APOM Grand Rounds

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

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

4. OPEx Overview • OPEx is the collection of Methods, Management and Mindset that help OHSU Healthcare achieve its goals in a systematic way • Based on Lean principles that maximize value for patients through Continuous Improvement and Respect for People

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

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

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

8. Definitions of Waste

9. The Importance of Standards • Provide a common understanding of the process – the right way to do the work • Improve predictability of results • Make abnormal vs. normal clear • Enhance problem solving

10. 5S for Workplace Organization Sort Separate the needed from unneeded items Simplify Create a place for everything and a way to keep everything in its place Sweep Create visual controls and indicators to easily determine normal and abnormal conditions Standardize Document methods and procedures to maintain the system consistently Sustain Ensure disciplined adherence to standard work to prevent backsliding

11. South Operating Room Patient Value Stream

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

13. Standard information • Epic/MyChart • E-mail • Website • Handout • Confirmation Call • Align surgical practice, OR scheduling • Standard letters • Practices have same elements • Visual way finding • Training to appropriate staff • ICARE • Unit-specific signature moments Patient

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

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

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

20. Kaizen Event: In Room to Anesthesia Ready

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

22. Breakthrough Kaizen Charter: In Room until Anesthesia Ready • Problem Statement: The time between a patient entering the Operating Room until the procedure starts has high variation in workflow and timing. This portion of the value stream can be broken up into two segments, “in room to anesthesia ready” and “anesthesia ready to procedure start”. The former segment includes the time after the patient enters the room until the anesthesia provider’s activity is sufficiently complete so that the case may progress towards procedure start. Variation in practice contributes to increased OR costs, patient safety risk, and unpredictable case duration (in room to out of room). This contributes to poor scheduling accuracy, delayed cases, and dissatisfaction of patients and personnel. • Goal/Target: • Reduce the mean time from In Room to Anesthesia Ready in OpTime from 23.3 minutes to 18.3 minutes.(This number should be adjusted based on the percentage of complicated • cases as compared to more straight forward cases; the more longer cases, the more opportunity.) • Reduce the range of the 10th (9 min) and 90th (45 min) percentile from 36 min. to 30 min. 10th percentile to 8 min. and 90th percentile to 38 min. • Reduce the range of the 25th (13 min) and 75th (29 min) percentile from 16 min . to 13min. 25th percentile to TBD and 75th percentile to TBD. • All changes will promote efficiency and safety from along the time line of turnover through procedure start: • first case start (80%) • turnover time (44 minutes) • anesthesia ready to procedure start (27.6 minutes) • Total time (Turnover + In Room to Anesthesia Ready + Anesthesia Ready to Procedure Start) = 44+23.3+27.6 = 95 min • Objectives: • Break down the elements from In Room to Anesthesia Ready • Implement standard work for all roles involved between “In Room” until “Anesthesia Ready” . • Standard work to include who, what their responsibility is, and when it should occur. • Include standard work for different situations (split rooms, first cases, second cases, vascular access/monitoring, etc.) • Remove waste in the process (provide specifics during the event; e.g. reduce motion related to ______) • Maintain or improve patient safety(CLABSI rates, line placement compliance, adhering to checklist utilization, patient transfer to OR table) • Provide the above data by individual and service factoring in important characteristics such as: invasive monitoring/access, anesthetic type, patient BMI and patient ICU status (+/- mechanical ventilation).* • Accommodate appropriate training in the context of safety and efficiency. • Used improved communication between anesthesia and surgery to optimize decision on invasive line placement. • In Scope • From doc of “in room” (circ) to “anesthesia ready” (anes . provider) • SOR cases • All days, all times (limited) • Emergent cases (limited) • GI cases • ICU patients Improvement Team • Anesthesia Staff: Aziz, Robinson • Anesthesia Resident: Ross Martini • CRNA: Livingston, Snow • Anesthesia Tech: Jonny Sands • SOR Circ.RN: Conley + Choi • Surgical Resident: Jesse Liu • Surgical PA: Paula Wilson • Out of Scope • “Anesthesia Ready” to “Proc Start” • Pediatric cases staffed by DCH (under 12 yrs. Age) • Other OR sites • Labor and delivery * = Implementation Coaches Resource Representatives • Admin Support, Measurement Specialist, Financial Analyst • Mac Eggling Key Stakeholders Mark Zornow, Bob Cross, Jeff Koh, David Larsen • Blue Blake • Mary Munoz • SPD • 6A RN • EVS: Winans Stojanovic • Neuro monitoring • Bob Hart • Ahmad Raslan • Nate Seldon • Linda Knox • Joanne Girard Project Sponsor: Jeff Kirsch Management Guidance Team: EMG, Core Team Process Owner*: Steve Robinson; Mike Aziz Facilitators: Randy O’Donnell, Rayna Tuski, Grace Ullum, Shauna Hoffman Sponsors and Process Owners are MGT members Key Dates: Assessment: 05/28 Planning:06/16-06/17 Go/No Go:06/17 Event Date: 07/21-07/25 Follow Up Day/Time: 30-day________________ 60-day_________________ 90-day__________________

24. Standard times

25. Process sequence

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

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

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

29. Time Estimator Tool • For use to help more accurately estimate time from entering the room to anesthesia ready • If an activity is after AR, assume 0 for purposes of estimating AR • This is just a tool.

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

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

32. 4. Standard patient workflow

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

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

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

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

38. Thank you! Questions?