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A Practical Guide to Applying

Lean Tools and Management

Principles to Health CareImprovement ProjectsROSS W. SIMON, BA; ELENA G. CANACARI, RN, CNOR

www.aorn.org/CE

3.6

ABSTRACT

Manufacturing organizations have used Lean management principles for years to

help eliminate waste, streamline processes, and cut costs. This pragmatic approachto structured problem solving can be applied to health care process improvement

projects. Health care leaders can use a step-by-step approach to document processes

and then identify problems and opportunities for improvement using a value stream

process map. Leaders can help a team identify problems and root causes and consider

additional problems associated with methods, materials, manpower, machinery, and

the environment by using a cause-and-effect diagram. The team then can organize

the problems identified into logical groups and prioritize the groups by impact and

difficulty. Leaders must manage action items carefully to instill a sense of account-

ability in those tasked to complete the work. Finally, the team leaders must ensure

that a plan is in place to hold the gains. AORN J 95 (January 2012) 85-100. ©AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.05.021

Key words: Lean thinking, Lean management principles, improvement projects,

structured problem solving, facilitation techniques.

A research team headed by James Womack,

PhD, at the Massachusetts Institute of Tech-

nology International Motor Vehicle Pro-

gram coined the term “Lean” to describe Toyota’s

business processes during the late 1980s.1 The core

idea of Lean is to maximize value for customers

while using fewer resources and minimizing waste.A Lean organization focuses its key processes on

continuous improvement.

Applying Lean management principles im-

proves workflow by reducing waste-related

delays, workarounds, and rework. Lean im-

provement focuses on increasing value for cus-

tomers, both internal and external, across the

entire value chain as viewed from the customers’

indicates that continuing education contact

hours are available for this activity. Earn the con-

tact hours by reading this article, reviewing the

purpose/goal and objectives, and completing the

online Examination and Learner Evaluation at

http://www.aorn.org/CE. The contact hours for

this article expire January 31, 2015.

doi: 10.1016/j.aorn.2011.05.021

© AORN, Inc, 2012 January 2012 Vol 95 No 1 ● AORN Journal 85

http://www.aorn.org/CE







perspective. Value is enhanced by eliminating

waste (ie, any activity that does not add value) in

the process; thus, quality, cost, and timeliness of

delivered services can be improved and time

made available to focus efforts on true value-

added activities.

Patients are key external customers to health

care organizations. The patient’s value chain

begins when the patient enters the surgeon’s

office. Internal customers are also important in

the process. For example, the OR is an internal

customer of the central processing department

(CPD) because the CPD is an internal supplier

of instruments, supplies, and equipment to the

OR. Conversely, the OR is an internal supplier

to the CPD when the OR returns bioburden-

laden instruments coated with an enzymatic

spray to facilitate cleaning. Therefore, depart-

ments can be both internal customers and sup-

pliers. Truly Lean organizations strive to supply

all customers, both external and internal, with

exceptional service.

The core values of Lean management theory

include

respect for people (eg, patients, staff members,managers, physicians),

continuous improvement (eg, easier, better,

faster, cheaper), and

human development.2

For the Lean approach to work, leaders must

create a favorable environment in which prob-

lems are recognized as opportunities for im-

provement. People are not problems, they are

problem solvers, and emphasis is placed on

finding solutions to problems rather than as-signing blame.

Lean principles help perioperative leaders

improve processes with a set of management

techniques that define how they can identify

and reduce waste. A Lean project we called

Going to Gemba with the Hip Breakdown Team

was conducted at Beth Israel Deaconess Medi-

cal Center, Boston, Massachusetts, from Janu-

ary 2009 to July 2010. Gemba is a Japanese

word meaning workplace or where the work

occurs. Direct observation of the work where it

occurs is a key element of Lean problem solv-

ing and process improvement. We had the op-

portunity to improve the OR breakdown process

for hip procedures. Inappropriate breakdown

procedures were resulting in increased costs,

and we realized that we could potentially im-

prove patient, surgeon, and staff satisfaction by

addressing such problems as

lost instrumentation,

improperly cleaned instruments,

ineffective use of resources,

work arounds (eg, immediate-use sterilization),

sharps hazards, and

holes in wrappers.

In this article, we provide the steps for conduct-

ing a Lean process improvement project, from

defining a project through maintaining the gains

achieved. Facilitation tools and techniques are

provided to help ensure that improvement team

meetings are focused and productive.

APPLYING LEAN MANAGEMENT TO

HEALTH CARELean management theory has a long history of

success in manufacturing. The same Lean princi-

ples and tools that are applied in manufacturing

plants are directly applicable to the health

care setting. The root cause for failures is often

the same for manufacturing and health care—

breakdowns in communication and misunder-

standing the needs of customers.

In reviewing the literature in preparation for

our project, we found many articles on using

Lean management techniques in health care that

gave general descriptions of Lean theories and

tools but provided little explanation of how they

are applied and at what phase of the improvement

project. Few articles described a practical ap-

proach for solving complex problems, especially

in opportunities that require an interdisciplinary

effort. Jargon is often used in these articles, most

January 2012 Vol 95 No 1 SIMON—CANACARI

86 AORN Journal



commonly Japanese production-line terms such as

jidoka (ie, the ability to stop production lines in

the event of problems such as equipment mal-

function or quality issues), poka-yoke (ie, mistake

proofing), and hoshin kanri (ie, a strategic plan-

ning process), which adds a layer of confusion

rather than enhancing understanding. In our proj-

ect, we limited the use of Japanese terms (eg,

Gemba, kaizen) to minimize confusion, although

we did not eliminate them completely.

Dr W. Edwards Deming provided a foundation

for Lean management theory in his “14 Points” pub-

lished in his book Out of the Crisis in 1982.3 The

points that are most applicable to health care include

leading the organization (ie, not just supervis-

ing people),

driving out fear,

breaking down barriers between departments,

and

transforming the organization, which is every-

one’s job, not just that of managers.

Lean theory is rooted in the scientific method and

the Plan-Do-Check-Act (PDCA) cycle,4 originally

developed by Walter A. Shewhart, a Bell Labora-

tories scientist who was Deming’s friend andmentor. The PDCA cycle is a four-step model for

carrying out change:

Plan—recognize an opportunity, plan a

change, and estimate the impact of the

planned change.

Do—test the change; carry out a small-scale

study.

Check—review the test results and identify

what you have learned.

Act—take action based on what is learned inthe study; if the change did not work, repeat

the cycle with a different plan; if the change

is successful, incorporate what is learned from

the test into the work process used in the area.

The PDCA cycle is repeated over and over to

continuously improve a process.

Lean thinking helps define both what has to be

done to solve a problem and how work is per-

formed. Lean approaches help managers recog-

nize and reduce the waste in processes. Wastes

are activities that add no value from a customer

perspective, including

Waiting—waiting for the next event to occuror next work activity

Motion— unnecessary movement by employ-

ees in the system

Transportation—unnecessary movement of the

product in a system (patient, specimens,

materials)

Defects—time spent doing something incor-

rectly, inspecting for errors, or correcting

errors

Overprocessing—doing work that is not val-ued by the customer or caused by definitions

of quality that are not aligned with patient

needs

Overproduction—doing more than what is

needed by the customer or doing it sooner

than needed.5

Understanding waste is critical to improvement

because wastes add cost but add no value; they

are typically viewed to be “part of the way wework here.” Building awareness in team mem-

bers that much of their routine work is actually

“waste” from a customer perspective can be

motivating, because wasteful activities are often

activities staff members already struggle with

every day but rarely have the ability to change.

Reducing waste in a process increases the ca-

pacity to do more value-adding work, such as

providing patient care.

When drafting the project charter, henceforth re-ferred to as the scope statement, involving individu-

als who have knowledge of the problem or opportu-

nity and also have a stake in its solution helps

ensure that there is a clear understanding of all as-

pects of the issue. These individuals also can add

suggested approaches to the scope statement, which

can help the team get off to a brisk and success-

ful start rather than wasting time at the first few

LEAN MANAGEMENT TOOLS AND PRINCIPLES www.aornjournal.org

AORN Journal 87



meetings identifying what the first steps of the proj-

ect should be.

Getting the right team members involved is

critical to success. Department managers involved

with drafting the scope statement can quickly

identify those who have the knowledge and expe-

rience necessary to solve the problem. Gaining

approval from supervisors to permit their staff

members to serve on the team is facilitated by

having managers participate in developing the

scope statement.

After brainstorming to identify all problems

and possible solutions, the improvement team

implements corrective actions and responds ac-

cording to the results. As defined in the PDCA

cycle, the results attained after corrective ac-

tions are implemented may not be what were

originally anticipated. “Checking” the results

often leads to additional corrective actions to

achieve desired outcomes. Lean theory is fo-

cused on achieving process perfection over

time, not necessarily on the first attempt. Lean

improvements are intended to make a process

better but not perfect. There is nothing wrong

with an initial failed attempt as long as team

members learn from their failures and adjust

accordingly.

Very few problems exist that are too com-

plex for a team of the right individuals to solve

when the team uses structured problem-solving

techniques and has strong management support.

Lean is not “another job” to be performed in

addition to normal work; it is the way people

work. Lean is about making the right work eas-

ier to do. Deciding when to use Lean principles

and tools is not always easy, however, and

there is no one approach to solving all

problems.

THE IMPROVEMENT TEAM PROCESS

Every team needs a sponsor, a leader, and a

facilitator. If the team encounters roadblocks

that prevent progress, the sponsor is responsible

for removing those roadblocks. The sponsor is

the go-to person if the team cannot move

forward.

The team leader is responsible for keeping the

team focused and productive and ultimately is

responsible for the success of the project. If addi-

tional resources are needed, the leader obtains

them. If team members do not volunteer to com-

plete tasks, the leader assigns the work. The

leader is also responsible for reporting progress to

those charged with managing and supporting the

Lean process in the organization. The leader is

focused on strategy and resources and deals with

questions such as

What should the team do next?

Who can help us with this part of the project?The facilitator is concerned with how the team

works and ensuring that progress is made at each

team meeting. Using the right tool or technique at

the right time is part of the facilitator’s responsi-

bility. Table 1 describes some key facilitation

techniques that help improvement teams stay fo-

cused and productive.

A dictatorial leader can deflate morale so that

members want to abandon the project; a good

leader energizes the team. Likewise, the team canflounder when the facilitator does not arm team

members with the right tool at the appropriate

time. The leader and facilitator work as a team

sharing in strategic planning from one meeting to

the next. For example, on the Surgical Hip Kit

Breakdown Process Team, the leader and facilita-

tor met before one meeting and developed a plan

to ask the team whether every instrument in a

pan of instruments was needed. The team subse-

quently decided to create a subteam to review thecontents of the instrument pans (ie, hip kits). The

subteam ultimately removed 14 lb of unnecessary

instruments from a hip kit. By doing so, we re-

duced an ergonomic hazard and decreased unnec-

essary work and related expenses in the CPD and

the OR.

Having a standard problem-solving process is

essential. This process includes eight steps:


88 AORN Journal



1. defining the scope statement,

2. identifying the current process and associated

problems using a value stream process map,

3. transferring the identified problems to a

cause-and-effect diagram,

4. organizing the problems into logical group-

ings in an affinity diagram,

5. prioritizing problems in an impact difficulty

grid,

6. managing action items with an activity

scorecard,

7. monitoring progress of key action items dur-

ing implementation, and

8. putting a plan in place to hold the gains

and spread the learning after project goals

have been accomplished and the team has

been disbanded.

Scope Statement

Any project can fail if the goal is not clearly

defined, understood, and accepted. Step 1 of the

improvement process requires that the manage-

ment team clearly define the details of the proj-ect with measurable and challenging yet achiev-

able goals. A scope statement (Figure 1) that

contains a clear definition of the problem to be

solved and the measureable goals to be

achieved is essential. Whenever possible, the

voice of the patient should be an element of the

project. The way in which this document is

drafted can strongly influence the success or

failure of a team’s project. The scope statement

should not be developed by one individual.This could be considered “cubical engineer-

ing”—one person attempts to define and re-

solve a problem in isolation with no input from

the people involved. The scope statement

should be drafted by those who

have key knowledge of the problem/

opportunity,

are supervisors or department managers of the

likely project team members, and

have a stake in solving the problem.Key elements of the scope statement include the

following:

background justification;

quantifiable goals;

a target completion date;

suggested approach;

membership including the sponsor, leader,

facilitator, core members who are expected

TABLE 1. Facilitation Techniques

Prepare for the meeting

Arrive to the team meeti ng room early —set it up so that

when participants enter the room the team is ready to

proceed, because nothing is more precious than time.

Make the topic being discussed visible in words

Sit close to a flip chart and use the chart to make key

elements of the discussion visible and understandable to

all team members.

When the need for action surfaces and there is a threat

that the needed action might not be clear to everyone,

write the action on the flip chart and ask “Is this

correct?”

Use the same technique when adding any information

to the activity scorecard. The flip chart marker is a

powerful instrument; when the facilitator writes on the

flip chart, team members become engaged and

galvanized.

Ask questions

Use the Socratic technique—do not tell, ask:

Would it make sense for us to . . .?

Should we consider . . .?

Use flow diagrams

Make processes under discussion visible as flow diagrams.

Define area layouts clearly

When discussing the physical layout of an area, use the flip

chart and draw it out. Hand waving is not a good

method of describing the physical characteristics of a

layout.

Use meeting time wisely Encourage completion of action items outside the

meeting.

Use meeting time strategically by reviewing the status

of action items and planning the next step. Some

activities, such as brainstorming and prioritizing,

require full team participation during a meeting; most

others do not.

Form subteams for activities requiring participation of

multiple team members.

Prevent sidebar discussions

When someone talks, everyone listens; discourage sidebar

discussions during meetings.


AORN Journal 89



Figure 1. An example of a scope statement—a document that management team members (ie, those with key

knowledge of the problem or opportunity) and the supervisors of likely team members create before the

project is launched to provide justification for the project, goals to be accomplished, a target completion

date, metrics, team membership, and simplified process flow.


90 AORN Journal



to attend every team meeting, extended

members who are brought onto the team as

needed; and

macro-flow, which is a simplified, process-

flow diagram of the current state, typically

consisting of about six steps.6

The macro-flow provides an overview of the

process on which the team will be working.

This overview is particularly helpful for those

who do not have a deep knowledge of the pro-

cess needing improvement. Although we did

not include a macro-flow in the scope statement

for this particular project, typically it is a stan-

dard element of a scope statement.

Lean improvement projects are not just per-formed by a select few “champions” in the orga-

nization, but rather by those who do the work

every day. For example, members of the team

to reduce turnaround time between total hip

replacements at Beth Israel Deaconess Medical

Center included

anesthetists;

a perioperative associate chief nurse;

attendants (ie, orderlies who assist with ORturnover);

the CPD second-shift supervisor;

CPD technicians,

the OR clinical advisor (ie, a service line

leader or coordinator who has oversight for

the day-to-day operations of specific service

lines);

the clinical manager of scheduling

operations;

clinical nurses from the OR, preoperativeholding area, and postanesthesia care unit;

a management engineer who guides the team

to use Lean thinking and structured problem-

solving tools;

an OR educator;

the perioperative project director;

surgeons; and

a surgical technologist.

Value Stream Process Map

Step 2 requires that improvement team members

prepare a detailed, process-flow diagram. Team

members must come to agreement in identifying

and then becoming familiar with all steps in the

process (Figure 2). There were a total of 66 pro-

cess steps in the value stream process map for our

project. The first step begins with “Patient sees

his/her doctor” and the last step is “Anesthesia

technologist places the suction liner into canister

on wall, leaves the OR, and washes hands.”

While listing each process step, the leader posts

problems and opportunities for improvement next

to the associated steps. The following are exam-

ples of a problem and an opportunity for im-

provement we identified while listing process

steps.

Process step #32: Central processing depart-

ment personnel pick instruments and dispos-

able supplies one day before the scheduled

procedure.

Problem: Loaner instrument and supply

kits are not always sterile and ready to use.

Process step #52: Anesthesia professional and

circulating nurse wheel the patient out of the

OR.

Opportunity for improvement: Call atten-

dant in sooner to assist with patient trans-

fer and to be available for turnover.

Cause-and-Effect Diagram

During step 3, improvement team members trans-

fer all problems identified while preparing the

value stream process map to a cause-and-effect

diagram template to help identify the root causes

of the problems (Figure 3). The question posedon the cause-and-effect diagram is “What are the

issues or root causes that contribute to the prob-

lem being solved or the opportunity for improve-

ment?” Team members place each problem next

to the appropriate rib. Standard categories include

methods,

materials,

manpower,


AORN Journal 91



32. CPD personnel

pick instruments and

disposable supplies

approximately 1

day before the

scheduled procedure.

33. Postanesthesia

care unit (PACU)

clinical advisor

writes the time when

beds are needed for

the entire day for all

patients and all ORs.

35. PACU orderly

checks with resource

nurse or unit coor-

dinator to find out

which rooms

patients will go into

and takes beds to

the assigned ORs

for each patient.

34. Holding area

nurse checks all

paperwork for

accuracy, availability,

and completeness.

36. Anesthesia

professional

completes the

preoperative form

and the anesthesia

consent form.

37. Anesthesia

professional places

IV and other

invasive lines.

38. Anesthesia

professional performs

pain block (50% of

patients receive a pain

block for postopera-

tive pain control);

femoral blocks are

just for knees.

Loanerinstrument and

supply kits are notalways sterile and

ready to use.

If there isnot an attendant in theholding area, the PACUclinical advisor couldsend an OR attendant

to get the bed or call thecentral transport depart-

ment to get the bed.

Possible delay dependingon whether the atten-dant can take the bed

out of the room after theprevious patient has beendischarged or whether anadditional bed should beobtained from the base-

ment but sometimes thereis not a bed available in

the basement.

If the informed

surgical consentform is not complete,the holding area nurse

may be delayed inpreparing the patient,

which also slowsdown the anesthesiaprofessional in his or

her preparationof the patient.

Interpreter servicesare not always avail-able when needed

because they had notbeen notified of theneed or they didn’tarrive early enough.

Biggest delay:

lack of bedavailability

affects everythingdownstream.

Figure 2. An excerpt from a value stream process map—a few key steps of the much larger, comprehensive

process-flow diagram. Note problems (ie, shaded annotations) that team members identified while creating

the value stream process map.


92 AORN Journal



39. Anesthesia

professional

in holding area

waits for room

readiness.

40. Anesthesia

professional

transports the

patient from the

holding area to

the OR.

42. Anesthesia

professional pre-

pares equipment

for the procedure.

41. On the day of

surgery, circulating

nurse checks all of

the equipment on the

1st time primary hip

procedure cart—typi-

cally, no problems are

encountered with pri-

mary hip procedures;

problems are usually

confined to revision

hip procedures.

43. Circulating nurse

and surgical tech-

nologist prepare the

room for the proce-

dure and ensure that

there are not any

roadblocks.

44. Surgeon closes

the incision.

45. Scrub person

puts the instruments

back into the pans.

SURGERY IS PERFORM ED

Instrumentavailability can beaffected if bookinginformation is not

communicated to theOR clinical advisor;resources may not

be keeping upwith demand.

Thecheck box

signifies that allequipment is

available for theprocedure. It is nota room readinesscheckbox. Whenthe timing of thecheck is delayed,

patient flow isinterrupted.

Induction

of anesthesiacomplete; surgeonshould be presentbut sometimes isnot, so circulatingnurse must page

to locate surgeon,which causes

a delay.

PACUworkflow for provid-ing beds and oxygen

holders and cylinders isnot always coordinated

with OR needs, whichcan cause a delay.

Figure 2. Continued


AORN Journal 93



machinery, and

the environment.7

Team members can add ribs with different names,

if appropriate. Then team members stand back

and ask, “What problems did we miss listing

when we created the value stream process map?”

Normally, team members identify additional prob-

lems, some of which may be very significant. The

next step is to amend the value stream process

map. For instance, in our project, after we trans-

ferred the problems to the cause-and-effect dia-

gram we identified the problem of bed availability

or, specifically, the lack thereof.

Affinity Diagram

Step 4 involves organizing the problems into logicalgroupings in an affinity diagram (Figure 4). This

reduces the number of problems to manage-

able groups and helps define root causes;

eliminates redundancy in problems identified

during the preparation of the value stream

process map;

ensures that solutions developed will address a

broad scope of related problems; and

helps identify a few strategic themes for prob-

lem resolution so the team is not trying to

address many individual problems or symp-

toms. The themes in our project included

the following:

instruments availability,

attendant availability,

holding area size,

scheduling mishaps,

machinery availability and function, and

other (eg, delay in a patient emerging

from anesthesia can delay room

breakdown).

Impact Difficulty Grid

During step 5, team members prioritize problems

based on the impact that solving the problem group will

have on meeting the team goals and

the difficulty of implementing solutions to re-

solve the problem group (Figure 5).

The outcome of this step helps the team decide

which group of problems should be addressed

initially to achieve the greatest improvement

with minimal effort. In our project, the impact/

If there is not an attendant in

the holding area, the post-

anesthesia care unit clinical

advisor should call the OR

resource nurse to determine if

the OR or the transport team

should provide the bed.

Lack of case pick location

(ie, a specific location

[eg, shelf] where supplies

are stored) in the central

processing department and

in the OR can cause delay.

Holding area A

is undersized.Sometimes the need for intraoperative

x-rays and autotransfusion are not added

to the OR schedule, which may require a

workaround to ensure availability at the

right time; if the clinical advisor does not

add this information to the OR schedule,

it may be missed and could cause services

to not be available when needed.

One day before surgery, orthopedic of-

fice personnel confirm that the surgical

procedure is scheduled. Sometimes the

patient refuses surgery, which causes

a gap in the schedule; this results in a

change to the block schedule, so the

preoperative nurse calls and asks the

patient to arrive early, which is stressfulfor the patient.

Manpower

Environment Materials Machinery

Methods

What causesdelays in roombreakdown?

Figure 3. A cause-and-effect diagram in which the problems identified in the value stream process map are

grouped into categories, such as methods, materials, machinery, manpower, and the environment. This is a

simplified diagram in which only one problem is shown for each rib; in reality, multiple problems wereidentified for all but one rib.


94 AORN Journal



difficulty analysis indicated that we should start

developing solutions for issues related to instru-

ments to make rapid and meaningful progress

toward meeting the team’s goals. Resolution of

instrument problems was achieved quickly with

minimal effort. Early wins help maintain a high

level of energy and team morale. Another prob-

lem, reviewing and updating preference lists,

also was solved quickly, which helped keep the

team motivated. Maintaining enthusiasm for the

project is necessary because complex projects

may require several months to complete.

Activity Scorecard

Step 6 involves managing action items by clearlydefining all corrective actions using the activity

scorecard (Figure 6). This scorecard is updated at

each weekly team meeting. Key elements of each

line item include the

task name,

issue addressed,

next activity,

priority relative to other action items (ie,

everything cannot be “high”),

responsible individual, target completion date, and

current status.

This tool drives progress at each team meeting. The

leader ensures that the matrix is visible to the team

members by using a document camera or overhead

projector when adding or updating action items.

Doing so helps avoid confusion when defining the

planned work. Making this “contract” visible during

Instruments:

Loaner Policy

Loaner instruments

not received on

time—need loaner

instrument guideline.

Attendant :

Possible Delay in

Bed Availability

Postoperatively

Possible delay depend-

ing on whether anattendant can take the

bed out of the room af-

ter the previous patient

has been discharged or

whether an additional

bed should be obtained

from the basement;

however, sometimes

there is not a bed avail-

able in the basement.

Holding Area:

Surgeon Availability

Induction of anesthesia

is complete; surgeon

should be present but

sometimes is not, whichcauses a delay because

the circulating nurse

must page to surgeon

to return to the OR.

Scheduling:

Consent Form

If the informed surgi-

cal consent form is not

complete, the surgeon

may need to breakscrub at the beginning

of the day or in between

procedures, which

slows down nurses in

the holding area and the

OR and slows down the

anesthesia professional.

Other:

Waking Patients

Patient requires

additional time for

awakening and

extubation sopersonnel cannot

begin to break down

the OR to prepare for

the next procedure.

Figure 4. An affinity diagram in which grouping seemingly disparate problems into logical groups helps the

team manage the many problems and opportunities for improvement identified and develop corrective

actions. This is a simplified diagram in which only one problem/opportunity for improvement is shown foreach category; in reality, there were multiple problems in each category.

High X

Attendants

X

Holding

Area

X

Instruments

Impact

Low

High Difficulty Low

X

Central

Processing

Department

Dirty

Elevator

Figure 5. An impact difficulty grid used to prioritize

the groups of problems identified in the affinity

diagram according to the impact on goal attainment

and difficulty to solve.


AORN Journal 95



team meetings instills a sense of accountability forthose tasked with completing work. This sets the

tone to ensure that work happens.

Implementation Plan

Step 7 is the implementation plan for corrective

actions to resolve the identified problems (Figure

7). This tool serves as a timeline for key action

items. It provides a high-level view of key tasks

and also aids in creating a sense of accountability

by highlighting sluggish response to plannedwork. For example, a key task in our implementa-

tion plan was the need to develop and implement

a loaner instrument policy.

Holding the Gains and Spreadingthe Learning

A key step when nearing completion of any im-

provement project is planning actions that will

sustain the gains that the team has achieved. All

too often, realized improvements are lost whenthe project closes and team members are dis-

banded because no plan was put in place to em-

bed the improvements in the way work

is performed.

Key metrics should be established as part of

the project, and someone or a group should be

assigned to regularly review the metrics. That

way action can be taken when the improve-

ments slip outside the desired parameters. Turn-

over time was the most important key metricfor our project. Performing regular audits sets

the stage for entrenching the improvement. It

might be necessary to augment the existing re-

sponsibilities of an individual or create new

ones to maintain the achieved gains. When new

employees join the organization, they should

receive training on the new and improved pro-

cess. Updating position descriptions, policies,

ID TITLE ISSUE(S) NEXT ACTIVITY Priority WhoTARGET

COMPLETION

DATESTATUS

1

Sharps data

To address sharps goal:

Develop a process to manage

sharps.

Remind attendants not

to take tables without

red tracking sheets.

MediumOR nurse

manager7/26/10

Brought “helpful hints regarding sharps” to OR

practice council and developed process for ensuring

that tables do not leave OR with sharps. Ordered extra

long,extra large stringers. Regarding “Follow up on 19

blades sent from podiatry clinic to central processingdepartment (CPD) week ending 6/4,” project director

spoke with podiatry clinic personnel about turnover.

OR nurse manager is now being paged when sharps

come to CPD. Attendants have been instructed to nottake tables out of the OR that are not identified with a

red tag.

2

Loaner policy

Obtaining loaner equipment and

supplies affects set-up times soneed to develop a loaner policy

for contractors that defines

expectations. Without control

of loaner items, a domino effect

can occur in CPD. Having a

workable, enforceable policy

will help relieve pressure on

CPD.

Work with the senior

materials managementspecialist to ensure

complete labeling of

loaner kits.Medium

Project

director,

perioperative

services

7/26/10

Currently using a scale to monitor weight of loaner

kits. Escalation (ie, speaking to the person who hasthe next higher rank) in order to get the work done

when loaner kits are delivered late. Total knee kits are

not labeled clearly.

3

Auditing

Need to develop an audit form

and schedule to check the

effectiveness of systems (eg,

kit tracking). Need to develop

and implement a plan to ensure

that the corrective actions

will stay in place after team is

disbanded.

Present and discuss

questions and

answers at the quality

improvement council

and then at the OR

practice council.Medium

Associate

chief nurse,

perioperativeservices and

RN clinicaladvisor

7/26/10

Towels will be included in metrics. Quality

improvement sheet has been designed.

4

Physician-

specific

instrumentation

Non-standardized physician

specialty instrumentation

requires increased storage

space and can contribute to

losing instrumentation.

Update count sheets

after surgeons’

instruments are added

to basic kits.

Medium

OR clinical

advisor

and coretechnologist

7/26/10

Succeeded in getting doctors to use curettes with

black handles.

Attending 6/21/10 Meeting:

Updates in BLUE

Figure 6. An activity scorecard, which helps the team manage the myriad corrective actions required to

resolve the problem.


96 AORN Journal



Ambulatory Takeaways

Applying Lean Management Principles in an Ambulatory Surgery Center

The basic principles of Lean management are applicable to all facilities where surgical and other

invasive procedures are performed. These tools and techniques can be applied in ambulatory sur-

gery centers (ASCs) in a more simplified but equally effective manner.

The internal and external customers of an ASC are similar to those of an acute care facility, but

often the stakeholders have different motivations because of an ASC’s organizational structure,

ownership, and customer base.1 For example, in a traditional facility, the surgeon is a provider,

whereas in an ASC, the surgeon also may be an owner or investor in the ASC as a business. In an

ASC, the patient’s value chain begins when the patient enters the surgeon’s office, which is espe-

cially true when physician-owned ASCs are contiguous with the professional medical offices.

For ASCs, Lean processes can be used to monitor quality indicators as a result of regulatory

requirements or quality indicators that the ASC governing board has selected to document efforts

and outcomes (eg, patient satisfaction, infection prevention). Waste and redundancy are high priori-

ties for all perioperative departments, but in a physician-owned ASC, there is an additional incen-

tive to use Lean processes to find cost savings. Reimbursement for ASCs is a flat, procedure-

based, fixed amount. Therefore, any additional high-cost items (eg, implants, medications, newly

released products) must be evaluated in a thorough multidisciplinary manner as described in the

Lean process. On the other hand, acute care, inpatient perioperative services are reimbursed based

on time-related (ie, minute) charges for the OR, anesthesia services, and direct costs of supplies

with approved markup beyond cost. In hospital-based outpatient departments, reimbursement is

also procedure based, but ASCs only receive 65% of hospital-based outpatient rates.2,3

As in all facilities, miscommunication is often the root cause of failures. Because there are

fewer staff members in an ASC, it is imperative to evaluate the workflow and patient care ren-

dered using a Lean process so that staff members who are very familiar with one another do not

develop unsafe or inefficient workarounds.4 It is important to use the Lean process when imple-

menting regulatory compliance processes, such as mistake-proofing activities (eg, time out, read

back and verifying verbal orders, no passing zones).4 In an ASC, the processes and tools may not

be as complex as in the acute care counterparts but can be equally effective in quality

improvement.

Deborah S. H. Mathis, MS, RN, CNOR, CRNFA, is the director of surgical services at Renue

Surgery Center, Brunswick, GA. Ms Mathis has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

1. Hickman DS. The feasibility of introduction of surgical technologists to a rural community hospital: an analysis for surgical ser-

vices [master’s thesis]. Wilmington, OH: Wilmington College; 1999.

2. Ambulatory surgical center payment. Centers for Medicare & Medicaid Services. https://www.cms.gov/ascpayment. Accessed

October 1, 2011.

3. Stegman MS. Hospital outpatient surgery versus freestanding ASC costs and reimbursement. J Health Care Compl. March/April

2005:39-41.

4. Hickman DS. Safety: talk your way to a culture of safety. Outpatient Surgery Magazine. http://www.outpatientsurgery.net/issues/

2009/12/safety. Accessed October 1, 2011.


98 AORN Journal

https://www.cms.gov/ascpayment


http://www.outpatientsurgery.net/issues/2009/12/safety








projects. Positive results from our project in-

cluded the following:

A standardized hip procedure breakdown pro-

cess was developed and implemented.

Room turnover time was decreased by 10

minutes.

A process for safely managing sharps was de-

veloped and implemented.

All hip preference lists and pick tickets were

updated.

The basic hip kit was standardized and its

weight was reduced by 14 lb.

A loaner instrument policy was developed and

implemented.

The role to manage loaner instrumentation

was developed and implemented.

One-piece flow in assembly of kits in the CPD

was developed and implemented.

The number of surgeon-specific kits was

reduced.

The use of an enzymatic cleaning solution

to pretreat contaminated instrumentation was

implemented throughout the hospital.

A red-tag tracking process for kits sent to the

CPD was implemented.

We also learned valuable lessons, such as

having all involved disciplines and key stake-

holders participate in the project. This allowed

everyone to gain an understanding and an ap-

preciation of each other’s role in caring for this

patient population. It also gave everyone an

understanding of Lean management in action.

In addition, when you bring together the people

who do the work and arm them with a struc-

tured problem-solving methodology, there is nolimit to what they can accomplish.

The Lean approach is simple and straightfor-

ward. Using cross-functional teams guided by

Lean principles and tools to solve complex prob-

lems in a health care setting allowed employees,

patients, and the organization all to benefit. Em-

ployees, who for years have tried unsuccessfully

to influence positive change through the manager/

employee relationship, now have the opportunity

to offer their thoughts and good suggestions in an

open, friendly, and structured environment where

their input is valued and acted upon. The organi-

zation benefits by tapping into a rich reservoir of

talent and experience to solve its most challeng-

ing problems.

References1. What is Lean? Lean Enterprise Institute. http://www

.lean.org/whatslean/. Accessed October 19, 2011.

2. Exploring the “Respect for People” principle of the

Toyota way. http://www.gembapantarei.com/2008/02/

exploring_the_respect_for_people_principle_of_the.html.

Accessed October 13, 2011.

3. Deming WE. Out of the Crisis: Quality, Productivity,

and Competitive Position. Cambridge, MA: Cambridge

University Press; 1982.4. Project planning and implementing tools: plan-do-check-

act cycle. American Society for Quality. http://asq.org/

learn-about-quality/project-planning-tools/overview/

pdca-cycle.html. Accessed September 11, 2011.

5. Graban M. Lean Hospitals: Improving Quality, Patient

Safety, and Employee Satisfaction. Boca Raton, FL: CRC

Press; 2009:43.

6. Flowchart tutorials: flowchart definitions and objectives.

Edraw Soft. http://www.edrawsoft.com/Flowchart-tutorial

.php. Accessed October 14, 2011.

7. Brassard M, Ritter D. The Memory Jogger . Salem, NH:

GOAL/QPC, Inc; 1994.

8. The New Lean Pocket Guide: Tools for Elimination of

Waste. Chelsea, MI: MCS Media; 2007:37.

ResourcesBrassard M. The Memory Jogger. Salem, NH: GOAL/QPC,

Inc; 1989.

Brassard M, Ritter D. The Memory Jogger. Salem, NH:

GOAL/QPC, Inc; 1994.

Butman J. Flying Fox: A Business Adventure in Teams and

Teamwork. New York, NY: AMACOM; 1994.

Byham WC, Cox J. Zapp! The Lightning of Empowerment.

New York, NY: Harmony Books; 1988.

Deming WE. Out of Crisis. Cambridge, MA: MIT Press;

2000.

Dennis P. Getting the Right Things Done. Cambridge, MA:

Lean Enterprise Institute, Inc; 2006.

Drew J, McCallom B, Roggenhofer S. Journey to Lean,

Making Operational Change Work. New York, NY:

Palgrave Macmillan; 2004.

Fetteroll EC, Hoffherr GD, Moran JW. Growing Teams: A

Down to Earth Approach. Salem, NH: GOAL/QPC, Inc;

1993.

Fogg CD. Team-Based Strategic Planning: A Complete

Guide to Structuring, Facilitating, and Implementing the

Process. Seattle, WA: CreateSpace; 1994.

Imai M. Kaizen: The Key to Japan’s Competitive Success.

Columbus, OH: McGraw Hill; 1986.


AORN Journal 99

http://www.lean.org/whatslean/


http://www.gembapantarei.com/2008/02/exploring_the_respect_for_people_principle_of_the.html


http://asq.org/learn-about-quality/project-planning-tools/overview/pdca-cycle.html



http://www.edrawsoft.com/Flowchart-tutorial.php













Isachsen O, Berens LV. Working Together: A Personality-

Centered Approach to Management. Lausanne, Switzer-

land: Institute of Management Development; 1988.

Katzenbach JR. Teams at the Top—Unleashing the Potential

of Both Teams and Individual Leaders. Boston, MA:

Harvard Business Publishing; 1998.

Katzenbach JR, Smith DK. The Discipline of Teams. Hobo-

ken, NJ: Wiley; 2001.

Kobayashi I. 20 Keys to Workplace Improvement. London,

England: Productivity Press; 1990.

Madison D. Process Mapping, Process Improvement, and

Process Management—A Practical Guide to Enhancing

Work and Information Flow. Chico, CA: Paton Press;

2005.

Scholtes PR. The Team Handbook. Emeryville, CA: Joiner

Associates, Inc; 1988.

Spear S. Chasing the Rabbit—How Market Leaders Out-

distance the Competition and How Great Companies

Can Catch Up and Win. Columbus, OH: McGraw Hill;

2009.

Stratton DA. An Approach to Quality Improvement that Works.

2nd ed. Milwaukee, WI: ASQC Quality Press; 1991.

Ross W. Simon, BA, is a senior management

engineer at Beth Israel Deaconess Medical

Center, Boston, MA. Mr Simon has no de-

clared affiliation that could be perceived as

posing a potential conflict of interest in the

publication of this article.

Elena G. Canacari, RN, CNOR, is an associ-

ate chief nurse of perioperative services at Beth

Israel Deaconess Medical Center, Boston, MA.

Ms Canacari has no declared affiliation that

could be perceived as posing a potential con-

flict of interest in the publication of this article.


100 AORN Journal



CONTINUING EDUCATION PROGRAM

3.6

www.aorn.org/CE A Practical Guide to Applying LeanTools and Management Principles to

Health Care Improvement Projects

PURPOSE/GOAL

To educate perioperative nurses about how to apply principles of Lean management

to health care improvement projects.

OBJECTIVES

1. Describe how Lean improvement focuses on understanding the customer.

2. Discuss how Lean management principles can be applied to health care.

3. Explain how Lean management principles are used to improve quality.

4. Differentiate between the Lean management leadership roles in a quality im-

provement project.

5. Identify key Lean management tools.

The Examination and Learner Evaluation are printed here for your conve-

nience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. Direct observation of the work where it occurs,

which is a key element of Lean problem solving

and process improvement, is described by the

Japanese term

a. kaizen. b. jidoka.

c. gemba. d. hoshin kanri.

2. The root cause for failures, including breakdowns

in communication and misunderstanding the

needs of customers, are often the same for manu-

facturing and health care.

a. true b. false

3. Wastes are activities that add no value from a

customer perspective; these include

1. time spent inspecting for and correcting

defects.

2. unnecessary movement by employees.

3. overprocessing and overproduction.

4. unnecessary transportation of equipment or

supplies.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

4. Involving individuals who have knowledge of the

problem when drafting the project charter or

scope statement

1. helps ensure that there is a clear understanding

of all aspects of the issue.

2. helps in identifying the first steps of the

project.

EXAMINATION

© AORN, Inc, 2012 January 2012 Vol 95 No 1 ● AORN Journal 101








3. is advantageous because they have a stake in

its solution.

a. 1 and 2 b. 1 and 3

c. 2 and 3 d. 1, 2, and 3

5.Lean theory is focused on achieving process per-fection immediately after implementation.

a. true b. false

6. The _______________ is concerned with how the

team works and ensuring that progress is made at

each team meeting.

a. facilitator

b. project manager

c. sponsor

d. team leader

7. A scope statement

1. clearly defines the details of the project.

2. contains a clear definition of the problem to be

solved.

3. identifies measurable goals.

4. includes the voice of the patient if possible.

5. is developed by one individual from the man-

agement team.

a. 1 and 2 b. 2, 3, and 5

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

8. Organizing the identified problems into logical

groupings is done using a/an

a. scope statement.

b. impact difficulty grid.c. affinity diagram.

d. cause-and-effect diagram.

9. Managing action items by clearly defining all cor-

rective actions is done with the use of a/an

a. implementation plan.

b. activity scorecard.

c. value stream process map.

d. impact difficulty grid.

10. Rapid-movement kaizen events

1. are two to three all-day meetings to make

rapid progress on one or more tasks.

2. require that employees be pulled away from

their normal job functions for a period of time.

3. are accomplished using small subgroups that

meet between the regular weekly team meet-

ings to accomplish tasks.

a. 1 and 2 b. 1 and 3

c. 2 and 3 d. 1, 2, and 3

The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor,

with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no de-clared affiliations that could be perceived as potential conflicts of interest in the publication of this article.

January 2012 Vol 95 No 1 CE EXAMINATION

102 AORN Journal



CONTINUING EDUCATION PROGRAM

3.6

www.aorn.org/CE A Practical Guide to Applying LeanTools and Management Principles to

Health Care Improvement Projects

This evaluation is used to determine the extent to

which this continuing education program met your

learning needs. Rate the items as described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Describe how Lean improvement focuses on under-

standing the customer.

Low 1. 2. 3. 4. 5. High

2. Discuss how Lean management principles can be

applied to health care.

Low 1. 2. 3. 4. 5. High

3. Explain how Lean management principles are used to

improve quality. Low 1. 2. 3. 4. 5. High

4. Differentiate between the Lean management leader-

ship roles in a quality improvement project.

Low 1. 2. 3. 4. 5. High

5. Identify key Lean management tools.

Low 1. 2. 3. 4. 5. High

CONTENT

6. To what extent did this article increase your knowl-

edge of the subject matter?

Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives

met? Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

9. Will you change your practice as a result of read-

ing this article? (If yes, answer question #9A. If

no, answer question #9B.)

9A. How will you change your practice? (Select all

that apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/imple-

ment a policy and procedure.

3. I will plan an informational meeting with phy-

sicians to seek their input and acceptance of

the need for change.

4. I will implement change and evaluate the ef-

fect of the change at regular intervals until the

change is incorporated as best practice.

5. Other: __________________________

9B. If you will not change your practice as a result of reading this article, why? (Select all that apply)

1. The content of the article is not relevant to my

practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make a

change.

4. Other: _______________________

10. Our accrediting body requires that we verify the

time you needed to complete the 3.6 continuing

education contact hour (216-minute) program: _

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center

approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this

activity for relicensure.

Event: #12502; Session: #0001; Fee: Members $18, Nonmembers $36

The deadline for this program is January 31, 2015.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Eachapplicant who successfully completes this program can immediately print a certificate of completion.

LEARNER EVALUATION



lean abstract.pdf

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