This document outlines a value stream analysis conducted at the Salisbury VA Medical Center from July 21-23, 2015 to improve surgical flow and efficiency. It identifies current metrics, issues, and proposed solutions. The aim is to increase surgeries per month from 290 to meet demand, increase Lag Time to 80% and FTS to 75%, and decrease wait times for select specialties. A series of projects and tests of change are proposed and assigned with target completion dates to address issues like scheduling, pre-op processes, surgeon coordination, and OR flow. Progress will be tracked through monthly meetings and metric updates.

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Surgical Flow Improvement Initiative (SFII)
Salisbury - W.G. (Bill) Hefner VA Medical Center
Value Stream Analysis (VSA) July 21-23 2015

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Name Title Email Phone
Thurmond Carter, MHA Surgery Admin Officer Thurmond.Carter@va.gov (704) 638-9000 x3285
Ellen Propst, RN Office of Performance and Quality Ellen.Propst@va.gov (704) 638-9000 x3704
Margaret Peeler, RN Office of Performance and Quality Margaret.Peeler@va.gov (704) 638-9000 x3713
Judith Pennington, RN OR Nurse Manager Judith.Pennington@va.gov (704) 638-9000 x2712
Kelly Swauger, RN Chief Nurse of Acute Care Kelly.Swauger@va.gov (704) 638-9000 x2796
Dr. Paul Lucha Chief of Surgical Services Paul.Lucha@va.gov (704) 638-9000 x3289
Barbara Wood, RN OR Barbara.Wood2@va.gov (704) 638-9000 x4126
Jessica Plyler, RN OR Jessica.Plyler@va.gov (704) 638-9000 x4125
Cheryl Bean, RN SPS Chief Cheryl.Bean@va.gov (704) 638-9000 x3235
Linda Brooks MSA / OR Scheduler Linda.Brooks@va.gov (704) 638-9000 x3207
Deborah Rybka, RN PACU Deborah.Rybka@va.gov (704) 638-9000 x4354
Dr. Helen Malone Surgeon, Gynecology Helen.Malone@va.gov (704) 638-9000 x3289
Bonnie Cauble Chief of Systems Redesign Bonnie.Cauble@va.gov (704) 638-9000 x3895
Karen Kneip, RN Systems Redesign Karen.Kneip@va.gov (704) 638-9000 x4377
Patrina Tyler, RN Urology Case Manager Patrina.Tyler@va.gov (704) 638-9000 x4342

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AIM Statements
AIM Statement 1: Increase the number of surgeries per month from 290 to XX (# - decision for surgery from CPRS
encounter) by 12/31/15
AIM Statement 2: Increase Lag Time to 80% and FTS to 75%
AIM Statement 3: Decrease the time from decision to surgery to surgery for Ophthalmology from 6 months to
(clinically appropriate time**) XX months by 12/31/15, Orthopedic from 3 months to XX months by 12/31/15, Urology
from 1.5 months to XX months by 12/31/15
Problem Statement
OR efficiency for Salisbury VA Surgical Service is not at optimum levels thus resulting in long wait
times for certain procedures and not currently meeting the demand for all needed surgeries.
Currently both OR Efficiency Metrics Lag Time (73%) and First Time Starts (56%) are below an
efficiency score of 3. The current demand for procedures is (# decision for surgery from CPRS
encounter) per month and the average for surgeries performed per month is 290. Wait time on the
EWL for certain surgical procedures range from 1.5 months to 6 months. If these issues are not
addressed, Salisbury VA Surgical Services will continue to have patient access issues.
In-scope: Decision Surgery to Discharge for all surgery Focusing on Ophthalmology, Orthopedic,
Urology, and FTS and Lag Time
Out of Scope:

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METRIC
CURRENT
(FY15 Q2)
Cancellation 13.5%
Utilization 81.8%
First Time Starts 56%
Lag Time 72.7%
Ophthalmology Cycle Time 6 months
Orthopedics Cycle Time 3 months
Urology Cycle Time 1.5 month
Number of Surgeries per month 280-300
Current State Attributes
• Scheduling process is cumbersome and has issues
with personnel and technology
• Lack of surgeons in Ophthalmology, Orthopedics,
Urology
• Lack of physical space
• Multiple causes impacting first time starts, multiple
steps to complete before starting surgery
• Room Prep cumbersome, requires great coordination
with staff arriving and getting the room
• Pre documentation is cumbersome
• Breakdown in communication between OR team, clinic,
SPS, and patient
• Breakdown in communication within clinics and within
the OR
• Organizational structures are not conducive to flow
(Silos)

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METRIC
CURRENT
(FY15 Q2)
TARGET
(12/31/2015)
Cancellation 13.5% 5%
Utilization 81.8% 80%
First Time Starts 56% 75%
Lag Time 72.7% 80%
Ophthalmology Cycle Time TBD TBD
Orthopedics Cycle Time TBD TBD
Urology Cycle Time TBD TBD
Number of Surgeries per month 280-300 Meet Demand

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IF we……. THEN we expect……
Primary Care provider to stratify patient before
consult
Decrease in cancellations, Reduced number of Vet visits, Reduced amount of
travel pay, Improved First Time Start, Decreased time from decision-to-surgery
to surgery
Surgeon places consult
Decrease in cancellations, Reduced number of Vet visits, Reduced amount of
travel pay, Improved First Time Start, Decreased time from decision-to-surgery
to surgery
Obtain access to Appointment Manager for
case managers
Decrease cycle time by 2-3 days, Increase pt. satisfaction - pt. gets all the info
they need at one time, Decrease inaccuracies, Decrease cancellations, Reduce
overbooking, Reduce number of Vet visits, Reduce amount of travel pay
Co-locate Pre-Op teaching nurses in proximity
to surgical services Increase pt. satisfaction, Increase efficiency
Create Pre-Op Teaching Clinic More accurately capture workload, Decrease pt. wait time, Increase efficiency
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IF we……. THEN we expect ……
Develop a uniform, reproducible and timely
process throughout surgical clinics for review of
Pre-Op assessment and labs at least 72 hours
prior to surgery
Increase access, Decrease cancellations, Increase First Time Starts, Increase
revenue Decrease Missed Opportunity Rate, Increase utilization, Increase
efficiency, Increase throughput (# of procedures)
Install Kiosk for pt. to do self check-in
Increase pt. satisfaction, Increase First Time Starts, Increase compliance and
quality assurance, Minimize risk of medication errors, Minimize workarounds,
Minimize rework of reentering medications into CPRS/BCMA
Set an MSA tour-of-duty for 0630-1500
Increase pt. satisfaction, Increase First Time Starts, Increase compliance and
quality assurance, Minimize risk of medication errors, Minimize workarounds,
Minimize rework of reentering medications into CPRS/BCMA
Obtain POC UPT comps to Pre-Op RNs
Decrease cycle time to 5-10 minutes, Increase First Time Start, Decrease Lag
Time, Decrease Overtime, Increase pt. satisfaction
Blood Bank supervisor educates nurses and
anesthesia on NPSG 01.03.01
Nursing and anesthesia to understand the new requirement for type, screen
and cross-match resulting in better patient care
Develop a solution for coordination of surgeon
and anesthesia on anesthesia blocks
Increase First Time Start, Decrease Lag Time, Increase efficiency, Increase
utilization, Decrease OT
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IF we ……. THEN we expect……
Develop a visual control board to improve OR
flow
Increase First Time Start, Decrease Lag Time, Decrease OT, Increase morale,
Increase accountability, Increase efficiency, Increase pt. satisfaction
Develop SOP, standardized pull sheets and
visual aids for pull sheets
Decrease delays, Increase efficiency, Decrease Lag Time, Decrease anesthesia
time, Improved pt. safety
Develop a more detailed description of surgery
on the OR schedule (i.e. Lap vs. Open,
Laterality, Body Parts, etc.)
Decrease Lag Time, Decrease cost (human, supplies, etc.), Decrease OT,
Increase throughput, Decrease cancellation, Increase pt. safety
Have a Rapid Process Improvement Event
(RPIE) for OR Room Turnover Decrease Lag Time
Have a comprehensive Pre-Op clinic (One-
Stop-Shop) for surgical patients
Increase throughput, Reduce cancellations, Reduce cycle time, Reduce pt. wait
time, Improve pt. satisfaction
Develop a timely, Veteran-centric, accountable
crutch attainment process and educate staff Improve pt. safety, Improved cost accounting
Schedule surgery time based on total times
(time-out, prep, position, draped procedure,
waking pt., moving)
Reduce OT, Reduce pt. wait time, Improve pt. satisfaction, Reduce
cancellations, Improve employee morale, Will more accurately reflect current
capability
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12
Type
of
Event
What Who When
PROJ Primary Care provider to stratify patient before consult Dr. Dalsania 10/30/2015
JDI Surgeon places consult Dr. Lucha 10/31/2015
PROJ
Develop a uniform, reproducible and timely process throughout surgical
clinics for review of Pre-Op assessment and labs at least 72 hours prior to
surgery
Dee Jones 10/31/2015
JDI Create Pre-Op teaching clinic Judi Pennington 8/31/2015
JDI Co-locate Pre-Op teaching nurses in proximity to surgical services Reggie Carter 8/31/2015
JDI Obtain access to Appointment Manager for case managers Kelly Swauger 8/31/2015
JDI Install Kiosk for pt. to do self check-in Pam Cartner 9/30/2015
JDI Set MSA TOD 0630-1500 Ken Green 9/30/2015
JDI Obtain POC UPT comps to Pre-Op RNs Judi Pennington 9/30/2015
JDI Blood Bank supervisor educates nurses and anesthesia on NPSG
01.03.01
Judi Pennington 9/8/2015
PROJ: Project
JDI: Just Do It
RPIW: Rapid Process Improvement Workshop

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Type
of
Event
What Who When
JDI
Develop a solution for coordination of surgeon and anesthesia on
anesthesia blocks
Dr. Lucha 8/31/2015
PROJ Develop a visual control board to improve OR flow Reggie Carter 10/31/2015
PROJ
Develop SOP, standardized pull sheets and visual aids for pull
sheets
Barbara Wood 9/30/2015
PROJ
Develop a more detailed description of surgery on the OR schedule
(i.e. Lap vs. Open, Laterality, Body Parts, etc.)
Meg Peeler 10/31/2015
RPIW
Have a Rapid Process Improvement Event (RPIE) for OR Room
Turnover
Jessica Plyler 9/25/2015
PROJ Have a Pre-Op clinic for surgical patients (One-Stop-Shop) Dr. Lucha 1/31/2016
PROJ
Develop a timely, Veteran-centric, accountable crutch attainment
process and educate staff
Reggie Carter 9/30/2015
PROJ
Schedule surgery time based on total times (time-out, prep,
position, draped procedure, waking pt., moving)
Judi Pennington 12/31/2015
PROJ: Project
JDI: Just Do It
RPIW: Rapid Process Improvement Workshop

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What Who When
Surgery collaborative meeting – Status of
plan / education
Reggie, Judy, Meg 1st Thursday of every
month 1400-1530
Update metrics and data; Email updates to
Jeremy
Meg, Jeremy 1st Thursday of every
month

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15
METRIC
CURRENT
(7/23/2015)
TARGET
(12/31/2015)
ACTUAL
(7/23/2015)
Cancellation 13.5% 5% 13.5%
Utilization 81.8% 80% 81.8%
First Time Starts 56% 75% 56%
Lag Time 72.7% 80% 72.7%
Ophthalmology Cycle
Time
TBD TBD TBD
Orthopedics Cycle Time TBD TBD TBD
Urology Cycle Time TBD TBD TBD
Number of Surgeries per
month
280-300
Meet
Demand
280-300
Confirmed State Attributes
• Scheduling process is cumbersome and
has issues with personnel and
technology
• Lack of surgeons in Ophthalmology,
Orthopedics, Urology
• Lack of Physical space
• Multiple causes impacting first time
starts, multiple steps to complete before
starting surgery
• Room Prep cumbersome, requires great
coordination with staff arriving and
getting the room
• Pre documentation is cumbersome
• Breakdown in communication between
OR team, clinic, SPS, and patient
• Breakdown in communication within
clinics and within the OR
• Organizational structure in OR and PACT
is not conducive to flow

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What went well?
• Kept on task.
• Very interactive.
• Good ideas and questions.
• Developed a good vision.
• Saw that it [process] can be better.
• Great team and teamwork.
• Good mix of people, positions and experience.
• Saw leadership being demonstrated.
• Process of VSA and Deep-Dives.
• Mapping identified where major problems / issues were.
• Identified achievable improvements.
• Egos and titles were left at the door.
What could have been
different?
• Use the same room all three days.
• Large enough room.
• Start planning earlier.
• Healthier breakfast options.
• More affected department stakeholders.
• Conduct off-site.
Lessons learned:
• Start planning earlier.
• Get a room reserved for all three days.
• Provide healthier breakfast options.
• Involve more key stakeholders.
• Look into off-site locations for the event.
• Good facilitation is important.
• Staying on track is important.