Using Lean principles, surgery centers can improve their workflow and increase efficiency. The key is to make workflow efficiency a priority from a managerial perspective.
“One of the most important things is being present with staff when the work is done so you understand how the workflow goes,” says Brian Selig, DNP, MHA, RN, director of perioperative services at the University of Kansas Health System. “It’s really important to make sure you understand what staff experiences so you don’t as a leader make assumptions that you know the answer. Be present with them and ask a lot of questions, including the whys.”
Why questions could include: Why did you make that decision?, Why did you pick that piece of equipment?, and Why was that stored there?
“You find the most outrageous answers that give you insight into how to improve the process,” Selig notes. For example, in answer to why a piece of equipment was stored in a certain place, staff might say things like “Because that’s where it fits” or “That’s where it always has been stored.” Hearing those types of answers gives a manager insight into how to improve the process, Selig says.
“Asking those questions helps staff be part of the change,” he adds. “In terms of low-hanging fruit, the best thing you can do as a leader is make sure you are out there and present on the unit.”
Part of Selig’s own Lean journey involved spending much more time with staff in their work environment than he had previously. “It changed how I interact with them,” Selig reports. “Having this focus on being where the work is done has helped me focus on being with the team.”
He blocks off time each day for spending time with staff. This could include 10 minutes in the operating room and then another 10 minutes in the office.
“Sometimes, I am there to watch someone prepare instruments for sterile processing, making sure they are adequately sprayed or employees are separating the clean from dirty,” Selig explains. “I want to make sure my staff is doing this right, and I want to understand what are their barriers to doing it right.”
When employees are not doing things the correct way, it is usually a process problem, he adds. “I think one of the things we learned quickly in our organization is how to sustain our processes,” Selig says. “We can make changes all we want, but unless we’re committed to sustaining them over time it’s a lot of wasted time and effort that teaches folks this is just another one of those things we’ll ask them to do.”
Realizing this is a major obstacle to sustaining Lean principles is a first step toward coming up with a plan to sustain a more efficient workflow. “One of the things I’ve learned is that having front-line leaders who are absolutely committed to our process is critical to our success in this,” Selig says. “For me, that means having managers and supervisors out on the floor, each day, supporting the initiatives and spending time observing their teams. They educate their team members when they see noncompliance with their new processes, and they are willing to speak up with surgeons when needed.”
To make the Lean program sustainable, the surgery center must develop a process that can prevent problems from occurring and a process to standardize the center’s workspace so it is the same every time people enter the facility. It also is critical to the program’s success to engage in difficult conversations with stakeholders.
“We spent a tremendous amount of time on how to collect specimens from patients, standardizing the process to not lose anything or mislabel anything,” Selig says. “That was a big effort with the nurses and the lab. Not only did we have to develop the right process, but we had to sustain it over time. Whoever did this had to be in the room, watching the specimen collection over and over again.”
If surgeons did not execute their part regarding specimens and the media, then the manager had to ask why they did it the way they did. “Then, we put in corrective measures to help us sustain them over time,” Selig explains. “Maybe we needed a poster in the room to prompt people about what type of media we have.”
For example, at Selig’s facility, there were four or five sentinel events several years ago. These involved mishandled surgical specimens. This problem could lead to repeat procedures or failed diagnoses. “When you have those kinds of events, you have to figure out why you’re having them and make sure you’re never having it again,” Selig stresses.
There were several steps Selig and colleagues took to reach the goal of eliminating sentinel events related to surgical specimens:
- Start with workshops. “We focused on how to develop a process that eliminates the possibility of error,” Selig explains. “We did two different Lean workshops, meeting with surgeons, operating room personnel, and quality and safety folks.”
- Develop new processes. Then, the group developed a process on removing specimens and moving these from the patient to a sterile field. “We made sure it got to the lab timely and with the right chain of custody,” Selig says.
- Create a chain of custody. “We created a standard work document that we go through step by step,” Selig says. “We say these are the steps that must happen and happen in a certain order every time,” he adds.
When the specimen is handed off, someone documents the type of specimen and medium. When the specimen moves to the next location, someone validates the patient’s name and record number, checking for a match with the requisition. Then, the lab timestamps it and validates they have received it. “If you have a requisition that matches the label, and it’s verified, then you’ve eliminated the risk,” Selig says. “If all those pieces are in place, every single time, then you eliminate those mistakes.”
After putting the new process in place, Selig reports the operating room lost only one specimen — which happened when the specimen was caught in a suction trap.