Hospital staff conducts its own pre-design to mitigate cardiovascular construction
The marquee service at this Louisiana academic medical center is its full spectrum of cardiovascular services. It is the only hospital in its region, for example, to offer the most current surgery for peripheral vascular disease (PVD). The surgery offers a way to open vessels distant from the brain or heart, thus alleviating pain and sometimes saving limbs in patients suffering from conditions like atherosclerosis or diabetes. The hospital offers courses in the latest PVD surgical techniques, drawing cardiologists and experts from cardiac catheterization labs (cath labs) from across the country.
“Our cardiology program’s volume has steadily increased over the past five years. Additionally, from 2009 – 2010, the cardiology program has increased 20% in cath lab procedures,” said the Chief Operating Officer. “Both of our cath labs function at capacity on various days of the week, which means they operate well into the evenings, requiring staff and other resources to accommodate demand.”
The initial proposal called for constructing an additional cath lab, in a separate location from the other two. The proposed budget for this plan was $4.5 million to build and equip this new space. But while the CEO was willing to consider the third cath lab, she wondered whether they could get more for their money.
“We came with a strong interest in using lean to help us look at our entire cardiovascular service line,” said the CEO. “It is the source of our biggest volume, and it’s a very important area to the hospital. In my opinion, we were using a lot of space inefficiently. We had opportunities within our own four walls to improve the patient experience, physician and staff experience, and give us an identity we could market to community. That vision was possible through lean.”
The vision: hybrid OR
Enter a cardiovascular surgeon and the hospital’s chief medical officer, with the idea of creating a dedicated Cardiovascular Center at the hospital, which would include a Hybrid Operating Room (OR). The Hybrid OR combines “conventional operating room capability with state-of-the-art endovascular imaging. The need for these Hybrid operating rooms has evolved as the endovascular revolution in vascular surgery has progressed.1”
The COO noted, “Cardiac surgery is becoming less invasive than it once was; conversely, cardiac catheterization, an imaging procedure, sometimes indicates immediate surgical intervention. The blending of one procedure into another creates the need for a well equipped operating suite with advanced imaging capabilities.
Current layout: challenge and opportunity
The hospital’s third floor is used as an overflow area. If the Surgical intensive care unit (ICU) on another floor exceeds its capacity, those patients flow from to the 6-bed Medical ICU on the third floor. Similarly, if the Med-Surg or telemetry units on other floors exceed their capacity, those patients are placed in the 13-bed overflow unit, also on the third floor. The third floor also houses patients who come in for outpatient surgery and dialysis. The current dialysis areas, originally built as two C-section rooms and still configured that way, make them easily convertible to surgical suites.
The CMO envisioned consolidating all cardiology surgery services in one area— the third floor. The areas currently used by cardiology on other floors (including ORs, Surgical ICU, telemetry beds, and Med-Surg beds) would then become available for other functions, making better sense of the layout all the way around. It was the combined vision of the CEO and CMO to collaborate a multi-disciplinary team to come up with ideas that led to an intense, highly specialized four-day 3P event— before anyone ever called an architect. The idea: to involve staff in determining how they want that space to work before turning the design over to the architect.
“The team effort was evident during whole process,” said the CEO. “People from across different departments worked side by side with the medical staff during one week to develop consensus on one space utilization scenario. It was an unsurpassed level of teamwork.”
Pre-planning with kaizen
Two weeks before the 3P, multidisciplinary teams, under the guidance of Lean practitioner Ken Lowe, conducted a kaizen (or rapid improvement) event in the cardiac cath lab. The plan initially called for the addition of a third cath lab. However, if enough capacity could be freed up through process improvement, then perhaps it might not be necessary.
The cath lab kaizen team focused on the pre-op holding area and discovered patients stayed there 46 minutes longer than necessary. The team standardized their processes and put into place a signal to call for the next patient to be transported (a “pull” rather than “push” system). The improvements reduced wait times by 20 minutes. The team believes that over time, further improvements will reduce the wait even more.
By calculating takt time, (the time available divided by the number of patients to see), the team discovered that they could conduct 14 cases per day, on average, using just the improvements they made that first week. Takt time told the group that they were at 78% of capacity: in other words, they had 22% more volume than they had initially realized, even working in the current layout. Further lean process improvements, like faster turnaround times and efficiencies gained by reconfiguring the rooms, meant more volume could open up. This would be important information to bring to the 3P when considering whether to add a third cath lab.
The team even calculated a hypothetical takt time for a new Hybrid OR, which can handle both regular surgery and advanced cardiac surgery.2 The Hybrid OR would accommodate 3.27 cases per day, meaning that capacity would start at around 81%. The numbers are clearly theoretical at this point, because at least one new surgery, the percutaneous heart valve repair, would be introduced to the region once the Hybrid OR becomes available at the facility. Nevertheless, these calculations and process improvements provided a valuable starting point for the 3P.
During 3P, the focus remains on the patient, and team members are actively engaged in designing their own actual processes that occur on the front line of care, not the processes that “should” occur. Because it involves several days of dedicated time from staff members in various disciplines throughout the hospital, 3P condenses months of space planning work into days. For that reason, 3P is considered “lightning fast.”
Where kaizen asks teams to use what they have, in a 3P, the teams are limited only by their imaginations. 3P asks teams to think about building anew, not limiting themselves to what is on hand.
Said lean practitioner, Maureen Sullivan, RN, “The last thing we want would be to build a new product that enshrines old, wasteful processes. At Toyota, new product design itself was taking too long, cost too much, and when it was all done, it didn’t match up with the actual way work was done on the shop floor. When you transfer that problem to the design of a new facility, and you can see the importance of dealing with reality, and using creativity and teamwork to achieve the most efficient design.”
The 3P exercise focuses on designing waste out of the process or product. In healthcare, it helps to think of the 3Ps this way:
- Product (service to the patient) – focuses on the equipment and/or physical space required to provide a value-added service to the customer. For example:
- Process – Where there is a customer, there is a process to deliver a product or service. The process looks at how the employee interacts with the equipment and space to provide value to the customer.
- Preparation – involves information gathering and action planning before, during and after the event.
The four-day 3P event started with a lean review under the auspices of lean practitioners from Healthcare Performance Partners; however, much of the session was conducted by staff members like the COO and CMO. The team consisted of 14 people from across the spectrum—the hospital’s Chief Nursing Officer, two CV surgeons, the physician assistant to the hospital’s CV surgeons, , clinical ICU supervisor, director of telemetry, director of plant operations, a wound care nurse and other staff and disciplines as needed. Together they agreed on:
- Scope: to create a dedicated cardiovascular destination at the facility.
- Objective: to evaluate under-utilized space in on the third floor of the hospital, including MICU, overflow and dialysis suites, in support of the dedicated cardiovascular unit.
Together the group went to gemba, or the place where the work is done, to observe. On the third floor, they discovered multiple opportunities to better use the space, full-time. On the second floor, they found a way to redesign the area currently used for cath lab recovery to build the third cath lab. Building the third cath lab within the hospital’s current walls, rather than building an entirely new space, saved capital dollars needed for construction.
Two teams, six options
The group broke into two teams, each charged with brainstorming three separate options for creating a cardiovascular center on the third floor. Creating space for the center required the teams to move several other functions currently located there, such as the dialysis suites and the gastrointestinal (GI) labs. Eventually, each group took the best features of each of their three options and consolidated them into one, which they then presented to the group.
Once the teams had arrived at a consolidated plan that they all agreed upon, they still had important work to do:
- Test the plan by inviting frontline workers in the affected areas to consider the new plan. For example, the physician assistant asked a CV technician whether this plan could work for her. The resulting suggestions were incorporated. Inviting frontline feedback helps validate the work, and generates buy-in from other staff.
- Take a detailed look at the “future state,” or how the areas would really work. To do this, they conducted a pathway exercise using colored yarn to indicate the pathways of work for various staff members like the circulator, respiratory therapist, patient and so forth. Because the exercise shows the pathways for work, it can help reveal problems like looping or forking, where workers must retrace their steps. This process makes visible the staff’s actual pathways in the new design. When the process becomes this visible, everybody learns.
- Consider capital, staffing, space, patient flow, implementation time and capacity (current and future). Along with safety for patient and worker, each team also had to consider these crucial factors as they developed their schemes.
On the third day of the 3P exercise, the teams presented the schemes they had devised to a cross-section of hospital leaders, physicians, and frontline workers. The CEO remained at the report out to listen, and to help with additional recommendations. In the end, the consensus was to take the lion’s share of ideas from Team One’s scheme, adding in several features from Team Two’s scheme.
Among the recommendations:
- Consolidate all cardiovascular functions on the third floor.
- Convert the two dialysis suites to ORs: one as a Cardiovascular OR, the other as a Hybrid OR. The group decided to move the dialysis suites to the fourth floor into a space that requires minimal construction to make the conversion.
- Install a third cath lab adjacent to the other two, not in a newly constructed space in a separate area of the hospital. Although the lean process improvements showed that current capacity could be expanded, the teams decided that a third lab would ultimately be required to handle work as new surgeries and cardiac offerings increased. Funding that exceeded the original $4.5 million estimate could be justified in this way.
- Move GI’s endoscopy suites to the second floor, into a space currently used for storage.
The CEO says that leadership is an “absolutely critical” part of the work. “People don’t want to do useless work,” she says. “If leaders are engaged, they know things will happen. This exercise yielded about 80% of the information an architect will need to move along quickly with the plans. Our staff’s contribution means we will get there quicker.”
Was it worth the effort?
Assembling a team of 14 people for four days and inviting in an outside firm to facilitate a 3P is a major undertaking. Still, the COO believes, the exercise was worth the investment on several levels.
“The 3P exercise is about more than physical layout,” he says. “It’s about how the operations will flow best. If we can dedicate a week to this comprehensive teamwork— involving multiple physicians, nurses, and other ancillary services — if you get them to come together and hear others’ perspectives, you will come up with the best design at the front end of the process as opposed to somewhere in the middle or after construction of the new design .”
“It’s not a group of consultants making the recommendations. The frontline workers are making the recommendations.”
He sees value in taking people away from their day jobs and out of their comfort zones for several days in a row. A day here and a day there merely fragments the process.
“If we had pulled staff intermittently to work on this space design,” he says, “their thoughts would have been fragmented too. Giving them time, space, and a collegial environment kept them motivated, on task, and moving along with end in mind. “
The CEO added that, while a week of staff commitment is considerable, “Exercises like kaizen and 3P give everyone the focus to get real work done. Those selected to participate feel very valued, and so it builds morale and spread the word when they get back to their units. But mainly, relying on the people doing the work is an efficient and effective way to get results. It’s not a group of consultants making the recommendations. The frontline workers are making the recommendations.”
The COO knows that it is unusual for a hospital to become this involved in looking at their processes before they ever call the architect. He believes that this reversal of process is good practice. Instead of having hospitals rely on architects to make initial recommendations, hospital teams need to come up with ideas based on their actual processes, and have the architect make recommendations from there.
He admits that, when he’s worked with architects in the past, the work becomes fragmented. When hospitals haven’t done their homework on the front end of space design, architects will typically come onsite for a day, speak with end users, go back to their firm, draw, and repeat the process three of four times until a consensus is achieved. This process can take months and all too often duplicates efforts of hospital staff members. Four days of a 3P, he believes, could eliminate three or four months of this back-and-forth with the architect. The architect’s work should also become more efficient and less frustrating, as suggestions from end users become more targeted from the start.
The COO likes the outcomes of the work. With a dedicated cardiovascular hospital-within-a-hospital on the third floor, the second floor OR can now better serve increasing demand in other specialties like: neurosurgery, general surgery, orthopedics, and otolaryngology (ENT). He also expects lean thinking and other efficiencies to expand throughout the organization as the hospital moves forward with self-directed kaizen events.
Additionally, the COO sees enhancement of organizational culture resulting from the 3P space design and kaizen process improvement events conducted.
“This absolutely has had an effect on us as a team. It was a hard job, and we started slow, but as we built the model, side by side, we developed this design together,” he says. “With all the different disciplines in the room, it breaks down barriers, and you saw nurses respectfully challenging doctors’ ideas, and doctors being very receptive.”
Hospital workers are not designers, but they understand how a space needs to work. Developing that full understanding before turning it over to the architect changes the paradigm. Processes like 3P can help build a culture of safety and change.
- Belkin, Michael, MD, Chief, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Boston, MA. The Design and Implementation of Hybrid Operating Rooms. Proceedings of Veith Symposium, Cleveland Clinic Foundation, www.veithsymposium.org/pdf/ vei/2761.pdf Accessed October 13, 2010.
- “Given the hospital’s significant investment in a state-of-the-art Hybrid operating room, there will be significant interest in ensuring that the suite is maximally utilized. In our experience, a variety of other services have become interested in the capabilities this operating room offers. Cardiac Surgery, Electrophysiology, Neurosurgery, Trauma Surgery and OB-GYN have found utility to the use for this room and have, at times, created challenges for room scheduling. “Integrated OR scheduling and open-block time in the Hybrid OR can offer solutions to access for these different services.” Belkin, op cit.