Surgical Improvement Project (SIP)

Surgical Improvement Project (SIP)UW Medical Center

February 9, 2005

Executive Sponsors: Lisa BrandenburgDr. Ed WalkerDr. Ernie Weymuller

AgendaWelcomeSIP OverviewLean Overview

Break

Swedish Medical Center Moving ForwardQ & A

SponsorsDr. Mika SinananJ.Duncan, M.Alotis,

Y.Jackson

Jeff McAuliffeDr. Mika Sinanan

5 min60 min

10 min

5 min10 min15 min

WasteQuality

Steady FlowProcess Standardization

Process WalkVisual Systems

Surgical Improvement Project Mission

Make UWMC the First Choice for Patients seeking Excellence in Surgical Care

Make UWMC a Premier Practice and Work Site for All Members of the Surgical Team

Assure a Safe, Patient Centered, and EfficientEnvironment that Contributes to Fiscal Success for UWMC

Integrate Academic, Educational, and Service Rolesof UWMC Surgical Faculty and Staff Seamlessly

PASCO

Surgical Improvement Project Teams

SIP 1Schedule to 00:01 on the Day of Surgery

SIP 2Day of Surgery: 00:02 to Incision

First CaseSIP 3

Day of Surgery: After Incision for First Case

to Midnight

SIP 4Leadership and

Culture

SIP 5Strategy/Strategic

Planning

Project Timeline

DEC JAN FEB MAR APR MAY JUL

Oversight Team Kickoff

Management GT Kickoff

SIP Teams’ Kickoff

Lean Principles

Current State Report Out

Future State Design

Future State Report Out

Implementation Plan

Milestones

Implementation

JUN

Surgical Improvement Project Countdown

172 days until August 1st

Lean Methodology Has A Rich History

OriginModeled after JIT training for industrial engineersToyota workshops for suppliers

CharacteristicsIntensive education and learning by doingAll organization levels learn togetherRapid turning of Plan-Do-Check-Act Cycle (PDCA)Creates spirit of improvementAnalysis, visioning and implementation during the project to achieve at least 50% improvement“Ownership” of improvements

Similar ApproachesToyota, Boeing, GM, GE, Hillenbrand, Genie IndustriesSwedish, Children's, Virginia Mason, HMC

What is Lean?

Reduce WasteReduce Flow TimeReduce CostReduce VariationIncrease Visual CuesImprove Teamwork

L E A N

TODAY50%

Do not reach for perfection –Go for 50% improvement

TODAY!

Lean

QualityWaste

Steady Flow

ProcessStabilizationProcess Walk

Visual Systems

Waste-ologyDefinition by Webster’s Dictionary:waste [ wayst ]

verb: to use something or use something up carelessly, extravagantly, or without effectnoun: unwanted or unusable by-products

Lean definition * : “Waste being any activity that does not add value to the final product….”

* Ohno, Shingo, Value Stream Mapping

Removal of Waste begets:Increased ResourceDecreased Cycle Time Reduced CostIncreased Quality

8 Deadly Wastes

Processing Search Time

Correction Transportation

Inventory Space

Wait Time Complexity

Waste Comes in Many Forms“Disguised as Useful Work”

Why Focus on Waste?

Because most processes are 95–99% non-value-added, a focus on eliminating waste is the best leverage for an improvement effort.

NVA 95%

Necessary Non-Value Added

VA5%

Value Added Timeline

Value-Added (VA)

Non-Value-Added (NVA)

Total time = 70 minutes

VA time = 6.5 minutes

Percent of NVA time = 91%

Travel distance = .25 mile

Number of Process steps = 25

Value-added steps = 4

Number of Inspection steps = 4

Number of queues = 11

First Unit Dose for Medication from Order to Patient Delivery

Write OrderDispense In

PharmacyEnter Data Administer

To Patient

Lean

Quality

Steady Flow


Visual Systems

Waste

What is An Acceptable Quality Standard?

At one error in 1000 events, here is what happens:

22,000 checks are deducted from the wrong bank account everyday500 incorrect surgeries are completed every week2,000 unsafe airplane landings made every day16,000 pieces of mail are lost by the Postal Service every hour

Level 5: Eliminate Opportunities for Errors(CPOE)

Suppliers 1 2 3 4 Customers

Process controls and design prevent error

5

Level 3: Work Unit Inspects(Needle and Sponge count)


Erroroccurs

Defectdetected

5

Suppliers 1 3 4 Customers

Errorcaused, detected and corrected

5

Level 4: Self Inspection and Correction(Patient ID, Surgery Site Check)

Feedback

2

Level 1: Customer Inspects(DOH)


Erroroccurs

Inspector finds defect

Feedback

5

Level 2: Company Inspects (at the end of the process)

(QA, Audit, Narcotic Count)

Suppliers 1 2 3 4

Erroroccurs

Customer finds defect

Feedback

Customers

Level 3: Work Unit Inspect

Level 2: Company Inspects

Level 1: Customer Inspects

Level 5: Eliminate Opportunities for Errors

Levels of Quality System

PreventErrors

Level 4: Self Inspection

Check forDefects

Detect Errors

Lean

QualityWaste

SteadyFlow


Visual Systems

Keep the Process Moving, Forward (Streamlined Process)

AFTER LEANBEFORE LEAN

Batch and Queue of Patients

Patient gets admitted

Patient waits to be seen

Patient gets seen by

PreOp RNPatient waits

Patient gets seen by Surgeon

Patient waitsPatient get taken to Holding

Area

Patient waits ETC….

Steady Flow Processing

Even, steady pace and rhythm to the work flowAttention and completion to “one-at-a-time”Agile, speedy customer response time

BEFORE AFTER

Benefits of Steady Flow Processing

Better communicationDecreased response timeIncreased productivity

Requires less spaceIdentifies quality problems upstream in the process

The Steps to Steady Flow Processing

1. Plan and implement the sequence of work activities and the physical layout

2. Standardize the work methods

3. Keep pace with customers’ demand—one complete transaction at a time

4. Cross-train everyone to balance the work

Lean

QualityWaste

Steady Flow


Visual Systems

Which Problem Would You Rather Have?

Problem 1 Problem 2

Performance

Target

Random Predictablevs.

Which Problem Would You Rather Have?

Problem 1 Problem 2

Performance

Target

Random Predictablevs.

Attack Variation

Which of these is the major cause of process variation in results?

People Materials

Equipment Work Methods

Results

Attack Variation

Which of these is the major cause of process variation in results?

People Materials

Equipment Work Methods

Results

Why is Variability Critical?

… Reliable Methods are:• Safer• More Predictable• More Controllable• More Repeatable • Less Costly

A Process is as Strong as the Weakest Link …

Output Measures

Monitoring a Stable Process

ProcessMeasure

ProcessMeasure

ProcessMeasure

…focus on the customer…reflect the purpose and scope of the process…are simple, repeatable, quantifiable…are accepted as fair and helpful…keeps the people and the process honest

Lean

QualityWaste

Steady Flow

ProcessStabilization

ProcessWalk

Visual Systems

Process Walk: 3 Essential Steps“Improvement does not happen in a conference room.”Go to the Actual PlaceTalk to the Actual People working in the processObserve the Actual Process

How do you do a Process Walk?

During the Walk1. Walk Worksheet2. Waste Worksheet

After the Walk3. Process Layout4. Process Flow5. Process Data Summary6. List of Problems and Opportunities

Tour Guide(s):

Jeff Jones

Date:

June 10, 2002

Process Name:

Responding to Customer Request For Job Quote

Total Process Time:

2 Weeks

Step

# Step Description

Person(s)

Responsible Inspection

Step Value Added Time

# in Que Feet Traveled

Opportunities for Improvemen

1 Receive customer call and document

customer request

Customer Service Rep

10 Staff phones to meet high demand oMondays

2 Place job in Customer Service Supervisor’s

in-box

Customer Service Rep

50

3 Reviews job and signs Cust. Service Supervisor

4 Job placed in out basket

Cust. Service Supervisor

8

5 Mail transported to engineering

Mail Clerk 200

6 Job checked for type Dept. Secretary

7 Taken to engineers desk

Dept. Secretary 20

8 Job drawings prepared

Engineer 30 3 Engineer has questions and can’t reacustomer

9 Drawing taken to Engineering Manager

Engineer 20

10 Check drawings Engineering Manager

6

11 Place drawings in out basket

Engineering Manager

12 Transport drawings to estimator

Mail Clerk 300

TOTALS 44 8 90 min. 8 queues 38

WIP orders 1960

Types of Waste

Observations from 3 Actuals Walk

Processing

Multiple “inspections.

Correction

Bid errors found by customer

Inventory

38 quotes in process

Wait Time

Wait time for customer. Wait time for responses from other departments.

Search Time

Jobs lost in process

Transportation

Long distances traveled by Mail Clerks.

Space

Poor use of refrigerator space–spoiled food pulled every week.

Complexity

Too much checking and inspection. Too many handoffs.

Process Layout

Locations

Workstations

People Movement

Flow ChartingEliminate assumptionsEveryone has a common understanding of the process and issues

Process Flow

RPI #2Central Services/ Processing

Current New Variation # of process steps 66 39 - 41% Total process time 834 min 512 min - 39% % of VA steps 42% 51% + 21% % of VA time 50% 66% + 32% # of checking steps 18 11 - 39% # of handoffs 12 8 - 33% # of queues 14 8 - 60% Work in progress 82 41 - 50%

Workflow45% reduction in the number of PYXIS “stock out” calls per day

66% reduction in wait time from report to fill in PYXIS

Physical LayoutA picture is worth a thousand words

Error reduction40% reduction in reported misfills

86% reduction in pick errors for the load process

BEFORE AFTER

Pharmacy RPI

Lean

QualityWaste

Steady Flow


VisualSystems

“A system of organization that is visible and intuitively obvious.”

Sort (Seiri)Set in Order (Seiton)Shine (Seiso)Standardize (Seiketsu)Sustain (Shitsuke)

BEFORE

AFTER

Visual System (5 S)

Benefits of a Visual System

Eliminates non-value-added search timeProvides a foundation for process standardizationReduces “space requirements”Communicates “how we are doing” to everyoneCan trigger corrective action

BEFORE

AFTER

Pharmacy RPI

History of Lean/RPI Improvements in Surgery

July 2001, SPD-Decontam - Providence

Sept 2001, SPD-Assembly- Providence

Oct 2001, SPD-Decontam - First Hill

Dec 2001, SPD-Assembly - First Hill

March 2002, Case Cart-Assembly - Providence

April 2002, OR 5S work - First Hill

Sept 2002, Case Cart Assembly - First Hill

May 2003, OR Turnaround - First Hill

July 2003, PreOp Chart Assembly - First Hill

May 2004, Periop Vision Workshop

Nov 2004, Patient Flow/Tracking, First Hill

Winter/Spring 2004, Value Stream Mapping

The Swedish Medical Center Experience


RPI - First Hill Campus Instrument Lead Time in Assembly

Assembly Lead Time

0

100

200

300

400

500

600

700

beforerpi

beforerpi

afterrpi #1

afterrpi #1

14-Jan 21-Jan 23-Jan 24-Jan 25-Jan 28-Jan 29-Jan 4-Feb 5-Feb 6-Feb 7-Feb 25-Feb

7-Mar 8-Mar 12-Mar

Aver

age

min

utes

RPI #1

RPI #2

Baseline

Target


Sterile Processing, FHC

Before - the “dumproom”

After - Employeedevelopment lounge

Location: Triangle Room, Sterile Processing, First Hill


SORT in the OR Core

ITEM RETRIEVED EST. EXPENSE CAPTUREDCysto-scope $12,000Toronto valve sizers 0Computer monitor $20020 ft of old catalogs & files 015 rolls of toilet paper $102 telephones $1003 pkgs of paper towels $21 OR wall writing shelf 050 hanging files $51 shelf $105 Ear Specials $50003 ENT instrument sets $30001 Osteome set $16001 Microplastic set $400050 misplaced instruments in peelpacks

$2200

1 sink removed 0Steris cupboard doors removed 0Total Estimated Inventory retrieved $28,127.00

Source: Case Cart Assembly RPI, Providence CampusThe Swedish Medical Center Experience

Case Cart Lead TimeFirst Hill Campus

0

5

10

15

20

25

30

35

40

Hours

1 2 3 4 5 6Before RPI After RPI

Case Cart AssemblyFirst Hill Campus

Range of Lead Time (excluding first start)

24- 40 hours

0.5 - 3.0 hours


Complete Case Cart DeliveryFirst Hill Campus

Percent of Incomplete Case Carts

0

20

40

60

80

100

18-A

ug

19-A

ug

20-A

ug

21-A

ug

22-A

ug

23-A

ug

24-A

ug

25-A

ug

26-A

ug

27-A

ug

28-A

ug

29-A

ug

30-A

ug

1-Se

p

2-Se

p

3-Se

p

4-Se

p

5-Se

p

6-Se

p

11-N

ov

12-N

ov

13-N

ov

14-N

ov

15-N

ov

16-N

ov

17-N

ov

18-N

ov

19-N

ov

20-N

ov

21-N

ov

22-N

ov

23-N

ov

24-N

ov

25-N

ov

% In

com

plet

e

RPI Held in Late September

Average = 22%

Average = 4% 82% improvement


Periop Value Stream Redesign

DOS work cellAncillary SvcsPull SystemOR Suite StdzSurgery Staffing Flow

CIS Supply Chain Operations Post CIS






Procedure list controlOR Core & Suite stockingPoint of Use MaterialsMaterial consignmentSpecial Orders






Patient flow & trackingSchedule finalization & release48 hour clinical review






Patient flow & trackingSchedule finalization & release48 hour clinical review

Interface with EMRBarcode usageCharging templates

Moving Forward

Surgical Improvement Project Mission

Make UWMC the First Choice for Patients seeking Excellence in Surgical Care

Make UWMC a Premier Practice and Work Site for All Members of the Surgical Team

Assure a Safe, Patient Centered, and EfficientEnvironment that Contributes to Fiscal Success for UWMC

Integrate Academic, Educational, and Service Rolesof UWMC Surgical Faculty and Staff Seamlessly

PASCO

Project Timeline

DEC JAN FEB MAR APR MAY JUL

Oversight Team Kickoff

Management GT Kickoff

SIP Teams’ Kickoff

Lean Principles

Current State Report Out

Future State Design

Future State Report Out

Implementation Plan

Milestones

Implementation

JUN

Communication

Decide to have surgery

Prepare for surgery

Go into surgery

Recover from surgery

Be discharged

Value Stream for Surgical Care

SIP 1 SIP 2 SIP 3

SIP 4 SIP 5

Communication

How will all of the changes be communicated?

Surgispot

Bulletin Board

MGT meeting

Oversight meeting

Website

Surgical Improvement Project

We have

172 days until August 1st

Any Questions?

Surgical Improvement Project (SIP)

Documents