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Surgical Improvement ProjectRapid 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 Steps 66
Total Process Time
1:30 - All cases
2:00 - Big cases
Distance Traveled 12,626 = 2.4 miles
Process Flow - Before
Process Map - Before
Work Balance:
HA Anesth Tech
Anesth Surgeon Scrub RN Circ RN
10
20
30
40
50
60
70
80
90
100
33
40
75
14
6770
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 - NewRoles -60 -20 -10 -5 0 5 10 15 20 25 30 35 40 45
Pre-Op Holding Nurse
Pre-Op Checklist
Call Surgeon
and Resident
Surgeon Speak to family DictatePositioning
/ drape / huddle
Surgical Resident
Wrap-up trash, gowns, drapes
Orders / Transfer
patient to PACU
Mark site / Confirm
H&P (next patient)
Obtain & review x-rays
/ Plan
Positioning / drape
Anesthesia
(One hour prior to
dressing) / Interview patient /
Review Info / Start epidural /
Start lines
Wake patient / Finalize record
Transfer patient to
PACU
Report in PACU
Return drugs / Obtain drugs for
next patient (include all
drugs)
Travel to OR with patient
Set-up monitors / Transfer patient
Induction of anesthesia
Positioning / Huddle
Anesthesia Tech
Equipment preparation
Assist with patient
extubation & transfer to
stretcher / bed
Strip machine /
Empty trash
Wipe-down machine /
Reorganize cables / Reset
machine
Set-up next case
Assist with
monitors
Assist induction
Assist positioning / Gown tieing
Scrub NurseInstruments into case cart / Rinse
or spray
Remove current CT's
& x-rays. Drop off
case cart, specimens,
drug box.
Get new case cart / Pick extras
Enter room / open case
cart & packs
Scrub and set-up table
Count sponges & Instruments
Pull up table, Bovie,
Suction, Gown, Glove
Circulator
Phone Call to PACU / Rn to RN
report
Interview patient
Call HA & Anesthesia Tech.
Confirm family presence, stay in waiting room for
surgeon
Update & finish record. Update
PL. Print to CT/ Neuro printer.
Begin turnover.
Log in next case /
Write info on board
Assist scrub in set-up
Assist in patient
transfer in OR, SCD's,
blanket, safety belt
Count with Scrub Nurse
Position, prep, drape,
huddle
Hospital Assistant
Verify positioning / supplies /
bed
Return equipmentTake out trash &
linenSweep &
Mop
Clean & make bed / Wipe down all surfaces
Restock room
Bring in equipment
Projects / Procedures / StandardsDescription Completed Owner Location
Turnover Process Map Y Heidi Room 12
Sending for Patients Y Heidi / Doug Room 12Surgeon communicate when leaving OR
Existing Policy
Surgeon present day of surgery
Existing Policy
RN to RN Hand-off Y Sara Room 12
Drug Pick-up JulieTransfer 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 12Scrub leaving room exceptions
Anesth Protocols
Y
Y
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
After10 (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 miles 46%
Process Map – After (46% improvement)
Work Balance:
HA Anesth Tech
Anesth Surgeon Scrub RN Circ RN
10
20
30
40
50
60
70
80
90
100
33
40
75
14
6770
23 20
32
20
30
40
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 PlanAudience Key Message Frequency Who
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 Mtg Greyson
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 Mtg Sara / Heidi
Communication Plan continued…Audience Key Message Frequency Who
DeliversOR RN’s/Thoracic RN’s
Thoracic Surgeons
Thoracic Residents
Anesthiologists
Plan for the Day Monthly Staff Mtg Heidi / 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.
Wed HA Mtg.
Kim
Kim
Measures / Audit PlanMetric / 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
Q&A???