SurgicalSurgical ImprovementImprovement ProjectProject

SIP 2 Data AnalysisSIP 2 Data Analysis

Main OR

Pavilion

Annex

5:30am 8:30am

Average Patient Check-in5:38 (sddev=0:16)

Average Patient Check-in5:56 (sddev=0:16)

Average Patient Check-in5:54 (sddev=0:16)

6:30 7:30

Ave: Anesthesia Start7:16 (sddev=0:20)

Ave: Anesthesia Start7:19 (sddev=0:19)

Ave: Anesthesia Start7:20 (sddev=0:19)

In Room Time7:42 (sddev=0:15)

In Room Time7:36 (sddev=0:16)

In Room Time7:39 (sddev=0:16)

Anesthesia Ready7:49 (sddev=0:19)

Anesthesia Ready7:57 (sddev=0:18)

Anesthesia Ready7:58 (sddev=0:21)

Incision8:20 (sddev=0:22)

Incision8:25 (sddev=0:28)

Incision8:10 (sddev=0:21)

SIP 2 : Key Metrics TimescaleFirst Cases Only - Averages include all cases April 2004 through March 2005 (Wednesday data removed)

5:30 8:30

5:30am 8:30am

5:30am 8:30am

Key Metrics - Analysis

Location Check in to Anes Start* (min)

Anest Start to In-room (min)

In-room to Anes Ready (min)

Anes Ready to Incision (min)

Main OR 98 23 19 27

Pavilion 84 16 13 21

Annex 85 23 15 23

* Wednesday – late start day, data removed

Variation by ServiceService Check-in to

Incision (min - mean)

SD

Neurosurg 199.4 25.9

Oto 162.6 7.1

Surg C 162.0 7.2

Orthopedics 159.4 16.6

Gen Surg 156.0 9.6

Gyn 145.8 14.9

Ophthalmology 128.6 4.3

Surgical Evaluation Anesthesia Evaluation Preanesthetic Care

Disease specific WU

Comorbidity Evaluation affecting

surgical siteSurgical

Plan

Surgical (Operative)

CareSurgical Consent

Mark Surgical

Site

Immediate Preop Eval (i.e. INR)

Immediate Preop Rx

(transfusion, platelets)

Anesthetic Treatment

Pt. Location

Comorbidty affecting

anesthetic AirwayPt educated and

consented IV

Specialized anesthetic

care (art line, epidural) Anesthetic

OR- Incision X X X Y X X X X X X X X X N

OR - in roomX X X N X X X X X X X X X Y

Preop 2 X X X N X Y X Y X Some Some X Y, if necessary Some

Preop 1 X X X N X Y X Some X Some Some Y N X

Check in - Preop Front Desk

X X X N X N X N X N N N N X

PAC X X X N X N Y N Y - anesthetic consent N N N N X

Surgeon's Clinic

Y Y Y N Y N N N N N N N N X

X assumed to be already completedY has not been done, and should be done in this areaN has not been done to this point

Patient Readiness Grid

SIP2 Problem Statements RPI 5S SIP2 JDI

Emergent/transplant impact on schedule X    

Incomplete Patient Orders X    

Surgeon "in house" requirement = delays     X

Concentration of case prep between 06:00 & 07:15 X    

Incomplete documentation X    

Patient not ready for surgery X    

Wrong case cart X    

Late starts due to anesthesia resident availability X    

Transport delays X    

Duplication of documentation     X

Timing of teaching X    

Patient in Pavilion Pre-OP till HA Pick-up

04:30

Pre-Op ChrgArrives

Pt. Admitted to PACU Till HA Pick-up

Print 6 OR Schedules Pre-Op Log in

Sheet PACU Log

05:00 06:00 6:30

Compares/ChecksNew OR Schedule

to Board

Assigns patientRooms for All 1st

Cases

Special NeedsPatients Arrive

PSR AdmitsPatients

LS/AM PacketsArrive

Sign Valuables Privacy Consent Directory

Call Admitting

Yes

No

Chg RN BringsPatient Back

Records Time &Own name on

Board & AnesthSheet

Admit Packet toFront Desk Pre-Op

Rack

Checks BloodStatus

RN Gets YellowPacket

Review SuppliesTEDsSCD’s

Get Antibiotic/Pyxis

Greet Patient20 questions

VSPre-Op Hold RNRequests Pickip

Enters Info CIS

Diabetic PatientsGet IV’s

MA’s Blood Draw EKG Chem Stick

Main HA Roll Call Check in-Gale Order of Patients

Lead HA WritesHA Schedule/

Roles on Pre-OpBoard

6 RN’s Present 16-20 Patients

Check StretchersCheck O2

Blankets/Pillow

Surgeon In/OutHunt for Various

Equipment/Charts

HA to PavilionChecks Board

for who isReady

Greets PatientChecks Signature

Blue CardID Band

Belongings

Drop Off Family atWR

Explain Volunteer& Breakfast

Take Patient toHolding

Preassigned Spot

Goodbye, CheckOther NeedsBelongings

Pre-Op Hold RNVisual Arrival

OR Paperwork isStamped

Patient in Holding Flow

Clean up pre-op

Patient in Holding

Re-arrange“license plates” -

prioritize bysurgeon

Call for Report

Get HA’s/Transporters out

the door

Patients Arrive inHolding

VS H&P ConsentSite

Marked

Anesthesia

Room Set Up Drugs Monitors Machines

See PatientID/ConsentH&P Risks

IVMonitors, Lines,

Blocks

Recheck RoomWait-site check

RN ExaminesPatient

Attending in HouseResident in Room?

Yes

Take patient toRoom

No

Wait

Patient in ORTimeline

06:45 07:05 07:30

AnesthesiaRN ‘s

Check Case

Cart/List

Pick Extras

Open Room

Circulator goesto Pre-Op Hold

Look for CaseCart

Talks toPatient

Consent Check

Allergies IV Meds, Rx Count Check SCD’s/

TED’s

ConsentOK?

Call Attending

NO

RN Calls for Patientfrom Holding

Inform AnesthesiaProvider

Anesthetist getsPatient

- Permission - OR Bed

Set Up Transport

SurgeonArrives

Induction

Intubation Foley Lines Positioning

PrepDrape

Dress SurgeonHuddle

Incision

Tour Guide(s):

Gale Ullenkodt, Abdul Ramzan, Kevin Smith

Date:

March 16th, 2005

Process Name:

SIP 2: Patient to Pre-Op Holding

Total Process Time:

65 minutes

Step

# Step Description

Person(s)

Responsible Inspection

Steps Value Added Time

# in Que Feet Traveled

Opportunities for Improvement

1

HA checks/marks board, picks up schedule, checks pt. info, blanket warmer

HA

4

0 min

11

246

2

Walk to Pavilion

HA 0

0 min

N/A

526

3

Mark Pavilion board, talk w Pt., Check chart/ID, Adjust bed, secure belongings

HA

2

5 min

N/A

15

4

Walk back to Main Pre-OP, Talk w/family

HA

0

2 min

N/A

526

Information for families

5

Enter Pre-Op Holding, intro RN, move name tag to stretcher

HA

0

1 min

N/A

60

6

RN collects data from patient using procedure checklist

RN

0

0 min

10

0

Duplication of Pavilion check-in process

7

Anesthesiology Resident talks with patient/starts IV

MD Resident

0

5 min

1

25

8

Obtain pharmaceuticals

RN

0

0 min

1

60

Pharmacy window pick-up process

9

Surgical site marking

Surgical resident

1

1 min

0

N/A

10

Page Surgical Attending

RN

0

0 min

N/A

15

Paging process

11

Anesthesiology Attending meets with patient

Anesthesiology Attending

0

5 min

0

N/A

Anesthesiologist 10 minutes late

12

Patient to OR

Anesthesiologist

N/A

0 min

N/A

35

TOTALS

12

7

19 min

11

1508

Process Walk-Patient in Holding

Tour Guide(s):

Kevin Smith Date:

March 16th, 2005

Process Name:

SIP 2: Patient in OR till Incision

Total Process Time:

18 minutes

Step

# Step Description

Person(s)

Responsible Inspection

Steps Value Added Time

# in Que Feet Traveled

Opportunities for Improvement

1

Patient enters OR

Anesthesiologist

0

0 min

N/A

45

2

Patient moved to table

RN, MD’s, HA

0

1min

N/A

N/A

3

Prep and drape

Surgeon & RN

1

5 min

N/A

N/A

4

Induction

Anesthesiologist

0

5 min

N/A

N/A

5

Huddle

Surgical Team

3

30 sec

N/A

N/A

6

Fluoro positioning

Surgeon

2

1 min

N/A

10

7

Incision

Surgeon

0

0 min

N/A

N/A

TOTALS 7

6

12.5 min

11

1508

Process Walk - Patient in OR

SummarySummary Agreement on definitions of times essential.Agreement on definitions of times essential. Billing times do not necessarily indicate work times (ie. Anesthesia start time Billing times do not necessarily indicate work times (ie. Anesthesia start time

based on billing time, not actual time)based on billing time, not actual time) Data indicates consistency of late starts at all sites.Data indicates consistency of late starts at all sites. Greatest delay, and greatest “pain” in the Main OR.Greatest delay, and greatest “pain” in the Main OR. Variation in time (SD) for the different sites, days of week, and overall steps Variation in time (SD) for the different sites, days of week, and overall steps

in the process: Check-in to Anest start, Anest start to In-room, In-room to in the process: Check-in to Anest start, Anest start to In-room, In-room to Anest ready, and Anest ready to Incision - are relatively uniform and small, Anest ready, and Anest ready to Incision - are relatively uniform and small, (15-20 min)(15-20 min)

Delay and variation analysis byDelay and variation analysis by– Service (Service (– Type of procedure (delay for craniotomy, spine, gastric bypass are Type of procedure (delay for craniotomy, spine, gastric bypass are

outliers)outliers)shows some services and types of patients have greater variation and delayshows some services and types of patients have greater variation and delay

1/2 to 2/3 of time is spent between patient arrival and Anesthesia start. 1/2 to 2/3 of time is spent between patient arrival and Anesthesia start. Mismatch between Mismatch between Preanesthesia Clinic criteriaPreanesthesia Clinic criteria for pt. arrival (based on for pt. arrival (based on

complexity of patient and amount of preop preparation) and complexity of patient and amount of preop preparation) and Main OR Main OR Transport criteriaTransport criteria to the Main OR Preanesthesia area (Gale’s area). to the Main OR Preanesthesia area (Gale’s area).

Mismatch between anesthesia staff arrival time and expectations for Mismatch between anesthesia staff arrival time and expectations for anesthesia start time.anesthesia start time.

Anesthesia faculty over committed to start two rooms simultaneously.Anesthesia faculty over committed to start two rooms simultaneously.