To be financially viable, a hospital’s operating rooms (ORs) need to be centered on creating access — keeping quality and utilization high and expenses low. “We need to plan ahead, be prepared, and set our volumes correctly,” said Erich Kirsch, director of Virginia Mason’s operating room processes. This means an organization’s OR team should be continually finding ways to improve their ORs’ turnover time. Studies in OR management have explored ways to improve access, focusing on shortening case durations, improving parallel processing, establishing targets and reporting results, adjusting scheduling, better defining processes, analyzing preoperative clinics, implementing new facility designs, and changing employee incentives, availability, workflows and training.1,2 Yet the challenges remain to keep access top of mind: How can an OR team continue to find ways to make a meaningful difference and sustain their improvements for patient safety, staff engagement and organizational costs?
When Virginia Mason’s team analyzed their inventory of surgical instruments, they saw that at any one time, thousands of instruments were in use during setup, surgery, breakdown or sterilization — and still the team saw a large amount of instruments in storage. They had worked for years to keep the inventory down,3 but they knew they could use lean tools and innovative thinking to build on that work.
One year later, after implementing the operating room’s transformational build-to-order (BTO) process, 58,728 unnecessary instruments — weighing 29,480 pounds — were removed from processing per year. In neurosurgery alone, the team decreased instrument assembly time by 42 percent, reduced inventory by 26 percent. After this work, they helped other team members produce similar setup reductions in specialties such as orthopedics.
|Instrument Assembly Time
How did Virginia Mason’s leaders, surgeons and staff work together to increase efficiency, build in quality and safety, and improve staff satisfaction for their teams in neurosurgery, orthopedic surgery, general surgery and thoracic surgery?
Starting with inventory, progressing with data collection
When the team first looked at the instruments in storage, they asked, How do we know what surgeons need and what they don’t need? Which instruments do surgeons use? Which don’t they use?
To answer these questions, they worked together to capture surgeons’ preferences based on actual usage. First, the leaders met with surgeons and staff to explain the vision and describe what questions they were trying to answer so that they could make improvements based on the most current data. The vision, said Sam Luker, Virginia Mason’s former director of sterile processing, was to create “better patient experience, fewer defects, faster setup and better throughput.”
Then the leaders — after evaluating their employees’ interest and aptitude — trained surgical technicians to become project coordinators and data collectors. Following the training, the new data collectors took their clipboards, pens and timers to operating rooms, setup areas, breakdown areas, sterilization rooms and storage rooms. They were there to observe what really happened in the different work areas so they could understand physician priorities and see how much time was being spent on the work that made a difference to patients and staff — and how much time was spent on wasteful processes that didn’t benefit patients and staff. As Luker explained, the coordinators were able to easily step into the operating rooms, introduce themselves and explain what type of data they’d be collecting. “The work was transparent from the beginning, and no one felt threatened or worried,” he said. “We talked with the surgeons early, in one-on-one meetings. The surgeons and staff knew we were all a team and that the data collectors were there to improve our work for patients.” The data collectors observed each surgeon and procedure five times, building data so that the team could create consistency and produce reliable outcomes.
Establishing a structure to guide the work
Armed with data, team members came together for a 3P (Production Preparation Process)4 workshop to set their vision for a dramatically more efficient process. By the end of the 3P, the participants had created a guiding team to oversee all the work, determine next steps and answer any questions that came up throughout the process. The new guiding team included a sterile processing leader, operating room leader, kaizen promotion office leader, neurosurgeon, surgical technologist, sterile processing technician, project support staff member and administrative support staff member.
Using lean methods and tools to get results
The team next employed the lean concept of 5S (sort, simplify, sweep, standardize, self-discipline). In their orthopedic case sets, they discovered that almost 60 percent of the items were rarely used. As Sam Luker said, “In one year, this equates to 700 tons of unnecessary instruments being processed.” Using their data, they sorted what instruments were actually used, simplified the process by removing the unused instruments (while keeping a safety net for emergent situations), swept the area by designing a continual inspection of case sets, standardized their tray layout, and created self-discipline using a team agreement that specified ongoing monitoring.
Then they created the build-to-order instrument sets, which employed the concept of just-in-time inventory — in which just the right surgical instruments would be delivered just when they were needed — as well as the customization to each surgeon’s needs for the procedure. The new setup techniques made the process easier for the surgical technologists.
The team’s use of a production board, too, helped everyone understand the demand and make it visible to those who were building the sets. And in an improvement event focusing on the setup for craniotomy procedures, the participants discovered how to customize each set, reducing the setup time and the OR space needs in the suite — eliminating an entire back table. By the end of this event, they were able to combine sets, reducing their setup time from 34 minutes to 2 1/2 minutes. “We believe that we could apply this method to half of our instrument sets and benefit sterile processing and the OR,” said Kirsch. The team compared times before and after the improvement events and found that the more limited case sets did not increase overall procedure time.
Getting results for other surgery sets
The results for improving the laminectomy surgical setup were even more impressive. After implementing the build-to-order sets, the instrument assembly went from 34 minutes to 20 minutes, 15 seconds. The instrument setup in the OR went from 24 minutes, 9 seconds, to 2 minutes, 29 seconds — a 90 percent decrease. The number of instruments used decreased from 152 to 59, and the number of instrument sets decreased from 5 to 2.
For the Zimmer total knee case, the team was able to remove 17% of the instruments; for the DePuy total knee case, they removed 33 percent of the instruments; and for a medium bone set, they removed 27 percent of the instruments.
Improving quality and safety
During the assessment of their instrument inventory before the lean improvement work, the team determined that the large number of unnecessary instruments in storage could have a big impact on safety. Not only was the probability greater for a surgical technologist to select the wrong instrument for a procedure, but the time spent searching for specific instruments and maintaining all these instruments — many of which were processed and sterilized yet never used — could potentially affect patient care.
Kirsch said, “When you process instruments that are never actually used in procedures, there’s wear and tear on all these instruments and it is wasteful for the people who process them.” The team’s results after eliminating the waste revealed that the new process for setup was quicker and easier, and the breakdown and processing times were faster, so they knew that the elimination of wasteful practices regarding inventory, handling and sterilization contributed to better quality and safety.5 They also used the data to determine which instruments should be backup items to support the surgical case for immediate use.
Reducing wait times for patients and staff
With build-to-order instrument setup, time is important for everyone. That’s why with an instrument setup time of under two and a half minutes, no one is waiting — not the surgeon, not the team, and most importantly, not the patient. This is very important during lifesaving operations such as craniotomies, when minutes count. It also improves the staff experience in supporting the cases.
Improving staff communication
Enabling open communication between the team members helps to keep access open and patients safe. Every Wednesday at 8 a.m., for example, the orthopedic multidisciplinary team meets for 30 minutes to discuss case volume for the next two weeks, on-time statistics and lead time and then determine how to ensure excellent access.
They also troubleshoot as a team when necessary to improve patient safety. For example, said Kirsch, “we’ve learned together that procedures starting before 5 p.m. are better for patients. If we schedule a 90-minute orthopedic procedure at or after 5 p.m., then the patient won’t be able to see a PT right away, and the potential grows for a longer stay, errors or a fall. So we start with the patient experience and work together to do what’s best for each patient we see.”
Improving physician satisfaction
This improvement work has also led to physician satisfaction. The lead time for booking orthopedic surgery, for example, went from 65 days down to 21 days. Kirsch said, “The surgeons don’t want to wait between procedures. They’re motivated to keep going, so they’re happy with the increase in volume.” Luker added, “It’s great to hear a surgeon say, ‘Wow. It takes a lot less time to do a craniotomy now.’”
Seeing financial gains
Virginia Mason has also realized financial benefits. “When you eliminate the waste, you free up the inventory and see cost savings,” Luker said. When the inventory was being used for non-value-added work, the instruments were tied up. Now, though, the instruments can be used to create new made-to-order sets.
The organization also saves on the number of lost, broken and damaged instruments because only the instruments that have actually been used in the OR and processed — and not all the extra instruments that used to be brought to the ORs yet never used — need to be inspected for quality before reuse.
Working together for continuous improvement
The build-to-order model improves quality, safety, efficiency and costs while benefiting patients and staff.
Kirsch sees that Virginia Mason’s continued dedication to lean methods and a respectful culture6 has helped the organization reap the benefits they’ve been working so hard to achieve. “I’ve been here for 18 years,” he said. “We’re so far ahead of other organizations that are money-based. The patient is always at the top of the pyramid at Virginia Mason, and that’s why things get better here and why we are transforming health care. We’re producing excellent, safe, consistent patient care.”
- Marjamaa R, Vakkuri A, Kirvela O. Operating room management: why, how and by whom? Acta Anaesthesiol Scand. 2008; 52(5): 596-600.
- Cendan JC, Good M. Interdisciplinary work flow assessment and redesign decreases operating room turnover time and allows for additional caseload. Arch Surg. 2006; 141: 65-69.
- King R. How can standardizing surgery tools prevent adverse events? Virginia Mason Institute website. https://
www.virginiamasoninstitute.org/ 2016/ 02/ can-standardizing-surgery-tools-prevent-adverse-events. Published February 25, 2016. Accessed August 24, 2016.
- Backous C. Using a 3P to create a vision and plan for better patient care. Virginia Mason Institute website. https://
www.virginiamasoninstitute.org/ 2016/ 07/ using-3p-to-create-better-patient-care/. Published July 20, 2016. Accessed October 4, 2016.
- Farrokhi FR, Gunther M, Williams B, Blackmore CC. Application of lean methodology for improved quality and efficiency in operating room instrument availability. J Healthc Qual. 2015; 37(5): 277-286.
- Virginia Mason Institute. Respect for people: a building block for engaged staff, satisfied patients. Virginia Mason Institute website. https://
www.virginiamasoninstitute.org/ 2013/ 01/ respect-for-people-building-block-for-engaged-staff-satisfied-patients/. Published January 16, 2013. Accessed October 4, 2016.