Surgical Scheduling: A Lean Approach to Process Improvement ROSS WILLIAM SIMON, BA; ELENA G. CANACARI, RN, CNOR
ABSTRACT A large teaching hospital in the northeast United States had an inefficient, paperbased process for scheduling orthopedic surgery that caused delays and contributed to site/side discrepancies. The hospital’s 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 patient’s preoperative visit in the surgeon’s 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. AORN J 99 (January 2014) 147-159. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.10.008 Key words: scheduling, orthopedic surgery, Lean.
B
efore February 2010, Beth Israel Deaconess Medical Center in Boston, Massachusetts, had an inefficient, paper-based process for scheduling orthopedic surgery. This process caused several issues: n
n n n
n
There was a three- to five-day lag time between patients knowing they need to be booked for surgery and being called by the office, and urgent bookings were put on a wait list, creating periods of uncertainty for patients; cases were backlogged; interdepartmental communication was poor; booking information was inaccurate and booking times were scheduled in more than one room with the same surgeon; and last-minute changes in procedure sequence led to waste and workarounds.
In addition to this, the facility was experiencing a 4% occurrence of site/side discrepancies in the preoperative clinic and 2% occurrence in the OR as well as frequent patient cancellations. These problems were significant enough that hospital and perioperative leaders decided that creating a formal team to address them was justified. Members of the team who developed the new orthopedic scheduling process, what parts of the process they represented, and any other roles they played on the team are shown in Table 1. As a result, while we were developing an automated booking system for ORs, the team also worked to improve the orthopedic surgical scheduling process, reduce patient cancellations, and reduce or eliminate site/side discrepancies. The project took place from February 2010 to March 2011.
http://dx.doi.org/10.1016/j.aorn.2013.10.008
Ó AORN, Inc, 2014
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TABLE 1. Members of the Team and Their Roles Job title
Represented
Chief administrative officer, orthopedics Administration manager, orthopedics Administrative assistant, surgical scheduling Anesthesiologist Associate chief nurse, perioperative services
Administration Procedure scheduling Procedure scheduling
Central processing department supervisor Clinical advisor, orthopedics Clinical manager, scheduling operations Senior management engineer
Surgical kit preparation and case pick
Orthopedic surgeons (2) OR scheduler OR systems administrator
Clinic, office, and intraoperative process OR procedure scheduling Process data extraction
Team co-leader
Preoperative and intraoperative process Central processing department, preoperative clinic, and OR process
Team co-leader, acted as a knowledge resource, assisted with strategy, sponsored the project, broke down barriers to progress
OR setup and intraoperative processes OR procedure scheduling Team facilitator, helped with problem solving and statistical analysis
Using structured Lean problem-solving techniques, the team developed and launched a safe, effective, patient-centered, timely, efficient, and accurate orthopedic surgical scheduling process. In the analysis phase, the team mapped out the process, starting with the patient’s call to schedule an appointment with the surgeon through preoperative activities onsite, and identified existing problems and opportunities for improvement. Then the team organized the myriad problems into logical groupings and prioritized these according to impact, which provided a strategy for moving forward with solutions. The team reviewed and created solutions for all of the identified problems, using an activity scorecard and a timeline for corrective action implementation to drive progress. The new process has solved several of the identified problems, such as eliminating site/side discrepancies and lag time between knowing the patient needs to be booked and then contacting the patient, reducing day before and day of cancellations, and reducing the frequency of procedure sequences being changed. The following article describes the process used to develop the plan to address this 148 j AORN Journal
Other roles on the team
Helped with statistical analysis
improvement opportunity, conduct the work, and the accomplishments. BACKGROUND Our facility is a large academic medical center located in the northeast United States. It is a level 1 trauma center with three operating suites and a total of 38 ORs, in which we care for all types of adult patients, except for those needing lung and heart transplants, for a total of 27,000 procedures per year. In addition to internal scheduling difficulties and inefficiencies, our facility was experiencing a 5.1% cancellation rate before the process improvements. In fact, patient-related causes are the most frequent reasons for cancellation of orthopedic procedures. In our review of patient reasons for cancellations within 48 hours of surgery, we learned that most often patients cancel because they change their mind about having surgery. Sometimes they cannot get a ride. Team members perceived that patients equated surgical appointments with other types of appointments (eg, the dentist) and were unaware of the effects of cancelling. Cancellations can have an
SURGICAL SCHEDULING: A LEAN APPROACH effect on other patients, for example, and cancelling within 48 hours affects the functional operation of the OR, because surgeons’ instrument kits that were prepared and delivered to the OR have to be brought back to the central processing department, unpacked, and stored, which creates work that does not add value. In the event of cancellations, OR schedulers also must juggle the schedule to accommodate the procedure order, leading to more nonevalue-added work and, sometimes, a reduction in OR usage. The team collected data from our perioperative information management system. Key metrics we monitored included n
the total number of site/side discrepancies, n the lag time between a surgeon knowing the patient needs to be booked for surgery and the orthopedic administrative assistant contacting the patient, n total procedure cancellations and the percentage that are cancelled the day before surgery, and n instances of changing the sequence of procedures less than 48 hours before surgery. In improving the orthopedic surgical scheduling process, we also wanted to improve patient safety. Before starting this project, site/side discrepancies in the preoperative clinic occurred in 4% of procedures and in 2% of procedures in the ORdunlike the new system, the old system did not require surgeons to enter side and site in real time when scheduling a surgery. One regulatory consideration that drove us to address site/side discrepancies was the Universal ProtocolTM for Preventing Wrong Site/Wrong Procedure,1 which is accessible as part of the National Patient Safety Goals.2 Additionally, the American College of Surgeons issued a statement that contains the following: “The American College of Surgeons (ACS) recognizes patient safety as being an item of the highest priority and strongly urges individual hospitals and health organizations to develop guidelines to ensure correct patient, correct site and correct procedure surgery.”3(p26) In addition to this, AORN created
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the AORN Comprehensive Surgical Checklist, which incorporates the World Health Organization’s checklist and The Joint Commission’s safety requirements for the Universal Protocol in a single document.4 GOALS Before the team was selected, we established three main goals for performing a quality improvement project: n
develop a safe, effective, patient-centered, timely, efficient, and accurate orthopedic scheduling process (ie, requirements that mirror elements of “The Six Domains of Healthcare Quality”5); n smooth the schedule so that block time allocation is more even across the days of the week, maximizing efficiency and utilization; and n improve patient safety by ensuring correct site/ side. We also incorporated the Lean process into our plans from the beginning. To make trends visible, we made extensive use of charting, graphing, and Pareto analysis (ie, a special form of vertical bar graph displaying the relative importance of all the problems or conditions with the most important on the left) to prioritize the problem-solving approach. Our patient cancellation data are displayed in Figure 1. ABOUT LEAN The term “Lean” was coined to describe Toyota’s business during the late 1980s.6 In Lean processes, a cross-functional team uses simple, structured problem-solving tools, often referred to as “Lean tools” or “the seven quality tools,”7 to move smoothly from problem identification to solution development and finally to ensuring that the implemented improvements will not fall out of use and allow the original problems to resurface. Successful Lean health care projects start with a clear definition of the project, often called a project charter (see Supplementary Figure 1 at http://www.aornjournal .org). AORN Journal j 149
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Figure 1. Patient-related causes were the most frequent reasons for cancellation of orthopedic procedures, although there were numerous reasons a patient might cancel within 48 hours of surgery.
The project charter should be drafted by those who have key knowledge of the problemdor opportunity for improvementdand the supervisors of the likely team members. We chose to use the term opportunity for improvement in place of problem for philosophical reasons. The word problem is perceived negatively, and Lean is rooted in the spirit of continuous improvement, where problems are embraced as opportunities for improvement rather than seen in a negative context. Lean leaders view problems as great opportunities for improvement. Essential elements of the project charter include n
n n n n
a description of the problem, providing the background and justification for working on the project; clear, measurable goals; a projected project completion date; a suggested approach; metrics that quantitatively define the problem or opportunity;
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n
team composition, including a leader, a facilitator, and a sponsor or sponsors who serve as resources if the team runs into a roadblock; and n a list of the major steps in the process, usually six or fewer.8 The Lean process provides a set of management principles that defines a way to manage projects. For example, improvement projects should not be conducted by only a select few champions in an organization; successful Lean improvement projects include those who do the work. The underlying belief of the Lean process is that the people who do the work know it best, and they should be given the authority to improve their work processes.9 The process knowledge and experience of those who do the work is far more valuable in both problem-solving and successfully implementing solutions than having members who have only peripheral contact with the work. Additionally, we found that members of the team do not need to have a deep knowledge of Lean principles
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Figure 2. In this excerpt from the swim lane process map used during a project to improve orthopedic surgery scheduling, the boxes represent steps in the processes and the hexagons represent problems identified when creating the process map. Process steps are included in a horizontal row dedicated for a particular department or function.
to be successful; they can be highly productive contributors to the project without spending hours in Lean training classes. The best way to learn about Lean is to participate in a well-facilitated improvement project during which the team moves through identifying problems or opportunities for improvement, generating solutions, and maintaining the improvement phases. METHODS At the first team meeting, the team facilitator, Ross Simon, senior management engineer, delivered an overview of Lean principles. Throughout the project, the facilitator offered problem-solving tools to help the team move swiftly and efficiently through the process. We overcame barriers by engaging stakeholders. Physicians served as champions to help design and pilot test the online surgical booking system. The
pilot test work started with a group of orthopedic surgeons who embraced the technology. We also brought in others, including administrators who worked for the surgeons. The team drove the process and did the work. For the first three months, the team met weekly for one hour to review the status of action items and decide what we needed to do next. After this initial period, we met every other week or monthly to ensure that the new process was working well. Our last formal meeting was held a year after the first meeting. Team meetings were primarily strategic; other than the few activities that we had to do together, such as brainstorming, we did the work outside of our regular meetings. By doing everything that we could outside of meetings, we maximized the usefulness of meeting time by using it strategically, identifying the status of activities, and collectively deciding on the next step. AORN Journal j 151
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Figure 3. Excerpt from a cause and effect diagram used during a project to improve orthopedic surgery scheduling. A cause and effect diagram can be used to help a quality improvement team consider any additional problems and root causes that might not be identified with an annotated swim lane process map.
Process Mapping As appropriate on most process-related Lean improvement projects, our first team activity was to meticulously list the process steps and note problems and opportunities for improvement associated with each step. During process mapping, the focus is on discovering the current processes of an organization, establishing the root cause problems with those processes, and looking for solutions.10 It was important that the team agree on the current process and issues so that we could develop robust solutions together. We found that people often disagreed or misunderstood the processes that we had in place, so mapping out the process provided an opportunity for us to appreciate each team member’s role and to annotate process steps to identify problems and opportunities for improvement. The team used a swim lane process map to document our processes (Figure 2). Swim lane diagrams were proposed by Geary Rummler and Alan Brache in their 1990 book Improving Performance.11 This method of diagramming facilitates plotting and tracing processes quickly 152 j AORN Journal
and easily and, in particular, displays the interconnections between processes, departments, and teams.12 As is typical of most complex processes, our swim lane process map included 84 process steps, 48 problems, and 13 opportunities for improvement. Next, we used a cause and effect diagram (Figure 3) to help us consider any additional problems and root causes we might not have identified with the annotated swim lane process map. Commonly called a fishbone diagram, cause and effect diagrams illustrate the factors affecting a process by sorting out and relating the causes of a problem.13 Every effect is likely to have several major categories of causes. The major causes in these diagrams often are summarized into four categories: people, machines, methods, and materials.14 Lean practitioners later added “environment” to include the workplace. To complete this diagram, team members placed all of the problems and opportunities for improvement that we identified in the swim lane process map next to the appropriate rib on the cause and effect diagram. Then we asked
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Figure 4. In this affinity diagram, the team split identified problems into seven groups. The types of solutions used to address each problem precede the problem on the diagram. AORN Journal j 153
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ourselves what we were missing that fell into the categories of methods, materials, manpower, machinery, and the environment. In using Lean methodology, it is important to lay out all of the problems before jumping to solutions. As usually happens with this type of process, we added additional causesdspecifically, we noted additional causes that contribute to inefficiency, inaccuracy, and lack of timeliness in the orthopedic surgical scheduling process. Our completed cause and effect diagram contained more than 50 problems. The number of problems we identified seemed daunting. To get a grasp on all of the issues, the team used an affinity diagram to organize the problems into logical groupings15,16 (Figure 4). We split the problems into seven logical groupings (ie, patient information, patient access, administration, scheduling, physicians, roadblocks, equipment). Placing seemingly disparate problems into logical groups reduces the number of problems into manageable groups, eliminates redundancies if problems are identified more than once earlier in the process, and helps ensure that the solutions developed later will address the broad scope of related problems. As the team developed and implemented solutions to the problems, we annotated each to indicate work that had been completed or was under way. As an example of how we grouped problems, the following fell into the category of patient information: n n n n n
the number of patient identifiers that are required, incorrect patient contact information, ineligible insurance, incorrectly spelled names, and missing orders for preadmission testing.
Prioritizing and Developing Solutions To develop a strategy for solving the problems, the team prioritized the categories according to how difficult they would be to solve and how much they would help us to meet our goals when they were solved. The team agreed to create an impact analysis chart based on Leankaizen methods,17 shown in Figure 5, for this purpose. 154 j AORN Journal
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Figure 5. An impact analysis grid can help identify which solutions will have the highest impact and the least difficulty to implement. Solutions to problems in the upper-left corner of the grid, for example, are both high impact and low difficulty.
To start, the team developed solutions to problems that fell into the upper left corner of the grid (ie, high impact, low difficulty), such as the lag time created when scheduling forms completed by surgeons were batched and brought from the clinic in one building to another building of the medical center where orthopedic administration is located. By completing this process, we achieved early and meaningful wins, such as reducing the number of last-minute changes by surgeons, which helped maintain order in the central processing department. These early wins helped the team maintain a high level of energy and morale, which is important because complex projects like this one may require several months to complete. Defining Tasks and Communicating Progress The team used an activity scorecard to define and communicate all of our tasks (Figure 6). The scorecard includes a short title for the task, the issue being addressed, the next activity to address the issue, the task’s priority relative to all of the other tasks,
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Figure 6. An excerpt from an activity scorecard used during a project to improve orthopedic surgery scheduling. Columns in the scorecard are (from left to right) the task number, short title of the task, the issue being addressed, the next activity, the task priority versus other tasks, who is responsible for completing the work, the target completion date, and the current status.
the name of the individual or individuals who are responsible for completing the task, the target completion date, and the current status. During team meetings, whenever the team identified an action that needed to be taken, it was entered onto the activity scorecard so everyone could see it. The scorecard, used instead of traditional meeting minutes, was updated and redistributed after each meeting. This helped us drive progress, keep members focused during team meetings, and add a sense of accountability to those who took on the tasks. In addition to the activity scorecard, we also used a graphical depiction of a simple implementation plan (Figure 7) as a timeline for key action items. This plan provided an overall view of the most important tasks. The team used it to help reinforce accountability by highlighting the timeliness of responses to planned work. RESULTS The differences between our original, paper-based orthopedic surgical scheduling process and the new online process were significant (Table 2). The new process gave our facility several benefits. The lag time between the surgeon knowing a patient needs to be booked for surgery and the orthopedic
administrative assistant contacting the patient was decreased from three days to less than one day. Improving process flow by eliminating batching (eg, our process where booking forms were collected over a period of days and then brought as a batch to the administrative assistant, who then contacted the patient) is an underpinning of Lean philosophy. Lean terminology includes “one-piece flow” or “single-piece flow,” which means that in a perfect flow environment, the product (or patient) would move in batches of one, because this minimizes delays.18 Now, because the surgeon completes booking online after seeing a patient, the booking is immediately visible to the orthopedic administrative assistant, and lag time is minimized. If patients decide to have surgery late in the afternoon one day, they will be called the next day to validate preoperative clinic and surgery dates and times. To address no-show and last-minute cancellations, the team adopted a practice used in the outpatient clinic at the medical center: we started including a notice in the surgical confirmation letter to patients stating that a $250 fee will be charged for cancellations within less than 48 hours before the scheduled appointment time. We have not charged any patients the $250 fee to date, but we have AORN Journal j 155
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Figure 7. A graphical depiction of a simple implementation plan can be used as a timeline for key action items during a process improvement project.
TABLE 2. Orthopedic Surgical Scheduling Process Flow Topic
Before
Timing of the surgeon The surgeon scheduled his or her surgeries on 5 scheduling surgery different paper booking forms. Surgical scheduling Scheduling forms were batched and brought from process the clinic in one building to another building on the medical center campus, where orthopedic administration is located. Contacting the patient Patients were contacted by the orthopedic adminafter his or her visit istrative assistant to schedule the day of surgery 3 with the surgeon to 5 days after the patient’s visit with the surgeon. Surgical consents and Regular faxes of consent and patient information patient information often were lost or unavailable. Special equipment
There was no standard format for listing special equipment needed for surgery. Site/side discrepancies There was a 4% occurrence of site/side discrepancies.
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After The surgeon schedules surgery online in real time. The surgical schedule is visible online in real time to the orthopedic scheduler.
Patients are contacted by the orthopedic administrative assistant within 1 day of the patient’s visit with the surgeon to schedule surgery. Consent and paperwork are electronically faxed and available throughout the patient’s perioperative experience. The listing and selection of special equipment is clear and concise in the online booking system. Because booking is in real time with the patient in attendance with the surgeon, there are no site/ side discrepancies.
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Figure 8. Patient cancellations within 48 hours of surgery were reduced between June 2009 and October 2010 as a result of the improved orthopedic scheduling process.
Figure 9. The number of instances of physicians changing the sequence of procedures within 48 hours of surgery was reduced between January and June 2010 as a result of the improved orthopedic scheduling process.
reduced the patient cancellation rate by 35%, from 5.1% to 3.3% (Figure 8). In addition to scheduling advantages, the new online booking system also helped with site/side discrepancies and dropped our occurrence of this error to zero. The online booking system is set up
such that the surgeon cannot bypass specification of site/side in the booking workflow, and the system forces physicians to think about the side of a surgery in real time, while he or she orders the booking and while the patient is in the office. In our previous system, the surgeon had to remember the AORN Journal j 157
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side at the end of the clinical day when he or she filled out paperwork for several patients. Before the implementation of the new process, we had an average of four procedures per week during which a site/side discrepancy was caught in preadmission testing and two per week caught in the preoperative area; after the new process was implemented, both went to zero. As is the case when patients cancel surgery within 48 hours of its scheduled start, supplies, time, and manpower are wasted when surgeons change the sequence of procedures less than 48 hours before surgery. The new process made the problem more visible to surgeons, so the team reduced the instances of changing the sequence of orthopedic procedures by 70%, from 20 occurrences per month to six occurrences per month (Figure 9). As an added benefit of the online scheduling system, patient satisfaction increased with the reduced delays. When we began the project, patient satisfaction, as measured by the Press Ganey metric of “likelihood to recommend,” was very good at 67.6%. At the completion of our project a year after starting it, we increased the score by nearly 20%, to an average of 84%. CONCLUSION Changing the culture of an organization to support a Lean approach to process improvement is not easy. Lecturing personnel on Lean principles will provide a foundation for Lean; however, personnel will not be convinced of its value or become proficient in the use of Lean tools and techniques without participating in well-facilitated process improvement teams that work on real, challenging problems and implement sustainable solutions. Work accomplished by the orthopedic surgical scheduling team has moved the medical center forward in this direction. Our facility has seen an increased spirit of collaborative partnerships and understanding of roles, a new mindset that views problems as opportunities, creative new solutions to old problems, an eliminated silo mentality, best
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SIMONdCANACARI practices shared between teams, a more team- and goal-oriented culture, and stakeholders who are empowered to solve problems. Practical examples of our accomplishments include that our project team developed an efficient, accurate, and timely orthopedic scheduling process; reduced day-before and day-of cancellations, reduced procedure sequence changes, increased patient satisfaction, and eliminated the disorganized schedule, which had caused us to be unable to get orthopedic procedures onto the schedule for four consecutive months. The online system also reduced schedule changes made by surgeons within 48 hours because it allows surgeons to review the surgery schedule proactively online in real time. The new process allowed us to allocate a dedicated block for urgent/emergent plastic orthopedic hand trauma and pilot test a preoperative clinic faxing/scanning project, and the new process improved the relationship between scheduling and orthopedics personnel to promote collaboration. We focused on orthopedic surgery scheduling with this project, and online scheduling has had such a positive effect on performance in orthopedics that work is under way to implement the process in other services at the medical center. The importance of improving patient safety with respect to site/side discrepancies created an urgency that facilitated moving this project forward. Regardless of the many advantages the new project has provided, without that sense of urgency, it has been a challenge to spread this process to other services in the medical center. SUPPLEMENTARY DATA The supplementary figure associated with this article can be found in the online version at http:// dx.doi.org/10.1016/j.aorn.2013.10.008. Editor’s note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
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References 1. Universal Protocol. The Joint Commission. http://www .jointcommission.org/standards_information/up.aspx. Accessed August 8, 2013. 2. National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/standards_information/ npsgs.aspx. Accessed August 8, 2013. 3. Statement on ensuring correct patient, correct site, and correct procedure surgery. Bull Am Coll Surg. 2002; 87(12):26. 4. Comprehensive checklist. AORN. http://www.aorn.org/ Clinical_Practice/ToolKits/Correct_Site_Surgery_Tool_ Kit/Comprehensive_checklist.aspx. Accessed August 8, 2013. 5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. http://www.iom.edu/ Reports/2001/Crossing-the-Quality-Chasm-A-New-HealthSystem-for-the-21st-Century.aspx. Accessed August 8, 2013. 6. What is Lean? Lean Enterprise Institute. http://www.lean .org/whatslean/. Accessed August 8, 2013. 7. Seven basic quality tools. ASQ. http://asq.org/learn-ab out-quality/seven-basic-quality-tools/overview/overview .html. Accessed August 8, 2013. 8. Flowchart tutorials. Edraw. http://www.edrawsoft.com/ Flowchart-tutorial.php. Accessed August 8, 2013. 9. Bernard JM. Lessons from 30 years of implementing Lean. Mass Ingenuity. http://www.massingenuity.com/ 2013/01/08/lessons-from-30-years-of-implementinglean/. Published January 8, 2013. Accessed October 9, 2013. 10. Value stream mapping FAQ. Agilean. http://www .agilean.com/resources/faqs/value_stream_mapping_faq/ value_stream_mapping_faq.htm. Accessed August 8, 2013. 11. Brache AP, Rummler GA. Improving Performance: How to Manage the White Space in the Organization Chart. San Francisco, CA: Jossey-Bass; 1990. 12. Swim lane diagrams: mapping and improving the processes in your organization. Mind Tools. http://www
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.mindtools.com/pages/article/newTMC_89.htm. Accessed August 8, 2013. Quality training: approaches to quality management 255. Tooling U-SME. http://www.toolingu.com/definition900255-107349-pareto-analysis.html. Accessed August 8, 2013. Brassard M. The Memory Jogger: A Pocket Guide of Tools for Continuous Improvement. Salem, NH: GOAL/ QPC; 1988:24. Affinity diagrams: organizing ideas into common themes. Mind Tools, http://www.mindtools.com/pages/article/ newTMC_86.htm. Accessed August 8, 2013. Affinity diagram. ASQ. http://asq.org/learn-about-quality/ idea-creation-tools/overview/affinity.html. Accessed August 8, 2013. Impact analysis: what, who, why and when. Leankaizen Ltd. http://www.leankaizen.co.uk/impact-analysis.html. Accessed August 8, 2013. Graben M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. Boca Raton, FL: CRC Press; 2009:153.
Ross William Simon, BA, is a senior management engineer at Beth Israel Deaconess Medical Center, Boston, MA. Mr Simon has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Elena G. Canacari, RN, CNOR, is associate chief nurse of perioperative services at Beth Israel Deaconess Medical Center, Boston, MA. Ms Canacari has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT A large teaching hospital in the northeast United States had an inefficient, paperbased process for scheduling orthopedic surgery that caused delays and contributed to site/side discrepancies. The hospital’s 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 patient’s preoperative visit in the surgeon’s 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. AORN J 99 (January 2014) 147-159. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.10.008 Key words: scheduling, orthopedic surgery, Lean.
B
efore February 2010, Beth Israel Deaconess Medical Center in Boston, Massachusetts, had an inefficient, paper-based process for scheduling orthopedic surgery. This process caused several issues: n
n n n
n
There was a three- to five-day lag time between patients knowing they need to be booked for surgery and being called by the office, and urgent bookings were put on a wait list, creating periods of uncertainty for patients; cases were backlogged; interdepartmental communication was poor; booking information was inaccurate and booking times were scheduled in more than one room with the same surgeon; and last-minute changes in procedure sequence led to waste and workarounds.
In addition to this, the facility was experiencing a 4% occurrence of site/side discrepancies in the preoperative clinic and 2% occurrence in the OR as well as frequent patient cancellations. These problems were significant enough that hospital and perioperative leaders decided that creating a formal team to address them was justified. Members of the team who developed the new orthopedic scheduling process, what parts of the process they represented, and any other roles they played on the team are shown in Table 1. As a result, while we were developing an automated booking system for ORs, the team also worked to improve the orthopedic surgical scheduling process, reduce patient cancellations, and reduce or eliminate site/side discrepancies. The project took place from February 2010 to March 2011.
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TABLE 1. Members of the Team and Their Roles Job title
Represented
Chief administrative officer, orthopedics Administration manager, orthopedics Administrative assistant, surgical scheduling Anesthesiologist Associate chief nurse, perioperative services
Administration Procedure scheduling Procedure scheduling
Central processing department supervisor Clinical advisor, orthopedics Clinical manager, scheduling operations Senior management engineer
Surgical kit preparation and case pick
Orthopedic surgeons (2) OR scheduler OR systems administrator
Clinic, office, and intraoperative process OR procedure scheduling Process data extraction
Team co-leader
Preoperative and intraoperative process Central processing department, preoperative clinic, and OR process
Team co-leader, acted as a knowledge resource, assisted with strategy, sponsored the project, broke down barriers to progress
OR setup and intraoperative processes OR procedure scheduling Team facilitator, helped with problem solving and statistical analysis
Using structured Lean problem-solving techniques, the team developed and launched a safe, effective, patient-centered, timely, efficient, and accurate orthopedic surgical scheduling process. In the analysis phase, the team mapped out the process, starting with the patient’s call to schedule an appointment with the surgeon through preoperative activities onsite, and identified existing problems and opportunities for improvement. Then the team organized the myriad problems into logical groupings and prioritized these according to impact, which provided a strategy for moving forward with solutions. The team reviewed and created solutions for all of the identified problems, using an activity scorecard and a timeline for corrective action implementation to drive progress. The new process has solved several of the identified problems, such as eliminating site/side discrepancies and lag time between knowing the patient needs to be booked and then contacting the patient, reducing day before and day of cancellations, and reducing the frequency of procedure sequences being changed. The following article describes the process used to develop the plan to address this 148 j AORN Journal
Other roles on the team
Helped with statistical analysis
improvement opportunity, conduct the work, and the accomplishments. BACKGROUND Our facility is a large academic medical center located in the northeast United States. It is a level 1 trauma center with three operating suites and a total of 38 ORs, in which we care for all types of adult patients, except for those needing lung and heart transplants, for a total of 27,000 procedures per year. In addition to internal scheduling difficulties and inefficiencies, our facility was experiencing a 5.1% cancellation rate before the process improvements. In fact, patient-related causes are the most frequent reasons for cancellation of orthopedic procedures. In our review of patient reasons for cancellations within 48 hours of surgery, we learned that most often patients cancel because they change their mind about having surgery. Sometimes they cannot get a ride. Team members perceived that patients equated surgical appointments with other types of appointments (eg, the dentist) and were unaware of the effects of cancelling. Cancellations can have an
SURGICAL SCHEDULING: A LEAN APPROACH effect on other patients, for example, and cancelling within 48 hours affects the functional operation of the OR, because surgeons’ instrument kits that were prepared and delivered to the OR have to be brought back to the central processing department, unpacked, and stored, which creates work that does not add value. In the event of cancellations, OR schedulers also must juggle the schedule to accommodate the procedure order, leading to more nonevalue-added work and, sometimes, a reduction in OR usage. The team collected data from our perioperative information management system. Key metrics we monitored included n
the total number of site/side discrepancies, n the lag time between a surgeon knowing the patient needs to be booked for surgery and the orthopedic administrative assistant contacting the patient, n total procedure cancellations and the percentage that are cancelled the day before surgery, and n instances of changing the sequence of procedures less than 48 hours before surgery. In improving the orthopedic surgical scheduling process, we also wanted to improve patient safety. Before starting this project, site/side discrepancies in the preoperative clinic occurred in 4% of procedures and in 2% of procedures in the ORdunlike the new system, the old system did not require surgeons to enter side and site in real time when scheduling a surgery. One regulatory consideration that drove us to address site/side discrepancies was the Universal ProtocolTM for Preventing Wrong Site/Wrong Procedure,1 which is accessible as part of the National Patient Safety Goals.2 Additionally, the American College of Surgeons issued a statement that contains the following: “The American College of Surgeons (ACS) recognizes patient safety as being an item of the highest priority and strongly urges individual hospitals and health organizations to develop guidelines to ensure correct patient, correct site and correct procedure surgery.”3(p26) In addition to this, AORN created
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the AORN Comprehensive Surgical Checklist, which incorporates the World Health Organization’s checklist and The Joint Commission’s safety requirements for the Universal Protocol in a single document.4 GOALS Before the team was selected, we established three main goals for performing a quality improvement project: n
develop a safe, effective, patient-centered, timely, efficient, and accurate orthopedic scheduling process (ie, requirements that mirror elements of “The Six Domains of Healthcare Quality”5); n smooth the schedule so that block time allocation is more even across the days of the week, maximizing efficiency and utilization; and n improve patient safety by ensuring correct site/ side. We also incorporated the Lean process into our plans from the beginning. To make trends visible, we made extensive use of charting, graphing, and Pareto analysis (ie, a special form of vertical bar graph displaying the relative importance of all the problems or conditions with the most important on the left) to prioritize the problem-solving approach. Our patient cancellation data are displayed in Figure 1. ABOUT LEAN The term “Lean” was coined to describe Toyota’s business during the late 1980s.6 In Lean processes, a cross-functional team uses simple, structured problem-solving tools, often referred to as “Lean tools” or “the seven quality tools,”7 to move smoothly from problem identification to solution development and finally to ensuring that the implemented improvements will not fall out of use and allow the original problems to resurface. Successful Lean health care projects start with a clear definition of the project, often called a project charter (see Supplementary Figure 1 at http://www.aornjournal .org). AORN Journal j 149
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Figure 1. Patient-related causes were the most frequent reasons for cancellation of orthopedic procedures, although there were numerous reasons a patient might cancel within 48 hours of surgery.
The project charter should be drafted by those who have key knowledge of the problemdor opportunity for improvementdand the supervisors of the likely team members. We chose to use the term opportunity for improvement in place of problem for philosophical reasons. The word problem is perceived negatively, and Lean is rooted in the spirit of continuous improvement, where problems are embraced as opportunities for improvement rather than seen in a negative context. Lean leaders view problems as great opportunities for improvement. Essential elements of the project charter include n
n n n n
a description of the problem, providing the background and justification for working on the project; clear, measurable goals; a projected project completion date; a suggested approach; metrics that quantitatively define the problem or opportunity;
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n
team composition, including a leader, a facilitator, and a sponsor or sponsors who serve as resources if the team runs into a roadblock; and n a list of the major steps in the process, usually six or fewer.8 The Lean process provides a set of management principles that defines a way to manage projects. For example, improvement projects should not be conducted by only a select few champions in an organization; successful Lean improvement projects include those who do the work. The underlying belief of the Lean process is that the people who do the work know it best, and they should be given the authority to improve their work processes.9 The process knowledge and experience of those who do the work is far more valuable in both problem-solving and successfully implementing solutions than having members who have only peripheral contact with the work. Additionally, we found that members of the team do not need to have a deep knowledge of Lean principles
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Figure 2. In this excerpt from the swim lane process map used during a project to improve orthopedic surgery scheduling, the boxes represent steps in the processes and the hexagons represent problems identified when creating the process map. Process steps are included in a horizontal row dedicated for a particular department or function.
to be successful; they can be highly productive contributors to the project without spending hours in Lean training classes. The best way to learn about Lean is to participate in a well-facilitated improvement project during which the team moves through identifying problems or opportunities for improvement, generating solutions, and maintaining the improvement phases. METHODS At the first team meeting, the team facilitator, Ross Simon, senior management engineer, delivered an overview of Lean principles. Throughout the project, the facilitator offered problem-solving tools to help the team move swiftly and efficiently through the process. We overcame barriers by engaging stakeholders. Physicians served as champions to help design and pilot test the online surgical booking system. The
pilot test work started with a group of orthopedic surgeons who embraced the technology. We also brought in others, including administrators who worked for the surgeons. The team drove the process and did the work. For the first three months, the team met weekly for one hour to review the status of action items and decide what we needed to do next. After this initial period, we met every other week or monthly to ensure that the new process was working well. Our last formal meeting was held a year after the first meeting. Team meetings were primarily strategic; other than the few activities that we had to do together, such as brainstorming, we did the work outside of our regular meetings. By doing everything that we could outside of meetings, we maximized the usefulness of meeting time by using it strategically, identifying the status of activities, and collectively deciding on the next step. AORN Journal j 151
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Figure 3. Excerpt from a cause and effect diagram used during a project to improve orthopedic surgery scheduling. A cause and effect diagram can be used to help a quality improvement team consider any additional problems and root causes that might not be identified with an annotated swim lane process map.
Process Mapping As appropriate on most process-related Lean improvement projects, our first team activity was to meticulously list the process steps and note problems and opportunities for improvement associated with each step. During process mapping, the focus is on discovering the current processes of an organization, establishing the root cause problems with those processes, and looking for solutions.10 It was important that the team agree on the current process and issues so that we could develop robust solutions together. We found that people often disagreed or misunderstood the processes that we had in place, so mapping out the process provided an opportunity for us to appreciate each team member’s role and to annotate process steps to identify problems and opportunities for improvement. The team used a swim lane process map to document our processes (Figure 2). Swim lane diagrams were proposed by Geary Rummler and Alan Brache in their 1990 book Improving Performance.11 This method of diagramming facilitates plotting and tracing processes quickly 152 j AORN Journal
and easily and, in particular, displays the interconnections between processes, departments, and teams.12 As is typical of most complex processes, our swim lane process map included 84 process steps, 48 problems, and 13 opportunities for improvement. Next, we used a cause and effect diagram (Figure 3) to help us consider any additional problems and root causes we might not have identified with the annotated swim lane process map. Commonly called a fishbone diagram, cause and effect diagrams illustrate the factors affecting a process by sorting out and relating the causes of a problem.13 Every effect is likely to have several major categories of causes. The major causes in these diagrams often are summarized into four categories: people, machines, methods, and materials.14 Lean practitioners later added “environment” to include the workplace. To complete this diagram, team members placed all of the problems and opportunities for improvement that we identified in the swim lane process map next to the appropriate rib on the cause and effect diagram. Then we asked
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Figure 4. In this affinity diagram, the team split identified problems into seven groups. The types of solutions used to address each problem precede the problem on the diagram. AORN Journal j 153
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ourselves what we were missing that fell into the categories of methods, materials, manpower, machinery, and the environment. In using Lean methodology, it is important to lay out all of the problems before jumping to solutions. As usually happens with this type of process, we added additional causesdspecifically, we noted additional causes that contribute to inefficiency, inaccuracy, and lack of timeliness in the orthopedic surgical scheduling process. Our completed cause and effect diagram contained more than 50 problems. The number of problems we identified seemed daunting. To get a grasp on all of the issues, the team used an affinity diagram to organize the problems into logical groupings15,16 (Figure 4). We split the problems into seven logical groupings (ie, patient information, patient access, administration, scheduling, physicians, roadblocks, equipment). Placing seemingly disparate problems into logical groups reduces the number of problems into manageable groups, eliminates redundancies if problems are identified more than once earlier in the process, and helps ensure that the solutions developed later will address the broad scope of related problems. As the team developed and implemented solutions to the problems, we annotated each to indicate work that had been completed or was under way. As an example of how we grouped problems, the following fell into the category of patient information: n n n n n
the number of patient identifiers that are required, incorrect patient contact information, ineligible insurance, incorrectly spelled names, and missing orders for preadmission testing.
Prioritizing and Developing Solutions To develop a strategy for solving the problems, the team prioritized the categories according to how difficult they would be to solve and how much they would help us to meet our goals when they were solved. The team agreed to create an impact analysis chart based on Leankaizen methods,17 shown in Figure 5, for this purpose. 154 j AORN Journal
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Figure 5. An impact analysis grid can help identify which solutions will have the highest impact and the least difficulty to implement. Solutions to problems in the upper-left corner of the grid, for example, are both high impact and low difficulty.
To start, the team developed solutions to problems that fell into the upper left corner of the grid (ie, high impact, low difficulty), such as the lag time created when scheduling forms completed by surgeons were batched and brought from the clinic in one building to another building of the medical center where orthopedic administration is located. By completing this process, we achieved early and meaningful wins, such as reducing the number of last-minute changes by surgeons, which helped maintain order in the central processing department. These early wins helped the team maintain a high level of energy and morale, which is important because complex projects like this one may require several months to complete. Defining Tasks and Communicating Progress The team used an activity scorecard to define and communicate all of our tasks (Figure 6). The scorecard includes a short title for the task, the issue being addressed, the next activity to address the issue, the task’s priority relative to all of the other tasks,
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Figure 6. An excerpt from an activity scorecard used during a project to improve orthopedic surgery scheduling. Columns in the scorecard are (from left to right) the task number, short title of the task, the issue being addressed, the next activity, the task priority versus other tasks, who is responsible for completing the work, the target completion date, and the current status.
the name of the individual or individuals who are responsible for completing the task, the target completion date, and the current status. During team meetings, whenever the team identified an action that needed to be taken, it was entered onto the activity scorecard so everyone could see it. The scorecard, used instead of traditional meeting minutes, was updated and redistributed after each meeting. This helped us drive progress, keep members focused during team meetings, and add a sense of accountability to those who took on the tasks. In addition to the activity scorecard, we also used a graphical depiction of a simple implementation plan (Figure 7) as a timeline for key action items. This plan provided an overall view of the most important tasks. The team used it to help reinforce accountability by highlighting the timeliness of responses to planned work. RESULTS The differences between our original, paper-based orthopedic surgical scheduling process and the new online process were significant (Table 2). The new process gave our facility several benefits. The lag time between the surgeon knowing a patient needs to be booked for surgery and the orthopedic
administrative assistant contacting the patient was decreased from three days to less than one day. Improving process flow by eliminating batching (eg, our process where booking forms were collected over a period of days and then brought as a batch to the administrative assistant, who then contacted the patient) is an underpinning of Lean philosophy. Lean terminology includes “one-piece flow” or “single-piece flow,” which means that in a perfect flow environment, the product (or patient) would move in batches of one, because this minimizes delays.18 Now, because the surgeon completes booking online after seeing a patient, the booking is immediately visible to the orthopedic administrative assistant, and lag time is minimized. If patients decide to have surgery late in the afternoon one day, they will be called the next day to validate preoperative clinic and surgery dates and times. To address no-show and last-minute cancellations, the team adopted a practice used in the outpatient clinic at the medical center: we started including a notice in the surgical confirmation letter to patients stating that a $250 fee will be charged for cancellations within less than 48 hours before the scheduled appointment time. We have not charged any patients the $250 fee to date, but we have AORN Journal j 155
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Figure 7. A graphical depiction of a simple implementation plan can be used as a timeline for key action items during a process improvement project.
TABLE 2. Orthopedic Surgical Scheduling Process Flow Topic
Before
Timing of the surgeon The surgeon scheduled his or her surgeries on 5 scheduling surgery different paper booking forms. Surgical scheduling Scheduling forms were batched and brought from process the clinic in one building to another building on the medical center campus, where orthopedic administration is located. Contacting the patient Patients were contacted by the orthopedic adminafter his or her visit istrative assistant to schedule the day of surgery 3 with the surgeon to 5 days after the patient’s visit with the surgeon. Surgical consents and Regular faxes of consent and patient information patient information often were lost or unavailable. Special equipment
There was no standard format for listing special equipment needed for surgery. Site/side discrepancies There was a 4% occurrence of site/side discrepancies.
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After The surgeon schedules surgery online in real time. The surgical schedule is visible online in real time to the orthopedic scheduler.
Patients are contacted by the orthopedic administrative assistant within 1 day of the patient’s visit with the surgeon to schedule surgery. Consent and paperwork are electronically faxed and available throughout the patient’s perioperative experience. The listing and selection of special equipment is clear and concise in the online booking system. Because booking is in real time with the patient in attendance with the surgeon, there are no site/ side discrepancies.
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Figure 8. Patient cancellations within 48 hours of surgery were reduced between June 2009 and October 2010 as a result of the improved orthopedic scheduling process.
Figure 9. The number of instances of physicians changing the sequence of procedures within 48 hours of surgery was reduced between January and June 2010 as a result of the improved orthopedic scheduling process.
reduced the patient cancellation rate by 35%, from 5.1% to 3.3% (Figure 8). In addition to scheduling advantages, the new online booking system also helped with site/side discrepancies and dropped our occurrence of this error to zero. The online booking system is set up
such that the surgeon cannot bypass specification of site/side in the booking workflow, and the system forces physicians to think about the side of a surgery in real time, while he or she orders the booking and while the patient is in the office. In our previous system, the surgeon had to remember the AORN Journal j 157
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side at the end of the clinical day when he or she filled out paperwork for several patients. Before the implementation of the new process, we had an average of four procedures per week during which a site/side discrepancy was caught in preadmission testing and two per week caught in the preoperative area; after the new process was implemented, both went to zero. As is the case when patients cancel surgery within 48 hours of its scheduled start, supplies, time, and manpower are wasted when surgeons change the sequence of procedures less than 48 hours before surgery. The new process made the problem more visible to surgeons, so the team reduced the instances of changing the sequence of orthopedic procedures by 70%, from 20 occurrences per month to six occurrences per month (Figure 9). As an added benefit of the online scheduling system, patient satisfaction increased with the reduced delays. When we began the project, patient satisfaction, as measured by the Press Ganey metric of “likelihood to recommend,” was very good at 67.6%. At the completion of our project a year after starting it, we increased the score by nearly 20%, to an average of 84%. CONCLUSION Changing the culture of an organization to support a Lean approach to process improvement is not easy. Lecturing personnel on Lean principles will provide a foundation for Lean; however, personnel will not be convinced of its value or become proficient in the use of Lean tools and techniques without participating in well-facilitated process improvement teams that work on real, challenging problems and implement sustainable solutions. Work accomplished by the orthopedic surgical scheduling team has moved the medical center forward in this direction. Our facility has seen an increased spirit of collaborative partnerships and understanding of roles, a new mindset that views problems as opportunities, creative new solutions to old problems, an eliminated silo mentality, best
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SIMONdCANACARI practices shared between teams, a more team- and goal-oriented culture, and stakeholders who are empowered to solve problems. Practical examples of our accomplishments include that our project team developed an efficient, accurate, and timely orthopedic scheduling process; reduced day-before and day-of cancellations, reduced procedure sequence changes, increased patient satisfaction, and eliminated the disorganized schedule, which had caused us to be unable to get orthopedic procedures onto the schedule for four consecutive months. The online system also reduced schedule changes made by surgeons within 48 hours because it allows surgeons to review the surgery schedule proactively online in real time. The new process allowed us to allocate a dedicated block for urgent/emergent plastic orthopedic hand trauma and pilot test a preoperative clinic faxing/scanning project, and the new process improved the relationship between scheduling and orthopedics personnel to promote collaboration. We focused on orthopedic surgery scheduling with this project, and online scheduling has had such a positive effect on performance in orthopedics that work is under way to implement the process in other services at the medical center. The importance of improving patient safety with respect to site/side discrepancies created an urgency that facilitated moving this project forward. Regardless of the many advantages the new project has provided, without that sense of urgency, it has been a challenge to spread this process to other services in the medical center. SUPPLEMENTARY DATA The supplementary figure associated with this article can be found in the online version at http:// dx.doi.org/10.1016/j.aorn.2013.10.008. Editor’s note: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a trademark of The Joint Commission, Oakbrook Terrace, IL.
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References 1. Universal Protocol. The Joint Commission. http://www .jointcommission.org/standards_information/up.aspx. Accessed August 8, 2013. 2. National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/standards_information/ npsgs.aspx. Accessed August 8, 2013. 3. Statement on ensuring correct patient, correct site, and correct procedure surgery. Bull Am Coll Surg. 2002; 87(12):26. 4. Comprehensive checklist. AORN. http://www.aorn.org/ Clinical_Practice/ToolKits/Correct_Site_Surgery_Tool_ Kit/Comprehensive_checklist.aspx. Accessed August 8, 2013. 5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. http://www.iom.edu/ Reports/2001/Crossing-the-Quality-Chasm-A-New-HealthSystem-for-the-21st-Century.aspx. Accessed August 8, 2013. 6. What is Lean? Lean Enterprise Institute. http://www.lean .org/whatslean/. Accessed August 8, 2013. 7. Seven basic quality tools. ASQ. http://asq.org/learn-ab out-quality/seven-basic-quality-tools/overview/overview .html. Accessed August 8, 2013. 8. Flowchart tutorials. Edraw. http://www.edrawsoft.com/ Flowchart-tutorial.php. Accessed August 8, 2013. 9. Bernard JM. Lessons from 30 years of implementing Lean. Mass Ingenuity. http://www.massingenuity.com/ 2013/01/08/lessons-from-30-years-of-implementinglean/. Published January 8, 2013. Accessed October 9, 2013. 10. Value stream mapping FAQ. Agilean. http://www .agilean.com/resources/faqs/value_stream_mapping_faq/ value_stream_mapping_faq.htm. Accessed August 8, 2013. 11. Brache AP, Rummler GA. Improving Performance: How to Manage the White Space in the Organization Chart. San Francisco, CA: Jossey-Bass; 1990. 12. Swim lane diagrams: mapping and improving the processes in your organization. Mind Tools. http://www
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Ross William Simon, BA, is a senior management engineer at Beth Israel Deaconess Medical Center, Boston, MA. Mr Simon has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Elena G. Canacari, RN, CNOR, is associate chief nurse of perioperative services at Beth Israel Deaconess Medical Center, Boston, MA. Ms Canacari has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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