Stay and Observation at the time of registration, ensure correct orders on all patient charts, and improve accuracy of registration of observation patients to 75% within six months, and 100% within seven months. By using the Six Sigma methodology, communication among departments and staff improved. This resulted in an increase in productivity and a faster billing cycle.

Problem

Incorrect registration processing of one day stay and observation assignments was leading to Medicare denials. These denials caused losses in revenue, decreased accounts receivable, and decreased productivity because of claims rebilling.

Improvement Process

Over the last few years, the Office of Inspector General (OIG) focused on the area of correct billing for one day stay and observation patients. Non-compliance in this area led to financial penalties, negative publicity, and additional audits.

The project team identified the registration process as a vital contributor to incorrect billing. Specific critical-to-quality (CTQs) measures were identified from voice of the customer and included, accurate patient ordering and accurate patient typing. Further, the team realized that the Registration Department did not always receive the patient orders thus, they relied solely on communication from nurses or unit secretaries for the order, resulting in false data. By determining this root cause, the team solved the problem by requiring a copy of the order be sent to the Registration Department and patient type be assigned only upon direct order receipt. Project implementation and completion occurred in eight months.

Standardization of the registration process resulted in decreased defects per million opportunities (DPMO), cost, and rework avoidance. By implementing improvements in the registration process, the team decreased Medicare denials, increased accounts receivable, increased productivity because of decreases in rework, and decreased meetings with the OIG.

Further, Six Sigma practice enabled implementation of standardized registration for one day stay and observation patients at three of the four facilities.

The project improved communication between departments, nurses, and case managers, allowing cooperation between these teams and ensuring correct registration of patients. Productivity improved because of less rework and a faster billing cycle.

Results

Through registration standardization, the hospital realized a
$308,000 savings in cost avoidance (average charges for one day stay
patients [$2,200] x number of incorrectly billed cases [140]) and a $37,770
savings in rework (20 hours a week), for a total savings of $345,770.

Improving compliance with CMS door-to-balloon core measures

Project

A team consisting of representatives from the Cath Lab, E.D. clinical informatics, pharmacy, and the Quality Department was selected to improve door-to- balloon time, using the Six Sigma DMAIC methodology as its improvement method. Voice of the Customer, process maps, cause-effect diagrams, and Failure Mode and Effects Analysis (FMEA) were used to identify a number of potential root causes for the delayed door-to-balloon time.

Problem

A large not-for-profit hospital was struggling to meet the Centers for Medicare and Medicaid Service’s (CMS) new standard for door-to-balloon time, which was reduced from 120 minutes to 90 minutes in July of 2006. Based on the third and fourth quarters of 2006, the hospital’s aggregate mean/index rate for door-to-balloon time within 90 minutes was only at 47 percent. The hospital knew that non-compliance with the new standard could result in lost revenue from CMS and have a negative impact on clinical outcomes, patient satisfaction, and length of stay.

Improvement Process

The scope of the project included all patients who met the CMS requirements for Percutaneous Coronary Intervention (PCI)
within 90 minutes. The boundaries of the process began when the patient entered the Emergency Department (E.D.), and ended when the balloon was inflated during the PCI. The team selected the DMAIC process as its improvement method. A Six Sigma DMAIC project is defined as a project that eliminates a chronic problem that is causing patient dissatisfaction, defects, costs of poor quality (COPQ), or other deficiencies in performance.

Define – Using performance data from the last half of 2006, the team determined the current process capability. During this time frame, 104 patients received PCI within the scope definition of the project. Of these 104 patients, only 51 received PCI within the 90–minute window. In order to understand how the customers and stakeholders felt about the process, and to further define their needs, the project team conducted voice of the customer interviews with physicians, E.D. staff, and Cath Lab staff. The interviewees believed that the cause of delays included staff timeliness of arrival to the Cath Lab, timeliness of diagnosis in the E.D., and the timeliness of placing the call to the Cath Lab staff.

The team spent time documenting the current process using a process flow diagram. By analyzing this process map, the team revealed many failures within the process that could potentially be root causes. The team broke the patients into two groups: those walking into the E.D. and those arriving by ambulance. For patients walking into the E.D., the team identified that the process from door-to- balloon consisted of 40 steps. The team performed Lean value analysis and identified a surprising revelation: only five of those steps (12.5%) were value added.

Twenty-one of the steps (52.5%) were considered business- required non-value added. This meant that 14 steps (35%) of the process were completely non- value added. The process for patients arriving by ambulance was similar to that of walk-ins. These patients went through 44 steps, only five of which were value added (11.4%). Twenty-four steps were business-required non- value added (54.5%) and 15 steps (34%) were non-value added.

Measure – The team collected data on the process. The current mean door-to-balloon time was just over 93 minutes, with a standard deviation of 22 minutes. This represents a process capable of meeting the 90–minute target only 55% of the time. In
statistical terms, the process produced 451,923 defects per million opportunities (DPMO) for a short-term sigma of 1.62. This indicated a great amount of variation in the process.

Using a cause-effect diagram, the project team identified some of the major theories causing delayed door-to-balloon time. They included:

  • The current process for placing the call to the Cath Lab team
  • Variation in E.D. physician practice
  • Variation in Cardiologist practice
  • Incomplete/inaccurate documentation/abstraction
  • Emergency Medical Services EKG is not used to make the initial diagnosis of STEMI (AMI with ST elevation on the EKG indicating infarction)

Analyze – Using the process maps, cause-effect diagrams, baseline measurements, Failure Mode and Effects Analysis (FMEA), and voice of the customer (VOC), the team identified a number of potential root causes of the delayed door- to-balloon time. These theories were tested using statistical analysis, and a number of theories were proven to be vital Xs.

Improve and Control – With several proven theories, the team generated a number of potential improvement strategies to reduce door-to-balloon time. The team narrowed the list of potential improvements, using such tools as the weighted selection matrix, and they identified several to be implemented. “Red Rules,” which are non-negotiable steps in the process with defined accountability, were developed. Some included:

  • Revise the Code-Save-A-Heart order set and flow sheet
  • Shift from retrospective to prospective data collection
  • Revise Physician progress notes to indicate the reason for the delay

Results

At the onset of the project, only 47% of patients met the door-to-balloon standard of less than 90 minutes. After the pilot improvement solutions were implemented, the door-to- balloon compliance rate rose to 82%, which was a statistically significant improvement. The sigma level increased from 1.62 to 2.41. The team continued to work on improvement solutions and compliance continued to improve after October 2008. The team was satisfied with the results and determined to continue using Six Sigma DMAIC to identify the next round of root causes.

Improving compliance with heart failure discharge instructions

Project

The project team consisted of a wide variety of clinical and support personnel. Its members represented outcomes management, nursing, respiratory, professional practice, medical staff, and finance. The team selected the Six Sigma DMAIC process as its improvement method. Using Juran’s Pareto Analysis, VOCs, cause-effect diagrams, and FMEA, the team developed improvement strategies and was able to reach its goal of a 90% compliance rate with heart failure discharge instruction.

Problem

A not-for-profit healthcare system found that adherence to clinical quality ob- served metrics for inpatient heart failure discharge instruction (HF-1) was consistently below national standards. For FY 2006, the average observed rate of compliance was 45.3%. Noncompliance could result in penalties with reimbursements from the Centers for Medicare and Medicaid Services (CMS), additional costs because of the potential of harmful events, and a decrease in patient satisfaction.

Improvement Process

The project Y was average length of stay (ALOS), measured in days for all adult inpatients coded with DRG 1272 (heart failure and shock). This included patients entering the facility through the Emergency Department (E.D.), direct admits from a physician, or patients arriving from another healthcare organization. The beginning boundary for the project was the time the admission order was logged. The ending boundary was when the patient was discharged from the bed and left the floor. Excluded from the project was the patient’s stay in the E.D., and observation patients (held

To better understand the current process, length of stay data were gathered and the process was characterized in terms of the major workflows. Over the preceding year, 57% of DRG 127 patients had a length of stay less than or equal to the target of 4.1 days. This had an associated baseline sigma level of 1.68 and cost of poor quality of $1,001,000 annually. A SIPOC high-level process map and detailed process maps were created for the following workflows: E.D., inpatient flow, floor arrival, critical care transfer, ongoing assessment, and discharge. This effort provided all team members with a deeper under- standing of the overall process.

After analyzing these process maps, the team brainstormed potential causes of extended length of stay and organized
them into possible cause categories. A cause-effect diagram was constructed for each possible cause category. Using the diagram, the team was able to further identify possible root causes. Subject matter experts organized these theories by common groupings. As a result 25 possible root causes were identi- fied. To narrow the group, the team prioritized the root causes based on the degree of expected impact on length of stay, and the degree of control the team had over them.

A detailed data-collection plan was created to document data sources, sample sizes, data analysis tools, and responsible parties for each of the possible root causes. In most cases, data were available in electronic logs, but new data had to be collected for others. Graphical analysis tools used included box plots, scatter plots, Pareto charts, and bar charts. In addition to descriptive statistics (average, median, standard deviation), statistical analysis tools including non- parametric hypothesis tests, regression, and Chi-square analysis were used. Some hypothesized root causes were:

  • Inpatient holding process was not standarized
  • Socially-related discharge needs assessments were not comprehensive
  • Socially-related discharge needs were not identified early in admission

Rigorous analysis of the data revealed the vital few Xs driving extended length of stay. Some included:

  • Inpatient holding process not standardized
  • CHF standard orders were not used (no parameters)
  • There was delay between the discharge order and the time the patient leaves the floor.

The team brainstormed possible solution strategies that would address each of the vital few Xs causing extended length of stay for congestive heart failure patients. Some included:

  • Patient holding: Develop ways to get the patient out of the E.D. faster; improve and expedite care for patients that are held.
  • CHF Standard Orders: Reduce variation in practices by developing an order set and interdisciplinary pathway and provide for the education of physicians and hospital staff in their use.
  • Delay in DC orders to leave floor: Develop a better communication process in relationship to the anticipated discharge date and the needs starting at day one of admission.

Additional detailed solutions were developed to enable these strategies. These solutions were rated against
13 specific performance and business criteria using a Pugh Concept Selection Matrix. The selected solution was piloted over a four-week period. During the pilot, the team collected data on length of stay and key process variables to ensure individual components of the overall solution were properly implemented and effective.

The pilot was successful in reducing length of stay to an average of 2.6 days for patients with hospitalists attending, with 91% of patients discharged within 4.1 days of admit. The team documented process changes on the original process maps and developed an implementation plan to formally roll out the new process.

A control plan was developed to ensure the improvements and gains would be sustained over the long term. Key elements included the control subjects (length of stay, readmission rate, and proven Xs), measurements (sensor, frequency, sample size), and actions (criteria for taking action, responsibilities).

Results

Results are being monitored as an ongoing activity. To date, the ALOS has been reduced 31%, from 5.18 days to 3.6 days and continues to drop towards the level shown possible in the pilot. Compared to the baseline of 57% of patients discharged within 4.1 days, more than 80% are now discharged within 4.1 days. Readmission rates are being monitored to ensure there is no increase.

Multi-National Manufacturer of Components for Electronic and Electrical Products

Project

The client has more than 50 plants worldwide and another 20 sales and distributions locations with four divisions, each focused on specific market segments. Price competition is strong, but key customers also expect reliable on-time delivery and quick response for new product development.

As the company has expanded and sustained its efforts, all aspects of the way business is conducted have benefited from the disciplined Lean and Six Sigma methods from Juran. They have used them to develop and implement improved pricing discipline. Many improvements have been made in Sales and Marketing processes. Even the Internal Audit function has greatly expanded its capacity to deliver operational audits without any increase in staffing. Six Sigma analytics have been applied to financial planning and analysis to deliver more useful and actionable information to executive leadership for making both tactical and strategic decisions.

“Thought you would like to know that despite the challenging year, we have managed to achieve our original [annual] $50M savings goal. Many thanks to your people and the high caliber of technical support, leadership and teamwork they have delivered. This goal was set before anyone suspected the economy would fall off the cliff, and production volumes with it. The process has been flexible enough to allow our organization to reprioritize and change focus just when we needed to make it happen.” . . . Vice President, Quality

Results

The number of steps in the special order process was reduced from twelve to three. The number of special orders has been reduced from 700 annually, to 200. Interrupted production runs have been reduced by a factor of 500 per year. Special orders that used to take six months are now being filled 85 percent of the time within two days. In a two-year period, the company’s overall quality effort supported 86 teams, which collectively
saved more than $5 million.

Improving Turnaround Time by Reducing Backlog

Project

In the case of one international airline, the problem in question was that internal turnaround time was not competitive with external maintenance, repair and overhaul (MRO) facilities. The data collected showed there was no discernible systematic process followed, resulting in a fast-growing list of open work orders. Queue time of components was not controlled, causing excessive backlog. The project goals put in place were the development/implementation of a controlled process for queue time in one shop, and replication across the board—as well as the reduction of the average cycle time by a minimum of 50%.

Solutions were developed for some proven root causes. For example, queue time measurements were inconsistent, so data was collected at pre-determined points to measure queue time consistently. Also, there were many different processes developed by different component shops, so processes needed to be documented and standardized.

It was determined that the company had to become more sensitized to the requirement of relying on accurate and timely data; more emphasis had to be placed on data collection and retrieval. It became important to analyze the use of data and how it relates to the strategic direction of the company to drive project decisions.

Improving the Speed of Service for a National Call Center

Project

Many service organizations rely in part on an effective contact center to provide the personal touch for customers in a convenient and effective environment. The first step toward transforming these vital organs of service is recognizing the traditional tools, such as average speed of answer or average talk time.

Yet clients have made major reductions in the cost of customer contact centers by focusing on the effectiveness of the processes first. One such call center reduced annual costs by $900,000 by diagnosing and removing the causes for delay during a customer call and improving the speed of service. By replicating these results to other call centers, the total company savings were $5.7 million per annum.

First-call resolution or “one and done” has been the elusive goal for many call centers. One Juran client determined that at least one-third of all calls were repeat contacts for the same issue. An aggressive series of focused projects identified the root causes for incomplete resolution and for customer dissatisfaction with the contact. The cumulative sum of these projects increased first-call resolution (as seen by the customer) from 70% to 85% while raising customer satisfaction from 75% to 92%. In addition, they were able to save and redirect significant service resources because total call volume per customer actually declined by 40%.

Improving Cash Flow by Reducing Turnaround Time for Referred Accounts

Project

A financial services firm was suffering reduced cash flow because the process by which it referred accounts to attorneys for collection was taking too long. With Juran’s training and coaching, a project team improved the turnaround time from 10.5 days to 3 days, thereby improving monthly cash flow by $236,000. Non-value added activity was eliminated. The number of functional hand-offs was reduced sharply. Root causes for delays while waiting for some of the paperwork were removed. Delays resulting from missing or defective parts of the
documentation were eliminated.

Improving Customer Satisfaction While Adding $30 Million to the Bottom Line

Project

A major national telecommunications company with a long tradition of quality asked Juran to help it move to a new level of performance and change its internal culture to one of customer focus. In the first year, the company saved an additional $30 million from improvements while experiencing major increases in customer satisfaction. The top senior managers participated in Juran training and were supported in their transformation with regular coaching.

Improvements during the first year covered the full range of business activity, from technical performance to customer service to financial operations. Among the key improvements were: (1) Substantially reducing the time from order to operation for high-capacity land lines, (2) Resolving customer claims more quickly with greater customer satisfaction, (3) Cutting by more than half the time required to restore service following equipment failure or external damage, (4) Improving the reliability of performance for major systems and switching, and (5) Improving the performance of debt management.

Their Lean Six Sigma projects are fully integrated into their strategic and annual plans, and are continuing to deliver on the four strategic focal points: Increasing bandwidth, improving customer satisfaction, developing new services to compete in the new digital marketplace, and increasing the efficiency of service delivery.

Improving Efficiency in MASH Units

Project

When the U.S. Army created its policy guide for moving 80-bed MASH units, its focus was on maximum efficiency. Unfortunately, that efficiency was targeted at loading up four transport trucks and breaking camp, not at unloading vehicles and setting up camp. The process of loading the 2.5-ton trucks for departure did not take into account the needs and logistics involved in rebuilding the MASH units at the next site. As a result, the unloading and construction process could draw valuable time away from the essential purpose of MASH units—to aid injured soldiers. A team of soldiers, stationed with the 25th Infantry Division in Hawaii, decided to redesign the process.

The team, made up of the unit commander, the executive officer, the first sergeant, and the ambulance platoon leader, applied some common sense to the process. The improvement was to load supplies onto the trucks in reverse order of need; the most important equipment would be placed on the trucks last, allowing it to be taken off the trucks first. The old process allowed eight hours from the time the order to “Move MASH unit” was handed down to the time the surgical ward could begin to take patients. The 25th Infantry Division’s redesigned process reduced the time needed to two hours. For its efforts, the unit was recognized as the best U.S. Army medical unit in the world for two years running.

Results

For a $25,000 investment in training, certification, and time to diagnose process-related problems, Juran has documented results for $375,000 per project or a ratio of 15:1.

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Our Legacy

Joseph M. Juran’s major contribution to society was in the field of quality management, and he is often called the father of quality. Perhaps most important, he is recognized as the person who added the managerial dimension to quality, broadening it from its statistical origins. His contributions to quality were so important that he is continually written about in many publications, such as The Harvard Business Review, BusinessWeek, The Financial Times, and many quality-related journals.

>> Read more about the Juran legacy.

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