W. Stehr1, E. K. Sinclair2 1UCSF Benioff Children’s Hospital Oakland,Division Of Pediatric Surgery,Oakland, CA, USA 2UCSF Benioff Children’s Hospital Oakland,Quality Built In,Oakland, CA, USA
Introduction: Rigid bronchoscopy and rigid esophagoscopy for removal of foreign bodies, are delicate and often emergent procedures. The equipment needed for these procedures is complex and very much dependent on the size of the patients. Many hospitals encounter challenges related to the management, maintenance and emergent assembly of this equipment. For the past 30 years this equipment at our Children’s Hospital was maintained in an ‘endoscopy cart’ with 6 drawers. Similar items like lenses or graspers were collocated in the same drawer. This system was prone to problems, as the instruments in the drawers were difficult to manage. The cart was located outside of the Sterile Processing Department (SPD), which led to a lot of variability and required additional operators for maintenance. It was our goal to create a safer and more standardized way of maintaining this equipment using the Toyota Lean management principles.
Methods: As a surrogate measure of motion and possible breakage, we measured the number of drawers that needed to be opened and how many lenses and instruments needed to be touched for a setup. We also measured whether the operating room (OR) technician was able to produce a functioning setup for a patient of a certain age and weight, and the time to completion of the setup. We then performed a 2 day workshop including surgeons, staff from OR and SPD, following the Toyota Lean principles and subsequently repeated the measurements.
Results: We performed (n=7) pre-workshop measures. These showed averages of 9.7 drawers opened, 4.6 lenses touched, 9.7 instruments touched, and a time to setup of 325 seconds. None of the setups were functional. After observation of the process the system was changed to a mobile open-shelf system containing patient-age specific instrument trays. The age groups (0-6 months; over 6 months) were chosen based on our utilization over the past 2 years. Matching sizes of lenses, scopes and graspers were color labeled and collocated in the trays. Immediately after the improvement workshop, different OR technicians produced the following numbers: For a complete setup 0 drawers needed to be opened, 2 lenses touched, 4 instruments touched, and average time to setup was reduced to 105 seconds. All setups were functional. These improvements have been sustained for 2 years.
Conclusion: Despite initial hesitancy to change an established but broken system, this improvement work was made possible through engagement of the key stakeholders. We applied Toyota Lean principles (visual management, kit building, less over processing and elimination of waste) to mistake proof the management and assembly of this delicate and high-risk endoscopy equipment. Our work lead to a 3fold reduction of setup time and 100% improvement of defect free equipment assembly. The new tray system requires less time for management and setup and has reduced the defect rate, even by less experienced operators, to near zero.