Click to edit subtitle style Samir S. Awad MD, MPH Professor of
Surgery Vice Chair Surgical Quality & Safety Baylor College of
Medicine Chief of Surgery Michael E. DeBakey VAMC Houston TX
Applying Lean Management to Improve Quality and Efficiency in
Surgery Slide 2 INTRODUCTION Scope of the problem Current Gaps Lean
Methodology Process BCM Department of Surgery Examples Slide 3
INTRODUCTION Every healthcare system has problems in quality,
safety, efficiency, service Problems harm patients, raise costs,
frustrate workers Economy: short & long term Slide 4
INTRODUCTION Goals Ideal Patient Care Experience Ideal
Clinician/Staff Experience Ideal Research/Trainee Experience Safest
health system in US Financial stability Slide 5 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 Slide 6 INTRODUCTION Strategies Spread
a consistent QI model across institution -Build on current QI base
-Study lessons from Lean Thinking Hundreds of problem solvers Slide
7 INTRODUCTION Plan: Use Lean Methodology to improve safety and
quality Efficiency Frontline workers help build it Slide 8
INTRODUCTION Baylor College of Medicine Quality System: Quality
Safety Efficiency Appropriateness Service Slide 9 Just-In-Time BCM
Quality System BCM Values: Respect, Compassion, Trust, Integrity,
Collaboration, Leadership Built-in Quality Slide 10 Using the
fewest resources to consistently deliver exactly what the customer
needs Just-in-Time Built-in-Quality Error-Free Dont Make, Accept,
or Send on an Error Make Value Flow by Eliminating Errors and Waste
Leveled Workload Continuous Improvement (P-D-C-A) and Learning
Standardized Work BCM Quality System Quality Safety Efficiency
Appropriateness Service Customer Defines Value Slide 11 Using the
fewest resources to consistently deliver appropriate care Right
Care, Right Time, Right Setting Just-in-Time Built-in-Quality
Error-Free Dont Make, Accept, or Send on an Error! BCM Quality
System Safe - Effective - Efficient - Patient-Centered - Timely -
Equitable Health Care Make Value Flow by Eliminating Errors and
Waste Leveled Workload Continuous Improvement (P-D-C-A) and
Learning Standardized Work Ideal Patient Care Experience Slide 12
Just-in-TimeBuilt-in-Quality QUANTITY QUALITY Error Proof Surface
Problems Stop and Respond to Abnormalities Solve Problems at Root
Cause Pacing by Demand Continuous Flow Pull Systems Work Force -
Skilled, Capable, Flexible - Engaged, Motivated - Design Work,
Solve Problems Technology and Equipment - Reliable, Tested - Serve
People and Processes - Preventive Maintenance -TPM Materials -
Materials Readiness - Supplier involvement Make Value Flow By
Eliminating Errors and Waste STABILITY Methods - Robust Processes -
Organized Workplace (5S) - Visual Control Leveled Workload
Continuous Improvement (P-D-C-A) and Learning Standardized Work
Customer Defines Value BCM Quality System Quality Safety Efficiency
Appropriateness Service Slide 13 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% Slide 14 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 Slide 15 Burning Platform for
Change? Slide 16 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 Slide 17 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 Slide 18 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 Slide 19 What is Lean Thinking? Several perspectives The
endless transformation of waste into value from the customers
perspective. ---Womack and Jones, Lean Thinking Slide 20 The 4P
model Problem Solving (Continuous Improvement And Learning) Process
(Eliminate Waste) People and Partners (Respect, Challenge, and Grow
Them) Philosophy (Long-Term Thinking) Slide 21 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 Slide 22
TRADITIONAL CULTURE VS. LEAN CULTURE TRADITIONALLEAN Functional
Silos Interdisciplinary teams Managers direct Managers teach/enable
Benchmark to justify not improving; just as good Seek the ultimate
performance, the absence of waste Blame people Root cause analysis
Rewards: individual Rewards: group sharing Supplier is enemy
Supplier is ally Guard Information Share information Volume lowers
cost Removing waste lowers cost Internal focus Customer focus
Expert driven Process driven Slide 23 Lean is not about working
harder or faster Lean is about finding waste and transforming it
into value our customers want. Slide 24 Process Improvement Tools
Slide 25 Clean it up, Make it Visual 5S STRAIGHTEN SHINE
STANDARDIZE SUSTAIN SORT Slide 26 VAS Supply Cart 5S Slide 27
Drawer: Pre-5S Slide 28 Slide 29 Drawer: Post- 5S Saved each nurse
an hour a day! Slide 30 Engaged team: front line workers and
managers Slide 31 31 The 8 Wastes D DEFECTS LEADING TO REWORK
Missing/incomplete information, defective products, and errors. All
re-work is waste. Ex: Medication errors, incomplete patient chart O
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 W WAITING People,
material, or equipment not being acted upon. Time spent waiting.
Ex: Are the labs ready? Is the patient here yet? N NOT HIGHEST
& BEST USE OF TALENT Correct use of people and ideas Ex:
Clinical personnel doing non-clinical activities T TRANSPORTATION
Moving patients, medications, products. Travel is time consuming.
Ex. Unnecessarily moving a patient from one place to another I
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 M MOTION Action or motion by the worker that does
not add value. Ex: Searching for charts E 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 LEAN Slide 32 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 Slide 33 Eliminating Waste Transportation Moving
patients, medications, products. Travel is time consuming. Ex.
Unnecessarily moving a patient from one place to another Slide 34
Eliminating Waste Motion Action or motion by the worker that does
not add value. Ex: Searching for charts Slide 35 Eliminating Waste
Waiting People, material, or equipment not being acted upon. Time
spent waiting. Ex: Are the labs ready? Is the patient here yet?
Slide 36 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 Slide 37
Eliminating Waste DEFECTS LEADING TO REWORK Missing/incomplete
information, defective products, and errors. All re-work is waste.
Ex: Medication errors, incomplete patient chart Slide 38
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 Slide 39 Value Stream Mapping
Workshop Understanding how things currently operate. This is the
foundation for the future state Value Stream Scope Designing a lean
flow through the application of lean principles Current State
Drawing Implementation Plan Determine the Value Stream to be
improved The goal of mapping! 30, 60, 90 day follow-up
Implementation of Improved Plan Future State Drawing Developing a
detailed plan of implementation to support objectives (what, who,
when) Standardize for later improvement Slide 40 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 Value
Stream Mapping 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.
Diagnose Slide 41 The Broken Office Visit Slide 42 Value Stream
Mapping: Learning to See Aha moments: I never knew this is how it
worked! I cant believe what a mess this process is! No wonder were
frustrated! Its a miracle a patient ever gets through it! Slide 43
Slide 44 Slide 45 Slide 46 Examples of Lean at Work Slide 47 47
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. Team Leadership 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) 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 Scope: Specific Focus:
Process start & stop points; OR Scheduling to hospital
discharge for CV Surgical Patients Risk (Leadership Perspective):
Physician Leadership Organizational fatigue to change Employee
empowerment to make change Risk tolerance of the organization
Restructuring Pre-Op Procedures Key Performance Metrics: CHI St.
Lukes Health Baylor St. LukesBaseline Last ReportTrend % Improve on
target On Time First Case Starts Goal: 90% On Time First Case
Starts 51.8 Room Turnover Times Goal: < 30 minutes 45 min Pre-Op
Readiness Goal: % Patients in CV Holding by 6:50a 77% Anticipated
Impact: HighModLow Anticipated Impact: Patient Satisfaction
Anticipated Impact: Increased Revenue Anticipated Impact: Improved
Productivity Team Members: 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 Slide 48 48 Historical Performance Trend - Baseline:
2014 Slide 49 Value Stream Map Three Major Value Streams Reviewed:
Patient Arrival/Registration Process through 6TOP CV Holding
Process Room Turnover Process Slide 50 50 The 8 Wastes D DEFECTS
LEADING TO REWORK Missing/incomplete information, defective
products, and errors. All re-work is waste. Ex: Medication errors,
incomplete patient chart O 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 W WAITING People, material, or equipment not being acted
upon. Time spent waiting. Ex: Are the labs ready? Is the patient
here yet? N NOT HIGHEST & BEST USE OF TALENT Correct use of
people and ideas Ex: Clinical personnel doing non-clinical
activities T TRANSPORTATION Moving patients, medications, products.
Travel is time consuming. Ex. Unnecessarily moving a patient from
one place to another I 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 M MOTION Action or motion by
the worker that does not add value. Ex: Searching for charts E
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 LEAN Slide 51 Issues & Waste Priority
Matrix Impact of Occurrence >45 15 0 Frequency of Occurrence
(percent of patients experiencing issue) >80%040% Priority Zone
Issue Prioritization matrix Example 1 2 4 6 7 8 9 10 11 12 13 14 15
16 17 18 19 20 21 22 23 24 25 26 27 28 29 31 32 33 34 35 36 37 38
39 40 41 43 44 45 3 30 42 5 6TOP Waste IdentifiedCV Turnover Waste
Identified 1Relabeling33Knowledge of case and equip. 2No
PAT34Complexity of case 3Waiting on MD orders35Limitation of Staff
4Obtaining Pt. Demo36RN,PCA,ORA Lunch times 5Untimely test
results37Equipment Issues 6Pt. not marked38MD/Anes/Trainees 7Need
H&P/Update39Room Down 8Clinical doc. Verified40Multi room
turnovers 9Patients sametime arrival41Incorrect Counts 10Multi.
Types of patients42Cir. Support, AICD (pickup) 11Pre-Op repeated
questions43Surgeon ava. 12Comm. 6T,CV holding, OR44No dedicated
elevator 13Pt. Valuables45Improper documentaion in Epic
14Medications not verified Pharm. 15Inadequate pt. tracking 16Floor
readiness 17Patient readiness CV Holding Waste Identified 18No
H&P / Update 19Untimely test results 20Patients not marked 21No
Consents (Anesthesia) 22No Consents (Surgeons) 23No blood prod.
Ordered 24Waiting on Pt. from other pre-op flrs. 25Staffing in CV
Holding 26Inadequate substitutes for PCA 27Patient Valuables
28Waiting on Surgeon for Orders 29Wrong orders for patient 30Wrong
case booked 31Duplication of work 32Holding area space constraints
Slide 52 Issue Tree What keeps us from starting and staying on
schedule in the CVOR? Mandatory Wednesday meeting Reason: much
easier to drive solutions to things on rightinstead of left
Patients not marked Fellows/ Residents in the OR Fellow/Resident
training Fellow / Resident unavailable Emergency surgery No
standard checklist for day of surgery High turnover MD doesnt
obtain consent (only talks to patient) No Consents Anesthesia
Consent not available at bedside Wrong case booked Limited # of
staff available Surgeon Unknown kind of anesthesia Circ Support /
Pacemaker/AICD Staff availability Communication challenging Off
shift worse Operational flow (how do they know what pts are on
sched? No central point of communication/ coordination Room
turnover process causes delays Multiple room turnovers Multiple
rooms start around same time and end around same time Instrument
equipment / availability Staff limitations with lunches / breaks
Lack of coordination No central point of communication /
coordination No H&P Update Documentation challenges EPIC
screens different for RN & MD Paper H&P because MD refuses
to use EPIC MD doesnt have EPIC in office MD has different EPIC
system in office No orders created Thinks RNs responsibility Imed
not used Doesnt know how to use Doesnt contain all procedures
Unable to update Consent doesnt match booked case Case order doesnt
follow schedule No blood product ordered Lack of education Untimely
test results Slide 53 53 Root Cause Priority Matrix Anticipated
Impact of Solution on Problem High Mod Low HighLowMod H Priority
Zone GG EE DD FF HH II JJ KK LL MM NN OO PP S Q P R T U V W X YZ
AABB CC D B A C E F G H I J K L M N O Slide 54 54 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 Slide 55 Standard Work Standard
work for patient prep process developed in collaboration with 6TOP
staff 6TOP staff cross trained the CV Holding staff during pilot
Slide 56 Pilot Implementation Plan 6TOPCV OR HoldingCV OR Baseline
State Pilot 1: Bypass 6TOP Slide 57 Primary Metric Pilot Start:
January 5, 2015 Pilot End: February 20, 2015 Baseline Median = 60%
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 Pre- Op. 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 2 nd
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%. Slide 58
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 Slide 59 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 Monitor and Report Slide 60 60 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. Team Leadership Executive Sponsor:
Wayne Keathley Process Owner: Judy Swanson Phys. Champion: Dr. S.
Awad Team Leader: Joe Turner / Roman Padilla Metrics Owner: Roman
Padilla Criteria for Success: PreOp and check-in permanently moved
to the 2 nd floor. Improve On Time First Starts Patient Issues can
be resolved in a timely manner Eliminate Rework Improve utilization
of the OR Assistants Risk (Leadership Perspective) Surgeons CV
Fellows CV Holding Staffing Anesthesia 6 Tower Staffing PAS
department Surgical Team ORA/SPCA Key Performance Metrics: CHI St.
Lukes Health Baylor St. Lukes Baseline 12/14 Last Report
02/2015Trend % Improve on target Scheduled On Time First Start
Goal: 90% 63%90%27% Patient Satisfaction Survey Average/ month
Goal: 5.0 4.55.011% Surgeon Satisfaction Survey Average / month
Goal: 5.0 Pending Anticipated Impact: HighModLow Anticipated
Impact: Patient Satisfaction Anticipated Impact: Surgeon
Satisfaction Anticipated Impact: Improved Efficiency Team Members:
Dr. David Collard Lillian Bailey Dr. James Anton Richarz Davidson
Alene Jackson Lysette Logan Chris Carrao Carolyn Davis Susan Lewis
Pam Windle LaShanti King Patricia Roth Divya Wilson Jonathan Gecomo
Mahvesh Siddiqui Tony Lovett Joseph Greco Tawana Jones Nelvin
Daniel Estimated Financial Impact: $1.78M Scope: Specific Focus:
Process start & stop points; CV Surgical patient check in
Transported to surgery Create measurements for improvement of our
patient and surgeon satisfaction scores Slide 61 Examples of Lean
at Work - Safety Slide 62 S Martinez MD, S Awad MD, CC Braxton MD
Michael E. Debakey Veterans Affairs Medical Center, Baylor College
of Medicine, Houston, TX A Systematic Approach to Preventing Sharps
Injuries in the Operative Care Line at an Urban Tertiary Care
Hospital Slide 63 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 Slide 64 Figure 1:
Sharps injuries by care line FY09-12 Slide 65 Slide 66 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 Slide 67 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 Slide 68 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 Slide 69 Results
Pre-ImplementationPost-ImplementationP - Value Operative Care line
32150.01 MD530.46 Resident1740.003 Student630.30 Nurse450.76 Slide
70 Results Project Implementation Slide 71 Conclusion Quality and
Safety improvement using Lean Methodology can decrease harm,
improve customer satisfaction, while decreasing costs Slide 72
QUESTIONS ?
