LEAN and Cardiology Nursing Management : Application of LEAN Principle in the Rectification of Flow Logistics in Patients Undergoing Coronary Angiograms in Queen Mary Hospital Wong M.S., Luk W.S., Chiang C.Y., Wong W.F., Wong F., Kan A., Wong K.L., Lam Y.M., Chan H.W., Hung S. & Wan R. Cardiology Division, Department of Medicine, Queen Mary Hospital
Background Coronary angiogram is a common invasive diagnostic procedure in cardiac units In our unit, patients were requested to admit at 8am on the procedure day and started fasting the midnight before Dissatisfaction with the long fasting time and waiting time A lot of complaints
What is Lean? Evolved from Toyota Production system Identification and elimination of waste Focus on reducing cycle time and increasing process speed
Objectives Applying LEAN principle to reduce the lead time of patients undergoing elective coronary angiogram To improve patient satisfaction and reduce ward congestion
QMH Cardiology Catheterization Laboratory : Critical To Quality (CTQ) Tree Project Focus: patients undergoing elective coronary angiogram
Coronary Angiography (S. I. P. O. C. Concepts) Different steps identified
S. I. P. O. C. Different steps identified P/T P/T P/T P/T P/T P/T W/T W/T W/T W/T W/T LEAD Time = Process Time for different steps + Waiting Time in between P/T W/T
Lead time analysis: Document Tagging Sheet Code No. Patient Label Date Document Tagging Sheet Process Name: Coronary angiogram Date Step Name / Value Stream 1 Clerk/ Registration IN OUT Time in minutes TIME TIME Task / Activity Delay/Wait time from previous step Check ID / OT list / arrange files 2 HCA /TSA Put on ID bracelet / check vital signs measure BW/BH/urine exam +/- provide denture box / wrap bracelet 3 Nurse Check/complete document dispense medication/check H stix Responds to enquires 4 H.O Prepare for IV access Insert IV access/recheck blood 5 Nurse Complete pre-cath. list / +/-set drip 6 On call to OT / Nurse 7 On call to OT / HCA Till arrive OT Recheck document Instruct patient to empty bladder Collect properties/ personal belongings Get ready the stretcher Assist patient to lie on stretcher Stripe off unnecessary clothing Cycle time Elapsed time Value added time Non-value added time
Methodology Identify the causes of long waiting time by: Fishbone Diagram To identify Loopholes in the system Root Cause Analysis To find out Why Counter-Measures
Fishbone Diagram X3: X4 PCI ( 通波仔 )cases are Cath. Lab. X6: staff usually put in AM sessions & start to prepare at X8: 2 cath labs start displacing to 08:30 while the Elective cases coronary have to be People operate X9: at 08:30 angiogram X3: OT staffs start to prepare OT at delayed if cases emergency X1: Since the patients till priority they for are 08:30 while the radiographer is on OT is controlled by OT staff, the radiographers start duty from 09:00 ward nurse has to advise the patients to continue waiting and /09:00 Bed is not available finished procedures for are added keep fasting till call by OT their duty at 09:00 these patients to rest X5: X9: Bed is not available for these patients to rest if no patient discharge X10: Operation may not be started on time due to machine breakdown or poor preparation of OT suite or patient Machine when all beds are fully X4: Long procedural cases are usually put in AM session and performed by experienced interventionist while coronary angiogram cases can be done by junior doctors. X2: occupied The operator may not be able to start X7: the operation Overbooking on time due of to ad hoc elective urgent cases duties X7: For better utilization of OT facilities and avoidance of long queue in doctors waiting list, therefore, the OT schedule may be too packed at a time X8: Scheduled cases have to be delayed if emergency procedures is added. Major cardiac intervention cases are X2: Doctors may not be able to start operation on time and there maybe long break in between cases due to other urgent duties X1: the order of usually placed at procedure is X5: Major cardiac intervention controlled cases are usually put on the first priority as to have better section by cath lab management when complication staff and the operator, arises. but not the ward X6: 2 theatres starts operate at nurses 08:30 /09:00 X10: Operation may be suspended Method due to machine breakdown or inadequate patient preparation higher priority in AM Reasons for prolonged Waiting Time
Root Cause Identification Chart Project Ys: Prolonged waiting time and prolonged fasting time Possible Root Cause Findings/Conclusion Is it a key root cause? (Y/N) X1: The patients priority for OT is controlled by OT staff and the operator X2: Doctors may not be able to start operation on time and there maybe long break in between cases due to other urgent duties. X4: Long procedural cases are usually put in AM section and performed by experienced interventionist while coronary angiogram cases can be done by junior doctors. X5: Major cardiac intervention cases are usually put on the first priority as to have better management when complication arises. There is no definite schedule for everyday s cath. list. The decision of which patient to be called depends on operator s preference making in difficult for OT staff to provide a scheduled cath. list. Thus, patients on list have to wait all the time since admission. Urgent duties have to be attended by operators whenever being informed. The patients on list have to wait until the operators are back to cath. lab. or other doctor could come to replace them. Since coronary angiogram is not the first priority of choice for AM session, most patients in this category will have to keep waiting until intervention cases are finished. Since coronary angiogram is not the first priority of choice for AM session, most patients in this category will have to keep waiting until intervention cases are finished. X3 & 6: OT staffs start to prepare at 08:30 The cath. lab. can start at 09:00 that the first patient could while the radiographer is on duty from 09:00. only be called no earlier than this time. Y Y Y Y N
Root Cause Identification Chart Project Ys: Prolonged waiting time and prolonged fasting time Possible Root Cause X7: The OT schedule may be too packed on the same day. Findings/Conclusion Too many cases scheduled on the same day implies patients have to wait longer and fast longer. Is it a key root cause? (Y/N) Y X8: Scheduled cases have to be delayed if emergency procedures are added. X9: Bed is not available for these patients to rest if beds are fully occupied X10: Operation may not be started on time due to machine breakdown or inadequate patient preparation All the listed case has to be delayed or even cancelled. After the procedure, patients need to rest in bed especially for having punctures on femoral artery. If bed is not really adequate, patients have been arranged to rest on the OT stretchers which are used for transferring to OT. It reviews that some patients are not necessary to come at 8:00. This condition has been happened but may not be count as the key root cause. N N N
Overbooking Key loopholes identified Lack of a discreet operative timetable Elective coronary angiogram cases are not the priority listing for AM sections There is no LEAN culture in the Division & ad hoc procedure often disrupt original schedule with a tendency that non-urgent cases need to give way to urgent cases
Counter-measures Patient admission time is rescheduled into 3 time slots: 8am, 10am and 2pm realistic booking Allow light meal up to 2 hours prior to the admission time no undue fasting (Support by Evidence Based Medicine) LEAN Facilitator close surveillance on Booking schedule no overbooking LEAN Facilitator monitor Catheterization Laboratory daily operation make sure Coronary Angiogram patients on schedule Specially assign a RN of 8a-4p duty to be i/c of these elective coro group increase staff competency & efficiency
Before LEAN 1st -19th Nov.2010 26 Patients Total Lead Time: 260 min. Preparation work Arrival to Laboratory Step 1-5 Step 6-7 Waiting time 193 min.
After LEAN 19th Jan -10th Feb 2011 32 Patients (Sustainable effect till present) Total Lead Time 103 min. Preparation work Arrival to Laboratory Step 1-5 Step 6-7 Waiting Time 47 min.
Total Lead Time (from admission time to arrival of cath lab) Boxplot of T otal L ead T im e ( I n M in) 500 400 Total Lead Time (In Min) 300 200 100 260 min. 103 min. 240 0 1st -19th Nov.2010 19th Jan.-10th Feb. 2011 Before Before LEAN (26) Post LEAN 2nd Pilot (32) & Sustained
Outcome Impact Mean lead time (baseline): 260 minutes Mean lead time (pilot): 103 minutes 60% decrease in wastage
Conclusion Lean Management is effective in reducing the waiting time of patients admitted for elective coronary angiogram in Queen Mary Hospital The Effect is sustainable LEAN concepts & methodology can be promoted to other aspects in the Health care System
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