Making the Case for Quality

October 2013

Systematically Improving
Operating Room Patient Flow
Through Value Stream Mapping and Kaizen Events
by Dennis Delisle

The focus of hospital senior leaders on operations expense reduction and management has been spurred
by increases in costs of pharmaceutical and medical supplies, revenue movement from inpatient to
outpatient settings, and malpractice insurance.1 Key to addressing these issues is successfully utiliz-
At a Glance … ing performance improvement methodologies to improve quality and decrease variation, which saves
money.2 At Thomas Jefferson University Hospitals, inpatient and outpatient operating room (OR)
activity accounts for a large percentage of total patient revenue. The majority of OR cases occur at the
• Value stream maps (VSMs)
are effective tools for academic medical center known as the Center City campus.
facilitating incremental
improvements to complex As part of the perioperative (the department responsible for all surgical procedure activities) strategic
healthcare processes. plan overview, a team of certified lean practitioners was assigned to analyze and improve the OR
• Thomas Jefferson University patient flow process. Given the existing high volume of procedures and strategic vision to increase
Hospitals utilized the VSM
case loads, it was critical to ensure consistent flow throughout the system. From preadmission test-
approach to identify and
execute seven lean projects ing through the post-anesthesia unit, the entire process was wrought with inefficiencies (i.e., delays
within the perioperative in preoperative patient processing, cases not starting on time, and slow OR turnover case to case) and
department over four years. bottlenecks that had compounding effects on the overall department.
• Results include
preadmission testing Representatives from all related disciplines and departments converged to tackle the complex problem.
reduction in length of
Facilitated by the lean team, a value stream mapping (VSM) event was held in August 2010 to deter-
visit from 110 to 92
minutes, 36 percent mine how to strategically solve key issues.
reduction in preoperative
patient waiting, and an About Thomas Jefferson
improvement of on-time
first-case starts from
University Hospitals
56 to 67 percent.
Thomas Jefferson University Hospitals
(Jefferson) is a 969-acute-care-bed healthcare
facility located in Philadelphia, PA. Jefferson
provides a full range of patient care in all
specialties and subspecialties. The southeast-
ern Pennsylvania, New Jersey, and northern
Delaware region includes more than 11 million
people. Annually, Jefferson clinical operations
include nearly 50,000 admissions, more than
Dennis Delisle, operations support director for Jefferson
120,000 emergency department visits, and almost University Hospitals, discussing a pay-off priority matrix
a half-million hospital-based outpatient visits. with team members.

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 • Physician offices
• OR scheduling
• Preadmission testing
• Registration
• Pre-procedure preparation
• Patient transportation
• Holding area unit
• Operating room
• Environmental services
• Post-anesthesia care unit

Given the numerous levels,

OR Kaizen 6 Team – Improving OR Patient Flow From SPU to Holding Area
functions, and responsibilities
involved, leaders determined that
Why Quality? the best approach to initiate the
project would be a VSM event. The full-day facilitated effort
Committed to lean thinking since 2008, in 2010 Jefferson included the lean team working with a group of process experts
hired a certified lean master to develop a robust education and throughout the entire OR patient flow process.
process improvement program. As part of this program, more
than 50 certified lean practitioners who are imbedded in vari- Jefferson’s Quality Journey
ous clinical and nonclinical departments volunteer their time for
Prior to initiation of the VSM event, the lean team conducted
improvement projects. In addition to the formal university-based
voice of customer interviews with representatives from manage-
lean thinking and certification program, Jefferson offers staff
ment and frontline staff. The interviews focused on qualitative
department-level training that emphasizes application of simple,
analysis of key issues and barriers to patient flow. Throughout
yet effective tools (i.e., 5S, visual management, process map-
the discussions, several themes became apparent: constant
ping) and leads to project execution on a smaller scale. Jefferson
changes to the OR schedule the day before or day of surgery,
is dedicated to providing world-class care, and approaches like
poor communication among perioperative units, excessive
lean thinking enable staff to contribute value-adding services processes and patient travel due to poor layout, inadequate tech-
while reducing wasteful efforts. nology for decision making and monitoring flow, and workflow
variation across all disciplines.
The consumer-driven healthcare market demands a high degree of
customer service and responsiveness. As such, Jefferson leaders Following the interviews, the lean team began observations. A
identified a need to streamline the perioperative department’s pro- critical element of lean thinking is gemba walks. Gemba is a
cesses. The perioperative department engaged a team of certified Japanese term that stands for the place of action, or where the
lean practitioners to strategically evaluate opportunities and facili- work takes place.3 The approach is simple: Go to where work is
tate change. Operating room patient flow is a complex process that being done, observe the processes and workflow, and talk with
involves multiple areas, including: staff to understand their challenges.4 Gemba walks also enable

OR Kaizen 5 Team – Improving On-Time, First-Case Starts

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the team to document process steps in the current state, a key The group then began the solution development process. The pro-
input in the VSM event. Additionally, observations were supple- posed solutions were prioritized based on impact (high/low) and
mented by the OR information system database providing key ease of implementation (easy/difficult). Figure 2 shows the current
performance indicators such as on-time, first-case starts, OR state, with proposed solutions represented as kaizen bursts.
turnover times, and cycle times across the patient flow process.
Together, these data helped shape the current state. This led to final recommendations of where the team should
focus (Figure 3: Proposed Action Plan). At the conclusion of the
The lean team developed a comprehensive agenda that included event, the entire team presented the findings and recommenda-
current state validation, brainstorming and prioritizing issues and tions to leadership, along with the timeline for implementation.
barriers, future state design, and creating an improvement plan
for incremental progress over time. Managers and perioperative Lean thinking emphasizes incremental improvement over time.
department leaders participated. Inclusion of the right stakehold- These improvement efforts are typically known as kaizen events.
ers (i.e., process expert, influential leader, creative problem solver, Kaizen, a Japanese term, represents “change for good.” Lean
etc.) is a critical element of successful improvement efforts. The teams facilitate kaizen events with process experts in order to
OR vice president and management team helped choose a group rapidly develop and implement solutions. Jefferson lean teams
of individuals to represent the broader department. utilize the define, measure, analyze, improve, and control
(DMAIC) project structure to execute initiatives. The main deliv-
Figure 1 depicts the validated current state at the time of the erables for each phase can be seen in Table B.
event. Participants went through a facilitated brainstorming ses-
sion to determine the key drivers of quality and efficiency issues. The VSM team identified two areas as the priority focus based
The problem-solving process used by the lean practitioners can on the majority of opportunities and solutions identified through
be seen in Table A. the VSM event. The first piece was patient arrival. Next, the

Table A — Problem-Solving Process

Step Description Deliverable
Brainstorm issues and barriers Through various brainstorming activities, participants discuss and Documented list of all issues and barriers that contribute to
document all issues and barriers related to the problem being inefficiencies and poor quality.
addressed.
Prioritize issues and barriers The team determines which issues and barriers are within their control. The highest priority issues/barriers (usually two to four in total) are
These filtered issues are subsequently prioritized through voting. selected for solution development.
Brainstorm potential solutions Through brainstorming activities, the team discusses and develops Documented list of all potential solutions to address the prioritized
potential solutions to address the prioritized issues and barriers from issues.
the prior step.
Prioritize solutions The team prioritizes solutions based on impact on the problem (high or All solutions are prioritized, highlighting the high-impact and easy-
low) and ease of implementation (easy or difficult). to-do ideas.
Develop action plan A detailed action plan is developed for all solutions that fall within the The action plan consists of what, who, when, required resources, and
high-impact, easy-to-do or low-impact, easy-to-do categories. expected outcome. Plans are executed within a six-week timeframe,
often with pilots occurring during the actual kaizen event.

  Figure 1 — OR Patient Flow VSM

Patient Surgeon

OR Patient Arrive Patient Enter

schedule Call from check-in @ Prep for arrives @
scheduling @ SPU surgery OR
finalized admissions holding area

OR Delivered Check-in Check-in Clerk Call Patient Arrive @ RN MD

Call from Patient Instruc- Prep for IV Enter
schedule to central by name Register by name pull back to changes holding assess- assess-
scheduling arrives tions surgery insertion OR
finalized scheduling chart cubicle clothes area ment ment

SPU = short-procedure unit

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  Figure 2 — OR Patient Flow VSM With Proposed Solutions

Patient Surgeon

OR Patient Arrive Patient Enter

schedule Call from check-in @ Prep for arrives @
scheduling @ SPU surgery OR
Expand finalized admissions holding area
ORSOS
access
Inpatient status Stretchers
OR in ORSOS
comments Add
Signage Patient tracking unit clerk Supply
Prioritize Add clerk First case
FAR closed calls system par levels
on schedule education More
10th St. open Admission Inpatient patient Separate med/ More computers MD
Larger OR Update computers Pixis Transporter IV
4:30 a.m. to 9410 education surg patient bags/tubes arrival time
labels scripts education
Physician Move JIT patient Patient ID OR transport Holding area Lab slips Implement New MD
process whiteboard Add clerk Pacemaker IV insertion
office education interviewers arrival time pull system education

OR Delivered Check-in Check-in Clerk Call Patient Arrive @ RN MD

Call from Patient Instruc- Prep for IV Enter
schedule to central by name Register by name pull back to changes holding assess- assess-
scheduling arrives tions surgery insertion OR
finalized scheduling chart cubicle clothes area ment ment

High/easy High/difficult Low/easy ORSOS = OR information system JIT = just-in-time

FAR = first available room Pixis = medication carousels on nursing units

  Figure 3 — OR Patient Flow VSM With Proposed Action Plan

Patient Surgeon

Kaizen 1 Kaizen 2
OR Patient Arrive Patient Enter
schedule Call from check-in @ Prep for arrives @
scheduling @ SPU surgery OR
finalized admissions holding area

OR Delivered Check-in Check-in Clerk Call Patient Arrive @ RN MD

Call from Patient Instruc- Prep for IV Enter
schedule to central by name Register by name pull back to changes holding assess- assess-
scheduling arrives tions surgery insertion OR
finalized scheduling chart cubicle clothes area ment ment

Table B — DMAIC Steps recommendation was to look at the holding area process where
patients have an IV line placed and are then interviewed by the
Phase Main Deliverables surgical and anesthesia teams (interventions and outcomes of all
efforts can be found in the results).
Define Project charter, voice of customer interviews, waste walks, high-level
process mapping
After execution of the first and second kaizen events, the lean
Measure Baseline data collection, roll-out of communication plan, time study team re-evaluated the VSM with perioperative department lead-
observations
ership to identify additional opportunities for improvement. Over
Analyze Data analysis, kaizen event agenda development and logistics the course of four years, the lean team systematically addressed
issues and challenges through seven formal kaizen events. The
Improve Kaizen event: develop and implement solutions
scope of the subsequent improvement efforts spanned scheduling
Control Follow-up action plan meetings, data analysis, final project summary through post-procedure processes and can be seen in Table C.

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The table shows the various kaizen events and scope of each. Various
Table C — Kaizen Events
kaizen events tackled similar processes and areas. The nature of lean think-
ing is continuous improvement, and as such, improvements made early on Kaizen Title Scope
were later evaluated and further streamlined. Along the OR improvement
journey, many staff—from several different departments, including OR, Kaizen 1: Improving patient flow Parking lot, registration, short-
transportation, patient access, and environmental services—were incorpo- from arrival to holding area procedure unit (SPU)

rated within the project team.

Kaizen 2: Improving patient flow Holding area
from arrival to holding area
Kaizen team participants were chosen in a similar fashion to the VSM
event. The lean team, along with OR leadership, targeted individuals with
Kaizen 3: Improving patient flow Patient testing center
process expertise and an orientation of continuous improvement or known in the patient testing center (preadmission process for
resistance to change. The last part is crucial in identifying and developing patients one to two days prior
to surgery)
meaningful and realistic solutions. Active resistors oftentimes have valid
reasons for their hesitation to get involved. The dissenting voice offers the Kaizen 4: Improving OR turnover Eight OR suites
group opportunities to challenge ideas, reflect on past success and failures,
and build a stronger process. Many individuals participated in more than Kaizen 5: Improving on-time, Scheduling to SPU
one kaizen given their interest, roles and responsibilities, and ability to first-case starts

implement action plans.

Kaizen 6: Improving OR patient SPU and holding area
flow from SPU to holding area
Results
Kaizen 7: Improving patient flow Patient testing center
The systematic approach to improve OR patient flow yields steady gains in the patient testing center
over time. In four years, the various kaizens have produced a bandwidth
of positive outcomes—from statistically significant and sustainable gains
(e.g., Kaizen 3), to marginal, qualitative improvements (e.g., Kaizen 2). Table D — Lessons Learned
The complexity of systems and processes, along with personnel, make each
project unique. Key lessons learned, such as those listed in Table D, are Theme Lessons Learned
leveraged from one effort to the next while results are shared with partici-
pants and department staff along the way. Change • Let go of the past and embrace change
• Think out of the box
Though many gains have been realized, work remains. The VSM enables • A small group can actually drive meaningful
change
the team to effectively segment and attack small portions of the overall • There’s always room for improvement
process. Gains realized from one effort contribute to the success of sub- • Keep an open mind to change
sequent initiatives.
Teamwork • Important to work as a team
Jefferson’s Continuing Commitment to Quality • Everyone melds ideas together to help
create solutions
• More aware of job responsibilities in
To date, many of the outcomes achieved continue to sustain and improve. other areas
As depicted in Table E, the lean teams continue to circle back to address • Gained respect for other areas
additional improvement opportunities in areas such as the short-procedure
unit, the patient testing center, and the holding area. To drive results down Staff involvement • Need to educate staff on changes early and
to frontline staff, Jefferson has evolved its lean approach to incorporate a often, communication/education is critical
• Staff need to know how valued their role is
structured education program. Since Kaizen 7, a team of lean practitioners within the process
engaged a multidisciplinary group from the perioperative department. The
eight-week education program emphasizes the application of lean thinking, Kaizens • Stay focused on goals to impact change in
and its associated tools, and concludes with a formal project proposal sub- short period of time
• Kaizen is needed to focus on problems and
mitted by the participants. make processes better
• Have patience with the kaizen problem-
These project ideas are subsequently evaluated by leadership (departmen- solving process
tal and lean program) and then executed with the appropriate method (i.e., • Go from good to excellent in customer
service by making patients a central focus
just do it, project management, full lean engagement, etc.). The goal of of the process
this revamped approach is to enable staff to solve their own problems at

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Table E — Kaizen Results
Kaizen Title Timeline Countermeasures Results
OR Patient Flow VSM May – August • Facilitated full-day current and future state VSM session to • Verified and finalized VSM
2010 identify and prioritize opportunities for improvement • Developed future state map
• Identified 20 high-impact interventions along the VSM
• Prioritized and determined Kaizen 1 and Kaizen 2 scopes
Kaizen 1: Improving September – • Moved patient registration to the bedside • Overall process time (patient arrival to ready for transport)
Patient Flow From November 2010 • Standardized charge nurse desk patient monitoring process reduced by 31.9 percent
Arrival to Holding • Pre-kaizen: 56.9 minutes/Post-kaizen: 38.8 minutes
• Streamlined short procedure unit (SPU) work processes to
Area (18.1 minutes overall). Waiting time was reduced by
coordinate with registration process
35.9 percent (from 25 to 15 minutes), patient travel time
was reduced by 63.3 percent (from 5 to 1.5 minutes),
and patient check-in time was reduced by 63.6 percent
(from 5 to 1.5 minutes).
Kaizen 2: Improving November 2010 – • Installed whiteboards in all three holding areas as visual cue to • Holding area length of stay (LOS) around 30 minutes
Patient Flow From February 2011 missing patient information (avg. 55.9)
Arrival to Holding • Implemented “1” box surgeon checklist, replacing • Less wasted motion for all staff
Area comprehensive, multidisciplinary checklist • Patient satisfaction regarding wait times improving
• Developed and implemented nurse scripting to address patient
expectations about waiting
• Developed surgeon on-time, first-case start performance report
Kaizen 3: Improving March – August • Reduced the number of processing steps • Pre-intervention LOS (109.65 minutes)/
Patient Flow in the 2011 • Brought patients back to exam room upon arrival Post-intervention (92.33 minutes, p<0.000)
Patient Testing Center • Pre-intervention achieved its daily target of 90-minute
• Registration completed in exam rooms
average LOS, 4.29 percent of the time. Post-intervention,
• Nurse practitioners performing EKGs and labs
the target was exceeded 35.0 percent of the time, marking
• Discharging patients from exam room a 715.9 percent improvement (p<0.000).
• Installed whiteboard to monitor patient flow, status at flow desk
Kaizen 4: Improving September 2011 – • Developed nursing assistant team assignments • Pre-intervention turnaround time was 48 minutes (standard
OR Turnover January 2012 • Implemented OR case room preparation checklist deviation 6.7). Post-intervention turnaround time was 44.1
minutes (standard deviation 3.7) (p=0.003). By stabilizing
• Posted turnover results on whiteboard for prior week
the output, subsequent improvement efforts are positioned
• Continued monitoring of cases exceeding 30-minute target in to favorably impact results. These data are now monitored
real time and posted on a weekly basis by the OR charge nurse.
• Developed future state swim lane map to target opportunities
for improvement
Kaizen 5: Improving March – August • Increased bedside registration availability to 4:45 a.m. – • Cycle times from patient arrival at SPU to surgery start
On-time, First-case 2012 8:30 a.m. were reduced in all four ORs.
Starts • OR schedule/mapping created a list of issues to identify • Overall, the SPU to HA time reduced by 35 minutes and
potential barriers to on-time starts the day before HA to start of case was reduced by nine minutes.
• Perioperative department to make pre-surgery calls instead of • The time from SPU arrival to start of case was 44 minutes
general central scheduling, include scripting for reinforcing faster post-kaizen.
patient arrival time • These operational efficiencies will help the SPU and HA
• Utilize newly created first-case starts tracking tool to monitor staff to prepare patients for on-time starts.
SPU/holding area (HA) cycle times
Kaizen 6: Improving December 2012 – • Conducted detailed time study of registrar/nurse/transport in • The first cases pre-kaizen were on time 55.7 percent of
OR Patient Flow July 2013 SPU to identify opportunities to streamline processes the time. Post-kaizen, 67.4 percent of the first cases began
From SPU to Holding • Collaborated with transportation department to assign two on time.
Area additional transport aides at 5:30 a.m. • Holding area arrival times had a modest improvement
• Incorporate schedule changes during mapping meeting day from 33.9 percent on-time to 36.8 percent.
before surgery to anticipate patient needs • Pre-kaizen cycle time from patient arrival at SPU to ready
for holding area was 47.43 minutes. The post-kaizen cycle
time was 44.94 minutes—achieving the 45-minute goal.
Kaizen 7: Improving September 2012 – • Registrar to receive OR schedule in advance to identify patients • The average LOS from May – November 2012 was
Patient Flow in the January 2013 for preservice 129.8 minutes. Post-intervention, the average LOS was
Patient Testing Center • Registrar to preregister patients 24 to 72 hours in advance 118.9 minutes.
of scheduled visit and clarify information during call (e.g., • Since September, LOS was reduced from an average of
demographic information/insurance coverage) 131.6 minutes to 117.8 minutes (p<0.00).
• Clerks preparing charts at least 24 hours prior to patient’s
scheduled visit
• Upon arrival, the preregistered patient is taken to an open
examination room and nurse practitioners and techs can begin
testing immediately
• The preservice model allows the registration staff to prepare
the chart in advance of patient arrival, effectively decreasing
patient LOS while increasing patient satisfaction

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the source and use experienced lean teams to address system- Lean Team Members
atic, multi-departmental barriers and issues. The lean team’s
Deb Castellucci, Ed Cullen, Katie Droz, Vanessa Gleason,
OR engagement success has been replicated in additional
Anna Grayson, Steve W. Gudowski, Fran Guiles, Megan Illg,
­clinical areas, including the pharmacy and oncology services.
Carrie Lamina, Tom Louden, Steve McDonald, Steve Moritz,
Organizations, both large and small, can leverage the powerful Mike Perino, Jill Richards, Rebecca Ryba, Beth-Ann Schauer,
impact of lean thinking. Use of tools such as VSMs provides an and Josh Schoppe
objective way to approach complex issues and facilitate incre-
mental improvement over time. References

1. Zidel, T. (2012). Lean Done Right. Chicago, IL: Health

For More Information Administration Press.
• Contact Dennis Delisle at dennis.delisle@jeffersonhospital. 2. Liker, J. (2004). The Toyota Way: 14 Management Principles
org to learn more about this project. From the World’s Greatest Manufacturer. Madison, WI:
• Find Thomas Jefferson University Hospitals online at McGraw Hill.
www.jeffersonhospital.org. 3. Womack, J. (2011). Gemba Walks. Cambridge, MA: Lean
• Find more case studies on quality improvement in healthcare Enterprise Institute, Inc.
in the ASQ Knowledge Center at asq.org/knowledge-center/ 4. Mann, D. (2010). Creating A Lean Culture (2nd Ed.). New
case-studies. York, NY: Taylor and Francis Group, LLC.

Acknowledgements About the Author

Kaizen Participants Dennis R. Delisle, MHSA, PMP, is the director of opera-

Shay Bradley, Gina Burton, Dane Caffrey, John Cibenko, tions support for Thomas Jefferson University Hospitals and
Allison Clerval, Jill Conroy, Maggie Conte, Tina Convery, adjunct instructor for Thomas Jefferson University’s School of
Susan Curcio, Nancy DuBois, Mary Eddis, John Ervin, Maria Population Health. Dennis is a certified Lean Master, Six Sigma
Franzini, Cindy Frederick, Valentina Freiberg, Bonnie Grady, Black Belt, and Project Management Professional, and is cur-
Bonnie Gray, Venus Gwynn, Kathy Jaffe, Keena Johnson, rently pursuing a doctor of science degree in health systems
Carl Leconey, Christina Lin, Helane Moore, Kristen Piller, management. He is responsible for the education and certifica-
Beth-Ann Piotrowski, Beth Piotrowski, Patricia Reilly, tion of lean practitioners, as well as the deployment of strategic
Monica Repko, Maria Ricci, Debbie Righter, Melanie Rogavaello, organizational initiatives. Dennis is a trained examiner for the
Doug Ryba, Elaine Schaeffer, Bob Sponsler, Janice Stewart, Keystone Alliance for Performance Excellence and co-leads
Darlene Sullivan, Linda Walsh, Diane Wolk, Aaron Woodward, Jefferson’s Performance Excellence program, utilizing the
Linda Yearly, Monica Young, and Christine Zeoli Malcolm Baldrige National Quality Award Criteria.

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