Streamlining Method Yields OR Savings

CHICAGO - Applying the Lean streamlining methodology across the entire surgical process significantly improved several operating room performance measures such as on-time starts and turnover time. At the same time, the operating margin in some ORs was increased by more than $45,000 per day, as demonstrated at the Mayo Clinic in Rochester, Minn.
 
“This was all during a period of increased growth and volume of cases," Dr. Robert Cima said at the annual meeting of the Western Surgical Association.

“What's even more important was that during this time when we had increased volume of cases, we actually had a decreased need for personnel because we were reducing the need for overtime staffing as well as the just the plain need for extra bodies," added Dr. Cima.

That translated into 37 fewer full-time surgical services employees, 50% fewer late shifts among certified registered nurse anesthetists, and an 18%-56% decrease in health care security services overtime.

The Lean and Six Sigma methodologies, popularized decades ago by companies like automobile maker Toyota as a way to eliminate wasteful steps and improve productivity, have typically been applied to a limited number of ORs or to specific operations.

The Mayo Clinic credits its success to applying the methodology across the entire surgical process and in all 88 of its main ORs performing both in- and outpatient procedures.

“Multiple areas of redundant or non-value-added steps were identified across the entire process flow that would not have been identified with a focus on specific steps," said Dr. Cima, a colorectal surgeon at the Mayo Clinic.

First, a multidisciplinary leadership team developed a map of the surgical process from the decision for surgery to leaving the OR. The team analyzed each step for personnel required, information process, and time expended. In all, 28 systems and 14 points of delay were identified, he said.

Next, multidisciplinary teams were formed and given 6 months to redesign systems around five essential work streams: minimizing unplanned surgical volume variation, streamlining the preoperative process, reducing nonoperative time, reducing redundant information collection, and engaging employees.

“Specific goals were set for each specialty," he said. “It was not 'one size fits all.'“

Each work stream was tweaked to standardize procedure descriptions, implement dedicated staggered surgery start times, and develop a first-case scheduling checklist to eliminate barriers to on-time OR starts.

When streamlining the preoperative process, Dr. Cima said, the most important thing is to start on time.

The hospital tried to get buy-in from employees by implementing OR briefings with the OR team, creating a communication council to effectively disseminate information through all levels of staff, and conducting a survey to identify major drivers of employee participation - many of which were not financial, Dr. Cima noted.
 
Some of the drivers included promotion of shared goals, encouragement of continuous professional growth, frequent recognition of individual employee contributions, and executive demonstration of values and commitment to the project.

Data collected before the intervention and 18 months afterward from the first three specialties tested showed that on-time starts increased from 50% to 80% for thoracic surgery, from 64% to 92% for gynecologic surgery, and from 60% to 92% for general/colorectal surgery.

The differences were all significant (P less than .05), he said.

The percentage of operations performed past 5 p.m. stayed relatively constant before and after intervention among thoracic surgeons at 34% vs. 36%, respectively. However, it decreased significantly for gynecologic surgeons (from 42% to 36%) and general/colorectal surgeons (from 37% to 31%) (P less than .05 for both).

The average nonoperative or turnover time was reduced by 10-15 minutes among the three specialties, or 25% for thoracic surgery, 43% for gynecologic surgery, and 32% for general/colorectal surgery, Dr. Cima said.

Staff overtime was reduced by an average of 17 minutes per month for thoracic surgery (16%), 19 minutes for gynecologic surgery (18%), and 46 minutes for general/colorectal surgery (53%).

The financial impact of these improvements was at times quite dramatic, he said.

For example, the financial margin increased 22% or $21,340 per OR/day for thoracic surgery, 16% or $24,570 per OR/day for gynecologic surgery, and 55% and $47,700 per OR/day for general/colorectal surgery.

“Some people say this is a Hawthorne effect . . . but this is sustainable and in some cases actually increases as the teams become more efficient," he said, noting that positive improvements have now been reported in nine separate specialties.

Invited discussant Dr. R. Stephen Smith called the project a “monumental effort," but questioned whether the methodology is applicable to the average worker in the average hospital.

“Surgeons and others who toil in the operating room are not analogous to Toyota assembly line workers in Japan," according to Dr. Smith, interim chair, department of surgery, Virginia Tech Carilion School of Medicine in Roanoke.

He also questioned how less affluent institutions could marshal the hospitalwide resources necessary to institute Lean/Six Sigma projects.

Dr. Cima responded that the project required very few resources, and that smaller institutions actually may be in a better position to implement Lean/Six Sigma because they are less constrained by bureaucracy.

Dr. Cima acknowledged that the hospital population may be unique in its commitment to the success of the overall institution, as opposed to individual productivity, but added that there are advantages for the employees to come together in smaller settings such as in ambulatory, outpatient surgical practices.

For example, surgeons may be able to return to the clinic earlier and see more cases if the surgical suite is run more efficiently.

“One of the efforts that has to be brought out to bring people together is to make sure everyone knows what they want out of it and what they are willing to give up," Dr. Cima said. “It is a collaborative effort."

During the discussion, Dr. Tyler Hughes, from Memorial Hospital in McPherson, Kan., asked whether institutions can survive if they don't push through these kinds of process improvements.

“I would submit that any institution that doesn't look at their processes - and not just a step, but the whole process - will not be able to survive the next 10-15 years," Dr. Cima responded.

“The government is clearly sending a signal that efficiency, value, and safety are the three main ways you're going to survive."

The study was supported by the Mayo Clinic, department of surgery. Dr. Cima and Dr. Smith reported no conflicts of interest.

CHICAGO - Applying the Lean streamlining methodology across the entire surgical process significantly improved several operating room performance measures such as on-time starts and turnover time. At the same time, the operating margin in some ORs was increased by more than $45,000 per day, as demonstrated at the Mayo Clinic in Rochester, Minn.
 
“This was all during a period of increased growth and volume of cases," Dr. Robert Cima said at the annual meeting of the Western Surgical Association.

“What's even more important was that during this time when we had increased volume of cases, we actually had a decreased need for personnel because we were reducing the need for overtime staffing as well as the just the plain need for extra bodies," added Dr. Cima.

That translated into 37 fewer full-time surgical services employees, 50% fewer late shifts among certified registered nurse anesthetists, and an 18%-56% decrease in health care security services overtime.

The Lean and Six Sigma methodologies, popularized decades ago by companies like automobile maker Toyota as a way to eliminate wasteful steps and improve productivity, have typically been applied to a limited number of ORs or to specific operations.

The Mayo Clinic credits its success to applying the methodology across the entire surgical process and in all 88 of its main ORs performing both in- and outpatient procedures.

“Multiple areas of redundant or non-value-added steps were identified across the entire process flow that would not have been identified with a focus on specific steps," said Dr. Cima, a colorectal surgeon at the Mayo Clinic.

First, a multidisciplinary leadership team developed a map of the surgical process from the decision for surgery to leaving the OR. The team analyzed each step for personnel required, information process, and time expended. In all, 28 systems and 14 points of delay were identified, he said.

Next, multidisciplinary teams were formed and given 6 months to redesign systems around five essential work streams: minimizing unplanned surgical volume variation, streamlining the preoperative process, reducing nonoperative time, reducing redundant information collection, and engaging employees.

“Specific goals were set for each specialty," he said. “It was not 'one size fits all.'“

Each work stream was tweaked to standardize procedure descriptions, implement dedicated staggered surgery start times, and develop a first-case scheduling checklist to eliminate barriers to on-time OR starts.

When streamlining the preoperative process, Dr. Cima said, the most important thing is to start on time.

The hospital tried to get buy-in from employees by implementing OR briefings with the OR team, creating a communication council to effectively disseminate information through all levels of staff, and conducting a survey to identify major drivers of employee participation - many of which were not financial, Dr. Cima noted.
 
Some of the drivers included promotion of shared goals, encouragement of continuous professional growth, frequent recognition of individual employee contributions, and executive demonstration of values and commitment to the project.

Data collected before the intervention and 18 months afterward from the first three specialties tested showed that on-time starts increased from 50% to 80% for thoracic surgery, from 64% to 92% for gynecologic surgery, and from 60% to 92% for general/colorectal surgery.

The differences were all significant (P less than .05), he said.

The percentage of operations performed past 5 p.m. stayed relatively constant before and after intervention among thoracic surgeons at 34% vs. 36%, respectively. However, it decreased significantly for gynecologic surgeons (from 42% to 36%) and general/colorectal surgeons (from 37% to 31%) (P less than .05 for both).

The average nonoperative or turnover time was reduced by 10-15 minutes among the three specialties, or 25% for thoracic surgery, 43% for gynecologic surgery, and 32% for general/colorectal surgery, Dr. Cima said.

Staff overtime was reduced by an average of 17 minutes per month for thoracic surgery (16%), 19 minutes for gynecologic surgery (18%), and 46 minutes for general/colorectal surgery (53%).

The financial impact of these improvements was at times quite dramatic, he said.

For example, the financial margin increased 22% or $21,340 per OR/day for thoracic surgery, 16% or $24,570 per OR/day for gynecologic surgery, and 55% and $47,700 per OR/day for general/colorectal surgery.

“Some people say this is a Hawthorne effect . . . but this is sustainable and in some cases actually increases as the teams become more efficient," he said, noting that positive improvements have now been reported in nine separate specialties.

Invited discussant Dr. R. Stephen Smith called the project a “monumental effort," but questioned whether the methodology is applicable to the average worker in the average hospital.

“Surgeons and others who toil in the operating room are not analogous to Toyota assembly line workers in Japan," according to Dr. Smith, interim chair, department of surgery, Virginia Tech Carilion School of Medicine in Roanoke.

He also questioned how less affluent institutions could marshal the hospitalwide resources necessary to institute Lean/Six Sigma projects.

Dr. Cima responded that the project required very few resources, and that smaller institutions actually may be in a better position to implement Lean/Six Sigma because they are less constrained by bureaucracy.

Dr. Cima acknowledged that the hospital population may be unique in its commitment to the success of the overall institution, as opposed to individual productivity, but added that there are advantages for the employees to come together in smaller settings such as in ambulatory, outpatient surgical practices.

For example, surgeons may be able to return to the clinic earlier and see more cases if the surgical suite is run more efficiently.

“One of the efforts that has to be brought out to bring people together is to make sure everyone knows what they want out of it and what they are willing to give up," Dr. Cima said. “It is a collaborative effort."

During the discussion, Dr. Tyler Hughes, from Memorial Hospital in McPherson, Kan., asked whether institutions can survive if they don't push through these kinds of process improvements.

“I would submit that any institution that doesn't look at their processes - and not just a step, but the whole process - will not be able to survive the next 10-15 years," Dr. Cima responded.

“The government is clearly sending a signal that efficiency, value, and safety are the three main ways you're going to survive."

The study was supported by the Mayo Clinic, department of surgery. Dr. Cima and Dr. Smith reported no conflicts of interest.

CHICAGO - Applying the Lean streamlining methodology across the entire surgical process significantly improved several operating room performance measures such as on-time starts and turnover time. At the same time, the operating margin in some ORs was increased by more than $45,000 per day, as demonstrated at the Mayo Clinic in Rochester, Minn.
 
“This was all during a period of increased growth and volume of cases," Dr. Robert Cima said at the annual meeting of the Western Surgical Association.

“What's even more important was that during this time when we had increased volume of cases, we actually had a decreased need for personnel because we were reducing the need for overtime staffing as well as the just the plain need for extra bodies," added Dr. Cima.

That translated into 37 fewer full-time surgical services employees, 50% fewer late shifts among certified registered nurse anesthetists, and an 18%-56% decrease in health care security services overtime.

The Lean and Six Sigma methodologies, popularized decades ago by companies like automobile maker Toyota as a way to eliminate wasteful steps and improve productivity, have typically been applied to a limited number of ORs or to specific operations.

The Mayo Clinic credits its success to applying the methodology across the entire surgical process and in all 88 of its main ORs performing both in- and outpatient procedures.

“Multiple areas of redundant or non-value-added steps were identified across the entire process flow that would not have been identified with a focus on specific steps," said Dr. Cima, a colorectal surgeon at the Mayo Clinic.

First, a multidisciplinary leadership team developed a map of the surgical process from the decision for surgery to leaving the OR. The team analyzed each step for personnel required, information process, and time expended. In all, 28 systems and 14 points of delay were identified, he said.

Next, multidisciplinary teams were formed and given 6 months to redesign systems around five essential work streams: minimizing unplanned surgical volume variation, streamlining the preoperative process, reducing nonoperative time, reducing redundant information collection, and engaging employees.

“Specific goals were set for each specialty," he said. “It was not 'one size fits all.'“

Each work stream was tweaked to standardize procedure descriptions, implement dedicated staggered surgery start times, and develop a first-case scheduling checklist to eliminate barriers to on-time OR starts.

When streamlining the preoperative process, Dr. Cima said, the most important thing is to start on time.

The hospital tried to get buy-in from employees by implementing OR briefings with the OR team, creating a communication council to effectively disseminate information through all levels of staff, and conducting a survey to identify major drivers of employee participation - many of which were not financial, Dr. Cima noted.
 
Some of the drivers included promotion of shared goals, encouragement of continuous professional growth, frequent recognition of individual employee contributions, and executive demonstration of values and commitment to the project.

Data collected before the intervention and 18 months afterward from the first three specialties tested showed that on-time starts increased from 50% to 80% for thoracic surgery, from 64% to 92% for gynecologic surgery, and from 60% to 92% for general/colorectal surgery.

The differences were all significant (P less than .05), he said.

The percentage of operations performed past 5 p.m. stayed relatively constant before and after intervention among thoracic surgeons at 34% vs. 36%, respectively. However, it decreased significantly for gynecologic surgeons (from 42% to 36%) and general/colorectal surgeons (from 37% to 31%) (P less than .05 for both).

The average nonoperative or turnover time was reduced by 10-15 minutes among the three specialties, or 25% for thoracic surgery, 43% for gynecologic surgery, and 32% for general/colorectal surgery, Dr. Cima said.

Staff overtime was reduced by an average of 17 minutes per month for thoracic surgery (16%), 19 minutes for gynecologic surgery (18%), and 46 minutes for general/colorectal surgery (53%).

The financial impact of these improvements was at times quite dramatic, he said.

For example, the financial margin increased 22% or $21,340 per OR/day for thoracic surgery, 16% or $24,570 per OR/day for gynecologic surgery, and 55% and $47,700 per OR/day for general/colorectal surgery.

“Some people say this is a Hawthorne effect . . . but this is sustainable and in some cases actually increases as the teams become more efficient," he said, noting that positive improvements have now been reported in nine separate specialties.

Invited discussant Dr. R. Stephen Smith called the project a “monumental effort," but questioned whether the methodology is applicable to the average worker in the average hospital.

“Surgeons and others who toil in the operating room are not analogous to Toyota assembly line workers in Japan," according to Dr. Smith, interim chair, department of surgery, Virginia Tech Carilion School of Medicine in Roanoke.

He also questioned how less affluent institutions could marshal the hospitalwide resources necessary to institute Lean/Six Sigma projects.

Dr. Cima responded that the project required very few resources, and that smaller institutions actually may be in a better position to implement Lean/Six Sigma because they are less constrained by bureaucracy.

Dr. Cima acknowledged that the hospital population may be unique in its commitment to the success of the overall institution, as opposed to individual productivity, but added that there are advantages for the employees to come together in smaller settings such as in ambulatory, outpatient surgical practices.

For example, surgeons may be able to return to the clinic earlier and see more cases if the surgical suite is run more efficiently.

“One of the efforts that has to be brought out to bring people together is to make sure everyone knows what they want out of it and what they are willing to give up," Dr. Cima said. “It is a collaborative effort."

During the discussion, Dr. Tyler Hughes, from Memorial Hospital in McPherson, Kan., asked whether institutions can survive if they don't push through these kinds of process improvements.

“I would submit that any institution that doesn't look at their processes - and not just a step, but the whole process - will not be able to survive the next 10-15 years," Dr. Cima responded.

“The government is clearly sending a signal that efficiency, value, and safety are the three main ways you're going to survive."

The study was supported by the Mayo Clinic, department of surgery. Dr. Cima and Dr. Smith reported no conflicts of interest.