surgical improvement project sip 2 data analysis
Post on 21-Dec-2015
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Main OR
Pavilion
Annex
5:30am 8:30am
Average Patient Check-in5:38 (sddev=0:16)
Average Patient Check-in5:56 (sddev=0:16)
Average Patient Check-in5:54 (sddev=0:16)
6:30 7:30
Ave: Anesthesia Start7:16 (sddev=0:20)
Ave: Anesthesia Start7:19 (sddev=0:19)
Ave: Anesthesia Start7:20 (sddev=0:19)
In Room Time7:42 (sddev=0:15)
In Room Time7:36 (sddev=0:16)
In Room Time7:39 (sddev=0:16)
Anesthesia Ready7:49 (sddev=0:19)
Anesthesia Ready7:57 (sddev=0:18)
Anesthesia Ready7:58 (sddev=0:21)
Incision8:20 (sddev=0:22)
Incision8:25 (sddev=0:28)
Incision8:10 (sddev=0:21)
SIP 2 : Key Metrics TimescaleFirst Cases Only - Averages include all cases April 2004 through March 2005 (Wednesday data removed)
5:30 8:30
5:30am 8:30am
5:30am 8:30am
Key Metrics - Analysis
Location Check in to Anes Start* (min)
Anest Start to In-room (min)
In-room to Anes Ready (min)
Anes Ready to Incision (min)
Main OR 98 23 19 27
Pavilion 84 16 13 21
Annex 85 23 15 23
* Wednesday – late start day, data removed
Variation by ServiceService Check-in to
Incision (min - mean)
SD
Neurosurg 199.4 25.9
Oto 162.6 7.1
Surg C 162.0 7.2
Orthopedics 159.4 16.6
Gen Surg 156.0 9.6
Gyn 145.8 14.9
Ophthalmology 128.6 4.3
Surgical Evaluation Anesthesia Evaluation Preanesthetic Care
Disease specific WU
Comorbidity Evaluation affecting
surgical siteSurgical
Plan
Surgical (Operative)
CareSurgical Consent
Mark Surgical
Site
Immediate Preop Eval (i.e. INR)
Immediate Preop Rx
(transfusion, platelets)
Anesthetic Treatment
Pt. Location
Comorbidty affecting
anesthetic AirwayPt educated and
consented IV
Specialized anesthetic
care (art line, epidural) Anesthetic
OR- Incision X X X Y X X X X X X X X X N
OR - in roomX X X N X X X X X X X X X Y
Preop 2 X X X N X Y X Y X Some Some X Y, if necessary Some
Preop 1 X X X N X Y X Some X Some Some Y N X
Check in - Preop Front Desk
X X X N X N X N X N N N N X
PAC X X X N X N Y N Y - anesthetic consent N N N N X
Surgeon's Clinic
Y Y Y N Y N N N N N N N N X
X assumed to be already completedY has not been done, and should be done in this areaN has not been done to this point
Patient Readiness Grid
SIP2 Problem Statements RPI 5S SIP2 JDI
Emergent/transplant impact on schedule X
Incomplete Patient Orders X
Surgeon "in house" requirement = delays X
Concentration of case prep between 06:00 & 07:15 X
Incomplete documentation X
Patient not ready for surgery X
Wrong case cart X
Late starts due to anesthesia resident availability X
Transport delays X
Duplication of documentation X
Timing of teaching X
Patient in Pavilion Pre-OP till HA Pick-up
04:30
Pre-Op ChrgArrives
Pt. Admitted to PACU Till HA Pick-up
Print 6 OR Schedules Pre-Op Log in
Sheet PACU Log
05:00 06:00 6:30
Compares/ChecksNew OR Schedule
to Board
Assigns patientRooms for All 1st
Cases
Special NeedsPatients Arrive
PSR AdmitsPatients
LS/AM PacketsArrive
Sign Valuables Privacy Consent Directory
Call Admitting
Yes
No
Chg RN BringsPatient Back
Records Time &Own name on
Board & AnesthSheet
Admit Packet toFront Desk Pre-Op
Rack
Checks BloodStatus
RN Gets YellowPacket
Review SuppliesTEDsSCD’s
Get Antibiotic/Pyxis
Greet Patient20 questions
VSPre-Op Hold RNRequests Pickip
Enters Info CIS
Diabetic PatientsGet IV’s
MA’s Blood Draw EKG Chem Stick
Main HA Roll Call Check in-Gale Order of Patients
Lead HA WritesHA Schedule/
Roles on Pre-OpBoard
6 RN’s Present 16-20 Patients
Check StretchersCheck O2
Blankets/Pillow
Surgeon In/OutHunt for Various
Equipment/Charts
HA to PavilionChecks Board
for who isReady
Greets PatientChecks Signature
Blue CardID Band
Belongings
Drop Off Family atWR
Explain Volunteer& Breakfast
Take Patient toHolding
Preassigned Spot
Goodbye, CheckOther NeedsBelongings
Pre-Op Hold RNVisual Arrival
OR Paperwork isStamped
Patient in Holding Flow
Clean up pre-op
Patient in Holding
Re-arrange“license plates” -
prioritize bysurgeon
Call for Report
Get HA’s/Transporters out
the door
Patients Arrive inHolding
VS H&P ConsentSite
Marked
Anesthesia
Room Set Up Drugs Monitors Machines
See PatientID/ConsentH&P Risks
IVMonitors, Lines,
Blocks
Recheck RoomWait-site check
RN ExaminesPatient
Attending in HouseResident in Room?
Yes
Take patient toRoom
No
Wait
Patient in ORTimeline
06:45 07:05 07:30
AnesthesiaRN ‘s
Check Case
Cart/List
Pick Extras
Open Room
Circulator goesto Pre-Op Hold
Look for CaseCart
Talks toPatient
Consent Check
Allergies IV Meds, Rx Count Check SCD’s/
TED’s
ConsentOK?
Call Attending
NO
RN Calls for Patientfrom Holding
Inform AnesthesiaProvider
Anesthetist getsPatient
- Permission - OR Bed
Set Up Transport
SurgeonArrives
Induction
Intubation Foley Lines Positioning
PrepDrape
Dress SurgeonHuddle
Incision
Tour Guide(s):
Gale Ullenkodt, Abdul Ramzan, Kevin Smith
Date:
March 16th, 2005
Process Name:
SIP 2: Patient to Pre-Op Holding
Total Process Time:
65 minutes
Step
# Step Description
Person(s)
Responsible Inspection
Steps Value Added Time
# in Que Feet Traveled
Opportunities for Improvement
1
HA checks/marks board, picks up schedule, checks pt. info, blanket warmer
HA
4
0 min
11
246
2
Walk to Pavilion
HA 0
0 min
N/A
526
3
Mark Pavilion board, talk w Pt., Check chart/ID, Adjust bed, secure belongings
HA
2
5 min
N/A
15
4
Walk back to Main Pre-OP, Talk w/family
HA
0
2 min
N/A
526
Information for families
5
Enter Pre-Op Holding, intro RN, move name tag to stretcher
HA
0
1 min
N/A
60
6
RN collects data from patient using procedure checklist
RN
0
0 min
10
0
Duplication of Pavilion check-in process
7
Anesthesiology Resident talks with patient/starts IV
MD Resident
0
5 min
1
25
8
Obtain pharmaceuticals
RN
0
0 min
1
60
Pharmacy window pick-up process
9
Surgical site marking
Surgical resident
1
1 min
0
N/A
10
Page Surgical Attending
RN
0
0 min
N/A
15
Paging process
11
Anesthesiology Attending meets with patient
Anesthesiology Attending
0
5 min
0
N/A
Anesthesiologist 10 minutes late
12
Patient to OR
Anesthesiologist
N/A
0 min
N/A
35
TOTALS
12
7
19 min
11
1508
Process Walk-Patient in Holding
Tour Guide(s):
Kevin Smith Date:
March 16th, 2005
Process Name:
SIP 2: Patient in OR till Incision
Total Process Time:
18 minutes
Step
# Step Description
Person(s)
Responsible Inspection
Steps Value Added Time
# in Que Feet Traveled
Opportunities for Improvement
1
Patient enters OR
Anesthesiologist
0
0 min
N/A
45
2
Patient moved to table
RN, MD’s, HA
0
1min
N/A
N/A
3
Prep and drape
Surgeon & RN
1
5 min
N/A
N/A
4
Induction
Anesthesiologist
0
5 min
N/A
N/A
5
Huddle
Surgical Team
3
30 sec
N/A
N/A
6
Fluoro positioning
Surgeon
2
1 min
N/A
10
7
Incision
Surgeon
0
0 min
N/A
N/A
TOTALS 7
6
12.5 min
11
1508
Process Walk - Patient in OR
SummarySummary Agreement on definitions of times essential.Agreement on definitions of times essential. Billing times do not necessarily indicate work times (ie. Anesthesia start time Billing times do not necessarily indicate work times (ie. Anesthesia start time
based on billing time, not actual time)based on billing time, not actual time) Data indicates consistency of late starts at all sites.Data indicates consistency of late starts at all sites. Greatest delay, and greatest “pain” in the Main OR.Greatest delay, and greatest “pain” in the Main OR. Variation in time (SD) for the different sites, days of week, and overall steps Variation in time (SD) for the different sites, days of week, and overall steps
in the process: Check-in to Anest start, Anest start to In-room, In-room to in the process: Check-in to Anest start, Anest start to In-room, In-room to Anest ready, and Anest ready to Incision - are relatively uniform and small, Anest ready, and Anest ready to Incision - are relatively uniform and small, (15-20 min)(15-20 min)
Delay and variation analysis byDelay and variation analysis by– Service (Service (– Type of procedure (delay for craniotomy, spine, gastric bypass are Type of procedure (delay for craniotomy, spine, gastric bypass are
outliers)outliers)shows some services and types of patients have greater variation and delayshows some services and types of patients have greater variation and delay
1/2 to 2/3 of time is spent between patient arrival and Anesthesia start. 1/2 to 2/3 of time is spent between patient arrival and Anesthesia start. Mismatch between Mismatch between Preanesthesia Clinic criteriaPreanesthesia Clinic criteria for pt. arrival (based on for pt. arrival (based on
complexity of patient and amount of preop preparation) and complexity of patient and amount of preop preparation) and Main OR Main OR Transport criteriaTransport criteria to the Main OR Preanesthesia area (Gale’s area). to the Main OR Preanesthesia area (Gale’s area).
Mismatch between anesthesia staff arrival time and expectations for Mismatch between anesthesia staff arrival time and expectations for anesthesia start time.anesthesia start time.
Anesthesia faculty over committed to start two rooms simultaneously.Anesthesia faculty over committed to start two rooms simultaneously.