June 13, 2018

LAC+USC Medical Center, a large urban teaching hospital, has seen a nearly 50% improvement in operating room (OR) on time starts since implementing a multi-year process improvement project begun in 2015, according to data published in the American Journal of Surgery.  As a result, the surgical teams at LAC+USC have been able to provide care for many more patients.

The data was collected from 415 operating days from May 2016 to December 2017, during which 14,981 elective surgeries and approximately 9,000 emergency surgeries were performed.  The mean rate of on-time starts for elective surgery cases went from 23.5% before to 73.0% after implementing the process improvement initiatives.

“I’m proud of LAC+USC Medical Center for achieving new operating room efficiencies, but most importantly I am pleased that thousands of patients will experience improved care,” said Los Angeles County Supervisor Hilda L. Solis. “This important work builds upon recent hospital successes to reduce severe overcrowding and wait time in the Emergency Department through innovative and thoughtful process redesign. I applaud LAC+USC’s efforts in moving forward to create what I call a Healthy Village with world-class integrated health delivery that ensures benefits and supports the local community.”

“This remarkable managerial and organizational achievement, completed without additional resources, demonstrates the County’s ongoing commitment to continuous improvement for our patients,” said hospital chief medical officer Brad Spellberg, MD.  “We are competing, and winning that competition, with the very best private hospitals.”

‘Lean’ process improvement methods originated in automotive production after World War II.  The aim is to reduce waste and keep only what adds value.  In healthcare, lean principles are used to identify the existence and causes of ‘waste’ such as delays and wait time, bottlenecks in service delivery, and inefficient processes and workflows.  Interventions are then rapidly tested to achieve a performance goal and envisioned future state that is more efficient and value-added for the patient.

Prior to the project’s implementation, hospital administrators were stymied for many years by high numbers of cancelled surgeries, outdated perioperative processes that overwhelmed registration and clinical staff, long patient queues on morning of surgery, and delays in operating suite turnaround times that impacted overall operating productivity.

A multidisciplinary Perioperative Lean Team consisting of preoperative nurses, OR circulating nurses, nurse anesthetists, advanced practice providers, and resident and attending physicians mapped current processes, identified value and waste, conducted root cause analyses and ultimately redesigned workflow processes.

“By working together as a team of physicians and nurses, we have been able to provide better, more timely care for our patients, while also making the process much more patient and family-friendly,” added lead author and hospital associate chief medical officer Chase Coffey, MD.

Among the interventions was improved operative communication through creation of a bedside morning “huddle” with the patient and surgical team, posting of a huddle board in the preoperative holding area to provide daily evaluation of first case starts, a daily debriefing with a multidisciplinary team that reviewed and improved performance daily, implementation of staggered appointment times, and improvements and enhancements to parking, campus signage and patient communication materials to facilitate day-of-surgery education and efficiency.

“Process improvement is complex and challenging work that doesn’t happen overnight or even in one year,” said Stephen Sener, MD, LAC+USC chief of surgery and associate medical director of perioperative services.  “It involves changing mindsets, organizational culture and engrained practices over decades, but once momentum kicks in, the transformation is remarkable.”

Sener said LAC+USC faces unique challenges that other private, non-teaching hospitals don’t, such as influxes of new resident physicians each year that need to be trained in hospital processes, being the busiest trauma center in Los Angeles which results in frequent emergent cases that alter the OR schedule at the last minute, high volume and complexity of surgical cases across the hospital’s 25 OR suites, and limited resources to invest in process redesign technologies.


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