Surgical Improvement Project Rapid Process Improvement 1 Reducing

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Surgical Improvement Project Rapid Process Improvement #1: Reducing Non-Operative Time in Thoracic Surgery July

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

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

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

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 Steps 66 Total Process Time 1: 30 -

Current State: Summary Chart Number of Steps 66 Total Process Time 1: 30 - All cases 2: 00 - Big cases Distance Traveled 12, 626 = 2. 4 miles

Process Flow - Before

Process Flow - Before

Process Map - Before

Process Map - Before

Work Balance: 100 90 80 75 70 70 67 60 50 40 40 33

Work Balance: 100 90 80 75 70 70 67 60 50 40 40 33 30 20 14 10 HA Anesth Tech Anesth Surgeon Scrub RN Circ RN

Wastes • Physical layout poorly planned • Anesthesia does not “meet” patient until previous

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

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 Sterile (10)

Wastes • Set up esophagoscope (3 times) • Opening (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

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

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 •

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

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

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

Process Map - New

Projects / Procedures / Standards Completed Owner Location Turnover Process Map Y Heidi Room

Projects / Procedures / Standards Completed Owner Location Turnover Process Map Y Heidi Room 12 Sending for Patients Y Heidi / Doug Room 12 Sara Room 12 Description Surgeon communicate when leaving OR Existing Policy Surgeon present day of surgery Existing Policy RN to RN Hand-off Y Drug Pick-up Julie Transfer of ICU Patients – Not done by Anesth Y Mary Claire HA cleaning checklist & definition list Y Kim Closet Door Plan for Day Template Y Doug Room 12 Scrub leaving room exceptions Y Doug Room 12 Anesth Protocols Y Andy Room 12 – Book

HA Standard Procedures

HA Standard Procedures

OR Team: Standard Procedures

OR Team: Standard Procedures

Anesthesiologist Protocols

Anesthesiologist Protocols

“Room Ready” Condition

“Room Ready” Condition

Chart Holder on Stretcher

Chart Holder on Stretcher

Anesthesia Costruc in Induction Room

Anesthesia Costruc in Induction Room

Summary Chart Current Number of 66 Steps Total Process 1: 30 (All cases) Time

Summary Chart Current Number of 66 Steps Total Process 1: 30 (All cases) Time Distance 12, 626 = 2. 4 miles After % Change 10 (External) 47 (Internal) 15% Trial 1 – 50 (0 delay) Trial 2 – 63 (30 delay) Trial 3 – 55 (25 delay) Trial 4 – 58 (28 delay) 50% achievable 1. 3 miles 46%

Process Map – After (46% improvement)

Process Map – After (46% improvement)

Work Balance: 100 Original work balance eff: 55% New work balance eff: 69% 90

Work Balance: 100 Original work balance eff: 55% New work balance eff: 69% 90 80 75 70 70 67 60 50 40 40 40 32 33 30 20 20 20 14 10 HA Anesth Tech Anesth Surgeon Scrub RN Circ RN

Follow-up Action Items • Complete 5 S activities in Room 12 – – –

Follow-up Action Items • Complete 5 S 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

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 Audience Anesthesia Techs Anesth Tech + Pre. Op RN’s Thoracic RN’s All

Communication Plan Audience Anesthesia Techs Anesth Tech + Pre. Op RN’s Thoracic RN’s All OR RN’s HA’s/OR RN’s Key Message New Protocol for 1) Rapid Turnover 2) Epidural Block Frequency Who Delivers Tues – Card Div Mtg Anesth Dept Mtg Andy Allen 1) All above & 2) Costruc change 3) Mark strap policy 4) Datex Cuff Stock Weekly Mtg Greyson 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 Mtg Sara / Heidi

Communication Plan continued… Audience Key Message Frequency Monthly Staff Mtg Who Delivers OR RN’s/Thoracic

Communication Plan continued… Audience Key Message Frequency Monthly Staff Mtg Who Delivers OR RN’s/Thoracic RN’s Thoracic Surgeons Thoracic Residents Anesthiologists Plan for the Day Heidi / Sara Thoracic RN’s OR RN’s Sending for next patient prompts Monthly Team Mtg. Heidi / Sara All HA’s Pre-Op RN’s Guidelines for picking up patients Wed HA Mtg. Kim All HA’s Cleaning List & Definitions Wed HA Mtg. Kim Doug Andy

Measures / Audit Plan Metric / Attribute Status Owner Freq Target Non-Op time Thoracic

Measures / Audit Plan Metric / Attribute Status Owner Freq Target Non-Op time Thoracic cases Yellow Jason Weekly 45 Min Pt w/ epidural & lines prior to end of previous case Red Alan Each Case & Weekly “ 0” Minutes added to turnover Patient Available Red Sherri & Judy Each case & Weekly Pt. available when sent for – 100% Plan of the day Red Doug Each Day 100% Anesth protocols followed – Emergence - Induction Red Andy Each case & Weekly 100% Pt in Pre-Op holding within 20 min & ready for anesth Red Shelley Each case & Weekly 100% Team awareness of roles & following roles Yellow Sara / Heidi Weekly Mtg Compliance