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Service Delivery Innovation Profile

Six Sigma–Inspired Workflow Redesign Enhances Access to Care and Increases Patient Satisfaction, Visits, and Revenues in Obstetrics and Gynecology Residency Clinic

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A hospital's obstetrics and gynecology residency training clinic used Six Sigma methodologies to identify and address inefficiencies in workflow processes related to patient flow and staffing. Through redeployment of staff, revised scheduling processes, and other changes, the program significantly reduced waiting times for appointments and the length of clinic visits and increased patient satisfaction, clinic volume, and revenues.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics along with comparisons with the experiences of an internal medicine residency clinic within the same organization.
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Developing Organizations

Charleston Area Medical Center; Women and Children's Hospital
Charleston, WVend do

Date First Implemented


Problem Addressed

Residency programs in ambulatory settings have been described as inefficient, variable, and unpredictable.1 Creating a learning environment for residents that is both patient-friendly and financially sustainable has been a challenge for many teaching hospitals, especially in obstetrics and gynecology (ob/gyn) clinics serving low-income, high-risk patients.
  • Long waits for care: Women and Children's Hospital ob/gyn residency training program struggled with substantial barriers to access. Patients waited 38 days for an appointment, and the average appointment took 3.2 hours.
  • Unhappy patients: Largely as a result of these long waits, patients became unhappy and began seeking care elsewhere. The mean patient satisfaction score was 5.75 on a 10-point scale, and the volume of visits dropped from 16,392 in 2003 to 11,746 in 2004.2
  • Unhappy staff: Residents and clinic staff became frustrated with canceled appointments, changing coverage schedules, competing priorities (surgery), and work hour restrictions that created barriers to efficiency and robust learning experiences.2

What They Did

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Description of the Innovative Activity

Charleston Area Medical Center used Six Sigma methodology (see the Context section for more background on this approach) to identify and address inefficiencies and improve clinic service and workflow efficiency in its outpatient ob/gyn residency training clinic. Key elements of the program are described below:
  • Redeployment of residents: To identify inefficiencies, a team mapped the experiences of new and returning patients in the clinic, documenting both the long waits to get appointments and the long periods spent in clinic waiting rooms. Much of the inefficiency resulted from disorganized resident assignments and rotations and the lack of "ownership" of the clinic by hospital and teaching staff. Residents were often assigned to other clinics, such as oncology, or their assignments weren't clear, so they ended up observing in the operating room instead of staying in the ob/gyn clinic to care for patients. Using the patient throughput analysis as a guide, the team completely reorganized resident assignments and schedules to guarantee there would be a resident and other providers in each clinic to serve patients when needed.
  • Revised learning opportunities for residents to better match patient needs: Residents were better integrated into clinic practices through use of creative scheduling and increased training that better prepared residents to provide care in roles that were previously filled by physicians and nurses. For example, residents now participate in patient intake, taking histories, conducting physicals, patient education, and monitoring patient progress between visits. Schedules are set to ensure residents have teachers available as they provide these services to increase clinic efficiency.
  • Expanded clinic hours and staffing: Clinic hours were extended to increase access to appointments. A nurse practitioner and a certified nurse midwife were added to the clinic's permanent staff to serve as "physician extenders" who provide continuous coverage when residents are on rotation.
  • Parallel patient care processes to enhance throughput: Certain steps that were previously done sequentially have either been eliminated or are now done in parallel, with the goal of increasing throughput and reducing waiting times. For example, laboratory tests are now conducted during the patient interview. In addition, special clinic sessions have been created for new patients; these sessions provide an opportunity to meet and screen new patients and to link them to residents who become their designated providers during pregnancy.
  • Culture of accountability: Staff, residents, and attending physicians have committed to holding each other accountable for on-time clinic starts, having needed information available, and engaging in effective communication. Residents, who previously had freewheeling schedules, initially opposed the stricter controls and scheduling systems; this resistance was overcome by having attending physicians reinforce and model a more timely work ethic.

Context of the Innovation

Charleston Area Medical Center is a nonprofit, academic, regional tertiary referral center. The center trains 12 ob/gyn residents each year (the program lasts 4 years, with three residents in each entering class). Women and Children's Hospital, a part of the Charleston Area Medical Center system, performs more than 3,000 deliveries per year, with one-half of the deliveries performed by residents. Roughly one-half of patients are covered by Medicaid or Medicare. Because of the long waits, patient dissatisfaction, and poor revenue stream, the medical director initiated a systematic overhaul of the clinic, using Six Sigma strategies. Six Sigma, used successfully by Motorola, General Electric, and other companies to boost productivity and profits, is a rigorous and systematic methodology that uses information and statistical analysis to measure and improve an organization's performance, practices, and systems by identifying and resolving defects in service delivery processes. Clinic leaders decided to use the model in an attempt to improve organizational efficiency and financial productivity and to create a more robust teaching environment that was economically viable.

Did It Work?

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Pre- and post-implementation data, along with comparisons to a hospital-affiliated internal medicine clinic that served as an informal, nonrandom control group, suggest that the program significantly reduced waiting times and increased patient satisfaction and clinic volume and revenues.
  • Reduced waiting times: The waiting time for a new obstetric appointment decreased from 38 to 8 days, and the wait for a new gynecologic appointment declined from 60 to 25 days. The total patient time spent in the clinic decreased from 3.2 hours to 1.5 hours. By contrast, waiting times in the hospital's internal medicine clinic (which did not implement any changes) remained roughly the same during this time period.
  • Higher patient satisfaction: Easier access to appointments and less in-office waiting led to higher levels of patient satisfaction. Mean patient satisfaction scores rose from 5.75 to 8.54 (on a 10-point scale). By contrast, patient satisfaction scores in the hospital's internal medicine clinic remained roughly the same during this time period.
  • More patient visits: Better patient flow and higher demand for services led to increases in patient volume. Initial gynecologic visits increased 87 percent (from 453 in the year before the changes to 850 in the year after), return gynecologic visits increased 66 percent (from 1,392 to 2,311 per year), initial obstetrical visits increased 55 percent (from 520 to 808 per year), and repeat obstetrical visits increased 45 percent (from 2,239 to 3,243 per year). Total clinic visits rose from roughly 13,000 in 2006 to 15,000 in 2007. By contrast, total visits in the hospital's internal medicine clinic remained stagnant during this time period.
  • More revenues: Higher patient volumes have translated into higher revenues. Gross clinic revenues increased by 73 percent in the first 6 months of 2006, whereas profits in fiscal year 2007 increased by more than $350,000 over the previous year. By contrast, revenues for the hospital's internal medicine clinic remained flat during this time period.
  • High resident satisfaction: Residents expressed satisfaction with the changes, especially having additional time to spend with patients, being directly observed by teaching physicians, and engaging in case discussions.
  • Future goals for improvement: The ob/gyn clinic's leadership plans to keep improving on these results. Future goals include increasing the following: examination room utilization (the clinic currently averages 45 percent overall utilization, with rates ranging from 20 to 100 percent depending on the availability of providers); patient satisfaction (the goal is to be above 90 percent); and in-office waiting times (the goal is to reduce them below the current level of 1.5 hours). The clinic also plans to introduce a sophisticated electronic medical record system to gain further efficiencies that are not currently available and to have the clinic better coordinate services with other hospital clinics, such as psychiatry, to reduce the number of times patients (particularly low-income patients who often face transportation problems) must come to the hospital campus for care.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics along with comparisons with the experiences of an internal medicine residency clinic within the same organization.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Designating project champions: Champions included the chief operating officer of the health system and the dean of the university's health sciences center. These individuals provided invaluable support of the project, including the ability to navigate organizational barriers and to create alignment between administration and faculty members.
  • Creating a team: Following the Six Sigma approach, the ob/gyn clinic created a clinical team, made up of representatives from hospital administration, teaching faculty, residents, and other clinic support staff, to lead the process. Patients were interviewed but did not serve the team. The team conducted all the analysis needed to identify current inefficiencies, understand customer needs, and develop improvements designed to meet these needs and improve the quality of care.
  • Mapping the patient experience: The team identified patients as the clinic's primary external customers and clinic staff as internal customers. The team mapped the patient experience by measuring "data points" at every step of the interaction, including laboratory turnaround time, patient interviews, chart assembly, patient examinations, and followup that occurs before the patient leaves the clinic. The team then identified those factors that were critical to quality within the clinic. Patient factors that were critical to quality include the following: waiting time to appointments ("I want to be seen when I need an appointment"), length of visits ("I want my visit to be less than 1 hour"), and getting needed services ("I want the care I need”). Resident and staff critical to quality factors included ease of operations and resident work-hour rules ("We want a smoothly running clinic and a dependable schedule that fits into our other requirements, such as surgery, hospital duty, and on-call status").
  • Applying Six Sigma strategies: Access and clinical efficiency improvements were implemented and managed using the following well-tested five-step approach—define, measure, analyze, improve, and control.
  • Setting a financial goal: The organization's leaders set a goal to increase annual revenues by $700,000 through enhanced access and utilization of the clinic. This figure was considered sufficient for the program to be sustainable on an ongoing basis.

Resources Used and Skills Needed

  • Staffing: The program required one staff person to conduct statistical analysis and analyze throughput data. As noted, the chief operating officer of the health system and the dean of the university health center served as project champions. In addition, a well-respected faculty member, who served as clinic manager and had some experience in Six Sigma, proved vital in keeping the program moving forward, while a Six Sigma expert helped to maintain the team's focus on the project and served as a mentor to the faculty member.
  • Costs: There were no costs associated with the reorganization and streamlining initiative, other than staff time.
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Funding Sources

Charleston Area Medical Center
The project was funded internally.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Appoint a champion and establish a motivated team committed to improving service to internal (providers and staff) and external (patients and families) customers.
  • Define factors that are critical to quality in the delivery of services, including both health care and education.
  • Assemble the data needed to measure the performance of the clinic or process and identify and analyze the factors that hinder the delivery of quality service.
  • Establish the capacity and knowledge to continuously monitor the data and evaluate performance and improvement.

Sustaining This Innovation

  • Continually chart progress to prevent slippage, and identify potential opportunities for further improvement. For example, the ob/gyn clinic has increased its capacity to use control charts to monitor ongoing performance.
  • Continually monitor and enforce adherence to strict scheduling and attendance requirements to make sure residents are available to provide coverage in the clinic when they are needed. The ob/gyn clinic continues to struggle with this issue.

More Information

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Contact the Innovator

Byron C. Calhoun, MD, FACOG, FACS, MBA
Professor and Vice-Chair, Department of Obstetrics & Gynecology
West Virginia University-Charleston
Charleston, WV 25302
Phone: (304) 388-1599
Fax: (304) 388-2915

Innovator Disclosures

Dr. Calhoun has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Pande PS, Neumann RP, Cabanagh RR. The Six Sigma way: how GE, Motorola, and other top companies are honing their performance. New York, NY: McGraw-Hill; 2000. p. 5, 7.

Pexton C. One piece of the patient safety puzzle: advantages of the Six Sigma approach. Journal of Patient Safety and Quality Healthcare. Jan/Feb 2005. Available at:

Bush S, Lao M, Simmons K, et al. Patient access and clinical efficiency improvement in a resident hospital–based women's medicine center clinic. Am J Manag Care. 2007;13(12):686-90. [PubMed]


1 Regan-Smith M, Young WW, Keller AM. An efficient and effective teaching model for ambulatory education. Acad Med. 2002;77(7):593-9. [PubMed]
2 Bush S, Lao M, Simmons K, et al. Patient access and clinical efficiency improvement in a resident hospital–based women's medicine center clinic. Am J Manag Care. 2007;13(12):686-90. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 20, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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