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Is Lean, a philosophy and method originally developed in the world of manufacturing, applicable to an environment like an OR? After all, human beings are not products, and the complexity and variety of challenges found in the OR dwarf most manufactured products. These are some of the understandable questions and concerns that are raised when we talk about Lean in the OR. The concerns reveal, however, a lack of understanding about what Lean actually is. It may seem foreign or exotic, something that might work for a Toyota but certainly not for us.

There is no disagreement, however, that something needs to change. Healthcare costs are going up much faster than incomes or inflation, and something (one way or another) will need to give. It has been estimated that by the year 2020, personal income taxes would need to increase by 75% to cover the increase in government healthcare cost. Another source estimates that by 2020 the average household will be spending around $25,000 per year on health insurance alone. As a potential tool for healthcare improvement, let’s take a look at some of the main characteristics of Lean, and see if we might have a fit in the OR.

Lean is based on the scientific method. Continual improvements are made by experimentation, trying things out, keeping what works and discarding what doesn’t. The Lean improvement model is called PDCA, Plan-Do-Check-Act. This approach is 100% compatible with our goals in the OR, or for “evidence-based practice”. There is certainly nothing exotic about this, other than the extraordinary focus that Lean organizations put on improvement.

Lean requires engagement. Lean is not about an outside expert coming into the OR and telling you how to do things the Lean way. It is team-based and requires the involvement and input of everyone in the department. Big changes may be needed, but often many small changes, suggested and implemented by department members, is what moves you forward.

Lean is primarily a philosophy. As opposed to being a collection of methods and tools, Lean is primarily a process improvement philosophy centered on the elimination of waste and improvement in patient flow. We may need to develop new tools and methods over time, but what is critical is a commitment to continuous improvement. There’s a Japanese word for that: kaizen.

Lean is not a cost-cutting or a headcount reduction program. We do expect costs to drop, and the number of people we need may change as improvements are made. But people do not lose their jobs by making improvements, and costs will be lowered through a relentless focus on elimination of waste.

Another clear indication that Lean can be applied effectively in the OR is the fact that it is already being done. Although manufacturing has a 30 year head-start over hospitals in applying Lean, there are pioneers across the world that have been applying these methods for close to a decade. The commitment continues to grow within the hospital community and no one (as far as we know) have yet said “This won’t work”.

Following in this book are a series of eleven essays on various topics related to Lean in the OR. They are intended not to be a comprehensive analysis of each topic, but rather a way to get the juices flowing and the discussions happening. And while we don’t think that Lean is the answer to all of the healthcare system challenges that we have, there is no doubt that it is making a big and positive contribution. Getting Lean is not an optional activity. It’s a requirement!

Chapter 1: Eliminating Waste in the OR

If you are familiar with the concept of Lean Healthcare, you are familiar with the idea of waste. A Lean Hospital is an organization that is continually improving patient safety and satisfaction, treatment outcomes, and staff development through the elimination of waste, and improvement in patient flow.

Lean always goes hand-in-hand with the term waste. In this chapter we’ll discuss the different forms of waste and some examples we would find in the OR and its associated services.

Overproduction. This form of waste takes place when we produce more than what is needed right now by the customer.

Examples of this waste in the Perioperative Services department are:

*Reassembling instrument sets in large batches while the autoclave sits idle. The symptom is “We do not have enough instrument sets.”

*Spiking IV bags in Pre-Surgery for the whole day, while patients wait. The symptom is “Our on-time starts are very low.”

You may think that over-producing is OK because you will need it eventually. Eventually is not now. Now is what matters, and now is when the patient is waiting. The time you missed you never get back, so do not over-produce.

Message to Charge Nurses and Clinical Managers: Do not make staff over-produce to keep them busy during a slow time. Have them do continuous improvement and you will get a great payback.

Transportation. We see this form of waste when the product or the patient (the value to be delivered) is moved without adding value.

Examples of this form of waste are:

*Blood specimens collected at the oncology unit go on a hospital tour before reaching the lab.

*IV and DVT pumps go from the patient room to Sterile Processing and back via utility rooms, for a few seconds of cleaning.

This waste is a bit more complex than saying “just stop doing that”, as it was the case with over-production. This waste requires you to ask why in a more forceful way, and to come up with practical alternatives.

Motion. This form of waste refers to staff members moving without adding value. This becomes evident in the amount of walking staff members do during their day. They are normally looking or “hunting” for something. Why is it that we cannot provide clinicians with the tools and supplies they need to take care of patients?

Some examples of motion waste are:

*Searching for a patient lift, a positioning device, an IV pump or any piece of equipment. The level of frustration staff members feel when they cannot find what they need is enormous. Delay of care can also be dangerous for the patient.

*Searching for paperwork. If your hospital still requires hand-written paperwork for surgical patients, you may find yourself scrambling for that document while the patient is on the table.

This is one of the easiest forms of waste to solve. The application of 7S methods and the abolishment of the Par Level system for supplies management would get you 75% of the way.

Waiting. This is idle time created when supplies, information, people, or equipment is not ready.

If you find yourself waiting on any kind of service you need to start asking why, and be ready to take action once you get the answer. Just one rule: blaming somebody else is not allowed.

Take a stroll through the waiting rooms. How many patients do you see waiting? Go to pre-surgery. How many patients are ready, but their OR is not? Go to PACU. How many patients are recovered, but there is no room for them to be moved to?

Over-processing. These are work steps that do not add value to the patient or customer.

This is the waste of overdoing. It is so easy to believe you are doing the right thing by overdoing. Think about the times you do this at home: “If three screws will do, five must be better”.

In one Perioperative Services Department, staff was checking case carts four times, due to the unspoken distrust of the prior processes.

Excess Inventory. When you see more supplies, equipment or paperwork than what the customer needs right now, you have excess inventory. The OR is the champion of excess inventory in the hospital. The OR wants to have enough inventory in case the worst happens, and then double that in case the Martians attack.

Excess inventory gives staff a false sense of security. When you need something, you then have to wade through piles of stuff to get to what you need. Are you seeing the waste yet?

To that, add the increased risk of expired items due to the piles you have to go through. Pick a couple of well-stocked shelves and see if you find any expired supplies.

The main culprit is the incredible anachronistic Par Level system that many ORs use for supplies management. It is mind boggling that hospitals still use such an inefficient method to deliver supplies to clinicians. Start by abolishing Par.

The result of implementing Lean supplies management will be a substantial reduction in inventory dollars coupled with the elimination of shortages.

Defects. Defects represent work that contains errors, requires rework, has mistakes or lacks something necessary.

Nothing proclaims a broken process quite like defective work. The temptation is to start with the old search for accountability, and looking for someone to blame. Instead, try looking at the broken process and asking why, or use simple assessment tools like a fishbone diagram. Engage other staff members in finding solutions. The results will amaze you.

A typical OR example is that of an incomplete instrument set. Your choices are: “Accountability!” or, after you solve the immediate need ask: “Why was the set incomplete?”

*Could it be that it was sent to SPD from the OR incomplete?

*Could it be that we need to develop work instructions for each instrument set?

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