COMPUTER SIMULATION AND SIX-SIGMA TOOLS APPLIED TO

PROCESS IMPROVEMENT IN AN EMERGENCY DEPARTMENT

Lance Roberts, University of Iowa
Dr. Charles Johnson, Texas State University
Dr. Ram Shanmugam, Texas State University
Sheetal Malhotra, Texas State University
Dr. Stephen Zinkgraf, Sigma Breakthrough Technologies Inc.
Maria Young, Sigma Breakthrough Technologies Inc.
John Putnam, Central Texas Medical Center
Lana Cameron, Central Texas Medical Center


Abstract
Simulation modeling was used along with Six
Sigma techniques to address issues of length of stay and
patient satisfaction in an emergency department. Goals
of the project were to increase the quality of care,
decrease the time in the ED for patients, and increase
patient satisfaction.

Investigators worked with hospital staff of an
emergency department to implement a Six Sigma
process improvement strategy focused on patient length
of stay, patient satisfaction, and cost savings. ProModel
computer simulation software was used to test
alternatives in process change prior to implementation.
DMAIC methodology identified several improvement
projects targeted at inefficient or ineffective ED
processes. Results have shown a dramatic reduction in
LOS, improvements in patient satisfaction, and cost
savings.

The Central Texas Medical Center (CTMC) is a
113-bed acute-care general hospital, and is one of 37
hospitals in ten states operated by the Adventist Health
System (AHS). Their mission is to provide physical,
mental, and spiritual services in efforts to build a
healthier community. They are committed to working
with the community to reduce the incidence of disease,
morbidity, mortality, accidents, and injuries (About
AHS, 2003). Fifty-seven percent of inpatient admissions
come through the emergency department. The
emergency department sees approximately 32,000
annual admissions each year.

In an effort to become more efficient, effective, and
adaptable at meeting community and business needs, the
hospital agreed to allow their Emergency Department
(ED) to be the focus of a Six Sigma Process
Improvement and Computer Simulation study. The goal of
the project is to use Six Sigma methodology specifically
the Define, Measure, Analyze, Improve, and Control
(DMAIC) improvement format to reengineer key
processes within the emergency department. Furthermore,
the hospital wanted to address the dissatisfaction of patients
who encounter long waiting times in the ED process.
Concurrently, the hospital would like to address the
frequency and sources of mistakes; and improve upon the
general quality level of care given to their patients. The
efficacy of the improvements would be measured by the
extent to which the Six Sigma methodology helped to
improve the quality of care while reducing patients length
of stay (LOS) and process errors. The key process inputs
identified as process improvement targets are as follows
equipment and supplies, diagnostic results, the patient chart,
materials, personnel, and doctor communication.

The following discussion will introduce a
healthcare case study to demonstrate the effectiveness of an
integrated process improvement roadmap in improving
quality, cost and speed in a hospital emergency department.

Introduction

A 1999 congressionally chartered report by the
Institute of Medicine found that anywhere from 44,000 to
98,000 patients die every year from preventable medical
errors made in hospitals (Factsheet, 2003). Alarmingly,
these numbers do not include harm from mistakes made in
outpatient settings (About Us, 2003). Contrast these
numbers to the numbers of deaths due to other causes:
motor vehicle accidents (43,458), breast cancer (42,292),
and AIDS (16,516). A 1991 Harvard Medical Practice
Study reported that 4 % of New York state hospital patients
suffered iatrogenic injuries that prolonged their stay or
resulted in measurable disability. Alarmingly, 14% of these
2
injuries were fatal. Based on these incidence rates, and
if extrapolated to the entire U.S. population, 180,000
people would die each year due to iatrogenic injury.
This equates to approximately three jumbo jet crashes
every 2 days (Leape, 1994). Obviously, the cost in terms
of lives is substantial. Medical errors can be defined as
the failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim
(Institute of Medicine, To Err is Human, 1999). The
most common types of errors are adverse drug reactions
and improper transfusions, surgical injuries and wrong-
site surgeries, suicides, restraint-related injuries and
deaths, burns, falls, pressure ulcers, and mistaken patient
identities. The highest error rates with serious
consequences are most likely to occur in intensive care
units, operating rooms, and emergency departments
(Institute of Medicine, To Err is Human, 1999). And,
there are many other hidden costs that are not as readily
measurable lost personal income, years of potential life
lost, disability, longer rehabilitation, and increased
insurance premiums which contribute to the burden
placed on society. These costs have been estimated to be
between $17 billion and $29 billion per year in hospitals
nationwide (Institute of Medicine, To Err is Human,
1999).

As the ranks of the unemployed/uninsured swell
and the health care workforce becomes smaller in
proportion to those seeking care the system swoons
under the load. An ABC World News Tonight Report
recently stated that there are now approximately 43.6
million uninsured and 46 million underinsured citizens in
the United States (ABC World News Tonight, 2003).
One out of ten children is uninsured and 59 percent of
individuals are unsure that they can pay for health
insurance in the future. Because of the skyrocketing
costs of healthcare families now pay 49 percent more for
health care than they did in the year 2000. A piece of
this cost is attributed to a 13.9 percent increase in
insurance premiums. So, Americans now spend 15.2
percent of our GNP on health care, or about $1.6 trillion.
Thus, emergency rooms have become the primary source
of health care for many Americans. Couple this with the
potentially devastating effects of terrorism attacks or an
epidemic outbreak of diseases, like SARS, the system
may reach a breaking point.
A visit to virtually any hospital emergency
waiting room exposes the fact that our emergency
departments are becoming increasingly crowded. The
Centers for Disease Control and Prevention (CDC)
reported in June 2003 that over the last decade
emergency room trips increased approximately 20
percent - from 89.8 million visits in 1992 to 107.5
million in 2001 (Jones, 2003). To make matters worse
the CDC also reported that the number of emergency
rooms dropped by 15 percent. Another study completed
by the American Hospital Association indicated that 62
percent of hospitals feel that they are operating at or over
their capacity. When the study considered only Level I
Trauma Centers and larger, 300-plus bed hospitals the
percentage jumps to 90 percent. And, the General
Accounting Office reported that 66 percent of emergency
departments diverted incoming ambulances in 2001 (Pexton,
2003). In addition, 1 out of every 10 hospitals reported
being on diversion status more than 20 percent of the year
(Jones, 2003). These numbers are alarming to the strategic
managers of our nations healthcare system. It has become
apparent to many stakeholders, both within and outside the
health care industry, that reengineering some of the key
processes would go a long way in enabling health care
organizations to be more efficient, effective, and adaptable.

Six Sigma process improvement techniques can
help improve health care. The following case study
demonstrates their effectiveness in a health care emergency
department environment.

Define Phase
Preparation for Project Team Members
The Six Sigma portion of the study required the
inclusion of CTMCs own employees in quality
improvement efforts. The Six Sigma philosophies integrate
quality into the day-to-day activities of every employee.
Thus, in order to implement a lasting business culture of
quality it is important that the leaders of any organization
support the strategies and vision behind Six Sigma projects.
An initial meeting was held on in which the methodologies
and goals of Six Sigma and Simulation were introduced to
CTMCs executive leaders. The scope and potential need
for resources were discussed. The leaders agreed to embark
on a cooperative effort - between the hospital, the university,
and SBTI - to make quality improvements within the
Emergency Department.



Initial Six Sigma Project Team meeting
The initial Six Sigma Project Team meeting yielded
the following results:

Financial measurements to be included in
the Project Charter:
Revenue per ED patient.
Length of Stay (LOS)
The identification of the voice of the
customer (VOC) and the voice of the
business (VOB):
3
VOC the decision was to
use the results of the Gallup
Organizations telephone
survey and the internal
CTMC telephone survey to
capture customers
satisfaction levels.
VOB internal project
leaders concluded that this
would envelope two goals of
the business increasing
quality care (especially in
regards to reducing the
number and sources of errors)
and lowering patient
admission times.
Sub departmental sources for the
internal project team members at
least one representative from each sub
department would participate in all
future Six Sigma Project Team
improvement activities:
Laboratory
Radiology
Registration
Respiratory
Therapy/Cardiology
Emergency Room
Department
Materials

In addition, in this first meeting a Murphys
Analysis was conducted to identify defects in the
current Emergency Department processes. The
Murphys Analysis is a negative brainstorming technique
used by the process improvement team to collectively
explore known problems with the current process. The
ideas generated in this exercise have an added benefit of
exposing problems that are unknown to other areas or
sub-departments of the Emergency Department staff.
This exercise helps orient all the team members to the
full spectrum of problems faced by team. Subsequent
Six Sigma tools help to focus process improvement
efforts only on the most glaring process problems.
These further tools facilitate the alignment of
improvement efforts with strategic business needs or
goals. The 6 Ms technique was employed within the
Murphys Analysis; each defect was categorized into one
of the 6 M categories:

Man
Machine
Mother Nature
Materials
Method
Measurement

The VOC Gallup Survey Results

A review of the Gallup Organizations telephone
survey of customers from Central Texas Medical Center
provides the voice of the customer (VOC) in regards to
satisfaction levels. The patient ranks their experience at the
hospital on a four-point Likert scale: 4 = Very Satisfied, 3 =
Satisfied, 2 = Somewhat Dissatisfied, 1 = Very Dissatisfied.
Descriptive statistics are computed for each quarter and
presented in the survey results. The historical records
reviewed comprised four quarters worth of data spanning
from Q3 2002 (July September) through Q2 2003 (April
June). The survey focused on four major areas of
measurement: Patient Loyalty, Overall Evaluation, People,
and Speed and Efficiency. The lowest mean in each of the
four quarters reviewed was Wait Time which is a
subcategory of the major area labeled Speed and Efficiency.
The mean Wait Time scores in each of the four
previous quarters were 2.73, 2.97, 2.90, and 2.95. Also,
only 27 % of patients reported Very Satisfied scores in
regards to Wait Time. When patients were asked where
unsatisfactory delays occurred, 81 % of all the patients
identified the delay before being taken to a treatment room.
And, 56 % of all the patients identified the delay before
being treated by a physician as unsatisfactory.
In addition, the major category of Speed and
Efficiency showed a mean that was below the mean for all
hospitals in the Gallup Healthcare Database. This data point
led to the reduction of patient waiting time as a prime
opportunity for improvement efforts. The Gallup surveys
suggest that a reduction in the mean waiting time and an
improvement in the speed and efficiency of the operations
would benefit the hospital, customers, and the community.

Metrics Identified

Metrics identified by the Six Sigma Project Team
were:

1. Average Length of Stay goal to see a 5%
reduction
2. Triage to ED Bed- - goal to reduce turnaround time
by 20 minutes
3. Left Without Being Seen goal to reduce to under
2 %
4. Patient Satisfaction goal to increase Gallup scores
in overall satisfaction, wait time, helpful and
courteous staff, ED efficiency, and speed of
service.

4
Measurement Phase

Process Description

The Six Sigma Project Team was developed to
include both internal and external membership. This
team met regularly to carry out the Six Sigma process
improvement methodology. The team listed five major
process steps for emergency department patients:

1. Patient presents to Triage
2. Patient presents to Registration
3. Management (initial health care administered
by nurse)
4. Treatment (course of primary care administered
by physician)
5. Disposition of patient

Process Map

The five major steps in the ED process serve as
the backbone for the construction of a SIPOC (Suppliers,
Inputs, Process, Outputs, and Customers) map. This
Project Team meeting included additional Project Team
members consisting of CTMC stakeholders representing
the major internal suppliers and customers to emergency
department processes. The Project Team members built
a SIPOC map by focusing on the top 5 or 6 high level
steps in the Emergency Department processes. These
top-level processes would be listed in sequential order
and be described by action verbs. Then, the team
members would list the Inputs to each process what
goes into the process - and list the Outputs to each
process what comes out of the process. The Inputs and
Outputs to the SIPOC map were to take into
consideration both the internal and external customers
and the descriptions of each item was to be listed as
nouns. In addition, three to five sub-processes were
listed under each major Process step. The sub-processes
list what happens within each process step. The ED
Process Map is shown in Appendix I. Finally, the
Process steps, Inputs, and Outputs would be used to
create the next tool in the Six Sigma methodology- the
Cause and Effect Matrix (C & E Matrix).

Cause and Effects Matrix
The C & E Matrix tool is used to prioritize
where to focus improvement efforts. It is built in an
Excel table format with the major Process Steps and their
respective Inputs listed in rows. The team reviews the
Outputs from the SIPOC map and rephrases the Outputs
as measurable requirements. These are then listed across
the top of the table as column headers. Each measurable
requirement is also assigned an output rating score.
Each Output was scored on a scale of one to ten. Higher
scores meant that the requirement was of prime importance
to the customer or the business. Thus, the voice of the
customer and the voice of the business help to guide the
Project Team in formulating the requirement ratings. Next,
the team assigns correlation scores between each of the
Process Inputs and each Output requirement. The scores
assigned could have only one of four levels:

0 = No Correlation
1 = The process input is slightly correlated to the
output requirement.
3 = The process input is moderately correlated to
the output requirement.
9 = The process input has a strong correlation with
the output requirement.

Finally, the sub-scores for each Process Input are
calculated by cross-multiplying the respective rating of
importance to the customer and the correlation score for
each cell in the Process Input row. Each of the sub-scores
are added together to yield a total score for the Process
Input. The highest total score identifies those Process Inputs
that are the most important in explaining the variation in the
Process Outputs. The results of the C & E Matrix are shown
in Appendix II. The most important Process Inputs become
the input to the Failure Modes and Effects Analysis (FMEA)
tool.

Summary of Six Sigma Measurement Phase

The Murphys Analysis, SIPOC map, C & E
matrix, and the current ED process procedures become the
inputs for the analysis phase of the Six Sigma methodology.
A review of the C & E matrix shows that the following
process steps/inputs are direct inputs into the Failure Modes
and Effects Analysis tool in the analysis phase:

Patient presents to Triage Equipment and
Supplies.
Patient presents to registration Chart
Treatment Diagnostic results
Treatment Materials

Computer Simulation

ProModels MedModel computer simulation
software requires the user to gather data in order to build an
as-is model of the emergency room processes. The
researchers used several methods in order to gather this data
interviews, tabulation of historical records, direct
observations, and physical measurements of facility layout.
Interviews and historical records were used to
generate the details for the entities (patients) and the
resources (the doctors, nurses, and sundry technicians). The
Emergency Departments ER Logbook contained historical
5
records that were useful in describing the patient and the
frequencies with which they required certain hospital
resources and services. The data collected were
analyzed to yield patient arrival times, patient acuity
levels, lengths of stays at certain points in the process,
and total length of patient stay. It was found that the best
fitting distribution for patient arrivals was of the Inverse
Gaussian typology. Interviews with key hospital
stakeholders were used to gather information regarding
the processing of patients, the staffing levels, and the
shift strategies employed. All of this information
provides the detail required to build a valid model that
accurately reflects the real-world system.

Analysis Phase

FMEA
The next step in the DMAIC process was the
construction of the Failure Modes and Effects Analysis
(FMEA). The FMEA is the primary tool for risk
assessment. The inputs include the results from the
Murphys Analysis, SIPOC, and the C & E Matrix. The
outputs yield a list of defects to be improved, a
prioritized list of actions to improve processes, and the
basis for a control plan. Each of the critical Process
Inputs identified in the C & E Matrix are transferred to
the FMEA each Process Input serving as a row header
in the FMEA spreadsheet. The team described the
Failure Mode what can go wrong with the input?
and the Potential Failure Effects what is the effect on
the outputs?. The team assigned a Severity Level score
(1 10, with a score of 10 representing the most severe
impact) for each Process Input. Next, the team described
and listed the Potential Causes of the Failure Mode.
And, the team would assigned an Occurrence score (1
10, with a score of 10 representing a very likely
occurrence) for each Potential Cause of the Failure
Mode. Next, the Current Controls were discussed by the
team and entered into the FMEA. The team then
assigned a Detection score (1 10, with a score of 10
representing the case where the detection of the cause or
failure would never occur). Finally, a Risk Priority
Number (RPN) was calculated by multiplying the
Severity, Occurrence, and Detection scores together for
each Process Input row. The FMEA, the portion
completed up to this point in the project, is shown in
Appendix III. The RPN is the output of the FMEA and
serves to prioritize process improvement actions. High
RPN scores are the basis for a process control plan. The
FMEA is best constructed with full participation of the
Project Team
Inputs identified in the C & E matrix were
transferred to the FMEA each Process Input serves as a
row header in the FMEA. The team then described the
Failure Mode what can go wrong with the input? and
the Potential Failure Effects what is the effect on
represent prime opportunities for improvement efforts. The
Process Inputs identified in the FMEA serve as the focus for
the Improve and Control stages of the Six Sigma DMAIC
methodology.

Direct Observations Length of Stay in ED

A proportionally stratified random sampling plan
was designed to directly observe emergency department
patients. Detailed data was captured on times for each stage
of treatment for 61 ED patients. Additionally, ED log data
was analyzed for over 1000 ED patients. Data analyzed
included lab turnaround, radiology turnaround, number of
visits to patient by nurses and physician, specimens
unacceptable, times for final instructions, and discharge
times. Table 1 shows the descriptive analysis of length of
stay.

Table 1. Length of Stay for ED Patients

Acuity
Level
Number of
Patients
Mean
Length of
Stay
(minutes)
Standard
Deviation
Minor
Emergency
Clinic
504 101 52.95
Low
Acuity
572 179 93.38
Medium
Acuity
181 188 91.09
High
Acuity
3 95 60.62

Low and Medium acuity patients were staying
close to 3 hours before discharge and had the greatest
variation. An examination of more detailed time
measurements led to several changes and process
improvements:

1. Tracking unacceptable lab specimens or lab analyses
with greater than 60minutes turnaround times.
2. Training of ED staff in blood-draw techniques to reduce
unacceptable sample rate.
3. Change in cardiac related tests routinely run.
4. Posting of turnaround times for increased staff
awareness.
5. Calibration of multiple lab instruments for tests to reduce
turnaround times in case of instrument problems.
6. Procedure changes related to paperwork and orders for
lab tests preventing labeling problems.
7. Procedure changes related to steps to add a lab or
radiology order mid-way in patient visit.
8. Increased communication and interaction between lab,
radiology, and ED related to problems.
6
9. Radiology staff wear pagers within hospital to reduce
response times for ED patient needs.
10. Changes in patient registration and triage to
immediately place patients into empty beds by triage
nurse instead of being pulled into beds by ED staff.
11. Conversion of PCA position to RN position and
change in responsibilities to free nurse for hospital
admission duties.
12. ED supply closets redesigned to allow better
organization, labeling, and stocking.

Checking with other hospitals, the average
percentage of lab specimen analyses with unacceptable
turnaround times was approximately 5 percent. After the
above changes were put into place, the percentage of
unacceptable turnaround times dropped to 2.5 percent.

The triage to ED bed time decreased from an
average of 43 minutes to 19 minutes; a greater than 50
percent reduction in time as seen in Figure 1.

Figure 1. Triage to ED Bed Time















The Six Sigma goal of reduced variation was seen in the
reduction in variation for the triage to ED bed time after
the process changes were implemented.

In addition, the number of left without being
seen patients showed a 60 percent reduction after the
process changes were implemented as seen in figure 2.

Before process changes were implemented, fifty
patients commonly left per month without being seen.
After the process changes were implemented, the rate
dropped to approximately 20 patients per month. Given
average revenue for ED patients, this conservatively
means an increase in revenue for the ED of over
$100,000 per year.

Figure 2. Left Without Being Seen














Patient satisfaction scores drawn from Gallup
telephone surveys have shown a remarkable increase in
satisfaction after the process changes were implemented.
Figure 3 shows the scores for quality of service, while figure
4 shows the scores for wait time satisfaction.

Figure 3. Gallup Patient Satisfaction Scores Quality of
Service


Figure 4. Gallup Patient Satisfaction Scores Wait Time

















Index
S
p

o
f

S
e
r
v
i
c
e
2ND04 1ST04 4TH03 3RD03 2ND03 1ST03 4TH02 3RD02
90
80
70
60
50
40
30
20
10
0
Time Series Plot of Sp of Service
7
Prior to implementation of the process changes,
the ED was ranked in the bottom quartile of its system
hospitals in patient satisfaction. After the process
changes, the ED was ranked in the top quartile of its
system hospitals in ED patient satisfaction.

Improvement and Control Phases

Through the use of the tools of Six Sigma and
Simulation, the hospital is making changes in their
processes that will help them be a much stronger patient
focused organization. The hospital has made significant
changes in patient registration and triage in response to
the Six Sigma Project Team.
Before the redesign, many patients entering the
emergency department were faced with two windows
one for Triage and one for Registration. Many patients
were incorrectly asking for medical assistance at the
Registration window. The Triage window is the
intended first stop for incoming customers. The hospital
has walled off the window that faces the front entrance,
thus making it more obvious to the patient that the first
stop is at the Triage window. This decreases the amount
of time wasted by the. Also, it eliminates some of the
work load for the Registration personnel as they no
longer need to reroute patients to the triage window.
Another improvement is to address the
equipment, supplies, and materials problem in the ED.
Currently, there is only one resupply room. The Material
department and Emergency Department have agreed to
create a cross-functional team to develop three separate
resupply areas. They plan to use the 5S technique (a
Japanese term and technique that is used to optimizes the
effectiveness of a particular workspace: Seiri -
Sort/Discard, Seiton - Arrange/Order, Seiso
Clean/Inspect, Seiketsu - Standardize/Improve, Shitsuke
Believe/Discipline.Sort) to improve the layout of their
two existing resupply closets. They will add a third
resupply area in the form of a metro rack near their
Trauma rooms.
At this point, the study is continuing into the
Improvement and Control stages. Once a process is
improved the team continues to measure that process.
It is important to determine if the improvement had the
desired effect. If the improvement in the process had the
desired effect, then it is the duty of the team to put
control processes in place. The control processes ensure
that the process does not slip back into a state of
uncontrollable variation.

Conclusion

Each hospital emergency department has its own,
unique business environment and operational constraints. A
non-punishing, data-oriented, process-focused approach to
solving process problems is the key towards making steady
organizational improvements. One of the key ideas is that
process improvements should be focused on the process
problems and not the people problems. Process
improvements can be found in even the best of emergency
departments. The necessity for these improvements are not
the result of bad people but rather the result of bad
processes.
This case study has shown that Six Sigma process
improvement techniques can improve the quality of care in a
health environment.
While many in health care say that we can never
achieve the level of quality found in manufacturing and
because of that, Six Sigma will not work in health care; they
are missing the point. Whether we achieve manufacturing
levels of quality or not is not whats important. Rather its
the fact that we must implement a system like Six Sigma to
help us structure our process improvement efforts and move
toward a health care system we all want to be a part of.
Quality improvement must become a central part of what it
means to be a health professional.

References
ABC World News Tonight (2003, October 19). Critical
Condition, ABC World News Tonight [Television
broadcast].
About AHS, The Adventist Health System, 2003.
Available: http://www.ahss.org/about.asp
About Us, The Leapfrog group, Retrieved August
4, 2003, from http://www.leapfroggroup.org/about.htm
Fact Sheet, The Leapfrog Group, June, 2003. Available:
http://www.leapfroggroup.org/Factsheets.htm
Institute of Medicine; To Err is Human: Building a Safer
Health System, November 1999. Available:
http://www.iom.edu/topic.asp?id=3718
Jones, Laurie; (2003). Strengthening a Stress Point in the
Health Care Safety Net. Advances The Robert Wood
Johnson Foundation quarterly newsletter, Issue #3.
Leape, Lucian L.; Error in Medicine, The Journal of the
American Medical Association, Vol. 272, No. 23, pp. 1851-
1857, December 21, 1994.
Pexton, Carolyn (2003). Issues and Solutions for Todays
Emergency Department, iSixSigma. Available:
http://www.healthcare.isixsigma.com/library/content/c03082
6a.asp
8
Appendix I. Emergency Department SIPOC Map







9
Appendix II. Cause and Effect Matrix


Rating of
Importance
to Customer
10 6 8
Rating



Q
u
a
l
i
t
y

C
a
r
e

E
r
r
o
r

R
e
d
u
c
t
i
o
n

S
p
e
e
d

o
f

S
e
r
v
i
c
e










Total

Process Step Process Input


1
Patient
Presents to
Triage
Patient
3 0 9 102
2
Nurse
9 3 1 116
3
Signage/Layout
3 1 9 108
4
EMS - Modes of
Entry
0 0 3 24
5
Equipment and
Supplies
9 9 9 216
1st
priority
6
Patient
Presents to
Registration
Patient
0 9 3 78
7
Chart
9 9 9 216
1st
priority
8
Outside Stimuli
9 0 3 114
9 Management
Patient to ER
Bed
1 1 9 88
10
Nurse
3 1 9 108
11
Labels
3 9 3 108
12
Chart
3 3 9 120
3rd
priority
13
Family and
Friends
3 0 9 102
14 Treatment
Doctor Contact
3 0 9 102
15
Diagnostic
Results
9 9 9 216
1st
priority
16
Equipment
3 3 3 72
17
Materials
9 9 9 216
1st
priority
18
Personnel
9 3 9 180
2nd
priority
19
Code Teams
1 1 3 40
20 Disposition
Doctor's Orders
3 1 9 108
21
EMS/Critical Air
3 1 9 108
22
Nurses/ER Tech
3 1 9 108
23
Doctor
Communication
9 1 3 120
3rd
priority










10
Appendix III. Failure Modes and Effects Analysis
Process
Step/Part
Number
Potential Failure
Mode
Potential Failure
Effects
S
E
V
Potential Causes
O
C
C
Current Controls
D
E
T
R
P
N
Equipment
and Supplies
Cannot find mobile
pc equipment I.e. IV
pump)
Delay in service.
10
Did not clean after
use. 9 0
Has not been returned
after a transfer from
other floors.
8 0
Supply shortages Delay in service.
10
Unorganized
reordering process.
9 0
ER staff unsure of
where inventory is
located.
0
Multiple people
reordering
0
10
Materials misplaces
the order.
3
Material dept. downloads
the reorder sheets.
1 30
10
Speed of receiving
supplies.
1
Currently have a 24-hour
turnaround on receiving.
1 10
10
Speed of preparing
supplies.
2
Currently use visual
indicators.
1 20
Computer
Systems
Expected Computer
Downtime
Must revert to
manual processes.
4
Manual processes
must be followed.
3 0
Personnel must
update computer
once it's online.
3 0
Diagnostic
Results
Wrong labels on the
specimen.
Delay in process.
10
Registration
mislabeling on the
chart.
3
Paula in registration
meets with staff if
problems arise.
8 240
Quality suffers.
10
ER mislabels the
specimens.
3 0
No label on the
specimen.
Delay in process.
10
ER rushing/busy
3 0
Test not ordered in
computer.
Delay in process.
9
ER rushing/busy
3 0
Miscommunication 4 0
Lab collects
specimens.
Delay in process.
4
Lack of experienced
phlebotimist.
4
No control.
10 160
Delay in delivery. Delay in process.
9
ER
miscommunication
4
No control.
10 360
Equipment
Malfunction
Delay in process.
10
Inclement weather.
3
Preventative
maintenance.
10 300
Hemolized
Specimen/short
sample
Delay in process.
9
Lack of experienced
phlebotimist. 5
No control.
10 450
Slow lab techs Delay in process. 10 Lack of abilities 8 Helping and coaching. 1 80
Lack of training. 8 0
Large work load. Delay in process.
8
Large
events/accidents.
3
Lab staffing is increased.
7 168
Respirator Therapist
unavailable.
Delay in process.
0
On call CT Tech Delay in process. Personnel issues-CT
Tech not answering
pager.
0
Nobody from ER calls
the CT Tech
0
Telerad Failure Delay in process. Old Apple product;
only 1 person that can
work on it.
No control.
10 0
Communication
failures-lack of
system
Delay in process.
10
Communication
breakdown. 8
No control.
10 800