The case study: Treating patients faster

The story

In the early 2000s, orthopaedic surgeons at the Franciscan Center for Hip and Knee Surgery in Mooresville, Indiana faced pressure on their income as insurance companies and the government reduced the payments they made for such procedures.

The partnership’s management team recognised that although the failing joints of ageing baby boomers would be a continual source of demand, something had to change if both partnership incomes and patient outcomes were to be maintained.

The challenge

Having ascertained that their own costs offered few opportunities for savings, the partnership decided that the best alternative was to increase productivity. But how could surgeons perform more operations within the working week when there are only so many hours that surgeons, like anyone, are alert enough to wield a scalpel safely and effectively?

The response

The surgeons at the Center began to see themselves as the bottleneck on an assembly line. Instead of taking one to two hours for a typical knee or hip replacement, the surgeons worked out how they could perform operations within 45 minutes. There would be side-benefits too: for instance, infections would diminish because the wound would be open for a shorter period of time.

A new regime was introduced to make the most of the surgeons’ time. Rather than doing everything in a single room, the surgeon shuttles between two adjacent operating rooms. Each room has its own team, and each team member does the same job for every operation. The operation itself is tightly choreographed, with each team member arriving at the patient at just the right moment to advance the procedure.

The surgeon performs one step after another at a deliberately steady pace.

Under the new regime, all sources of variation to the procedure are reduced. The two days when operations are performed are planned meticulously. Potential problems are discussed beforehand.

During the two days of surgery each week, 15 to 20 patients have replacements performed, roughly double the previous number. The surgeon spends the rest of the working week visiting patients who have recently been operated on or meeting and diagnosing new patients.

Meanwhile, two new teams were set up to address pre- and post-operation issues.

The first handles just pre-operation tasks to make sure patients know what is in store during and after surgery. The job of the doctors, nurses and physical therapists is to ensure patients are in peak condition for surgery and that all necessary information is communicated to the operating team beforehand.

The post-operation team monitors pain relief, recovery and the start of physical therapy.

The centre introduced metrics to track issues such as quality of outcome or reduction of waste – for example, the percentage of patients discharged directly to their home, or the number of operations that did not start on time.

The lessons

Assembly lines consistently create quality products and the keys to productivity in knee and hip replacements are no different from other repetitive processes.

First, reduce all sources of variation. Everyone, surgeons and other team members alike, is organised to proceed at a steady pace that is made possible by anticipating and reducing fluctuations in the variety and quantity of tasks.

Second, reduce the throughput time of the process – in this case, the time it takes for materials being worked on (the patients) to be dealt with.

Third, by analysing how it could achieve “swift, even flow”, the centre discovered that it could cut waste (such as delays or avoidable infections) and miscommunication (for instance, details about patients’ requirements), while also improving the quality of the treatment.

-Financial Times, 24 July 2012