Transcript Operational Efficiencies

Applying Lean Management to
Improve Quality and Efficiency in
Surgery
Click
Samirto
S. edit
Awadsubtitle
MD, MPHstyle
Professor of Surgery
Vice Chair Surgical Quality & Safety
Baylor College of Medicine
Chief of Surgery
Michael E. DeBakey VAMC
Houston TX
INTRODUCTION
•
•
•
•
Scope of the problem
Current Gaps
Lean Methodology Process
BCM Department of Surgery
Examples
INTRODUCTION
• Every healthcare system has
problems in quality, safety, efficiency,
service
• Problems harm patients, raise costs,
frustrate workers
• Economy: short & long term
INTRODUCTION
• Goals
– Ideal Patient Care Experience
– Ideal Clinician/Staff Experience
– Ideal Research/Trainee Experience
– Safest health system in US
– Financial stability
INTRODUCTION
• Analysis
– Workers/mgrs:
• +/- trained in problem solving
• Little standardized work
– Problems complex, cross units; work often
invisible
– Unclear responsibility for problems
– Unclear priorities
– Time, cost pressures: stress
INTRODUCTION
• Strategies
– Spread a consistent QI model across
institution
-Build on current QI base
-Study lessons from Lean Thinking
– Hundreds of problem solvers
INTRODUCTION
• Plan:
– Use Lean Methodology to improve
safety and quality  Efficiency
– Frontline workers help build it
INTRODUCTION
Baylor College of Medicine Quality
System:
•Quality
•Safety
•Efficiency
•Appropriateness
•Service
BCM Quality System
Just-In-Time
Built-in Quality
BCM Values:
Respect, Compassion, Trust, Integrity, Collaboration, Leadership
BCM Quality System
Quality – Safety – Efficiency – Appropriateness – Service
Built-in-Quality
Just-in-Time
Error-Free
Using the fewest
resources to
consistently deliver
exactly
what the customer
needs
Leveled
Workload
Customer
Defines Value
Continuous Improvement
(P-D-C-A) and Learning
Don’t Make,
Accept, or
Send on
an Error
Standardized
Work
Make Value Flow by Eliminating Errors and Waste
BCM Quality System
Safe - Effective - Efficient - Patient-Centered - Timely - Equitable Health
Care
Built-in-Quality
Just-in-Time
Using the fewest
resources to
consistently deliver
appropriate care
Ideal
Patient Care
Experience
Don’t Make,
Accept, or
Send on
an Error!
Right Care,
Right Time,
Right Setting
Leveled
Workload
Error-Free
Continuous Improvement
(P-D-C-A) and Learning
Standardized
Work
Make Value Flow by Eliminating Errors and Waste
BCM Quality System
Quality – Safety – Efficiency – Appropriateness – Service
• Pacing by Demand
• Error Proof
• Continuous Flow
• Pull Systems
• Surface Problems
• Stop and Respond
to Abnormalities
• Solve Problems
at Root Cause
Customer
Defines Value
Leveled
Workload
STABILITY
Built-in-Quality
Continuous Improvement
(P-D-C-A) and Learning
Work Force
- Skilled, Capable, Flexible
- Engaged, Motivated
- Design Work, Solve Problems
Methods
- Robust Processes
- Organized Workplace (5S)
- Visual Control
QUALITY
QUANTITY
Just-in-Time
Standardized
Work
Technology and Equipment
Materials
- Reliable, Tested
- Materials Readiness
- Serve People and Processes
- Supplier involvement
- Preventive Maintenance -TPM
Make Value Flow By Eliminating Errors and Waste
Examples of Gaps at and most health
systems
• Quality:
• Not all patients get right antibiotic timing
• Hospital Acquired infections
• Readmission rates
•
• Safety:
•
•
•
•
Medication errors (10x infusion pump dose)
Labs labeled with wrong patient name
Retained foreign objects
Hand sanitizing “in and out of bedside” less than 100%
Examples of Gaps at and most health
systems
• Efficiency:
•
•
•
•
•
Nurse, doctor searching for equipment, forms, pts…
Outdated DPCs, wrong instruments for case
Higher OR case length: fewer cases, less $$, RIFs
Duplication of clinic personnel without standardized work
Prolonged length of stay
• Appropriateness:
• Drugs ordered up, not used; imaging v. examining
• Service: Patients lost, staff look too busy to help
Burning Platform for Change?
Where Do We Want to Go?
Our future state vision: The Ideal Patient Care Experience
Based on Institute of Medicine Report
“Crossing the Quality Chasm”
Care that is:
• Safe
• Effective
• Patient-Centered
• Timely
• Efficient
• Equitable
The Ideal Patient Care Experience
• The IOM “Chasm”
Report gives us a vision
of where to go
• Lean Thinking gives us
the holistic approach
and business system to
get there
The Ideal Patient Care Experience
• The IOM “Chasm”
Report gives us a vision
of where to go
• Lean Thinking gives us
the holistic approach
and business system to
get there
What is Lean Thinking?
Several perspectives…
“The endless transformation of waste into
value from the customer’s perspective”.
---Womack and Jones,
Lean Thinking
The “4P”
model
Problem
Solving
(Continuous
Improvement
And
Learning)
Process
(Eliminate Waste)
People and Partners
(Respect, Challenge, and
Grow Them)
Philosophy
(Long-Term Thinking)
Impact of Lean in the Industry
Direct Labor/productivity improved
45-75%
Cost Reduced
25-55%
Throughput/Flow Increased
60-90%
Quality (Defects/Scrap) Reduced
50-90%
Inventory Reduced
60-90%
Space Reduced
35-50%
Lead Time Reduced
50-90%
Source: Virginia Mason Medical Center
TRADITIONAL CULTURE VS. LEAN CULTURE
TRADITIONAL
Functional Silos
Managers direct
LEAN
Interdisciplinary teams
Managers teach/enable
Benchmark to justify not
improving; “just as good”
Seek the ultimate
performance, the absence
of waste
Root cause analysis
Blame people
Rewards: individual
Supplier is enemy
Guard Information
Volume lowers cost
Internal focus
Expert driven
Rewards: group sharing
Supplier is ally
Share information
Removing waste lowers cost
Customer focus
Process driven
Lean is not about working harder or faster
Lean is about finding waste and transforming
it into value our customers want.
Process Improvement Tools
Clean it up, Make it Visual – 5S
SORT
STRAIGHTEN
SUSTAIN
SHINE
STANDARDIZE
VAS Supply Cart 5S
Drawer: Pre-5S
Drawer: Post- 5S
Saved each nurse an hour a day!
Engaged team:
front line workers
and managers
The 8 Wastes
D
DEFECTS LEADING TO
REWORK
O
OVERPRODUCTION
W
WAITING
N
NOT HIGHEST & BEST
USE OF TALENT
T
TRANSPORTATION
I
INVENTORY
M
MOTION
E
EXTRA PROCESSING
LEAN
Missing/incomplete information, defective products, and errors. All re-work is
waste.
Ex: Medication errors, incomplete patient chart
Producing more products or information than is needed. (This is the most common
form of waste
Ex: Having several of the same item on hand when only one is needed
People, material, or equipment not being acted upon. Time spent waiting.
Ex: Are the labs ready? Is the patient here yet?
Correct use of people and ideas
Ex: Clinical personnel doing non-clinical activities
Moving patients, medications, products. Travel is time consuming.
Ex. Unnecessarily moving a patient from one place to another
Material or information that just sits can potentially become lost or damaged.
Ex: Piling up smaller tasks to be completed later in a batch
Action or motion by the worker that does not add value.
Ex: Searching for charts
Processing tasks that are not essential or value added to the patient.
Ex: Writing information from the computer onto a piece of paper
31
Eliminating Waste
• Overproduction
– Producing more
products or
information than is
needed. (This is the
most common form of
waste
• Ex: Having several of
the same item on
hand when only one is
needed
Eliminating Waste
Transportation
– Moving patients,
medications,
products. Travel is
time consuming.
• Ex. Unnecessarily
moving a patient
from one place to
another
Eliminating Waste
• Motion
– Action or motion by the
worker that does not
add value.
• Ex: Searching for charts
Eliminating Waste
Waiting
– People, material, or
equipment not being
acted upon. Time
spent waiting.
• Ex: Are the labs
ready? Is the patient
here yet?
Eliminating Waste
EXTRA PROCESSING
– Processing tasks that
are not essential or
value added to the
patient.
• Ex: Writing
information from the
computer onto a
piece of paper
Eliminating Waste
DEFECTS LEADING TO
REWORK
– Missing/incomplete
information, defective
products, and errors.
All re-work is waste.
• Ex: Medication errors,
incomplete patient
chart
Eliminating Waste
• Inventory
– Material or
information that just
sits can potentially
become lost or
damaged.
• Ex: Piling up smaller tasks
to be completed later in a
batch
Value Stream Mapping Workshop
Value Stream Scope
Determine the Value Stream
to be improved
Current State
Drawing
Understanding how things
currently operate. This is the
foundation for the future state
Future State
Drawing
Implementation
Plan
Implementation of
Improved Plan
Designing a lean flow through
application of lean principles
Developing a detailed plan of
implementation to support
objectives (what, who, when)
The goal of mapping!
30, 60, 90 day follow-up
t
Value Stream Mapping
Diagnose
A value stream is all the actions (both value added and non-value added) currently
required to bring a product through the main flows – from raw material into the arms
of the customer.
Helps you visualize more
than just the single-process
level
Helps you see more than
waste. Mapping helps you
see the sources of waste
Provides a common
language for your team
Makes decisions about
flow apparent, so you can
discuss them.
Ties together lean concepts
and techniques
Forms the basis for the
implementation plan
Shows the linkage between
the information flow and
material flow.
40
The Broken Office Visit
Value Stream Mapping:
Learning to See
• “Aha” moments:
–
–
–
–
I never knew this is how it worked!
I can’t believe what a mess this process is!
No wonder we’re frustrated!
It’s a miracle a patient ever gets through it!
Examples of Lean at Work
CVOR Patient Flow Project Charter
Project Start: September 8, 2014
Purpose Statement:
To create Cardiovascular surgical bed capacity to accommodate patient
volume increases set forth in the FY15 budget.
Criteria for Success:
•First case surgical start time - daily & monthly reporting
•Room turnover time – daily & monthly reporting
•Pre-op readiness– daily & monthly reporting
•Day of discharge – daily & monthly reporting
Team Leadership
Team Members:
Executive Sponsor: David Berger,
MD/Judy Swanson
Phys. Champion: Sam Awad, MD
Team Leader: Joe Turner/Puneet
Freibott/Angelle Rhemann
Process Owner: Judy Swanson to
delegate
Perf. Excellence Coach: James Hearn
Metrics Owner: Rachel Atherton (GE)
Brenda Mangon
Tony Lovett
Hoai Nguyen
LaShanti King;
Jennifer Grant
Norma Covarubious
Dr. Collard
Dr. Anton
Kristi Custard
Claudine Cornett
Susan Lewis; Roman Padilla; Kim McLeod
High
Anticipated Impact:
Mod Low
Anticipated Impact: Patient Satisfaction
Anticipated Impact: Increased Revenue
Anticipated Impact: Improved Productivity
Scope: Specific Focus:
Process start & stop points;
• OR Scheduling to hospital discharge for CV Surgical Patients
Key Performance Metrics:
CHI St. Luke’s Health Baylor St. Luke’s
On Time First Case Starts
Goal: 90% On Time First Case Starts
Risk (Leadership Perspective):
• Physician Leadership
• Organizational fatigue to change
• Employee empowerment to make change
• Risk tolerance of the organization
• Restructuring Pre-Op Procedures
Room Turnover Times
Goal: < 30 minutes
Pre-Op Readiness
Goal: % Patients in CV Holding by 6:50a
Baseline
Last
Report
Trend
%
Improve
on
target
51.8
45 min
77%
47
Historical Performance Trend - Baseline: 2014
48
Value Stream Map
Three Major Value Streams Reviewed:
• Patient Arrival/Registration Process through
6TOP
• CV Holding Process
• Room Turnover Process
The 8 Wastes
D
DEFECTS LEADING TO
REWORK
O
OVERPRODUCTION
W
WAITING
N
NOT HIGHEST & BEST
USE OF TALENT
T
TRANSPORTATION
I
INVENTORY
M
MOTION
E
EXTRA PROCESSING
LEAN
Missing/incomplete information, defective products, and errors. All re-work is
waste.
Ex: Medication errors, incomplete patient chart
Producing more products or information than is needed. (This is the most common
form of waste
Ex: Having several of the same item on hand when only one is needed
People, material, or equipment not being acted upon. Time spent waiting.
Ex: Are the labs ready? Is the patient here yet?
Correct use of people and ideas
Ex: Clinical personnel doing non-clinical activities
Moving patients, medications, products. Travel is time consuming.
Ex. Unnecessarily moving a patient from one place to another
Material or information that just sits can potentially become lost or damaged.
Ex: Piling up smaller tasks to be completed later in a batch
Action or motion by the worker that does not add value.
Ex: Searching for charts
Processing tasks that are not essential or value added to the patient.
Ex: Writing information from the computer onto a piece of paper
50
Issues & Waste Priority Matrix
Issue Prioritization matrix – Example
CV Turnover Waste Identified
1
Relabeling
33 Knowledge of case and equip.
2
No PAT
34 Complexity of case
3 Waiting on MD orders
35 Limitation of Staff
4
Obtaining Pt. Demo
36 RN,PCA,ORA Lunch times
5
Untimely test results
37 Equipment Issues
6
Pt. not marked
38 MD/Anes/Trainees
7
Need H&P/Update
39 Room Down
8
Clinical doc. Verified
40 Multi room turnovers
9
Patients sametime arrival
41 Incorrect Counts
10 Multi. Types of patients
42 Cir. Support, AICD (pickup)
11 Pre-Op repeated questions
43 Surgeon ava.
12 Comm. 6T,CV holding, OR
44 No dedicated elevator
13 Pt. Valuables
45 Improper documentaion in Epic
14 Medications not verified Pharm.
15 Inadequate pt. tracking
16 Floor readiness
17 Patient readiness
CV Holding Waste Identified
Priority Zone
>45
31
1
15
28
19 Untimely test results
15
20 Patients not marked
21 No Consents (Anesthesia)
39
32
22 No Consents (Surgeons)
23 No blood prod. Ordered
24 Waiting on Pt. from other pre-op flrs.
26 Inadequate substitutes for PCA
27 Patient Valuables
28 Waiting on Surgeon for Orders
29 Wrong orders for patient
30 Wrong case booked
31 Duplication of work
32 Holding area space constraints
16
23
41
43 13 25
19 26
18 No H&P / Update
25 Staffing in CV Holding
33
45
Impact of
Occurrence
6TOP Waste Identified
0
0
18
30
42 3 11
35
5
9
4
14
2 36
40
12
7
22
6
44
8
21
10
34
37
17
24
38
20
29
27
40%
Frequency of Occurrence
(percent of patients experiencing issue)
>80%
Issue Tree
Fellow / Resident
unavailable
Patients not
marked
Fellows/ Residents in the OR
Fellow/Resident training
No H&P Update
EPIC screens different for
RN & MD
Documentation challenges
Paper H&P because MD
refuses to use EPIC
No blood
product ordered
Consent not available at
bedside
Untimely test
results
Anesthesia
What keeps us
from starting
and staying on
schedule in
the CVOR?
Unknown kind of
anesthesia
Emergency surgery
Mandatory Wednesday
meeting
No standard checklist for day
of surgery
High turnover
MD doesn’t have EPIC in
office
MD has different EPIC
system in office
Lack of education
No orders created
Unable to update
Thinks RNs responsibility
Doesn’t know how to use
No Consents
Surgeon
MD doesn’t obtain consent
(only talks to patient)
Wrong case booked
Limited # of staff available
Imed not used
Consent doesn’t match
booked case
Doesn’t contain all
procedures
Case order doesn’t follow
schedule
Staff availability
Off shift worse
Circ Support /
Pacemaker/AICD
Communication challenging
Operational flow (how do they
know what pts are on sched?
No central point of
communication/ coordination
Room turnover
process causes
delays
No central point of communication /
coordination
Staff limitations with lunches / breaks
Instrument equipment / availability
Multiple room turnovers
Lack of coordination
Multiple rooms start around same time and
end around same time
Root Cause Priority Matrix
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
Operational Flow of
Circ Support AICD
Lack of knowledge
of pt. condition
and device
Lack of
Coordination / No
Central Control
No accountability
(PCA, Phar, etc)
Dedicated patient
elevators
Coordination
between Anes and
RN
Shortage of skill set
Competition and
Compensation
Communication w/
Circ support AICD
office
Staff limitations
Logistical issues
Perfusion – lack of
equip/staff
Not everyone can
relieve on all cases
No H&P / Update
Untimely test
results
Z
AA
Wrong case booked
(unknown case sequence)
Duplication of work
CC
Holding and Space
constraints
DD
No H&P / Update (A)
EE
Lack of Education (A)
FF
No orientation (A)
Consent not at bedside
when patient seen (D)
HH
Patients not marked (C)
II
Lack of education (C)
Fellow / Res. Lack of
checklist for day of
surgery (C)
Anesthesia not seen pt
(D)
JJ
KK
LL
No consents (anes) (D)
MM
Lack of education (MD)
Unk. Kind of anesthesia
(D)
Lack of education (RN)
(D)
Paper H&P
NN
R
Patients not marked
OO
S
No consents (Anes)
PP
HH
High DD
Waiting on surgeon for
orders (6T OP)
BB
GG
Priority Zone
EE
II
FF
JJ
GG
A
B
OO
C
KK
O
NN
Z
K
PP
P
R
M
G
E
H
Low
L
T
X
AA
I
F
Mod
Y
J
BB
D
Q
Low
LL
MM
W
U
Anticipated Impact of
Solution on Problem
A
Root Causes
Limited # of certain
No / Wrong Consents
T
sets / items
(surgeons)
No blood product
•Sugarbaker Sets
U
ordered
Waiting on pt. from
•Coselli Sets
V
other preop floors
•Lasers
W
Staffing in CV Holding
Inadequate substitutes
•Hybrid Suites
X
for PCA
Instrument and
Equipment
Y
Patient valuables
Availability
N
S
H
V
CC
Mod
High
53
 Key Discoveries
• 6TOP & CV Holding area processes are redundant and create an extra
stop in CV patient flow
• Patient preparatory process has significant amount of waste:
• Defects leading to rework – wrong case booked
• Waiting – multiple rooms requiring turnover at the same time
• Transportation –Patient arriving going to 6T0P 2nd floor CV
Holding  then to OR
• Inventory – patients arriving at same time sometimes leading to
long waits
• Motion – equipment availability and familiarity of staff with
equipment for certain cases can lead to extra motion
• Extra processing – errors in the consent can lead to requesting the
same information more than once
54
Standard Work
STANDARDIZED WORK SHEET
AREA
PROCESS NAME
CVOR Preop
PACU
Preop
No.
WORK ELEMENT
1
RN 1: Arrives @ 0430 to review orders, and remove IV
start kits and meidcations from the AcuDose on 6 Tower.
All charts, medications, and supplies are brought to the
2nd floor preop area.
2
RN 1: Picks up revised OR schedule from the OR
secretary. Reviews OR schedule for any changes.
3
RN 1: Places 1st case charts in correct numbered slot
and places remaining charts in locked cabinet above the
chart rack. The patient board is checked for accuracy
based on the revised schedule and updated as
necessary.
4
RN 1: Reviews volunteer's patient sheet made the
previous day for accuracy. Changes made if applicable.
First cases are notated on the sheet. The volunteer's
sheet along with all the armbands are given to the
receptionist/volunteer in the waiting area.
5
RN 2, PCA, Pegistrar arrive to unit @ 0500.
6
PCA with RN 2 assist - complete bay/bed set-up.
TAKT TIME
DATE
DEPARTMENT
WORK
WAIT
SYMBOL
TIME
TIME TIME
APPROVAL
1st Supervisor
2nd Supervisor
3rd Supervisor
Mgr.
SIGN-OFFS
2/12/2015
KEYPOINT
DATE
WALK
TEAM MEMBER MOTION
KEY POINTS
(OR PICTURE)
This step will be eliminated once all the elements
are in place on the 2nd floor (charts prep,
AcuDose, etc). Process will then be added to 14d
H
HIPPA
• Standard work for patient prep
process developed in collaboration
with 6TOP staff
PCA completes the following:
7
a. Retrieves Scale and Dynamap
b. Places OR name tags on the foot of each bed in the
bay
c. Completes control check on glucometer
d. Calls blood bank for Specimen Needed/Units Available
sheet
Unit secretary arrives @ 0530. Role includes:
a. Assigining patients to correct bays
b. Paging physicians for H&Ps and site markings
8
c. Generating or reprinting consents as needed
d. Verifing T&S and available units on blood bank sheet
This is a licensed function and can possibly be
done the night before
e. completes blood pick up slips for the OR rooms
9
Upon patient arrival, volunteer documents arrival time of
first cases on the provided paper log, places an armband
and patient tracker on the patient, and clicks the patient
as arrived in Epic. The volunteer/receptionist then
escorts the patient only to the CVOR preop area in order
of patient arrival.
10
Upon arrival to the unit the PCA obtains the patients
height, weight, and vital signs.
11
Patient's time of arrival is written on patient board.
13
Patient is escorted to the bed and instructed on
gowning.
Patient is seen by registrar - in order of arrival.
Registration admission process is complete by marking
patient name with letter "A" in designated column on the
patient board.
14
RN is assigned to preop patient via self assign and
places their initials in the appropriate column on the
patient care board.
15
RN complets the preprocedure preop once the paitent is
cleared for services and is in an admitted status. The RN
preop includes:
12
H
HIPPA
• 6TOP staff cross trained the CV
Holding staff during pilot
CV Fellow is paged at this point.
**charge nurse function once a charge nurse is
identified
a. Reviews orders
b. Verifies consent and medication matches orders
c. Notifies PCA of delegated tasks: POCT and EKG
d. RN gathers remaining supplies needed and goes to
the bedside
16
e. RN starts IV and collects lab specimens - all lab
specimens are to be sent as STAT
If labs are not ordered as STAT, the nurse modifies
the order to reflect STAT (1st cases)
***Renal Patients: Glucose and Potassium sent to rapid
response lab
Transported by PCA
f. RN completes assessment, screenings, and DOS
preop checklist
Epic
g. RN obtains signature on procedural and research
consent if applicable
h. Anesthesia Delegated orders are used when needed
i. RN places checkmark by patient name on the patient
care board in the designated column.
17
Signifies the RN is complete with the patient
RN notifies Unit Secretary of any outstanding defects
and pages the physician to correct.
RN notifies OR room if IV access still needed
18
After all notifications - RN reviews the patient care board
and assigns self to the next patient.
19
Additional things such as CV Fellow, Anesthesia, and
body clipping must occur before patient is wheeled back
to the OR.
SUB TOTALS
#
CHANGE REASON
DATE
SYMBOL LEGEND
H
Safety
WORK WAIT WALK
GRAND
TOTAL
Quality
In-Process
HIPPA
SIGN OFF
Pilot 1:
Bypass 6TOP
Baseline State
Pilot Implementation Plan
6TOP
CV OR Holding
CV OR
Primary Metric
Pilot Start: January 5, 2015
Baseline
Median = 60%
Pilot End: February 20, 2015
Pilot
Median = 80%
Source of Significant Impact
Improvement of our “On Time First Starts” was accomplished by converting the CV holding department into a CV PreOp. This transition resulted in redirecting our surgical patients directly to the CV holding area and having the
admitting, and pre-op processes began on the 2nd floor. As you can see by our side by side outcome metrics that prior
to this transition our “On Time First Starts” were 60% or less. After various work out sessions and root cause analysis it
was evident that improving the patient flow and having the ability to admit and pre-op our patients on the same floor
has contributed to this dramatic change in our “On Time First Starts” to 90%.
Daily Huddle Board
Daily Huddle Board placed in area
common to CVOR and CV Holding
Focus placed on metrics directly
related to First Case OnTime Starts
Monitor and Report
• Governance
– Daily Management System
– Hospital Operations Group
• Quarterly presentations on key metrics
– OR Section Meeting
• Performance Review
– Daily review by CV OR staff and CV Holding staff
– Monthly Gemba Walks
– Quarterly review at Management Review
• Next Steps
– Expand improvements to all BSLMC ORs
– Room turn over Work Out
Charter
Project Start: Jan. 5, 2014
Purpose Statement: This pilot project will be observing the benefits of
allowing our CV surgical patients to be checked in and pre-oped in our
CV Holding area. This would allow patients to be seen in one designated
area and improve our on time first case start times. This transition
would also eliminate rework and stabilize our ORA/SPCA staffing issues
in the mornings. Another purpose of this pilot would be to ensure our
patients have a safe and comfortable experience.
Criteria for Success:
•PreOp and check-in permanently moved to the 2nd floor.
•Improve “On Time First Starts”
•Patient Issues can be resolved in a timely manner
•Eliminate Rework
•Improve utilization of the OR Assistants
Scope: Specific Focus:
Team Leadership
Team Members:
Executive Sponsor: Wayne Keathley
Process Owner: Judy Swanson
Phys. Champion: Dr. S. Awad
Team Leader: Joe Turner / Roman
Padilla
Metrics Owner: Roman Padilla
Dr. David Collard
Dr. James Anton
Alene Jackson
Chris Carrao
Susan Lewis
LaShanti King
Divya Wilson
Jonathan Gecomo
Tony Lovett
Tawana Jones
Mahvesh Siddiqui
Joseph Greco
Nelvin Daniel
High
Anticipated Impact:
Mod Low
Anticipated Impact: Patient Satisfaction
Anticipated Impact: Surgeon Satisfaction
Anticipated Impact: Improved Efficiency
%
Improve
on
target
Baseline
12/14
Last
Report
02/2015
Scheduled On Time First Start
Goal: 90%
63%
90%
27%
Patient Satisfaction Survey Average/
month
Goal: 5.0
4.5
5.0
11%
Process start & stop points;
Key Performance Metrics:
• CV Surgical patient check in – Transported to surgery
• Create measurements for improvement of our patient and surgeon
satisfaction scores
CHI St. Luke’s Health Baylor St. Luke’s
Risk (Leadership Perspective)
•Surgeons
CV Fellows
•CV Holding Staffing
Anesthesia
•6 Tower Staffing
PAS department
•Surgical Team
•ORA/SPCA
Lillian Bailey
Richarz Davidson
Lysette Logan
Carolyn Davis
Pam Windle
Patricia Roth
Surgeon Satisfaction Survey Average /
month
Goal: 5.0
Estimated Financial Impact:
Trend
Pending
$1.78M
60
Examples of Lean at Work - Safety
A Systematic Approach to Preventing Sharps
Injuries in the Operative Care Line at an
Urban Tertiary Care Hospital
S Martinez MD, S Awad MD, CC Braxton MD
Michael E. Debakey Veterans Affairs Medical Center,
Baylor College of Medicine, Houston, TX
Introduction
• Percutaneous sharps injuries remain an occupational
health hazard for surgical personnel
• The risk of infection following injury is 30% for HBV, 1-3%
for HCV, and 0.3% for HIV
• Needlestick Safety and Prevention Act 2000 and revised
OSHA Bloodborne Pathogens Standard enacted to address
this health hazard
• Despite these efforts, an estimated 384,000 percutaneous
sharps injuries are reported annually by hospital personnel
• Estimated cost for a sharps injury ranges from $500 to
$3000
80
100.0%
70
80.0%
Number
60
50
60.0%
40
30
40.0%
20
20.0%
10
0
0.0%
Figure 1: Sharps injuries by care line FY09-12
FY09-12 Sharps Injuries by Occupation
Resident
Tech
Nurse
Other
MD
Student
17, 10%
19, 11%
63, 37.7%
21, 13%
23, 14%
24, 14%
2) Observational data collection
• Direct observations were conducted of surgical
personnel in the OR
• Data on needle and instrument handling were
collected
• No consistent method of sharps handling
techniques was observed
• Use of hands-free techniques and neutral zones
was infrequent
3) Educational interventions
• A multi-component educational campaign was
launched in September 2012 for the OCL.
• Data were presented at the monthly OR committee
and OR staff meetings to increase awareness
• A culture of safety was emphasized to empower the
surgical team members and to create accountability
• Video-based learning was implemented for rotating
residents and students demonstrating safe sharps
handling
4) Implementation of sharps safety practices
• Safe zone or neutral zone
• Hands-free technique
• Call and response system e.g. “MD knife back,
RN knife back”
Results
Pre-Implementation
Post-Implementation
P - Value
Operative Care
line
MD
32
15
0.01
5
3
0.46
Resident
17
4
0.003
Student
6
3
0.30
Nurse
4
5
0.76
Results
Project
Implementation
Conclusion
• Quality and Safety improvement using
Lean Methodology can decrease harm,
improve customer satisfaction, while
decreasing costs
QUESTIONS ?