surgical scheduling: a lean approach to process improvement

B

Surgical Scheduling: A LeanApproach to Process ImprovementROSS WILLIAM SIMON, BA; ELENA G. CANACARI, RN, CNOR

ABSTRACT

A large teaching hospital in the northeast United States had an inefficient, paper-

based process for scheduling orthopedic surgery that caused delays and contrib-

uted to site/side discrepancies. The hospital’s leaders formed a team with the

goals of developing a safe, effective, patient-centered, timely, efficient, and

accurate orthopedic scheduling process; smoothing the schedule so that block

time was allocated more evenly; and ensuring correct site/side. Under the

resulting process, real-time patient information is entered into a database during

the patient’s preoperative visit in the surgeon’s office. The team found the new

process reduced the occurrence of site/side discrepancies to zero, reduced in-

stances of changing the sequence of orthopedic procedures by 70%, and increased

patient satisfaction. AORN J 99 (January 2014) 147-159. � AORN, Inc, 2014.

http://dx.doi.org/10.1016/j.aorn.2013.10.008

Key words: scheduling, orthopedic surgery, Lean.

efore February 2010, Beth Israel Deaconess

Medical Center in Boston, Massachusetts,

had an inefficient, paper-based process for

scheduling orthopedic surgery. This process caused

several issues:

n There was a three- to five-day lag time between

patients knowing they need to be booked for

surgery and being called by the office, and ur-

gent bookings were put on a wait list, creating

periods of uncertainty for patients;

n cases were backlogged;

n interdepartmental communication was poor;

n booking information was inaccurate and

booking times were scheduled in more than

one room with the same surgeon; and

n last-minute changes in procedure sequence led

to waste and workarounds.

http://dx.doi.org/10.1016/j.aorn.2013.10.008

� AORN, Inc, 2014

In addition to this, the facility was experienc-

ing a 4% occurrence of site/side discrepancies

in the preoperative clinic and 2% occurrence

in the OR as well as frequent patient cancella-

tions. These problems were significant enough

that hospital and perioperative leaders decided

that creating a formal team to address them was

justified. Members of the team who developed

the new orthopedic scheduling process, what

parts of the process they represented, and any

other roles they played on the team are shown in

Table 1. As a result, while we were developing

an automated booking system for ORs, the team

also worked to improve the orthopedic surgical

scheduling process, reduce patient cancellations,

and reduce or eliminate site/side discrepancies.

The project took place from February 2010 to

March 2011.

January 2014 Vol 99 No 1 � AORN Journal j 147

TABLE 1. Members of the Team and Their Roles

Job title Represented Other roles on the team

Chief administrative officer, orthopedics Administration Team co-leaderAdministration manager, orthopedics Procedure schedulingAdministrative assistant, surgical

schedulingProcedure scheduling

Anesthesiologist Preoperative and intraoperative processAssociate chief nurse, perioperative

servicesCentral processing department, preop-erative clinic, and OR process

Team co-leader, acted as a knowledgeresource, assisted with strategy,sponsored the project, broke downbarriers to progress

Central processing departmentsupervisor

Surgical kit preparation and case pick

Clinical advisor, orthopedics OR setup and intraoperative processesClinical manager, scheduling operations OR procedure schedulingSenior management engineer Team facilitator, helped with problem

solving and statistical analysisOrthopedic surgeons (2) Clinic, office, and intraoperative processOR scheduler OR procedure schedulingOR systems administrator Process data extraction Helped with statistical analysis

January 2014 Vol 99 No 1 SIMONdCANACARI

Using structured Lean problem-solving tech-

niques, the team developed and launched a safe,

effective, patient-centered, timely, efficient, and

accurate orthopedic surgical scheduling process.

In the analysis phase, the team mapped out the

process, starting with the patient’s call to schedule

an appointment with the surgeon through preop-

erative activities onsite, and identified existing

problems and opportunities for improvement. Then

the team organized the myriad problems into log-

ical groupings and prioritized these according to

impact, which provided a strategy for moving

forward with solutions. The team reviewed and

created solutions for all of the identified problems,

using an activity scorecard and a timeline for cor-

rective action implementation to drive progress. The

new process has solved several of the identified

problems, such as eliminating site/side discrep-

ancies and lag time between knowing the patient

needs to be booked and then contacting the patient,

reducing day before and day of cancellations, and

reducing the frequency of procedure sequences

being changed. The following article describes the

process used to develop the plan to address this

148 j AORN Journal

improvement opportunity, conduct the work, and

the accomplishments.

BACKGROUND

Our facility is a large academic medical center

located in the northeast United States. It is a level

1 trauma center with three operating suites and a

total of 38 ORs, in which we care for all types of

adult patients, except for those needing lung and

heart transplants, for a total of 27,000 procedures

per year.

In addition to internal scheduling difficulties and

inefficiencies, our facility was experiencing a 5.1%

cancellation rate before the process improvements.

In fact, patient-related causes are the most frequent

reasons for cancellation of orthopedic procedures.

In our review of patient reasons for cancellations

within 48 hours of surgery, we learned that most

often patients cancel because they change their

mind about having surgery. Sometimes they cannot

get a ride. Team members perceived that patients

equated surgical appointments with other types of

appointments (eg, the dentist) and were unaware of

the effects of cancelling. Cancellations can have an

SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org

effect on other patients, for example, and cancel-

ling within 48 hours affects the functional opera-

tion of the OR, because surgeons’ instrument kits

that were prepared and delivered to the OR have to

be brought back to the central processing depart-

ment, unpacked, and stored, which creates work

that does not add value. In the event of cancella-

tions, OR schedulers also must juggle the schedule

to accommodate the procedure order, leading to

more nonevalue-added work and, sometimes, a

reduction in OR usage.

The team collected data from our perioperative

information management system. Key metrics we

monitored included

n the total number of site/side discrepancies,

n the lag time between a surgeon knowing the

patient needs to be booked for surgery and the

orthopedic administrative assistant contacting

the patient,

n total procedure cancellations and the percentage

that are cancelled the day before surgery, and

n instances of changing the sequence of proce-

dures less than 48 hours before surgery.

In improving the orthopedic surgical scheduling

process, we also wanted to improve patient safety.

Before starting this project, site/side discrepancies

in the preoperative clinic occurred in 4% of pro-

cedures and in 2% of procedures in the ORdunlike

the new system, the old system did not require

surgeons to enter side and site in real time when

scheduling a surgery. One regulatory consideration

that drove us to address site/side discrepancies was

the Universal ProtocolTM for Preventing Wrong

Site/Wrong Procedure,1 which is accessible as part

of the National Patient Safety Goals.2 Additionally,

the American College of Surgeons issued a state-

ment that contains the following: “The American

College of Surgeons (ACS) recognizes patient sa-

fety as being an item of the highest priority and

strongly urges individual hospitals and health or-

ganizations to develop guidelines to ensure cor-

rect patient, correct site and correct procedure

surgery.”3(p26) In addition to this, AORN created

the AORN Comprehensive Surgical Checklist,

which incorporates the World Health Organiza-

tion’s checklist and The Joint Commission’s safety

requirements for the Universal Protocol in a sin-

gle document.4

GOALS

Before the team was selected, we established three

main goals for performing a quality improvement

project:

n develop a safe, effective, patient-centered, time-

ly, efficient, and accurate orthopedic scheduling

process (ie, requirements that mirror elements

of “The Six Domains of Healthcare Quality”5);

n smooth the schedule so that block time alloca-

tion is more even across the days of the week,

maximizing efficiency and utilization; and

n improve patient safety by ensuring correct site/

side.

We also incorporated the Lean process into our

plans from the beginning. To make trends visible,

we made extensive use of charting, graphing, and

Pareto analysis (ie, a special form of vertical bar

graph displaying the relative importance of all the

problems or conditions with the most important

on the left) to prioritize the problem-solving ap-

proach. Our patient cancellation data are displayed

in Figure 1.

ABOUT LEAN

The term “Lean” was coined to describe Toyota’s

business during the late 1980s.6 In Lean process-

es, a cross-functional team uses simple, structured

problem-solving tools, often referred to as “Lean

tools” or “the seven quality tools,”7 to move

smoothly from problem identification to solution

development and finally to ensuring that the im-

plemented improvements will not fall out of use and

allow the original problems to resurface. Successful

Lean health care projects start with a clear defini-

tion of the project, often called a project charter (see

Supplementary Figure 1 at http://www.aornjournal

.org).

AORN Journal j 149

Figure 1. Patient-related causes were the most frequent reasons for cancellation of orthopedic procedures,although there were numerous reasons a patient might cancel within 48 hours of surgery.

January 2014 Vol 99 No 1 SIMONdCANACARI

The project charter should be drafted by those

who have key knowledge of the problemdor op-

portunity for improvementdand the supervisors

of the likely team members. We chose to use

the term opportunity for improvement in place

of problem for philosophical reasons. The word

problem is perceived negatively, and Lean is

rooted in the spirit of continuous improvement,

where problems are embraced as opportunities

for improvement rather than seen in a negative

context. Lean leaders view problems as great op-

portunities for improvement. Essential elements of

the project charter include

n a description of the problem, providing the

background and justification for working on the

project;

n clear, measurable goals;

n a projected project completion date;

n a suggested approach;

n metrics that quantitatively define the problem or

opportunity;

150 j AORN Journal

n team composition, including a leader, a facili-

tator, and a sponsor or sponsors who serve as

resources if the team runs into a roadblock; and

n a list of the major steps in the process, usually

six or fewer.8

The Lean process provides a set of management

principles that defines a way to manage projects.

For example, improvement projects should not be

conducted by only a select few champions in an

organization; successful Lean improvement pro-

jects include those who do the work. The under-

lying belief of the Lean process is that the people

who do the work know it best, and they should

be given the authority to improve their work pro-

cesses.9 The process knowledge and experience

of those who do the work is far more valuable

in both problem-solving and successfully imple-

menting solutions than having members who have

only peripheral contact with the work. Addition-

ally, we found that members of the team do not

need to have a deep knowledge of Lean principles

Figure 2. In this excerpt from the swim lane process map used during a project to improve orthopedic surgeryscheduling, the boxes represent steps in the processes and the hexagons represent problems identified whencreating the process map. Process steps are included in a horizontal row dedicated for a particular departmentor function.

SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org

to be successful; they can be highly productive

contributors to the project without spending hours

in Lean training classes. The best way to learn

about Lean is to participate in a well-facilitated

improvement project during which the team moves

through identifying problems or opportunities for

improvement, generating solutions, and maintain-

ing the improvement phases.

METHODS

At the first team meeting, the team facilitator, Ross

Simon, senior management engineer, delivered an

overview of Lean principles. Throughout the proj-

ect, the facilitator offered problem-solving tools to

help the team move swiftly and efficiently through

the process.

We overcame barriers by engaging stakeholders.

Physicians served as champions to help design and

pilot test the online surgical booking system. The

pilot test work started with a group of orthopedic

surgeons who embraced the technology. We also

brought in others, including administrators who

worked for the surgeons. The team drove the pro-

cess and did the work. For the first three months,

the team met weekly for one hour to review the

status of action items and decide what we needed

to do next. After this initial period, we met every

other week or monthly to ensure that the new pro-

cess was working well. Our last formal meeting was

held a year after the first meeting. Team meetings

were primarily strategic; other than the few activ-

ities that we had to do together, such as brain-

storming, we did the work outside of our regular

meetings. By doing everything that we could out-

side of meetings, we maximized the usefulness of

meeting time by using it strategically, identifying

the status of activities, and collectively deciding

on the next step.

AORN Journal j 151

Figure 3. Excerpt from a cause and effect diagram used during a project to improve orthopedic surgeryscheduling. A cause and effect diagram can be used to help a quality improvement team consider any additionalproblems and root causes that might not be identified with an annotated swim lane process map.

January 2014 Vol 99 No 1 SIMONdCANACARI

Process Mapping

As appropriate on most process-related Lean im-

provement projects, our first team activity was to

meticulously list the process steps and note prob-

lems and opportunities for improvement associated

with each step. During process mapping, the focus

is on discovering the current processes of an or-

ganization, establishing the root cause problems

with those processes, and looking for solutions.10

It was important that the team agree on the cur-

rent process and issues so that we could develop

robust solutions together. We found that people

often disagreed or misunderstood the processes

that we had in place, so mapping out the process

provided an opportunity for us to appreciate each

team member’s role and to annotate process steps

to identify problems and opportunities for im-

provement. The team used a swim lane process

map to document our processes (Figure 2). Swim

lane diagrams were proposed by Geary Rummler

and Alan Brache in their 1990 book Improving

Performance.11 This method of diagramming fa-

cilitates plotting and tracing processes quickly

152 j AORN Journal

and easily and, in particular, displays the inter-

connections between processes, departments, and

teams.12 As is typical of most complex processes,

our swim lane process map included 84 process

steps, 48 problems, and 13 opportunities for

improvement.

Next, we used a cause and effect diagram

(Figure 3) to help us consider any additional pro-

blems and root causes we might not have identified

with the annotated swim lane process map. Com-

monly called a fishbone diagram, cause and effect

diagrams illustrate the factors affecting a process

by sorting out and relating the causes of a problem.13

Every effect is likely to have several major cate-

gories of causes. The major causes in these dia-

grams often are summarized into four categories:

people, machines, methods, and materials.14 Lean

practitioners later added “environment” to include

the workplace. To complete this diagram, team

members placed all of the problems and opportu-

nities for improvement that we identified in the

swim lane process map next to the appropriate rib

on the cause and effect diagram. Then we asked

Figure 4. In this affinity diagram, the team split identified problems into seven groups. The types of solutionsused to address each problem precede the problem on the diagram.

AORN Journal j 153

SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org

Figure 5. An impact analysis grid can help identifywhich solutions will have the highest impact and theleast difficulty to implement. Solutions to problems inthe upper-left corner of the grid, for example, areboth high impact and low difficulty.

January 2014 Vol 99 No 1 SIMONdCANACARI

ourselves what we were missing that fell into the

categories of methods, materials, manpower, ma-

chinery, and the environment. In using Lean meth-

odology, it is important to lay out all of the problems

before jumping to solutions. As usually happens

with this type of process, we added additional

causesdspecifically, we noted additional causes

that contribute to inefficiency, inaccuracy, and lack

of timeliness in the orthopedic surgical scheduling

process. Our completed cause and effect diagram

contained more than 50 problems.

The number of problems we identified seemed

daunting. To get a grasp on all of the issues, the team

used an affinity diagram to organize the problems

into logical groupings15,16 (Figure 4). We split the

problems into seven logical groupings (ie, patient

information, patient access, administration, sched-

uling, physicians, roadblocks, equipment). Placing

seemingly disparate problems into logical groups

reduces the number of problems into manageable

groups, eliminates redundancies if problems are

identified more than once earlier in the process,

and helps ensure that the solutions developed later

will address the broad scope of related problems.

As the team developed and implemented solutions

to the problems, we annotated each to indicate work

that had been completed or was under way. As an

example of how we grouped problems, the fol-

lowing fell into the category of patient information:

n the number of patient identifiers that are

required,

n incorrect patient contact information,

n ineligible insurance,

n incorrectly spelled names, and

n missing orders for preadmission testing.

Prioritizing and Developing Solutions

To develop a strategy for solving the problems, the

team prioritized the categories according to how

difficult they would be to solve and how much they

would help us to meet our goals when they were

solved. The team agreed to create an impact anal-

ysis chart based on Leankaizen methods,17 shown

in Figure 5, for this purpose.

154 j AORN Journal

To start, the team developed solutions to prob-

lems that fell into the upper left corner of the grid

(ie, high impact, low difficulty), such as the lag

time created when scheduling forms completed

by surgeons were batched and brought from the

clinic in one building to another building of the

medical center where orthopedic administration is

located. By completing this process, we achieved

early and meaningful wins, such as reducing the

number of last-minute changes by surgeons, which

helped maintain order in the central processing de-

partment. These early wins helped the team main-

tain a high level of energy and morale, which is

important because complex projects like this one

may require several months to complete.

Defining Tasks and CommunicatingProgress

The team used an activity scorecard to define and

communicate all of our tasks (Figure 6). The score-

card includes a short title for the task, the issue being

addressed, the next activity to address the issue,

the task’s priority relative to all of the other tasks,

Figure 6. An excerpt from an activity scorecard used during a project to improve orthopedic surgery scheduling.Columns in the scorecard are (from left to right) the task number, short title of the task, the issue beingaddressed, the next activity, the task priority versus other tasks, who is responsible for completing the work,the target completion date, and the current status.

SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org

the name of the individual or individuals who are

responsible for completing the task, the target com-

pletion date, and the current status. During team

meetings, whenever the team identified an action

that needed to be taken, it was entered onto the

activity scorecard so everyone could see it. The

scorecard, used instead of traditional meeting mi-

nutes, was updated and redistributed after each

meeting. This helped us drive progress, keep

members focused during team meetings, and add

a sense of accountability to those who took on the

tasks.

In addition to the activity scorecard, we also

used a graphical depiction of a simple implemen-

tation plan (Figure 7) as a timeline for key action

items. This plan provided an overall view of the

most important tasks. The team used it to help

reinforce accountability by highlighting the time-

liness of responses to planned work.

RESULTS

The differences between our original, paper-based

orthopedic surgical scheduling process and the new

online process were significant (Table 2). The new

process gave our facility several benefits. The lag

time between the surgeon knowing a patient needs

to be booked for surgery and the orthopedic

administrative assistant contacting the patient was

decreased from three days to less than one day.

Improving process flow by eliminating batching

(eg, our process where booking forms were col-

lected over a period of days and then brought as

a batch to the administrative assistant, who then

contacted the patient) is an underpinning of Lean

philosophy. Lean terminology includes “one-piece

flow” or “single-piece flow,” which means that

in a perfect flow environment, the product (or pa-

tient) would move in batches of one, because this

minimizes delays.18 Now, because the surgeon

completes booking online after seeing a patient, the

booking is immediately visible to the orthopedic

administrative assistant, and lag time is minimized.

If patients decide to have surgery late in the after-

noon one day, they will be called the next day to

validate preoperative clinic and surgery dates and

times.

To address no-show and last-minute cancel-

lations, the team adopted a practice used in the

outpatient clinic at the medical center: we started

including a notice in the surgical confirmation letter

to patients stating that a $250 fee will be charged

for cancellations within less than 48 hours before the

scheduled appointment time. We have not charged

any patients the $250 fee to date, but we have

AORN Journal j 155

Figure 7. A graphical depiction of a simple implementation plan can be used as a timeline for key action itemsduring a process improvement project.

TABLE 2. Orthopedic Surgical Scheduling Process Flow

Topic Before After

Timing of the surgeonscheduling surgery

The surgeon scheduled his or her surgeries on 5different paper booking forms.

The surgeon schedules surgery online in real time.

Surgical schedulingprocess

Scheduling forms were batched and brought fromthe clinic in one building to another building on themedical center campus, where orthopedicadministration is located.

The surgical schedule is visible online in real time tothe orthopedic scheduler.

Contacting the patientafter his or her visitwith the surgeon

Patients were contacted by the orthopedic admin-istrative assistant to schedule the day of surgery 3to 5 days after the patient’s visit with the surgeon.

Patients are contacted by the orthopedic admin-istrative assistant within 1 day of the patient’svisit with the surgeon to schedule surgery.

Surgical consents andpatient information

Regular faxes of consent and patient informationoften were lost or unavailable.

Consent and paperwork are electronically faxedand available throughout the patient’s perioper-ative experience.

Special equipment There was no standard format for listing specialequipment needed for surgery.

The listing and selection of special equipment isclear and concise in the online booking system.

Site/side discrepancies There was a 4% occurrence of site/sidediscrepancies.

Because booking is in real time with the patient inattendance with the surgeon, there are no site/side discrepancies.

156 j AORN Journal

January 2014 Vol 99 No 1 SIMONdCANACARI

Figure 9. The number of instances of physicians changing the sequence of procedures within 48 hours of sur-gery was reduced between January and June 2010 as a result of the improved orthopedic scheduling process.

Figure 8. Patient cancellations within 48 hours of surgery were reduced between June 2009 and October 2010as a result of the improved orthopedic scheduling process.

SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org

reduced the patient cancellation rate by 35%, from

5.1% to 3.3% (Figure 8).

In addition to scheduling advantages, the new

online booking system also helped with site/side

discrepancies and dropped our occurrence of this

error to zero. The online booking system is set up

such that the surgeon cannot bypass specification

of site/side in the booking workflow, and the sys-

tem forces physicians to think about the side of

a surgery in real time, while he or she orders the

booking and while the patient is in the office. In our

previous system, the surgeon had to remember the

AORN Journal j 157

January 2014 Vol 99 No 1 SIMONdCANACARI

side at the end of the clinical day when he or she

filled out paperwork for several patients. Before the

implementation of the new process, we had an av-

erage of four procedures per week during which a

site/side discrepancy was caught in preadmission

testing and two per week caught in the preoperative

area; after the new process was implemented, both

went to zero.

As is the case when patients cancel surgery

within 48 hours of its scheduled start, supplies, time,

and manpower are wasted when surgeons change

the sequence of procedures less than 48 hours before

surgery. The new process made the problem more

visible to surgeons, so the team reduced the in-

stances of changing the sequence of orthopedic

procedures by 70%, from 20 occurrences per

month to six occurrences per month (Figure 9).

As an added benefit of the online scheduling

system, patient satisfaction increased with the re-

duced delays. When we began the project, patient

satisfaction, as measured by the Press Ganey metric

of “likelihood to recommend,” was very good at

67.6%. At the completion of our project a year after

starting it, we increased the score by nearly 20%,

to an average of 84%.

CONCLUSION

Changing the culture of an organization to support

a Lean approach to process improvement is not

easy. Lecturing personnel on Lean principles will

provide a foundation for Lean; however, personnel

will not be convinced of its value or become

proficient in the use of Lean tools and techniques

without participating in well-facilitated process

improvement teams that work on real, challenging

problems and implement sustainable solutions.

Work accomplished by the orthopedic surgical

scheduling team has moved the medical center

forward in this direction. Our facility has seen an

increased spirit of collaborative partnerships and

understanding of roles, a new mindset that views

problems as opportunities, creative new solutions

to old problems, an eliminated silo mentality, best

158 j AORN Journal

practices shared between teams, a more team- and

goal-oriented culture, and stakeholders who are

empowered to solve problems.

Practical examples of our accomplishments

include that our project team developed an effi-

cient, accurate, and timely orthopedic scheduling

process; reduced day-before and day-of cancella-

tions, reduced procedure sequence changes, in-

creased patient satisfaction, and eliminated the

disorganized schedule, which had caused us to

be unable to get orthopedic procedures onto the

schedule for four consecutive months. The online

system also reduced schedule changes made by

surgeons within 48 hours because it allows sur-

geons to review the surgery schedule proactively

online in real time.

The new process allowed us to allocate a dedi-

cated block for urgent/emergent plastic orthopedic

hand trauma and pilot test a preoperative clinic

faxing/scanning project, and the new process im-

proved the relationship between scheduling and

orthopedics personnel to promote collaboration. We

focused on orthopedic surgery scheduling with this

project, and online scheduling has had such a posi-

tive effect on performance in orthopedics that work

is under way to implement the process in other ser-

vices at the medical center. The importance of

improving patient safety with respect to site/side

discrepancies created an urgency that facilitated

moving this project forward. Regardless of the many

advantages the new project has provided, without

that sense of urgency, it has been a challenge to

spread this process to other services in the medical

center.

SUPPLEMENTARY DATA

The supplementary figure associated with this

article can be found in the online version at http://

dx.doi.org/10.1016/j.aorn.2013.10.008.

Editor’s note: The Universal Protocol for

Preventing Wrong Site, Wrong Procedure,

Wrong Person Surgery is a trademark of The

Joint Commission, Oakbrook Terrace, IL.

SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org

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Ross William Simon, BA, is a senior manage-

ment engineer at Beth Israel Deaconess Medical

Center, Boston, MA. Mr Simon has no declared

affiliation that could be perceived as posing a

potential conflict of interest in the publication of

this article.

Elena G. Canacari, RN, CNOR, is associate

chief nurse of perioperative services at Beth

Israel Deaconess Medical Center, Boston, MA.

Ms Canacari has no declared affiliation that

could be perceived as posing a potential conflict

of interest in the publication of this article.

AORN Journal j 159