Finding and Eliminating Waste in the OR
Identifying Waste in the OR If you are familiar with the concept of Lean Healthcare, you are familiar with the idea of waste.
A Lean Hospital is an organization that is continually improving patient safety and satisfaction, treatment outcomes, and staff development through the elimination of waste, and improvement in patient flow.
Lean always goes hand-in-hand with the term waste.
In this article we'll discuss the different forms of waste and some examples we would find in the OR and its associated services.
Overproduction This form of waste takes place when we produce more than what is needed right now by the customer.
Examples of this waste in Periop are: • Reassembling instrument sets in large batches while the autoclave sits idle.
The rationale is "We do not have enough instrument sets.
" • Spiking IV bags in Pre-Surg for the whole day, while patients wait.
The rationale is "Our on-time starts are very low.
" You may think that over-producing is OK because you will need it eventually.
Eventually is not now.
Now is what matters, and now is when the patient is waiting.
The time you missed you never get back, so do not over-produce.
Message to Charge Nurses and Clinical Managers: Do not make staff over-produce to keep them busy during a slow time.
Have them do continuous improvement and you will get a great payback.
Transportation We see this form of waste when the product or the patient (the value to be delivered) is moved without adding value.
Examples of this form of waste are: • Blood specimens collected at the oncology unit go on a hospital tour before reaching the lab.
• IV and DVT pumps go from the patient room to Sterile Processing and back via utility rooms, for a few seconds of cleaning.
This waste is a bit more complex than saying "just stop doing that", as it was the case with over-production.
This waste requires you to ask why in a more forceful way, and to come up with practical alternatives.
Motion This form of waste refers to staff members moving without adding value.
This becomes evident in the amount of walking staff members do during their day.
They are normally looking or hunting for something.
Why is it that we cannot provide clinicians with the tools and supplies they need to take care of patients? Some examples of motion waste are: • Searching for a patient lift, a positioning device, an IV pump or any piece of equipment.
The level of frustration staff members feel when they cannot find what they need is enormous.
Delay of care can also be dangerous for the patient.
• Searching for paperwork.
If your hospital still requires hand-written paperwork for surgical patients, you may find yourself scrambling for that document while the patient is on the table.
This is one of the easiest forms of waste to solve.
The application of 7S methods and the abolishment of the Par Level system for supplies management would get you 75% of the way.
Waiting This is idle time created when supplies, information, people, or equipment are not ready.
If you find yourself waiting on any kind of service you need to start asking why, and be ready to take action once you get the answer.
Just one rule: blaming somebody else is not allowed.
Take a stroll through the waiting rooms.
How many patients do you see waiting? Go to pre-surg.
How many patients are ready, but their OR is not? Go to PACU.
How many patients are recovered, but there is no room for them to be moved to? Over-processing These are work steps that do not add value to the patient or customer.
This is the waste of overdoing.
It is so easy to believe you are doing the right thing by overdoing.
Think about the times you do this at home: "If three screws will do, five must be better".
In one Periop department staff was checking case carts four times, due to the unspoken distrust of the prior processes.
Excess Inventory When you see more supplies, equipment or paperwork than what the customer needs right now, you have excess inventory.
The OR is the champion of excess inventory in the hospital.
The OR wants to have enough inventory in case the worst happens, and then double that in case the Martians attack.
Excess inventory gives staff a false sense of security.
When you need something, you then have to wade through piles of stuff to get to what you need.
Are you seeing the waste yet? To that add the increased risk of expired items due to the piles you have to go through.
Pick a couple of well-stocked shelves and see if you find any expired supplies.
The main culprit is the incredible anachronistic Par Level system that many ORs use for supplies management.
It is mind boggling that hospitals still use such an inefficient method to deliver supplies to clinicians.
Start by abolishing Par.
The result of implementing Lean supplies management will be a substantial reduction in inventory dollars coupled with the elimination of shortages.
Defects Defects are work that contains errors, requires rework, has mistakes or lacks something necessary.
Nothing says proclaims a broken process quite like defective work.
The risk is starting with the old search for accountability, in other words looking for someone to blame.
Instead, try looking for the broken process by asking why, or by using simple assessment tools like a fishbone diagram.
Then engage other staff in finding solutions.
The results will amaze you.
A typical OR example is that of an incomplete instrument set.
Your choices are: "Accountability!" or, after you solve the immediate need ask: "Why was the set incomplete?" • Could it be that it was sent to SPD from the OR incomplete? • Could it be that we need to develop work instructions for each instrument set? • Could it be that the instrument was sent to sharpening? And the list goes on.
What are you going to do once you get the answers? Ineffective Use of Computers This form of waste refers to time spent at the computer, not using the available software efficiently.
No one would question the fact that the use of computers is a must in the modern hospital.
However, when their use detracts from patient care, we must stop and ask why.
Take another stroll and go to pre-surg.
Stand in the department and count the number of clinicians in patient rooms versus the number in front of a computer screen.
What is the ratio? What should that ratio be? Human Potential The waste of human potential is not taking advantage of people's natural desire to be a part of something good.
This is the worst form of waste, because by engaging staff you will identify and reduce or eliminate all the other forms of waste.
This is not about the touchy-feely stuff like "Our staff is our most valuable asset" or "we practice respect for our people".
Show respect for staff by engaging them in the solutions to the problems that afflict their processes.
Check the results.
You will be amazed.
Now is your turn.
What forms of waste do you see in your OR? What is your plan to identify and eliminate them?
A Lean Hospital is an organization that is continually improving patient safety and satisfaction, treatment outcomes, and staff development through the elimination of waste, and improvement in patient flow.
Lean always goes hand-in-hand with the term waste.
In this article we'll discuss the different forms of waste and some examples we would find in the OR and its associated services.
Overproduction This form of waste takes place when we produce more than what is needed right now by the customer.
Examples of this waste in Periop are: • Reassembling instrument sets in large batches while the autoclave sits idle.
The rationale is "We do not have enough instrument sets.
" • Spiking IV bags in Pre-Surg for the whole day, while patients wait.
The rationale is "Our on-time starts are very low.
" You may think that over-producing is OK because you will need it eventually.
Eventually is not now.
Now is what matters, and now is when the patient is waiting.
The time you missed you never get back, so do not over-produce.
Message to Charge Nurses and Clinical Managers: Do not make staff over-produce to keep them busy during a slow time.
Have them do continuous improvement and you will get a great payback.
Transportation We see this form of waste when the product or the patient (the value to be delivered) is moved without adding value.
Examples of this form of waste are: • Blood specimens collected at the oncology unit go on a hospital tour before reaching the lab.
• IV and DVT pumps go from the patient room to Sterile Processing and back via utility rooms, for a few seconds of cleaning.
This waste is a bit more complex than saying "just stop doing that", as it was the case with over-production.
This waste requires you to ask why in a more forceful way, and to come up with practical alternatives.
Motion This form of waste refers to staff members moving without adding value.
This becomes evident in the amount of walking staff members do during their day.
They are normally looking or hunting for something.
Why is it that we cannot provide clinicians with the tools and supplies they need to take care of patients? Some examples of motion waste are: • Searching for a patient lift, a positioning device, an IV pump or any piece of equipment.
The level of frustration staff members feel when they cannot find what they need is enormous.
Delay of care can also be dangerous for the patient.
• Searching for paperwork.
If your hospital still requires hand-written paperwork for surgical patients, you may find yourself scrambling for that document while the patient is on the table.
This is one of the easiest forms of waste to solve.
The application of 7S methods and the abolishment of the Par Level system for supplies management would get you 75% of the way.
Waiting This is idle time created when supplies, information, people, or equipment are not ready.
If you find yourself waiting on any kind of service you need to start asking why, and be ready to take action once you get the answer.
Just one rule: blaming somebody else is not allowed.
Take a stroll through the waiting rooms.
How many patients do you see waiting? Go to pre-surg.
How many patients are ready, but their OR is not? Go to PACU.
How many patients are recovered, but there is no room for them to be moved to? Over-processing These are work steps that do not add value to the patient or customer.
This is the waste of overdoing.
It is so easy to believe you are doing the right thing by overdoing.
Think about the times you do this at home: "If three screws will do, five must be better".
In one Periop department staff was checking case carts four times, due to the unspoken distrust of the prior processes.
Excess Inventory When you see more supplies, equipment or paperwork than what the customer needs right now, you have excess inventory.
The OR is the champion of excess inventory in the hospital.
The OR wants to have enough inventory in case the worst happens, and then double that in case the Martians attack.
Excess inventory gives staff a false sense of security.
When you need something, you then have to wade through piles of stuff to get to what you need.
Are you seeing the waste yet? To that add the increased risk of expired items due to the piles you have to go through.
Pick a couple of well-stocked shelves and see if you find any expired supplies.
The main culprit is the incredible anachronistic Par Level system that many ORs use for supplies management.
It is mind boggling that hospitals still use such an inefficient method to deliver supplies to clinicians.
Start by abolishing Par.
The result of implementing Lean supplies management will be a substantial reduction in inventory dollars coupled with the elimination of shortages.
Defects Defects are work that contains errors, requires rework, has mistakes or lacks something necessary.
Nothing says proclaims a broken process quite like defective work.
The risk is starting with the old search for accountability, in other words looking for someone to blame.
Instead, try looking for the broken process by asking why, or by using simple assessment tools like a fishbone diagram.
Then engage other staff in finding solutions.
The results will amaze you.
A typical OR example is that of an incomplete instrument set.
Your choices are: "Accountability!" or, after you solve the immediate need ask: "Why was the set incomplete?" • Could it be that it was sent to SPD from the OR incomplete? • Could it be that we need to develop work instructions for each instrument set? • Could it be that the instrument was sent to sharpening? And the list goes on.
What are you going to do once you get the answers? Ineffective Use of Computers This form of waste refers to time spent at the computer, not using the available software efficiently.
No one would question the fact that the use of computers is a must in the modern hospital.
However, when their use detracts from patient care, we must stop and ask why.
Take another stroll and go to pre-surg.
Stand in the department and count the number of clinicians in patient rooms versus the number in front of a computer screen.
What is the ratio? What should that ratio be? Human Potential The waste of human potential is not taking advantage of people's natural desire to be a part of something good.
This is the worst form of waste, because by engaging staff you will identify and reduce or eliminate all the other forms of waste.
This is not about the touchy-feely stuff like "Our staff is our most valuable asset" or "we practice respect for our people".
Show respect for staff by engaging them in the solutions to the problems that afflict their processes.
Check the results.
You will be amazed.
Now is your turn.
What forms of waste do you see in your OR? What is your plan to identify and eliminate them?