JOHN DOUGHERTY, MHS, PA
SR. DIRECTOR GLOBAL GENESIS PROGRAMS,
INTUITIVE SURGICAL, INC
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Tackle the Turnover
DISCLOSURE:
I AM A FULL TIME EMPLOYEE OF INTUITIVE SURGICAL, INC.
Tackle the Turnover
Get
Aligned
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Get
LEAN
Get
Efficient
Get
Results
Get Aligned
• Who’s Involved?
• What will you measure?
• Where are you now?
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• Where do you want to be?
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Who’s involved?
Who’s Involved?
Surgeons
Anesthesia
Support
Pre & Post
Op
Who’s going to do the work?
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OR Staff
What to measure?
TURNOVER TIME=
OR Staff: “… first patient leaves until next
patient enters”
…FOCUS ON NON-OPERATIVE TIME
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Surgeon: “… close to cut”
Non-Operative Time
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• Patient enters to incision
• Incision closed to patient leaves
• Patient leaves to patient enters
Where are you now, and where do
you want to be?
• What is your current data?
− Are you already capturing it and are you
aligned?
• How does that compare?
− Internal and External Benchmarks
• Where will you focus and what is your goal?
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− “Reduce in-room to incision time by 15% before
July 1…”
Get LEAN
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“The first rule of any technology ... is that
automation applied to an efficient operation
will magnify the efficiency. The second is that
automation applied to an inefficient operation
will magnify the inefficiency.”
Bill Gates
LEAN Preference
Card Review
Reduce Room
Footprints
Room Configuration
Roles & Responsibilities
Tray Consolidation
In-Room
Stocking
Back Table
Discipline
Dispose of Expired
Instruments
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Watch Outs
Traffic / sterility
hazard
Storage
Wasted space
Cart
Cart is on opposite
side of room from
workspace
Existing
O.R. 20 Layout – Pre-op
1
Cart
3
2
4
5
Storage
1
Overview of changes
Place cart closer
to working area
2
Move Surgeon Console to
opposite wall
3
Move back table and
Patient Cart to back wall
4
Move Vision Cart
towards anesthesia and to
opposite side of room
5
Move anesthesia to side
wall and reorient
patient table
Recommended
O.R. 20 Layout – Pre-op
Reducing Disposables
Using LEAN process to improve efficiency and
reduce disposable item use
Pre- Lean Preference Card Project Post- Lean Preference Card Project
13%
Open
31%
Hold
69%
28%
Hold
59%
Removed
*Breakdown of actual disposable items on preference card by percentage opened v. held unopened in room
for da Vinci procedures before and after a Genesis Lean Preference Card Review
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Open
Tray Reduction
Si Current Trays
Cost
$2,200
2
Large Needle Driver
1
Monopolar Curved Scissors
$3,200
1
ProGrasp™Forceps
$2,200
1
Fenestrated Bipolar Forceps
$2,700
1
Maryland Bipolar Forceps
$2,700
1
Permanent Cautery Hook
$2,000
7
Total
$17,200
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# in Tray Instrument
Tray Reduction
From Date
06/01/2016
To Date
01/20/2017
Instruments
Total Usage Report (Without version column data)
PART #
INSTRUMENT NAME
Type
470006
Xi™ Large Needle Driver
Driver
182 SK0616
470179
Xi™ Hot Shears™ Monopolar Curved Scissors
Scissors
175 SK0616
470205
Xi™ Fenestrated Bipolar Forceps
Forceps
172 SK0616
470093
Xi™ ProGrasp™ Forceps
Forceps
148 SK0616
480322
Xi™ Vessel Sealer
Sealer
108 SK0616
470347
Xi™ Tip-Up Fenestrated Grasper
Grasper
99 SK0616
470230
Xi™ Large Clip Applier
Applier
274 SK0616
470049
Xi™ Cadiere Forceps
Forceps
62 SK0616
470344
Xi™ Curved Bipolar Dissector
Dissector
42 SK0616
470183
Xi™ Permanent Monopolar Cautery Hook
Hook
34 SK0616
470309
Xi™ Mega™ SutureCut™ Needle Driver
Driver
23 SK0616
470190
Xi™ Cobra Grasper
Grasper
18 SK0616
470172
Xi™ Maryland Bipolar Forceps
Forceps
13 SK0616
480275
Xi™ 8mm Harmonic™ ACE® Curved Shears
Scissors
4 SK0616
470318
Xi™ Small Graptor™ Grasping Retractor
Retractor
2 SK0616
SYSTEM
SERIAL #
15
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TIMES
USED
Tray Reduction
Recommended Si Trays
Si Current Trays
# in Tray Instrument
Cost
$2,200
2
Large Needle Driver
1
Monopolar Curved Scissors
$3,200
# in Tray
Instrument
Cost
2
Large Needle Driver
$2,200
ProGrasp™Forceps
1
Monopolar Curved Scissors
$3,200
$2,200
Fenestrated Bipolar Forceps
1
ProGrasp™Forceps
$2,200
1
$2,700
1
Maryland Bipolar Forceps
$2,700
1
Fenestrated Bipolar Forceps
$2,700
1
Permanent Cautery Hook
$2,000
5
7
Total
Total
$12,500
$17,200
Current Tray Inventory Cost (5 sets)
Recommended Tray Inventory Cost (5
sets)
Potential Savings
$86,000
$62,500
$23,500
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1
Get Efficient
• Analyze your workflow
− Shift process steps from
Internal to External
• Eliminate “Built in Wait
Times”
• Create your own Task
Overlap Model
− Use parallel processes &
your own best practices
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− Complete joint activities
first
External and Internal Processes
There are two types of activities in the
operating room:

External: Those elements that can be done while the OR is
actively engaged in a surgical procedure
Internal: Those activities that must be done while the OR is
“down” and is not engaged in a surgical procedure
The goal is to convert Internal tasks into External Tasks
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
Sequential Tasking
External I
Internal
External II
“Turnover Time”
Patient Leaves Room
Each box
represents one
task
Red Zone
Time Zero
Time
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Serial task execution
Patient Enters Room
Parallel Tasking
External I
Internal
External II
To this
Go from this
Parallel task
execution
change-over Time
To this
Go from this
Red Zone
Time Zero
Time
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The number of boxes
you have stacked up at
any given moment
determines many people
you need .
Parallel Tasking
External I
Internal
External II
Continually
Pull this in
Red Zone
Time Zero
Time
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Parallel task
execution
change-over Time
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Task Overlap Model
DIY: Where Should You Start?
1. Define and List the current steps in your process
2. Decide whether the activity is absolutely necessary or not
a. Eliminate those that are not necessary or value-added
3. Check process logic - are process steps in the best order?
a.
If a surgeon needs the bovie before the gas plug the bovie in first
4. Categorize activities as either:
− external, (meaning that the activity could be performed while the
patient is in the room)
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− internal (meaning that it is an activity that must be performed while
the patient is out of the room) or
DIY: Where Should You Start?
5. Convert any steps possible to external
6. Brainstorm ideas and solutions with the team
7. Perform tasks in parallel where possible
8. Refine the tools and materials necessary for a robotic surgery
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a. Standardize and reduce to only those that are necessary
b. Implement this core pick list for ALL surgeons (reduce variability)
Defined Roles
Page for house
keeping
Arrange robotic
equipment for next case
Remove daily case
cart and trash
Room Turnover/ Setup
Clean calibration station and
positioning devices
Open Sterile items for back
table
Put away empty trays to
appropriate case cart
Calibrate/ drape cameras with
scrub
Drape the robot
Count instruments with scrub
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Clean up process
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Get (and Share) Results
How will you communicate?
•
•
•
•
Daily Reminders
Weekly Progress
Monthly Averages
Quarterly Results
Other Tips:
• Start with On-Time Starts
• Lunch & Break “Lockdown”
• Turnover Radio Calls/ Overhead Page
• In-Room Reminders
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• Surgeon Text System
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QUESTIONS?
OR, TO LEARN MORE ABOUT INTUITIVE SURGICAL’S GENESIS PROGRAM
[email protected]
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