1. APOM Grand Rounds OPEx SOR Value Stream
Kaizen Event: In Room to Anesthesia Ready
Dr. Michael Aziz

3. What is OPEx? OHSU Performance Excellence System (OPEx)
An approach to drive rapid performance improvement using a common vocabulary, tools and methods
Grounded in “lean manufacturing” techniques initially developed by Toyota, since used in many industries including healthcare
Evolution of performance improvement efforts put in place for clinical enterprise, but potentially deployable across OHSU

4. OPEx Overview
OPEx is the collection of Methods, Management and Mindset that help OHSU Healthcare achieve its goals in a systematic way
Based on Lean principles that maximize value for patients through Continuous Improvement and Respect for People
The OPEx tools such as kaizen events are the Methods by which we improve our work
Leader standard work and Daily Management Systems are the Management Systems that sustain our improvements
Engagement – the base of the OPEx house – is one part of the Mindset that will change how we think about the way we work. Mindset will be the biggest driver in reaching hospital excellence with OPEx.

5. OPEx core elements
Methods are the most discussed, but least important part of improvement efforts
Management system structures strategy deployment, operationalizes use of methods
Mindset is the most challenging, but most important element; requires long-term effort

6. Respect and Engage Everyone in Waste Reduction
Lean Healthcare Principles
Level Load the Work
Standard Work
Continuous Flow:
Pull vs. Push
Patients and Families First
“Just In Time”
Right service in the right amount at the right time in the right place
Eliminate batches
Rapid Changeover
“Built In Quality”
Make problems visible
Never let a defect
pass along to the next step
Error Proof
Stop when
there is a quality problem
5S and Visual Control
Respect and Engage Everyone in Waste Reduction

7. Lean is Customer Focused Strategy that Improves Quality, Cost, and Response Time by Removing Waste
The “relentless pursuit of waste” as competitive leverage
Uses the least amount of resources to create the greatest possible value for the customer, makes value flow
A culture of respect and never-ending improvement at all organization levels

8. Definitions of Waste Waste Definition Transportation
Unnecessary movement of materials or supplies
Inventory
Supplies, equipment, or information not needed by the customer now
Motion
Unnecessary movement of people
Waiting
Delays in the value stream (absence of flow)
Over processing
Work that creates no value
Overproduction
Producing more than customer needs right now
Defects/Poor Quality
Product or service that does not conform to customer requirements
Concept:
This is the first step in becoming “waste-ologists”.
Review:
Transportation – movement from one place to another
Inventory – particularly insidious and costly. Why? (takes up valuable space, things expire, there’s a value to the inventory itself, and it has to be managed. Someone has to keep track of that stuff) Do we tend to have a “just in case” mentality when it comes to inventory? Comes from fear of not wanting to run out.
Motion – movement such as reaching and searching

9. The Importance of Standards
Provide a common understanding of the process – the right way to do the work
Improve predictability of results
Make abnormal vs. normal clear
Enhance problem solving
Why do people use different methods?
Because:
a) there is no standard,
b) there is a standard, but the person is not capable of using it (not trained ), or;
c) there is a standard, and the person is not committed to using it.
So it is really the absence of trained, followed, committed standards that cause most variation, not people.
Taichi Ohno is considered the father of the Toyota Production System. His observation was that we need a stable base from which to make improvements, otherwise we have poor focus in our improvement efforts– shooting at moving targets.

10. 5S for Workplace Organization
Sort
Separate the needed from unneeded items
Simplify
Create a place for everything and a way to keep everything in its place
Sweep
Create visual controls and indicators to easily determine normal and abnormal conditions
Standardize
Document methods and procedures to maintain the system consistently
This slide shows English translations of the original Japanese words that begin with S.
The Ss together form a system that supports becoming organized, efficient and safe
The first S ensures we have everything we need and nothing we don’t need.
The second ensures that everything is in its place, ready to use.
The last three Ss support doing this every day in every place and not backsliding.
Sustain
Ensure disciplined adherence to standard work to prevent backsliding

11. South Operating Room Patient Value Stream

12. Improvement Events (Kaizen) - completed
Properly Prepared Patient
(patient is ready for surgery and OHSU is ready for the patient)
Surgical Practice Clinic
O.R. Scheduling
Pre-operative Medicine Clinic
Pre-Operative Unit
South Operating Room
Peri- anesthesia Recovery
Surgical Patient Flow & Experience
Improvement Events (Kaizen) - completed
Information to patient & family
Properly prepared patient 2.0
Recovery duration
On-time 1st case start
O.R. Turnover Time
PMC capacity
Properly prepared patient 1.0
Anesth Ready to Proc Start
Intra-op documentation
Procedure
card
Work place organization
Inventory Management
Standard Work and Daily Management Systems (DMS)
future
Tray replenish.
Proc
Start to Proc End
Level loading across the week
Level loading within the day
In Room to Anesth Ready
Proc End to Room Exit
Consolidate instrum.

13. Pre-op Medicine Clinic
Surgical Practice
Pre-op Medicine Clinic
OR Scheduling
Admitting
Standard information
Epic/MyChart
Website
Handout
Confirmation Call
Align surgical practice, OR scheduling
Standard letters
Practices have same elements
Visual way finding
Training to appropriate staff
ICARE
Unit-specific signature moments
Patient

14. Standard Work for First Case Starts: Patients, 6A Staff, SOR RNs Anesthesia, and Surgeons
Consistently monitor and countermeasure
Highlights:
Daily Huddles leading to interdisciplinary communication and collaboration
Daily Management Systems trending and addressing abnormalities
Focus on evaluating standard work and workarounds

16. Standard work for eight different roles Initial improvement, sustained
Larger barriers had specific work to:
Address gaps in schedule
Signaling for the next patient
Next steps to address “longer” delays

19. Executive Summary Performance Transformation Next improvements
SCIP
Patient Experience
System to improve further
Efficiency improvement
Turnover time
First case starts
5S of O.R, cores, and workrooms
Preparation of and for patients
Pre-operative Medicine Clinic capacity
Outpatient mix in SOR
No events focused on this yet
Next improvements
Intra-op times (all segments from patient entering the room until patient leaving the room)
Level loading the OR
System-wide support and effects (hospital loading, outpatient clinic schedules)
Mindset Transformation
Events have engaged
Surgery practices, Scheduling, PMC, SPD, Pre-Op, OR personnel, Logistics
Events pull in new staff and managers
DMS is throughout Periop
“Deeper” problem solving and escalation may need further improvement
Primary metric is, “How many of our patients weren’t clinically prepared and how many of our patients were we not ready for today?”
The pace and capacity for change is growing

20. Kaizen Event: In Room to Anesthesia Ready

21. Anesthesia Ready
Anesthesia Ready occurs when the patient is anesthetized and stabilized for the team to proceed to positioning, prepping and incision.
Some anesthesia procedures may be completed after anesthesia ready based on the patient condition and requirements of the case.

22. Breakthrough Kaizen Charter: In Room until Anesthesia Ready
Problem Statement: The time between a patient entering the Operating Room until the procedure starts has high variation in workflow and timing. This portion of the value stream can be broken up into two segments, “in room to anesthesia ready” and “anesthesia ready to procedure start”. The former segment includes the time after the patient enters the room until the anesthesia provider’s activity is sufficiently complete so that the case may progress towards procedure start. Variation in practice contributes to increased OR costs, patient safety risk, and unpredictable case duration (in room to out of room). This contributes to poor scheduling accuracy, delayed cases, and dissatisfaction of patients and personnel.
Goal/Target:
Reduce the mean time from In Room to Anesthesia Ready in OpTime from 23.3 minutes to 18.3 minutes. (This number should be adjusted based on the percentage of complicated
cases as compared to more straight forward cases; the more longer cases, the more opportunity.)
Reduce the range of the 10th (9 min) and 90th (45 min) percentile from 36 min. to 30 min. 10th percentile to 8 min. and 90th percentile to 38 min.
Reduce the range of the 25th (13 min) and 75th (29 min) percentile from 16 min . to 13min. 25th percentile to TBD and 75th percentile to TBD.
All changes will promote efficiency and safety from along the time line of turnover through procedure start:
first case start (80%)
turnover time (44 minutes)
anesthesia ready to procedure start (27.6 minutes)
Total time (Turnover + In Room to Anesthesia Ready + Anesthesia Ready to Procedure Start) = = 95 min
Objectives:
Break down the elements from In Room to Anesthesia Ready
Implement standard work for all roles involved between “In Room” until “Anesthesia Ready” .
Standard work to include who, what their responsibility is, and when it should occur.
Include standard work for different situations (split rooms, first cases, second cases, vascular access/monitoring, etc.)
Remove waste in the process (provide specifics during the event; e.g. reduce motion related to ______)
Maintain or improve patient safety(CLABSI rates, line placement compliance, adhering to checklist utilization, patient transfer to OR table)
Provide the above data by individual and service factoring in important characteristics such as: invasive monitoring/access, anesthetic type, patient BMI and patient ICU status (+/- mechanical ventilation).*
Accommodate appropriate training in the context of safety and efficiency.
Used improved communication between anesthesia and surgery to optimize decision on invasive line placement.
In Scope
All days, all times (limited)
From doc of “in room” (circ) to “anesthesia ready” (anes . provider)
Emergent cases (limited)
GI cases
ICU patients
SOR cases
Improvement Team
Anesthesia Staff: Aziz, Robinson
SOR Circ.RN: Conley + Choi
Anesthesia Resident: Ross Martini
Surgical Resident: Jesse Liu
CRNA: Livingston, Snow
Surgical PA: Paula Wilson
Anesthesia Tech: Jonny Sands
Out of Scope
Pediatric cases staffed by DCH (under 12 yrs. Age)
“Anesthesia Ready” to “Proc Start”
Other OR sites
Labor and delivery
* = Implementation Coaches
Admin Support, Measurement Specialist, Financial Analyst
Mac Eggling
Key Stakeholders
Mark Zornow, Bob Cross, Jeff Koh, David Larsen
Resource Representatives
Blue Blake
EVS: Winans Stojanovic
Nate Seldon
Mary Munoz
Neuro monitoring
Linda Knox
SPD
Bob Hart
Joanne Girard
6A RN
Ahmad Raslan
Project Sponsor: Jeff Kirsch
Management Guidance Team: EMG, Core Team
Process Owner*: Steve Robinson; Mike Aziz
Facilitators: Randy O’Donnell, Rayna Tuski, Grace Ullum, Shauna Hoffman
Sponsors and Process Owners are MGT members
Key Dates:
Assessment: 05/28 Planning: 06/16-06/17 Go/No Go: 06/17 Event Date: 07/21-07/25
Follow Up Day/Time: 30-day________________ day_________________ 90-day__________________

23. Key points:
The “house” is built on the “True North” elements of OHSU’s approach to performance improvement.
“True North” elements are what we will constantly measure ourselves against.
The purpose of performance improvement—at right—is supported by seven philosophy statements.
Each statement builds on the previous one: Together, they form an argument about how OHSU is choosing to do improvement.

24. Standard times Patients Min Total Weighted time
Base time without complexity
13,174 11
144,914
ICU
1,524 6
9,144 1
Difficult airway
1,317 3
3,952
Art
3,244 5
16,220
CVL
1,833 20
36,660 PA
122 7
854
Teaching
2,635 10
26,348 2
238,092
18.1
Average

25. Process sequence

26. Pt Movement Nurses Team Synergy Anesthesia Surgeon Room Equipment
& Supplies
Pt Movement
Nurses
Review Implants & supplies in
room
*Questions about Position, no surgeon
* Right suture- needs during Anes
* Motion, Leaving Rm for supplies
* Reclipping, shaving site
* Positioning Equip
* Transferring Pt back & Forth
* Extra Time for IV setup
*Ask for appropriate ABX
*Untangling Cord , gowns, & lines
*2 Circulators perhaps wasteful
* Repositioning
* Missing Items from Case Cart
* Reworked supplies
* Reposition Bed
*Microscope Not working
*Reaching for Carts, supplies
Waste During IR to AR
* Delay in Prep
*Surgeon leaving
* Unsure how to position, drape
* Working on other pts, not in room
* Waiting for Anes. Attending
* Positioning Communication w/ surgery services
* Anes Tech , wait 12 min for A line
* Unsure If Ok to start w/out Attend
* Unsupervised Broc
* Not knowing surgical plan
* Order of Operations for line placement
* Surgeon Resident 20 min late
* Waiting for surgeon to cut
*Surgeon Needs: Epidural?
* Low assistance from team
* Attending moving lights after positioning
*Improper location of Anes equip.
*Residents booking cases they don’t understand
* Low lateral processing
* Anes Tech traveled to get ABX
* Team not hearing “Anes ready”
Team Synergy
Anesthesia
Surgeon

27. Pre-Op and Nursing standards
Projects
Huddle Go-Live
Pre-Op and Nursing standards
Standard Work for patient flow for all roles
Surgeon Standards
Anesthesia Standards and Anesthesia Workspace

28. 1. Huddle Go-Live
Issue Description: Variation in practice contributes to increase OR cost, patient safety risk and unpredictable case duration.
Post Improvement Benefits: The team huddle will improve communication between the surgical team, anesthesia team and staff with regard to critical needs in order to prepare the next patient for surgery.

29. Time Estimator Tool In room to ETT Artline CVL PA IV Standard 7-10 5
Time Estimator Assistant
In room to ETT
Artline
CVL PA IV
Standard
7-10 5 15 3
Learner
+3-5
+5-10
Difficult
+5-15
Fiberoptic
+10-15
BMI>35 +5
subtotals
Total
For use to help more accurately estimate time from entering the room to anesthesia ready
If an activity is after AR, assume 0 for purposes of estimating AR
This is just a tool.

30. 2. Pre-Op
Issue Description: Currently, there is an unreliable method of communication to assess status of previous OR case and determine precise time of patient rollout. 6A OR
Post Improvement Benefits: This change in standards and expectations will improve communication between OR Nursing staff and Pre-Operative Nursing staff to potentiate patient preparedness for the OR and improve patient satisfaction.
Patient

31. 3. Anesthesia Set-up
Issue Description: Lack of standard set-up contributes to less preparedness and more time spent gathering items post induction pre-anesthesia ready.
Post Improvement Benefits: This standard will decrease motion and time, and provide consistent expectations for quality of patient care.

32. 4. Standard patient workflow

33. Arterial line Be sure it is indicated Is it needed: before induction
after induction
after incision
Pre-order; cart set up
Prep as soon as feasible (even during induction)
Attending AT
Circulator/scrub (ask Rayna)
Two tries then escalate
Ultrasound
Expert provider/alternate attending
Consider abandoning the procedure and develop an alternate plan

34. Proper equipment in the room Call for additional help whenever needed
Difficult Airways
Proper equipment in the room
Call for additional help whenever needed
Two attempts then escalate
Alternate techniques
Alternate provider
Alternate airway, alternate plan, or abandon procedure

36. Standards in detail Nursing standards
SCD’s, Warm blankets, Hovermatt, and Slip
Workflow
Parallel activities
Leads huddle
Surgeon Standards
Attendance
Automated page
Previous case huddle prep
Anesthesia Standards
Teaching
Central line setup
Andon escalation
Automated paging with Vocera escalation

37. Implementation Plans 1. 6A 2. Anesthesia 3. OR Nursing 4. Surgeon
Further education for implementation of new standards/expectations to be done by 30 day follow up
2. Anesthesia
Add to grand rounds
notification to staff from Steve and Mike
3. OR Nursing
Nursing standards at next service coordinator meeting
Following the service coordinator meeting, disseminate at 0655 service coordinator huddles
Huddle go-live presentation at next service coordinator meeting, disseminate at 0655 service coordinator huddles
4. Surgeon
Disseminate via to surgeon chiefs and presented at the next available surgeon chiefs meeting
Include in roadshow faculty meetings
5. Anesthesia techs
Attend staff meetings to verify new standard work and evaluate abnormalities with anesthesia techs availability

38. Thank you! Questions?