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Lean Principles Optimize On-time Vascular Surgery Operating Room Starts and Decrease Resident Work Hours
Courtney J. Warner, MD, Daniel B. Walsh, MD, Alexander J. Horvath, Teri R. Walsh, RN, Daniel P. Herrick, Steven J. Prentiss, Jack L. Cronenwett, MD, Richard J. Powell, MD.
Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
OBJECTIVES: Lean process improvement techniques are used in industry to improve efficiency and quality while controlling costs. These techniques are not commonly applied in healthcare. This study assessed effectiveness of lean principles on 1st case on-time operating room starts and quantified effects on resident work hours.
METHODS: Standard process improvement techniques (DMAIC methodology) were used to identify causes of delayed vascular surgery starts. Value stream maps and process flow diagrams were analyzed with Pareto and Run Charts. High yield changes were identified and simulated in computer and live settings prior to implementation. Primary outcome measure was percent on-time operating room starts; secondary outcomes included hospital cost, resident rounding time and work hours. Data were compared to existing benchmarks.
RESULTS: Prior to implementation, 37% of cases started on time. Process mapping identified late resident arrival in preoperative holding as a cause of delayed on-time starts. Resident rounding process inefficiencies were identified and changed through the use of checklists, standardization and elimination of non-value added activity. Following implementation of process improvements, 1st case on-time starts improved to 71% (p=.006, see chart). Resident rounding time was reduced by 33% (from 70 to 47 minutes), with a potential decrease of 2 work hours per resident/week. This resulted in a potential cost savings of $387.63 per case or $131,794 per year.
CONCLUSIONS: Use of lean principles allowed rapid identification and implementation of perioperative process changes which improved efficiency while resulting in significant cost savings. Downstream effects included improved resident efficiency with decreased work hours. 
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