A Lean Six Sigma project in Madigan Army Medical Center's OB/GYN clinic generated an extra million dollars in revenue for the clinic in Fiscal Year 2007, despite a reduced patient population.

"At the start of my Green Belt project, we believed that about 21 percent of the clinic's records were incomplete," said Sherry Van Patten, the project team leader.
In less than two months, that dropped to an average of 0.06 percent - about six incomplete records for every 10,000 records.

"Everyone at the clinic cooperated in helping us show so much improvement in such a short time," Van Patten added. "It feels good to help them claim credit for all procedures and encounters they do."

The team followed the standard five-phase DMAIC (define-measure-analyze-improve-control) improvement method built into Lean Six Sigma.

"We went to every workstation and interviewed the staff for a half-hour or 45 minutes, asking them to walk us through what they did," said Sharon Smith, lead coder for OB/GYN.

Through the observation and interviews, the team saw where there was duplication, where people weren't documenting what they were doing, and so on. The team also discovered that the end-of-day checks were not always completed.

That led them to the conclusion that training was a key issue.

"Some staff hadn't been trained at all in using the hospital appointment and documentation database, and in some cases each role had been trained in isolation," explained Kathy Pegum, chief of the medical records branch.

"We knew from looking at the records and the interviews and observations that there were many, many different causes of incomplete records," said Van Patten. A data field could have been missed, or a physician didn't get a co-signature or code something correctly, for example.

The team used a Failure Modes and Effects (FMEA) analysis, an LSS tool to determine the relative importance of different contributors to the problem.

"We went through the process step-by-step and thought about what went wrong in each step, and the impact that it had on the process," said Van Patten. "It opened our eyes to the stopgaps in the workflow and showed us where training would be most critical."

The final plan focused on three critical control points: (1) patient check in, (2) documentation of procedures by physicians and nurses, and (3) end-of-day records check. Specific actions addressed:

(1) Improving documentation/coding compliance.

(2) Initial/retraining for staff.

(3) Clarifying the responsibilities of each role (nurses, techs, clerks).

(4) Establishing standard business practices.

(5) Assisting in the transition to a paperless system.

(6) Coordinating with other functions for provider's validation in CHCSI.

(7) Closing out incomplete records with clinic staff.

"We learned that the providers didn't realize just how important it was to code encounters properly," said Eileen Kosel, assistant chief of medical records. "Complete records are needed so the medical center can figure out how much time we spend on different procedures and allocate resources accordingly."

After this project was completed, the team was asked to take their improvements to other clinics at Madigan. Over the following months, they worked with other clinics in the facility for one to two weeks each, depending on the size of the clinic. Team members knew exactly what to look for in the processes at other clinics because they had studied the OB/GYN process in depth.

The team has also helped out facilities in Alaska (Bassett Army Community Hospital) and California (Weed Army Community Hospital and Monterey Medical Clinic).

"There wasn't one clinic that didn't have some of the same problems that we had identified in OB/GYN," commented Kathy Pegum. "Some details were different, but the overall pattern was the same."