APOM Grand Rounds
OPEx
SOR Value Stream
Kaizen Event: In Room to Anesthesia Ready
Dr. Michael Aziz
What is OPEx?
• OHSU Performance Excellence System (OPEx)
– An approach to drive rapid performance improvement
using a common vocabulary, tools and methods
– Grounded in “lean manufacturing” techniques initially
developed by Toyota, since used in many industries
including healthcare
– Evolution of performance improvement efforts put in
place for clinical enterprise, but potentially
deployable across OHSU
OPEx Overview
• OPEx is the collection of
Methods, Management and
Mindset that help OHSU
Healthcare achieve its goals in
a systematic way
• Based on Lean principles that maximize value
for patients through Continuous Improvement
and Respect for People
OPEx core elements
• Methods are the most discussed, but least
important part of improvement efforts
• Management system structures strategy
deployment, operationalizes use of methods
• Mindset is the most challenging, but most
important element; requires long-term effort
Lean Healthcare Principles
Patients and Families First
“Just In
Time”
Right service
in the right
amount at
the right time
in the right
place
Eliminate
batches
Rapid
Changeover
Level Load the
Work
Standard Work
“Built In
Quality”
Make problems
visible
Never let a
defect
pass along to
the next step
Error Proof
Continuous Flow:
Pull vs. Push
Stop when
there is a quality
problem
5S and Visual Control
Respect and Engage Everyone in Waste Reduction
Lean is Customer Focused Strategy
that Improves Quality, Cost, and Response Time by Removing
Waste
• The “relentless pursuit of waste” as competitive
leverage
• Uses the least amount of resources to create the
greatest possible value for the customer, makes
value flow
• A culture of respect and never-ending improvement
at all organization levels
Definitions of Waste
Waste
Definition
Transportation
Unnecessary movement of materials or supplies
Inventory
Supplies, equipment, or information not needed by the
customer now
Motion
Unnecessary movement of people
Waiting
Delays in the value stream (absence of flow)
Over processing
Work that creates no value
Overproduction
Producing more than customer needs right now
Defects/Poor
Quality
Product or service that does not conform to customer
requirements
The Importance of Standards
• Provide a common understanding of the
process – the right way to do the work
• Improve predictability of results
• Make abnormal vs. normal clear
• Enhance problem solving
5S for Workplace Organization
Sort
Separate the needed from unneeded items
Simplify
Create a place for everything and a way to
keep everything in its place
Sweep
Standardize
Sustain
Create visual controls and indicators to easily
determine normal and abnormal conditions
Document methods and procedures to maintain the
system consistently
Ensure disciplined adherence to standard work
to prevent backsliding
South Operating Room Patient
Value Stream
Properly Prepared Patient
(patient is ready for surgery and OHSU is ready for the patient)
Surgical Patient Flow & Experience
Improvement Events
(Kaizen) - completed
Surgical
Practice
Clinic
O.R.
Scheduling
Preoperative
Medicine
Clinic
PreOperative
Unit
South
Operating
Room
Perianesthesia
Recovery
O.R.
Turnover
Time
Recovery
duration
Information to patient & family
Properly prepared patient 2.0
Properly prepared
patient 1.0
PMC
capacity
On-time
1st case
start
Procedure
card
Anesth
Ready to
Proc Start
Intra-op
documentation
Work place
organization
Inventory Management
future
Standard Work and Daily Management Systems (DMS)
Level
loading
across the
week
Level
loading
within the
day
Tray
replenish.
Consolidate
instrum.
In Room
to Anesth
Ready
Proc
Start to
Proc
End
Proc End
to Room
Exit
Monthly %ile
100
Quarterly %ile
Target
Mean Score
80
60
40
•
Admitting
Patient
Practices have same elements
Visual way finding
Training to appropriate staff
–
–
ICARE
Unit-specific signature moments
OR
Scheduling
Pre-op
Medicine
Clinic
Jun
May
Apr
Mar
Feb
Jan '14
Dec
Nov
Oct
Sep
Aug
Jul '13
Jun
May
Apr
Mar
Feb
Jan '13
Align surgical practice, OR scheduling
Standard letters
–
•
•
Surgical
Practice
Epic/MyChart
E-mail
Website
Handout
Confirmation Call
–
•
Dec
Standard information
–
–
–
–
•
Nov
Oct
Sep
0
Aug
20
Jul '12
%ile vs. All Press Ganey
Patient Experience: Information to Family
(50th Percentile Target) – based on date survey returned
First Case Start - On Time %
(7:30 in the OR, 8:30 on Mondays)
•
•
Standard Work for First Case Starts: Patients,
6A Staff, SOR RNs Anesthesia, and Surgeons
Consistently monitor and countermeasure
Highlights:
•
•
•
Daily Huddles leading to interdisciplinary
communication and collaboration
Daily Management Systems trending and
addressing abnormalities
Focus on evaluating standard work and
workarounds
Jun
May
Apr
Mar
Feb
Jan '14
Dec
Nov
Oct
Sep
Aug
Jul '14
Jun
May
Apr
Mar
Target
Feb
Jan '13
Dec
Nov
Oct
Sep
Aug
Jul '12
Jun
May
Apr
Mar
100%
90%
80%
70%
60%
50%
40%
30%
Feb '12
% on-time
Monthly %
O.R. Turnover Time (from patient out to next patient in)
•
Standard work for eight different roles
•
Initial improvement, sustained
•
Larger barriers had specific work to:
•
–
Address gaps in schedule
–
Signaling for the next patient
Next steps to address “longer” delays
Jun
May
Apr
Mar
Feb
Jan '14
Dec
Nov
Oct
Sep
Aug
Jul '14
Jun
Target
May
Apr
Mar
Feb
Median
Jan '13
Dec
Nov
Oct
Sep
Aug
Jul '12
Jun
May
Apr
Mar
55
50
45
40
35
30
25
20
Feb '12
Minutes
Average
% Compliance
(% of patients whose care met all of the measures)
80
May
Apr
Mar
Quarterly %Compliance
Feb
Jan '14
Dec
Nov
Oct
Sep
Aug
Jul '13
Monthly % Compliance
Jun
May
Apr
Mar
Feb
Jan '13
Dec
Nov
Oct
Sep
Aug
Jul '12
Surgical Care Improvement Project (SCIP) Composite Score
Target
100
98
96
94
92
90
88
86
84
82
Executive Summary
• Performance Transformation
– SCIP
– Patient Experience
• System to improve further
– Efficiency improvement
•
•
•
•
•
Turnover time
First case starts
5S of O.R, cores, and workrooms
Preparation of and for patients
Pre-operative Medicine Clinic capacity
– Outpatient mix in SOR
• No events focused on this yet
• Next improvements
– Intra-op times (all segments from patient
entering the room until patient leaving the
room)
– Level loading the OR
• System-wide support and effects (hospital
loading, outpatient clinic schedules)
• Mindset Transformation
– Events have engaged
• Surgery practices, Scheduling,
PMC, SPD, Pre-Op, OR
personnel, Logistics
• Events pull in new staff and
managers
– DMS is throughout Periop
• “Deeper” problem solving and
escalation may need further
improvement
• Primary metric is, “How many
of our patients weren’t
clinically prepared and how
many of our patients were we
not ready for today?”
– The pace and capacity for
change is growing
Kaizen Event:
In Room to Anesthesia Ready
Anesthesia Ready
• Anesthesia Ready occurs when the patient
is anesthetized and stabilized for the team
to proceed to positioning, prepping and
incision.
• Some anesthesia procedures may be
completed after anesthesia ready based
on the patient condition and requirements
of the case.
Breakthrough Kaizen Charter: In Room until Anesthesia Ready
Problem Statement: The time between a patient entering the Operating Room until the procedure starts has high variation in workflow and timing. This portion of the value stream can be broken up into two segments, “in room
to anesthesia ready” and “anesthesia ready to procedure start”. The former segment includes the time after the patient enters the room until the anesthesia provider’s activity is sufficiently complete so that the case may
progress towards procedure start. Variation in practice contributes to increased OR costs, patient safety risk, and unpredictable case duration (in room to out of room). This contributes to poor scheduling accuracy, delayed
cases, and dissatisfaction of patients and personnel.
Goal/Target:
• Reduce the mean time from In Room to Anesthesia Ready in OpTime from 23.3 minutes to 18.3 minutes. (This number should be adjusted based on the percentage of complicated
cases as compared to more straight forward cases; the more longer cases, the more opportunity.)
• Reduce the range of the 10th (9 min) and 90th (45 min) percentile from 36 min. to 30 min. 10th percentile to 8 min. and 90th percentile to 38 min.
• Reduce the range of the 25th (13 min) and 75th (29 min) percentile from 16 min . to 13min. 25th percentile to TBD and 75th percentile to TBD.
• All changes will promote efficiency and safety from along the time line of turnover through procedure start:
• first case start (80%)
• turnover time (44 minutes)
• anesthesia ready to procedure start (27.6 minutes)
• Total time (Turnover + In Room to Anesthesia Ready + Anesthesia Ready to Procedure Start) = 44+23.3+27.6 = 95 min
Objectives:
• Break down the elements from In Room to Anesthesia Ready
• Implement standard work for all roles involved between “In Room” until “Anesthesia Ready” .
• Standard work to include who, what their responsibility is, and when it should occur.
• Include standard work for different situations (split rooms, first cases, second cases, vascular access/monitoring, etc.)
• Remove waste in the process (provide specifics during the event; e.g. reduce motion related to ______)
• Maintain or improve patient safety(CLABSI rates, line placement compliance, adhering to checklist utilization, patient transfer to OR table)
• Provide the above data by individual and service factoring in important characteristics such as: invasive monitoring/access, anesthetic type, patient BMI and patient ICU status (+/- mechanical ventilation).*
• Accommodate appropriate training in the context of safety and efficiency.
• Used improved communication between anesthesia and surgery to optimize decision on invasive line placement.
In Scope
• From doc of “in room” (circ) to
“anesthesia ready” (anes .
provider)
• SOR cases
•
•
•
•
All days, all times (limited)
Emergent cases (limited)
GI cases
ICU patients
Out of Scope
DCH (under 12 yrs. Age)
• “Anesthesia Ready” to “Proc• Other OR sites
Start”
• Labor and delivery
• Pediatric cases staffed by
Admin Support,
Measurement Specialist,
Financial Analyst
• Mac Eggling
Key Stakeholders
Mark Zornow, Bob Cross,
Jeff Koh, David Larsen
Improvement Team
• Anesthesia Staff: Aziz, •
Robinson
• Anesthesia Resident:
•
Ross Martini
• CRNA: Livingston, Snow •
• Anesthesia Tech: Jonny
Sands
SOR Circ.RN: Conley +
Choi
Surgical Resident: Jesse
Liu
Surgical PA: Paula
Wilson
* = Implementation Coache
Resource Representatives
• Blue Blake
• EVS: Winans Stojanovic • Nate Seldon
• Mary Munoz
• Neuro monitoring
• Linda Knox
• SPD
• Bob Hart
• Joanne Girard
• 6A RN
• Ahmad Raslan
Project Sponsor: Jeff Kirsch
Management Guidance Team: EMG, Core Team
Process Owner*: Steve Robinson; Mike Aziz
Facilitators: Randy O’Donnell, Rayna Tuski, Grace Ullum, Shauna Hoffman
Sponsors and Process Owners are MGT mem
Key Dates:
Assessment: 05/28
Planning: 06/16-06/17
Go/No Go: 06/17
Event Date: 07/21-07/25
Follow Up Day/Time: 30-day________________ 60-day_________________ 90-day__________________
Standard times
Min
Base time
without
complexity
13,174
11
144,914
11
ICU
1,524
6
9,144
1
Difficult airway
1,317
3
3,952
0
Art
3,244
5
16,220
1
CVL
1,833
20
36,660
3
122
7
854
0
2,635
10
26,348
2
238,092
18.1
PA
Teaching
Average
Total
Weighted time
Patients
18.1
Minutes in stepIdeal medium
complexity patient
5
5
5
3
6
6
6
4
7
7
7
5
1
1
3
5
1
0
1
1
3
3-anticipate
more required
8-positioning on
interventions
ramp, utilizing glide
after
scope, bougie
induction
3
Central line
Anesthesia
Ready
Additional lines
Peripheral IV
4
4
4
Art line
3
3
3
2
Hemodynamical
ly Stablized
2
2
2
Induction of
Anesthesia
1
1
1
1
Administering
meds/ventilating
patient/securing
airway
Monitor applied
0
0
0
0
PreOxygenation
Move Patient to
OR Table
Sub steps
Ideal low complexity
Medium complexity
High complexity
ICU patient
Minutes in stepIdeal low
complexity patient
Patient in Room
STEPS
Room Ready
Process sequence
8
8
6
9
9
7
5 (Aline) or 15
(Cline)
7
9
9
7
11
5
24-34
8
2-pt. requires
3-anticipate
assistance
more required
Minutes in stepwith moving
8-positioning on
interventions
Ideal high
or
ramp, utilizing glide
after
complexity patient
repositioning
1
3
scope, bougie
induction
3
5
15
40
Low complexity: pt. expected to not need more than one additional PIV and std. airway (only IV)
Medium complexity: in addition to low complexity rqmts. also needs advanced airway mgmt (difficult) and/or one invasive monitoring line (A line or C line)
High complexity: unstable pt. that requires close hemodynamic monitoring and multiple additional lines (all lines)
In south OR, what percentage of training happens in each case?
10
Training time
for each
complexity
type
Pt Movement
Room Equipment
& Supplies
Nurses
*Questions about Position,
no surgeon
* Transferring Pt back &
Forth
•Review Implants & supplies in
room
* Reclipping, shaving site
* Right suture- needs during Anes
* Motion, Leaving Rm for supplies
* Positioning Equip
* Extra Time for IV setup
*Ask for appropriate ABX
*2 Circulators perhaps wasteful *Untangling Cord , gowns, & lines
* Missing Items from Case Cart
* Reworked supplies
* Reposition Bed
*Microscope Not working
*Reaching for
Carts, supplies
Waste
* Repositioning
During
IR to AR
* Delay in Prep
* Unsure how to position, drape
* Positioning Communication w/
surgery services
* Not knowing surgical plan
* Waiting for surgeon to cut
* Low assistance from team
* Low lateral processing
* Team not hearing “Anes ready”
Team Synergy
* Waiting for Anes. Attending
* Anes Tech , wait 12 min for A
line
*Surgeon leaving
* Working on other pts, not
in room
* Unsure If Ok to start w/out Attend
* Unsupervised Broc
* Order of Operations for line
* Surgeon Resident 20 min late
placement
*Surgeon Needs: Epidural?
*Improper location of Anes equip. * Attending moving lights after positioning
*Residents booking cases they don’t
* Anes Tech traveled to get ABX understand
Anesthesia
Surgeon
Projects
1.
2.
3.
4.
5.
Huddle Go-Live
Pre-Op and Nursing standards
Standard Work for patient flow for all roles
Surgeon Standards
Anesthesia Standards and Anesthesia
Workspace
1. Huddle Go-Live
Issue Description: Variation in
practice contributes to increase
OR cost, patient safety risk and
unpredictable case duration.
Post Improvement Benefits: The
team huddle will improve
communication between the
surgical team, anesthesia team
and staff with regard to critical
needs in order to prepare the next
patient for surgery.
Time Estimator Tool
Time Estimator Assistant
In room
to ETT
Artline
CVL
Standard
7-10
5
15
Learner
+3-5
+3-5
+5-10
Difficult
+3-5
+5-10
+5-15
Fiberoptic
BMI>35
PA
IV
5
3
+5-15
+10-15
+5
subtotals
•For use to help more accurately estimate time from entering the room to anesthesia ready
•If an activity is after AR, assume 0 for purposes of estimating AR
•This is just a tool.
Total
2. Pre-Op
Issue Description: Currently, there is
an unreliable method of
communication to assess status of
previous OR case and determine
precise time of patient rollout.
6A
OR
Post Improvement Benefits: This
change in standards and
expectations will improve
communication between OR Nursing
staff and Pre-Operative Nursing staff
to potentiate patient preparedness
for the OR and improve patient
satisfaction.
Patient
3. Anesthesia Set-up
Issue Description: Lack of
standard set-up contributes to less
preparedness and more time
spent gathering items post
induction pre-anesthesia ready.
Post Improvement Benefits: This
standard will decrease motion
and time, and provide consistent
expectations for quality of patient
care.
4. Standard patient workflow
Team approach to continuous patient flow towards Anesthesia Ready (DRAFT - 07-23-2014)
time (minutes)
Patient
Circulator
-1
Pre setup
Anesthesia
(prior to
start
patient enter)
case open in
Holding warm Epic (ready
blanket
to click "in
room")
Scrub
0
Pt. enters room
pushing bed
Anes Attending
receives "in room"
page
3
4
7
Monitors
O2; consider at
complete pre Induction
time of monitor
O2
sequence
placement
Airway
Tube
management secured
SCD; helps with
monitors; may
count
at bedside,
may be
holding mask;
may
count,etc.
at
bedside
helping
doing
Airway
managemen
t
May help or go get
scrubbed
Place O2; may
places monitors
place while
and advises others
helps
placing
head of bed
on best location of
monitors;
monitors
premeds prn
arrives to
helps if in
room if not
helps if in room
room
already
present
Hot line, Aline, Central
Line setup
(PRN)
prep for Aline, open Cline kit (PRN)
helps; may
move
stretcher out
Surgical resident/PA
Surgery attending
Onto table
click "pt in room"
(this will send page to
surgery
helps
team/attending &
anesthesia attending;
help open doors;
helps if not
greets patient
scrubbed
Anes res/ CRNA
Anes Support
1
Airway
Standard:
managemen
in room at
t; start IV;
5 minutes
set up Art
Assist with
airway (PRN)
ready to go
forward
receives page
? In room
GOAL: on
table
GOAL: monitors
and O2 on.
GOAL:
tube
secured
Arterial line
•
•
•
•
•
•
Be sure it is indicated
Is it needed:
– before induction
– after induction
– after incision
Pre-order; cart set up
Prep as soon as feasible (even during induction)
– Attending
– AT
– Circulator/scrub (ask Rayna)
Two tries then escalate
– Attending
– Ultrasound
– Expert provider/alternate attending
Consider abandoning the procedure and develop an alternate plan
Difficult Airways
• Proper equipment in the room
• Call for additional help whenever needed
• Two attempts then escalate
– Alternate techniques
– Alternate provider
• Alternate airway, alternate plan, or
abandon procedure
Standards in detail
1.
2.
3.
Nursing standards

SCD’s, Warm blankets, Hovermatt, and Slip

Workflow

Parallel activities

Leads huddle
Surgeon Standards
 Attendance
 Automated page
 Parallel activities
 Previous case huddle prep
Anesthesia Standards
 Teaching
 Central line setup
 Andon escalation
 Automated paging with Vocera escalation
 Parallel activities
Implementation Plans
1. 6A
•
Further education for implementation of new standards/expectations to be
done by 30 day follow up
2. Anesthesia
•
•
Add to grand rounds
Email notification to staff from Steve and Mike
3. OR Nursing
•
•
•
Nursing standards at next service coordinator meeting
Following the service coordinator meeting, disseminate at 0655 service
coordinator huddles
Huddle go-live presentation at next service coordinator meeting,
disseminate at 0655 service coordinator huddles
4. Surgeon
•
•
Disseminate via email to surgeon chiefs and presented at the next available
surgeon chiefs meeting
Include in roadshow faculty meetings
5. Anesthesia techs
•
Attend staff meetings to verify new standard work and evaluate
abnormalities with anesthesia techs availability
Thank you!
Questions?