Saving Money with Six Sigma

• Mannie Garza
• December 2008 EMS Insider Vol. 35 No. 12
• 2008 Dec 8

Lee County EMS in Fort Myers, Fla., undertook an ambitious quality improvement effort two years ago that has yielded impressive results. 

Operations Chief Kim Dickerson worked for LCEMS for 10 years and Capt. Warren Panem, EMT-P, for eight when they left a few years ago to run the paramedic program at a local college and get their MBAs.

"The MBA program gave us a good look at the business side," Dickerson said. "We didn’t know we’d end up back in EMS."

When she and Panem returned to LCEMS, they decided the Six Sigma process improvement approach used by many large businesses might work to improve processes at the county ambulance service. (LCEMS employs some 300 EMTs and paramedics, who run 75,000 calls a year in 36 ALS units and two BLS units. LCEMS also has one specialty care transport unit and a helicopter.) 

"Six Sigma is a process improvement approach that focuses on the ability to reduce variation," explained Panem, who co-chairs the LCEMS Six Sigma Steering Committee with Deputy Chief Scott Tuttle. "The basis of Six Sigma is examining processes and then using the data gathered to identify and fix problems within an organization."

Dickerson added, "Six Sigma helps you take a proactive course to look at root causes of problems and make changes." 

Idaho EMS Director Dia Gainor wrote on Six Sigma in the June and December 2003 issues of the  EMS Inside r and reported using it to improve systems within her office. However, LCEMS may be the first EMS agency to embrace it wholeheartedly.

Six Sigma training comes in four levels, earning those trained at each level a white belt, yellow belt, green belt and, ultimately, a black belt. In May 2006, LCEMS began putting every LCEMS employee through "white-belt training," a 16-hour course on the basics of Six Sigma. Twenty-six LCEMS staff members received 32 additional hours of training to become yellow belts, 12 went on to green belt training and six staff members have now become black belts. "Green belt is where the rubber meets the road," Panem said.

The green belts were tasked with leading six initial projects to improve LCEMS processes related to hiring, continuous quality improvement, response times, offloads, revenue recovery and customer satisfaction. The teams chose the projects, with one criterion for each project being that it would have at least a $50,000 positive impact on LCEMS.

According to Panem, Six Sigma aimed to change the mentality and culture of the entire organization, making improvement everyone’s responsibility. "This has improved employee and customer satisfaction significantly," he said.

"When we started this, we had 23% vacancy and huge mandatory overtime. We now have about 5% turnover, and our people are rested so they give better care," Panem said.

Emergency department (ED) offload times were another significant problem. The Six Sigma team tasked with this challenge came up with two plans: The first was to have an EMS shift commander determine the best destination for each patient (based on the patient’s needs and hospital status as shown by EMSystems software). "Some hospitals complained they were being picked on, so we now have big plasma screens in each hospital so they can see what every hospital is doing," Dickerson said. 

The second part of the plan required working with local EDs to have a charge nurse make it a priority to find a bed for an incoming ambulance patient. Now, if an offload takes more than a specified time, the ED director is notified. If the logjam continues, the hospital administrator is called and, finally, an LCEMS supervisor comes to the ED to help. "Each hospital is provided with monthly charts showing [its] performance, and hospitals now get upset if our crews don’t call 'offload' when they offload," Dickerson said.

"We partnered with the hospital and reduced our offload times by 60%," Panem said. 

According to Dickerson, the offload changes also resulted in "a big improvement in our response times." 

Another challenge was to find a better way to handle the agency's 5,000 interfacility transports each year. Previously, LCEMS ALS units performed both emergency and interfacility transports, but the Six Sigma team discovered that 46% of the interfacility transports were billed at the BLS rate. Last February, LCEMS added two BLS units to handle interfacility transports and assigned three ALS units to handle only such runs. Besides improving overall LCEMS response times, this approach has saved LCEMS $220,000, according to Panem.

He also notes that the Six Sigma team estimated the project to cut offload times could save LCEMS $165,000 annually by improving unit-hour utilization, but Panem estimates the savings are closer to $560,000 a year. The agency has spent $80,000 on Six Sigma training. 

LCEMS also now "builds employee evaluations around data," Panem said. "Every employee can go online and pull out anyone’s name and see [that person’s] time out of chute, response times, offload times and compare them to see how they’re doing."

Dickerson said the agency is also using Six Sigma to look at inventory issues and may move to just-in-time ordering instead of stockpiling supplies.

"We're now making evidence-based decisions," she said. "And we're now working with the hospitals to get patient outcomes so we can close our data loops." 

"Six Sigma works," Dickerson said. 

For more information, visit  www.lee-ems.com/ems/contact.htm  and  http://home.safelee.org/public/sixsigma.

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