40 ISE Magazine | www.iise.org/ISEmagazine

Rehabilitation Hospital Navicent Health (RHNH),

located in Macon, Georgia, has been serving patients

since September 1988. The facility is the oldest and

most experienced medical rehabilitation provider in

central Georgia and one of only three specialty free-

standing hospitals in the state. The 58-bed facility is

accredited by DNV GL (Det Norske Veritas and Germanischer

Lloyd) and ISO 9001:2015 certiﬁed (www.navicenthealth.org/

service-center/rehabilitation-hospital-navicent-health).

In 2013, Navicent Health began the continuous improve-

ment journey with internal lean Six Sigma training via the In-

stitute of Industrial and Systems Engineers. The organization

imbedded two Six Sigma black belt leaders, with other full-

time responsibilities, in the facility with the intent of creating a

culture of continuous improvement and transforming the care

journey for many patients, families and communities.

Recently, a multidisciplinary team was assembled to im-

prove patient discharge outcomes in the spirit of continuous

improvement. Typically, rehab patients come to this facility

from those with higher care levels to prepare them for a transi-

tion back to the community with the goal of assuming normal

lives as much as possible. The team began targeting the num-

ber of patients discharged each month from RHNH to skilled

nursing facilities, community locations and acute care facilities.

In short, the ideal goal is to discharge more patients from the

rehab hospital to a community location and fewer to skilled

nursing facilities and acute care facilities. The overarching fo-

cus was to improve health, healing and hope for all patients,

Improving outcomes at a rehab hospital

Lean Six Sigma principles help Georgia facility reach discharge goals

By Cassandra Stallworth, Gina Tipton and Casey Bedgood

February 2021 | ISE Magazine 41

families and communities. Moreover, the operational aim is to

meet national benchmark goals for each category.

Deﬁne

The team began the continuous improvement journey by

deﬁning the problem. At a deeper glance, it was evident that

skilled nursing facility discharges were much higher than the

national benchmark (i.e., goal). The monthly performance was

14 discharges per month for the prior year with a goal of nine

discharges or fewer per month. With these discharges, less is

better. See Figure 1 for details pre-project.

The team also discovered that discharges to community lo-

cations and acute care facilities also were not meeting the goal.

For the same time period, community discharges averaged 71

per month compared to a goal of 72 per month. For these dis-

charges, more is better. In terms of discharges to acute care

facilities, RHNH was sending 11 per month to these facilities

with a goal of 10 per month on average. For these patients, less

is better.

You may ask why this matters. It is important because dis-

charging patients home to the community means they have

better health statuses, quality of life and lower healthcare costs

overall. Also, if patients have lower health levels leaving re-

hab facilities, they will spend more time in advanced care set-

tings that are more expensive, less convenient and absorb al-

ready scarce resources that others may need. Thus, costs will

be higher and the quality of life for patients, families and other

stakeholders will be less than optimal.

Meeting national benchmark goals for all three discharge

categories leads to higher revenue levels, decreases costs and

enhances the human aspect. If key performance indicators con-

tinued to trend unfavorably to the goal, the organization will

experience lost revenue, unsustainable cost increases and chal-

lenges to the community perception’s and hospital’s reputation.

To improve the current state, the team set a goal to meet the

national benchmark for each discharge category – community,

skilled nursing facility and acute care – within six months of

the project initiation. From a dollar improvement standpoint,

the goal was to improve by at least $100,000 in the same time

period through cost reduction and revenue growth. These

goals were vitally important as rehab facilities typically experi-

ence higher costs and lower reimbursement, even in ideal op-

erating environments. So, the team had to make improvement

a reality.

As the goal-setting process transpired, the team also con-

sidered possible constraints. The most signiﬁcant limitations

related to historical processes and organizational culture. Cul-

ture is how work is done in an organization. As the saying

goes, “Old habits die hard” (organization and environmentally

dependent). The overarching discovery was that old processes

and the current state of doing business needed to change in

order to realize improvement and make it stick.

Measure

Once the deﬁne phase was complete, the team focused on

measuring the current state. The KPI of focus included dis-

charge rates to community locations, skilled nursing facilities

and acute care facilities. They were measured monthly and fo-

cused on the actual number of discharges for each category

favorable to goal.

In addition, dollar savings of improvements for all three

KPIs was measured as previously noted. When measuring each

KPI, the focus was to display trends over time using a simple

run chart. There were three focal points: goals, performance

to goals and trends (i.e., favorable or unfavorable to goal). See

Figure 2 (on Page 42) for details.

Analyze

After deﬁning the problem and measuring historical perfor-

mance, the team analyzed the issues using a variety of tools.

FIGURE 1

Discharge totals

Skilled nursing facility discharges prior to the project (lower number is better).

1 2 3 4 5 6 7 8 9 10 11 12 13

Discharges

Month

Skilled nursing facility (SNF) discharges before project

(lower number is better)

SNF Discharges Average SNF Discharges SNF Discharge Goal

42 ISE Magazine | www.iise.org/ISEmagazine

Improving outcomes at a rehab hospital

Analysis tools included run charts, control charts, histograms,

detailed process maps, ﬁshbone diagram and swim lane dia-

gram. The run charts revealed that each KPI category was not

meeting the national benchmark as noted in the deﬁne phase.

Further analysis revealed that control charts for skilled nursing

facilities and communities were in control, stable and predict-

able. For discharges to acute settings, the control chart was out

of control, not stable or predictable.

Individual moving range control charts were used for this

analysis. The ﬁshbone diagram helped the team pinpoint three

micro issue sources: people, process and resourcing. These is-

sues centered around patient/family expectations for rehab care

they were receiving, lack of ﬁnancial means and housing ac-

commodations and patient family goals for their care experi-

ence. Irrespectively, the team realized these barriers had to be

overcome in order to improve the situation long-term.

Improve/implement

To improve the situation long term, the team focused on four

areas: improved forms with management accountability; new

management for case managers to handle transitions between

care sites; family plus patient education; and shifting patient/

family goals. See Figure 3 for focus areas in the process map.

The team implemented three improvements. First, it

shifted patient/family goal setting to start on patient arrival

to Rehab Hospital Navicent Health. This gave patients and

FIGURE 2

Measuring KPI

Discharging patients home to the community means they have better health statuses, quality of life and lower healthcare costs overall.

FIGURE 3

Putting a plan in place

The hospital’s key focus areas for improvement.

February 2021 | ISE Magazine 43

their families realistic targets, expectations and resourcing to

achieve desired outcomes. The tollgates for each goal were

measured, tracked and monitored for ideal progression during

the patient’s stay.

Second, the team focused heavily on improving initial and

ongoing education to patients and their families. Education

is key to allowing all stakeholders to “see the forest for the

trees” and plan for what “will” come next, along with what

“could” come next. This helped eliminate ambiguity, uncer-

tainty and provided clarity as to the care provided at each

goal step.

Finally, the improvement team enhanced patient treatment

plans to include feedback from patients and families by care

teams, based on their outcome goals. The takeaway was to

include the voice of the customer early on. What did patients

and families want? What did they really need? What realisti-

cally could be accomplished at the rehab hospital? Each of

these questions was answered before any goals were set and

really transferred ownership of the outcomes, care trajectory

and end results to the customers.

Once these improvements were implemented, the team

began to remeasure each KPI and noticed immediate im-

provements. In short, all three discharge KPI categories were

improved signiﬁcantly. Discharges from the rehab hospital to

skilled nursing facilities were improved by 33%. Also, com-

munity discharges were improved by 5% while acute care

discharges were improved by 37%. See Figure 4 for details.

The team also used box plots to compare performance be-

fore and after improvements. As noted in Figure 5, all three

KPI categories experienced ideal improvements in both aver-

age performance and variation (i.e., range). As noted earlier,

the goal was to decrease skilled nursing facility discharges and

FIGURE 4

Measuring outcomes

A KPI overview of improvements showed all three discharge categories were improved signiﬁcantly.

FIGURE 5

Box plot ﬁgures

Data showed all three KPI categories experienced ideal improvements in both average performance and variation.

44 ISE Magazine | www.iise.org/ISEmagazine

Improving outcomes at a rehab hospital

acute care discharges while increasing community discharg-

es. Figure 5 illustrates improvement for each KPI category

was achieved.

To further test the project results, test of hypothesis (paired

comparison small sample size) was used. The theory stated

that skilled nursing facility discharges would decrease with

improvements and aggressive process redesign. The null hy-

pothesis states there is no change, while the alternative hypoth-

esis states there is a change. One tail test was used. The results

showed T test (2.236) was greater than 1 Tail T table (2.132).

Thus, the process improvements decreased skilled nursing fa-

cility discharges at the 95% conﬁdence level.

Moreover, a correlation analysis was used to compare com-

munity discharges to skilled nursing facility discharges, post

improvement. The correlation coefﬁcient “r” was used as the

determining factor. When comparing many months of data

post improvements for both variables, the analysis showed a

strong correlation as “r equaled -.7”. Thus, as skilled nursing

facility discharges decreased, community discharges increased.

There was an indirect correlation between the two variables.

From a dollar improvement standpoint, the efforts saved

$113,085 during the project time frame from February-June

2020 with savings trends expected to continue (See Figure 6).

Control

The control plan consists of monitoring, reporting and con-

tinued measurement of the KPIs previously noted: discharged

patients from RHNH to community locations, acute care fa-

cilities and skilled nursing facilities, with an emphasis on this

subgroup. The realized dollar impact is ap-

proximately $6,500 average per improved

discharge. Daily monitoring occurs via data,

reports and leadership oversight in various

dashboards, report-out sessions and leadership

meetings. This information is cascaded up to

the board and quality management system.

Customer requirements are and should be

the centerpiece of all administrative planning.

The main takeaways from this project are

people, process and structure. People are the

most important aspect of healthcare delivery.

The customer not only includes patients, but

families and communities served. The team

learned early on that identifying the custom-

ers along with their needs, expectations and

desires were crucial to improving discharge

outcomes.

Process and structure are often understated

and cannot be overlooked. Creating a repeat-

able process that is hard-wired into organiza-

tional culture will accelerate success or lead to

failure if not handled properly. It cannot be

overstated to keep it simple: Establish a good process, follow it

and be willing to change what is not working.

Moreover, part of a sound improvement structure is ensur-

ing mechanisms exist for accurate and accessible data. You

don’t know what you don’t know and you will never know

what you cannot measure. Simply put, know your numbers,

track them frequently and pivot when goals are not being met

or trends are unfavorable to the goal.

It is important to note that the team accomplished this great

project during the height of the COVID-19 pandemic when

time was limited, resources were scarce and focus shifted away

from the normal state of doing business. If ever asked, does

lean Six Sigma really work? Simply put: Every time if used

properly. 

Cassandra Stallworth is a quality clinical analyst (infection prevention)

at Rehab Hospital Navicent Health and an IISE-trained lean green

belt, Six Sigma green belt and Six Sigma black belt. She was the black

belt and process owner for this project.

Gina Tipton is vice president of Rehab Hospital Navicent Health and

an IISE-trained lean green belt, Six Sigma green belt and Six Sigma

black belt. She was the executive sponsor and black belt adviser for this

project.

Casey Bedgood is the system accreditation optimization ofﬁcer at Navi-

cent Health and an IISE-trained lean green belt, Six Sigma green belt

and Six Sigma black belt. He was an adviser and black belt sponsor for

this project.

FIGURE 6

Dollar improvement

As skilled nursing facility discharges decreased, community discharges increased,

saving resources overall.

Find fresh ideas at HSPI

The Process Improvement track scheduled for the virtual Healthcare Systems

Process Improvement Conference 2021 will include numerous presentations on

applying lean Six Sigma principles toward solutions to beneﬁt patients, caregivers

and facilities.

The conference, sponsored by the Society for Health Systems, is set for Feb.

24-26. To download a full program schedule, visit iise.org/HSPI. Register at

iise.org/HSPI/register.