APOM Grand Rounds
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Transcript of APOM Grand Rounds
APOM Grand Rounds
OPExSOR Value StreamKaizen Event: In Room to Anesthesia ReadyDr. Michael Aziz
What is OPEx?
• OHSU Performance Excellence System (OPEx)
– An approach to drive rapid performance improvement using a common vocabulary, tools and methods
– Grounded in “lean manufacturing” techniques initially developed by Toyota, since used in many industries including healthcare
– Evolution of performance improvement efforts put in place for clinical enterprise, but potentially deployable across OHSU
OPEx Overview
• OPEx is the collection of Methods, Management and Mindset that help OHSU Healthcare achieve its goals in a systematic way
• Based on Lean principles that maximize value for patients through Continuous Improvement and Respect for People
OPEx core elements
• Methods are the most discussed, but least important part of improvement efforts
• Management system structures strategy deployment, operationalizes use of methods
• Mindset is the most challenging, but most important element; requires long-term effort
Lean Healthcare Principles
Level Load the Work
Standard Work
Continuous Flow:Pull vs. Push
Patients and Families First
“Just In Time”
Right service in the right amount at the right time in the right place
Eliminate batches
Rapid Changeover
“Built In Quality”
Make problems visible
Never let a defectpass along to the next step
Error Proof
Stop whenthere is a
quality problem5S and Visual
ControlRespect and Engage Everyone in Waste Reduction
Lean is Customer Focused Strategythat Improves Quality, Cost, and Response Time by Removing
Waste
• The “relentless pursuit of waste” as competitive leverage
• Uses the least amount of resources to create the greatest possible value for the customer, makes value flow
• A culture of respect and never-ending improvement at all organization levels
Waste Definition
Transportation Unnecessary movement of materials or supplies
Inventory Supplies, equipment, or information not needed by the customer now
Motion Unnecessary movement of people
Waiting Delays in the value stream (absence of flow)
Over processing Work that creates no value
Overproduction Producing more than customer needs right now
Defects/Poor Quality
Product or service that does not conform to customer requirements
Definitions of Waste
The Importance of Standards
• Provide a common understanding of the process – the right way to do the work
• Improve predictability of results• Make abnormal vs. normal clear• Enhance problem solving
5S for Workplace Organization
Separate the needed from unneeded items
Create a place for everything and a way to keep everything in its place
Create visual controls and indicators to easily determine normal and abnormal conditions
Document methods and procedures to maintain the system consistently
Ensure disciplined adherence to standard work to prevent backsliding
Simplify
Standardize
Sort
Sweep
Sustain
South Operating Room Patient
Value Stream
Standard Work and Daily Management Systems (DMS)Tray
replenish.
Properly prepared patient 1.0
PMC capacity
Inventory Management
Properly Prepared Patient(patient is ready for surgery and OHSU is ready for the patient)
Surgical Patient Flow & Experience
O.R. Turnover
Time
Procedurecard
Recovery duration
Properly prepared patient 2.0
Information to patient & family
Work place organization
On-time 1st case
start
Imp
rove
men
t E
ven
ts
(Kai
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) -
com
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Intra-op documentatio
n
futu
re In Room to Anesth
Ready
Proc Start to
Proc End
Level loading
across the week
Level loading
within the day
Proc End to Room
ExitConsolidate
instrum.
Anesth Ready to Proc Start
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'13
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Feb
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Patient Experience: Information to Family(50th Percentile Target) – based on date survey returned
Monthly %ile Quarterly %ile Target Mean Score
%il
e v
s.
All
Pre
ss
Ga
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y
• Standard information– Epic/MyChart– E-mail– Website– Handout
• Confirmation Call– Align surgical practice, OR scheduling
• Standard letters– Practices have same elements
• Visual way finding• Training to appropriate staff
– ICARE– Unit-specific signature moments
Patient
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'12
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12
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'13
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Sep Oct
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Feb
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May Jun30%
40%50%60%70%80%90%
100%
First Case Start - On Time % (7:30 in the OR, 8:30 on Mondays)
Monthly % Target
% o
n-t
ime
• Standard Work for First Case Starts: Patients, 6A Staff, SOR RNs Anesthesia, and Surgeons
• Consistently monitor and countermeasure
Highlights:• Daily Huddles leading to interdisciplinary
communication and collaboration• Daily Management Systems trending and
addressing abnormalities• Focus on evaluating standard work and
workarounds
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O.R. Turnover Time (from patient out to next patient in)Average Median Target
Min
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• Standard work for eight different roles
• Initial improvement, sustained
• Larger barriers had specific work to:
– Address gaps in schedule
– Signaling for the next patient
• Next steps to address “longer” delays
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Surgical Care Improvement Project (SCIP) Composite Score
Monthly % Compliance Quarterly %Compliance Target
% C
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(% o
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car
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f th
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easu
res)
Executive Summary
• Performance Transformation– SCIP– Patient Experience
• System to improve further– Efficiency improvement
• Turnover time• First case starts• 5S of O.R, cores, and workrooms• Preparation of and for patients• Pre-operative Medicine Clinic capacity
– Outpatient mix in SOR• No events focused on this yet
• Next improvements– Intra-op times (all segments from patient
entering the room until patient leaving the room)
– Level loading the OR• System-wide support and effects (hospital
loading, outpatient clinic schedules)
• Mindset Transformation– Events have engaged
• Surgery practices, Scheduling, PMC, SPD, Pre-Op, OR personnel, Logistics
• Events pull in new staff and managers
– DMS is throughout Periop• “Deeper” problem solving and
escalation may need further improvement
• Primary metric is, “How many of our patients weren’t clinically prepared and how many of our patients were we not ready for today?”
– The pace and capacity for change is growing
Kaizen Event: In Room to Anesthesia Ready
Anesthesia Ready
• Anesthesia Ready occurs when the patient is anesthetized and stabilized for the team to proceed to positioning, prepping and incision.
• Some anesthesia procedures may be completed after anesthesia ready based on the patient condition and requirements of the case.
Breakthrough Kaizen Charter: In Room until Anesthesia ReadyProblem Statement: The time between a patient entering the Operating Room until the procedure starts has high variation in workflow and timing. This portion of the value stream can be broken up into two segments, “in room to anesthesia ready” and “anesthesia ready to procedure start”. The former segment includes the time after the patient enters the room until the anesthesia provider’s activity is sufficiently complete so that the case may progress towards procedure start. Variation in practice contributes to increased OR costs, patient safety risk, and unpredictable case duration (in room to out of room). This contributes to poor scheduling accuracy, delayed cases, and dissatisfaction of patients and personnel.
Goal/Target: • Reduce the mean time from In Room to Anesthesia Ready in OpTime from 23.3 minutes to 18.3 minutes. (This number should be adjusted based on the percentage of complicated cases as compared to more straight forward cases; the more longer cases, the more opportunity.)• Reduce the range of the 10th (9 min) and 90th (45 min) percentile from 36 min. to 30 min. 10 th percentile to 8 min. and 90th percentile to 38 min.• Reduce the range of the 25th (13 min) and 75th (29 min) percentile from 16 min . to 13min. 25 th percentile to TBD and 75th percentile to TBD.• All changes will promote efficiency and safety from along the time line of turnover through procedure start:
• first case start (80%)• turnover time (44 minutes)• anesthesia ready to procedure start (27.6 minutes)• Total time (Turnover + In Room to Anesthesia Ready + Anesthesia Ready to Procedure Start) = 44+23.3+27.6 = 95 min
Objectives: • Break down the elements from In Room to Anesthesia Ready• Implement standard work for all roles involved between “In Room” until “Anesthesia Ready” .
• Standard work to include who, what their responsibility is, and when it should occur.• Include standard work for different situations (split rooms, first cases, second cases, vascular access/monitoring, etc.)
• Remove waste in the process (provide specifics during the event; e.g. reduce motion related to ______)• Maintain or improve patient safety(CLABSI rates, line placement compliance, adhering to checklist utilization, patient transfer to OR table)• Provide the above data by individual and service factoring in important characteristics such as: invasive monitoring/access, anesthetic type, patient BMI and patient ICU status (+/- mechanical ventilation).*• Accommodate appropriate training in the context of safety and efficiency.• Used improved communication between anesthesia and surgery to optimize decision on invasive line placement.In Scope
• From doc of “in room” (circ) to “anesthesia ready” (anes . provider)
• SOR cases
• All days, all times (limited)• Emergent cases (limited)• GI cases• ICU patients
Out of Scope • “Anesthesia Ready” to
“Proc Start”• Pediatric cases staffed by
DCH (under 12 yrs. Age)• Other OR sites• Labor and delivery
Improvement Team
Project Sponsor: Jeff KirschManagement Guidance Team: EMG, Core TeamProcess Owner*: Steve Robinson; Mike AzizFacilitators: Randy O’Donnell, Rayna Tuski, Grace Ullum, Shauna Hoffman
Resource Representatives
Key Dates:Assessment: 05/28 Planning: 06/16-06/17 Go/No Go: 06/17 Event Date: 07/21-07/25Follow Up Day/Time: 30-day________________ 60-day_________________ 90-day__________________
Admin Support, Measurement Specialist, Financial Analyst• Mac Eggling
Key StakeholdersMark Zornow, Bob Cross, Jeff Koh, David Larsen
Sponsors and Process Owners are MGT members
* = Implementation Coaches
• Anesthesia Staff: Aziz, Robinson
• Anesthesia Resident: Ross Martini
• CRNA: Livingston, Snow• Anesthesia Tech: Jonny
Sands• SOR Circ.RN: Conley +
Choi • Surgical Resident: Jesse
Liu• Surgical PA: Paula
Wilson
• Blue Blake• Mary Munoz• SPD• 6A RN
• EVS: Winans Stojanovic• Neuro monitoring• Bob Hart• Ahmad Raslan
• Nate Seldon• Linda Knox• Joanne Girard
Standard times
Patients Min Total Weighted timeBase time without complexity 13,174 11 144,914 11
ICU 1,524 6 9,144 1
Difficult airway 1,317 3 3,952 0
Art 3,244 5 16,220 1
CVL 1,833 20 36,660 3
PA 122 7 854 0
Teaching 2,635 10 26,348 2
238,092 18.1
Average 18.1
Process sequence
STEPS Room
Rea
dy
Patie
nt in
Roo
m
Mov
e Pa
tient
to
OR
Tabl
e
Mon
itor a
pplie
d
Pre-
Oxy
gena
tion
Indu
ction
of
Anes
thes
ia
Hem
odyn
amica
lly
Sta
blize
d
Anes
thes
ia
Read
y
Sub steps Adm
inis
teri
ng
med
s/ve
ntila
ting
patie
nt/s
ecur
ing
airw
ay
Peri
pher
al IV
Art
line
Cent
ral l
ine
Ideal low complexity 0 1 2 3 4 5 6 7 7Medium complexity 0 1 2 3 4 5 6 7 8 9 9High complexity 0 1 2 3 4 5 6 7 8 9 9ICU patient 0 1 2 3 4 5 6 7 7Minutes in step-Ideal low complexity patient 1 1 3 5 1 0 11 5
Minutes in step-Ideal medium complexity patient 1 1 3
8-positioning on ramp, utilizing glide
scope, bougie
3-anticipate more required interventions
after induction 3 24-34 8
Minutes in step-Ideal high complexity patient
2-pt. requires assistance
with moving or
repositioning 1 3
8-positioning on ramp, utilizing glide
scope, bougie
3-anticipate more required interventions
after induction 3 5 15 40 10
Training time for each
complexity type
Addi
tiona
l line
s
5 (Aline) or 15 (Cline)
Low complexity: pt. expected to not need more than one additional PIV and std. airway (only IV) Medium complexity: in addition to low complexity rqmts. also needs advanced airway mgmt (diffi cult) and/or one invasive monitoring line (A line or C line) High complexity: unstable pt. that requires close hemodynamic monitoring and multiple additional lines (all lines) In south OR, what percentage of training happens in each case?
Waste During IR to AR
Room Equipment& Supplies
Surgeon
Nurses
Anesthesia
Pt Movement*Questions about Position, no surgeon
* Transferring Pt back & Forth
* Right suture- needs during Anes
* Low assistance from team
Team Synergy
* Low lateral processing
* Motion, Leaving Rm for supplies
*Surgeon leaving
* Positioning Equip*Ask for appropriate ABX*Untangling Cord , gowns, & lines
*Improper location of Anes equip.
* Team not hearing “Anes ready”* Anes Tech traveled to get ABX
* Working on other pts, not in room
* Reclipping, shaving site
•Review Implants & supplies in room
* Repositioning * Missing Items from Case Cart
* Delay in Prep
* Unsure how to position, drape
* Positioning Communication w/ surgery services * Unsure If Ok to start w/out Attend
* Unsupervised Broc
* Extra Time for IV setup
* Waiting for Anes. Attending
* Reworked supplies
* Anes Tech , wait 12 min for A line
* Reposition Bed *Microscope Not working
* Not knowing surgical plan
*Reaching for Carts, supplies
*2 Circulators perhaps wasteful
* Surgeon Resident 20 min late* Order of Operations for line placement
* Attending moving lights after positioning *Surgeon Needs: Epidural?* Waiting for surgeon to cut
*Residents booking cases they don’t understand
Projects
1. Huddle Go-Live2. Pre-Op and Nursing standards3. Standard Work for patient flow for all roles4. Surgeon Standards5. Anesthesia Standards and Anesthesia
Workspace
1. Huddle Go-Live
Post Improvement Benefits: The team huddle will improve communication between the surgical team, anesthesia team and staff with regard to critical needs in order to prepare the next patient for surgery.
Issue Description: Variation in practice contributes to increase OR cost, patient safety risk and unpredictable case duration.
Time Estimator Tool
Time Estimator Assistant
In room to ETT Artline CVL PA IV
Standard 7-10 5 15 5 3
Learner +3-5 +3-5 +5-10
Difficult +3-5 +5-10 +5-15 +5-15
Fiberoptic +10-15
BMI>35 +5
subtotals Total
•For use to help more accurately estimate time from entering the room to anesthesia ready•If an activity is after AR, assume 0 for purposes of estimating AR•This is just a tool.
2. Pre-Op
Issue Description: Currently, there is an unreliable method of communication to assess status of previous OR case and determine precise time of patient rollout.
Post Improvement Benefits: This change in standards and expectations will improve communication between OR Nursing staff and Pre-Operative Nursing staff to potentiate patient preparedness for the OR and improve patient satisfaction.
6A
OR
Patient
3. Anesthesia Set-up
Issue Description: Lack of standard set-up contributes to less preparedness and more time spent gathering items post induction pre-anesthesia ready.
Post Improvement Benefits: This standard will decrease motion and time, and provide consistent expectations for quality of patient care.
4. Standard patient workflow
Team approach to continuous patient flow towards Anesthesia Ready (DRAFT - 07-23-2014)time (minutes) -1 0 1 3 4 7
PatientPre setup (prior to patient enter)
Anesthesia start
Pt. enters room Onto table MonitorsO2; consider at time of monitor placement
complete pre O2
Induction sequence
Airway management
Tube secured
CirculatorHolding warm blanket
case open in Epic (ready to click "in room")
click "pt in room" (this will send page to surgery team/attending & anesthesia attending; help open doors;
helpsSCD; helps with monitors; may count
at bedside, may be holding mask; may count,etc.
at bedside
helping
Scrub greets patienthelps if not scrubbed
May help or go get scrubbed
Anes res/ CRNA pushing bed helps
places monitors and advises others on best location of monitors
Place O2; may place while placing monitors; premeds prn
head of bed doingAirway management
Anes Attendingreceives "in room" page
helps if in room
helps if in room
arrives to room if not already present
Standard: in room at 5 minutes
Airway management; start IV; set up Art
Anes Support
Hot line, A-line, Central Line setup (PRN)
prep for A-line, open C-line kit (PRN)
Assist with airway (PRN)
Surgical resident/PAhelps; may move stretcher out
ready to go forward
Surgery attending receives page ? In room
GOAL: on table
GOAL: monitors and O2 on.
GOAL: tube
secured
Arterial line
• Be sure it is indicated• Is it needed:
– before induction– after induction– after incision
• Pre-order; cart set up• Prep as soon as feasible (even during induction)
– Attending– AT– Circulator/scrub (ask Rayna)
• Two tries then escalate– Attending– Ultrasound– Expert provider/alternate attending
• Consider abandoning the procedure and develop an alternate plan
Difficult Airways
• Proper equipment in the room• Call for additional help whenever needed• Two attempts then escalate
– Alternate techniques– Alternate provider
• Alternate airway, alternate plan, or abandon procedure
Standards in detail
1. Nursing standards SCD’s, Warm blankets, Hovermatt, and Slip Workflow Parallel activities Leads huddle
2. Surgeon Standards Attendance Automated page Parallel activities Previous case huddle prep
3. Anesthesia Standards Teaching Central line setup Andon escalation Automated paging with Vocera escalation Parallel activities
Implementation Plans
1. 6A• Further education for implementation of new standards/expectations to be
done by 30 day follow up
2. Anesthesia • Add to grand rounds • Email notification to staff from Steve and Mike
3. OR Nursing • Nursing standards at next service coordinator meeting• Following the service coordinator meeting, disseminate at 0655 service
coordinator huddles• Huddle go-live presentation at next service coordinator meeting,
disseminate at 0655 service coordinator huddles
4. Surgeon • Disseminate via email to surgeon chiefs and presented at the next available
surgeon chiefs meeting• Include in roadshow faculty meetings
5. Anesthesia techs• Attend staff meetings to verify new standard work and evaluate
abnormalities with anesthesia techs availability
Thank you!
Questions?