Lean Green Stream In Surgery-CLATTERBRIDGE Rapid Improvement Workshop 15th - 19th May 2006

The Lean Team:- Carol Makin,Terry Tarr,Paul Kutarski,Martin Greaney,Glyn Thomas,Jenny O’Connor,Jo Goodfellow,Jeanette Berry,Pam Leonard,Frank Hoey,Gaynor Williams,Nicki McAllister,Gaynor Westray,Sheila O’Neill,Angie Tilston,Kath Shirley,Jo Hardman,Roger Smith,Steve Vaughan,Alison Johnson,Tom Moloney,Ann Eason,Rob Kiff,Linda Holland,Laura Hibbs,Julie Ryan,Claire Bashford,Stephanie Searl. Facilitators:- Ian Glenday,David Brunt

Why work on the Lean Green Stream ?Working on the green stream can dramatically improve productivitythrough economies of repetition and predictable scheduling.What did we find?We can run green theatre lists and improve patient care whilst improvingworking livesHow will these changes affect what we do today?Identify and remove obstacles to maximize green stream flow.What are the imperatives to make this work?Stick to the rules.

What are the Benefits of Lean Flow?• Disciplined approach to scheduling• Repetition by doing the same things at the same time on every

cycle means we will get better• Puts focus on bottlenecks and eliminates them• Leads to natural continuous improvement• Improves predictability of supplies• Improves communication and aligns teams

What is the Impact?• Improved performance and efficiencies due to economies of repetition.• Identifying and eliminating bottlenecks.• Highlights capability and capacity opportunities• Less firefighting, Less confusion, Less uncertainty Improved morale• Predictable scheduling and theatre lists• Improved communication between booking and theatre teams• Do more with less

The Green StreamTypically 6% of procedures equals 50% of workload.At Clatterbridge 4.2% of procedures account for 52%of theatre throughputClatterbridge Green StreamLA flexible cystoscopy 15%GA cystoscopy 11%Hernias and varicose veins 7%Hip/knee replacementsplus knee arthroscopy 9%Excision of lumps and bumps 4%Lower GI endoscopy 3%Carpal tunnel 3%

Total 52%

Green Stream Rules• Green lists are fixed• Patients will not be cancelled from green lists• Theatre will start on time

• (Start time = knife to skin)• Breaks and lunch will be scheduled to minimise disruption• There will be no change to theatre list order on the day of surgery• Anaesthetic Department to co-ordinate anaesthetist’s and

surgeon’s sessions• Patients will be scheduled when they fulfil pre-assessment criteria• Clerks book green stream lists according to standard templates• Mixed lists begin with “green cases”• Pooling should occur• Admit patients on day of surgery• Medical staff to book leave 6 weeks in advance

Staff NigglesObjectives• Identify niggles• Fix 50% now• Instant and visible communicationOutcomes• Total niggles identified 168• Practical Issues identified as fixable 59 (35%)

• We fixed 45 (74%)• We actioned 14 (26%)

• Niggles given to Flow stream 64 (38%)• Long term niggles 45 (27%)

• room sizes estates issues• staff attitudes training etc

Outpatients and pre-assessmentObjectives

• Reduce patient “touches” for green stream patients• Develop a robust booking procedure

Outcomes Smoother patient flow:

• Reduce patient “touches” from 26 to 13• Review of outpatient scheduling• Pre op assessment at time of out patient appointment• Robust booking procedures at time of decision to operate• Reduce paperwork• ECG / phlebotomy in pre operative assessment• Pre op chest x-ray in OPD radiology• One day process

• microscopic haematuria referrals linked to LA flexible cytoscopy slots and ultrasound scans

Day Case UnitProblems• 34 patient “touches”• Poor flow of both patient and staff journey through Day Case Unit• Mixed sex change and treatment areas• Mix of local and general anaesthesia cases• InformationOutcomes• Reduced patient touches for general anaesthesia from 34 to 11 – (66%)• Reduced patient touches for local anaesthesia from 34 to 8 – (75%)• Introduced staggered ward rounds for general anaesthesia (One Anaesthetist and One Surgeon)• Established cystoscopy pathway as part of urology one day service• Established single sex area on both Units based on current activity of 70:30 gender ratio• Established ‘expected time of discharge’ to reduce delays for both patients and relatives• Reduced unnecessary duplication for staff• All changes cost neutral to date

Next Steps• Communicate and roll out• Disseminate the rules• Collect robust and appropriate data• Make the green stream visible

• Green theatre lists• Maintain the vision• Take it further

• Run green lists over 50 weeks/year• Communicate with the wider NHS

Aim: To improve the quality of the patient’s journey

Design and print by Medical Illustration DepartmenDesign and print by Medical Illustration Department APHt APH

Shelf reduced

Handles removed / floor marked

Cables tidied / phones wall mounted