VMPS and Surgery Applying the Virginia Mason Production System to the Operating Room Rabia Nizamani, MD General Surgery, R3 Thursday, July 19, 2012

What is VMPS? Adaptation of lean management used in manufacturing Toyota Production System Set of principles and tools to encourage and facilitate continuous incremental improvement

The Goals of VMPS Use lessons from commercial industry to: Reduce waste Reduce costs Improve safety Improve quality And ultimately… Deliver quality care to more patients for less money

Defining Value-Added Care Does this task contribute to meeting patient needs? Is the patient willing to pay for this task? Does this task transform the service? Does the patient want or need this transformation? Is this task done correctly the first time, every time?

If not, it might be waste… Type 1 Non-value added activities that are currently required Type 2 Non-value added activities that can be stopped immediately without detrimental effects

Taiichi Ohno’s 7 Wastes Waste Transportation Defects Processing Conveying, transferring, picking up, setting down, piling up and otherwise moving unnecessary items. Defects Waste related to costs for inspection of defects in materials and processes, customer complaints and repairs Processing Unnecessary processes and operations Traditionally accepted as necessary Overproduction Producing what is unnecessary, when it is unnecessary, and in unnecessary amounts Motion Unnecessary movement or movement that does not add value. Movement that is done too quickly or slowly. Inventory Maintaining excessive amounts of supplies, materials, or information for any length of time. Having more on hand than what is needed and used. Time Waiting for people or services to be provided. Time when processes, people or equipment are idle. Waste

Do or do not…there is no try. Managing Data PDSA Scientific Method Plan Do Study Act Formulate hypothesis Test it Analyze the results Determine next steps Do or do not…there is no try.

5S – Managing the Work Space Sort Simplify Sweep Standardize Self-discipline

Change Events Kaizen continuous improvement of existing processes 1-3 day (Kaizen) and 5 day (RPIW) events to evaluate and improve a value stream

5S in the OR Pilot project to 5S the Minimally Invasive Spine surgery set Evolution to create methodology to 5S any sterile instrument set

5S Results

5S Outcomes Pre-5S Post-5S Difference Instruments 197 58 -139 Set-up time 13 mins 8 mins -5 mins Processing cost/case* $152 $45 -$107 *528 cases annually, est annual savings ~$56,500

Set-up Includes gathering, transporting, opening, assembling, adjusting, etc Internal vs external set-up Can often externalize internal set-up Then reduce remaining set-up

More Change Events - 3P Production Preparation Process Form of Kaikaku Radical improvement “to blow up and start over” Leads to further Kaizen work

Setting-up for Faster Turnover

Set-up Reduction Outcomes Main OR’s L5 OR’s % reduction Pt travel 189 steps 48 steps 74% Anes travel 243 steps 73 steps 70% Turnover time 37 min 17 min 54% Note turnover time – the staff is the same, only facility is different

Mistake-Proofing Inspection Standard Work Visual Controls Devices… Prevent mistakes from becoming defects Standard Work Defines and assigns responsibilities - transparency Allows identification of opportunities Visual Controls Kanbans and Andons Devices… Kanban – visual cue that a task must be done; andon – alarm to alert to problems, eg nurse call light

5S, Set-up, Mistake-Proofing Which anesthesia cart would you prefer… Reorganized after patient died – wrong med given; now resus meds are kept separate from induction and reversal meds, contents of each syringe are specified by its location As a provider? As a patient?

Acknowledgements Graduate Medical Education Division of General, Thoracic and Vascular Surgery Division of Plastic Surgery Department of Anesthesia Sterile Processing Department Staff Operating Room Staff Dr. Farrokh Farrokhi