Fluid Talk blog
Kaizen! The quest for a smarter OR
Author: Scott Diel
You could call it the invasion of the Toyota Motor Company. Entering operating rooms the world over is the concept of kaizen, the Japanese concept of a journey of continuous improvement – small, incremental changes adding up to a big difference.
In various articles and reports about the modern OR, the vocabulary of lean manufacturing is making inroads: standardized materials management, inventory reduction, and even “daily huddles” have become commonplace. Lean production methods focus on the removal of wastes – backed by the belief that any operation that fails to create value for the end customer is wasteful.
For many hospitals, the OR is considered the financial epicentre. It often accounts for 35 to 40 percent of costs, yet produces 60 to 70 percent of a hospital’s revenue. Numbers like these make the OR a natural place to start improving both patient satisfaction and its financial performance.
Patients are the primary concern of doctors and nurses, and manufacturing principles created for widgets in largely automated factories don’t always apply one-for-one in the OR. Nonetheless, the benefits of efficiency in the OR are indeed quantifiable when we look at, for instance, patient turnaround.
Tom Ladds, a former nurse and past President of the British Association of Urology Nurses, now works as a medical device consultant across Europe. Ladds offers the urology OR as an example where the average turnover time between patients is 25 to 30 minutes. “If you make an across-the-board effort to improve efficiency, fifteen minutes is a realistic turnover time.” Ladds subscribes to the kaizen mindset and cautions that there is no silver bullet.
“Depending on the specialty we’re talking about, you have to consider a variety of factors: how fluids are managed, cleaning, resetting fluid collections and other technologies, and prepping for the next patient.”
“Each effort you make may only affect change by a single percentage figure,” says Ladds. “But if a new technique or tool knocks two minutes off the 30 minutes then it’s a contribution. If ten tools knock 20 minutes off, then that’s significant. A four-patient day can realistically become a six-patient day. That’s real news for a hospital which treats 100,000 people per month.”
Surgical suction’s role
Since suction is a preoperative-, perioperative-, and postoperative factor, ¬it is an essential part of OR efficiency patient safety.
The importance of suction in the OR was examined in a 2013 study. Senior surgeons, OR nurses, and anaesthesiologists polled cited the importance of suction for both patient safety and OR efficiency. Anne Sopanen, who worked as an OR nurse for 25 years at Helsinki’s Children’s Hospital and is now and Clinical Specialist at Serres, sees eliminating human error through automation and digitization as a path to efficiency:
“The nurse has to plan surgical suction before the patient arrives. She’s got to make sure the system is working, and sometimes it happens that the machine isn’t working properly. Or she’s got to change the bags during surgery, or in some countries, leave the OR between operations to manually empty them. There’s risk of contamination. Every OR minute is expensive. There are different ways to measure it in different countries but in Finland it’s estimated at up to 30 euros per minute," says Sopanen.
Barriers to change
If the gains are so obvious, and if patient turnover in some operating theatres can be increased 25 percent, why aren’t all hospitals taking action?
“They are taking action,” says Tom Ladds, “but these are complicated environments.” The inertia in large organizations makes them resistant to change and financial views are often short term. “They plan best around a political cycle of four to five years, but budgets are planned on one-year terms. Consequently, new equipment that returns its investment in five years doesn’t get purchased because of the need to meet an end-of-year budget.”
Conventional wisdom is that change occurs first in bottom-line-driven, private hospitals, but Ladds says this is not always the case. “Britain’s NHS is a large, tax-funded organization and it’s under political pressure to be efficient. If you can handle 25 percent more cases in the same amount of OR time with the same amount of personnel — routine prostate operations, for example — then hospitals understand that. More throughput means shorter waiting lists, which means less political pressure.”
A ‘smarter’ OR
As the earth’s population approaches 10 billion, with significant portions over the age of 60, healthcare everywhere will continue to be transformed. In the United States alone, health expenditures are expected to approach 20 percent of gross domestic product as soon as 2020.
According to data from WHO member states, it’s estimated that over 230 million major surgical procedures are undertaken every year worldwide. As new technologies increasingly make out-patient surgery an option, the OR’s role as a profit producer for hospitals will come under even greater scrutiny.
Japan’s concept of kaizen, a long-term approach to work which systematically achieves incremental changes in processes will be even more relevant. And OR professionals may wish to be ever mindful of the Japanese proverb, “Be not afraid of going slowly. Be afraid of standing still.”