Perioperative Care and Operating Room Management 3 (2016) 25–28

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Perioperative Care and Operating Room Management

journal homepage: www.elsevier.com/locate/pcorm

Lean philosophy and the public hospital

Maria Castaldi a,b,n, Dordaneh Sugano b, Kapri Kreps a, Anna Cassidy a, Jody Kaban a,b
a
Jacobi Medical Center, Department of Surgery, Bronx, NY, United States
b
Albert Einstein College of Medicine, Bronx, NY, United States

art ic l e i nf o a b s t r a c t

Article history: The Toyota Production System or Lean philosophy has been implemented in many facets of medicine
Received 20 July 2015 from outpatient areas to critical care units to ancillary services. There has been some doubt about the
Received in revised form applicability of this process outside of large private medical centers particularly in relationship to op-
9 March 2016
erating room services. We describe the success of the Lean process for the surgical services of a public,
Accepted 2 May 2016
inner-city hospital.
Available online 10 May 2016
Lean methodology was applied to operating room (OR) performance measures of utilization, on-time
Keywords: starts, turn over time, and same day cancellations. Secondary measures of OR minutes used, OR cases
Organizational efficiency completed, individual service cancellations for emergencies, and cross service bumping for emergencies
Process assessment
were also evaluated. One years worth of data prior to the start of Lean was compared to one year after the
Public hospitals
completion of Lean. Improved performance was consistently demonstrated in all measures except same
Municipal hospitals
Operating rooms day cancellations.
LEAN & 2016 Elsevier Inc. All rights reserved.

1. Introduction allocate the necessary resources to institute Lean projects.8 The

The Toyota Production System or Lean methodology, originally
designed to streamline manufacturing, is increasingly being ap-
plied to hospital operations. The strategy was embraced by the
manufacturing sector, and in more recent years has been suc-
cessfully applied to improving the provision of healthcare services.
The Lean philosophy focuses around the concepts of “value” and
“waste,” breaking down a complex production process into in-
dividual steps to create a “Value Stream”. A “Value Stream Analysis
(VSA)” assesses the value of each step required to bring a product
from concept to delivery. Any step that is not valuable from the
perspective of the consumer is considered “waste” and eliminated.
Using the patient and/or physician as the consumer, Lean philo-
sophy has been used to evaluate efficiency and safety for out-
patient,1,2 in-patient3–5 and emergency department6,7 settings.
Hospitals utilizing this philosophy have ranged from community
based, private practice settings to larger tertiary care academic
hospitals. There has been limited reporting of the use of Lean or
Six Sigma methodology in municipal or “safety-net” hospitals. In
fact, some have questioned how less affluent institutions would
n
Correspondence to: Department of Surgery, Albert Einstein College of Medicine,
Jacobi Medical Center, Room 510, 1400 Pelham Parkway South, Bronx, NY 10461,
United States.
E-mail addresses: Maria.Castaldi@nbhn.net (M. Castaldi),
dordaneh.sugano@med.einstein.yu.edu (D. Sugano),
Kapri.Kreps@nbhn.net (K. Kreps), Anna.Cassidy@nbhn.net (A. Cassidy),
Jody.Kaban@nbhn.net (J. Kaban).
Health and Hospitals Corporation (HHC) of New York City, the
largest public healthcare system in the country began using Lean
methodology in 2007. Our hospital among the largest in the HHC
network implemented Lean philosophy with the goal of improving
operating room (OR) efficiency without the addition of significant
resources.
2. Methods
Our center is a level I trauma center and the largest safety net
hospital located in the poorest borough of New York City.9 The
main OR has ten rooms servicing all surgical disciplines except
cardiac surgery and transplantation. Approximately 300 people
including network physicians, fellows, residents, nurses and allied
care professionals participate in the operating room activities. In
cooperation with Simpler Consulting, L.P., a consulting service for
lean enterprise transformation, we performed a VSA, identifying
11 areas of possible inefficiency in perioperative services. Multi-
disciplinary perioperative value stream leadership teams were
formed to evaluate and improve on each of these 11 areas in what
is known as a Rapid Improvement Event (RIE). Eleven RIEs were
completed for the peri-operative value stream in three categories:
peri-operative patient processing, physician related issues in the
OR, and non-physician related issues in the OR. Each RIE was
rolled out with a multidisciplinary team of frontline, as well as
support personnel to identify key performance measures and
set targets. The RIE team met for 3–5 days consecutively for

http://dx.doi.org/10.1016/j.pcorm.2016.05.006
2405-6030/& 2016 Elsevier Inc. All rights reserved.
26 M. Castaldi et al. / Perioperative Care and Operating Room Management 3 (2016) 25–28

investigational work through of new processes and suggested
modifications. The reason for action was identified by VSA, gap
analysis performed to determine the cause of problems creating
gap between initial and target states, and a completion plan
generated. Each of the 11 RIE teams analyzed the way a particular
process was undertaken, known as the initial state, then devised
an improved process that was ready for implementation at week's
end. A confirmed state tracked and showed the benefits and re-
sults of each RIE. If targets were not reached by agreed upon dates,
gap analysis was restudied. Data was collected by the RIE teams at
30, 60, and 90 days using a process control board, visual man-
agement board, huddle board, and tracking sheets.
The overall goal of applying the Lean philosophy to our surgical
services was to increase efficiency in the entire peri-operative
process with the more specific goal of increasing OR utilization by
decreasing “resource waste” or OR down time. Delays in first case
starts, prolonged turn over time (TOT), and unused OR time were
defined as resource waste. Measures of OR performance include
utilization, on-time starts, TOT, and same-day cancellations. OR
utilization was defined as all OR time used during standard
working hours divided by the total amount of standard working
hours (measured in minutes for greater accuracy). On-time start
was defined as patient in the room within 15 min of the published
start time. TOT was calculated from the time one patient left the

Table 1
Description of the 11 Rapid Improvement Events (RIE) in the VSA, including the reason for improvement, the actions taken to achieve improvement, and the effect of the RIE
on peri-operative efficiency and patient care.

RIE Reason for action Implementation Effect

1.Ambulatory Surgery Pa-
tient Flow
2.Packaging of Surgical in-
patients to the OR
3.Materials Management
4.Turn Over Time (TOT) of
the OR
5.On-time Starts
6.Scheduling Practices
7.Block Scheduling
8.Set up of case cart for Or- Existing case cart system for Orthopedic
thopedic Service
9.Cost of Running an OR
10.Optimally preparing the Current PAT process continues to be frag-
elective patient for the OR mented and difficult to navigate for both
(RIE #10)
11.Referral patterns from
outpatient department to referrals from primary care providers to
OR
Delays in processing Ambulatory Surgery Designate 5 cubicles for ambulatory Flow time improved by 50%
patients, impacting our ability to do more surgery patients in PACU
cases. Enforce post-op huddle
Enforce post-op phone communica-
tion with PACU
No standardized format to ensure timely Anesthesia to review elective surgery Cancellations decreased from 48% to 30.4%. Pa-
preparation of Inpatients for the Operating schedule posted the day prior to tients reviewed by Anesthesiologist prior to day of
Room, resulting in unnecessary cancella- surgery surgery increased to 50%. Patient processing
tions and delays. Standardize work documents for forms completion increased from 30% to 82%.
scheduling, holding area
Implement peri-operative nursing
standards protocol
Cumbersome approval and delivery process. Integrate buyer and OR material Inventory accurate for service needs; service
No standardization of product inventory, management specific cards and carts created.
directly impacting delivery process for pa- Create templates for OR supplies
tient care. Master Inventory list on all OR
products
Educate and enforce vendor policy
and procedures
Create service-specific booking sheets
Create inclusive package of OR and
booking policies and procedures
TOT is too long effecting surgeon, patient, Establish RTOR time at end of case. 11% improvement in TOT from baseline monthly
family, and staff satisfaction Streamlining of room cleaning average of 50 min to 41 min.
process.
Establish instant communication
upon patient delivery to OR to trigger
OR prep
Only 13% of surgeons were found to start Establish system to improve first case First case on-time starts have improved from a
cases on time, affecting not only their case start time baseline 54% to 84%.
but also following cases Improve documentation and report-
ing of delays caused by surgeon, an-
esthesiologist, nurse, or patient
Suboptimal OR time utilization due to in- Establish actual OR time minutes for 8% increase in OR minutes
sufficient communication and lack of stan- common procedures in order to create a 22% increase in OR utilization to 490%
dardization, resulting in loss of revenue. more accurate OR schedule.
Institution of online booking forms.
The block schedule restricts access to OR for Bring all areas of preoperative services Near 100% utilization of urgent room.
urgent and emergency cases, preventing together.
maximal OR time use Institute online forms. Bumping of cases between services decreased by
Create “urgent room” for urgent in- 75%.
house cases which cannot be booked
more than 24 h in advance
Formal process to ensure Orthopedic Orthopedic tray completion increased from 54% to
service causes delays. and loaner trays are complete on time. 57%. Loaner tray completion increased from 20%
to 62%.
Defined OR related costs not easily identifi- Compile, organize, and analyze data on cost of idle time þeach minute of TOT cost¼ $30/
able or collectable. Cost reporting is ad hoc costs from respective services, Refine Min.
and methodology lacks standardization. fixed vs. variable costs $32K a month ¼ $384K annually (average)
Early notification to bed board. Reduced patient travel distance from 670 feet to
Bed board huddle. 200 feet
patients and staff Designated bed assignment prior to
admission.
Unable to determine what percentage of Establish standard electronic referral Consultative service requests with appointment
forms with specific guidelines confirmation implemented in the electronic
surgical subspecialties make it to the OR Review referral policies of surgical medical record.
subspecialties
 M. Castaldi et al. / Perioperative Care and Operating Room Management 3 (2016) 25–28
room until the time the next patient entered the room.
One fiscal year worth of data prior to the start of Lean was
compared to one fiscal year after the completion of Lean. The peri-
operative RIEs took approximately 8 months to complete. Statistics
were completed with t-tests with p¼0.05 as statistically significant.
3. Results
Each RIE team analyzed their area of improvement, determin-
ing a reason for action, employing VSA to formulate concrete so-
lutions for reducing waste of resources. The summaries of each RIE
are summarized in Table 1. The most striking results were ob-
served in RIE numbers 4, 5, 6, and 7: TOT, on time starts, sche-
duling practices, and block scheduling, respectively. TOT decreased
by over 10% after lean (po 0.0001). On-time starts increased by
58% (p o0.0001). OR utilization has increased to over 90% in the
last six months of the study, and OR minutes increased by
63,690 min or 8% (p ¼0.02), with an increase of 215 cases or 4%
(p ¼0.1). With the creation of an “urgent room” for in-house cases,
utilization of this room has been near 100%. Overall case cancel-
lation did not improve, nor did services' bumping of themselves
for urgent cases. However, bumping of one service's cases by an-
other service's emergencies was decreased by 75% (po 0.0001).
Bumping of outpatient cases for the two busiest services, general
surgery and orthopedics, showed mixed results. General surgery
showed a trend of fewer cancellations of non-inpatient cases
secondary to emergencies with a decrease of 66% but this did not
reach statistical significance (p ¼0.15).
Other RIEs showed varied results. For ambulatory surgery pa-
tients, average flow time decreased, with 76% patients recovering
within 1 h, up from 14%. For inpatients, cancellations of procedures
were reduced from 48% to 30.4% over a period of 60 days. In ad-
dition, after implementation of the policy that patients be re-
viewed by an anesthesiologist prior to the day of surgery, com-
pliance with this policy was at 50% after 60 days. Completion of
patient processing forms was increased from 30% to 82%.
Pre and post lean results with target states for the primary
measures of OR utilization, on-time starts, turn over time, and day
of surgery cancellations are depicted in Table 2 Similarly, pre and
post lean results for secondary measures of OR minutes used, OR
cases completed, individual service same day cancellations for
emergencies, and cross service bumping for emergencies are de-
picted in Table 3.
4. Discussion
The population of the Bronx according to the 2010 United
States census is 54% Hispanic, 37% African-American and over 30%
foreign born. More than 25% of the borough residents have no
insurance and 28% live below the poverty level.10 Our center is one
of six regional networks established by the New York City Health
and Hospital Corporation (HHC) in 1994 to improve patient care
and better respond to community needs in the Bronx. The North
Bronx Healthcare Network is the sole public provider of health
Table 2
Primary Measures.
Measurements Pre-Lean Post-Lean p Value
OR utilization 65.5% 80% 0.0007
Day of surgery cancellations 13.3% 12.5% 0.69
On time starts 54% 84% 0.0001
Turn over time 54 min 41 min 0.0001
27
Table 3
Secondary Measures.
Measurements Pre-lLean Post-lean p Value
OR minutes 815,795 879,485 0.02
OR cases 5897 6112 0.15
General surgery cancellations for emergencies 12 4 0.11
Orthopedic surgery cancellations for 6 17 0.051
emergencies
Cross service bumping for emergencies 43 11 0.0001
care in the north Bronx, with an annual average of 35,400 in-
patient discharges, 162,000 emergency department visits, 558,500
outpatient visits, and 4300 ambulatory surgery visits. We are re-
cognized by the community we serve as the socially responsible,
experienced provider of choice for the medically underserved, be
they uninsured, Medicaid or Medicare recipients. In addition, we
are a large teaching affiliate of a major academic center. Municipal
or “safety net” hospitals in the United States have traditionally run
at a different pace than private hospitals. Historically this has
meant resident teaching and experience has taken precedence
over hospital efficiency and financial viability. Times have chan-
ged, resources are tight, and financial scrutiny is intense. Efficiency
measures and performance indicators are paramount in the sur-
vival of healthcare systems and are now a priority in municipal
hospital systems as well.
Some of the suggested limitations for Lean methodology in the
health care arena have been scarcity of financial resources for
smaller hospitals and high levels of bureaucracy for large
hospitals.8 Public hospitals seem particularly vulnerable to these
issues in achieving and maintaining success with the Lean philo-
sophy. While administration at our institution is fully committed
to the Lean process, funds in support of Lean initiatives cannot be
allocated or mobilized with the same vigor that a large private
hospital might. Public institutions of all sizes also tend to have
significant bureaucratic constraints, as does ours. Despite these
limitations we have shown that Lean methodology can have sig-
nificant success in the municipal hospital system. HHC has been
applying the Lean philosophy in New York City public hospitals
since 2007 for sustainable quality, efficiency, and financial im-
provement. With the use of Lean we have made substantial im-
provements in OR utilization, on-time starts, and turn over time.
Most hospitals using Lean philosophy in their operating room
did so with some combination of allocating new resources,
creating special operating or pre-procedure rooms, using dedi-
cated teams, or limiting the types or length of procedures
included.11–14 The only published report of a municipal hospital
utilizing Lean philosophy in the OR we identified; initiated the
process as they were opening an entirely new OR suite and were
able to obtain large amounts of new equipment.13 When the Lean
process was started for the operating room at our institution, the
decision was made that all improvements would have to be ac-
complished without additional resources such as increased nur-
sing or anesthesia personnel, specialized equipment or specialized
operating rooms. The urgent room was created through realloca-
tion of OR block time, as well as adjustments to nursing and an-
esthesia schedules. The addition of the urgent room was hugely
popular among the surgeons and has been well utilized. Before its
creation completion of the elective schedule was often hindered
by urgent or emergent cases. Unfortunately the urgent room has
Target not solved this problem. Most services are still bumping them-
selves for urgent cases. Many of our subspecialty groups have only
75–90% one surgeon available on a given day making it hard to eliminate
4% this practice. Only general surgery consistently has multiple sur-
90%
35 Min
geons in the hospital everyday allowing them to decrease their
elective case cancellation rate by two thirds. Orthopedic surgery,
28 M. Castaldi et al. / Perioperative Care and Operating Room Management 3 (2016) 25–28
our second busiest group, lost several faculty members during the
post-lean study period affecting their ability to efficiently deal
with urgent cases. As a consequence their elective case cancella-
tion rate more than doubled. However, cross service bumping
which caused significant difficulties between specialties has been
nearly eliminated.
One of the challenges for a municipal hospital is sustaining the
improvements made after completing the first round of the lean
process. We are currently doing second and third pass reviews of
these peri-operative RIEs in order to sustain and further im-
provements. We have lost an urgent room one day a week due to
resource reallocation. Man power issues continue on the physician
end limiting some of the expected improvements in case cancel-
lations secondary to emergencies. However, this VSA has resulted
in significant financial benefit. Each minute of turn over time has
amounted to 30 dollars per minute, $32K a month and $384K
annually on the average. Additionally, cost of idle time due to cases
that do not start on time has further been reduced. As anticipated
health reform coverage expansion will bring more underserved
patients into our hospital, implementation of LEAN methodology
has been innovative and preparative to handle this increased pa-
tient load.
The competing demands of long term progress versus im-
mediate needs make it hard to sustain these efforts. Immediate
needs frequently win out over long term goals when resources are
tight. Despite these challenges, we have not been the only safety
net hospital to experience success with LEAN methodology. Kings
County Hospital of the HHC has described a number of successful
initiatives adopted by the emergency medicine.15 We, however,
are the only public institution to describe success with peri-op-
erative services using LEAN methodology. The VSA described is
meant to serve as a model for other HHC facilities by utilizing a
system that empowers employees at all levels to see and eliminate
waste, and develop new, effective ways to provide and support
patient care.
Unlike private hospitals that have been looking at operating
room performance measures for some time, many municipal
hospitals have only just recently started to look at these measures.
Besides the tangible benefits of increased OR efficiency are the
improvements in patient and physician satisfaction which we have
only begun to look at quantitatively. The Lean philosophy
can be implemented successfully in different types of medical
institutions, specifically hospitals serving underprivileged pa-
tients. In fact, Lean methodology is crucial in such institutions
where funds are so severely limited that change can really only be
accomplished through initiatives that eliminate waste and re-
dundancy to ultimately improve patient care and safety.
Disclosure information
The authors report no financial nor commercial conflicts.
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