For a couple of years now I have heard about and witnessed (via friends in the industry) the consolidation of resources in the oil & gas industry through layoffs and closures. This activity was due to a push to flood the market with supply, driving the price of oil down, and in turn causing turmoil among the smaller players. On the drive in this morning, I heard a news report about how the Texas oil & gas industry had brought major international players in this space to a stand still. When they flooded the market, the ingenuity of these American organizations responded by developing ways to produce their product at a lower cost.
When the main driver of revenue was threatened by oversupply, the free market system responded with innovation and a will to improve.
There is an analogy here to the healthcare industry and it begins in the surgery suites of your typical acute care hospital. The value stream that takes the patient through the process of undergoing surgery in a hospital is a main revenue driver. A main competitor of hospital operating rooms, Ambulatory Surgery Centers (ASCs) provide outpatient surgery services for patients at a reduced cost without the added expense or length of stay of a typical hospital surgical stay. ASCs typically operate at a higher efficiency than an acute care hospital operating room. To get more out of their value stream, hospital operating have had to innovate and change to meet these market demands. In my experience, hospital surgical suites can often carry significant opportunity to identify and eliminate existing waste in key processes using lean.
Some common areas to look for lean waste in a surgical department include:
- Pre-operative (pre-op) process
- Supply & Inventory process
- Scheduling Process
Before the patient arrives at the hospital, there are a number of tests that are necessary so that the physician can have the information needed on the day of surgery. There are pre-surgery labs, instructions, health assessments and background information provided to the patient on the surgery itself. All of this activity can be accomplished through the establishment of a Pre-Admission Testing (PAT) process.
Appointments for a PAT clinic are usually held a day or two before surgery, but some assessments and lab results provide the information needed within a 30-day window.
A key consideration here is the patient’s time and distance from the facility. In some cases, it doesn’t make sense for a patient to drive into a regional facility for a PAT clinic appointment when the surgery is to take place a couple of days later. A solution to this issue may be a collaboration with surrounding community providers to provide testing services that are in a convenient location for the patient.
In addition to collaborating with surrounding community providers, phone screens are a good use of resources for this patients with a lower risk profile. This provides a better experience to the patient, and it allows the healthcare organization to reach more patients with increased efficiency.
The readiness of an operating room to host a surgery has just as much impact on an efficient flow of patients as the patient’s readiness. This can be looked at in two different ways: the beginning of the day (first case starts) and the room turnover in between.
With first case starts, it is imperative that the rooms that are brought “online” at the beginning of the day are ready to start on-time and according to the schedule. There are some common time stamps (and factors) to consider when evaluating the effectiveness of a first case start process.
- Room set-up time: when is the room ready to receive the patient with all necessary equipment and personnel (factors to consider: room open time, staff arrival time, % of time equipment needed is ready at scheduled start time)
- Draped and ready time: when is the patient’s surgical site draped and prepped for surgery (% of time patient is in room 10 minutes prior to scheduled start, complexity of the pre-surgery positioning)
- Physician arrival time: when is the physician ready to perform the surgery
When considering the room turnover process, a look first at the standard work for an operating room turnover clean is a good place to start. There should be an audit performed against the standard work to ensure it is being followed. Once this is done, some key questions to consider include:
- How long does it take on average to perform a turnover clean?
- How long does it take on average to set-up the room after the turnover clean has taken place?
- What percentage of the time is the time is the next case performed by the same surgeon?
Day of Surgery Patient Prep
It is crucial that the patient prep on the day of surgery run smoothly. Some of the prep is contingent on a solid PAT platform (discussed earlier in this article). There is, however, some activity that MUST be performed the day of surgery and rely on the two main actors in this play: the physician(s)and the patient
The team of physicians involved in the surgery will need to see the patient prior to surgery. This could potentially happen in the room. From a patient perspective it provides a higher-touch experience to have this conversation in the pre-op holding area. The surgeon initials the surgical site and the anesthesiologists reviews the anesthesia assessment looking new risk factors.
Supply & Inventory Processes
Specialty Surgical Equipment
Surgical care is aggressive and often cutting edge. It saves many, many lives each year and has a natural ‘entrepreneurial’ feel to it. This often results in the necessity of using specialty equipment to perform specialized procedure. A specialized piece of equipment may be used by multiple physicians and will cause a natural strain on system efficiency. Perform an audit reviewing the % of time a specialty piece of equipment is not available. If it is due to being in use in another room, a cost-benefit analysis of purchasing another one is in order. In instances where the equipment is not sterilized and ready for use, consider looking for ways to improve the process.
Center Core Supply
An important piece of an operating room in a hospital is the center core supply room. This area has the potential to bring an operating room to a standstill with a specific supply out of stock. As a result, many center core supply rooms will have stock levels that are well above the daily/weekly demand. To be clear, it can be life-saving to have a needed surgical supply on hand. There must be quick and decisive intervention to prevent or limit harm.
So, what’s the solution?
One solution is a kanban system. In this article, I define the lean tool known as a kanban system as, “an inventory control system”. It uses visual cues to communicate a status or need to the user. In this case, a kanban system indicates when a critical item is low or when special item is out. For example, if a critical item is getting low on inventory, this system would visually alert the supply room personnel that its time to order more of this item. If it is an uncommonly used item, the visual cue may indicate to the personnel ordering supplies that this supply is no longer in inventory. A well run center core supply room can save an operating room department hundreds of thousands of dollars on supply cost every year if properly run.
There will likely also be a few high-demand items that don’t fall into the category of specialty equipment. Pretty much anything could fall into this category. A few examples are:
- Staff use of lead aprons
- special headsets used to provide additional light to the surgical site, and
- certain equipment favored by the surgeon
The high demand for items such as this can create an environment where staff will hide items for later use. This often compounds the problem.
One solution is the use of a 5S system of organization for equipment in the operating room. 5S stands for the 5 steps taken to organize an area: Sweep, Set-in-order, Shine, Standardize and Sustain. Using this technique results in a visual management system bringing order to equipment placement when not in use. Here’s a good article on 5S by Mark Graban of the Lean Blog.
First Case Scheduling
As mentioned above, first cases in a room can set the pace for the rest of the schedule that day. The first case slots are also the most desirable to many physicians. These cases start early, do not have to deal with prior case delays and allow the physician to hold clinic. It is imperative that first cases start as close to the scheduled time as possible.
One way to do that is to establish rules on the placement of first cases on the schedule.
One team instituted a requirement that documents be complete in order to schedule as a first case.
By engaging stakeholders, the team collaborated on the identification of a set of criteria for first case schedule placement. They also reviewed the scheduling processes to realize the necessary changes in information flow.
Schedule Utilization Analysis
Block schedule vs non-block schedule? Hybrid schedule? Here are a couple of questions that can be answered by an in depth analysis room utilization.
- A block schedule identifies by physician a unit of time that a room will be in use.
- Depending on volume, a provider may have multiples blocks of time spread across multiple days of the week.
- A non-block schedule would take cases as they came and place them throughout the week.
- The hybrid schedule is a mix of block time for higher volume contributors and non-block for low volume providers
A few scheduling factors to consider include: utilization, on-time start rate and monthly volume. Looking at these and any other factors deemed important, will guide a discussion around optimal schedule configuration.
Delays are going to happen in the schedule throughout the day. Minimizing delays is management’s job, and there are few substitutes for a supervisor who knows how to ‘work the schedule’. Keeping the delicate balance between the needs of the facility and the needs of the surgeon is an important job.
Standard work for turnover of rooms throughout the day can be a key tool in helping the day run smoothly.
These are just a few methods to consider when embarking on a lean journey in a Surgery Department’s day-to-day operations. Lean concepts such as the use of a Daily Management System, rooting out the 8 lean wastes in the day to day operations, employing visual communication and prioritizing a process improvement agenda can all provide a good foundation for continuous learning and improvement.
In this article, I described areas to apply lean management principles to a hospital housekeeping department.
Find this and other posts of mine at my blog covering lean in healthcare. (www.smartleanhealthcare.com)