Surgical Improvement ProjectRapid Process Improvement #1:

Reducing Non-Operative Time in Thoracic Surgery

July 19 – 22, 2005

Why a Rapid Process Improvement (RPI)?

An approach for bringing a team with profound

knowledge together to learn tools & techniques to:

• Search for and eliminate waste• Reduce time throughout the entire turnover process• Reduce cost• Apply the improvements in the workplace during

the week, refine and sustain them

RPI #1 Charter / Expectations

• Reduce non-operative time by 30%

• Implement standard work & work balance

• Staff engagement in the turnover process

RPI Team Members

• Surgeon: Doug Wood

• Anesthesiologist: Andy Bowdle

• Scrub Nurse: Sara Myer

• Circulating Nurse: Heidi Copeland

• Anesthesiologist Tech: Greyson Hackett

• Hospital Assistant: Kim Wambolt

• Ortho RN: Karen Ingram

Current State: Summary Chart

Number of Steps 66

Total Process Time

1:30 - All cases

2:00 - Big cases

Distance Traveled 12,626 = 2.4 miles

Process Flow - Before

Process Map - Before

Work Balance:

HA Anesth Tech

Anesth Surgeon Scrub RN Circ RN

10

20

30

40

50

60

70

80

90

100

33

40

75

14

6770

Wastes• Physical layout poorly planned

• Anesthesia does not “meet” patient until previous case completed

• Waiting for resident prior to induction

• Waiting for attending surgeon

• Search for equipment & patient data

• Time hooking up patient

– Patient on bed induction

Wastes• Patient records not available

• Patient x-rays not available

• Waiting for surgeon to clarify plan

• “Which bed?”

• “Has bed been done?”

– Lack of communication

• 2 HA’s emptying linen/trash

• 2 HA’s wiping equipment - duplication

• Too much time (9 minutes) finding extras

Wastes• Set up esophagoscope (3 times)

• Opening (5)

• Set-up (5)

• Set-up Sterile (10)

• Anesthesia tech made 7 trips in and out of Room 12, multiple trips to washroom and cleaning room

• Transport from ICU

– who is required to do?

– external, prep

• Circulating RN made several trips looking for equipment

Wastes• Placing Epidural block between cases

• Searching for equipment (cuff) – 3 minutes

• Assessing which lines are which

• Searching for information

– Patient record

– Allergies, etc

Opportunities• Overlap intro with patient to previous case

• Lines finished before previous case completed

• Induction prior to end of previous case

• 12 minutes between dressing and call for HA’s

• 3 minute travel time

• Set up during previous case

– Collect extras

– Open

– Organize

• Restocking and communication could take place while patient wakes

Opportunities• Extubation can take 20 minutes

– Develop standards

– Change practice

• Standard sequence of attaching patient to monitors

• Use of Visual Systems

– Patient status

– Spaghetti of lines

– Patient info

– Etc.

• Home for chart, all forms

• HA part of team through “whole” process

Vision Statements

• Decrease Process Steps 20%• Decrease Time 30%• Decrease Distance• Standardize Turnovers• Improve Work Balance 20%• Reduce Handoffs, Increase Communication

• Apply Visual Systems• “Plan for the Day”

Projects completed

• Non-operative time tasks balanced across functions (4 trial runs)

• Developed standard procedures (11)• Anesthesia costruc installed in induction

room • Improved room layout - design

– Surgeon / RN workstation– “ready condition”– Monitor cables

Process Map - NewRoles -60 -20 -10 -5 0 5 10 15 20 25 30 35 40 45

Pre-Op Holding Nurse

Pre-Op Checklist

Call Surgeon

and Resident

Surgeon Speak to family DictatePositioning

/ drape / huddle

Surgical Resident

Wrap-up trash, gowns, drapes

Orders / Transfer

patient to PACU

Mark site / Confirm

H&P (next patient)

Obtain & review x-rays

/ Plan

Positioning / drape

Anesthesia

(One hour prior to

dressing) / Interview patient /

Review Info / Start epidural /

Start lines

Wake patient / Finalize record

Transfer patient to

PACU

Report in PACU

Return drugs / Obtain drugs for

next patient (include all

drugs)

Travel to OR with patient

Set-up monitors / Transfer patient

Induction of anesthesia

Positioning / Huddle

Anesthesia Tech

Equipment preparation

Assist with patient

extubation & transfer to

stretcher / bed

Strip machine /

Empty trash

Wipe-down machine /

Reorganize cables / Reset

machine

Set-up next case

Assist with

monitors

Assist induction

Assist positioning / Gown tieing

Scrub NurseInstruments into case cart / Rinse

or spray

Remove current CT's

& x-rays. Drop off

case cart, specimens,

drug box.

Get new case cart / Pick extras

Enter room / open case

cart & packs

Scrub and set-up table

Count sponges & Instruments

Pull up table, Bovie,

Suction, Gown, Glove

Circulator

Phone Call to PACU / Rn to RN

report

Interview patient

Call HA & Anesthesia Tech.

Confirm family presence, stay in waiting room for

surgeon

Update & finish record. Update

PL. Print to CT/ Neuro printer.

Begin turnover.

Log in next case /

Write info on board

Assist scrub in set-up

Assist in patient

transfer in OR, SCD's,

blanket, safety belt

Count with Scrub Nurse

Position, prep, drape,

huddle

Hospital Assistant

Verify positioning / supplies /

bed

Return equipmentTake out trash &

linenSweep &

Mop

Clean & make bed / Wipe down all surfaces

Restock room

Bring in equipment

Projects / Procedures / StandardsDescription Completed Owner Location

Turnover Process Map Y Heidi Room 12

Sending for Patients Y Heidi / Doug Room 12Surgeon communicate when leaving OR

Existing Policy

Surgeon present day of surgery

Existing Policy

RN to RN Hand-off Y Sara Room 12

Drug Pick-up JulieTransfer of ICU Patients – Not done by Anesth

Y Mary Claire

HA cleaning checklist & definition list

Y Kim Closet Door

Plan for Day Template Y Doug Room 12Scrub leaving room exceptions

Anesth Protocols

Y

Y

Doug

Andy

Room 12

Room 12 – Book

HA Standard Procedures

OR Team:Standard

Procedures

Anesthesiologist Protocols

“Room Ready” Condition

Chart Holder on Stretcher

Anesthesia Costruc in Induction

Room

Summary Chart

Number of Steps

Current

66

After10 (External)

47 (Internal)

% Change

15%

Total Process Time

1:30 (All cases)

Trial 1 – 50 (0 delay)

Trial 2 – 63 (30 delay)

Trial 3 – 55 (25 delay)

Trial 4 – 58 (28 delay)

50% achievable

Distance 12,626 = 2.4 miles 1.3 miles 46%

Process Map – After (46% improvement)

Work Balance:

HA Anesth Tech

Anesth Surgeon Scrub RN Circ RN

10

20

30

40

50

60

70

80

90

100

33

40

75

14

6770

23 20

32

20

30

40

Original work balance eff: 55%New work balance eff: 69%

Follow-up Action Items

• Complete 5S activities in Room 12– Tape floor for “room ready” position of equipment– Install surgeon workstation installed– Monitor cables retraction system– Mount standard procedures– Install printer (in core between 11 & 12)– Trial chart holder on stretcher

• “On-deck” ICU bed – location marked and bed assigned

Follow-up Action Items

• Improve lunch coverage of HA’s and AT’s• New facilitator nurse assignments • Anesthesia coverage in pre-op area• Understand / correct issues with pre-op

not being open after 5:00• Train staff on new procedures – audit to

ensure they are being followed• Address “disincentives” for having

improved room turns

Communication PlanAudience Key Message Frequency Who

Delivers

Anesthesia

Anesthesia Techs

New Protocol for

1) Rapid Turnover

2) Epidural Block

Tues – Card Div Mtg

Anesth Dept Mtg

Andy

Allen

Anesth Tech

Anesth Tech + Pre-Op RN’s

1) All above &

2) Costruc change

3) Mark strap policy

4) Datex Cuff Stock

Weekly Mtg Greyson

Thoracic RN’s

All OR RN’s

HA’s/OR RN’s

1) Scrub RN Liberation

for next case prep

2) Process Map

Change in Circ RN

report to PACU

3) RN prompts for HA

cleaning / calling HA’s

earlier

Team Mtg & OR Mtg Sara / Heidi

Communication Plan continued…Audience Key Message Frequency Who

DeliversOR RN’s/Thoracic RN’s

Thoracic Surgeons

Thoracic Residents

Anesthiologists

Plan for the Day Monthly Staff Mtg Heidi / Sara

Doug

Andy

Thoracic RN’s

OR RN’s

Sending for next patient prompts

Monthly Team Mtg. Heidi / Sara

All HA’s

Pre-Op RN’s

All HA’s

Guidelines for picking up patients

Cleaning List & Definitions

Wed HA Mtg.

Wed HA Mtg.

Kim

Kim

Measures / Audit PlanMetric / Attribute Status Owner Freq Target

Non-Op time Thoracic cases

Yellow Jason Weekly 45 Min

Pt w/ epidural & lines prior to end of previous case

Red Alan Each Case & Weekly

“0” Minutes added to turnover

Patient Available Red Sherri & Judy Each case & Weekly

Pt. available when sent for –

100%

Plan of the day Red Doug Each Day 100%

Anesth protocols followed – Emergence

- Induction

Red Andy Each case & Weekly

100%

Pt in Pre-Op holding within 20 min & ready

for anesth

Red Shelley Each case & Weekly

100%

Team awareness of roles & following roles

Yellow Sara / Heidi Weekly Mtg Compliance

Q&A???