44

Journal for Healthcare Quality

Using Six Sigma Methodology to Reduce
Patient Transfer Times from Floor to
Critical-Care Beds
Stephan J. Silich, Robert V. Wetz, Nancy Riebling, Christine Coleman, Georges Khoueiry, Nidal Abi Rafeh,
Emma Bagon, Anita Szerszen
Abstract: Introduction: In response to concerns regarding delays
in transferring critically ill patients to intensive care units (ICU), a
quality improvement project, using the Six Sigma process, was
undertaken to correct issues leading to transfer delay. Objective:
To test the efcacy of a Six Sigma intervention to reduce transfer
time and establish a patient transfer process that would effec-
tively enhance communication between hospital caregivers and
improve the continuum of care for patients. Methods: The project
was conducted at a 714-bed tertiary care hospital in Staten Island,
New York. A Six Sigma multidisciplinary team was assembled to
assess areas that needed improvement, manage the intervention,
and analyze the results. Results: The Six Sigma process identied
eight key steps in the transfer of patients from general medical
oors to critical care areas. Preintervention data and a root-cause
analysis helped to establish the goal transfer-time limits of 3 h for
any individual transfer and 90 min for the average of all trans-
fers. Conclusions: The Six Sigma approach is a problem-solving
methodology that resulted in almost a 60% reduction in patient-
transfer time from a general medical oor to a critical care area.
The Six Sigma process is a feasible method for implementing
healthcare related quality of care projects, especially those that
are complex.
Keywords
patient safety
quality improvement
Six Sigma/Lean
Introduction
A delay in transferring newly critically ill pa-
tients to an intensive care unit (ICU) may lead
to an unfavorable impact due to the subopti-
mal environment for delivering the appropri-
ate treatment (Beckmann, Gillies, Berenholtz,
Wu, & Pronovost, 2004). For example, patients
with septic shock had a signicant delay in re-
ceiving intravenous uid boluses and inotropic
agents on a medical oor as compared to those
in an ICU (Duke, Green, & Briedis, 2004).
A 6-hr transfer delay of critically ill patients
fromthe emergency department to the ICUwas
shown to increase hospital and ICU lengths of
stay (LOS) and in-hospital mortality (Chaln,
Treciak, Likourezos, Baumann, & Dellinger,
2007). A greater mortality was also observed
in patients requiring mechanical ventilation
or renal replacement therapy when ICU ad-
mission was delayed (De Feo & Barnard,
2005).
At our hospital, ICU transfer delays resulted
in (1) poor utilization of physician resources
(e.g., residents being utilized to observe the
cardiac monitor of upgraded patients) and (2)
increased nursing demands to provide inten-
sive care to these patients without a change in
nurse:patient ratio. This further affected the
physician and nursing staffs abilities to care
for other patients. Transfer delays beyond 5
hr were not uncommon and resulted in de-
creased patient, family, and staff satisfaction.
In response to these issues, the institution as-
sembled a Six Sigma Team.
Six Sigma can be described as a manage-
ment philosophy that focuses on developing
and delivering near-perfect products and ser-
vices (Pyzdek, 2003). It was originally developed
by Motorola in 1986 and further enhanced by
General Electric (Jiju, 2004). Sigma is a sta-
tistical term that measures how far a given pro-
cess deviates from the mean (Lundberg et al.,
1998). There are six standard deviations in
variable performance of a given process. The
central idea behind Six Sigma is that if the de-
fects of a process can be measured, then so-
lutions can be designed to eliminate them. A
defect is anything that could lead to customer
dissatisfaction (Fairbanks, 2007). Six Sigma de-
nes quality as having less than 3.4 defects per
million opportunities (DPMO). The Six Sigma
score correlates with the number of defects; less
defects yield a higher score.
Six Sigma Teams consist of people from dif-
ferent departments within an institution who
are involved in the process that needs improve-
ment. The leadership and technical roles of Six
Sigma are organized in hierarchical fashion.
Master Black Belts are experts in Six Sigma
that assist in data calculations and function as
resources to the team. The teamis led by Black
Belts whohave prior experience withSix Sigma
and can function as a leader. Green Belts are
team members that have some experience in
Six Sigma and have been selected by the in-
stitution to become more familiar with the Six
Journal for Healthcare Quality
Vol. 34, No. 1, pp. 4454
C 2011 National Association for
Healthcare Quality
Journal for Healthcare Quality
Vol. 34 No. 1 January/February 2012
45
Sigma process. Yellow and White Belts are rel-
atively new to Six Sigma (Sonnenfeld, 1985).
A major tenet of Six Sigma is that the process
must be organized and data driven. Six Sigma
members use the ve-stepDMAIC(dene, mea-
sure, analyze, improve, and control) approach,
which is an acronym for dening the major is-
sues; measuring the system process or practice
prior to any interventions; analyzing the initial
data to develop a root-cause analysis; improv-
ing the system process through intervention;
and nally the control phase where data are
collected to assess the impact of the interven-
tion. We hypothesized that using this approach
would establish a more efcient practice that
would signicantly decrease the average trans-
fer time.
Methods
Setting
This study was performed at a 714-bed, tertiary
care, teaching hospital located in New York
City.
Scope of the Project
The team consisted of a Physician Sponsor,
Chief Medical Resident, Director of Bed Man-
agement, Patient Care Unit Manager, Charge
Nurse, Unit Clerk, Director of Environmen-
tal Services, Assistant Director of Health In-
formation Management, and Manager of the
Transport Department. A hospital administra-
tor was the assigned Black Belt responsible
for team building and project management.
Three team members (Director of Bed Man-
agement, Assistant Director of Health Informa-
tion Management, and a hospital administra-
tor from the North-Shore Long Island Jewish
(NSLIJ) Healthcare System) underwent Green
Belt training. Several members had prior expe-
rience throughother Six Sigma projects (Yellow
Belts) and some members were hearing about
Six Sigma for the rst time (White Belts).
The initial step was the development of the
Project Charter to clearly dene the problem
statement, business case, and goal and scope
of the project, which was to include all patient
transfers to the ICU and the cardiac care unit
(CCU).
Dene Phase
A high-level process map (Figure 1) was cre-
ated to graphically display and better under-
stand the major events that were occurring. At
our hospital, physicians (mostly residents) were
being utilized to personally observe the heart
monitor in nontelemetry settings. It was also
learned that some oor nurses had difculty
administering care (e.g., intravenous pressure
agents) that was unfamiliar to them. Family
complaints also arose when there was a per-
ceived, overly long wait to transfer patients to
the ICU/CCU. The objective of this Six Sigma
deployment was to improve the patient trans-
fer time, which would in turn have a benecial
impact on quality by providing critical care in
the appropriately monitored setting, improving
the utilization of the residents, improve patient
safety by not having untrained staff administer
intensive drug regimens, and increase patient,
family, and staff satisfaction.
The nancial impact of this project was
deemed too difcult to accurately measure.
However, it was recognized that quickly freeing
up residents allowed them to return to caring
for other patients, thus limiting potential de-
lays in LOS. Limiting potential errors, by hav-
ing critical-care-trained staff provide the care,
could decrease resource wasting and avoid po-
tential malpractice suits. Limiting patient com-
plaints and improving patient/family satisfac-
tion can generate potential income because
complaint investigations are costly and higher
satisfaction can better ensure that patients will
want to return and refer others to the hospi-
tal. Finally, improved staff satisfaction can help
limit staff turnover, which limits recruitment
and training costs.
The most clearly dened, objective measure-
ments identied were the time stamps at differ-
ent steps generated by the computerized pro-
grams used in the transfer process. The clarity
of these measurements facilitated the collec-
tion of data and easily identied which steps
generated the most amount of time. The objec-
tiveness of using time stamps ensured that the
measures could not be easily refuted.
Measure Phase
A data-collection plan was created to include
eight identiable phases for time measure-
ment: (1) bed management notied via phone
or transfer order; (2) bed management assigns
bed; (3) bed management faxes transfer re-
quest to the sending unit; (4) environmental
services ag the bed clean (ready/available
bed); (5) sending unit informs the receiv-
ing unit; (6) sending unit clerk inputs trans-
fer order into the computer; (7) transport
46
Journal for Healthcare Quality
Figure 1. High-Level Process Map (Dene Phase)

Supplier: The person or organization who provides the inputs to your process.

Input: The materials, resources, and data required to execute your process.

Process: The series of steps or activities that uses one or more kinds of INPUTS
and changes them to an OUTPUT that is of value to the CUSTOMER.

Output: The tangible products or services that result from the process.

Customer: The person or organization who receives the outputs of the process.
SUPPLIER INPUT PROCESS OUTPUT CUSTOMER
ATTENDING
PHYSICIAN
PHYSICIAN
ORDER
BED MANAGEMENT
NOTIFIED OF
TRANSFER REQUEST
TRANSPORT
ORDER
RESIDENT
PATIENT
UNIT RESIDENT
ORDER WITH
CORRECT
DIAGNOSIS
BED MANAGEMENT
ASSIGNS BED
ASSIGNED BED
RESIDENT
PATIENT
NURSING UNIT
NURSING
REPORT
BED MANAGEMENT
NOTIFIES RECEIVING
UNIT & SENDING UNIT
FAXED REPORT RECEIVING UNIT
SENDING UNIT
FAXED
REPORT
SENDING UNIT
ORDERS THE
TRANSFER
COMPLETED
TRANSPORT
ORDER
TRANSPORT
DEPT
PATIENT
TRANSPORT
TRANSPORT
ORDER
PATIENT
TRANSFERRED
TO UNIT
COMPLETED
PATIENT
TRANSFER
PATIENT
High-Level Process Map
Start Point: The moment Bed Management is
notified of the transfer request
End Point: The moment Bed Management is
notified that the patient is in the Critical Care Bed
department dispatches transporter; and (8) re-
ceiving unit clerk inputs electronic transport
order as completed. The process and measure-
ment also included a breakdown of the three
different work shifts, as well as the number
of beds involved in the transfer (one-, two- or
three-bed transfers). For example, if a patient
was transferred from the oor straight to an
awaiting ICU bed, that was considered a one-
bed transfer. If there was no available bed in
the ICU and an existing patient in the ICU had
to be moved out so a patient could be moved
in, that would be a two-bed transfer and so on.
Preliminary measurements revealed that the
average time for a patient to be transferred
from a oor bed to a critical-care bed was
214 min, with a maximum delay time of 420
min. Additional data showed that the amount
of variation in the process (assessed by the stan-
dard deviation) was 170 min. Initial capabil-
ity analysis revealed 423,728 DPMO. The sigma
score was only 1.6. The performance goals rec-
ommended by the Master Black Belt were to
reduce the standard deviation by 50%and raise
the sigma score to approximately 2.2, thus de-
creasing the DPMO to 242,000. Subsequently,
the goals for this project were set at 90 min
for average transfer time and an upper speci-
cation limit (USL) set at 180 min for a max-
imum individual transfer time. The USL of
180 min was largely determined by the fact
that the measurement phase showed that the
maximum number of beds that needed to be
cleaned in any one unit transfer was three.
One hour per each patient transferred in a
three-bedtransfer wouldallowfor proper clean-
ing of the room, transfer orders to be writ-
ten, proper communication handoffs between
hospital personnel, and safe transfer of the pa-
tients and their belongings. The USL is an up-
per limit above which the process performance
is deemed unacceptable (a defect). The lower
specication limit (LSL) was set at 0 min,
which limited analysis of transfers that went
Vol. 34 No. 1 January/February 2012
47
Figure 2. Root Cause Analysis as a Fishbone Diagram (Analyze Phase)
Utilization
Measurement Materials
Environment
Order sheets
Printers
MDs
Weekend day shift
Night shift
Chart misplaced
Chart not flagged
Unable to reach MD
Process
Transfers
Orders not inputted
Fishbone
(Cause and Effect Diagram)
No beds available
Nurses
Clerks
Bed management
Teletracking reports
Chart documentation
Environmental services
People
Faxes
Transporters
Machines
Fax machine Day shift
Discharges
Series computer system
Tele monitors
Transporters not dispatched
RNs do not discharge patient
Bed vs. stretcher
Rounds
Phones
Weekend night shift
Ventilator
1, 2, or 3 bed transfer
Variation in
Turn-around
Time for
Transferring
Patients
exceptionally well. The customers (represen-
tative residents, nurses, bed management per-
sonnel, transporters, etc.) of this transfer pro-
cess, with the exception of the patients, agreed
to these goals/limits.
Analyze Phase
The data collected in the Measure Phase were
analyzed to create a list of process steps and
identify sources of variation in the process.
Complex processes often have a myriad of de-
nable steps. Identifying the few vital steps, or
vital Xs as they are often referred to, will help
in avoiding the natural tendency of trying to
manage every process step. By determining the
vital Xs, it becomes possible to focus on only
those that are critical to producing the desired
outcomes.
The rst tool used was a Fishbone Dia-
gram, a cause and effect illustration that en-
hances identication of potential factors caus-
ing an overall outcomein this case, the de-
lay in transfer (Figure 2). The statement of the
problem was placed in the box at the head
of the diagram. The remainder of the sh-
bone consisted of one line drawn across the
page, attached to the problem statement, and
several vertical lines or bones. These vertical
branches, chosen as subcategories of the major
categories of inuence, were labeled with the
specic cause and effect titles. The specics of
the shbone diagram were developed by group
discussion. When completed, the diagram pro-
vided a visual understanding of the root causes
of the problem and allowed the brainstorming
for possible solutions to begin.
Next, a Failure Mode and Effects Analysis
(FMEA) was done (Figure 3). The FMEA iden-
ties potential and actual points of failure, as
well as corrective actions. In particular, this tool
identies an effect (outcome) and quanties it
based on the level of severity (using a scale
of 110). It shows how likely an effect is to oc-
cur. The likelihood of effect or the frequency
of occurrence is used to describe how often
the outcome is initiated by the root cause. The
process of stopping the unwanted outcome is
referred to as detectability. Thus, the resul-
tant value is the risk priority number (RPN),
which is computed by multiplying the sever-
ity by the occurrence by the detectability.
Of the eight steps identied, the FMEA yielded
four critical steps with high RPNs.
Finally, a series of Hypothesis Testing
(Figure 4), which uses statistics to determine
48
Journal for Healthcare Quality
Figure 3. Failure Mode and Effect Analysis (Analyze Phase)
Process Step /
Input
Potential Failure
Mode
Potential Failure
Effects
S
E
V
E
R
I
T
Y

Potential Causes
O
C
C
U
R
R
E
N
C
E



Current Controls
D
E
T
E
C
T
I
O
N



RPN
What is the
process step and
Input under
investigation?
In what ways does
the Key Input go
wrong?
What is the impact
on the Key Output
Variables
(Customer
Requirements)?

What causes the Key
Input to go wrong

What are the
existing controls &
procedures that
prevent either the
cause or the Failure
Mode?

Bed Management
Notified
(X-1)

- MD Delays
- Notification


Delays Transfer

9

-Lack of Process
Knowledge
- MD issues
- Communuication


1

No Controls in Place

7

63


Bed Management
Assigns Bed
(X-2)

- No Bed Available
- No Discharges
- No Transfers
- Holding Patients

Patient cant be
transferred


10

- 100% Occupancy
- NoTransfers

9

Daily Utilization
Rounds

6

540
Bed Management
Faxes Sending
Unit
(X-3)

- Fax broken
- Bed Manag busy

Sending Unit
unprepared for
Transfer

4

Competing Priorities

4

Manager Supervision

2

32

Envion Serv Flags
Bed Clean
(X-4)

Technical Breakdown

Bed Manag cant
assign bed


7

- Lack of Personnel
- Lack of Technical
Skills

5

Bed Management
Oversight via
Teletracking Monitor

1

35
Sending RN
Faxes Report to
Receiving RN
(X-5)

- Fax Problems
- Too busy

Receiving Unit
cant accept transfer

7

- Timely Notification
- Clinical Issues
- Shift Change


5

RN Manager &
Supervisor

8

280
Sending Clerk
Inputs Order in
Series
(X-6)

- No Standardized
Process
- Clerk Staffing

- Transport not
notified
- Respiratory not
notified
(If vented pat)

5

- Lack of Personnel
- Shift Change
- Employee Oversight

4

Clerk Supervisor
Transport Supervisor

5

100
Transport
Dispatches
Transporter
(X-7)

- No standardized
Process
- Transporter Staffing
Transport not
dispatched but no
effect (MD & RN
will transport
patient)

4

- Lack of Personnel
- Shift Change
- Employee Oversight

3

No Controls in Place
(Supervisor
Removed)

9

108
Receiving Unit
Inputs into Series
(X-8)
Conflicting priority of
clerks
Patient may leave
Unit with unclear
continuum of care

2
- Shift Change
- Competing Priorities
- Clinical Issues

4

Manager Supervision

2

16

Failure Mode: the manner in which a specific process fails.

Cause: a condition that produces a failure mode.

Failure Effect: impact on customer requirements if failure mode is not prevented.

RPN: Risk Priority Number, which is computed by multiplying the severity by the occurrence by the
detectability.

Circles: represent the process steps that resulted in the highest RPNs.
the probability that a given hypothesis is true,
was undertaken. In brief, a series of various hy-
pothesis tests were examined by calculating a
p-value, which is also known as the observed
signicance level or the probability value. The
p-value helped delineate the causes that were
vital, which focused the determining of the
potential specic causes for the differences.
After careful analysis of these three tools, it
was determined that the increased turn-around
time centered on Bed Managements ability to
assign a clean, ready bed. Thus, there needed
to be an available bed in order for Bed Man-
agement to facilitate this process. The turn-
around time greatly increased depending on
the number of bed transfers needed. When the
assignment involved a one-, two-, or three-bed
transfer, the average turn-around time was 126,
249, or 404 min, respectively.
It was also discovered that there was an in-
crease in turn-around time related to how long
it took for the sending unit to communicate the
Vol. 34 No. 1 January/February 2012
49
Figure 4. Hypothesis Testing to Determine the Pre-implementation Vital Xs
(Analyze Phase)
order (via phone/fax) with the receiving unit,
which was due to poor communication and too
many process steps. However, there was no sta-
tistical signicance in turn-around time in re-
lation to the shift time, the day of the week,
whether it was a phone or fax order, the specic
unit the patient was transferred to and from
and whether or not the transport department
was utilized.
Although it was not originally deemed a vi-
tal X, it was agreed upon by the team that the
medical residents completion of the transfer
orders was a key step. It was found that there was
no standardized process for a resident-driven
completion of the transfer orders. Some resi-
dents completed their orders immediately, oth-
ers completed them later. Also, there appeared
(by direct observation) to be poor communi-
cation between the physicians and the nursing
staff in the critical-care areas.
Improvement Phase
The following critical elements were recog-
nized: (1) poor process ow; (2) incon-
sistent communication; (3) no standardized
order writing process; (4) overutilization of re-
mote cardiac monitoring; and (5) lack of un-
derstanding at the staff level of the importance
of this issue. Next, a specic solution plan was
developed.
One new process was to pilot having a clean,
ready bed always available in a large room (ICU
Annex) used for equipment and device storage
that is located directly across the hall from the
ICU entrance. The environmental services di-
rector (ESD) and the ICU charge nurse would
have accountability for ensuring that a clean,
ready bed was always available. The ICU di-
rector personally educated all supervisors on
the new policy. This solution eliminated the
need for the units to call the ESD for bed
delivery.
Another improvement was the creation of
an electronic bed assignment notication
via the installation of Tele-Tracking software
in the ICU/CCU and Telemetry Unit. The
head of Bed Management installed the soft-
ware, educated all personnel, and ensured that
it was utilized on all shifts. Bed Management
would notify the receiving and sending units
via Tele-Tracking. Additionally, a notication
alert would now be utilized so that when Bed
50
Journal for Healthcare Quality
Figure 5. Summary of Results (Control Phase)
MEAN TIME
FROM FLOOR
TO ICU
STANDARD
DEVIATION
SIX
SIGMA
SCORE
YIELD DEFECTS PER
MILLION
OPPORTUNITIES
PRE-IMPLEMENTATION 214 min 170 min 1.6 54.00% 423,728
TEAM GOAL 90 min 85 min 2.2 75.80% 242,000
SEPT & OCT 2009 92 min 33 min 3.7 98.61% 13,333
NOVEMBER 2009 91 min 45 min 3.4 97.13% 23,255
DECEMBER 2009 91 min 42 min 3.3 96.41% 31,250
JANUARY 2010 85 min 32 min 100% 0
FEBRUARY 2010 81 min 37 min 96.41% 29,411
MARCH 2010 84 min 34 min
6.0
3.3
3.5 97.73% 28,571
APRIL 2010 70 min 29 min 6.0 100% 0
MAY 2010 77 min 31 min 6.0 100% 0
JUNE 2010 84 min 25 min 6.0 100% 0
JULY 2010 81 min 22 min 6.0 100% 0
AUGUST 2010 73 min 30 min 6.0 100% 0
SEPTEMBER 2010 88 min 39 min 6.0 100% 0
OCTOBER 2010 87 min 37 min 6.0 100% 0

Yield: represents the percent of good products or services.

Defect Counts: monitor the number of times things go wrong in Defects Per Million
Opportunities (DPMO).

Defect: any event that does not meet the customers need.

Opportunity: any event that can be measured that provides a chance of not meeting a customers
requirement.

Six Sigma Score: is a commonly used measure of process capability that represents the number
of short-term standard deviations between the center of a process and the
closest specification limit.
Management assigned a bed, it would ag as
such in both the sending and receiving units,
notifying the respective clerks of the bed assign-
ment. This eliminated multiple process steps
(i.e., the need to fax, phone, and page no-
tications) and resulted in less work for the
nurses in the ICU/CCU. Also, the ready to
move function in Tele-Tracking was instituted
by the sending unit clerk. This provided real
time notication that patients were ready to be
moved.
The process for writing transfer orders out of
the ICU/CCU was also changed. The goal was
to ensure that transfer orders were completed
immediately after rounds. All residents were
instructed to ag the patients charts for
discharge/transfer to alert the unit clerk to
place the transfer order, which notied bed
management. This solution would expedite the
transport of patients out of the ICU/CCU to
make beds more quickly available for incoming
patients.
Afourthnewprocedure called for the accept-
ing critical-care physiciantodetermine whether
or not a remote cardiac monitor was to be
placed on the patient awaiting transfer to the
units. It was realized that while some upgraded
patients (e.g., those ruling in for a myocardial
infarction) required constant cardiac monitor-
ing, others did not. Once a monitor was placed
on a patient in a nontelemetry ward, a resident
physician had to be assigned to the room to
constantly observe the patient for fatal arrhyth-
mias. If the cardiac monitor was safely deemed
unnecessary by the attending intensivist, then
this freed up the resident to facilitate the trans-
fer, as well as care for other patients.
Finally, the project itself called attention to
the importance of quickly moving critically ill
patients to the critical-care areas. Because all
departments that shared a role in this process
were part of the Six Sigma Team, neweducation
and enhanced teamwork skills developed from
this project.
Vol. 34 No. 1 January/February 2012
51
Figure 6. Before and After Process Capability

















Graph Above: 0-1000: is number of minutes Graph Above: 0-210: is number of minutes

LSL: Lower Specification Limit (0 min).

USL: Upper Specification Limit (180 min).

Target: 90 min.
Transfers: 59 DPMO: 242,000
Mean: 214 min Sigma: 2.2
St Dev: 170 min Yield: 75.80%
Transfers: 462 DPMO: 10,700
Mean: 84 min Sigma: 3.8
St Dev: 35 min Yield: 98.93%
Postimprovement Preimprovement
Control Phase
In this phase, most of the Six Sigma Team be-
comes disbanded. Constant data tracking and
documentationwere done by the process owner
(in this case, the Director of Bed Management)
and the Black Belt to measure any improve-
ments and ensure that they would be sustained.
In addition, the team sponsor and the nursing
and physician staffs were updated on a monthly
basis with on-going data.
Results
After implementation of the new processes,
data were collected and analyzed on patient
transfers over a period of 1 year for 462 consec-
utive patient transfers to the ICU/CCU (Fig-
ure 5). The target of decreasing the average
transfer time to less than 90 min was immedi-
ately approached and then nally attained by
the fourth month. In the rst 6 months, there
were still rare instances of individual transfer
times exceeding 180 min, which only allowed
the sigma score to reach the mid-three range
(but it did break the 2.2 goal). However, by
the eighth month, there were no defects and a
sigma score of six along with a yield of 100%
were reached and maintained for the remain-
der of the control phase.
For the entire control phase, the mean time
for the transfer of patients from a oor to a
critical-care bed was 84 min as compared to the
initial mean (preimprovement analysis) of 214
min; a marked reduction in the transfer time
of 138 min (Figure 6). Additionally, the stan-
dard deviation in the transfer time was reduced
by 135 min. The standard deviation is one of
the most common measures of variability in a
data set; as it gets smaller, the process capability
gets better. The postimprovement data showed
a standard deviation of only 35 min. The overall
sigma score was raised from 1.6 to 3.8 and the
yield, which represents the percentage of the
process that is acceptable to the customer, was
raised from 54% to 98.9%.
After seven consecutive months of no de-
fects, the project was turned over to the pro-
cess owner in December 2010 and the team was
disbanded. A project summary is depicted in
Figure 7.
The improvedprocess alignedwiththe hospi-
tals strategic business objective, set forth in the
Project Charter, which outlined the following
goals and standards of the project:
r
Customer satisfaction: Patients, their fami-
lies, residents, and staff all experienced
timely transfers, which led to increased sat-
isfaction.
52
Journal for Healthcare Quality
Figure 7. Project Summary
Process Steps Problems Post-Improvement Solution

Resolution

Patients transferred OUT
of CCA to accommodate
new patients transferred
into the CCA


Untimely transfers out of
the CCA lead to a lack of
beds available to accept
transfers INTO the CCA

Replacement bed sent by
Environmental Services
after nursing request placed

No standardized process
for medical residents to
write transfer orders for
transferring patients out of
the CCA

Bed Management directly notifies
Receiving Unit of transfer



CCA retrieves clean bed from the ICU
Annex


Process standardized to begin immediately
after rounds with prompt notification of the
CCA clerk and nursing staff.

Eliminated delayed
notification by nursing



No delay in waiting for
a clean replacement
bed

Ensured orders are
completed at time or
decision to transfer
patient. Notification
also more timely.


Upgraded floor patient
placed on cardiac monitor

Mandated resident to
observe monitor, which
delayed care to other
patients

Intensivist makes the determination if
monitoring is medically necessary prior to
transfer to CCA


Enhanced resident
utilization and time
management

Multiple communication
steps between the sending
and receiving units


Overly complex
communication process

Installed Tele-tracking in all CCA and
transport department

Conducted software training/education


Streamlined
communication and
patient throughput

Multiple process steps
involving clerks, nurses
and transporters of the
sending unit to transfer
patient


Large delay created in the
notification process that the
patient was ready to be
moved

Implemented use of Ready to Move
function in Teletracking



Real Time
Electronic Notification
that patient is ready to
be moved out of CCA


CCA: critical care areas (e.g., Intensive Care Unit or Cardiac Care Unit)
r
Operational excellence: Improved utilization
of residents and nurses enhanced opera-
tional excellence.
r
Quality: Better communication procedures
led to a decrease in the risk of adverse
events for a patient transferred to a moni-
tored bed.
r
Economic prot: Though not directly mea-
sured, immediate and delayed nancial
benets (see Section Dene Phase)
were likely realized, as well as unneces-
sary costs were avoided (e.g., complaint
investigations).
Discussion
Six Sigma provided a comprehensive analysis of
the patient transfer process prior to implement-
ing new solutions. Six Sigma utilizes data, the
voice of the customer(s), and statistical analysis
to determine the factors that are most critical to
quality improvement. It also requires account-
ability and constant evaluation after implemen-
tation of newsolutions (a control phase), which
fosters sustainability. Furthermore, the use of
the Six Sigma jargon provides for a universal
language that can compare and contrast the
effectiveness of different projects.
A very key step was to set realistic improve-
ment goals that were measureable. This can-
not be overstated. The analyze phase helped to
understand what would be a realistic goal for
individual and average patient transfer times.
Interviews with staff to nd out their con-
cerns and insights were very helpful. Assem-
bling a team of individuals who performed in-
tegral roles of the patient transfer process was
important. This ensured buy-in prior to the
implementation phase and served as the basis
for creating the shbone (cause and effect)
diagram and conducting the FMEA.
One limitation of our study is that im-
provements could have been secondary to
the Hawthorne effect, which postulates that
Vol. 34 No. 1 January/February 2012
53
processes being watched improve because they
are being watched (Tennant, 2001). Nonethe-
less, we believe the changes that were made to
the overall process lead to the signicant re-
sults. Another limitation was that we could not
pilot the new solutions in one area of the hospi-
tal while continuing the old process, to serve as
a real-time control in another. However, a true
historical control was used, whichwas measured
in the months just before the implementation
phase. Lastly, the nancial impacts of the new
processes were not directly measured.
Although the NSLIJ system has employed
and trained Six Sigma experts, other organi-
zations can still benet from using the various
tools often implemented in a Six Sigma project,
even without the specic Six Sigma resources
and experts. For example, an organization can
assemble a teamof various disciplines to dene,
measure, analyze, improve, and control a frag-
mented process. They can create a cause and
effect diagram, run an FMEA, identify key steps
(the vital Xs), brainstorm, and formulate prac-
tical solutions and measure the outcome of the
implementedstrategy. For this specic problem
(ICU transfer delays), implementing a comput-
erized bed-tracking software program, having a
clean, ready bed near the ICU, improving the
efciency and communication of transfers into
and out of the ICU and determining the need
for cardiac monitoring prior to transfer led to
almost immediate, major reductions in transfer
times, which were sustained over 1 year.
References
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& Dellinger, R. P. (2007). Impact of delayed transfer of
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Pyzdek, T. (2003). The Six Sigma handbook: A complete guide
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Authors Biographies
Stephan J. Silich, JD, is the Director of Business Develop-
ment and Six Sigma Certied Blackbelt for Staten Island
University Hospital in Staten Island, New York.
Robert V. Wetz, MD, is the Associate Chairman of Medicine
& Residency Program Director for the Department of
Medicine at Staten Island University Hospital in Staten
Island, New York.
Nancy Riebling, MS, MT, is the Director of Operational
Performance Solutions and Six Sigma Certied Mas-
ter Blackbelt for North Shore-LIJ HealthSystem in Long
Island, New York.
Christine Coleman is the Director of Bed Management
for Staten Island University Hospital in Staten Island,
New York.
Georges Khoueiry, MD, is the Associate Director of Student
Education for the Department of Medicine at Staten Island
University Hospital in Staten Island, New York.
Nidal Abi Rafeh, MD, is a cardiology fellow at
Staten Island University Hospital in Staten Island,
New York.
Emma Bagon, RN, is the Patient Care Unit Manager in the
Intensive Care Unit at Staten Island University Hospital
in Staten Island, New York.
Anita Szerszen, DO, is the Director of Geriatric Research
and co-chair of the Research Division for the Department
of Medicine at Staten Island University Hospital in Staten
Island, New York.
For more information on this article, contact Stephan J.
Silich at ssilich@siuh.edu.
Journal for Healthcare Quality is pleased to offer
the opportunity to earn continuing education
(CE) credit to those who read this article and
take the online posttest at http://www.nahq.
org/education/content/jhq-ce.html. This co-
ntinuing education offering, JHQ 233, will
provide 1 contact hour to those who complete
it appropriately.
Core CPHQ Examination Content Area
III. Performance Measurement & Improve-
ment
CE 233-Objectives
1. Describe the different phases of a Six Sigma
Project using the DMAIC approach.
54
Journal for Healthcare Quality
2. Identify the different roles of the members of a
Six Sigma Team.
3. Describe possible solutions to achieving faster
transfer times for patients being moved from a
general medical oor to a critical care area.
Six Sigma Questions
1. Of the following, which process would more likely
ensure staff buy-in for a complex, Six Sigma
project?
A. Allow the involved staff to obtain their own data for
the measure phase and compare it to the data found
by the Six Sigma team.
B. If the Six Sigma project is done correctly, the staff
will automatically buy-in to the changes.
C. Invite key personnel that are part of the scope of
the project to be Six Sigma team members from the
beginning.
D. Show the appropriate department heads the data
from the measure phase and have them relay the
data to their staff.
E. Show the staff the completed project charter after 6
months of the analyze phase to allow for appropri-
ate adjustments prior to presentation to the staff.
2. The upper specication limit (USL) of the per-
formance goals for a Six Sigma project is set by:
A. allowing the six sigma team to determine a realistic
goal that would be pleasing to the customers.
B. determining which limit would consistently yield a
sigma score of six.
C. random determination using Six Sigma statistical
analyses (e.g., FEMA).
D. the Master Black Belt.
E. waiting until the control phase is complete.
3. According to the article, one way to improve the
transfer time for patients being upgraded to the
critical care unit would be:
A. to assign security personnel to oversee and expedite
the transfer of all critically ill patients.
B. to have the nurses and residents transport the pa-
tient from the oor to the critical care area them-
selves.
C. to install an electronic, tele-tracking, bed manage-
ment software program.
D. to place all upgraded patients on a cardiac monitor
while outside of the critical care area.
E. to write all transfer orders out of the critical care
areas by the end of the work day.
4. What are the 5 phases in a Six Sigma project?
A. Dene, Measure, Analyze, Improve and Control
B. Dene, Measure, Assess, Implement and Control
C. Design, Measure, Analyze, Improve and Control
D. Design, Measure, Assess, Implement and Control
5. A Fishbone Diagram is used to help identify the
relationship between:
A. A Good Process and Bad Process.
B. Cause and Effect.
C. A.DPMO (Defects per million opportunities) and
Six Sigma.
D. A.The pre-implementation processes and the post-
implementation processes.
6. A FMEA (Failure Mode Effects and Analysis) is
used to:
A. Estimate the potential nancial gains of a Six Sigma
project.
B. Estimate the risk of failure.
C. Identify defects within a series of linked events.
D. Identify redundancies within complex processes.
7. Which of the following is a direct nancial benet
of a Six Sigma project?
A. Cost avoidance
B. Customer Satisfaction
C. Incremental Revenue
D. Task Elimination
8. Whichof the following is a benet of process map-
ping?
A. It can identify indirect cause and effect relation-
ships.
B. It can reveal unnecessary, complex and redundant
steps.
C. It determines the likelihood of obtaining a high
sigma score for each individual process step.
D. It provides the sequence of events for the imple-
mentation phase.
9. According to the article, which of the following
was found to directly lead to increased (worse)
patient transfer times?
A. Not using the transport department lead to worse
patient transfer times.
B. Particular oors had worse transfer times.
C. The more patients that had to be transferred to
allow one patient to enter the critical care area (i.e.,
multi-bed transfers) had increased transfer times.
D. Transfers that occurred during the night shifts had
worse transfer times from the oor to the critical
care area.
E. Weekend transfers during the winter months had
worse transfer times.
10. Which of the following best denes the role of a
green belt in a Six Sigma project?
A. Anemployee that is completely newto the Six Sigma
process.
B. Personnel that are being trained to eventually run
their own Six Sigma projects.
C. The data collector and biostatistician for the
project.
D. The nancial supporter and manager of the Six
Sigma project.
E. A.The team member responsible for compiling the
various gures and graphs.