Eliminating 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 chapter 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 the Perioperative Services department are:
- Reassembling instrument sets in large batches while the autoclave sits idle. The symptom is “We do not have enough instrument sets.”
- Spiking IV bags in Pre-Surgery for the whole day, while patients wait. The symptom 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 is 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-surgery. 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 Perioperative Services 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 represent work that contains errors, requires rework, has mistakes or lacks something necessary.
Nothing proclaims a broken process quite like defective work. The temptation is to start with the old search for accountability, and looking for someone to blame. Instead, try looking at the broken process and asking why, or use simple assessment tools like a fishbone diagram. Engage other staff members 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-surgery. 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 it?
Managing "A" Items in the OR
Imagine this: You walk into a local bank to open an account. As you're speaking to a bank representative, you notice that there are no tellers. Instead, customers seem to be walking into the unguarded vault and helping themselves, either depositing or taking the cash. The bank rep explains: "We can't really afford to hire people to just keep track of the cash, so we operate with the honor system. When you take some cash or drop some off, you are supposed to leave us a note. Once a month we'll do a count and reconcile the balances. Most people are pretty good at following the system, but we always have some variances to write up or down. But paying tellers to just keep track of the cash is a waste we just can't afford." By this time you're running for the door.
As ridiculous as this seems, this is exactly the way that many (most) hospital OR's handle their supplies and materials. Much of the material in the OR falls under the inventory classification of A items, items with a high dollar value. Examples of A items include implants, stents, and grafts. The dollar value of this material in the OR can easily total several million dollars or more, and represent 70% of your total inventory investment.
How do we keep track of all of these dollars, in the form of supplies? Very few OR departments actually maintain a perpetual inventory system, that keeps track of material like a bank keeps track of cash. In other words, at any given point in time the OR doesn't really know what is in stock without physically looking. Complete physical inventories are done periodically, sometimes as infrequently as every six months, and there are significant accounting write-ups or write-downs whenever this is done. Needless to say, this is a source of heartburn for the hospital financial department as well.
So why is this apparently common state of affairs, something that would be unacceptable in a bank or even a manufacturing company, allowed to continue in hospitals? Here are some of the reasons we hear:
1. Our focus is on the patient. We can't expect nurses and doctors to become "bean-counters". They're too busy.
2. Supplies and materials are often needed urgently. We can't slow down to fill out paperwork or transact what we need, because it's too time consuming.
3. We can't afford to hire any new FTEs to track materials, because that's just another overhead expense, and we need to control costs.
4. That's not the way things are done in a hospital.
Before we offer some suggestions for improvement, let's take a look at the hard costs related to lax inventory management. In that way we can make a more informed decision about what we can afford, or what level of attention to supplies might be needed. Here are some of the symptoms:
1. Shortages. If we don't know with precision what we have, then an inevitable results will be a higher level of shortages. The results can be serious for our patients, and also drive high expediting and overnight freight costs.
2. Inaccuracies in billing. Not everything gets billed out correctly if we don't have tight reins on inventory management.
3. Excessive supplies handling. The "par level" method used to assess inventory needs is horribly inefficient. It should be replaced with the system used by most world-class organizations, kanban. See my ezinearticle on Par and Kanban.
4. Inaccurate financial statements. The accounting rules tell us that if we don't really know what we have, we also don't really know what our costs are for any given financial reporting period.
5. Excess inventory. If inventory records are not accurate, we tend to compensate by overstocking. In a recent improvement project, we removed over $500,000 in excess inventory from an OR, without breathing hard.
What should you do about managing A items? There are several possibilities, ranging from the very manual to the high tech. The simplest suggestion is to do what most high performing organizations do: have a quick-response stockroom in the OR, with individuals assigned to inventory control, inventory transactions and patient service for materials. Set a goal of being able to put your hands on any item within 10 seconds, and set up the storage area to be able to accomplish this. Plan to staff the area for hours that match the schedule of OR need.
An intermediate-level solution would involve the use of bar-codes to speed up transactions and reduce errors. Nurses and techs can be trained to use the bar-code system, and reduce the workload on the materials staff. Barcoding is not a new technology, and virtually every inventory system supports it.
On the high-tech side, install RFID-based cabinets. An RFID cabinet is a locked storage container that is able to track what is inside via a Radio Frequency Identification tag attached to each high-dollar item. In order to unlock the cabinet an employee badge and a patient case number are needed. The RFID cabinet has the advantage of being able to capture billing information in addition to inventory information, and greatly reducing human error.
Regardless of the path you choose to follow, it is important to make a commitment to a high level of inventory control for A items in the OR. This effort will pay for itself many times over.
