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Use of Lean Performance Improvement Processes Significantly Improves On-Time Surgical Starts in the Inpatient Setting

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Dupont Hospital introduced the principles of the Lean production model to its surgery department because of frequent delays in surgical starts. By standardizing staff roles, organizing equipment more effectively, and reducing unnecessary steps in workflow, Dupont more than doubled the percentage of on-time surgery starts, from 27 to 66 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of on-time surgical starts and post-implementation data on staff, surgeon, and anesthesiologist arrival times.
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Developing Organizations

Dupont Hospital
Fort Wayne, INend do

Use By Other Organizations

The Lean processes and the ideas they have inspired, including the virtual corrals for storing equipment, are being used on other units throughout Dupont Hospital.

Date First Implemented


Problem Addressed

First-case surgical delays are common and often cause further delays in cases throughout the day,1 leading to increases in overtime costs and declines in staff morale and patient and family satisfaction.
  • Many causes of operating room (OR) delays: OR delays can stem from many causes, including clinical complications; unavailable instruments or supplies; unavailable laboratory results; arrival delays among patients, anesthesiologists, or surgeons; or delays in room preparation between procedures.2 At Dupont Hospital, for example, only 27 percent of surgical cases started on time before this program was implemented. Although a number of factors led to the late starts, late-arriving surgeons, nurses, technicians, and other staff were frequently to blame.
  • Negative consequences of delays: The failure to identify and respond to delays can have a negative financial impact for the hospital and surgeons, because fewer procedures can be completed per day. Operating room inefficiencies also lead to delays in patient care; suboptimal use of OR capacity; overtime costs; and high levels of patient, physician, and staff dissatisfaction.2

What They Did

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Description of the Innovative Activity

Dupont Hospital applied principles from the Lean production model to improve preoperative efficiency and on-time surgical start times through the elimination of unnecessary and redundant steps, better organization of supplies, and standardization of staff roles. Key elements of the program include the following:
  • Better preoperative preparation and organization: Each night, nurses put together the charts for the next day's surgical cases. Included on each chart is a "green sheet" on which providers document the expected patient flow before each surgical procedure, including which discipline conducts the preoperative visit and when the patient should be seen, any potential operational barriers in the preoperative process, and the places and times the patient should be taken during the preoperative process. The data captured on the green sheet are summarized and posted later that same day for staff to review and to allow for subsequent assessment of the preoperative process.
  • Standardization of supplies and equipment: Perioperative nurses use the Lean principle known as the "5 S's" (shine, sort, sustain, set apart, and standardize) to standardize supplies and equipment.
    • Standardized storage procedures: "Virtual corrals" are used with a picture of what the complete corral should look like. The storage area for each piece of equipment is outlined on the floor with red tape and photographs, with the names of the equipment placed on the adjacent wall, making it very clear where the equipment should be stored (thus allowing for easy access when needed).
    • Standardized cart of commonly used supplies: To assist those who restock the carts, each cart includes photographs of each drawer with a list of supplies and appropriate stocking levels.
  • Standardization of and reminders about roles: To be as efficient as possible, the perioperative team has adopted a "pit-crew philosophy" through which roles are standardized and highly structured to reduce duplication. The roles of nurses, surgical technologists, anesthesiologists, and surgeons are choreographed around the patients’ movements before the scheduled surgery starting time. For example, when the patient is wheeled past the surgery desk, the designated team member at the desk calls the physician’s lounge to inform the surgeon that the patient is on the way to the OR. This process uses Lean workflow principles to create a standard workflow that eliminates the need for waiting.
  • Standardized, structured communication: The on-time start Lean team members have standardized the work involved in "patient handoffs" between preoperative nursing staff and surgical nurses. Nurses use the Situation, Background, Assessment, Recommendation methodology to eliminate rework, overproduction, and extra activities and motion that commonly occur at handoff. To provide a visual cue, a red sign is placed on the patient's bed rail or a note is written on a dry erase board in the preoperative room to alert circulating nurses that items are needed before proceeding to the surgical suite.
  • Ensuring staff timeliness: The following activities help to ensure timeliness of staff:
    • Early arrival times: For the first case of the day, the surgeon is expected to arrive 45 minutes before surgery, and the anesthesiologist, nurses, and technicians are expected to arrive 40 minutes before incision time. Signs about expected arrival times are posted in easy-to-see places. To ensure on-time starts, the preoperative nurse places reminder calls to the surgeon if he or she has not arrived 30 minutes before start time. Arrival times for the surgeon, anesthesiologist, and scrub nurse are recorded on the green sheet for all surgeries that start between 7 and 9 a.m.
    • Biweekly meetings to share ideas: The staff meets on a biweekly basis to conduct process mapping and share ideas on how to improve on-time performance, including discussions of operational barriers and ways to overcome them.
    • Peer incentive: Surgeons and anesthesiologists who consistently meet their on-time start goals are publicly acknowledged. For surgeries that start on time each month, the responsible physicians and anesthesiologists receive a token reward and have their names posted on the wall. The names of physicians and anesthesiologists who are chronically late for surgery are also posted in the hope that peer pressure will help them to improve.
  • Feedback: Data and month-end results are reported and shared with physicians and team members to ensure that they remain involved and aware.

Context of the Innovation

Dupont Hospital is a 122-bed acute care inpatient facility in Fort Wayne, IN. Between 2000 and 2006, the hospital more than doubled in size, after which the organization's leadership decided to make 2007 a year of process improvement in all areas. Frequent delays in surgical starts made this a high-priority area. Dupont hired trainers from the Healthcare Technical Assistance Program at Purdue University to educate them about the Lean philosophy and Lean process improvement techniques.

Did It Work?

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The process improvements have increased staff timeliness and more than doubled the percentage of surgeries that begin on time.
  • More timely staff arrivals: Team members have become more punctual at the preoperative visit. Hospital nursing and technical staff arrive on time 100 percent of the time, while anesthesiologists are punctual 85 percent of the time and surgeons 44 percent of the time. A strong relationship exists between on-time arrivals and on-time first case start times.
  • More on-time surgical starts: The program has roughly doubled the percentage of on-time surgical starts, from 27 percent before the program began to approximately 66 percent by April 2009. Although the percentage of on-time starts has plateaued, the program's ultimate goal (set in August 2007) is to reach an 80 percent on-time rate. To help achieve this goal, the physician executives are now more closely monitoring chronically late surgeons.
  • Cost savings: Estimated cost savings for the hospital are approximately $90,000 per year. (This figure does not include any savings or freed-up time for physicians.) The cost savings are the result of lower nurse overtime due to reduced waiting times, elimination of redundant work, and standardization of workflow processes.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of on-time surgical starts and post-implementation data on staff, surgeon, and anesthesiologist arrival times.

How They Did It

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Planning and Development Process

The planning and development process included the following:
  • Leadership and frontline staff training: Every Friday for 8 weeks, Healthcare Technical Assistance Program trainers spent 4 hours training nine members of the hospital leadership team and frontline staff to use Lean techniques. Staff members attending these trainings included a scrub nurse, surgical technician, preoperative nurses, and leaders in the preoperative and technical surgical areas. During the training sessions, staff conducted process mapping to identify potential bottlenecks during the time between patient arrival at the surgical suite to incision.
  • Defining standardized terms: To ensure shared understanding, the leadership team defined “first start” as the first surgical procedure performed in an OR each day between 7 and 9 a.m. They defined “on-time start” as the first incision that occurs at or before the scheduled procedure time.
  • Creating awareness and setting expectations: The leadership team used a variety of techniques to create awareness of the new expectations, including hanging posters in strategic areas defining on-time and first starts. Letters were sent to all surgeons to explain the new expectations related to arrival times for cases.

Resources Used and Skills Needed

  • Staffing: No new staff members were needed to make the process changes associated with this program. Staff attended meetings as a part of their regular duties.
  • Costs: The hospital hired an outside consultant (Healthcare Technical Assistance Program) to train staff on Lean principles and processes.
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Funding Sources

Dupont Hospital
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Adoption Considerations

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Getting Started with This Innovation

  • Get leadership support: Elicit the support of the executive and management team for the required process changes; providing background on Lean principles and their potential to enhance efficiency can help in gaining the backing of hospital leaders.
  • Stress importance of timeliness: Encourage executives and management to regularly stress the importance of timeliness as an integral part of the patient care process for all physician, nursing, and other staff. The surgeon arrival time is a major contributing factor that affects the overall success of the initiative. Recognition of "on-time" physicians is vital.
  • Collect baseline data: Collect baseline data to enable measurement of the program's impact.
  • Set a framework for improvement: Create a charter with a problem statement, goal statement, and project scope to ensure that the entire team is "on the same page."
  • Map the current process: Conduct process mapping to allow the team to identify problem areas.
  • Provide training: Train frontline staff in the Lean model. If hiring outside trainers is not possible, good published information about use of the Lean process (including in the health care industry) is available.
  • Support and empower frontline and unit staff: Lean process changes do not work well without staff support, and morale often increases when staff take ownership of the process and resulting improvements.
  • Allow staff the time to participate: Provide staff with the time they need to attend the regular team meetings, as regular attendance at these sessions is critical to success.

Sustaining This Innovation

  • Hold ongoing meetings: Hold regular team meetings to sustain the process changes and discuss opportunities to continually improve performance.
  • Share data: Post surgery starting times on a daily basis to maintain awareness of and enthusiasm for meeting and exceeding goals. Collecting and posting data every day helps frontline staff see the positive results of the changes and thus embrace them as a "way of life."
  • Maintain the virtual corral: Maintain the virtual corral to ensure that equipment can be retrieved readily whenever needed.

Use By Other Organizations

The Lean processes and the ideas they have inspired, including the virtual corrals for storing equipment, are being used on other units throughout Dupont Hospital.

Additional Considerations

Small, incremental changes are worthwhile, and their benefits can spread throughout the whole facility.

More Information

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1 Overdyk FJ, Harvey SC, Fishman RL, et al. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg. 1998;86:896-906. [PubMed]
2 Harders M, Malangoni MA, Weight S, et al. Improving operating room efficiency through process redesign. Surgery. 2006;140:509-16. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 20, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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