- Email: [email protected]
Maximizing efficiency on trauma surgeon rounds
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 7 ( 2 0 7 ) 1 9 8 e2 0 4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Maximizing efficiency on trauma surgeon rounds Aliaksandr Ramaniuk, DO, MBA,a Barbara J. Dickson, CNP,b Sean Mahoney, MSN, RN,b and Michael S. O’Mara, MD, MBA, FACSb,* a b
Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio Department of Trauma and Acute Care Surgery, Grant Medical Center, Ohio Health, Columbus, Ohio
article info
abstract
Article history:
Background: Rounding by trauma surgeons is a complex multidisciplinary teamebased
Received 3 February 2014
process in the inpatient setting. Implementation of lean methodology aims to increase
Received in revised form
understanding of the value stream and eliminate nonvalue-added (NVA) components. We
13 July 2016
hypothesized that analysis of trauma rounds with education and intervention would
Accepted 18 August 2016
improve surgeon efficacy.
Available online 26 August 2016
Materials and methods: Level 1 trauma center with 4300 admissions per year. Average nonintensive care unit census was 55. Five full-time attending trauma surgeons were evalu-
Keywords:
ated. Value-added (VA) and NVA components of rounding were identified. The components
Lean
of each patient interaction during daily rounds were documented. Summary data were
Lean methodology
presented to the surgeons. An action plan of improvement was provided at group and
Rounding
individual interventions. Change plans were presented to the multidisciplinary team. Data
Trauma
were recollected 6 mo after intervention.
Surgeons
Results: The percent of interactions with NVA components decreased (16.0% to 10.7%, P ¼ 0.0001). There was no change between the two periods in time of evaluation of individual patients (4.0 and 3.5 min, P ¼ 0.43). Overall time to complete rounds did not change. There was a reduction in the number of interactions containing NVA components (odds ratio ¼ 2.5). Conclusions: The trauma surgeons were able to reduce the NVA components of rounds. We did not see a decrease in rounding time or individual patient time. This implies that surgeons were able to reinvest freed time into patient care, or that the NVA components were somehow not increasing process time. Direct intervention for isolated improvements can be effective in the rounding process, and efforts should be focused upon improving the value of time spent rather than reducing time invested. ª 2016 Elsevier Inc. All rights reserved.
Introduction The principles of Lean and Value Stream Management, which have been effectively used in the manufacturing industry for years, are beginning to be implemented into the field of healthcare to increase efficiency, minimize waste, and ultimately improve patient care.1 Health care delivery requires
extraordinary complex organization, with thousands of interacting processes, not unlike the manufacturing industry.2 The core idea of lean involves determining the value of any given process by distinguishing value added from nonvalue-added (NVA) processes, eliminating waste, and increasing efficiency, with the goal of every step in care adding value to the patient.3 Successful quality and efficiency
* Corresponding author. Department of Trauma and Acute Care Surgery, Grant Medical Center, 111 S Grant Ave, Columbus, OH, 43215. Tel.: þ1 614 566 9021; fax: þ1 614 566 8392. E-mail address: [email protected] (M.S. O’Mara). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.08.064
199
ramaniuk et al trauma surgeon rounding
improvement measures require implementation of small, incremental changes, continuous observation, measurement, intervention, and perpetual improvement. To date, a number of medical systems have improved their processes though various lean techniques, yet there have been few published articles looking at improving rounding efficiency, especially in considering the complexities of multidisciplinary trauma rounds.4 A 2014 study from London assessed the variability of quality of surgical ward rounds and demonstrated poor-quality rounds placed patients at an up to 6-fold risk of developing preventable complications.5 Several projects of evidence-based lean improvements of rounding efficiency have proven successful. Akron Children’s Hospital reduced NVA time per patient by 64%.3 Children’s Healthcare of Atlanta looked at the impact of lean on rounding in pediatric intensive care unit, with a significant decrease in rounding time through a reduction in time spent on nonessential activities.6 These projects have shown that the rounding process is one that is amenable to lean type evaluation. We hypothesized that via initiation of lean-based analytical, educational, and interventional activities, the trauma surgeons’ efficacy and rounding speed would improve.
Materials and methods Grant Medical Center is a level 1 trauma center admitting more than 4300 trauma patients per year. The average nonintensive care unit census during this study was 55 patients. Five full-time attending trauma surgeons were evaluated. For this study, we instituted an uncontrolled preintervention and postintervention cohort study using lean principles to assess and address areas of inefficiency in the surgeon rounding process. Collection of the data from this performance improvement project for use as a research study was approved by the OhioHealth Institutional Review Board that governs investigator initiated research at Grant Medical Center. An initial session was held with key stakeholders in attendance. At this session were a trauma surgeon, a nurse practitioner, an inpatient floor nurse, and a nurse educator. The senior author functioned as moderator, chair, and record keeper. The senior author is the trauma medical director, and
as part of his master’s in business administration received training in lean techniques, as well as having ongoing experience with efficiency interventions. Identified members of the rounding team were the attending surgeon, the nurse practitioners, a pharmacist, the bedside nurses, and the case managers. All components of the team to patient interaction were considered and were then defined to be value added or nonvalue added. All these components identified were included in the analysis. Value was defined from the perspective of what would be valuable to the patient during the actual rounding process. Value-added (VA) components included: patient report by the nurse practitioner, review of labs or radiology, bedside evaluation of the patient, the writing of notes in the patient electronic record, family-torounding team conversations, nursing conversations, consultation with therapists (speech, physical, or occupational therapy), consultation with case managers, or consultation with pharmacists. NVA components were identified as: conversation with consultant teams or physicians, answering pages or phone calls, teaching, nonpatient care conversations, travel between patient care units, delays in accessing information technology, breaks taken away from rounds, and physician-to-physician reports between two of the attending trauma surgeons (Table 1). Communication between attending surgeons and with consultant services was considered to be important, but the prerounding conference was determined to be the best forum for this interaction, for when it occurred during the bedside rounds this interaction was actually disruptive to rounds. The primary identified “wastes” can be classified as “overprocessing” and “waiting.” Waiting is defined by any idle time produced when two independent processes are not completely synchronized.7 Without complete synchronization and effective communication between members, extended rounds which include numerous NVA tasks kept the team members from accomplishing other duties relevant to patient care. Overprocessing waste results when unnecessary steps were taken to complete a task, reduces efficiency as the operators that are overprocessing could be performing other value adding tasks that would independently improve patient care.3 Consultant conversations and physician-to-physician sign out were considered so important that they were a part of a conference-style multidisciplinary morning report that occurred daily before physician rounds. Representatives of
Table 1 e Components of lean evaluation of trauma surgeon rounds. Key stakeholders
Rounding team
Value added
Nonvalue added
Trauma surgeon
Attending surgeon
Patient report by NP
Nurse practitioner
Nurse practitioners
Review of laboratories and radiology
Answering pages or phone calls
Inpatient floor nurse
Pharmacist
Bedside evaluation
Teaching
Nurse educator
Conversation with consultant teams
Bedside nurses
Writing of notes
Nonepatient-care conversations
Case managers
Family conversations
Travel between units
Nursing conversations
Delays in accessing IT
Consultation of therapists
Breaks taken away from rounds
Consultation with case managers
Physician-to-physician reports
Consultation with pharmacists
200
j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 7 ( 2 0 7 ) 1 9 8 e2 0 4
consultant services (orthopedic surgery, neurosurgery, and plastic surgery), physical therapy, occupational therapy, speech therapy, nursing, case management, and social work attend these rounds on a daily basis. This morning report process had been defined by a previous improvement project and underwent continual reassessment.8 The current system in place at Grant Medical Center includes a daily morning report at 8:45 AM. The attending surgeon announces to the rounding team the location and the time at which the surgeon intends to do rounds, which is either immediately after morning report or at a later time. The attending surgeon may further elect to review the patient list, laboratories, and radiology, before rounding, with the nurse practitioners. Daily rounds were monitored and the components of each patient interaction and the entire flow of rounds were documented. Observers were medical students and nurse practitioners that had been educated in the components of the rounding flow, and how to identify and document these components. This was done for 2 d of rounding for each of the five surgeons (more than 100 patient interactions per surgeon). The senior author was observed, but his data were excluded to minimize bias. The surgeons were aware of the data collection activity but were not aware of the goals or reasons for the data collection. The data were summarized and analyzed by the original stakeholder group. Areas of improvement were identified based upon observed behaviors and the proportions of NVA behaviors. Summary data were presented to the surgeons. An action plan of improvement was provided at individual interventions. The summary data were also presented to the surgeons as a group and discussion made to identify areas of group improvement. Once these conversations had occurred, the agreed-upon changes were summarized into a change plan. The change plan was presented to the multidisciplinary team. Data were then recollected and analyzed 6 mo after the original intervention. During the preimprovement data collection phase, several areas of potential improvement became apparent. Attending trauma surgeon team rounds were inconsistent from surgeon to surgeon. These inconsistencies included the surgeons not communicating when rounds would occur, the surgeons rounding in a different order and location on different days, the surgeons not communicating how and where the rounding would progress, and in the way and time amount the surgeons spent communicating with the patients and their families. To address inefficiencies and eliminate the waste in the process, certain concepts and structures were integrated. The structure of the morning report included the expectation of the presence all the necessary members. Clear communication became expected, and a summary of the expectations of rounds for the team was circulated (Fig. 1). The goal of this communication was to decrease inconsistency. The expectations set forth defined when morning report would occur, who would be present, what information about rounds needed to be transmitted, and the details of how rounds would proceed following the morning report. A summary document from the surgeon feedback and discussions was also created to summarize the key changes and interventions (Fig. 2). This was circulated among the surgeons only.
Two-sided, two-sample t-tests were used to compare the means of continuous variables between independent groups. To control for covariates (e.g., surgeon effect) while comparing means between groups of interest, analysis of variance was used, and least-squares means (holding other covariates constant) were reported. Dichotomous outcomes were analyzed via logistic regression modeling; odds ratios (ORs) were reported for significant predictors. All statistical analyses were performed using SAS, version 9.2 (SAS Institute, Cary, North Carolina). P-values < 0.05 were considered statistically significant. Rounding times were evaluated on an individual basis, but total times for rounding were then normalized to a 55 patient day.
Results During the initial rounding evaluation, based on the patient centered value perspective, 16% of patient interactions contained NVA components. After intervention, this was reduced to only 10.7% of patient interactions containing NVA components (P ¼ 0.0001, Table 2). The mean time spent rounding during initial evaluation was 4.0 min per patient, and 3.5 min per patient after interaction (P ¼ 0.43). The average total rounding time on all patients in the initial evaluation period was 192 min, which did not change in the postintervention period at 199 min. We separated out all interactions that included NVA activities. During the initial evaluation, if a patient interaction included NVA and VA activities, the average time of the interaction was 8.6 min, after the intervention these NVA þ VA interactions took 6.2 min (P ¼ 0.39). In interactions with no NVA components, having only VA, there was consistency, with these interactions lasting 3.2 min before intervention and 3.5 min after evaluation (P ¼ 0.59). The difference was the increase in the number of interactions having only VA components. In the initial evaluation interactions, individual interactions were 2.5 times likelier to contain NVA than postintervention (OR ¼ 2.5, 95% CI 1.6-4.0; Table 2).
Discussion Based on the statistical analysis of our results, the individual surgeons’ mean rounding time per patient, although not statistically significant, showed a decreasing trend of 12.5%. However, when analyzing only the VA components, the decrease in the mean time from preintervention to postintervention trend was not observed. The percentage of cases that included NVA activities significantly decreased by 33.1%, which indicated that the surgeons were able to identify and cut the time spent on NVA activities while not compromising the total rounding length or individual patient evaluations. The OR calculation further revealed that preimprovement rounds were 2.5 times more likely to include NVA activities than postimprovement. It appears the surgeons reinvested the time gained back into VA components of the patient interactions. This could not be measured, although, due to the overall brevity of individual components of each interaction.
ramaniuk et al trauma surgeon rounding
201
Fig. 1 e Daily rounding team educational handout. ST [ speech therapy; PT [ physical therapy; OT [ occupational therapy.
Recent focus on surgeon rounding processes has served to highlight the lack of standardization in postoperative care and to require a systematic, evidence-based approach focusing on quality and efficiency.5 The trend toward increased implementation and publication of quality improvement (QI) projects demands greater completeness, accuracy, transparency, and rigor in QI research. A QI program can fail as a result of an ineffective intervention or the lack of successful implementation of an already proven effective intervention.8 Following the Standards for Quality Improvement Reporting Excellence guidelines for QI reporting along with other methodologic frameworks of effectiveness evaluation, aims to provide the strongest possible evidence on exactly how, and whether, improvement interventions work.9 The study design for evaluating the effectiveness of QI intervention in our case was an uncontrolled preintervention and postintervention cohort study. It has the advantages of
being possibly the most feasible design for single-center study. However, important sources of bias to be considered are the potential confounding by unrelated temporal trends, regression to the mean, and the Hawthorne effect. In this study design, credibility of results increase with repeated measurements, and it is a practical alternative to a randomized control trial design when the number of centers is small and resources are limited.10 In the application of lean management to the rounding process, value added is defined by the stakeholders. This should include all members of the multidisciplinary rounding team but should be filtered through the patient’s perspective. Rather than defining value as health care per dollar spent, patients view value more broadly as benefits received for burdens endured.4 The goal of the process was to strive to eliminate NVA activates and to appropriately allocate nonessential activities to times that do not interfere with
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j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 1 7 ( 2 0 7 ) 1 9 8 e2 0 4
Fig. 2 e Daily rounding surgeon interventions summary sheet. rounding.11 In the case of rounding, the time spent with the patient by the surgeon becomes the most tangible (to the patient) VA activity. Although the time spent on teaching by the surgeons was defined as NVA, we recognized its essence to progress, training, and improvement and therefore aimed to limit it to one teaching point per patient. One might also
consider note writing to be a NVA component to the patient, but the communication it provided and the immediacy of doing it during rounds made us included it as a VA component. An easy argument could be made to reverse these two pieces, making education a value added and documentation a NVA component of rounding. These decisions need to be
ramaniuk et al trauma surgeon rounding
Table 2 e Duration of individual patient interactions during rounds (min). Analysis category
“Pre” overall
“Post” overall
Pvalue
Mean time/Pt
4.0
3.5
0.43
Interactions with NVA þ VA
8.6
6.2
0.39
Interactions with only VA
3.2
3.5
0.59
16.0%
10.7%
% Of interactions with NVA Odds ratio (pre/post) of having an NVA component
203
importance as the material flow.7 The implementation of the lean management in our study, despite demonstrating early success, points to the necessity of further evaluation and continuous improvement. It also revealed several areas that require further attention and improvement.
Conclusions
0.0001
2.5 (95% confidence interval 1.6-4.0)
NVA ¼ nonevalue-added components included in interaction; VA ¼ interaction includes value-added components; Pt ¼ patient.
individualized to the service, practitioners, and patient population involved. Another key weakness of how this process was assessed was the assumption that what the “expert” group thought of as value added to the patient was indeed additive. There is no patient perspective, observation, or analysis included here. Further studies would definitely need to include patient analysis both before and after intervention. The improvements of the rounding process required enforced structure of the rounding schema. The proposed regimentation dictated the trauma surgeons’ responsibility to ensure that all plans of care are in place and enacted. Surgeons were expected to provide leadership and organization to allow front line members of the team (nurse practitioners, case managers, therapists, pharmacists, and bedside nurses) to easier resolve issues.4,12 Rounds were to be done in an orderly, consistent fashion with all members of the team: the attending trauma surgeon, NPs, pharmacist, case managers, social workers, and the bedside nurses. If the surgeon chose to round at a time not immediately after morning report, it was the surgeon’s responsibility to communicate this to the team and to communicate with members of the team the plan for each patient. The QI measures focused on timely rounding, integrated multidisciplinary approach, and effective communication. The structural modifications implemented lie at the core of the principles of lean, including continuous synchronized flow, leadership structure that empowers front line workers, direct observation, and flexible regimentation.4,7,12,13 Increased focus on improvements in efficient delivery of information and services, as well as structured delegation of tasks to those most qualified will further decrease ambiguity of responsibilities in front line members. Further study must also focus on the aspect of unity of purpose. Rounding is not an isolated process, but a piece that contributes to the wider function of the organization. By improving the understanding and focus of the team members and rounding stakeholders on the purpose of quality and efficiency, the system will continue to improve to the benefit of the patient.4 Incremental changes, metrics, and development of improved communication, flow of information, and technological availability will advance the results attained in the study. The flow of information is treated with as much
A key teaching of lean is to make small changes, measure again, and then continually improve the process.7 Ultimately, lean operational management requires an unceasing, longterm, systematic approach. Often noted in texts on lean management are warnings of isolated victories and improvements, which fail to improve the whole. Short sighted waste elimination techniques and simple replication of tools rather than principles, leads to failure of organizations trying to improve efficiency and quality through lean management.13 A significant effort has been made in improving the quality and efficiency of the rounding surgeons, with the intent of increasing value in patient care. As the results demonstrated, trauma surgeons were able to identify and reduce NVA components of rounds and to reallocate the time toward the VA components of care, without changing the individual patient evaluation time. This implies increased efficiency of the rounding process. Our study has shown that with careful and dedicated execution, lean offers promise in improving quality, efficiency, optimum patient care, and might ultimately transform the patient experience.
Acknowledgment Authors Contributions: The authors M.S.O., B.J.D., and S.M. in conceptual design; A.R., B.J.D., and S,M in data acquisition; M.S.O. and A.R. in data analysis; A.R. and M.S.O in manuscript preparation.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
references
1. Spear SJ. Fixing health care from the inside, today. Harv Bus Rev. 2005;83:78e91. 2. Going lean in health care. IHI innovation series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005. Available at: www.IHI.org. Accessed March 1, 2016. 3. Chand DV. Observational study using the tools of Lean Six Sigma to improve the efficiency of the resident rounding process. J Grad Med Educ. 2011;3:144e149. 4. Toussaint JS, Berry LL. The promise of lean in health care. Mayo Clin Proc. 2013;88:74e82. 5. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259:222e226.
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6. Vats A, Goin KH, Villarreal MC, Yilmaz T, Fortenberry JD, Keskinocak P. The impact of a lean rounding process in a pediatric intensive care unit. Crit Care Med. 2012;40:608e617. 7. Rother M, Shook J, Womack JP, Jones DT. Learning to See. Boston: Lean Enterprise Institute; 2003. Version 1.3. 8. O’Mara MS, Ramaniuk A, Graymire V, Rozzell M, Martin S. Lean methodology for performance improvement in the trauma discharge process. J Trauma Acute Care Surg. 2014;77:137e142. 9. Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting:
10.
11.
12. 13.
explanation and elaboration. Qual Saf Health Care. 2008;17:i13ei32. Kao LS, Lally KP, Thomas EJ, Tyson JE. Improving quality improvement: a methodologic framework for evaluating effectiveness of surgical quality improvement. J Am Coll Surg. 2009;208:621e626. Besunder JB, Super DM. Lean six sigma: trimming the fat! Effectively managing precious resources. Crit Care Med. 2012;40:699e700. Spear S, Bowen HK. Decoding the DNA of the Toyota production system. Harv Bus Rev. 1999;77:97e106. Spear SJ. Learning to lead at Toyota. Harv Bus Rev. 2004;82:78e86.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Maximizing efficiency on trauma surgeon rounds Aliaksandr Ramaniuk, DO, MBA,a Barbara J. Dickson, CNP,b Sean Mahoney, MSN, RN,b and Michael S. O’Mara, MD, MBA, FACSb,* a b
Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio Department of Trauma and Acute Care Surgery, Grant Medical Center, Ohio Health, Columbus, Ohio
article info
abstract
Article history:
Background: Rounding by trauma surgeons is a complex multidisciplinary teamebased
Received 3 February 2014
process in the inpatient setting. Implementation of lean methodology aims to increase
Received in revised form
understanding of the value stream and eliminate nonvalue-added (NVA) components. We
13 July 2016
hypothesized that analysis of trauma rounds with education and intervention would
Accepted 18 August 2016
improve surgeon efficacy.
Available online 26 August 2016
Materials and methods: Level 1 trauma center with 4300 admissions per year. Average nonintensive care unit census was 55. Five full-time attending trauma surgeons were evalu-
Keywords:
ated. Value-added (VA) and NVA components of rounding were identified. The components
Lean
of each patient interaction during daily rounds were documented. Summary data were
Lean methodology
presented to the surgeons. An action plan of improvement was provided at group and
Rounding
individual interventions. Change plans were presented to the multidisciplinary team. Data
Trauma
were recollected 6 mo after intervention.
Surgeons
Results: The percent of interactions with NVA components decreased (16.0% to 10.7%, P ¼ 0.0001). There was no change between the two periods in time of evaluation of individual patients (4.0 and 3.5 min, P ¼ 0.43). Overall time to complete rounds did not change. There was a reduction in the number of interactions containing NVA components (odds ratio ¼ 2.5). Conclusions: The trauma surgeons were able to reduce the NVA components of rounds. We did not see a decrease in rounding time or individual patient time. This implies that surgeons were able to reinvest freed time into patient care, or that the NVA components were somehow not increasing process time. Direct intervention for isolated improvements can be effective in the rounding process, and efforts should be focused upon improving the value of time spent rather than reducing time invested. ª 2016 Elsevier Inc. All rights reserved.
Introduction The principles of Lean and Value Stream Management, which have been effectively used in the manufacturing industry for years, are beginning to be implemented into the field of healthcare to increase efficiency, minimize waste, and ultimately improve patient care.1 Health care delivery requires
extraordinary complex organization, with thousands of interacting processes, not unlike the manufacturing industry.2 The core idea of lean involves determining the value of any given process by distinguishing value added from nonvalue-added (NVA) processes, eliminating waste, and increasing efficiency, with the goal of every step in care adding value to the patient.3 Successful quality and efficiency
* Corresponding author. Department of Trauma and Acute Care Surgery, Grant Medical Center, 111 S Grant Ave, Columbus, OH, 43215. Tel.: þ1 614 566 9021; fax: þ1 614 566 8392. E-mail address: [email protected] (M.S. O’Mara). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.08.064
199
ramaniuk et al trauma surgeon rounding
improvement measures require implementation of small, incremental changes, continuous observation, measurement, intervention, and perpetual improvement. To date, a number of medical systems have improved their processes though various lean techniques, yet there have been few published articles looking at improving rounding efficiency, especially in considering the complexities of multidisciplinary trauma rounds.4 A 2014 study from London assessed the variability of quality of surgical ward rounds and demonstrated poor-quality rounds placed patients at an up to 6-fold risk of developing preventable complications.5 Several projects of evidence-based lean improvements of rounding efficiency have proven successful. Akron Children’s Hospital reduced NVA time per patient by 64%.3 Children’s Healthcare of Atlanta looked at the impact of lean on rounding in pediatric intensive care unit, with a significant decrease in rounding time through a reduction in time spent on nonessential activities.6 These projects have shown that the rounding process is one that is amenable to lean type evaluation. We hypothesized that via initiation of lean-based analytical, educational, and interventional activities, the trauma surgeons’ efficacy and rounding speed would improve.
Materials and methods Grant Medical Center is a level 1 trauma center admitting more than 4300 trauma patients per year. The average nonintensive care unit census during this study was 55 patients. Five full-time attending trauma surgeons were evaluated. For this study, we instituted an uncontrolled preintervention and postintervention cohort study using lean principles to assess and address areas of inefficiency in the surgeon rounding process. Collection of the data from this performance improvement project for use as a research study was approved by the OhioHealth Institutional Review Board that governs investigator initiated research at Grant Medical Center. An initial session was held with key stakeholders in attendance. At this session were a trauma surgeon, a nurse practitioner, an inpatient floor nurse, and a nurse educator. The senior author functioned as moderator, chair, and record keeper. The senior author is the trauma medical director, and
as part of his master’s in business administration received training in lean techniques, as well as having ongoing experience with efficiency interventions. Identified members of the rounding team were the attending surgeon, the nurse practitioners, a pharmacist, the bedside nurses, and the case managers. All components of the team to patient interaction were considered and were then defined to be value added or nonvalue added. All these components identified were included in the analysis. Value was defined from the perspective of what would be valuable to the patient during the actual rounding process. Value-added (VA) components included: patient report by the nurse practitioner, review of labs or radiology, bedside evaluation of the patient, the writing of notes in the patient electronic record, family-torounding team conversations, nursing conversations, consultation with therapists (speech, physical, or occupational therapy), consultation with case managers, or consultation with pharmacists. NVA components were identified as: conversation with consultant teams or physicians, answering pages or phone calls, teaching, nonpatient care conversations, travel between patient care units, delays in accessing information technology, breaks taken away from rounds, and physician-to-physician reports between two of the attending trauma surgeons (Table 1). Communication between attending surgeons and with consultant services was considered to be important, but the prerounding conference was determined to be the best forum for this interaction, for when it occurred during the bedside rounds this interaction was actually disruptive to rounds. The primary identified “wastes” can be classified as “overprocessing” and “waiting.” Waiting is defined by any idle time produced when two independent processes are not completely synchronized.7 Without complete synchronization and effective communication between members, extended rounds which include numerous NVA tasks kept the team members from accomplishing other duties relevant to patient care. Overprocessing waste results when unnecessary steps were taken to complete a task, reduces efficiency as the operators that are overprocessing could be performing other value adding tasks that would independently improve patient care.3 Consultant conversations and physician-to-physician sign out were considered so important that they were a part of a conference-style multidisciplinary morning report that occurred daily before physician rounds. Representatives of
Table 1 e Components of lean evaluation of trauma surgeon rounds. Key stakeholders
Rounding team
Value added
Nonvalue added
Trauma surgeon
Attending surgeon
Patient report by NP
Nurse practitioner
Nurse practitioners
Review of laboratories and radiology
Answering pages or phone calls
Inpatient floor nurse
Pharmacist
Bedside evaluation
Teaching
Nurse educator
Conversation with consultant teams
Bedside nurses
Writing of notes
Nonepatient-care conversations
Case managers
Family conversations
Travel between units
Nursing conversations
Delays in accessing IT
Consultation of therapists
Breaks taken away from rounds
Consultation with case managers
Physician-to-physician reports
Consultation with pharmacists
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consultant services (orthopedic surgery, neurosurgery, and plastic surgery), physical therapy, occupational therapy, speech therapy, nursing, case management, and social work attend these rounds on a daily basis. This morning report process had been defined by a previous improvement project and underwent continual reassessment.8 The current system in place at Grant Medical Center includes a daily morning report at 8:45 AM. The attending surgeon announces to the rounding team the location and the time at which the surgeon intends to do rounds, which is either immediately after morning report or at a later time. The attending surgeon may further elect to review the patient list, laboratories, and radiology, before rounding, with the nurse practitioners. Daily rounds were monitored and the components of each patient interaction and the entire flow of rounds were documented. Observers were medical students and nurse practitioners that had been educated in the components of the rounding flow, and how to identify and document these components. This was done for 2 d of rounding for each of the five surgeons (more than 100 patient interactions per surgeon). The senior author was observed, but his data were excluded to minimize bias. The surgeons were aware of the data collection activity but were not aware of the goals or reasons for the data collection. The data were summarized and analyzed by the original stakeholder group. Areas of improvement were identified based upon observed behaviors and the proportions of NVA behaviors. Summary data were presented to the surgeons. An action plan of improvement was provided at individual interventions. The summary data were also presented to the surgeons as a group and discussion made to identify areas of group improvement. Once these conversations had occurred, the agreed-upon changes were summarized into a change plan. The change plan was presented to the multidisciplinary team. Data were then recollected and analyzed 6 mo after the original intervention. During the preimprovement data collection phase, several areas of potential improvement became apparent. Attending trauma surgeon team rounds were inconsistent from surgeon to surgeon. These inconsistencies included the surgeons not communicating when rounds would occur, the surgeons rounding in a different order and location on different days, the surgeons not communicating how and where the rounding would progress, and in the way and time amount the surgeons spent communicating with the patients and their families. To address inefficiencies and eliminate the waste in the process, certain concepts and structures were integrated. The structure of the morning report included the expectation of the presence all the necessary members. Clear communication became expected, and a summary of the expectations of rounds for the team was circulated (Fig. 1). The goal of this communication was to decrease inconsistency. The expectations set forth defined when morning report would occur, who would be present, what information about rounds needed to be transmitted, and the details of how rounds would proceed following the morning report. A summary document from the surgeon feedback and discussions was also created to summarize the key changes and interventions (Fig. 2). This was circulated among the surgeons only.
Two-sided, two-sample t-tests were used to compare the means of continuous variables between independent groups. To control for covariates (e.g., surgeon effect) while comparing means between groups of interest, analysis of variance was used, and least-squares means (holding other covariates constant) were reported. Dichotomous outcomes were analyzed via logistic regression modeling; odds ratios (ORs) were reported for significant predictors. All statistical analyses were performed using SAS, version 9.2 (SAS Institute, Cary, North Carolina). P-values < 0.05 were considered statistically significant. Rounding times were evaluated on an individual basis, but total times for rounding were then normalized to a 55 patient day.
Results During the initial rounding evaluation, based on the patient centered value perspective, 16% of patient interactions contained NVA components. After intervention, this was reduced to only 10.7% of patient interactions containing NVA components (P ¼ 0.0001, Table 2). The mean time spent rounding during initial evaluation was 4.0 min per patient, and 3.5 min per patient after interaction (P ¼ 0.43). The average total rounding time on all patients in the initial evaluation period was 192 min, which did not change in the postintervention period at 199 min. We separated out all interactions that included NVA activities. During the initial evaluation, if a patient interaction included NVA and VA activities, the average time of the interaction was 8.6 min, after the intervention these NVA þ VA interactions took 6.2 min (P ¼ 0.39). In interactions with no NVA components, having only VA, there was consistency, with these interactions lasting 3.2 min before intervention and 3.5 min after evaluation (P ¼ 0.59). The difference was the increase in the number of interactions having only VA components. In the initial evaluation interactions, individual interactions were 2.5 times likelier to contain NVA than postintervention (OR ¼ 2.5, 95% CI 1.6-4.0; Table 2).
Discussion Based on the statistical analysis of our results, the individual surgeons’ mean rounding time per patient, although not statistically significant, showed a decreasing trend of 12.5%. However, when analyzing only the VA components, the decrease in the mean time from preintervention to postintervention trend was not observed. The percentage of cases that included NVA activities significantly decreased by 33.1%, which indicated that the surgeons were able to identify and cut the time spent on NVA activities while not compromising the total rounding length or individual patient evaluations. The OR calculation further revealed that preimprovement rounds were 2.5 times more likely to include NVA activities than postimprovement. It appears the surgeons reinvested the time gained back into VA components of the patient interactions. This could not be measured, although, due to the overall brevity of individual components of each interaction.
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Fig. 1 e Daily rounding team educational handout. ST [ speech therapy; PT [ physical therapy; OT [ occupational therapy.
Recent focus on surgeon rounding processes has served to highlight the lack of standardization in postoperative care and to require a systematic, evidence-based approach focusing on quality and efficiency.5 The trend toward increased implementation and publication of quality improvement (QI) projects demands greater completeness, accuracy, transparency, and rigor in QI research. A QI program can fail as a result of an ineffective intervention or the lack of successful implementation of an already proven effective intervention.8 Following the Standards for Quality Improvement Reporting Excellence guidelines for QI reporting along with other methodologic frameworks of effectiveness evaluation, aims to provide the strongest possible evidence on exactly how, and whether, improvement interventions work.9 The study design for evaluating the effectiveness of QI intervention in our case was an uncontrolled preintervention and postintervention cohort study. It has the advantages of
being possibly the most feasible design for single-center study. However, important sources of bias to be considered are the potential confounding by unrelated temporal trends, regression to the mean, and the Hawthorne effect. In this study design, credibility of results increase with repeated measurements, and it is a practical alternative to a randomized control trial design when the number of centers is small and resources are limited.10 In the application of lean management to the rounding process, value added is defined by the stakeholders. This should include all members of the multidisciplinary rounding team but should be filtered through the patient’s perspective. Rather than defining value as health care per dollar spent, patients view value more broadly as benefits received for burdens endured.4 The goal of the process was to strive to eliminate NVA activates and to appropriately allocate nonessential activities to times that do not interfere with
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Fig. 2 e Daily rounding surgeon interventions summary sheet. rounding.11 In the case of rounding, the time spent with the patient by the surgeon becomes the most tangible (to the patient) VA activity. Although the time spent on teaching by the surgeons was defined as NVA, we recognized its essence to progress, training, and improvement and therefore aimed to limit it to one teaching point per patient. One might also
consider note writing to be a NVA component to the patient, but the communication it provided and the immediacy of doing it during rounds made us included it as a VA component. An easy argument could be made to reverse these two pieces, making education a value added and documentation a NVA component of rounding. These decisions need to be
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Table 2 e Duration of individual patient interactions during rounds (min). Analysis category
“Pre” overall
“Post” overall
Pvalue
Mean time/Pt
4.0
3.5
0.43
Interactions with NVA þ VA
8.6
6.2
0.39
Interactions with only VA
3.2
3.5
0.59
16.0%
10.7%
% Of interactions with NVA Odds ratio (pre/post) of having an NVA component
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importance as the material flow.7 The implementation of the lean management in our study, despite demonstrating early success, points to the necessity of further evaluation and continuous improvement. It also revealed several areas that require further attention and improvement.
Conclusions
0.0001
2.5 (95% confidence interval 1.6-4.0)
NVA ¼ nonevalue-added components included in interaction; VA ¼ interaction includes value-added components; Pt ¼ patient.
individualized to the service, practitioners, and patient population involved. Another key weakness of how this process was assessed was the assumption that what the “expert” group thought of as value added to the patient was indeed additive. There is no patient perspective, observation, or analysis included here. Further studies would definitely need to include patient analysis both before and after intervention. The improvements of the rounding process required enforced structure of the rounding schema. The proposed regimentation dictated the trauma surgeons’ responsibility to ensure that all plans of care are in place and enacted. Surgeons were expected to provide leadership and organization to allow front line members of the team (nurse practitioners, case managers, therapists, pharmacists, and bedside nurses) to easier resolve issues.4,12 Rounds were to be done in an orderly, consistent fashion with all members of the team: the attending trauma surgeon, NPs, pharmacist, case managers, social workers, and the bedside nurses. If the surgeon chose to round at a time not immediately after morning report, it was the surgeon’s responsibility to communicate this to the team and to communicate with members of the team the plan for each patient. The QI measures focused on timely rounding, integrated multidisciplinary approach, and effective communication. The structural modifications implemented lie at the core of the principles of lean, including continuous synchronized flow, leadership structure that empowers front line workers, direct observation, and flexible regimentation.4,7,12,13 Increased focus on improvements in efficient delivery of information and services, as well as structured delegation of tasks to those most qualified will further decrease ambiguity of responsibilities in front line members. Further study must also focus on the aspect of unity of purpose. Rounding is not an isolated process, but a piece that contributes to the wider function of the organization. By improving the understanding and focus of the team members and rounding stakeholders on the purpose of quality and efficiency, the system will continue to improve to the benefit of the patient.4 Incremental changes, metrics, and development of improved communication, flow of information, and technological availability will advance the results attained in the study. The flow of information is treated with as much
A key teaching of lean is to make small changes, measure again, and then continually improve the process.7 Ultimately, lean operational management requires an unceasing, longterm, systematic approach. Often noted in texts on lean management are warnings of isolated victories and improvements, which fail to improve the whole. Short sighted waste elimination techniques and simple replication of tools rather than principles, leads to failure of organizations trying to improve efficiency and quality through lean management.13 A significant effort has been made in improving the quality and efficiency of the rounding surgeons, with the intent of increasing value in patient care. As the results demonstrated, trauma surgeons were able to identify and reduce NVA components of rounds and to reallocate the time toward the VA components of care, without changing the individual patient evaluation time. This implies increased efficiency of the rounding process. Our study has shown that with careful and dedicated execution, lean offers promise in improving quality, efficiency, optimum patient care, and might ultimately transform the patient experience.
Acknowledgment Authors Contributions: The authors M.S.O., B.J.D., and S.M. in conceptual design; A.R., B.J.D., and S,M in data acquisition; M.S.O. and A.R. in data analysis; A.R. and M.S.O in manuscript preparation.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
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