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When the Rubber Misses the Road

OR Late Starts

The University of Tennessee Medical

center (UT Medical Center) is an accredited

tertiary care, surgical and academic

medical facility located in Knoxville,

Tennessee. The facility manages 494 beds

and maintains a reputation for providing

quality patient care. According to the U.S.

News and World Report website, UT

Medical Center received an overall patient

satisfaction score of 77 %, as compared to

state and national average scores of 68 %.

The center strives to deliver premier patient

care and is committed to educating its

employees in continuous improvement

methodologies.

Thomas Fields

Director Surgery / PeriOperative Services

The ability to adapt in our ever changing

healthcare environment requires a diverse

toolbox. Lean should be a key tool in every

OR. It provides the framework to engage

stakeholders to reduce waste and improve

the Healthcare experience.

In the fall of 2009, UT Medical Center faced

many challenges common in todays

medical centers. One of the key challenges

facing the centers OR department was

delivering consistent On Time Starts fordaily scheduled first surgeries. In the

hospital setting, especially vital in the OR,

starting surgeries on time is cr itical for

seamless patient flow: delays early in the

process cause further delays in the work

flow stream leading to cancelations,

potential overtime, patients waiting, etc.

With this challenge, the medical center

saw an opportunity to build a more robust

patient service delivery standard, which

led management to seek solutions that

were based on a Lean for healthcare

model. Building on previous Lean learnings

and desiring to leverage this experience,

the medical center forged a partnership

with the European Stryker Lean Team,

bringing a broad, global healthcare

perspective to the proposed Lean initiative.

Stryker is a publicly traded global medical

devices company which has been in

business since 1941.

Value Added Partnership

Lean has its beginnings in the automotive

industry, and is well established in

manufacturing circles. The foundation for

Lean derives from the Toyota Production

System, also known as TPM. The basis for

TPM focuses on creating and improving

processes based on value from the

customers perspective. Value is defined as

any activity in a process for which a

customer or patient is:

a) willing to pay;

b) changing the service provided to

the patient;

c) performed for the first time.

As an example, in most cases, a patient is

willing to pay for doctors advice and

guidance, but may be reluctant or unwilling

to pay for unnecessary testing due to

David Hall

Senior Vice President and Chief Operating Officer,

The University of Tennessee Medical Center

Healthcare organizations are challenged to provide high quality and safe care to

patients through reliable and ef fective processes. Nowhere is this more evident

than in the Operating Room (OR). Lean is a performance improvement methodology

that focuses on creating value from the customers perspective by eliminating

waste and reducing risk that comes with variability. Lean has been adopted in

our organization because it makes common sense and is facilitated by the people

actually doing the work. Our experience in the OR demonstrates how focused

individuals with creativity and the use of proven Lean techniques can make a

positive impact on efficiency.

Achievements

Reduced number of surgery start

delays by 38%

Additional OR revenue potential of

$461,000 by year end 2010

Improvements in Sterilization area for

first patients

Supplies reduced and adjusted to

reflect JIT supply management

Surgery delay reasons being tracked

and reported monthly

Improved work area efficiency in

Holding Room area

Registration patient readiness plan

enacted reducing delay lead time

Streamlined PAT (patient testing

center) process for first patients

Decreased patient flow times

Increased patient and staff

satisfaction

Shorter response and waiting times

Rhonda W. Barton

Director for Executive Education,

University of Tennessee

Partnering with UT Medical Center

was a natural fit for the UT Center

for Executive Education. Combining

the expertise of Dr. med. Hank Schiffers,

MD, MBA with lean practitioners has

created a program to improve patient

outcomes in an ever-changing

environment.

Authors: Wm. David Hall*, Dr. med. Hank Schiffers, MD, MBA**; Rhonda W. Barton*; Thomas Fields*; Vanita Glenn-Adams**;

Bert Hoffmann**; Tami Anderson*; John Bell, M.D.* * UT Medical Center, Knoxville TN; ** Stryker Corp.

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mismanagement or for extra administrative

paper work oftentimes needed to perform

a procedure. It is estimated that most

processes consist of greater than 85 %

non-value added activities. One of the

key objectives of Lean is to remove waste

from processes, decreasing non-value

added activities.

Tami Anderson

Director, Accreditation and Patient Safety

Senior leadership has been very

supportive of Lean at The University of

Tennessee Medical Center. This was

demonstrated visibly this year, through

their making completion of Lean projects

a goal for many of our vice presidents.

More than seventy of our staff and

physicians have undergone formal training

in Lean and we are reaching the point

where Lean thinking is evident in many

of our planning meetings, not just those

specifically designed around Lean.

In pursuit of service excellence, the

University of Tennessee Center for

Executive Education (UTCEE) and UT

Medical Center, in partnership with Stryker,

trained 12 people in a 2 Day Lean OR

Yellow Belt training course, which wasimmediately followed by a three day

Kaizen, a continuous Rapid Improvement

Event (RIE), where the focus was first

patient On Time Starts in the OR.

Currently UTs Center of Executive

Education includes Strykers Lean OR

course in their of ferings. Subsequently,

UT Medical Center worked in partnership

with Stryker to execute the 20 plus

process optimization solutions devised

during the Kaizen event. In the process of

uncovering solutions, the Stryker Team

used the (I) DATE-M model to execute

UTMC objectives.

Process Optimization Realized

While myriad solutions were devised, a few

key improvements rendered noticeable

results in the process. The first area of

focus was Patient Registration (PR). To

improve patient readiness PR underwent

changes to ensure that patients were

well informed and prepared before the

scheduled surgery date. To facilitate this

process, phone calls are being placed to

patients by a registrar employee to assist

the patient in pre surgery administration.

John Bell, MD

Professor, Department of Surgery

Director, Cancer Institute

The Lean process has been added to our

organization as an integrated tool which

helps us identify opportunities to improve

the service we provide to our patients,families and employees. It is a welcome

addition to assisting us in performing our

mission to the community.

Reduction in Late Starts

60

70

80

90

100

40

50

30

2009 2010

100

62

Index

The (I) DATE-M Process cycle

(I) Identify: Strategic need for change & goals (becomes a yearly activity on corporate

level as you start continuous improvement).

D Define: High level project definition, gateway and resource planning, establish

baseline measurements & Lean performance indicators, identify process

team

A Audit: Current state, data collection, high level Value Stream Map (VSM), identify

bottlenecks

T Train: Identify required knowledge and train the team, brainstorm & prioritize

improvement ideas

E Execute: Micro-Level VSM at bottleneck, define improvements, build necessarymaterials, test it, launch it

M Monitor: Measure results continuously, control process stability

The Structure for all Lean for Healthcare Projects

Increased Start Time Accuracy

Density

0.04

0.03

0.02

0.01

0.00-500 -25 0 25 50 75 100

Mean StDev N8.280 29.89 23910.22 19.84 2737.383 18.19 2306.954 9.314 196

MonthNov 2009Dez 2009Jan 2010Feb 2010

Increased Revenue

2009 2010

Index

100

125

150

175

200

50

75

25

+461,000

(Copyright Dr. med. Hank Schiffers, 2009)

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Another improvement solution centered on

employee scheduling. To provide greater

patient readiness, a 15 minute staggered

shift change was enacted. With the staff

starting at 6:45 instead of 7:00, more time

was available in ensuring rooms were

available and ready for the first patients.

This change is balancing the workload and

decreasing lead and wait times. In this

example, lead time is defined as the total

time measured starting at patient arrival in

registration to Roll-in.

In the Holding Room (HR) a 5+S was

executed with the objective of obtaining

better supply management and patient

flow. Supply usage was reviewed and

adjusted based on actual or Just in Time

(JIT) usage. Supply carts were fashioned

to only hold supplies needed for specific

procedures and to emphasize a placefor everything and everything in its place,

a key directive for a 5+S initiative.

Kimberly Fain

Staff Nurse, O.R.

My experience with Lean Healthcare has

added a sense of empowerment to my

ability to impact my work environment as

a healthcare professional. Being involved

in Kaizen projects has enlightened me to

how small changes implemented by the

employees that are doing the job can have

big effects on the entire system and

improve patient care.

Additionally, OR physicians are playing a

significant role in the continuous

improvement initiative. Requested by the

physicians a reporting structure was

created to track the number of patient OR

delays per individual physician. Currently,

UT Medical Center physicians use thissystem as a learning opportunity which

influences the management how first

patient slots are managed. This information

is reported to the OR committee on a

monthly basis and is posted for viewing,

creating more transparency in the process.

Measurable Results

As validated by UT Medical Center, notable

improvements resulted from the execution

of the solutions. Due to the time savings

captured from November through February

2010, the medical center has the potential

to earn an additional $ 461,000 in revenue

projected through year end. The number

of physicians hitting the threshold of 70 %

accuracy in On Time Start doubled from

17 to 34. 56.7 % of physicians improved

or maintained their First Time Start

accuracy where as only 11.7 % reduced

it leading to a total improvement of 6 %

(StDev +/- 17 %) increased accuracy.

Overall the Standard Deviation of On Time

Start accuracy dropped from 29.89 to

9.314 resulting in a much more predictable

process outcome. Additionally the number

of delayed cases decreased by 21 %

from November through May. These

savings are further substantiated through

improvements in employee morale and

patient satisfaction.

On-going Challenges / Next Steps

Today, UT Medical Center is embarking on

a Lean for healthcare transformation, which

is evidenced in managements commitment

to Lean and the on-going continuousimprovement initiatives underway. Still,

challenges can impact Lean management

execution. As an example, gaining

employee buy-in can be difficult from the

on-set of a Lean journey. To prevent

Continous Improvement First time starts per surgeon

High Level Patient Process Flow

Outpatient General Surgery

Patientarrives

InformationDesk

PatientRegistration

SurgeryLounge

ChangingRoom

HoldingRoom

OperationRoom

100 %

90 %

80 %

70 %

60 %

50 %

40 %

30 %

20 %

10 %

0 %

Physicia

n1

...2

...3

...4

...5

...6

...7

...8

...9

...10

...11

...12

...12

...14

...15

...16

...17

...18

...19

...20

...21

...22

...23

...24

...25

...26

...27

...28

...29

...30

...31

...32

Quota in %

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gridlock early in the process, UT Medical

Center encouraged strong employee

participation and weekly live online

coaching sessions with Stryker resulting

in solid buy-in from the employee base.

H. Sperry Nelson, MD

Professor, Department of Surgery

I learned a considerable amount through

this opportunity. Lean provides a process

where all team members can work together

to solve a problem.

Sustaining achieved results is another

challenge. UT Medical Center is currently

employing methodologies such as

dashboard management which displays

Lean KPIs and daily Lean briefings. These

are examples of strategies being employed

to help drive the Lean transformation at

the medical center.

Building on the Lean success thus far

achieved in the OR area, UT Medical

Center is looking to leverage this success

and focus attention on patient readiness

to gain even greater results. Additionally,

other areas in the medical center are

meeting to discuss potential Leanopportunities now and in the future.

Learned tremendous amount in short time

I am very excited to start the process in my department

Very good training program, enjoyed the OR simulation program

We hope to have everyone on Lean thinking

Feels crazy at first then comes full circle

The simulation was incredible

Entire Lean team was excellent! In 2 days I feel blessed to have met,

been taught, by the Lean team If you need an American coworker-call me

Very valuable in that we are required to apply in our home setting and not

just another training session that will be forgotten

Idea to starting small is appealing

Lean OR participants quotes*

Quota 1st Time Start

Quota 1st Time Start - Monday vs Friday

50 %

40 %

30 %

20 %

10 %

0 %

-10 %

-20 %

-30 %

-40 %

...33

...34

...35

...36

...37

...38

...39

...40

...41

...42

...43

...44

...45

...46

...47

...48

...49

...50

...51

...52

...53

...54

...55

...56

...57

...58

...59

...60

76 %

74 %

72 %

70 %

68 %

66 %

64 %

62 %60 %

58 %

85 %

80 %

75 %

70 %

65 %

60 %

55 %

50 %

45 %

40 %

12/2009 01/2010 02/2010 03/2010 04/2010 05/2010

12/2009 01/2010 02/2010 03/2010 04/2010 05/2010

65.7 63.5 71.3 74.3 71.3 71.5

55.

6

80.

2

48.

5

71.1

68.

7

68.1

65.

9

78.

0

72.

2

78.

7

75.

3

74.1

Quota Monday

Quota Friday

Quota 1st Time Start

Change +- in %

*Stryker Lean OR Training, CEE University of Tennessee, December 2009

Over time performance

improvement hittingon time 1st Time Start.

Comparison of abilityin hitting 1st Time StartMonday vs. Fridayover time

Quota: % hitting on time First Time Start by physician, December 2009Quota: % change in hitting First Time Start by physician, May 2010

Average on time First Time Start, December 2009

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HCS-CSU-001Artikel-Nr.: HCS-CSU-001Stand: August 2010