Lean Six Sigma application for reducing non productive time in operation
theatres in a university teaching hospital
Dr Girdhar Gyani, Dr Sanjeev Singh
Introduction:
Healthcare, as with any other service operations, requires continuous and systematic innovation to
remain cost effective, efficient and provide high quality services. Operation Theatres (OTs) are the
key area which involves huge capital investment, it is highly manpower intensive too along with
being a high cost centre. It is a high priority service area from the management point of view, which
requires adequate attention and willingness to improve efficiency for better returns on investment6.
The area of application of LSS (Lean Six Sigma) at our setting was selected based on following
parameters; clinical excellence, safety requirements, physician productivity, patient satisfaction,
ease of implementation, financial impact, time taken for completion of the project and
sustainability. From the retrospective study on OT utilisation it was evident that there is nonproductive time, which requires comprehensive correction. The objective of the study includes
increasing the efficiency of the OT utilization in order to avoid the Non Productive Time in OT,
improve efficiency and reduce related financial loss.
Case Presentation:
A core team was identified who collected data retrospectively in select operation theater. Based on
the above study, a problem statement and a business case was enumerated. The DMAIC4 (Define,
Measure, Analysis, Improve and Control) method was used to achieve the objectives of the study.
After in depth study following parameters were defined as measurable.
Non Productive Time 1 (NPT 1) = Induction Begin time – patient In time in the theater
Non Productive Time 2 (NPT 2) = Incision In time – Induction End time
Non Productive Time 3 (NPT 3) = OT Readiness Time - Patient Out Time
Though there were other data fields which were also captured during the process but the above 3
parameters were the most important areas of non productive time, which if corrected could lead to
better efficiency leading to financial gains. VOC (Voice of customer)10 was done after interviewing
key stakeholders like surgeons, anesthetists and nursing staff, for complete understanding of their
difficulties and opportunities of improvement. SIPOC (Supplier, Input, Process, Output, Customer)5
enumerated the understanding of workflow which involved 7 processes (wheeling into the theatre,
Induction of Anaesthesia, Incision for surgery, closure of operating site, Rounding from anesthesia,
wheeling out of patient and Preparing the theatre for next case). SIPOC gave a bird’s eye view
towards the OT workflow. A project charter was prepared with detailing of DMAIC phase with target
completion dates and with actual completion dates. During the process of value stream mapping7,
value add, non value add and operational value add activities were mapped with voluntarily working
towards reduction / removal of non value added activities.
Management and Outcome:
In the Define phase the problem statement was described as data available on OT utilization for the
year 2010 showing 7 minutes duration between case being wheeled inside the theater and induction
of anesthesia time, 17 minutes was taken between end of induction of anesthesia and starting of
incision for surgery. 37 minutes was the average turnaround time for the next case to be taken in
the theatre after the previous case is over, hence the total nonproductive time in a theater was
approximately 60 minutes.
During the measure phase, the analysis of the existing system with various measurement techniques
for the defects and levels of perfection was done. Value analysis of the value stream analysis was
done, 27 were found to be value added activity, 66 were adjudged as operational value add and 6
were non value added which were removed during the implementation phase.
Analyze phase was undertaken to determine any disparity that may exist in the goals set and the
current performance levels achieved. The understanding of the relationship between cause and
effect was necessary to bring about any improvements, if needed. Brainstorming session was carried
out and all the causes were listed in the affinity diagram. Modified FMEA 9,12 was carried out and Risk
Priority Number was considered for further analysis,
In Improvement phase, necessary steps were taken to prepare the organization towards
achievement of the goals (target six sigma). Creative development of processes13 and tools14 brought
about a new lease on life for the organization’s processes and took them nearer to the
organizational objectives
Under the control phase response plan for dealing with the enumerated problems, were formulated.
Management support was also be built up for logistical response and sustaining the achievement of
the long term goals of the project.
Discussion:
Through the implementation of Lean six sigma in OT, it is evident that total NPT has been come
down from 60 minutes to 28 minutes. Overall gain from the implementation of the study was
possible because of providing back up for the accessories which have multiple uses, ready availability
of cleaning crew, transparent central OT scheduling, monitoring postponement and cancellation of
surgeries and its evaluation, preemptively working on making post operative beds available for the
surgical cases. During this period, owing to engagement of key stake holders and management, the
overall discipline and day care surgeries also improved.
There was an evident benefit of $80,000 by making system more efficient and performing more
surgical cases. Top management gave high priority in reducing the cost and better utilization of
theatre during the study period.
Questions:
Can Lean Six Sigma tool as a quality and management tool be applied in healthcare settings?
1. If so, explain how this might be done (200 words)
2. If not, explain why not (200 words)
3. Outline the applicability of Lean Six Sigma to a healthcare setting with which you are familiar
(200 words)