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Service Delivery Innovation Profile

Process Improvements Based on Lean Principles Reduce Operating Room Foot Traffic, Leading to Reduced Risk of Infection and Enhanced Staff Productivity and Satisfaction

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Exempla Lutheran Medical Center used Lean principles adopted from the Toyota Production System to reduce foot traffic into and out of the surgical suite, chiefly by improving equipment and supply availability in the operating room. Process changes included revising surgical preference lists and methods for updating those lists, holding post-case briefings, and using communication tools to ensure equipment and supply availability. Since introducing these changes, foot traffic into and out of the operating room has declined by 32 percent, leading to reductions in surgical site infections and enhanced staff productivity and satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of foot traffic, surgical site infections, staff time spent looking for missing items, and staff satisfaction levels.
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Developing Organizations

Exempla Lutheran Medical Center
Wheat Ridge, COend do

Date First Implemented


Problem Addressed

Excessive foot traffic into and out of the operating room (OR) can lead to airflow disruptions that increase the risk of surgical site infections, and can cause distractions that can lead to potential errors.
  • Foot traffic as a potential source of infections: OR-based nosocomial infections have been documented as a common source of surgical site infection.1 Positive-pressure airflow systems put in place in all modern surgical suites exchange the air in the suite frequently, thus removing small (often microscopic) sources of bacteria that can cause infection. These systems also help to maintain a cool temperature to limit colonization of bacteria in surgical sites and on instruments.2 Any disruption in the airflow system during the procedure, such as that caused by the opening and closing of surgical suite doors (e.g., to get missing supplies), can increase the risk of infection.
  • Foot traffic as a potential source of distraction: When OR staff have to leave and reenter the OR, the resulting foot traffic creates the potential for increased levels of distraction for the surgeon and other OR team members. Eliminating these interruptions allows the team to concentrate on the patient (rather than on missing equipment or items), thus reducing the potential for error.
  • Root cause of OR foot traffic problems: Exempla Lutheran staff examined the root causes of OR foot traffic and found that staff often did not have the supplies, instruments, and equipment needed, or that these items were not properly located, thus requiring nurse circulators and OR assistants to leave the OR and return with the items.

What They Did

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Description of the Innovative Activity

Exempla Lutheran Medical Center used Toyota Lean principles (see the Planning and Development section) to reduce foot traffic into and out of the surgical suite, chiefly by improving equipment and supply availability. Key elements of the program are described below:
  • Simplified and standardized preference lists: Surgeon supply preference lists have been reorganized to improve the completeness of the case carts for surgeons performing multiple procedures. Information provided in April 2009 indicates that the following changes were made to the preference lists: elimination of unnecessary and unused items; standardization of formatting for headings, font, and spacing to make the preference lists more user friendly; and designation of a location on the preference list for “have available” items that needed to be available but not opened.
  • Standardized process to update preference lists: Information provided in April 2009 indicates that a single location on the paper copy of the preference list has been created for listing updates, with operating room data specialists checking the lists and implementing the update within 1 day.
  • Postcase briefings: These quick briefings, held after every surgical procedure, allow surgeons and other staff to provide immediate feedback on any problems related to missing supplies that occur during the case. These briefings also provide an opportunity to request changes in the supply preference list.
  • Communication tools: Information provided in April 2009 indicates that the surgeon and the clinical manager periodically review the surgeon-specific report of all preference lists to ensure the most up to date and accurate preference lists are used. In addition, a "missing-item" report tag attached to the front of the case carts allows for quick communication when items are missing from the case cart; the scrub technician responsible for setting up the room reviews these tags and locates the missing items.

Context of the Innovation

Exempla Lutheran Medical Center, part of Exempla Healthcare in Denver, CO, is a 400-bed community hospital providing a comprehensive spectrum of specialized care. To achieve identified hospital goals of patient safety, patient satisfaction, employee satisfaction, and fiduciary responsibility, hospital leadership identified opportunities for cross-departmental (service line) process and outcome improvements and incorporated Lean principles (adopted from the Toyota Production System) into performance improvement activities. The Lean methodology uses frontline staff to evaluate and improve patient care processes, with an eye toward reducing waste by standardizing materials and procedures and redesigning workflow as needed. At Exempla Lutheran Medical Center, infection control is an ongoing cross-departmental function, and the OR/anesthesia/central supply service line was chosen as an area in which Lean principles could be used to assess and reduce foot traffic in surgical suites.

Did It Work?

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The processes introduced by the OR team reduced OR foot traffic by 32 percent, contributed to a reduction in surgical site infections, saved staff time, and improved staff satisfaction.
  • Reduced foot traffic: Exempla Lutheran experienced a 32 percent reduction in total OR foot traffic between July and September 2006.
  • Fewer infections: Surgical site infections declined by 14 percent between the first quarter of 2006 and the first quarter of 2007; although a direct cause-and-effect connection between reduced foot traffic and infections cannot be made, hospital leadership believes that reduced foot traffic contributed to the decline.
  • Redirected staff time: The program freed up 7.9 staff hours per day between July and September 2006, as the surgical team no longer spends much time finding missing items, and thus has more time to focus on patient care.
  • Improved staff satisfaction: The program has resulted in a 6 percentage point improvement in staff satisfaction, from 65 to 71 percent, on the question, “The necessary material and equipment are available when I need to perform my job” between the first quarter of 2006 and the first quarter of 2007.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of foot traffic, surgical site infections, staff time spent looking for missing items, and staff satisfaction levels.

How They Did It

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Planning and Development Process

The planning and development process, based on Toyota Lean principles for rapid improvement, included the following:
  • Four-day rapid improvement cycle: Exempla Lutheran conducted a “rapid improvement cycle,” a 4-day event bringing together frontline staff and physicians to analyze current work processes and discuss what was and was not working in the system.
    • Root cause analysis: The team analyzed the root causes of excessive foot traffic by reviewing baseline data and observing the process for updating preference lists and storing supplies. The team reviewed a sample of cases, recording how often, when, and why the staff left and reentered the OR, and what door they used to enter and exit. The team identified why there were interruptions during surgery and whether the supplies needed during surgery were in the right location. The team found that preference lists were often convoluted, inaccurate, and incomplete.
    • Process redesign: The team then redesigned processes related to surgeon preference lists, supply case carts, and inter- and intrastaff communication.
  • Followup observation: After the rapid improvement event, the team monitored the results of their new processes for 90 days to ensure that they were effective, with minor refinements being made as needed.

Resources Used and Skills Needed

  • Staffing: The program required no new staff, as existing staff participated as a part of their regular duties. Lean team members included representatives from all areas of perioperative care, including scrub technicians, OR assistants, a physician champion, representatives from the sterile processing department, an OR auditor, a clinical manager, the OR director, and the chief nursing officer. In addition, a "spotter" who was unfamiliar with the OR served as an objective observer of the care processes.
  • Costs: No costs were incurred as a result of the initiative. The improvement team’s nonclinical time required for participation in the improvement is an ongoing budgeted expectation as part of Exempla Lutheran Medical Center’s process improvement work.
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Funding Sources

Exempla Lutheran Medical Center
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Adoption Considerations

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Getting Started with This Innovation

  • Ensure strong leadership support: Enlist the support of the chief executive officer in removing communication barriers among staff and in serving as the initial and ongoing champion for the process. Although Lean principles can be a powerful catalyst for change, implementing them also disrupts the way people do their work, which means that strong leadership is needed to overcome potential resistance.
  • Encourage collaboration: Use a collaborative leadership model, as "command-and-control" leadership is not conducive to implementing Lean principles.
  • Compare assumptions with reality: Ask the entire team for their perceptions of the process, and then take them to the OR to observe it. Observation is critical to creating and implementing change, and this step allows team members to compare what they think happens with what actually happens, thus seeing for themselves where change is needed.
  • Design a standardized process: Identify a standard process and align everyone in the delivery of care according to that standard. A clear expectation should be that work will be done in a uniform way and not the way an individual sees fit.

Sustaining This Innovation

  • Monitor processes: Be vigilant in monitoring new processes daily for at least 90 days until they become stable.
  • Encourage continuous improvement: Revise new processes as needed, as Lean principles encourage a process of continuous improvement.

More Information

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Contact the Innovator

Mary Shepler RN, BSN, MA
Vice President and Chief Nursing Officer
Exempla St. Joseph Hospital
1835 Franklin Street
Denver, CO 80218
Phone: (303) 425-4500

Innovator Disclosures

Ms. Shepler has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The white paper, Going Lean in Health Care, is available from the Institute for Healthcare Improvement at:

The National Resource Center for Health Information Technology and the Patient Safety Research Coordinating Center. AHRQ 2006 Annual Patient Safety and Health Information. Technology Conference: Strengthening the Connections. June 4–6, 2006. Washington, DC. Available at:


1 Mangram AJ, Horan TC, Pearson ML, et al. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999 Apr;27(2):97-132. [PubMed]
2 Memarzadeh F, Manning A. Reducing nosocomial infections in ORs. Infection Control Today. June 1, 2003. Available at:
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: December 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 29, 2010.
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.