Case Study Applying Lean And Six Sigma To The Surgical Services Process

Copyright © 2011 JOP Consulting

Jim [email protected]

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.

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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?


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


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


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


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


Patient In Room

Understanding TAT*

Patient Out

Procedure Duration

Case Duration

IncisionClose ofIncision

AnesthesiaInduction

AnesthesiaEmergent

* Turn Around Time


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


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.


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.


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


t


t


t


t


t


t


t


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


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

*


Summary

Was the Implementation successful?Use of Tools and Data Analysis

Lean

Six Sigma

Training


Summary

What went wrong?Key Stakeholders

Measurement System

Market Share


Summary

Lessons LearnedCulture

Measurement System


Questions and More Information?

Jim PearsonJ.O.P. Consulting, Inc.www.JOPConsulting.com

[email protected]

http://www.jopconsulting.com/

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Case Study Applying Lean And Six Sigma To The Surgical Services Process

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