When the Rubber Misses the Road –

OR Late Starts
Rhonda W. Barton David Hall
Director for Executive Education, Senior Vice President and Chief Operating Officer,
University of Tennessee The University of Tennessee Medical Center

“Partnering with UT Medical Center
was a natural fit for the UT Center
for Executive Education. Combining
the expertise of Dr. med. Hank Schiffers,
MD, MBA with lean practitioners has
created a program to improve patient
outcomes in an ever-changing
environment.”
“Healthcare organizations are challenged to provide high quality and safe care to
patients through reliable and effective processes. Nowhere is this more evident
than in the Operating Room (OR). Lean is a performance improvement methodology
that focuses on creating value from the customer’s perspective by eliminating
waste and reducing risk that comes with variability. Lean has been adopted in
our organization because it makes common sense and is facilitated by the people
actually doing the work. Our experience in the OR demonstrates how focused
individuals with creativity and the use of proven Lean techniques can make a
positive impact on efficiency.“

Authors: Wm. David Hall*, Dr. med. Hank Schiffers, MD, MBA**; Rhonda W. Barton*; Thomas Fields*; Vanita Glenn-Adams**;
Bert Hoffmann**; Tami Anderson*; John Bell, M.D.* * UT Medical Center, Knoxville TN; ** Stryker Corp.

Achievements The University of Tennessee Medical flow stream leading to cancelations,

• Reduced number of surgery start
delays by 38%
• Additional OR revenue potential of
$461,000 by year end 2010
• Improvements in Sterilization area for
first patients
• Supplies reduced and adjusted to
reflect JIT supply management
• Surgery delay reasons being tracked
and reported monthly
center (UT Medical Center) is an accredited
tertiary care, surgical and academic
medical facility located in Knoxville,
Tennessee. The facility manages 494 beds
and maintains a reputation for providing
quality patient care. According to the U.S.
News and World Report website, UT
Medical Center received an overall patient
satisfaction score of 77 %, as compared to
state and national average scores of 68 %.
The center strives to deliver premier patient
care and is committed to educating its
employees in continuous improvement
methodologies.
potential overtime, patients waiting, etc.
With this challenge, the medical center
saw an opportunity to build a more robust
patient service delivery standard, which
led management to seek solutions that
were based on a Lean for healthcare
model. Building on previous Lean learnings
and desiring to leverage this experience,
the medical center forged a partnership
with the European Stryker Lean Team,
bringing a broad, global healthcare
perspective to the proposed Lean initiative.
Stryker is a publicly traded global medical
devices company which has been in
business since 1941.

• Improved work area efficiency in Thomas Fields

Holding Room area
• Registration patient readiness plan
enacted reducing delay lead time
• Streamlined PAT (patient testing
center) process for first patients
• Decreased patient flow times
• Increased patient and staff
satisfaction
• Shorter response and waiting times
Director Surgery / PeriOperative Services
“The ability to adapt in our ever changing
healthcare environment requires a diverse
toolbox. Lean should be a key tool in every
OR. It provides the framework to engage
stakeholders to reduce waste and improve
the Healthcare experience.”
In the fall of 2009, UT Medical Center faced
many challenges common in today’s
medical centers. One of the key challenges
facing the center’s OR department was
delivering consistent On Time Starts for
daily scheduled first surgeries. In the
hospital setting, especially vital in the OR,
starting surgeries on time is critical for
seamless patient flow: delays early in the
process cause further delays in the work
Value Added Partnership
Lean has its beginnings in the automotive
industry, and is well established in
manufacturing circles. The foundation for
Lean derives from the Toyota Production
System, also known as TPM. The basis for
TPM focuses on creating and improving
processes based on value from the
customer’s perspective. Value is defined as
any activity in a process for which a
customer or patient is:
a) willing to pay;
b) changing the service provided to
the patient;
c) performed for the first time.
As an example, in most cases, a patient is
willing to pay for doctor’s advice and
guidance, but may be reluctant or unwilling
to pay for unnecessary testing due to
The Structure for all Lean for Healthcare Projects

The (I) DATE-M© Process cycle Reduction in Late Starts

(I) Identify:
Strategic need for change & goals (becomes a yearly activity on corporate
Index
level as you start continuous improvement).
100
D Define: High level project definition, gateway and resource planning, establish
baseline measurements & Lean performance indicators, identify process 90
team 80
A Audit: Current state, data collection, high level Value Stream Map (VSM), identify
70
bottlenecks
60 100
T Train: Identify required knowledge and train the team, brainstorm & prioritize
improvement ideas 50
E Execute: Micro-Level VSM at bottleneck, define improvements, build necessary 40 62
materials, test it, launch it
30
M Monitor: Measure results continuously, control process stability
2009 2010
(Copyright Dr. med. Hank Schiffers, 2009)

mismanagement or for extra administrative Education includes Stryker’s Lean OR

paper work oftentimes needed to perform course in their offerings. Subsequently,
a procedure. It is estimated that most UT Medical Center worked in partnership Increased Revenue
processes consist of greater than 85 % with Stryker to execute the 20 plus
Index
non-value added activities. One of the process optimization solutions devised
200
key objectives of Lean is to remove waste during the Kaizen event. In the process of
from processes, decreasing non-value uncovering solutions, the Stryker Team 175 +461,000 €
added activities. used the (I) DATE-M© model to execute 150
UTMC objectives. 125

100
Tami Anderson
Director, Accreditation and Patient Safety Process Optimization Realized 75
While myriad solutions were devised, a few 50
“Senior leadership has been very key improvements rendered noticeable 25
supportive of Lean at The University of results in the process. The first area of
Tennessee Medical Center. This was focus was Patient Registration (PR). To 2009 2010
demonstrated visibly this year, through improve patient readiness PR underwent
their making completion of Lean projects changes to ensure that patients were
a goal for many of our vice presidents. well informed and prepared before the
More than seventy of our staff and scheduled surgery date. To facilitate this
physicians have undergone formal training process, phone calls are being placed to Increased Start Time Accuracy
in Lean and we are reaching the point patients by a registrar employee to assist
Density
where “Lean thinking” is evident in many the patient in pre surgery administration.
of our planning meetings, not just those 0.04
specifically designed around Lean.”
John Bell, MD 0.03
Professor, Department of Surgery
In pursuit of service excellence, the Director, Cancer Institute 0.02
University of Tennessee Center for
Executive Education (UTCEE) and UT “The Lean process has been added to our 0.01
Medical Center, in partnership with Stryker, organization as an integrated tool which
trained 12 people in a 2 Day Lean OR helps us identify opportunities to improve 0.00
0 -50 -25 0 25 50 75 100
Yellow Belt training course, which was the service we provide to our patients,
immediately followed by a three day families and employees. It is a welcome Month Mean StDev N
Kaizen, a continuous Rapid Improvement addition to assisting us in performing our Nov 2009 8.280 29.89 239
Dez 2009 10.22 19.84 273
Event (RIE), where the focus was first mission to the community.” Jan 2010 7.383 18.19 230
patient On Time Starts in the OR. Feb 2010 6.954 9.314 196
Currently UT’s Center of Executive
Continous Improvement – First time starts per surgeon
Quota in %
100 %

90 %

80 %

70 %

60 %

50 %

40 %

30 %

20 %

10 %

0%
1

9
10

11

12

12

14

15

16

17

18

19

20

21

22

23

24

25

26

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ic
ys
Ph

High Level Patient Process Flow monthly basis and is posted for viewing,
creating more transparency in the process.

Outpatient General Surgery

Patient Information
arrives Desk
Another improvement solution centered on
employee scheduling. To provide greater
patient readiness, a 15 minute staggered
shift change was enacted. With the staff
starting at 6:45 instead of 7:00, more time
was available in ensuring rooms were
available and ready for the first patients.
This change is balancing the workload and
decreasing lead and wait times. In this
example, lead time is defined as the total
time measured starting at patient arrival in
registration to Roll-in.
In the Holding Room (HR) a 5+¹S was
executed with the objective of obtaining
better supply management and patient
flow. Supply usage was reviewed and
adjusted based on actual or Just in Time
(JIT) usage. Supply carts were fashioned
to only hold supplies needed for specific
procedures and to emphasize a “place
for everything and everything in its place”,
a key directive for a 5+¹S initiative.
Patient Surgery Changing Holding Operation
Registration Lounge Room Room Room
Kimberly Fain
Staff Nurse, O.R.
“My experience with Lean Healthcare has
added a sense of empowerment to my
ability to impact my work environment as
a healthcare professional. Being involved
in Kaizen projects has enlightened me to
how small changes implemented by the
employees that are doing the job can have
big effects on the entire system and
improve patient care.”
Additionally, OR physicians are playing a
significant role in the continuous
improvement initiative. Requested by the
physicians a reporting structure was
created to track the number of patient OR
delays per individual physician. Currently,
UT Medical Center physicians use this
system as a learning opportunity which
influences the management how first
patient slots are managed. This information
is reported to the OR committee on a
Measurable Results
As validated by UT Medical Center, notable
improvements resulted from the execution
of the solutions. Due to the time savings
captured from November through February
2010, the medical center has the potential
to earn an additional $ 461,000 in revenue
projected through year end. The number
of physicians hitting the threshold of 70 %
accuracy in On Time Start doubled from
17 to 34. 56.7 % of physicians improved
or maintained their First Time Start
accuracy where as only 11.7 % reduced
it leading to a total improvement of 6 %
(StDev +/- 17 %) increased accuracy.
Overall the Standard Deviation of On Time
Start accuracy dropped from 29.89 to
9.314 resulting in a much more predictable
process outcome. Additionally the number
of delayed cases decreased by 21 %
from November through May. These
savings are further substantiated through
improvements in employee morale and
patient satisfaction.
On-going Challenges / Next Steps
Today, UT Medical Center is embarking on
a Lean for healthcare transformation, which
is evidenced in management’s commitment
to Lean and the on-going continuous
improvement initiatives underway. Still,
challenges can impact Lean management
execution. As an example, gaining
employee buy-in can be difficult from the
on-set of a Lean journey. To prevent
 Change +∕- in %
50 %

40 %

30 %

20 %

10 %

0%

-10 %

-20 %

-30 %

-40 %
3

0
3

6
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Quota: % hitting on time First Time Start by physician, December 2009
Quota: % change in hitting First Time Start by physician, May 2010
Average on time First Time Start, December 2009

gridlock early in the process, UT Medical Quota 1st Time Start

Center encouraged strong employee 76 %
participation and weekly live online 74 %
72 %
coaching sessions with Stryker resulting
70 %
in solid buy-in from the employee base. 68 %
66 % Quota 1st Time Start
64 % Over time performance
62 % 65.7 63.5 71.3 74.3 71.3 71.5 improvement hitting
H. Sperry Nelson, MD
60 % on time 1st Time Start.
Professor, Department of Surgery 58 %
12/2009 01/2010 02/2010 03/2010 04/2010 05/2010

“I learned a considerable amount through

this opportunity. Lean provides a process Quota 1st Time Start - Monday vs Friday
where all team members can work together 85 %
to solve a problem.” 80 %
75 %
Quota Monday
70 %
65 % Quota Friday
60 % Comparison of ability
Sustaining achieved results is another 55 % in hitting 1st Time Start
55.6
80.2

48.5

72.2

65.9
68.7

78.0

50 %
75.3
78.7
68.1

Monday vs. Friday

71.1

74.1

challenge. UT Medical Center is currently

45 % over time
employing methodologies such as 40 %
dashboard management which displays 12/2009 01/2010 02/2010 03/2010 04/2010 05/2010

Lean KPIs and daily Lean briefings. These

are examples of strategies being employed
to help drive the Lean transformation at Lean OR participants quotes*
the medical center.
• “Learned tremendous amount in short time”
Building on the Lean success thus far • “I am very excited to start the process in my department”
achieved in the OR area, UT Medical • “Very good training program, enjoyed the OR simulation program”
Center is looking to leverage this success • “We hope to have everyone on Lean thinking”
and focus attention on patient readiness • “Feels crazy at first then comes full circle”
to gain even greater results. Additionally, • “The simulation was incredible”
other areas in the medical center are • “Entire Lean team was excellent! – In 2 days I feel blessed to have met,
meeting to discuss potential Lean been taught, by the Lean team”
opportunities now and in the future. • “If you need an American coworker-call me”
• “ Very valuable in that we are required to apply in our home setting and not
just another training session that will be forgotten”
• “Idea to starting small is appealing“

*Stryker Lean OR Training, CEE University of Tennessee, December 2009

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HCS-CSU-001
Artikel-Nr.: HCS-CSU-001
Stand: August 2010