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 certied (www.navicenthealth.org/
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.
The team began the continuous improvement journey by
dening 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 perceptions and hospitals 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.
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.
After dening the problem and measuring historical perfor-
mance, the team analyzed the issues using a variety of tools.
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
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 dene 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.
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
Measuring KPI
Discharging patients home to the community means they have better health statuses, quality of life and lower healthcare costs overall.
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
Measuring outcomes
A KPI overview of improvements showed all three discharge categories were improved significantly.
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% condence 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).
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
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
dont know what you dont 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
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
Casey Bedgood is the system accreditation optimization ofcer 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.
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