Part 4. Change Concepts for Improving Adult Cardiac Surgery. In this section, you will learn a group. of change concepts that can be applied in

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1 Change Concepts for Improving Adult Cardiac Surgery Part 4 In this section, you will learn a group of change concepts that can be applied in different ways throughout the system of adult cardiac surgery.

2 102 Breakthrough Series Guide: Improving Outcomes and Reducing Costs in Adult Cardiac Surgery Change Concepts for Improving Adult The following are general change concepts that organizations can use to improve outcomes and reduce costs in adult cardiac surgery. These concepts and examples represent the strategies that have proven most effective. Organizations can use the following list of change concepts to develop good ideas for process changes that will lead to rapid, significant improvements. Each change concept is followed by examples of specific process changes based on the concept.

3 Part 4 Change Concepts for Improving Adult Cardiac Surgery 103 Cardiac Surgery 1 Do Tasks in Parallel 2 Use Multiple Processes 3 Use Pull Systems 4 Standardize 5 Minimize Handoffs 6 Synchronize 7 Consider People to Be in the Same System 8 Smooth the Work Flow For a comprehensive explanation of the use of change concepts in accelerating improvement in a variety of business contexts, see Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; Improve Predictions 10 Identify and Manage the Constraint 11 Convert Internal Steps to External 12 Eliminate Things That Are Not Used 13 Reduce or Eliminate Overuse

4 104 Breakthrough Series Guide: Improving Outcomes and Reducing Costs in Adult Cardiac Surgery 1 Do Tasks in Parallel Instead of doing tasks sequentially, redesign the process to do some or all tasks in parallel. In many processes, tasks are done in sequence: the second task is not begun until the first task is completed. This is especially true when different groups within the organization are involved in the different steps of a process. Redesigning the process so that some or all tasks are done in parallel can often save time and reduce costs. When tasks are done in parallel, the work in step 5, for example, can begin as soon as step 1 is complete, rather than waiting until steps 2, 3, and 4 are done. Inform all key staff concurrently of cardiac catheterization results. To expedite moving patients from catheterization to cardiac surgery, the cath lab cardiologist should inform all key staff including the attending physician, the cardiac surgeon, the cardiothoracic surgery office, and the referring cardiologist of the catheterization results. Instead of having each individual call the next in sequence the cath lab cardiologist calls the referring physician, who calls the surgeon, who calls the cardiothoracic surgery office for scheduling, and so on all key staff are notified directly by the cath lab. In this way, organizations can save days of waiting from catheterization to cardiac surgery. To reduce operating room turnover time, develop a list of tasks that must be performed prior to incision and do them in parallel. At one organization, tasks in the turnover process were performed in sequence: no steps could proceed until the scrub nurse finished setting up the instrument table, at which time the patient was brought in and prepared while the scrub nurse stood idle. The team redesigned the process to do tasks in parallel: now staff bring the patient into the room while the scrub nurse sets up. By the time the scrub nurse has completed the setup, the patient is fully prepared for surgery and the operation can begin.

5 Part 4 Change Concepts for Improving Adult Cardiac Surgery Use Multiple Processes Rather than use a single one-size-fits-all process, use multiple versions of the process, each customized to meet the different needs of patients or providers. Example Use multiple, customized processes to prepare patients for elective CABG. Instead of using one standard process for preparing the patient and family for cardiac surgery, an organization offers three options: home health providers will visit the home prior to surgery, see patients when they come in for their preoperative visit, or prepare them by phone. Patients can choose whichever process suits them best. 3 Use Pull Systems When work is being transferred through a process, instead of pushing it from one step to the next, have the later step pull it from the previous step. The timely transition of work from one step in the process to another is the primary responsibility of the downstream, or subsequent, process for example, the ICU orchestrating the transfer of patients from the operating room or the post-anesthesia care unit (PACU). This is in contrast to most traditional push systems, in which the transition of work is the responsibility of the upstream, or prior process for example, the operating room or the PACU pushing patients into the ICU. Example Use a pull system to move patients expeditiously from the cath lab to the operating room. Once the cath lab cardiologist has decided that a patient is a surgical candidate, the lab notifies the cardiac surgical office, which immediately notifies the on-call surgeon. The surgeon or a partner sees the patient as soon as possible, often within minutes of the request for consultation, while the patient is still in the cath lab. If the surgeon decides to proceed with surgery, he or she schedules the patient in the next available operating room slot preferably, on the same day the catheterization is performed. In such a process, cath-to-cabg time is a matter of hours instead of days.

6 106 Breakthrough Series Guide: Improving Outcomes and Reducing Costs in Adult Cardiac Surgery 4 Standardize Perform the same task in the same way. Performing the same task in a variety of ways results in broad variation in practice, a reduced ability to monitor outcomes, and wasted time, effort, and money. Understanding and designing standard approaches to repetitively performed tasks yields great efficiencies. In addition, it is easier to make changes to standardized tasks and to determine if those changes are leading to improvement. To reduce extubation time, standardize anesthetic management, pain control, and weaning methods. To reduce surgical mortality, standardize the approach to dealing with high-risk patients. To reduce turnover time and shorten CABG time, standardize operating room turnover and operative procedures. To reduce the rate of atrial fibrillation, standardize prophylaxis and treatment. Treatment of atrial fibrillation typically varies widely within an organization, often increasing lengths of stay by two days or more for patients who develop atrial fibrillation. Organizations that standardize their treatment of atrial fibrillation report limiting increases in length of stay to less than half a day. Standardize case carts. Instead of providing each surgeon with a unique set of instruments a practice associated with very high inventory costs have all surgeons use essentially the same instruments. Standardize heart valves and other instruments. To achieve such standardization, surgeons must agree to forgo some personal preferences. Often, these preferences reflect the nuances of surgeons individual training but without evidence of improved outcomes.

7 Part 4 Change Concepts for Improving Adult Cardiac Surgery Minimize Handoffs Redesign the work flow to minimize unnecessary handoffs in the process. Many systems require that elements for example, a customer, a form, or a product be transferred to multiple people, offices, or workstations to complete the processing or service. The handoff from one stage to the next can incur increased time and costs and cause problems in the quality of care. Staff may lose or improperly transmit information. Handoffs can also be dangerous. Patients in transition, for example, could be harmed if something is forgotten or lines are detached. It is often preferable to redesign these processes so that fewer workers are involved. For example, reduce layers of management that require multiple reviewers, meetings, and approvals. Expand clerical jobs to include scheduling, staffing, planning, and analysis. Cross train workers to handle many functions rather than one specific function. Reduce handoffs in surgery. Staff often hand off patients multiple times between providers or between floors moving from the floor to the preoperative area, preoperative area to the operating room, operating room to the post-anesthesia care unit, PACU to the ICU, and ICU to the floor. Information, too, may be handed off for example, a patient's history or a staff member's knowledge of what happened during surgery. Reduce handoffs between providers by creating a single cardiac surgery unit that functions as both a critical care area and a general post-cardiac surgery ward. Patients move from the operating room to the cardiac surgery unit and remain there for the rest of their stay. Because patients do not need to be moved from floor to floor, nurses remain familiar with them during their complete postoperative stay, thus minimizing the risks and costs of transferring them between units.

8 108 Breakthrough Series Guide: Improving Outcomes and Reducing Costs in Adult Cardiac Surgery 6 Synchronize Synchronize all of the steps in a process to a clearly defined, agreed-upon reference point. Complex systems such as surgery usually require coordinating multiple processes that function at different times and at different speeds. Staff often spend considerable amounts of time waiting for one step in the process to be completed before moving on to the next step. Using a precisely defined, generally agreed-upon synchronization point allows everyone to know when they must begin their tasks in order to have them completed on time. Individuals can work together to determine which tasks to perform in parallel in order to be ready by the synchronization point. Synchronize steps in the surgery process to the time of incision. Surgery requires much coordination prior to beginning: scrub and circulating nurses must prepare the operating room, hospital transport must deliver the patient on time, anesthesia must prepare the patient after arrival, and the surgeon must be present, scrubbed, and prepared to begin. Incision time is the logical synchronization point for surgery because it is the one common point at which all tasks must converge. Everyone nursing, anesthesia, housekeeping, and surgery must complete their tasks before the incision can be made. Define start time precisely. Despite the fact that several processes must occur prior to incision, operating room staff often disagree about the definition of start time of a case. For example, does 8:00 AM surgery mean that the patient arrives at registration at 8:00 AM, the patient is brought into the operating room at 8:00 AM, induction occurs at 8:00 AM, or cut time is 8:00 AM? Confusion concerning the definition of start time often leads to unnecessary delays and inefficient use of staff time.

9 Part 4 Change Concepts for Improving Adult Cardiac Surgery Consider People to Be in the Same System Help people see themselves as part of the same system, and make the patient the center of that system. Individuals who share a common purpose will work to optimize the large system instead of trying to optimize their own part of the system. Consider the cath lab, the cardiologist, the surgeons, and operating room scheduling as parts of the same system. Often, staff see these areas as separate domains rather than parts of a system that shares the common goal of optimizing care for patients. Barriers that prevent smooth communication and coordination among these areas result in prolonged, unnecessary waiting in the hospital between cardiac catheterization and surgery. Each part of the system each department and each individual must understand the common purpose and their role within the system. Reduce cath-to-cabg time by having people see themselves as part of the same system. Instead of waiting for multiple information handoffs between providers, the cardiac cath lab makes the preliminary decision to proceed with surgery and calls the operating room directly to schedule the case as soon as possible. After scheduling the case, the cath lab notifies the attending physician and the cardiac surgeon. If necessary, the surgeon can always cancel the case. However, because the providers have a common understanding about the criteria for proceeding with surgery, surgeons rarely reverse the cath lab s decision. Consequently, the time patients must wait in the hospital between catheterization and CABG is significantly reduced.

10 110 Breakthrough Series Guide: Improving Outcomes and Reducing Costs in Adult Cardiac Surgery 8 Smooth the Work Flow Take steps to reduce fluctuations in demand. Changes in demand often cause the work flow to fluctuate widely at different times of the year, month, week, or day. Rather than trying to increase staff to handle the times of peak demand, managers can often take steps to even out the demand. This results in a smooth work flow rather than continual peaks and valleys. Example Schedule elective cardiac surgery patients at times of lower demand. The demand for cardiac surgery varies. Instead of creating a system that smoothes the work flow, many organizations staff for maximum capacity even though they rarely require it. The high cost of this practice could easily be reduced if staff scheduled elective patients at times of lower demand. The key is to determine average demand, staff for the average, and work to distribute this demand evenly. 9 Improve Predictions Predict demand based on past experience and plan capacity to meet these predictions. Plans, resources, and staffing are based on predictions. Use simple historical data displayed in control charts to study variation and construct accurate predictions. Use historically based prediction of a surgeon s length of case to improve operating room scheduling. Use a historically based prediction of the number of emergency cases to improve staffing. Use a historically based prediction of mortality risk to improve patients' ability to make an informed decision about surgery. Organizations that incorporate prediction of surgical mortality into their preoperative assessment of all cardiac surgery patients are able to identify high-risk patients, develop special mechanisms for managing these patients, and reduce overall cardiac surgery mortality.

11 Part 4 Change Concepts for Improving Adult Cardiac Surgery Identify and Manage the Constraint Find and remove the bottlenecks in the system. A constraint or bottleneck is any point in a system that prohibits the smooth flow of patients or information to the next point in the system that is, any point that restricts the throughput of the system. A constraint within an organization is any resource for which the demand is greater than its available capacity. For example, operating room availability may be a constraint to moving more patients into surgery; limited ICU beds may be a constraint to increasing operating room throughput; and slow staff response to managing postoperative atrial fibrillation may be a constraint to timely management and discharge. Constraints or bottlenecks should be identified and reduced or eliminated to improve the performance of the system. They can usually be identified by looking for points where people are waiting (for example, waiting for surgery) or where work is piling up. Example Remove constraints to transferring patients out of the ICU. The constraint to moving patients out of the ICU within 12 hours of surgery or early the next day is often prolonged extubation, or the lack of beds, telemetry, or nursing personnel. When such constraints delay transfer from the ICU, they, in turn, become constraints to increasing operating room throughput and cause additional backups further upstream. In some cases for example, early extubation managing a constraint can also reduce direct costs. In other instances for example, adding telemetry beds reducing the constraint may increase cost. However, this cost must be weighed against the costs of not relieving the constraint: the additional resources consumed upstream versus the limitations on total system throughput.

12 112 Breakthrough Series Guide: Improving Outcomes and Reducing Costs in Adult Cardiac Surgery 11 Convert Internal Steps to External Perform tasks that are typically done as part of the process either ahead of time or later. To save time, convert a task done within the process (internal) to a task done outside of the process (external). Example To reduce turnover time between CABGs, prepare the instrument table while the prior case is still in progress. The nursing staff can set up the instrument table in a separate room so that it is completely ready to go, and then place sterile drapes over it. When the prior case is completed, the dirty table is removed from the room, housekeeping cleans the floor, and the pre-prepared table is moved in. All the scrub nurse has to do is remove the sterile drapes. In this way, a task typically done within the process of room turnover preparation of the back table is converted to a task done outside of the process. 12 Eliminate Things That Are Not Used Cease to supply unwanted or rarely used items. As they examine routine practices, clinicians discover that some items they had assumed were necessary for example, certain surgical instruments are rarely if ever used. Similarly, inventories often contain items that are rarely if ever used for example, certain heart valves that can easily be replaced by other, more commonly used items in the inventory. Eliminating items that are not used and standardizing items that are used can lead to significant reductions in inventories. Examine cardiac surgery inventories systematically and eliminate things that are not used. Examine case carts after case completion to identify instruments that are rarely if ever used. Eliminate unnecessary tests. Eliminate routine preoperative pulmonary function tests and bleeding times. The results of these tests are not used.

13 Part 4 Change Concepts for Improving Adult Cardiac Surgery Reduce or Eliminate Overuse Do not provide or utilize resources beyond the amount required to satisfactorily complete a task. In health care, overuse may include providing patients with advanced diagnostic technologies that have not been shown to lead to better outcomes. Reducing or eliminating overuse reduces costs as well as the risk of adverse events related to unnecessary care. Identifying overuse is not always easy; often, clinicians assume that diagnostic or treatment modalities provide some benefit to the patient, even in the absence of supporting data. Reduce excess postoperative ventilatory support. Despite the common practice of keeping postoperative patients intubated for 12 hours or more, there is no data to support such a practice. Many centers have developed systems capable of safely extubating patients within 4 to 6 hours of the completion of surgery. Their data demonstrate that providing less ventilator support to patients, even those with underlying pulmonary disease, is associated with either equivalent or improved patient outcomes. Reduce excessive use of Swan Ganz catheters. Many organizations have found that the routine use of Swan Ganz catheters is not necessary for all patients undergoing cardiac surgery. However, organizations continue this practice because they assume, without supporting data, that managing patients successfully requires this level of hemodynamic monitoring. Several programs have successfully reduced their use of Swan Ganz catheters by using predefined criteria to determine which patients are likely to benefit from additional hemodynamic monitoring, taking into account the increased risk and cost.

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