The DMAIC (Define, Measure, Analyze, Improve, Control) problem solving meth- odology was used to improve the OR turnaround and start the OR cases on time.
Define Phase
The following steps were performed in the Define Phase:
1. Develop project charter 2. Perform stakeholder analysis 3. Identify critical to satisfaction (CTS) 4. Select team and launch the project 5. Create project plan.
Develop Project Charter
The executive team has identified an opportunity to improve the time it takes to clean and set up the OR between cases, as well as start the first cases in each room
Fig. 4.1 Provide surgical services value chain
107
on time in the morning. The corporate goal for turning the room around is 30 min- utes or less, however the average turnaround time in the OR is 40 minutes. The average time for starting cases on time is 23 minutes late.
Project Overview The OR turn around time is not meeting the deployed corpo- rate targets of an average 30 minutes turnaround time. Turnaround time is defined as time from wheels out of the patient from the prior surgery to wheels in of the patient for the next surgery. Our current average turn around time is 40 minutes.
Customer/Stakeholders The stakeholders for the project include the OR sur- geons, nurses, anaesthesiologists, anaesthesiologist technicians, sterilizer pro- cessing, OR liaisons, OR case scheduling, OR director, charge nurse, inventory control, patients (in and out patients), and families.
The CTS criteria of the stakeholders includes quick turnaround time of the OR, starting the OR cases on time, patient care and safety, patient satisfaction, physi- cian and staff satisfaction, and staff productivity.
The goals of the project are to reduce the OR turnaround time between cases while providing continued patient care and safety, to meet the average 30 minutes turnaround time.
The project includes the processes involved in cleaning the room after a case and preparing the room for the next case, and communication for making the turn- around happen. This time is the time from wheels out of the patient to wheels in of the following patient. The project also includes the activities related to starting cases on time in the morning for each OR.
We anticipate a reduction of time between cases, and a decrease in overtime due to cases not starting on time.
The project charter is shown in Fig. 4.2, Project Charter.
Fig. 4.2 OR turnaround and on time case starts project charter Define Phase
Perform Stakeholder Analysis
The primary stakeholders are the OR surgeons, and staff. The OR staff includes the nurses [including nurses, nurse managers (Circulator, Pre-op holding, Charge nurses, clinical coordinators)]. Other stakeholders are anaesthesiologists and anaesthesi- ologist techs who provide anaesthesiology care; sterile processing OR liaisons and sterilizer processors who are associates who provide communication between Sterile Processing and the OR and Sterilize Processors who sterilize OR instruments.
Patients and their families who have surgery in the OR are also primary stakeholders of the project. The primary stakeholder analysis is shown in Fig. 4.3.
There are several secondary stakeholders of the project. Inventory control man- ages OR materials and supplies. Ancillary services include the lab and radiology that provide diagnostics for surgery patients. Case scheduling schedules OR cases.
Physician offices schedule surgeries for their patients. Vendors provide medical devices, and perform diagnostic testing for OR patients. The last secondary stake- holder group is recovery who cares for the patients when they complete the surgi- cal case. The secondary stakeholders are shown in Fig. 4.4.
Suppliers-Inputs-Processes-Outputs-Customers
The Suppliers-Inputs-Processes-Outputs-Customers (SIPOC) for the case turna- round is shown in Fig. 4.5. There are five high-level process steps in the OR
Fig. 4.3 Primary stakeholders
109
turnaround process. When the case is about 10 minutes from being complete, the OR nurse calls to the front desk to notify them that the technicians should be available to start cleaning the room. When the case is complete and the bandages are on, the OR team moves the patient from the OR table to a bed. The patient is moved to recovery. The team cleans the room, removing trash, used instruments, and equipment after it is wiped down. The materials for the next case have already been staged outside the room, and were prepared the day before the case. Once the room is cleaned from the prior case, the scrub nurse and circulating nurse set up the room for the next case.
The SIPOC for the processes for starting the OR cases on time in the morn- ing is shown in Fig. 4.6. There are four high-level processes for starting a case on time in the morning. The focus for starting the cases on time in the morning for the first cases in each OR is important. If the first cases do not start on time in the morning, then the timeliness of the entire schedule is jeopardized for the entire day. The materials, equipment, and instruments are planned the prior day through the night shift based on the schedule for the surgical cases for the next day. The materials, equipment, and instruments are picked from the Core inven- tory room, that is stored within the center of the OR area. The OR team readies the room in the morning, ensuring that all of the supplies, equipment and instru- ments are available and set up in the room. If the patient and OR team are ready, the case starts on time.
Fig. 4.4 Secondary stakeholders Define Phase
Identify Critical to Satisfaction
The CTS criteria for this project are:
• Quick turnaround time of OR: This includes cleaning the room from the prior case to readying the room for the new case.
• On time case starts: This includes picking materials, equipment and instruments the day before for the case, and readying the room in the morning to start the first cases in each room on time.
Suppliers Inputs Process Outputs Customers
Medical staff Patient Materials control Ancillary services Case scheduling Vendors Physician offices
Materials, equipment, supplies,devices Patient Info OR Schedule Anesthesia,meds
Complete surgery case
Move patient to recovery
Clean room
Patient info/status Materials Call of completion
Physicians Associates Patient
Physicians Associates Patients
Patient Patient info/
status
Patient info/
status
Physicians Associates Patient Recovery
Prepare materials
Prepare room Associates
Materials Mgt.
Anesthesia Tech.
Correct
supplies Room Status Physicians
Associates Patient
Case scheduling Vendors Material control Associates
Case schedule Pick List
Equipment,etc. Associates Physician Patients Anesthesia Associates
Physicians Patients Anesthesia
Materials, equipment, supplies, devices OR Schedule Anesthesia, meds
OR Status Associates
Patients Physicians SIPOC Surgical Services – Turnaround Case
Fig. 4.5 Case turnaround SIPOC
111
• Patient care and safety: Ensuring and providing patient care and safety.
• Patient satisfaction: Ensuring the satisfaction of the patients.
• Associate satisfaction: Ensuring the satisfaction of the OR staff, balancing patient care, safety, and timeliness.
• Physician satisfaction: Ensuring the OR physicians’ satisfaction.
• Productivity: Ensuring appropriate use of personnel resources in the OR to man- age operating costs.
Select Team and Launch the Project
The team was formed, consisting of the OR Executive Director, the OR surgi- cal coordinators, inventory control, instrument sterile processing, Pre-op, Post- op, Chief of Anesthesia, Operational Excellence Master Black Belt, and Black Belts.
Suppliers Inputs Process Outputs Customers
Case scheduling Inventory control
Case preference cards
OR case schedule Prepare and plan
Pick materials
Ready case in morning
Needs for materials Needs for equipment Needs for instruments
Inventory control Sterile processing
Inventory control Sterile Processing
Printed preference cards
Materials Equipment Instruments Preference cards
OR Team
Start case (on time) OR Team
Diagnostics Pre-Op
Materials Equipment Instruments Preference cards Results/patient info.
Room Status Patient Status
OR Team Patient
OR team Patient
Patient info.
Room status
Room status OR Team
Admin
SIPOC Surgical Services – On Time Starts
Fig. 4.6 On time start SIPOC Define Phase
Create Project Plan
The project was started in October. The Define phase was completed by October 31. The Measure phase started in November and was completed on January 8 of the next year. The Analyze phase ended January 22nd. The Improve phase finished December 31st. The Control Phase was completed in April of year 3. The project milestones are shown in Fig. 4.7.
Rules of Engagement:
The following rules of engagement were embraced by the project team:
• Be present and be committed at the meetings
• Look at issues, not people; not to be defensive
• Be open to new ideas
• Think outside the box
• Help each other work together as a team
• Be respectful for people to finish their thoughts
• Focused structure: agendas, outcomes, parking lot issues
• Limit our time; keep our meetings to the time; finish meetings
• Fix the process, do not fix blame
• Everyone’s point of view is appreciated and important
• It’s your meeting and project, feel comfortable to contribute.
The rules of engagement are critical to ensure the smooth running of the team meetings, so that the team can stay on topic, and change management can begin.
Fig. 4.7 Project milestones
113
The Define phase is important in defining a clear project scope, identifying the project stakeholders, and planning for the rest of the project. The team moved next into the Measure phase.
Measure Phase
The Measure Phase included the following activities:
1. Define the current process
2. Define detailed voice of customer (VOC)
3. Define the voice of process (VOP) and current performance 4. Validate measurement system.
Define the Current Process
The first step was to map the current process by creating detailed process maps of the processes to turnaround the OR between surgical cases, shown in Fig. 4.8, and the processes for readying the rooms for on-time starts of cases in the morning, shown in Fig. 4.9.
OR Turnaround Process
PrepteamNurseAnesthesiologistSurgicalTeam Start
No
No
Yes Surgery ends Yes
(Bandage on)
Nurse and anesthesiologist go with patient to give report (anesthesia end
time)
Nurse calls recovery room
10 minutes before case finished
Tech is at door?
MOVE OUT (Scrub tech 1, tech 1) – remove instruments , linens, trash, wipe down flat surfaces , mop the floor, remake the bed , reline containers with bag for trash linen , anesthesia
tech cleans anest . Equipment, move equipment , readjust position
of bed
Nurse finishes paperwork and specimen
Nurse calls front desk for
moving help
Go to holding to see next
patient Recovery
room available ?
Anesthesia goes to holding area
to see next patient
Front desk calls other technicians (from different
zones ) Wait for
anesthesia to wear off, extubate
Move patient to recovery
room
Move In Picked case, clean linens , equipment
Hold Patient
Tech 1 moves in equipment
Scrub tech opens picked
case
Scrub tech scrubs, sets up
Inform front desk Missing
item? Major? Delay?
Go to holding to get patient
Wheels in (Turn around
time ends ) Yes
No
Yes No
Yes (Delay) Nurse goes to
check if picked case is correct
Review patient’s history Anesthesia obtains consent
Order premeds
Go to room and start setting up (count accountables )
Delay?
Delay? Delay?
No
End Yes
Fig. 4.8 Process map of OR turnaround Define Phase
We also filmed the turnarounds of the rooms, including the cleaning of the room, and the set up of the supplies and instruments by the OR team.
Data Collection Plan
To measure the CTS’ we developed the data collection plan shown in Figs. 4.10 and 4.11. We measured and baselined the time to turnaround the OR, as well as the time to start the first cases in each room for the day. We measured the delays to starting the cases on time for the first cases and turning the cases during the day. We assessed staff and physician satisfaction using surveys developed for this project. We used the existing productivity measures that assess the productive staff hours compared to the number of procedures performed.
We operationally defined each measure to ensure a consistent measurement system.
OR Turnaround Time
OR turnaround time is the time from when the patient is wheeled out after sur- gery is complete to when the next patient is wheeled into the OR. The purpose is to understand the time it takes to turnaround the OR from one case to the fol- lowing case within the same room, excluding surgeons who have two rooms. We extracted the data from the Operating Room Management system and calculated
On Time Starts for OR Cases
SurgicalTeamSterile ProcessingInventory ControlORScheduler
Schedule OR cases for next
day Start
Print preference cards for OR
schedule
Pick supplies and instruments
Missing items?
Highlight missing items on preference cards Yes
Sterilize instruments based on OR schedule
Move instruments to
OR core area
Stage items outside of OR
No
Prepare room in morning for first case
Room ready?
Start case , log time Patient
ready?
Delay
?
Delay
?
Yes Yes
No No
End
Fig. 4.9 Process map of on time starts of OR cases
115
the moving range of the difference between the actual start time of the next case minus the actual end time of the prior case, for the same room and same surgeon.
We removed values greater than 90 minutes as cases not intended or scheduled to follow directly after the prior case in the same room. We also removed cases with the same surgeon at the same time in different rooms since one of the rooms is purposely held for the specific surgeon to reduce surgeon downtime.
Fig. 4.10 Data collection plan, page 1
Critical to Satisfaction
(CTS)
Metric Data
Collection Mechanism
(survey, interview, focus group,
etc.)
Analysis mechanism
(statistics, statistical tests, etc.)
Sampling plan (sample size,
sample frequency)
Sampling instructions (who, where,
when, how)
Patient care and safety delays
Delays impacting turnaround time, patient care and safety
Purple sheet, and put into Excel spreadsheet
See Pareto chart: Largest delay is MD Late Associate
satisfaction Survey All staff for 2
weeks See results
Productivity Total productive minutes
Current standard 7.85 hours of staffing for 1 hour of surgery
YTD (1/22/10):
99.4%
Fig. 4.11 Data collection plan, page 2 Measure Phase
On Time Starts (of Cases)
The On Time Start measures the timeliness of the OR cases starting when sched- uled. The purpose is to assess the timeliness of the start of the OR cases based on their scheduled start times. For the first case for a surgeon, we measured the first case of a surgeon that started by either 7:30 or 8:00 a.m. start times. For surgeons with two rooms used sequentially, we removed those times since the range of time would appear as negative across the surgeon. We also measured the on time starts of all cases.
Delays Impacting Turnaround Time and On Time Starts of Cases
This measure assesses delays that impact starting cases on time, and turning around the room in a timely manner. The purpose is to understand the root causes of delays that impact turnaround time. The delays are currently recorded in the OR and entered into an Excel spreadsheet for tracking. We created a bar chart of the frequency by delay reason.
Associate Satisfaction
The associate satisfaction survey assesses the job satisfaction of the staff that works in the OR. The purpose is to understand the perception of staff satisfaction with their jobs.
This assesses whether the staff believes that they have the tools to do their jobs, whether management supports them and enables them and removes barriers to provide great patient care. We created a staff satisfaction survey that was distrib- uted to all OR staff, to measure a baseline. We analyzed the data through statistical Chi Square analysis by question, to determine whether the associates are satisfied with their jobs in the OR.
Productivity
The productivity metric measures total productive time of the staff in the OR. The pur- pose is to assess the efficiency of the staff that provides services in the OR. We used the existing productivity measures as a baseline for the fourth quarter of year one.
Define Detailed Voice of Customer
The voice of the customer surveys were used to assess patient, staff, and physi- cian's satisfaction with the OR processes.
117
All but one of the questions’ ratings was statistically significant. All but one of the questions were rated the highest percent of ratings in the 5-Strongly Agree cat- egory. The question, “5. My case started on time today.” Had 7 ratings of strongly disagree and agree, and five rated as strongly agree, with no ratings of disagree, and only one rating of neither agree nor disagree. This indicates that some of the cases start on time, while others do not.
The following questions all received a high percentage of strongly agree rat- ings: front desk communication; the turnaround time; patient safety; equipment and supplies available; people worked together; it bothers staff when cases do not start on time; patients were ready in holding. The ratings are shown in Fig. 4.12.
The results show overall fairly high satisfaction with the processes around OR case readiness and turnaround of rooms, as well as communication and manage- ment. The only area where there was a mix of responses was in “My case started on time today.” This supports the need for this project.
Define the Voice of Process and Current Performance
The Pareto Chart in Fig. 4.13 shows the percentage of cases by surgery procedure category. Orthopedic cases consist of 31 % of the cases in the OR, followed by general surgery cases consisting of 25 % of the cases.
The graphic in Fig. 4.14 illustrates the major activities and average timeline for the cardiac cases. There is an average of 21 minutes to clean and setup the room, and then another 23 minutes to set up anesthesia equipment for the surgery, before wheels in. There is an average 34 minutes of patient prep and anesthesia patient time before incision. The surgeries averaged 84 minutes, with a 10-minutes patient wake up after the close.
Question % Rating
Strongly Disagree
% Rating Somewhat Disagree
% Rating
Neutral % Rating Somewhat Agree
% Rating Strongly Agree
Chi-Square p-value / Significant
(Yes/No) 1. The front desk/management
team communicated effectively with me today regarding my cases/cases.
0 2 4 3 12 0.008
(Yes)
2. The turnaround time was appropriate for this procedure
2 1 2 3 12 0.000
(Yes) 3. Patient safety took precedence
over starting on time today.
0 0 1 3 17 0.000
(Yes) 4. I had the equipment and supplies
I needed to do my cases. 0 2 1 5 14 0.000
(Yes)
5. My case started on time today 7 0 1 7 5 .187
(Yes) 6. People worked together in the
department today to get the job done.
1 1 0 5 16 0.000
(Yes) 7. It bothers me when cases do not
get started on time. 0 0 2 4 14 0.002
(Yes) 8. My patients were ready in
holding today leaving me time to attend to room preparation
2 2 4 3 11 0.011
(Yes)
Fig. 4.12 Staff satisfaction survey Measure Phase
Turnaround Times
The baseline for the turnaround time is an average of 40 minutes with a standard deviation of 21 minutes. The histogram is shown in Fig. 4.15.
The average turnaround time by surgical procedure category is shown in Fig. 4.16. Neurology cases have the longest average turnaround time of 50 min- utes, followed by vascular cases with an average of 47 minutes. The lowest aver- age turnaround case types are ICD with 24 minutes, Ear nose throat (ENT) with 25 minutes, and Cardiac cases average 31 minutes.
The average case turnaround times also differed by surgeon. We stratified the average turnaround time for each surgeon.
On Time Starts
The on time start average time is minus 19 minutes, representing start times that are 19 minutes late, with a standard deviation of 22 minutes. The average on time start for those cases that start on time or early, averages 10 minutes, with a
Fig. 4.13 Pareto chart of surgical cases by procedure category
Fig. 4.14 OR cardiac process timeline