Surgical Improvement Project Rapid 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 Steps66 Total Process Time 1:30 - All cases 2:00 - Big cases Distance Traveled12,626 = 2.4 miles

Process Flow - Before

Process Map - Before

Work Balance: HA Anesth Tech AnesthSurgeonScrub RNCirc RN

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 - New

Projects / Procedures / Standards Description CompletedOwnerLocation Turnover Process Map YHeidiRoom 12 Sending for Patients YHeidi / DougRoom 12 Surgeon communicate when leaving OR Existing Policy Surgeon present day of surgery Existing Policy RN to RN Hand-off YSaraRoom 12 Drug Pick-up Julie Transfer of ICU Patients – Not done by Anesth YMary Claire HA cleaning checklist & definition list YKimCloset Door Plan for Day Template YDougRoom 12 Scrub leaving room exceptions Anesth Protocols YYYY 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 After 10 (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 miles46%

Process Map – After (46% improvement)

Work Balance: HA Anesth Tech AnesthSurgeonScrub RNCirc RN 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 Plan AudienceKey MessageFrequencyWho 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 MtgGreyson 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 MtgSara / Heidi

Communication Plan continued… AudienceKey MessageFrequencyWho Delivers OR RN’s/Thoracic RN’s Thoracic Surgeons Thoracic Residents Anesthiologists Plan for the DayMonthly Staff MtgHeidi / 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. Kim

Measures / Audit Plan Metric / AttributeStatusOwnerFreqTarget Non-Op time Thoracic cases YellowJasonWeekly45 Min Pt w/ epidural & lines prior to end of previous case RedAlanEach Case & Weekly “0” Minutes added to turnover Patient AvailableRedSherri & JudyEach case & Weekly Pt. available when sent for – 100% Plan of the dayRedDougEach Day100% Anesth protocols followed – Emergence - Induction RedAndyEach case & Weekly 100% Pt in Pre-Op holding within 20 min & ready for anesth RedShelleyEach case & Weekly 100% Team awareness of roles & following roles YellowSara / HeidiWeekly MtgCompliance

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