case study applying lean and six sigma to the surgical services process
TRANSCRIPT
Copyright © 2011 JOP Consulting
Revision 4
Case Study: Applying Lean and Six Sigma to the Surgical Services Process
A Successful, Sustainable Implementation must first understand the culture of change and the Goals of the Organization.
Copyright © 2011 JOP Consulting 2
Agenda
Improving Revenue and Reducing Costs The ProblemAnalyzing the ProcessThe Implementation Plan
Was the Implementation Successful?The Impact of Process Improvement on your Clinical StaffHow your Measurement Systems can Negatively impact change
What Actions are Necessary to Assure Success?
Copyright © 2011 JOP Consulting 3
The Problems
Efficiency in the OR was not acceptable
Turn Around Times were Excessive
Financial Pressure to Reduce Staff Cost
Improve Operational EFFICIENCY
Improve the FINANCIALS for ‘Everyone’
Enhance Surgeon PRODUCTIVITY
Improve Patient LOYALTY
Implement SUSTAINABLE Solutions
The Goals
Copyright © 2011 JOP Consulting 4
Surgical Services Value StreamFunctional Goals Currently Drive the Process
Pre-Surgical
TestSame
Day Admit OR PACU Discharge
* Sterile Processing Department (SPD) analysis part of OR
Copyright © 2011 JOP Consulting 5
Pre-Surgical Test
Metric: Approval Rate• Owner: Surgeon• Quantity (In, Out) of cases• Case Type• Time (Ave, SD) per case• Revenue Potential
Metric: Chart Prep• Owner: Surgeon/Hospital• Quantity (In, Out) of cases• Time (Ave, SD)• Completeness, Rework
Metric: SPD Prep• Owner: Hospital• Quantity of cases needing
special instruments• Cost• Holding Costs• Labor
Copyright © 2011 JOP Consulting 6
Operating Room
Metric: Arrival Rate• Owner: Hospital• Quantity (In, Out) • Case Type• Scheduled/Unscheduled
Ratio• Time (Ave, SD) per case
Metric: Turn Around Time• Owner: Hospital• Case Type• Surgeon• OR Room• Time (Ave, SD) per case
Copyright © 2011 JOP Consulting 7
Patient In Room
Understanding TAT*
Patient Out
Procedure Duration
Case Duration
IncisionClose ofIncision
AnesthesiaInduction
AnesthesiaEmergent
* Turn Around Time
Copyright © 2011 JOP Consulting 8
A More Realistic View of OR TAT
Close
Transfer Patient to PACU w/RN
Complete Charts
Complete Anesthesia Process
Break Down Room
Clean OR, Anesth
Set up OR, Anesth
PositionPrepDrape
Anesthesia Induction
Incision Start
Patient
Enters OR
Patient #1 Leaves Room Patient #2 Enters Room
Surgeon in Room
Notes: - Block Sizes are relative- SPD included in Analysis
ANESTHESIA
SURGEON
NURSING
Anesthesia Prep, (Interview Patient), Plan of Care Initiated in SDS
RN Patient Chart Review in SDA
RN transfers Patient to OR
TAT‘Wheels Out – Wheels In’
TAT‘Actual Anesthesia Start -
Incision Start ’
Timeout
TATActual vs. Scheduled
Copyright © 2011 JOP Consulting 9
Tuesday Hour of Day
day date 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Tue 02-Feb 6 6 6 6 6 5 5 5 4 1 3 2
Tue 09-Feb 7 7 7 6 7 7 6 6 6 4 3 2
Tue 16-Feb 7 7 6 6 5 3 2 2 4 4 4 3
Tue 23-Feb 6 6 6 6 6 6 5 5 6 2 3 3 2 3 1
Tue 02-Mar 6 7 7 7 7 6 5 5 5 3 1 1
Tue 09-Mar 1 1 8 8 6 7 7 6 6 6 5 5 4 2 1 1 1
Tue 16-Mar 3 4 4 6 7 5 5 5 4 4 3 1
Tue 23-Mar 1 1 6 6 6 5 5 6 6 6 7 4 2 1 2 2 2 2 1
Tue 30-Mar 6 6 6 6 6 7 7 7 4 2 1 1 1
Tue 06-Apr 5 5 6 5 6 5 3 1 2 3 3 1
Tue 13-Apr 1 6 7 6 6 4 3 3 3 4 4 2 1 1 1 1 1
Tue 20-Apr 7 7 7 7 7 7 7 8 8 5 2 1 1 1 1
Tue 27-Apr 1 7 7 7 5 6 6 6 6 5 4 3 3 2 2 2
Avg/hr .2 .2 .0 .0 .0 .0 .0 5.8 6.3 6.2 6.0 6.2 5.6 5.1 5.0 4.8 3.5 2.8 1.7 .8 .7 .5 .3 .2
Heat Map Showing Active OR Rooms
Heat Map • Darker Colors show more rooms in use.• Number indicates active cases.
Copyright © 2011 JOP Consulting 10
Actual Anesthesia Start Time – Incision TimeBy Specialty
Surgeon (All)Anesthesia Type (All)
Patient TypeDAY SURGERY
class Elective
General Neurology Orthopedics
Anesthesiologist Name Count Average Std Dev Count Average Std Dev Count Average Std Dev12 18 3 5 17 6 6 30 1015 21 5 6 28 9 12 34 1015 19 4 10 24 4 10 34 1021 20 6 17 23 6 6 26 1023 23 9 7 30 7 9 42 828 24 12 10 28 7 11 36 1214 22 8 21 28 12 9 36 1211 25 11 9 29 9 8 25 1431 19 8 13 26 15 18 32 1118 26 12 9 29 12 13 38 1518 21 9 4 28 9 13 45 2621 18 4 10 24 8 8 30 1210 26 5 1 3413 22 17 18 27 8 10 30 9
Grand Total 250 21 9 140 26 9 133 34 14
Notes:•Variation within a Specialty is less but can vary between plus and minus 9 to 14 minutes •A component of Variation is driven by Procedure type that is typically fixed•Ortho Variation is higher than General and Neurology. It is predictable and can be proactively managed to improve Block Schedule performance.
Copyright © 2011 JOP Consulting 11
Anesthesologist Name
i
DataTotal Count of incision start -actual start timeMM (J)
,
Total Average of incision start -actual start timeMM (J)
,
Total StdDev of incision start -actual start time, MM (J)
Surgeon Anesthesia Type
Count of incision star- actual starttime, MM (J)
t
Average ofincision star- actual starttime, MM (J)
t
StdDev of incision star- actual starttime, MM (J)
t
Count of incision star- actual starttime, MM (J)
t
Average ofincision star- actual starttime, MM (J)
t
StdDev of incision star- actual starttime, MM (J)
t
Count of incision star- actual starttime, MM (J)
t
Average ofincision star- actual starttime, MM (J)
t
StdDev of incision star- actual starttime, MM (J)
t
Count of incision star- actual starttime, MM (J)
t
Average ofincision star- actual starttime, MM (J)
t
StdDev of incision star- actual starttime, MM (J
t
)General Endotracheal Tube 7 18.14 2.48 25 20.00 4.27 4 18.50 3.32 4 20.00 6.06 40 19.53 4.06General LMA 3 17.67 2.89 3 20.00 1.00 3 20.67 5.03 9 19.44 3.24General/Epidural Block 1 36.00 #DIV/0! 1 36.00 #DIV/0!MAC 1 32.00 #DIV/0! 1 32.00 #DIV/0!Spinal 1 14.00 #DIV/0! 1 14.00 #DIV/0!
11 19.64 5.90 29 20.41 4.55 4 18.50 3.32 8 19.50 5.29 52 19.96 4.80General Endotracheal Tube 11 34.00 12.84 12 44.33 18.51 6 -41.33 186.15 5 34.60 11.17 34 24.44 80.04General LMA 2 28.50 2.12 1 21.00 #DIV/0! 3 23.67 5.13 6 24.83 4.54MAC 3 16.00 6.00 1 20.00 #DIV/0! 1 27.00 #DIV/0! 1 17.00 #DIV/0! 6 18.67 5.79
14 30.14 13.82 15 40.60 18.24 8 -25.00 160.22 9 29.00 10.83 46 23.74 68.61Block 1 25.00 #DIV/0! 1 25.00 #DIV/0!General Endotracheal Tube 1 47.00 #DIV/0! 9 40.67 8.50 4 43.50 6.45 1 53.00 #DIV/0! 15 42.67 7.87General LMA 1 40.00 #DIV/0! 1 38.00 #DIV/0! 3 27.67 11.02 5 32.20 9.98General/Femoral Blk/SciaticBlk 1 39.00 #DIV/0! 1 48.00 #DIV/0! 2 43.50 6.36General/Femoral Block 3 46.33 5.69 1 60.00 #DIV/0! 4 49.75 8.26General/Scalene Block 2 42.00 7.07 5 50.20 10.21 2 74.50 24.75 1 41.00 #DIV/0! 10 52.50 16.42MAC 1 22.00 #DIV/0! 1 22.00 #DIV/0!Other, see notes 1 60.00 #DIV/0! 1 60.00 #DIV/0!Spinal 1 45.00 #DIV/0! 1 45.00 #DIV/0!
6 39.17 8.11 20 45.45 9.17 9 49.22 19.78 5 35.40 13.81 40 44.10 13.03Grand Total 31 28.16 12.57 64 32.97 15.63 21 15.10 101.55 22 27.00 11.41 138 28.22 41.35
Anesthesia 1 Anesthesia 2 Anesthesia 3 Anesthesia 4
Surgeon 1 Ave: 18 minSt Dev: 2.5 min
Ave: 20 minSt Dev: 4.3 min
Ave: 18.5 minSt Dev: 3.3 min
Ave: 20 minSt Dev: 6.6 min
Surgeon 2 Ave: 34 minSt Dev: 12.8 min
Ave: 44 minSt Dev: 18 min
Ave: --- minSt Dev: --- min
Ave: 34.6 minSt Dev: 11.1 min
Surgeon 3 Ave: 47 minSt. Dev : ---
Ave: 40 minSt. Dev : 8.5 min
Ave: 43 minSt. Dev : 6.5
Ave: 53 minSt. Dev : ---
Actual Anesthesia Start Time – Incision TimeBy Surgeon by Anesthesiologist Notes:
•One Anesthesia Type – Gen. Endotracheal Tube •Variation from Procedure, Setup, Prep
Surgeon 1 – GastroSurgeon 2 – CardioSurgeon 3 - Ortho
Copyright © 2011 JOP Consulting 12
Actual Anesthesia Start Time – Incision TimeBy Physical Operating Room
Count Average Std DevTotal Count
Total Average
Total StdD
Anesthesiologist Name OR 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR11 OR 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR11 OR 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR11
A 4 1 7 1 1 10 8 3 3 21 23 13 37 24 21 17 23 36 3 5 6 3 5 11 38 21 8
B 6 8 5 2 9 9 5 23 25 14 27 32 21 31 4 11 7 12 10 9 10 44 25 10
C 1 8 4 6 3 7 9 4 3 27 22 24 20 33 22 23 29 28 4 9 5 21 7 8 13 5 45 24 9
D 1 13 10 9 5 3 9 5 2 13 21 23 44 21 27 18 26 29 5 7 79 6 4 3 10 4 57 25 31
E 5 7 4 4 1 1 21 3 6 25 31 27 36 20 25 20 34 45 2 14 3 7 6 5 6 52 27 11
F 10 2 9 2 1 20 3 8 23 22 33 33 31 21 35 36 6 0 14 0 11 7 14 55 27 12
G 1 2 22 5 3 7 8 7 21 26 23 25 35 21 27 41 1 10 9 12 13 6 16 55 26 12
H 2 10 5 5 3 3 3 3 30 27 27 27 20 19 27 32 0 12 11 11 12 4 9 19 34 26 11I 3 15 6 6 4 6 14 4 10 31 19 22 20 33 31 21 32 35 22 7 10 9 22 12 10 12 12 68 25 12
J 2 6 12 16 2 1 4 4 10 26 24 27 25 27 49 24 40 37 0 12 13 10 15 2 10 16 57 29 13K 1 11 4 1 2 1 5 5 8 21 19 26 18 32 34 26 48 44 4 6 7 14 32 24 38 31 20
L 4 16 21 14 1 4 3 4 28 19 20 26 29 16 25 35 26 6 6 10 3 8 16 67 22 10M 5 1 5 26 34 25 1 8 11 26 6N 3 7 8 5 6 1 7 8 2 37 27 23 26 30 35 15 31 26 36 22 5 10 10 2 9 11 47 26 14
Grand Total 27 117 113 76 38 48 125 58 66 27 23 23 28 28 28 21 31 37 16 9 9 28 11 10 8 13 15 668 26 15
Surgeon (All)Anesthesia Type (All)Patient Type DAY SURGERY
Notes:•Why significant variation within each specialty OR?•Why significant variation by Anesthesiologist?
* OR 4 Neurology Block Time, M-W-F
*
Copyright © 2011 JOP Consulting 13
Summary
Was the Implementation successful?Use of Tools and Data Analysis
Lean
Six Sigma
Training
Copyright © 2011 JOP Consulting 14
Summary
What went wrong?Key Stakeholders
Measurement System
Market Share
Copyright © 2011 JOP Consulting 15
Summary
Lessons LearnedCulture
Measurement System
Copyright © 2011 JOP Consulting 16
Questions and More Information?
Jim PearsonJ.O.P. Consulting, Inc.www.JOPConsulting.com