Elena Canacari

A Practical Guide to Applying Lean Tools and Management Principles to Health Care Improvement Projects

Manufacturing organizations have used Lean management principles for years to help eliminate waste, streamline processes, and cut costs. This pragmatic approach to structured problem solving can be applied to health care process improvement projects. Health care leaders can use a step-by-step approach to document processes and then identify problems and opportunities for improvement using a value stream process map. Leaders can help a team identify problems and root causes and consider additional problems associated with methods, materials, manpower, machinery, and the environment by using a cause-and-effect diagram. The team then can organize the problems identified into logical groups and prioritize the groups by impact and difficulty. Leaders must manage action items carefully to instill a sense of accountability in those tasked to complete the work. Finally, the team leaders must ensure that a plan is in place to hold the gains.

Intraoperative waste in spine surgery: incidence, cost, and effectiveness of an educational program.

Study Design. Prospective observational study. Objective. This study aims to quantify the incidence of intraoperative waste in spine surgery and to examine the efficacy of an educational program directed at surgeons to induce a reduction in the intraoperative waste. Summary of background data. Spine procedures are associated with high costs. Implants are a main contributor of these costs. Intraoperative waste further exacerbates the high cost of surgery. Methods. Data were collected during a 25-month period from one academic medical center (15-month observational period, 10-month post–awareness program). The total number of spine procedures and the incidence of intraoperative waste were recorded prospectively. Other variables recorded included the type of product wasted, cost associated with the product or implant wasted, and reason for the waste. Results. Intraoperative waste occurred in 20.2% of the procedures prior to the educational program and in 10.3% of the procedures after the implementation of the program (P < 0.0001). Monthly costs associated with surgical waste were, on average,

Lean principles to optimize instrument utilization for spine surgery in an academic medical center: an opportunity to standardize, cut costs, and build a culture of improvement.

17680 prior to the awareness intervention and

Surgical Scheduling: A Lean Approach to Process Improvement

5876 afterwards (P = 0.0006). Prior to the intervention, surgical waste represented 4.3% of total operative spine budget. After the awareness program this proportion decrease to an average of 1.2% (P = 0.003). Conclusion. Intraoperative waste in spine surgery exacerbates the already costly procedures. Extrapolation of this data to the national level leads to an annual estimate of

Miscount Incidents: A Novel Approach to Exploring Risk Factors for Unintentionally Retained Surgical Items

126,722,000 attributable to intraoperative spine waste. A simple educational program proved to be and continues to be effective in making surgeons aware of the import of their choices and the costs related to surgical waste.

Strategies for Preventing Wrong Site, Wrong Procedure, Wrong Patient Surgery

Study Design. Case study Objective. To optimize the utilization of operating room instruments for orthopedic and neurosurgical spine cases in an urban level 1 academic medical center through application of Lean principles. Summary of Background Data. Process improvement systems such as Lean have been adapted to health care and offer an opportunity for frank assessment of surgical routines to increase efficiency and enhance value. The goal has been to safely reduce the financial burden to the health care system without compromising care and if possible reallocate these resources or gains in efficiency to further improve the value to the patient. Methods. The investigators identified instruments as a source of waste in the operating room and proposed a Lean process assessment. The instruments and the instrument processing workflow were described. An audit documented the utilization of each instrument by orthopedic surgeons and neurosurgeons through observation of spine cases. The data were then presented to the stakeholders, including surgeons, the perioperative director, and representatives from nursing, central processing, and the surgical technicians. Results. Of the 38 cases audited, only 89 (58%) of the instruments were used at least once. On the basis of the data and stakeholder consensus, 63 (41%) of the instruments were removed, resulting in a weight reduction of 17.5 lb and consolidation of 2 instrument sets into 1. Projected cost savings were approximately

10 years in, why time out still matters.

41,000 annually. Although new instruments were purchased to standardize sets, the return on investment was estimated to be 2 years. Conclusion. Inefficient surgical routines may comprise significant resource waste in an institution. Process assessment is an important tool in decreasing health care costs, with objectivity provided by Lean or similar principles, and essential impetus to change provided by stakeholders. Level of Evidence: 4

Eliminating workplace hazards in the OR

A large teaching hospital in the northeast United States had an inefficient, paper-based process for scheduling orthopedic surgery that caused delays and contributed to site/side discrepancies. The hospitals leaders formed a team with the goals of developing a safe, effective, patient-centered, timely, efficient, and accurate orthopedic scheduling process; smoothing the schedule so that block time was allocated more evenly; and ensuring correct site/side. Under the resulting process, real-time patient information is entered into a database during the patients preoperative visit in the surgeons office. The team found the new process reduced the occurrence of site/side discrepancies to zero, reduced instances of changing the sequence of orthopedic procedures by 70%, and increased patient satisfaction.

Implementation of an Ambulatory Pacu Length of Stay Project

BACKGROUND An estimated 1,500 operations result in retained surgical items (RSIs) each year in the United States, resulting in substantial morbidity. The rarity of these events makes studying them difficult, but miscount incidents may provide a window into understanding risk factors for RSIs. METHODS A cohort study of all consecutive operative cases during a 12-month period was conducted at a large academic medical center to identify risk factors for surgical miscounts. A multidisciplinary electronic miscount reconciliation checklist (necessitating both surgeon and nurse input) was introduced into the internally developed electronic Perioperative Information Management System to build a predictive model for RSI cases. RESULTS Among 23,955 operations, 84 resulted in miscount incidents (0.35% [95% confidence interval: 0.28% to 0.43%]). Increased case duration was strongly associated with increased risk of a miscount in unadjusted analyses (p < .0001). In the nested case-control analysis, both the case duration and the number of providers present were independently associated with a more than doubling of the odds of a miscount, even after adjustment for one another, the elective/urgent/emergent status of a case, and personnel changes occurring during the case. CONCLUSIONS The finding that both the length of the case and the number of providers involved in the case were independent risk factors for miscount incidents may offer insight into risk-targeted strategies to prevent RSIs, such as postoperative imaging, bar-coded surgical items, and radiofrequency technology. Miscounts trigger use of the Incorrect Count Safety Checklist, which can be used to determine whether a count completed at the procedures conclusion is consistent across disciplines (circulating nurses, scrub persons, surgeons).

Lean Principles to Optimize Instrument Utilization for Spine Surgery in an Academic Medical Center: An Opportunity to Standardize, Cut Costs and Build a Culture of Improvement

Note from column coordinator Charlotte Guglielmi: It is my pleasure to introduce a new column for our journal. I have heard time and time again that nurses need to better understand the different perspectives that each member of the surgical team brings to the table on topics that affect the care we deliver to our patients. We know that teamwork and effective communication enhance the safe care of patients. This column will provide a venue for colleagues from multiple disciplines to share opinions and commentary on some of the most critical clinical issues that face all of us. As each topic is identified, a critical question will be posed to the authors who will respond from their perspective. Linda Groah, AORN executive director and chief executive officer, will conclude each discussion with a summary of AORN’s response to the issue. I am