Assignments
cherodjones
Week6_CaseStudyReadingAssignment-1.pdf
Making the Case for Quality
Systematically Improving Operating Room Patient Flow Through Value Stream Mapping and Kaizen Events
• Value stream maps (VSMs) are effective tools for facilitating incremental improvements to complex healthcare processes.
• Thomas Jefferson University Hospitals utilized the VSM approach to identify and execute seven lean projects within the perioperative department over four years.
• Results include preadmission testing reduction in length of visit from 110 to 92 minutes, 36 percent reduction in preoperative patient waiting, and an improvement of on-time first-case starts from 56 to 67 percent.
At a Glance …
The focus of hospital senior leaders on operations expense reduction and management has been spurred
by increases in costs of pharmaceutical and medical supplies, revenue movement from inpatient to
outpatient settings, and malpractice insurance.1 Key to addressing these issues is successfully utiliz-
ing performance improvement methodologies to improve quality and decrease variation, which saves
money.2 At Thomas Jefferson University Hospitals, inpatient and outpatient operating room (OR)
activity accounts for a large percentage of total patient revenue. The majority of OR cases occur at the
academic medical center known as the Center City campus.
As part of the perioperative (the department responsible for all surgical procedure activities) strategic
plan overview, a team of certified lean practitioners was assigned to analyze and improve the OR
patient flow process. Given the existing high volume of procedures and strategic vision to increase
case loads, it was critical to ensure consistent flow throughout the system. From preadmission test-
ing through the post-anesthesia unit, the entire process was wrought with inefficiencies (i.e., delays
in preoperative patient processing, cases not starting on time, and slow OR turnover case to case) and
bottlenecks that had compounding effects on the overall department.
Representatives from all related disciplines and departments converged to tackle the complex problem.
Facilitated by the lean team, a value stream mapping (VSM) event was held in August 2010 to deter-
mine how to strategically solve key issues.
About Thomas Jefferson University Hospitals
Thomas Jefferson University Hospitals
(Jefferson) is a 969-acute-care-bed healthcare
facility located in Philadelphia, PA. Jefferson provides a full range of patient care in all
specialties and subspecialties. The southeast-
ern Pennsylvania, New Jersey, and northern
Delaware region includes more than 11 million
people. Annually, Jefferson clinical operations include nearly 50,000 admissions, more than
120,000 emergency department visits, and almost
a half-million hospital-based outpatient visits.
by Dennis Delisle
October 2013
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Dennis Delisle, operations support director for Jefferson University Hospitals, discussing a pay-off priority matrix with team members.
Why Quality?
Committed to lean thinking since 2008, in 2010 Jefferson
hired a certified lean master to develop a robust education and
process improvement program. As part of this program, more
than 50 certified lean practitioners who are imbedded in vari-
ous clinical and nonclinical departments volunteer their time for
improvement projects. In addition to the formal university-based
lean thinking and certification program, Jefferson offers staff
department-level training that emphasizes application of simple,
yet effective tools (i.e., 5S, visual management, process map-
ping) and leads to project execution on a smaller scale. Jefferson
is dedicated to providing world-class care, and approaches like
lean thinking enable staff to contribute value-adding services
while reducing wasteful efforts.
The consumer-driven healthcare market demands a high degree of
customer service and responsiveness. As such, Jefferson leaders
identified a need to streamline the perioperative department’s pro-
cesses. The perioperative department engaged a team of certified
lean practitioners to strategically evaluate opportunities and facili-
tate change. Operating room patient flow is a complex process that
involves multiple areas, including:
• Physician offices • OR scheduling • Preadmission testing • Registration • Pre-procedure preparation • Patient transportation • Holding area unit • Operating room • Environmental services • Post-anesthesia care unit
Given the numerous levels, functions, and responsibilities involved, leaders determined that the best approach to initiate the
project would be a VSM event. The full-day facilitated effort included the lean team working with a group of process experts throughout the entire OR patient flow process.
Jefferson’s Quality Journey
Prior to initiation of the VSM event, the lean team conducted voice of customer interviews with representatives from manage- ment and frontline staff. The interviews focused on qualitative analysis of key issues and barriers to patient flow. Throughout the discussions, several themes became apparent: constant changes to the OR schedule the day before or day of surgery, poor communication among perioperative units, excessive processes and patient travel due to poor layout, inadequate tech- nology for decision making and monitoring flow, and workflow variation across all disciplines.
Following the interviews, the lean team began observations. A critical element of lean thinking is gemba walks. Gemba is a Japanese term that stands for the place of action, or where the work takes place.3 The approach is simple: Go to where work is being done, observe the processes and workflow, and talk with staff to understand their challenges.4 Gemba walks also enable
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OR Kaizen 5 Team – Improving On-Time, First-Case Starts
OR Kaizen 6 Team – Improving OR Patient Flow From SPU to Holding Area
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the team to document process steps in the current state, a key input in the VSM event. Additionally, observations were supple- mented by the OR information system database providing key performance indicators such as on-time, first-case starts, OR turnover times, and cycle times across the patient flow process. Together, these data helped shape the current state.
The lean team developed a comprehensive agenda that included current state validation, brainstorming and prioritizing issues and barriers, future state design, and creating an improvement plan for incremental progress over time. Managers and perioperative department leaders participated. Inclusion of the right stakehold- ers (i.e., process expert, influential leader, creative problem solver, etc.) is a critical element of successful improvement efforts. The OR vice president and management team helped choose a group of individuals to represent the broader department.
Figure 1 depicts the validated current state at the time of the event. Participants went through a facilitated brainstorming ses- sion to determine the key drivers of quality and efficiency issues. The problem-solving process used by the lean practitioners can be seen in Table A.
The group then began the solution development process. The pro- posed solutions were prioritized based on impact (high/low) and ease of implementation (easy/difficult). Figure 2 shows the current state, with proposed solutions represented as kaizen bursts.
This led to final recommendations of where the team should focus (Figure 3: Proposed Action Plan). At the conclusion of the event, the entire team presented the findings and recommenda- tions to leadership, along with the timeline for implementation.
Lean thinking emphasizes incremental improvement over time. These improvement efforts are typically known as kaizen events. Kaizen, a Japanese term, represents “change for good.” Lean teams facilitate kaizen events with process experts in order to rapidly develop and implement solutions. Jefferson lean teams utilize the define, measure, analyze, improve, and control (DMAIC) project structure to execute initiatives. The main deliv- erables for each phase can be seen in Table B.
The VSM team identified two areas as the priority focus based on the majority of opportunities and solutions identified through the VSM event. The first piece was patient arrival. Next, the
Table A — Problem-Solving Process
Step Description Deliverable
Brainstorm issues and barriers Through various brainstorming activities, participants discuss and document all issues and barriers related to the problem being addressed.
Documented list of all issues and barriers that contribute to inefficiencies and poor quality.
Prioritize issues and barriers The team determines which issues and barriers are within their control. These filtered issues are subsequently prioritized through voting.
The highest priority issues/barriers (usually two to four in total) are selected for solution development.
Brainstorm potential solutions Through brainstorming activities, the team discusses and develops potential solutions to address the prioritized issues and barriers from the prior step.
Documented list of all potential solutions to address the prioritized issues.
Prioritize solutions The team prioritizes solutions based on impact on the problem (high or low) and ease of implementation (easy or difficult).
All solutions are prioritized, highlighting the high-impact and easy- to-do ideas.
Develop action plan A detailed action plan is developed for all solutions that fall within the high-impact, easy-to-do or low-impact, easy-to-do categories.
The action plan consists of what, who, when, required resources, and expected outcome. Plans are executed within a six-week timeframe, often with pilots occurring during the actual kaizen event.
Patient Surgeon
OR schedule nalized
OR schedule nalized
Delivered to central scheduling
Patient arrives
Check-in by name Register
Check-in by name
Clerk pull
chart
Call back to cubicle
Instruc- tions
Patient changes clothes
Prep for surgery
Arrive @ holding
area
RN assess- ment
IV insertion
MD assess- ment
Enter OR
Call from scheduling
Call from scheduling
Patient check-in @ admissions
Arrive @ SPU
Prep for surgery
Patient arrives @
holding area Enter OR
SPU = short-procedure unit
Figure 1 — OR Patient Flow VSM
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recommendation was to look at the holding area process where patients have an IV line placed and are then interviewed by the surgical and anesthesia teams (interventions and outcomes of all efforts can be found in the results).
After execution of the first and second kaizen events, the lean team re-evaluated the VSM with perioperative department lead- ership to identify additional opportunities for improvement. Over the course of four years, the lean team systematically addressed issues and challenges through seven formal kaizen events. The scope of the subsequent improvement efforts spanned scheduling through post-procedure processes and can be seen in Table C.
Patient Surgeon
OR schedule nalized
OR schedule nalized
Delivered to central scheduling
Patient arrives
Check-in by name Register
Check-in by name
Clerk pull
chart
Call back to cubicle
Instruc- tions
Patient changes clothes
Prep for surgery
Arrive @ holding
area
RN assess- ment
IV insertion
MD assess- ment
Enter OR
Call from scheduling
Call from scheduling
Patient check-in @ admissions
Arrive @ SPU
Prep for surgery
Patient arrives @
holding area Enter OR
High/easy High/dif cult
Expand ORSOS access
OR comments
Prioritize calls
Signage Patient tracking system
Admission to 9410
Patient ID process
OR transport time
Holding area whiteboard
Separate med/ surg patient
Inpatient patient education
Add clerk
Inpatient status in ORSOS
More computers
Add clerk Lab slips
Pixis
Stretchers
First case education
Transporter education
Pacemaker IV insertion New MD education
MD arrival timeIV bags/tubes
Supply par levels
Add unit clerk
More computers
Implement pull system
10th St. open 4:30 a.m.
JIT patient arrival
Update scripts Move
interviewers
FAR closed on schedule Larger OR
labels Physician
of ce education
Low/easy ORSOS = OR information system JIT = just-in-time FAR = rst available room Pixis = medication carousels on nursing units
Patient Surgeon
OR schedule nalized
OR schedule nalized
Delivered to central scheduling
Patient arrives
Check-in by name Register
Check-in by name
Clerk pull
chart
Call back to cubicle
Instruc- tions
Patient changes clothes
Prep for surgery
Arrive @ holding
area
RN assess- ment
IV insertion
MD assess- ment
Enter OR
Call from scheduling
Call from scheduling
Patient check-in @ admissions
Arrive @ SPU
Prep for surgery
Patient arrives @
holding area Enter OR
Kaizen 1 Kaizen 2
Figure 2 — OR Patient Flow VSM With Proposed Solutions
Figure 3 — OR Patient Flow VSM With Proposed Action Plan
Table B — DMAIC Steps
Phase Main Deliverables
Define Project charter, voice of customer interviews, waste walks, high-level process mapping
Measure Baseline data collection, roll-out of communication plan, time study observations
Analyze Data analysis, kaizen event agenda development and logistics
Improve Kaizen event: develop and implement solutions
Control Follow-up action plan meetings, data analysis, final project summary
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The table shows the various kaizen events and scope of each. Various kaizen events tackled similar processes and areas. The nature of lean think- ing is continuous improvement, and as such, improvements made early on were later evaluated and further streamlined. Along the OR improvement journey, many staff—from several different departments, including OR, transportation, patient access, and environmental services—were incorpo- rated within the project team.
Kaizen team participants were chosen in a similar fashion to the VSM event. The lean team, along with OR leadership, targeted individuals with process expertise and an orientation of continuous improvement or known resistance to change. The last part is crucial in identifying and developing meaningful and realistic solutions. Active resistors oftentimes have valid reasons for their hesitation to get involved. The dissenting voice offers the group opportunities to challenge ideas, reflect on past success and failures, and build a stronger process. Many individuals participated in more than one kaizen given their interest, roles and responsibilities, and ability to implement action plans.
Results
The systematic approach to improve OR patient flow yields steady gains over time. In four years, the various kaizens have produced a bandwidth of positive outcomes—from statistically significant and sustainable gains (e.g., Kaizen 3), to marginal, qualitative improvements (e.g., Kaizen 2). The complexity of systems and processes, along with personnel, make each project unique. Key lessons learned, such as those listed in Table D, are leveraged from one effort to the next while results are shared with partici- pants and department staff along the way.
Though many gains have been realized, work remains. The VSM enables the team to effectively segment and attack small portions of the overall process. Gains realized from one effort contribute to the success of sub- sequent initiatives.
Jefferson’s Continuing Commitment to Quality
To date, many of the outcomes achieved continue to sustain and improve. As depicted in Table E, the lean teams continue to circle back to address additional improvement opportunities in areas such as the short-procedure unit, the patient testing center, and the holding area. To drive results down to frontline staff, Jefferson has evolved its lean approach to incorporate a structured education program. Since Kaizen 7, a team of lean practitioners engaged a multidisciplinary group from the perioperative department. The eight-week education program emphasizes the application of lean thinking, and its associated tools, and concludes with a formal project proposal sub- mitted by the participants.
These project ideas are subsequently evaluated by leadership (departmen- tal and lean program) and then executed with the appropriate method (i.e., just do it, project management, full lean engagement, etc.). The goal of this revamped approach is to enable staff to solve their own problems at
Table C — Kaizen Events
Kaizen Title Scope
Kaizen 1: Improving patient flow from arrival to holding area
Parking lot, registration, short- procedure unit (SPU)
Kaizen 2: Improving patient flow from arrival to holding area
Holding area
Kaizen 3: Improving patient flow in the patient testing center
Patient testing center (preadmission process for patients one to two days prior to surgery)
Kaizen 4: Improving OR turnover Eight OR suites
Kaizen 5: Improving on-time, first-case starts
Scheduling to SPU
Kaizen 6: Improving OR patient flow from SPU to holding area
SPU and holding area
Kaizen 7: Improving patient flow in the patient testing center
Patient testing center
Table D — Lessons Learned
Theme Lessons Learned
Change • Let go of the past and embrace change
• Think out of the box
• A small group can actually drive meaningful change
• There’s always room for improvement
• Keep an open mind to change
Teamwork • Important to work as a team
• Everyone melds ideas together to help create solutions
• More aware of job responsibilities in other areas
• Gained respect for other areas
Staff involvement • Need to educate staff on changes early and often, communication/education is critical
• Staff need to know how valued their role is within the process
Kaizens • Stay focused on goals to impact change in short period of time
• Kaizen is needed to focus on problems and make processes better
• Have patience with the kaizen problem- solving process
• Go from good to excellent in customer service by making patients a central focus of the process
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Table E — Kaizen Results
Kaizen Title Timeline Countermeasures Results
OR Patient Flow VSM May – August 2010
• Facilitated full-day current and future state VSM session to identify and prioritize opportunities for improvement
• Verified and finalized VSM
• Developed future state map
• Identified 20 high-impact interventions along the VSM
• Prioritized and determined Kaizen 1 and Kaizen 2 scopes
Kaizen 1: Improving Patient Flow From Arrival to Holding Area
September – November 2010
• Moved patient registration to the bedside
• Standardized charge nurse desk patient monitoring process
• Streamlined short procedure unit (SPU) work processes to coordinate with registration process
• Overall process time (patient arrival to ready for transport) reduced by 31.9 percent
• Pre-kaizen: 56.9 minutes/Post-kaizen: 38.8 minutes (18.1 minutes overall). Waiting time was reduced by 35.9 percent (from 25 to 15 minutes), patient travel time was reduced by 63.3 percent (from 5 to 1.5 minutes), and patient check-in time was reduced by 63.6 percent (from 5 to 1.5 minutes).
Kaizen 2: Improving Patient Flow From Arrival to Holding Area
November 2010 – February 2011
• Installed whiteboards in all three holding areas as visual cue to missing patient information
• Implemented “1” box surgeon checklist, replacing comprehensive, multidisciplinary checklist
• Developed and implemented nurse scripting to address patient expectations about waiting
• Developed surgeon on-time, first-case start performance report
• Holding area length of stay (LOS) around 30 minutes (avg. 55.9)
• Less wasted motion for all staff
• Patient satisfaction regarding wait times improving
Kaizen 3: Improving Patient Flow in the Patient Testing Center
March – August 2011
• Reduced the number of processing steps
• Brought patients back to exam room upon arrival
• Registration completed in exam rooms
• Nurse practitioners performing EKGs and labs
• Discharging patients from exam room
• Installed whiteboard to monitor patient flow, status at flow desk
• Pre-intervention LOS (109.65 minutes)/ Post-intervention (92.33 minutes, p<0.000)
• Pre-intervention achieved its daily target of 90-minute average LOS, 4.29 percent of the time. Post-intervention, the target was exceeded 35.0 percent of the time, marking a 715.9 percent improvement (p<0.000).
Kaizen 4: Improving OR Turnover
September 2011 – January 2012
• Developed nursing assistant team assignments
• Implemented OR case room preparation checklist
• Posted turnover results on whiteboard for prior week
• Continued monitoring of cases exceeding 30-minute target in real time
• Developed future state swim lane map to target opportunities for improvement
• Pre-intervention turnaround time was 48 minutes (standard deviation 6.7). Post-intervention turnaround time was 44.1 minutes (standard deviation 3.7) (p=0.003). By stabilizing the output, subsequent improvement efforts are positioned to favorably impact results. These data are now monitored and posted on a weekly basis by the OR charge nurse.
Kaizen 5: Improving On-time, First-case Starts
March – August 2012
• Increased bedside registration availability to 4:45 a.m. – 8:30 a.m.
• OR schedule/mapping created a list of issues to identify potential barriers to on-time starts the day before
• Perioperative department to make pre-surgery calls instead of general central scheduling, include scripting for reinforcing patient arrival time
• Utilize newly created first-case starts tracking tool to monitor SPU/holding area (HA) cycle times
• Cycle times from patient arrival at SPU to surgery start were reduced in all four ORs.
• Overall, the SPU to HA time reduced by 35 minutes and HA to start of case was reduced by nine minutes.
• The time from SPU arrival to start of case was 44 minutes faster post-kaizen.
• These operational efficiencies will help the SPU and HA staff to prepare patients for on-time starts.
Kaizen 6: Improving OR Patient Flow From SPU to Holding Area
December 2012 – July 2013
• Conducted detailed time study of registrar/nurse/transport in SPU to identify opportunities to streamline processes
• Collaborated with transportation department to assign two additional transport aides at 5:30 a.m.
• Incorporate schedule changes during mapping meeting day before surgery to anticipate patient needs
• The first cases pre-kaizen were on time 55.7 percent of the time. Post-kaizen, 67.4 percent of the first cases began on time.
• Holding area arrival times had a modest improvement from 33.9 percent on-time to 36.8 percent.
• Pre-kaizen cycle time from patient arrival at SPU to ready for holding area was 47.43 minutes. The post-kaizen cycle time was 44.94 minutes—achieving the 45-minute goal.
Kaizen 7: Improving Patient Flow in the Patient Testing Center
September 2012 – January 2013
• Registrar to receive OR schedule in advance to identify patients for preservice
• Registrar to preregister patients 24 to 72 hours in advance of scheduled visit and clarify information during call (e.g., demographic information/insurance coverage)
• Clerks preparing charts at least 24 hours prior to patient’s scheduled visit
• Upon arrival, the preregistered patient is taken to an open examination room and nurse practitioners and techs can begin testing immediately
• The preservice model allows the registration staff to prepare the chart in advance of patient arrival, effectively decreasing patient LOS while increasing patient satisfaction
• The average LOS from May – November 2012 was 129.8 minutes. Post-intervention, the average LOS was 118.9 minutes.
• Since September, LOS was reduced from an average of 131.6 minutes to 117.8 minutes (p<0.00).
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the source and use experienced lean teams to address system- atic, multi-departmental barriers and issues. The lean team’s OR engagement success has been replicated in additional clinical areas, including the pharmacy and oncology services.
Organizations, both large and small, can leverage the powerful impact of lean thinking. Use of tools such as VSMs provides an objective way to approach complex issues and facilitate incre- mental improvement over time.
For More Information
• Contact Dennis Delisle at dennis.delisle@jeffersonhospital. org to learn more about this project.
• Find Thomas Jefferson University Hospitals online at www.jeffersonhospital.org.
• Find more case studies on quality improvement in healthcare in the ASQ Knowledge Center at asq.org/knowledge-center/ case-studies.
Acknowledgements
Kaizen Participants
Shay Bradley, Gina Burton, Dane Caffrey, John Cibenko, Allison Clerval, Jill Conroy, Maggie Conte, Tina Convery, Susan Curcio, Nancy DuBois, Mary Eddis, John Ervin, Maria Franzini, Cindy Frederick, Valentina Freiberg, Bonnie Grady, Bonnie Gray, Venus Gwynn, Kathy Jaffe, Keena Johnson, Carl Leconey, Christina Lin, Helane Moore, Kristen Piller, Beth-Ann Piotrowski, Beth Piotrowski, Patricia Reilly, Monica Repko, Maria Ricci, Debbie Righter, Melanie Rogavaello, Doug Ryba, Elaine Schaeffer, Bob Sponsler, Janice Stewart, Darlene Sullivan, Linda Walsh, Diane Wolk, Aaron Woodward, Linda Yearly, Monica Young, and Christine Zeoli
Lean Team Members
Deb Castellucci, Ed Cullen, Katie Droz, Vanessa Gleason, Anna Grayson, Steve W. Gudowski, Fran Guiles, Megan Illg, Carrie Lamina, Tom Louden, Steve McDonald, Steve Moritz, Mike Perino, Jill Richards, Rebecca Ryba, Beth-Ann Schauer, and Josh Schoppe
References
1. Zidel, T. (2012). Lean Done Right. Chicago, IL: Health Administration Press.
2. Liker, J. (2004). The Toyota Way: 14 Management Principles From the World’s Greatest Manufacturer. Madison, WI: McGraw Hill.
3. Womack, J. (2011). Gemba Walks. Cambridge, MA: Lean Enterprise Institute, Inc.
4. Mann, D. (2010). Creating A Lean Culture (2nd Ed.). New York, NY: Taylor and Francis Group, LLC.
About the Author
Dennis R. Delisle, MHSA, PMP, is the director of opera- tions support for Thomas Jefferson University Hospitals and adjunct instructor for Thomas Jefferson University’s School of Population Health. Dennis is a certified Lean Master, Six Sigma Black Belt, and Project Management Professional, and is cur- rently pursuing a doctor of science degree in health systems management. He is responsible for the education and certifica- tion of lean practitioners, as well as the deployment of strategic organizational initiatives. Dennis is a trained examiner for the Keystone Alliance for Performance Excellence and co-leads Jefferson’s Performance Excellence program, utilizing the Malcolm Baldrige National Quality Award Criteria.
