Tag: lean

Pam Murphy, a registered nurse and director of surgical services at Piedmont Newnan Hospital, has seen it all in her 23 years of employment at the hospital.

In 2007, when the hospital was chosen as a pilot site for a lean implementation for the Piedmont Healthcare System, she knew that participation from the hospital’s staff would be critical. She also knew there would be a concern that lean – a methodology that aims to eliminate waste – would mean doing more with less.

“A lot of staff members first thought that we were just trying to get efficient so we could eliminate positions. We had to assure them that this was not the case; we just wanted to be as efficient as we could be so we could build the business,” she recalled. “The hard part for an organization is committing the resources, something especially difficult in healthcare. Once you do that, however, you can attack the issue in one week and come up with solutions.”

The focus of Piedmont Newnan’s process improvement project was the six operating rooms on its main campus. Jennifer Trapp-Lingenfelter and Kelley Hundt of Georgia Tech’s Enterprise Innovation Institute helped train Piedmont staff in lean principles, an operational strategy that focuses on eliminating waste while increasing value-added work. Lean techniques improve profitability, customer satisfaction, throughput time and employee morale.

“We knew that the turnaround time on the operating rooms was our biggest issue, but when we did the value stream map that outlined the entire process, we decided to tackle something we knew could make a big difference,” said Murphy. “We decided to focus on the case carts, which are used for pulling together everything that we need for a surgical procedure.”

The case cart project began in December 2007 with an introduction to lean principles. According to Trapp-Lingenfelter, at least 90 percent of the OR staff had received basic lean training by the end of the project, a critical component of the success. A cross-functional team composed of nurses, surgical technologists and central service personnel went to the OR and the central sterilization department to observe the case cart process and note which steps were value-added and which ones involved waste.

Prior to the lean implementation, the case cart accuracy at Piedmont Newnan was approximately 50 percent. The team observed that there was no formal scheduling process for the central sterilization department, no designated person to pull together case carts, no standard process to pull the case carts and a lack of labeling and organization. These issues led to a significant amount of re-work.

After the team analyzed the process, it identified solutions that could be implemented that same week – such as 5S, a method for organizing the workplace. The team developed a new standard case cart design, labeled cabinets and carts, established parking spots for case carts, defined the path for picking items that go in the carts, alphabetized instruments, designated a return bin for unused supplies, centralized the case cart picking tools and set a minimum inventory level for all instruments. Now all case carts are pulled the day of a procedure, with the exception of 7:30 a.m. surgeries pulled the afternoon before. In addition, missing items are highlighted in yellow, the standard picking procedure is posted and one person is assigned the responsibility of picking the case carts.

“Before the lean process, whenever we had down time we would tell staff to pull case carts for the next day. They would begin to look down the list and see items that were currently in use or needed to be in use that afternoon, so we would end up with case carts that were missing instruments,” Murphy noted. “As a result of this project, we realized that our computer system would allow us to see where equipment was, so we built a location into everything. Now, if I gave you a card with a list of items that needed to be pulled for a surgery tomorrow, you could go pull everything even if you had never been in my OR before.”

As a result of the lean implementation, case carts can now be pulled in five minutes versus 20 minutes before and the overall case cart accuracy has risen from 50 percent to 98 percent. Supply items that need to be available on case carts but which may not be used with all procedures are only opened if needed, reducing waste. The bins have yielded a projected savings of $118,000 annually.

“The success of the case cart project was a win-win, so when we decided to tackle turnaround times, we had buy-in from the staff and they had already been educated on the process,” said Murphy.

In this project, the team developed a process that defined roles, responsibilities and visual controls to reduce the time required to clean and prepare an operating room for a new procedure. Prior to the implementation, the average turnaround time for patient out to patient in was 19 minutes; it now averages 14 minutes. Physician turnaround time went from 51 minutes to 40 minutes. Piedmont Newnan has also been able to increase its percentage of on-time procedure starts and decrease after-hours cases and resulting overtime pay. Moving forward, the team will set goals specific to each specialty.

The projects at Piedmont Newnan were so successful that they were recognized by VHA Georgia, part of the national healthcare alliance, VHA Inc. Last year, 10 Georgia hospitals were recognized for improving their supply chain performance, clinical care, operational efficiency and community benefit performance. Piedmont Newnan Hospital was selected as a winner of the 2008 VHA Inc. Georgia Regional Leadership Awards in the Operational Excellence category for improvements in the operating room that increased patient care and improved patient and physician satisfaction.

“Sustainability is probably the hardest part because you have to be willing to commit to it. If you conduct a 5S procedure on an area and then let it go, it’s going to end up looking like your junky kitchen drawer again,” Murphy observed. “Having someone come in from the outside gets you to think about how things can be done differently. Having another set of eyes that aren’t familiar with your process helps you open your eyes and see ways to make improvements.”

Through its Healthcare Performance Group, Georgia Tech project leaders work with healthcare professionals to conduct lean assessments, teach basic lean concepts, develop value stream maps to analyze the flow of materials and information, create quality systems and implement rapid process improvement projects. For more information on healthcare performance improvement services offered by Georgia Tech’s Enterprise Innovation Institute, contact Jennifer Trapp-Lingenfelter (404-386-7472) or (jenn.lingenfelter@innovate.gatech.edu).

About Enterprise Innovation Institute:
The Georgia Tech Enterprise Innovation Institute helps companies, entrepreneurs, economic developers and communities improve their competitiveness through the application of science, technology and innovation. It is one of the most comprehensive university-based programs of business and industry assistance, technology commercialization and economic development in the nation.

Research News & Publications Office
Enterprise Innovation Institute
Georgia Institute of Technology
75 Fifth Street, N.W., Suite 314
Atlanta, Georgia 30308 USA

Media Relations Contact: John Toon (404-894-6986); E-mail (john.toon@innovate.gatech.edu).

Writer: Nancy Fullbright

More than 75 surgical services leaders across the country recently heard about how Piedmont Newnan Hospital was able to decrease its turnaround times by 30 percent and increase case cart accuracy to 100 percent with a little assistance from Georgia Tech. Pam Murphy, director of surgical services at Piedmont Newnan Hospital, and Jennifer Trapp-Lingenfelter, a project manager for Georgia Tech’s Enterprise Innovation Institute EI², presented at a workshop at the OR Manager conference in Las Vegas, Oct. 7. The six-hour workshop, “Implementing Lean in the OR,” explained how operating rooms can facilitate lean projects and, more importantly, how to sustain the improvements.

Lean is the practice of evaluating the steps of a process to determine the cost-value added to a final product or service. It seeks to minimize the resources required for production by eliminating waste that inflates cost and turnaround times, and decreases efficiency.

Piedmont Newnan began working with Georgia Tech in December 2007 with an introduction to lean principles. According to Trapp-Lingenfelter, at least 90 percent of the operating room staff had basic lean training by the end of the project, a critical component of their success. The cross-functional team comprised of nurses, surgical technologists and central service personnel who went to the OR and the central sterilization department to observe the case cart process and note which steps were value-added and which ones involved waste.

“A lot of staff first thought that we were just trying to get efficient so we could eliminate positions. We had to assure them that this was not the case; we just wanted to be as efficient as we can be so we can build the business,” recalled Murphy. “The hard part for an organization is committing the resources, something especially difficult in health care. Once you do that, however, you can attack the issue in one week and come up with solutions.”

As a result of the lean implementation, case carts can now be pulled in five minutes versus 20 minutes and the overall case cart accuracy has risen from 50 percent to as high as 100 percent. Whereas staff would open all supplies prior to this project, they now refer to “do not open” bins, items that may be used in a case but do not need to be opened until that time. The bins have yielded a projected savings of $118,000 annually. Piedmont Newnan has also been able to increase its percentage of on-time procedure starts and decrease after-hours cases.

Through EI²’s Healthcare Performance Group, project leaders work with healthcare professionals to conduct lean assessments, teach basic lean concepts, develop value stream maps to analyze the flow of materials and information, develop quality systems and implement rapid process improvement projects. For more information on healthcare performance improvement services offered by Georgia Tech’s Enterprise Innovation Institute, contact Jennifer Trapp-Lingenfelter, Healthcare Performance Group (404-386-7472); E-mail: (jenn.lingenfelter@innovate.gatech.edu).

About Piedmont Newnan Hospital:

Piedmont Newnan Hospital (PNH) is a 143-bed, acute-care hospital in Newnan, Georgia, offering 24-hour emergency services, women’s services and general medical/surgical services. Diagnostic services include CT, nuclear medicine, MRI, PET, ultrasound and fluoroscopy. A complete range of medical/surgical services includes laparoscopic surgery, physical therapy, respiratory therapy, sleep studies and cardiac catheterization and rehabilitation. With approximately 856 employees and a medical staff of over 150 physicians, PNH is a member of Piedmont Healthcare (PHC), a not-for-profit organization that also includes Piedmont Hospital, a 481-bed acute tertiary care facility offering all major medical, surgical and diagnostic services located on 26 acres in the north Atlanta community of Buckhead; Piedmont Fayette Hospital, a 143-bed, acute-care community hospital located on Highway 54 in Fayetteville; and Piedmont Mountainside Hospital, a 42-bed community hospital in Jasper. Piedmont Healthcare also is the parent company of the Piedmont Heart Institute (PHI), which combines more than 75 cardiovascular specialists in Piedmont Heart Institute Physicians with over 30 locations across north Georgia, and the Fuqua Heart Center of Atlanta at Piedmont Hospital; Piedmont Philanthropy, the philanthropic entity for private fundraising initiatives; the Piedmont Physicians Group, with more than 100 primary care physicians in over 30 offices throughout metro Atlanta; and the Piedmont Clinic, a 600-member physician network. For more information, visit piedmontnewnan.org.

About Enterprise Innovation Institute:

The Georgia Tech Enterprise Innovation Institute helps companies, entrepreneurs, economic developers and communities improve their competitiveness through the application of science, technology and innovation. It is one of the most comprehensive university-based programs of business and industry assistance, technology commercialization and economic development in the nation.

Research News & Publications Office
Enterprise Innovation Institute
Georgia Institute of Technology
75 Fifth Street, N.W., Suite 314
Atlanta, Georgia 30308 USA

Media Relations Contact: John Toon (404-894-6986); E-mail (john.toon@innovate.gatech.edu).

Writer: Nancy Fullbright

This article is reprinted from OR Manager, Vol. 25, No. 5, May 2009.

When Pam Murphy, RN, director of surgical services at 144-bed Piedmont Newnan Hospital in Newnan, Georgia, first heard a Lean presentation, she says, “It made sense, because we are so process driven. The whole focus is, ‘What is touching the patient, and what is value added?’”

Piedmont Newnan’s ORs were the pilot site for a Lean project for the Piedmont Healthcare system. The hospital has 8 ORs on 2 campuses. Piedmont was aided by Georgia Tech’s Enterprise Innovation Institute in Atlanta.

Developed by Toyota, Lean in health care brings clinicians and other staff together to improve processes that waste time and resources.

Involving the staff

Murphy knew the staff’s participation would be critical. She also knew they would have a concern: Does Lean mean doing more with less? Would people lose their jobs?

Backed by the administration, Murphy assured them no one would lose their jobs because of Lean.

Another concern—with staffing tight, how do you get staff off to participate in a project? How might that affect productivity numbers?

Again, Murphy had top-level support. A Lean account was set up for charging employees’ time so managers wouldn’t be penalized for lower productivity.

“That was a key decision by the executive team,” says Jenn Lingenfelter, project manager for Georgia Tech’s Health Care Performance Group, who worked with Piedmont Newnan.

Getting started

Since the Lean project started in December 2007, the ORs have conducted two 5-day Lean rapid process improvement (RPI) projects (also called kaizen events), one on case carts and the other on turnover time.

The hospital wanted to start with turnover time, but Lingenfelter urged the team to step back and take a wider view of the surgical process. In doing so, they realized one issue affecting turnover time was that case carts weren’t available and supplied correctly, which meant rework before cases.

Murphy recognized that if she and the staff could improve the case cart process, they would attract buy-in from other staff and physicians and build momentum for other projects.

These are the steps they took.

Training for staff

In Lean, improvement initiatives bubble up from the front lines, so the staff is critical to Lean. Lingenfelter began by introducing managers and an initial group of staff to Lean. By the end of her involvement, 90% to 100% of the OR staff had basic Lean training.

Selecting a team

For the case cart RPI, a cross-functional team of front-line OR staff was selected, including nurses, surgical technologists (STs), and central service (CS) personnel.
Murphy had planned for coverage 6 weeks ahead by arranging for per diem staff and having other staff report earlier in the day.

‘Going to the gemba’

After an introduction to Lean, the RPI team went to the OR and CS departments to observe the case cart process. In Lean, this is called “going to the gemba”—going to where the actual work is done. Getting the team out of their daily routine helps them to spot activities that waste time and energy.

The team split up to observe the instrument flow in the CS department, case-cart picking, and the opening of case carts and setup in the OR. They gathered baseline data by timing how long it took to pick a case and assemble a case cart.
The observers helped pique interest of the rest of the staff.

“The team would say, ‘This is what we’re looking at. What do you think?’ That helped to spread the excitement,” Murphy notes.

Mapping the process

After the observations, the team met in a conference room to map out the process on the wall. They noted which steps were value added and which involved waste.

Themes emerged:
• The preference lists were in reasonable shape but needed tweaking. The lists are computerized but didn’t include locations where supplies were stored.
• There was not a formal way of picking a case.
• The staff didn’t trust one another to pull cases accurately because everyone did it in a different way.
• Items were not placed in standardized locations on the case carts.
• In the OR, many items were opened “just in case” instead of held in reserve, as indicated on the preference list. That caused a lot of waste.

Whirlwind of improvements

The team divided into smaller teams to tackle each issue.

“We prioritized ideas and focused on those we could do that week. It was like a whirlwind,” Lingenfelter says.

One focus was a standardized case-picking method.

“In manufacturing, a distribution center is arranged so you go down Aisle 1 and pick items, then you go to Aisle 2, and so forth. With the case carts, staff were zig-zagging and backtracking,” she says.

The team worked with the IT department to develop a systematic pick path.

The preference lists were standardized to mirror the layout of the supply room so the person pulling a case would always start in the same location. Another breakthrough was to eliminate pulling all of the cases the day before. That had caused some case carts to be incomplete, meaning rework to look for supplies before a case and “stealing” from case carts already pulled.

Instead, the team decided that the only cases pulled the day before would be the first cases of the day. That reduced the space needed for case carts and eliminated incomplete case carts. The staff’s biggest concern was that case carts would not be ready, but Murphy says that has not been an issue.

A standard arrangement

The team also developed a standard arrangement of items on the cart so items needed first are on the top shelf and so forth. Other changes were:
• entering supply locations on the preference cards
• labeling shelves and bins in the automated supply cabinets
• cautioning staff not to pull cases from memory but to use the preference cards—even if they had been there for 20 years.

Updating preference cards

The team also fine-tuned the process for updating preference cards:
• The person picking the case prints out the preference card and highlights any missing items, such as an instrument set still in CS.
• The preference card goes with the case cart to the OR.
• In the OR, the OR staff write any missing items on the preference card.
• After the case, the preference card is taken to a designated location. The cards are tallied for missing items to determine an accuracy rate.
• Preference cards needing changes are transferred to another box where one person does the updates, typically within 2 or 3 days.

An ‘aha moment’

The RPI’s biggest win and greatest savings came from an “aha moment” during the observations.

“We found people had gotten into the habit of opening everything for a case,” Murphy says, even items labeled on the preference card as “do not open unless needed.”

In an easy fix, a “do not open” bin was added to the case carts. All such supplies for a case are placed in the bin when a case is picked. After the case, the bin with any unopened supplies goes back to CS with the case cart, and the supplies are restocked.

The savings—$118,000 over a year.

After the RPI, the overall case cart accuracy rate rose from 50% to 98% accuracy to 100% accuracy in November and December 2008, Murphy says.

Keeping up the momentum

Lean is meant to be a cultural change, not a short-term project. How do you keep it going?

“You have to continue to monitor and measure. Otherwise, the staff loses sight of where they are,” Murphy says. She reports the preference card accuracy rate to the staff regularly.

The spirit of Lean needs to become part of everyone’s thinking, Murphy notes.

Many of the staff have been involved in Lean projects.

“The only reason we succeeded was because of the staff,” Murphy says. “The staff were the ones who came up with the ideas.”

If a process slips, they will say, “Wait a minute. That’s not part of our Lean process.”

When performance drops off, the staff who were on the RPI teams “will sit back down and look at what’s going on. They’re the ones who own it and drive it,” Murphy says.

Success can be infectious.

“This project was so much fun,” Lingenfelter says. “You feel like you’ve made a difference. You see a difference not only in the bottom line but in the culture.”
—Pat Patterson

©OR Manager, Inc. 2009. All rights reserved. 800/442-9918. www.ormanager.com

About the Enterprise Innovation Institute:
The Georgia Tech Enterprise Innovation Institute helps companies, entrepreneurs, economic developers and communities improve their competitiveness through the application of science, technology and innovation. It is one of the most comprehensive university-based programs of business and industry assistance, technology commercialization and economic development in the nation.

Research News & Publications Office
Enterprise Innovation Institute
Georgia Institute of Technology
75 Fifth Street, N.W., Suite 314
Atlanta, Georgia 30308 USA

Media Relations Contact: John Toon (404-894-6986); E-mail (john.toon@innovate.gatech.edu).