September 24, 2013
The South Operating Room accounts for the lion’s share of surgeries, inpatients and revenues at OHSU Hospital and touches almost every part of the organization, from scheduling to transport. Like a large and complex machine, the OR’s many moving parts are hard to take in at eye level – where employees rightly focus much of their attention.
The OHSU Performance Excellence System or “OPEx” has opened up a kind of aerial view of its operations and key points where they can be improved.
Since March of this year, South OR faculty and staff have partnered with Perioperative Services and the Quality Department to map and improve a major “value stream” – the flow of all steps, materials and information needed to deliver surgeries to patients. With Rayna Tuski, Interim Surgery Director, managing a Value Stream Core Team, significant progress has been made in reducing waste – steps that patients don’t value and would be reluctant to pay for, such as waiting or delays.
“I’ve seen a lot of change processes here, some of them quite successful, but I’ve never seen a more systematic or effective approach to making and sustaining improvements,” said Steve Robinson, M.D., professor of anesthesiology and perioperative medicine. Dr. Robinson has a 27-year history at OHSU.
Asked about high points in the OPEx journey, he mentioned “aha moments” when tools yield new insights. For example, “spaghetti diagrams” capture surgical teams’ movements in the OR. Invariably, the visual record looks like a tangled mass of pasta, a sure sign of waste. “I’ve watched surgeons, anesthesiologists and nurses suddenly realize that they can work smarter, not harder, and achieve better results,” said Dr. Robinson, who completed Lean Leader Training last February.
Other members of the Value Stream Core Team share his conviction that OPEx works. Surgery Scheduling Manager since 2011, Tina Foss and her staff saw the percentage of correctly scheduled elective surgeries jump from 74 to 94 percent in pilot service lines over a 3-week period this summer. Scheduling “abnormalities” – such as missing lab tests or consent forms – caused delays, higher costs, increased safety risks, and patient and employee dissatisfaction.
Foss has found it easy to engage her staff in improvement efforts. “They feel empowered by coming together to discuss problems they have all experienced, and to plan immediate steps for improving them.” For example, they created visual checklists to ensure that all patient information is in hand the day before surgery. Foss reported a sense of excitement on the team as changes were put into practice and tested. Scheduling data continue to be analyzed using visual dashboards called Daily Management Systems, which have become the focus of team huddles. Experiments in process improvement have given schedulers a new appreciation for OHSU’s mission of scientific discovery.
Breaking down functional silos and building team work are a vital part of the OPEx effect. For example, Sterile Processing Manager Jerry Hutchison said that he and his team are now “joined at the hip” with South OR staff because they share common goals and metrics for managing materials and reducing the average cost per surgery. When there are errors in pick lists, his staff loads the wrong instruments into carts, delivers them to the OR, and then has to transport them back to the Department and put them away. “In the past, we would never think of approaching nurses to suggest changes on their side.” Now everyone understands that they have a common stake in doing what’s right for patients and they work together to improve processes.
Performance gains in the South OR hold promise for the whole clinical enterprise. As understanding and use of OPEx spread, OHSU is poised to make new headway toward the Triple Aim of improving health outcomes and the patient experience while reducing the cost of care. But the Value Stream Core Team is far from complacent. All cautioned that the pace of change and use of resources have to be managed carefully, especially as OPEx is scaled up. Regular inputs of energy and resources will be needed to sustain and build on improvements in the South OR and other pilot locations.
“With OPEx, there’s no finish line, only the pursuit of continuous improvement” said Dr. Robinson. “We have to celebrate the journey.” For those who work in the South OR, that means many small acts of discipline each day as they carry out processes they help to define as “standard work” and track the impact on meeting performance standards. At the same time, they are freed up to focus more of their energy and creativity on the things that really matter to patients.
Click here to read a full report on the Value Stream.