Quick Changeover in the OR
Gerard Leone
Richard D. Rahn
Flow Publishing Inc.
Boulder, Colorado
Copyright ©2010 Flow Publishing Inc.
All rights reserved. Permission is granted to copy or reprint portions of this book for noncommercial use, except that they may not be posted online without permission.
ISBN- 978-1-4659-5249-3
Smashwords Edition
Table of Contents
Introduction
Chapter 1: A Brief History of the Quick Changeover Method
Chapter 2: Getting Ready for Quick Changeover
Chapter 3: Separating Internal and External Steps
Chapter 4: Streamlining Changeover Work Flow
Chapter 5: Quick Changeover and Supplies Management
Chapter 6: Knowledge Check
Chapter 7: Standard Work and Quick Changeover
Chapter 8: Measuring Performance and Visual Controls
Chapter 9: Revolution in the OR
Chapter 10: Kaizen in the OR
Introduction
Most hospitals across the United States are feeling the financial pressures. There never seem to be enough resources to deliver as much care as required by the community and with the quality the hospital considers the community deserves. Staff members and administrators stretch themselves to the max to take care of all the patients that require care. The gravity of the situation is all the more evident in the Perioperative Services Department. This is a department that uses more resources than any other place in the hospital. The resources used in the Perioperative Services Department are some of the most expensive in the entire hospital, making the financial pressures even more critical.
One additional pressure the Perioperative Department faces is competition. Hospitals in general do not see themselves as competing with other hospitals, unless they are in a crowded market. It is unlikely that a parent will drive a few extra miles with a child with a broken arm in search of a better deal. It just does not happen. This is not the case with the OR. According to the CDC, only 58% of all surgeries take place in a hospital. Then, there is the pressure from overseas hospitals and surgery centers offering much lower rates for private payers.
In this environment, the Perioperative Services Department must look everywhere for improvements, from acquiring, storing, issuing, using, and charging for supplies to maximizing the utilization of one the most expensive fixed assets in the entire hospital, the OR Suite.
To maximize the utilization of every OR Suite while increasing quality of care, Leadership must look beyond the traditional tools and embrace the power of Lean thinking. One of the most widespread tools in the Lean toolbox is Quick Changeover, known in the manufacturing circles as SMED, or Single Minute Exchange of Dies.
This book describes the Quick Changeover tool in detail from the OR perspective and for OR staff members. However, the contents of this book apply to all procedure rooms, as well as patient rooms in the hospital.
The objective of this book is to:
Provide you with an understanding of Quick Changeover and its application to the OR Suite.
Supply you all the necessary definitions, especially of Internal Changeover Steps and External Changeover Steps.
Describe the Quick Changeover steps of Separating, Converting, and Streamlining.
Provide you with examples of the key tools, like the Standard Work Definition, Spaghetti Diagrams, and checklists.
Place Quick Changeover within the largest context of a Lean initiative with the management of medical supplies, a Lean Management System, and Kaizen.
This book, like all the other books in this series, will deliver much more value when its content is discussed with your team members as you work on actual OR Suite Changeover optimization projects.
We hope you enjoy the book and tell us about your projects.
Chapter 1: Benefits of Quick Changeover for the OR Suite
Like any fixed asset, an OR Suite delivers value only when in use. We must, however, qualify the “use” of an OR Suite. The fact that activity is taking place inside the OR Suite does not directly mean this fixed asset is delivering value. During the time the OR Suite is being cleaned, set up, repaired, inspected, or any of the long list of activities that we label as non-value adding, it is “in use” but it is not delivering value. For the OR Suite to deliver value, it must be involved in an actual patient procedure. This is true for any procedure room or other asset throughout the hospital.
This appears to be a minor or even obvious point, but it is a critical one. You might hear “Our hospital is not the preferred place of practice for the community surgeons because we do too few procedures per day.” If your reaction is “How can this be? I am working myself silly in this place” then you are not yet looking at the issue through Lean eyes. Administrators may also approach the issue the wrong way by thinking that this is “somebody’s fault” and all that is needed is some more management pressure. We need to make this point as clear as we can:
It is NOT the people, it is the process.
If you have personnel issues, put this book down and go solve your people problem and come back later when you can trust your people. We must start from a place of believing that we all want to be a part of something good; nobody wants to be member of the losing team.
To keep the OR Suite delivering value, you must maximize the time it is performing procedures, or looking at the issue from the other side you must minimize the time the suite is NOT performing procedures. Any time an OR Suite is not involved in a procedure, it is either being changed over or it is idle. For the purpose of our discussion, we are not going to worry about idle time, since it tends to reveal a low procedure volume. If you had that problem, you would not be reading this book. So, we are ready to make this pivotal statement:
To maximize the delivery of value, you must minimize changeover time.
Minimizing OR Suite changeover time will result in a series of benefits derived from maximizing the delivery of value. Some of the benefits include improved patient throughput and patient flow, improved asset and staff productivity, improved quality of care, improved on-start times, and increased revenue for the hospital.
Improved Patient Throughput. By reducing the amount of time spent on changeovers, you convert the non-value-adding time of changeover to the value-adding time of procedures. Let’s do some quick math. Think of a Perioperative Services Department that has 8 OR Suites that perform 40 procedures per day with average procedure times of 90 minutes and average changeover times of 45 minutes. These numbers indicate that this department spends 40 x 45 minutes on changeovers, for a grand total of 1,800 minutes/day. What would it happen if your team was able to remove 15 minutes from each changeover, bringing the average down to 30 min? The new grand total would be 40 x 30 equaling 1,200 minutes for a net gain of 600 minutes that can be reinvested in procedures. Considering an average of 90 minutes per procedure, you are looking at almost 7 more procedures per day. Some of this time savings should be reinvested in better quality procedures.
Improved Asset and Staff Productivity. The definition of the term productivity is sometimes subject to argument. The simplest and most effective way to look at productivity is as a ratio of output-to-input. In other words, how much value do you get from the resources you contribute? By increasing patient throughput, you are increasing the numerator of the ratio without affecting the denominator. For staff members that get nervous that “they are trying to make us work harder”, we recommend you stop for a second and ask yourself if you became an OR Nurse or an Instrument Tech to wait around for the room to become available, or for the case cart to arrive, or to go hunting to complete a case cart. You entered this this noble field to take care of patients.
Improved Quality of Care. By reducing the amount of time you spend on changeovers, you can spend more time taking care of patients. This does not always mean to push more volume all the way to the max. Stop and ask yourself “How do I improve quality of care?” The answer is “By spending more time on quality”. This may come in the form of devoting the time to the pre-procedure checklist, applying the enzymatic foam to the outgoing instrument set, doing a proper post-procedure instrument count, or the many best practices we know improve quality. All those best practices require time, time that can be recovered from wasteful changeover steps.
Improved On-Time Starts. Most hospitals measure on-time starts only by the first case of the day. That may be the current state of affairs, but as more hospitals look at improving the efficiency of their operations, measuring all on-time starts will become a more widespread practice. By having a predictable and repeatable changeover procedure, you can assure staff and surgeons, that by the time they deliver the patient to PACU, and go see the next patient in pre-surg, the room will be ready to go. This may sound next to impossible as you read this, but do not be discouraged by the fact that the answers are not available right now. Part of the “Kaizen Spirit” is to shoot for perfection and reap the benefits along the way.
Increased Revenue for the Hospital. It is a pretty straightforward conclusion: if you continue with the math we started above, the increased number of procedures will result in increased revenue for the hospital. We must now caution you one more time that you need to think about reinvesting some of the time you recover on improved quality. A few years ago, we helped a team at a client hospital complete a project that could save the equivalent of $2.2 million in RN time. When the team proudly presented their project to the Executive team, after the applause the CFO raised his hand to make the following statement: “As you know, none of this is real money, unless we get rid of a bunch of nurses. Well, I am here to tell you that this is not money I want. This time must be reinvested in making the nurses job more meaningful and in taking better care of our patients. We will find actual cash in the many other projects we have in the Continuous Improvement database.”
Every hospital must stay focused on financial performance to remain viable. Asset utilization is one of the key aspects of a hospital’s financial performance. Quick Changeover can represent a multi-million dollar opportunity, as it will enable all procedure rooms to deliver more value to patients. This is also true for other stakeholders like surgeons, nurses and instrument techs, as they will be able to spend more time taking care of patients and less time in non-value-adding activities. In the coming chapters we will be discussing the actual process for achieving these benefits.
Knowledge Check - Introduction
The OR Suite and the OR staff are delivering value during a Changeover.
True
False
The Main Benefits of Quick Changeover in the OR Suite are:
Improved Patient throughput.
Higher Fixed Asset Productivity
Increased Staff Productivity
Better Quality of Care
Improved On-time Starts
Higher Revenue for the Hospital
All of the above
The Quick OR Suite Changeover opportunity is small (from a financial perspective) and can be measured in only thousands of dollars.
True
False
Chapter 1: A Brief History of the Quick Changeover Method
The time was the late 1950’s. Struggling to survive after near-bankruptcy in the early part of the decade, the Toyota Motor Company had dedicated itself to rebuilding, and to the ideal of “Kaizen” or continuous improvement in all of its processes. One of the challenges they faced was excessively long changeover times on their large presses, the machines that stamp out body parts. They had discovered that one of their competitors was able to change over the identical machine in three hours from one part to another, as compared to Toyota’s current best time of six hours. They had assigned the task of reducing the time to at least equal the competition to a young engineer named Shigeo Shingo, and after several months of team effort he was ready to report the results.
“We had achieved our goal,” Shingo reported in his autobiography, “and we were proud to be able to report success. However, after the initial congratulations from the plant manager, he gave us our next assignment. What I want you to do, he said, is to now reduce the time from three hours to three minutes. We all thought he was literally crazy.” After the initial shock wore off, and because he couldn’t say no, the wheels began to turn in Shingo’s mind, and the light bulb went on when he realized that the goal was not to eliminate three hours of labor time, but to reduce the time that the expensive piece of equipment was unavailable for use. This insight was the beginning of what is now called SMED, Single Minute Exchange of Dies, or quick changeover in less than 10 minutes.
Roll time forward about 20 years. Americans in the late 1970’s and early 1980’s began to take learning trips to Japan, to try to uncover the secrets of the Japanese Economic Miracle. One of the leaders of these executive tours, Norman Bodek, returned with a copy (in badly translated English) of a book titled The SMED System by Shigeo Shingo. Copies were distributed, an much improved translation was done, and this book was one of the first exposures by Westerners to the Quick Changeover methodology, and also launched Bodek’s company Productivity Press.
SMED is a rather strange term, even for manufacturing folks, and we won’t be using it in this book, preferring instead the term Quick Changeover. The methods, however, apply well to our needs in a hospital environment. As you’ll see, the Quick Chaangeover steps are also very common-sense and easy to understand, although to get the maximum result some creative thinking and effort will be needed.
The term “Single Minute” really means “less than 10 minutes”, and this was actually achieved by Shingo with his stamping presses. Is a 10 minute changeover in an OR suite possible? The answer is probably yes. Is it desirable? Maybe not. If this is our goal, and you simply had to do it, then you could come up with a process that could achieve that goal. We sent a man to the moon, so we think you could changeover an OR suite in less than 10 minutes. The cost of doing so, however, may outweigh the benefits. The good news is that by applying the Quick Changeover methodology you can make major improvements at very low cost. Let’s take advantage of these opportunities first before we get too ambitious, or set artificial goals for ourselves.
Today the Quick Changeover method is one of the core methods of Lean, and practiced by thousands of organizations around the globe. It will also soon be a core competency of the Lean Hospital and the perioperative services department.
Knowledge Check - Chapter 1
The term SMED is an acronym for:
Shingo Manufacturing Equipment Development
Single Machine Efficiency Device
Single Minute Exchange of Dies
Trick Question: SMED is the Japanese Word for “Quick Changeover”
The expression “Single Minute” in Quick Changeover means:
Less than a minute
Around a minute but no more than 2 minutes
Less than 10 minutes
Less than 1 hour
True or False: Unless you are able to reduce a changeover to “single minute” range, your Quick Changeover project has not been successful.
True
False
Chapter 2: Getting Ready for Quick Changeover
One of the keys to success for any Lean improvement project (Kaizen Event) is to do as much as possible ahead of time. Logically, if you wait until the actual event to do something that could have already been done, you are consuming valuable Kaizen time that could be applied to brainstorming, implementation, training, documentation and other necessary aspects of the effort. Not coincidentally, this recommendation is also the first phase of a Quick Changeover project, called Separating Internal from External, to be discussed in the next chapter. An external step is a work step that can be done while the process is working. In the case of an OR, an external step can be done while the prior procedure is still going on. An internal step, the opposite, cannot be done while the prior procedure is going on, and can only be done when the OR Suite is not in use. More on this later.
This chapter discusses the tasks that can and should be done ahead of time, prior to a Quick Changeover conversion Kaizen event. A failure to complete this work ahead of time can jeopardize the success of the event, since some of the action items are quite time-consuming.
Document the Current State
Task 1 for our advanced preparation is to Document the Current State. You need to understand in detail how OR Suite changeovers are being done today, warts and all. The way things are done today is called the Current State, and it is important to capture a realistic picture of the existing changeover process as a foundation for the analysis and improvement ideas to come. You will need a detailed step-by-step documentation of the process, by skill set (nurse, tech, ORA, etc.). Above is an example of the form used for this purpose. The form itself, called the Standard Work Definition, can be downloaded from the Lean Hospital website in spreadsheet format; see the chapter in this book on Standard Work for a more in-depth explanation of this form, and how to fill it out.
Could the current state be documented during the Kaizen event itself? Yes, but we don’t recommend waiting. We don’t want to take the risk of something going wrong, and delaying the creative work of the Kaizen event itself. Let’s make sure that the Current State is documented beforehand.
Think in terms of shadowing a nurse or tech around during the changeover process. There are three critical pieces of information you will need to capture:
Document the work steps. For each logical “chunk” of work, write down a short description of the work step. You should be fairly detailed. A typical work step might be: “Push case cart to outgoing dirty elevator and return”.
Document the time required to complete the previous work step. You are interested in an average time, and you don’t need to get hung up over the fact that the times will vary somewhat from person to person, or case to case. If possible, take a sample of times with different people, and use the average. In most cases it will be sufficient to document the times in whole minutes, instead of seconds. Using our previous example, you might find that the time required to move a case cart (and come back) averages 3 minutes.
3. Document the “Self Check Description”. For each of the work steps, ask yourself the question “Could a person trying to do a good job do this step wrong?” People will make mistakes, and if a mistake is possible then you need to document the need for an inspection or check, before you move on to the next work step. In our previous example, it may be possible to drop the cart off in the wrong place, outside of designated parking lanes. The Self Check Description might therefore say “Verify that the case cart is parked in the formally dedicated locations, within the taped lines. Wash hands after dropping off cart.”