A project to optimize family practice patient flow at the Guthrie Ambulatory Healthcare Clinic, part of the U.S. Army Medical Activity (MEDDAC) at Fort Drum, N.Y., was initiated in November 2007. The goal: to reduce process cycle time while maintaining the same quality of care and to increase patient satisfaction from the time the patient checks in for their appointment through the nurse screening process.


To conduct a solid measurement system analysis of the nurse screening process, patient arrivals were videotaped. Using a Gage R&R, appraisers were tested to ensure repeatability and reproducibility. After validation, the video was used to train the team members who were responsible for collecting time data to ensure they understand the operational definitions. This allowed them to capture clean data to complete baseline statistical analysis.

Initial data review showed a widespread under-the-bell curve, indicating large variation in the nurse screening process. This discovery allowed the team to implement the project’s first quick win: a nurse screening standard operating procedure (SOP) that included snapshots of the electronic medical record screens to facilitate capture of required patient information.


The Six Sigma team used an affinity diagram, cause and effect matrix, failure mode and effects analysis and Pareto charts to determine root causes of the delay in cycle time. Two more quick wins were identified in this phase.

The first quick win was to conduct a 5S in the exam rooms. All the rooms were standardized to include cabinets, drawers and handouts. The team placed a diagram in each drawer that shows the location of supplies and stock levels. This has resulted in all staff being able to readily find what they need to provide timely and quality patient care.

The second quick win was the development of a patient education icon. This icon is located on all MEDDAC staff computer desktops. This icon links to standardized patient information handouts for self-care, illnesses and disease management. Also embedded in the link are local school and child development physical forms. These forms facilitated a solution that was implemented in the Improve phase.


During this phase, the team developed an SOP and algorithm for inclement weather. This procedure ensures patient care when there is a delay or early closure due to inclement weather conditions. Patients are triaged and either walked in, referred to the Acute Care Clinic or network urgent care centers, or deferred to emergency rooms as necessary. If patients do not need immediate care, an appointment is made for them at a later time.

They also developed an SOP for school physicals. When a parent calls to make a school physical appointment for their child, the clerk asks if they have had a physical within a prescribed amount of time. If the child has, the clerk enters a telephone consult to the head nurse. The head nurse validates the information in the medical record, prints the physical form from the patient education icon and gives it to the provider. The provider completes the form and it is left in the reception area for pick-up by the parent at their convenience. This frees an appointment for someone who needs to be seen for illness, relieves the parent from taking time off of work and alleviates the need to have the child removed from school to have a physical, thus increasing patient satisfaction.


In this phase control plans and SOPs were developed to ensure the process stays in control and gains are maintained. Trigger points were established that identify when staff retraining on processes needs to occur or root-cause analysis needs to be conducted.

Successful Results

After completion of the project, satisfaction with wait times jumped from 64 percent of patients satisfied to 77 percent satisfied. The clinic was also able to accommodate two more appointments per provider per day. The team recorded an increase in the process yield and sigma level, as well as a decrease in process variation.

The project was presented at the 2009 DoD Continuous Process Improvement Symposium and won first place in the Medical category.

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