workshop chaired by David Brunt shown at the 1st Global Healthcare Summit on 25th June 2007

1. Lean Healthcare
Summit
Lean Healthcare
Summit
Lean Practice and Value Streams
Operating Theatre Utilisation
discussion workshop 26 June 2007
Carol Makin
Lean Practice and Value Streams
Operating Theatre Utilisation
discussion workshop 26 June 2007
Carol Makin

2. Overview of presentationOverview of presentation
• Practical approach with examples based on
Clatterbridge Hospital rapid improvement
workshop May 2006
• Defining our problem
• Understanding our patient’s journey
• Finding our green stream
• Lessons learnt
• Practical approach with examples based on
Clatterbridge Hospital rapid improvement
workshop May 2006
• Defining our problem
• Understanding our patient’s journey
• Finding our green stream
• Lessons learnt

4. AimAim
To improve the quality
of the patient’s journey
To improve the quality
of the patient’s journey

5. Consider ….Consider ….
Have you ever met a
surgeon who doesn’t
want to operate?
How often have you met
a surgeon frustrated
that he can’t get his
case to theatre?
Have you ever met a
surgeon who doesn’t
want to operate?
How often have you met
a surgeon frustrated
that he can’t get his
case to theatre?

6. Where is the problem?Where is the problem?
• Porters?
• Anaesthetists?
• Theatre staff?
• Surgeons?
• Management?
• Solution?
– More staff, more time,
more resources……..
• Porters?
• Anaesthetists?
• Theatre staff?
• Surgeons?
• Management?
• Solution?
– More staff, more time,
more resources……..

7. Value stream mapValue stream map
Get down to the shop floor and
walk the walk
Get down to the shop floor and
walk the walk

8. Understand sequence of eventsUnderstand sequence of events
• Referral & OPA
• Pre-op assessment
• Admission
• Theatre
• Recovery & return to ward
• Discharge
• Follow up
• Referral & OPA
• Pre-op assessment
• Admission
• Theatre
• Recovery & return to ward
• Discharge
• Follow up

9. The Glenday SieveThe Glenday Sieve
70%99%
50%95%
6%50%
% “task”
Range
% Cumulative
activity

10. Clatterbridge green streamClatterbridge green stream
• LA & GA cystoscopy 26%
• hip/knee replacement & ‘scopes 9%
• hernias & vvs 7%
• lumps & bumps 4%
• lower GI endoscopy 3%
• carpal tunnel 3%
4.2% of procedures account for 52% of throughput
• LA & GA cystoscopy 26%
• hip/knee replacement & ‘scopes 9%
• hernias & vvs 7%
• lumps & bumps 4%
• lower GI endoscopy 3%
• carpal tunnel 3%
4.2% of procedures account for 52% of throughput

11. Agree green list rulesAgree green list rules
• ‘Green’ or ‘green start’ lists printed on
green paper
• Identify start, break and finish times
• No changes to order of list
• 4 weeks notice of list cancellations
• Standardise equipment
• Daily co-ordinators meeting
• ‘Green’ or ‘green start’ lists printed on
green paper
• Identify start, break and finish times
• No changes to order of list
• 4 weeks notice of list cancellations
• Standardise equipment
• Daily co-ordinators meeting

12. Orthopaedic exampleOrthopaedic example
• Rules
– Tuesday all day list CGH
– 4 primary knee replacements
– 8.30 start in anaesthetic room, 17.00 finish
– breaks and lunch to be taken flexibly to allow
continuous working
– list co-ordinated by Mr Parkinson/Margaret Hill
x 4365
• Rules
– Tuesday all day list CGH
– 4 primary knee replacements
– 8.30 start in anaesthetic room, 17.00 finish
– breaks and lunch to be taken flexibly to allow
continuous working
– list co-ordinated by Mr Parkinson/Margaret Hill
x 4365

13. Co-ordinators meetingCo-ordinators meeting
• Identify issues disrupting flow through
theatre on previous working day
• Predict and aim to prevent issues which
might arise today
• Knowledge shared
• Identify issues disrupting flow through
theatre on previous working day
• Predict and aim to prevent issues which
might arise today
• Knowledge shared

14. Results in other areasResults in other areas
• Pre-op assessment streamlined
– ECGs and bloods done in department
– 29% increase in same day assessment
– orthopaedic pre-op review clinic transferred to ward
area
• Pre-op assessment streamlined
– ECGs and bloods done in department
– 29% increase in same day assessment
– orthopaedic pre-op review clinic transferred to ward
area

15. Day unit throughput increased by 33%Day unit throughput increased by 33%
0
50
100
150
200
250
300
350
400
450
500
2001-2 2002-3 2003-4 2004-5 2005-6 2006-7
anal fissure
haemorrhoidectomy
cholecystectomy
varicose veins
inguinal hernia
circumcision

16. Day unit changesDay unit changes
• Day unit throughput increased by 33%
– LAs separated from GAs
– beds replaced by trolleys
– in patient beds reduced
– national move to increase day cases
• Day unit throughput increased by 33%
– LAs separated from GAs
– beds replaced by trolleys
– in patient beds reduced
– national move to increase day cases

17. Ward changesWard changes
• In patient ward flip
– 28% reduction in bed base
– £147k yearly savings
• In patient ward flip
– 28% reduction in bed base
– £147k yearly savings

18. NigglesNiggles
59 issues identified as fixable
74% fixed 26% actioned
Need a mechanism to identify problems
No problems means problems
Problems lead to opportunities
59 issues identified as fixable
74% fixed 26% actioned
Need a mechanism to identify problems
No problems means problems
Problems lead to opportunities

19. ImpactImpact
• Improved performance and efficiencies
• Identifying and eliminating bottle necks
• Improved communication between teams
• Predictable scheduling and theatre lists
• Highlights capability and capacity opportunities
• Less firefighting, less confusion, less uncertainty
• Improved morale
• Do more with less
• Improved performance and efficiencies
• Identifying and eliminating bottle necks
• Improved communication between teams
• Predictable scheduling and theatre lists
• Highlights capability and capacity opportunities
• Less firefighting, less confusion, less uncertainty
• Improved morale
• Do more with less

20. Lessons learntLessons learnt
• Committed team to progress actions
• All day lists need all day staff
• New surgeons and new lists set up as green
• Prospectively measure theatre utilisation
and publish
• Work with early adopters, don’t waste time
on laggards
• Committed team to progress actions
• All day lists need all day staff
• New surgeons and new lists set up as green
• Prospectively measure theatre utilisation
and publish
• Work with early adopters, don’t waste time
on laggards

21. Future?Future?
• Every member of the team valued
• Annualised hours
• More flexible working
• Pooled waiting lists for common conditions
• Less inventory on shelves
• Niggles considered normal
• Continuous process - never finished
• Every member of the team valued
• Annualised hours
• More flexible working
• Pooled waiting lists for common conditions
• Less inventory on shelves
• Niggles considered normal
• Continuous process - never finished