Adapting Lean Processes for the Hospital/Surgical Environment

Abstract

Hospital operating theatres are a focus for cost reduction, especially as expenses can run into billions of dollars (in the United Kingdom’s National Health Service, theatres have been estimated to cost >£1 billion). About 46% of patients discharged from hospital have undergone surgery (Gordon et al. 1988; Audit Commission, 2003; Berwick, 2005; Cegan, 2005). Yet, cancellation rates can reach up to 20% and waiting lists for surgery exist in many countries (Gauld & Derrett, 2000; Buhaug, 2002; Bellan, 2008). The concepts of ‘Lean’ or ‘Six Sigma’ thinking have shown great promise in industry, because they seek to reduce variations in inputs (eg, in quality of raw materials or steps in manufacturing processes), which increases efficiency and reduces costs. Although attempts have been made to apply these concepts to healthcare, it is not proven that their introduction has made progress or reduced costs (Vest & Gamm, 2009; Pandit et al., 2010). Therefore, these ideas may need considerable adaptation for the healthcare setting. This article focuses on three approaches to help understand the problems, and therefore to solve them: first, the notion of matching surgical capacity to demand for surgery; second, the idea of what constitutes ‘efficiency’ and ‘productivity‘ in a surgical list; and third, we describe how effective planning of a surgical list using quantitative data reduces over-runs and patient cancellation. Together these ideas demonstrate how ’Lean‘ is suitably adapted to the existing circumstances in the surgical-anaesthetic setting. At the outset, it is important to distinguish between operational, strategic and tactical decision-making in relation to operating theatre management. Operational decisions concern day-to-day local problems (eg, late starts or transportation problems). The relevant solutions are hospital-specific and may not apply to all hospitals and set the environment in which the organisations function. Strategic decisions concern the global direction/delivery of the service (for example, socialised vs private healthcare, relationships between funders and providers, etc). These decisions affect all hospitals. Tactical decisions are short-to-medium term concerning service planning to implement the strategic decisions (for example, optimum models for theatre scheduling, theatre allocations etc). Tactical analyses apply to all hospitals working within the same strategic environment. Whereas Lean/Six Sigma approaches are usually focussed upon processes within a patient’s journey in hospital (see: http://www.institute.nhs.uk/) and so are traditionally considered