A Lean Surgery Project To Get You Started

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There are some quality improvement projects that are so straightforward we see them repeated across the country.  One of these straightforward projects is decreasing the amount of surgical instruments we have in our operative pans.  The impetus to do this is that we only infrequently use the many clamps and devices that we routinely have sterilized for different procedures.  This project, which we commonly refer to as “Leaning the pan”, is so useful and intuitive that it is repeated across the country.  Here we take a second to describe how the project looks and some ways in which you might decide to apply  it in your practice.


First, much of this Lean project focuses on the concept of value added time, or VAT.  It turns out, in most systems, only approximately 1% of the time is spent adding value to whatever implement or service we are providing. It’s a striking statistic that we see repeated across systems.  Again, only approximately 1% of our time is generally spent in things for which the customer will pay.  As we have described before on the blog, here, one of the challenges we have in healthcare is establishing who the customer is.  In part, the customer is the patient who receives the service.  In another very real sense the customer is the third party payer who reimburses us for our procedures.  The third party payer does not reimburse us any more or less if we use 20 Kelly clamps or 10 Kelly clamps to finish a procedure.  Do we need 40 Kelly clamps in a pan?  If we use the most expensive Gortex stitch, or the least expensive silk suture, our reimbursement does not vary.  So, this concept of value added time is key in Leaning the pan.


We can demonstrate as we go through this quality improvement project that we are decreasing the amount of time that we spend doing things that do not add value to the case.  In short, we can demonstrate that our proportion of value added time increases just as our proportion of non-value added time decreases.  Again, notice that we have introduced this concept of value added time which focuses us squarely on the idea that in general, in most systems, we only spend approximately 1% of our time adding value to our output in systems. So, as we begin to set up the preconditions for this project, one of the ideas we can focus on is how much time a procedure takes.  Here, the concept of operational definition becomes important.  When does a procedure start and end?  The procedure can start from the time the nurse opens the pan and spends time counting (along with the scrub nurse) the implements in the pan.  Alternatively, we can focus on room turnover time and including the counting as part of that defined time.  This is just one way to demonstrate a decreased time spent as non-value added time and it highlights the importance of definition.  Less instruments to count translates into less length of time spent counting.  We can also define the procedural time as the time from when the instruments are sterilized and repackaged.  Again, as with all quality improvements projects, the operational definition of what time we are measuring and what we call procedural time is key.


Another useful idea in Leaning the pan is the Pareto diagram.  As you probably remember, the Pareto Principle (or 80/20 rule) was originally developed by Italian economist Vilfredo Pareto.  It demonstrated that approximately 80% of the effect seen is caused by 20% of the possible causes for that effect.  In other words, there are a vital few which create the bulk of the effect in a system.  This has been extrapolated to multiple other systems beyond the initial data Pareto utilized to describe this principle.  Pareto was focused on wealth in Italy. However, it turns out the the 80/20 principle has been applied to many other systems and practices throughout the business and quality improvement world.  In short, there is now a named diagram and lean six sigma tool called a Pareto diagram.


The Pareto diagram is a histogram that demonstrates frequency of use or occurrence of different items or implements in a system. See Figure 1.  In general, we know that if we select 10 instruments and plot out how frequently they are used, we will find that only approximately 2 of the 10 instruments are responsible for over 80% of the usage of instruments in a procedure.



Fig. 1:  sample Pareto Diagram from excel-easy.com
Fig. 1: sample Pareto Diagram from excel-easy.com


The example above highlights how two complaints of ten possibilities about food (overpriced and small portions) are responsible for around 80% of issues.  Similarly, this tool may be used as a graphic way to demonstrate that the bulk of instruments in the operative pan are not used or are used rarely.  There are several options here.  First we could create a data collection plan to demonstrate how many times each instrument is used in the pan.  Clearly this takes some data collection.  Next we could demonstrate, as a Pareto diagram, instrument usage.  Next we could say “Ok  let’s remove from the pan the rarely used instruments or perhaps keep a few of the rarely used instruments that are particularly hard to find.”


In any case, we will discover that the bulk of the instruments that we sterilize every time are not vital for performance of the procedure and are, in fact, negligible.  So, the Pareto diagram is a useful tool to demonstrate which instruments can (and should) be removed from the pan  Again, this may take some data collection.


We have now demonstrated a straightforward way to demonstrate a change in value added time with our surgical instrument sterilization project and we have also demonstrated one of the key ways to highlight what instruments are used and what instruments can go.  Next, let’s discuss some of the interesting solutions and consequences from leaning the pan projects across the country.  First, we can usually establish consensus from a team of surgeons based on data from which tools and instruments are used.  We can establish one pan which has data behind it that shows which instruments we all use as surgeons.  This eliminates each doctor from requiring their own special pan.  We can then take those hard to find instruments or things that individual surgeons feel are must-haves or must-have-available and put those in accessory packs for each surgeon.  So, the basic laparotomy tray can be the same for everyone with its Lean, time-saving methodology.  This saves time not just for one procedure but, over the total number of procedures, a surprising amount of time:  if we performed 1000 exploratory laparotomies in a year and saved 5 minutes per laparotomy we have clearly save 5000 minutes of non-value added time over the course of the year.  Some simple math demonstrates that this is hours of non-value added time eliminated from the procedure per year.  Things like this are useful and key to establish the utility of these projects.  Let’s look at some other keys.


One of the other keys to a successful project is a project charter.  Before we even begin a Leaning the surgical pan project it is useful to have a stakeholder meeting with all the people involved in sterilizing trays and pans etc. This way, there can be a discussion about some of the things required by our system and the reason why things are the way they are now.  It is important to get a sense of the reason why things are the way they are at the beginning of the quality improvement project.  A project charter will include the scope of the project, the people involved, and an outline of the days required for the project to be completed.  In a study of most Lean Sensei and Lean Six Sigma Black Belts, we discovered that one of the most frequently used tools in the body of knowledge is this project charter at the onset of this project.  This is key in that it clearly focuses us on what is important for the project, timeline, stakeholders, and what the outcome measures will be.  Again, for the Leaning the pan project we would recommend value added time as one of the key outcome measures.


Another key outcome measure should include something about cost.  This helps with the business case for managing up the organization.  Typically, in Lean and Six Sigma projects we use the cost of poor quality (COPQ) which we have described previously here.  In this case, the cost of poor quality is somewhat more challenging to establish.  Remember, the cost of poor quality is composed of four “buckets”.  These include the cost of internal failures, external failures, surveillance and prevention.  For more information on the COPQ and how it is calculated look here.  In this case the COPQ is harder to demonstrate.  What internal failures and external failures exist with this Leaning the pan model?  We, instead of using a strict COPQ in this case, recommend demonstrating any cost savings based on the cost of instrument sterilization, the amount of time instruments can be sterilized before being replaced (life extension for instruments), and the savings that flow from the decreased amount of time utilized in counting a tray (ie more cases).


In short, it will be very challenging to demonstrate direct cost savings with this type of Leaning the pan project.  We have seen around the country with this project  that it is challenging to demonstrate firm cost savings on the income statement or balance sheet.  However, this is a good starter Lean project and can really help the surgeons and operative team see the value in the Lean methodology.   It can also help build consensus as an early, straightforward project in your Lean or Six Sigma journey.


In conclusion we have described the process of Leaning the operating room pan.  As most Lean projects go, this one is relatively straightforward and includes the concept of value added time in addition to the Pareto diagram.  It is more challenging to use other Lean tools such as value stream mapping and load leveling with a project like this.  However, some standard Lean tools can greatly assist the practitioner in this nice warm-up project.  The cost of poor quality is more challenging to establish and much of the case for the savings and decrease in waste from projects like this may come from the representation of how value added time increases as a proportion of time spent.


Discussion, thoughts, or personal reports of how you demonstrated cost savings or “leaned the pan” in your operating room?  We would love to hear your comments and thoughts beneath.


My lean version of this article 1) get stakeholder buy in 2) project charters are useful 3) make the business case 4) cut instruments down by 80% 

dmkashmer moderator

@Cascadia Ha!  Yes and I would add one more step:  collect data.  A Pareto Diagram from some useful data about equipment usage goes a long way toward telling us what can be removed.  Really like your Lean version of the article.