Case Study Applying Lean And Six Sigma To The Surgical Services Process

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  • 1. Case Study: Applying Lean and Six Sigma to the Surgical Services Process A Successful, Sustainable Implementation must first understand Jim Pearson James@JOPconsulting.com the culture of change and the Goals of the Organization. Revision 4Copyright © 2011 JOP Consulting
  • 2. Agenda Improving Revenue and Reducing Costs The Problem Analyzing the Process The Implementation Plan Was the Implementation Successful? The Impact of Process Improvement on your Clinical Staff How your Measurement Systems can Negatively impact change What Actions are Necessary to Assure Success?Copyright © 2011 JOP Consulting 2
  • 3. The Problems The Goals Efficiency in the OR was not Improve Operational EFFICIENCY acceptable Improve the FINANCIALS for Turn Around Times were ‘Everyone’ Excessive Enhance Surgeon PRODUCTIVITY Financial Pressure to Reduce Staff Cost Improve Patient LOYALTY Implement SUSTAINABLE SolutionsCopyright © 2011 JOP Consulting 3
  • 4. Surgical Services Value Stream Functional Goals Currently Drive the Process Pre- Same Surgical OR PACU Discharge Day Admit Test * Sterile Processing Department (SPD) analysis part of ORCopyright © 2011 JOP Consulting 4
  • 5. Pre-Surgical Test Metric: Chart Prep • Owner: Surgeon/Hospital • Quantity (In, Out) of cases • Time (Ave, SD) • Completeness, ReworkMetric: Approval Rate• Owner: Surgeon• Quantity (In, Out) of cases• Case Type• Time (Ave, SD) per case• Revenue Potential Metric: SPD Prep • Owner: Hospital • Quantity of cases needing special instruments • Cost • Holding CostsCopyright © 2011 JOP Consulting • Labor 5
  • 6. Operating Room Metric: Arrival Rate • Owner: Hospital • Quantity (In, Out) • Case Type • Scheduled/Unscheduled Ratio • Time (Ave, SD) per case Metric: Turn Around Time • Owner: Hospital • Case Type • Surgeon • OR Room • Time (Ave, SD) per caseCopyright © 2011 JOP Consulting 6
  • 7. Understanding TAT* Patient In Room Patient Out Close of Incision Incision Procedure Duration Anesthesia Anesthesia Induction Emergent Case Duration * Turn Around TimeCopyright © 2011 JOP Consulting 7
  • 8. A More Realistic View of OR TAT Anesthesia Prep, (Interview Patient), Plan of Care Initiated in Surgeon in Room SDS Close IncisionSURGEON Start Complete Transfer T Anesthesia Anesthesia Patient to i ANESTHESIA Induction Process PACU w/RN m e Clean Patient Position o Complete Charts Break Set up Down OR, OR, Prep u NURSING Enters OR Room Anesth Anesth Drape t RN Patient Chart Review in SDA RN transfers Patient to OR Patient #1 Leaves Room Patient #2 Enters Room TAT TAT ‘Actual Anesthesia Start - ‘Wheels Out – Wheels In’ Incision Start ’ Notes: - Block Sizes are relative TAT - SPD included in Analysis Actual vs. Scheduled Copyright © 2011 JOP Consulting 8
  • 9. Heat Map Showing Active OR Rooms Tuesday Hour of Day day date 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Tue 02-Feb 6 6 6 6 6 5 5 5 4 1 3 2 Tue 09-Feb 7 7 7 6 7 7 6 6 6 4 3 2 Tue 16-Feb 7 7 6 6 5 3 2 2 4 4 4 3 Tue 23-Feb 6 6 6 6 6 6 5 5 6 2 3 3 2 3 1 Tue 02-Mar 6 7 7 7 7 6 5 5 5 3 1 1 Tue 09-Mar 1 1 8 8 6 7 7 6 6 6 5 5 4 2 1 1 1 Tue 16-Mar 3 4 4 6 7 5 5 5 4 4 3 1 Tue 23-Mar 1 1 6 6 6 5 5 6 6 6 7 4 2 1 2 2 2 2 1 Tue 30-Mar 6 6 6 6 6 7 7 7 4 2 1 1 1 Tue 06-Apr 5 5 6 5 6 5 3 1 2 3 3 1 Tue 13-Apr 1 6 7 6 6 4 3 3 3 4 4 2 1 1 1 1 1 Tue 20-Apr 7 7 7 7 7 7 7 8 8 5 2 1 1 1 1 Tue 27-Apr 1 7 7 7 5 6 6 6 6 5 4 3 3 2 2 2 Avg/hr .2 .2 .0 .0 .0 .0 .0 5.8 6.3 6.2 6.0 6.2 5.6 5.1 5.0 4.8 3.5 2.8 1.7 .8 .7 .5 .3 .2 Heat Map • Darker Colors show more rooms in use. • Number indicates active cases.Copyright © 2011 JOP Consulting 9
  • 10. Actual Anesthesia Start Time – Incision Time By Specialty Notes: •Variation within a Specialty is less but can vary between plus and minus 9 to 14 minutes •A component of Variation is driven by Procedure type that is typically fixed •Ortho Variation is higher than General and Neurology. It is predictable and can be proactively managed to Surgeon (All) improve Block Schedule performance. Anesthesia Type (All) DAY Patient Type SURGERY class Elective General Neurology Orthopedics Anesthesiologist Name Count Average Std Dev Count Average Std Dev Count Average Std Dev 12 18 3 5 17 6 6 30 10 15 21 5 6 28 9 12 34 10 15 19 4 10 24 4 10 34 10 21 20 6 17 23 6 6 26 10 23 23 9 7 30 7 9 42 8 28 24 12 10 28 7 11 36 12 14 22 8 21 28 12 9 36 12 11 25 11 9 29 9 8 25 14 31 19 8 13 26 15 18 32 11 18 26 12 9 29 12 13 38 15 18 21 9 4 28 9 13 45 26 21 18 4 10 24 8 8 30 12 10 26 5 1 34 13 22 17 18 27 8 10 30 9 Grand Total 250 21 9 140 26 9 133 34 14Copyright © 2011 JOP Consulting 10
  • 11. Actual Anesthesia Start Time – Incision Time By Surgeon by Anesthesiologist Notes: •One Anesthesia Type – Gen. Endotracheal Tube Anesthesi •Variation from Procedure, ologist Name Data Setup, Prep Total Total Total Count of Average StdDev of incision of incision incision start - start - start - actual actual actual start time, start time, start time, MM (J) MM (J) MM (J) Count of Average of StdDev of Count of Average of StdDev of Count of Average of StdDev of Count of Average of StdDev of incision start incision start incision start incision start incision start incision start incision start incision start incision start incision start incision start incision start - actual start - actual start - actual start - actual start - actual start - actual start - actual start - actual start - actual start - actual start - actual start - actual start Surgeon Anesthesia Type time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) time, MM (J) General Endotracheal Tube 7 18.14 2.48 25 20.00 4.27 4 18.50 3.32 4 20.00 6.06 40 19.53 4.06 General LMA 3 17.67 2.89 3 20.00 1.00 3 20.67 5.03 9 19.44 3.24 General/Epidural Block 1 36.00 #DIV/0! 1 36.00 #DIV/0! MAC 1 32.00 #DIV/0! 1 32.00 #DIV/0! Spinal 1 14.00 #DIV/0! 1 14.00 #DIV/0! 11 19.64 5.90 29 20.41 4.55 4 18.50 3.32 8 19.50 5.29 52 19.96 4.80 General Endotracheal Tube 11 34.00 12.84 12 44.33 18.51 6 -41.33 186.15 5 34.60 11.17 34 24.44 80.04 General LMA 2 28.50 2.12 1 21.00 #DIV/0! 3 23.67 5.13 6 24.83 4.54 MAC 3 16.00 6.00 1 20.00 #DIV/0! 1 27.00 #DIV/0! 1 17.00 #DIV/0! 6 18.67 5.79 14 30.14 13.82 15 40.60 18.24 8 -25.00 160.22 9 29.00 10.83 46 23.74 68.61 Block 1 25.00 #DIV/0! 1 25.00 #DIV/0! General Endotracheal Tube 1 47.00 #DIV/0! 9 40.67 8.50 4 43.50 General LMA 1 40.00 #DIV/0! Anesthesia11 38.00 Anesthesia 2#DIV/0! 6.45 1 #DIV/0! 3 53.00 27.67 11.02 15 5 42.67 Anesthesia 3 32.20 7.87 9.98 Anesthesia 4 General/Femoral Blk/SciaticBlk 1 39.00 #DIV/0! 1 48.00 #DIV/0! 2 43.50 6.36 General/Femoral Block 3 46.33 5.69 1 60.00 #DIV/0! 4 49.75 8.26 General/Scalene Block Surgeon 1 7.07 2 42.00 5 Ave: 10.2118 min 74.50 50.20 2 Ave: 1 20 min 24.75 41.00 #DIV/0! 10 Ave: 16.42 52.50 18.5 min Ave: 20 min MAC 1 22.00 #DIV/0! 1 22.00 #DIV/0! Other, see notes Spinal 1 1 St Dev: 2.5 min 60.00 45.00 #DIV/0! #DIV/0! St Dev: 4.3 min 1 1 St 60.00 #DIV/0! min Dev:#DIV/0! 45.00 3.3 St Dev: 6.6 min 6 39.17 8.11 20 45.45 9.17 9 49.22 19.78 5 35.40 13.81 40 44.10 13.03 Grand Total 31 28.16 12.57 64 32.97 15.63 21 15.10 101.55 22 27.00 11.41 138 28.22 41.35 Surgeon 2 Ave: 34 min Ave: 44 min Ave: --- min Ave: 34.6 min St Dev: 12.8 min St Dev: 18 min St Dev: --- min St Dev: 11.1 min Surgeon 3 Ave: 47 min Ave: 40 min Ave: 43 min Ave: 53 min St. Dev : --- St. Dev : 8.5 min St. Dev : 6.5 St. Dev : --- Surgeon 1 – GastroCopyright © 2011 JOP Consulting Surgeon 2 – Cardio 11 Surgeon 3 - Ortho
  • 12. Actual Anesthesia Start Time – Incision Time By Physical Operating Room Surgeon (All) Notes: Anesthesia Type (All) •Why significant variation within each specialty OR? Patient Type DAY SURGERY •Why significant variation by Anesthesiologist? Count Average Std Dev Total Total TotalAnesthesiolo * Count Average StdDgist Name OR 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR11 OR 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR11 OR 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR11 A 4 1 7 1 1 10 8 3 3 21 23 13 37 24 21 17 23 36 3 5 6 3 5 11 38 21 8 B 6 8 5 2 9 9 5 23 25 14 27 32 21 31 4 11 7 12 10 9 10 44 25 10 C 1 8 4 6 3 7 9 4 3 27 22 24 20 33 22 23 29 28 4 9 5 21 7 8 13 5 45 24 9 D 1 13 10 9 5 3 9 5 2 13 21 23 44 21 27 18 26 29 5 7 79 6 4 3 10 4 57 25 31 E 5 7 4 4 1 1 21 3 6 25 31 27 36 20 25 20 34 45 2 14 3 7 6 5 6 52 27 11 F 10 2 9 2 1 20 3 8 23 22 33 33 31 21 35 36 6 0 14 0 11 7 14 55 27 12 G 1 2 22 5 3 7 8 7 21 26 23 25 35 21 27 41 1 10 9 12 13 6 16 55 26 12 H 2 10 5 5 3 3 3 3 30 27 27 27 20 19 27 32 0 12 11 11 12 4 9 19 34 26 11 I 3 15 6 6 4 6 14 4 10 31 19 22 20 33 31 21 32 35 22 7 10 9 22 12 10 12 12 68 25 12 J 2 6 12 16 2 1 4 4 10 26 24 27 25 27 49 24 40 37 0 12 13 10 15 2 10 16 57 29 13 K 1 11 4 1 2 1 5 5 8 21 19 26 18 32 34 26 48 44 4 6 7 14 32 24 38 31 20 L 4 16 21 14 1 4 3 4 28 19 20 26 29 16 25 35 26 6 6 10 3 8 16 67 22 10 M 5 1 5 26 34 25 1 8 11 26 6 N 3 7 8 5 6 1 7 8 2 37 27 23 26 30 35 15 31 26 36 22 5 10 10 2 9 11 47 26 14Grand Total 27 117 113 76 38 48 125 58 66 27 23 23 28 28 28 21 31 37 16 9 9 28 11 10 8 13 15 668 26 15 Copyright © 2011 JOP Consulting 12 * OR 4 Neurology Block Time, M-W-F
  • 13. Summary Was the Implementation successful? Use of Tools and Data Analysis Lean Six Sigma TrainingCopyright © 2011 JOP Consulting 13
  • 14. Summary What went wrong? Key Stakeholders Measurement System Market ShareCopyright © 2011 JOP Consulting 14
  • 15. Summary Lessons Learned Culture Measurement SystemCopyright © 2011 JOP Consulting 15
  • 16. Questions and More Information? Jim Pearson J.O.P. Consulting, Inc. www.JOPConsulting.com James@JOPConsulting.com 508-429-4823Copyright © 2011 JOP Consulting 16