The “swim lane” mapping process also helped Sandra Feiner, R.N., communicate to her coworkers the importance for nurses of interviewing patients before they’re sedated, even though the work may at first appear redundant. “We’re doing one last double check of important documentation and making sure the patient is 100 percent ready for surgery,” says Feiner, who oversees care in the otolaryngology ORs. “Those few minutes while the patient is still awake is also our chance to get to know them a bit, meet their families, and reassure them they’re in good hands.”
Bradford echoes her colleagues’ sentiments. “It was freeing, actually, to all be pulling in the same direction,” she says. “Creating a team of people who trust each other and who can ask questions and work together as a team is probably the most important take-away from this process.”
The anecdotal evidence is backed up by data. The study measured staff morale, feelings of support, and thoughts about problem-solving on a five-point scale before and after the lean implementation. Progress was made in every category, with the composite score rising from 2.93 to 3.61 — an improvement of more than 20 percent. The research also surveyed surgical residents and found that the increased emphasis on efficiency did not have a detrimental effect on their education. More importantly, perhaps, they’ll carry their experience with lean philosophy into their future careers, says Bradford.
In their search for valueless work, or muda, Bradford and her colleagues identified several places where time was being wasted. Each was relatively small and simple, but collectively made a significant impact. For example, time could be lost when anesthesiology faculty who were responsible for multiple rooms were not immediately available to induce a patient. Though not appropriate for every case, one underutilized option was to use the overhead paging system to call for another faculty member to assist.
“Interestingly enough,” confides Healy, “that system already existed. The surgeons in the OR weren’t always aware it could be done and we anesthesiologists just assumed they knew about it. That’s one of the key things we learned — that we all probably assume too much.”
Meanwhile, ORs were sitting empty between the completion of cleaning and the arrival of the next patient. “One of the easiest changes was to say ‘room ready’ about 10 or 15 minutes earlier so that the transportation could be done in parallel with the last part of the room preparation,” says Bradford. As a result, OR turnaround time — the time from the end of dressing one patient to the first incision on the next patient — fell from 89 minutes to 69 minutes. “When you’re doing several cases a day, that can make a huge difference,” she says.
The time savings also led to financial gains from reducing by half the number of cases that finished after 5 p.m. and required overtime for hourly workers.
The right system, the right culture
Although he wasn’t a doctor, what naturalist John Muir said of the entire universe is equally true of health care systems: When you try to pick out anything by itself, you find it’s hitched to everything else.
Creating 6,500 hours of new operating room capacity would also require having enough inpatient beds for all those new patients. As problems are addressed, bottlenecks shift downstream: Work hard to fix delays and make sure all your morning cases start on time, and you may discover they’re now backing up in the recovery room.
“The U-M has been so successful that we don’t have enough beds and operating rooms to easily accommodate all the patients who want to come here,” Mulholland says. “So the top-priority projects within the surgical value stream deal with capacity, which can be improved by more efficient and coordinated use of our physical assets.”
Going lean also means changing some of the traditional ways of thinking about medical practice. “Hierarchies are being flattened, and for good reason,” Mulholland says. “It’s a reflection of the world we live in. In the operating room there will always be differentiation. The anesthesiologist will put the patients to sleep, the surgeon will wield the scalpel, but they all share knowledge. One group is not smarter than any other group.”
“We always go around and introduce ourselves by our first names,” explains Bradford. “In the OR, I’m Carol, not Dr. Bradford — even through some of my residents have a hard time getting used to that.”
Recently Billi, also associate vice president for medical affairs, got to see hospital operations from a new perspective. “It was really enlightening and humbling to actually be a family member of a patient,” he says.
Billi observed nurses running back and forth because there wasn’t enough laundry, being diverted by call lights going off because meals weren’t delivered on time, and sorting things out after a patient’s X-ray was scheduled at the same time as a blood transfusion. “You have these nurses who are incredibly talented and capable, who are spending time doing these workarounds, and they probably don’t see them as workarounds because it’s been the standard way of getting the job done,” he says.