University of Michigan Health System Program and Operations Analysis
General Surgery Operating Room Analysis Final Report
To:
Janine Robinson, RN, OR Core B Manager (Client) Mary Duck, Industrial Engineer Expert & Lean Coach, POA (Coordinator) Prof. Mark Van Oyen, Associate Professor of Industrial and Operations Engineering (IOE 481 Professor)
From: IOE 481 Project Team, Program and Operations Analysis Group 6: Gil Alpert Matthew Clark Ariela Crystal
Date: April 27, 2009
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Table of Contents Executive Summary………………………………………………………………………...
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Introduction…………………………………………………………………………….…...
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Background……………………………………………………………………..….……….
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Goals and Objectives………………………………………………………………..............
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Project Scope………………………………………………………………………………..
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Shadowing…………………………………………………………………………………...
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Data Collection…………………………………………………………………...…………….. Findings……………………………………………………………………………….…………
Surveys………………………………………………………………………………….…… Data Collection…………………………………………………………………………….…… Findings……………………………………………………………………….…………………
Observing Stock and Storage……………………………………………………………… Data Collection…………………………………………………………………………….…… Data Analysis………………………………………………………………………….………... Findings………………………………………………………………………………….………
Spaghetti Diagrams………………………………………………………………………… Data Collection…………………………………………………………………………………. Findings…………………………………………………………………………………………
Time Studies…………………...…………………………………………………………… Data Collection………………………………………………………………………………… Data Analysis…………………………………………………………………………….…….. Findings………………………………………………………………………………….……...
Motion Studies……………………………………………………………………………… Data Collection………………………………………………………………………………… Data Analysis……………………………………………………………………………………
ORMIS Data……………………………...………………………………………………… Data Collection…………………………………………………………………….…………… Data Analysis…………………………………………………………………………………... Findings…………………………………………………………………………………………
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Conclusions………………………………………………...…………………........................ 14 Recommendations…………………………………………………………………………… 15 2
Expected Impact……………………………………………………………………………..
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Appendix A: Survey Results……………………………………………..………………… 17 Appendix B: Observing Stock……………………………………………………………… Appendix B1: Supply Stock Photographs…………………………………………………….
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Appendix C: Spaghetti Diagrams…………..…………………………………………...…
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Appendix D: Time Studies Analysis……………………………………………………….. 27 Appendix D1: Time Study Data Collection…………………………………………………… 27 Appendix D2: Time Study Data Analysis……………………………………………………... 28 Appendix E: Motion Study…………………………………………………………………
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Appendix F: ORMIS Analysis Results….…………………………………………………
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Appendix F1: Appendix F2: Appendix F3: Appendix F4: Appendix F5: Appendix F6:
Total Thyroidectomy ORMIS Analysis……………………………………… Parathyroidectomy ORMIS Analysis……………………………………..…. Exploratory Laparotomy ORMIS Analysis…………………………………. Colectomy ORMIS Analysis………………………………………………….. Wire Localized Breast Biopsy ORMIS Analysis…………………………….. Laparoscopic Cholecystectomy ORMIS Analysis……………………………
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Tables and Figures Report Table 1: Summary of Time Study Findings……………………………..…………………............... Figure 1: Average Total Time Out of OR During Surgery for OR 13, Core B, & Core C….............. Figure 2: Average Number of Runs out of OR for OR 13, Core B, & Core C……………………… Figure 3: Boxplot of Time of Each Run Out of OR for OR 13, Core B, & Core C………………… Appendix B: Observing Stock Table B1: Summary of OR Supply Stock…………………………………………………………… Appendix B1: Supply Stock Photographs Figure B1: OR 13 Supply Stock…………………………………………………………………….. Figure B2: OR 9 Supply Stock……………………………………………………………………… Appendix C: Spaghetti Diagrams Figure C.1: SGI Surgery in OR 13…………………………………………………………………... Figure C.2: SGI Surgery in OR 9, Core B…………………………………………………………... Figure C.3: SGI Surgery in OR 20, Core C…………………………………………………………. Appendix D1: Time Study Data Collection Figure D1: Example Time Study Data Collection Card…………………………………………….. Appendix D2: Time Study Data Analysis Figure D2.A: Pie Chart of OR 13 Run Locations……………………………………………………. Figure D2.B: Pie Chart of Core B Run Locations…………………………………………………… Figure D2.C: Pie Chart of Core C Run Locations…………………………………………………… Appendix E: Motion Study Figure E1: Example Motion Study Data Collection Card………………………………………….. Appendix F: ORMIS Analysis Table F.1 ORMIS Data Analysis: Average Times by Surgery…………………………………….. Appendix F1: Total Thyroidectomy ORMIS Analysis Figure F1.A Graph of Average Total Thyroidectomy Times………………………………………... Figure F1.B Boxplot of Total Thyroidectomy Room Set up Times by OR…………………………. Figure F1.C Boxplot of Total Thyroidectomy Induction/Positioning Times by OR………………... Figure F1.D Boxplot of Total Thyroidectomy Surgery Times by OR………………………………. Figure F1.E Boxplot of Total Thyroidectomy Closing- Patient Out Times by OR…………………. Figure F1.F Boxplot of Total Thyroidectomy Overall Surgery Times by OR………………………. Appendix F2: Parathyroidectomy ORMIS Analysis Figure F2.A Graph of Average Parathyroidectomy Times………………………………………….. Figure F2.B Boxplot of Parathyroidectomy Room Set up Times by OR……………………………. Figure F2.C Boxplot of Parathyroidectomy Induction/Positioning Times by OR…………………... Figure F2.D Boxplot of Parathyroidectomy Surgery Times by OR…………………………………. Figure F2.E Boxplot of Parathyroidectomy Closing- Patient Out Times by OR……………………. Figure F2.F Boxplot of Parathyroidectomy Overall Surgery Times by OR………………………… Appendix F3: Exploratory Laparotomy ORMIS Analysis Figure F3.A Graph of Average Exploratory Laparotomy Times……………………………………. Figure F3.B Boxplot of Exploratory Laparotomy Room Set up Times by OR……………………… Figure F3.C Boxplot of Exploratory Laparotomy Induction/Positioning Times by OR…………….. Figure F3.D Boxplot of Exploratory Laparotomy Surgery Times by OR…………………………… Figure F3.E Boxplot of Exploratory Laparotomy Closing- Patient Out Times by OR……………… Figure F3.F Boxplot of Exploratory Laparotomy Overall Surgery Times by OR…………………... Appendix F4: Colectomy ORMIS Analysis Figure F4.A Graph of Average Colectomy Times…………………………………………………... Figure F4.B Boxplot of Colectomy Room Set up Times by OR…………………………………….. 4
2 10 10 11 22 23 23 24 25 26 27 28 28 29 30 31 32 32 33 33 34 34 35 35 36 36 37 37 38 38 39 39 40 40 41 41
Figure F4.C Boxplot of Colectomy Induction/Positioning Times by OR…………………………… Figure F4.D Boxplot of Colectomy Surgery Times by OR………………………………………….. Figure F4.E Boxplot of Colectomy Closing- Patient Out Times by OR…………………………….. Figure F4.F Boxplot of Colectomy Overall Surgery Times by OR…………………………………. Appendix F5: Wire Localized Breast Biopsy ORMIS Analysis Figure F5.A Graph of Average Wire Localized Breast Biopsy Times……………………………… Figure F5.B Boxplot of Wire Localized Breast Biopsy Room Set up Times by OR……………….. Figure F5.C Boxplot of Wire Localized Breast Biopsy Induction/Positioning Times by OR……… Figure F5.D Boxplot of Wire Localized Breast Biopsy Surgery Times by OR…………………….. Figure F5.E Boxplot of Wire Localized Breast Biopsy Closing- Patient Out Times by OR………... Figure F5.F Boxplot of Wire Localized Breast Biopsy Overall Surgery Times by OR……………... Appendix F6: Laparoscopic Cholecystectomy ORMIS Analysis Figure F6.A Graph of Average Laparoscopic Cholecystectomy Times…………………………….. Figure F6.B Boxplot of Laparoscopic Cholecystectomy Room Set up Times by OR………………. Figure F6.C Boxplot of Laparoscopic Cholecystectomy Induction/Positioning Times by OR……... Figure F6.D Boxplot of Laparoscopic Cholecystectomy Surgery Times by OR……………………. Figure F6.E Boxplot of Laparoscopic Cholecystectomy Closing- Patient Out Times by OR………. Figure F6.F Boxplot of Laparoscopic Cholecystectomy Overall Surgery Times by OR…………….
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Executive Summary This project entails the findings and recommendations of the analysis IOE 481 Team 6, conducted on the Scrubs and Circulator activities and their frustrations within the General Surgery Service at the University of Michigan Hospital. The Core B Manager requested that the team observe the current daily process of preparing the ORs for surgery, identifying the tasks the Circulators perform during surgery, and identifying delays directly related to them. Background The OR department at the University of Michigan Hospital consists of 26 different operating rooms grouped into three cores (A, B, and C). The General Surgery Service is primarily staffed by Core B, they also work in Core C, and occasionally in Core A. Currently there is only one dedicated “home room” (Operating Room 13). A dedicated “home room” is an operating room in which only one type of surgery is regularly scheduled, allowing for frequently used items to be stocked and available. The primary objective of this project was to determine if operating in a dedicated homeroom impacts surgery time. Secondary objectives were to determine if operating room location (OR 13, Core B or Core C) corresponds to waste and the workload of the Circulators. Methodology Team 6 went about this project using the following methods: • Shadowed Service Leads and Circulators. A total of 15 surgeries were shadowed. Service Leads were shadowed only in the mornings for room preparation. The Circulators were shadowed for room preparation, tasks during surgery, and room-changeover. • Interviewed and conducted surveys from Service Leads, Scrubs, and Circulators. The Surveys contained 10 questions aimed to understand the problems and frustrations of the General Surgery staff. • Observing the stock area. The team examined the organization and standardization of the supply stocks. The observations included the supply cabinets and drawers in the ORs, and the stock areas in Cores B and C. • Conducted time studies on the tasks of the Circulators when they left the OR during surgery. In order to conduct the time studies, time study cards were developed and includes the general case info, total time out of OR each time the Circulator left, reason for leaving, description of specific item retrieved, and location that the Circulator went to retrieve the item. Comparisons of differences in OR 13, Core B, and Core C were made on the total number of runs out of OR, time of each run out of OR, and percent of time going to other cores. • Conducted Motion Studies on the task of the Circulators. Pedometers were used to assess the distances the Circulators walk to prepare a room and during surgery. • Observed information from ORMIS data. The team received ORMIS data from May, 2008 to February, 2009. In order to avoid high variability, only the most frequent procedures in General Surgery were used. Surgery times were broken into intervals of 6
room set up, induction/positioning, surgery, and closing-patient out. These results were compared between OR 13, Core B, and Core C Findings The shadowing process showed that there was a lack of familiarity with the layout of Core C. Circulators were often not sure where to find supplies when looking in the Core C stock area. The survey responses indicated strong frustrations with the equipment storage location, setup of the supply stock, and the need to work outside of Core B. Of the surveys collected 100% expressed some level of frustration with having to work in Core C, as well as with the current process of preparing a room for surgery. Also, responses indicated that there were significant differences between preparing OR 13 and preparing the other ORs. It was also indicated that the staff preferred working in Core B over Core C. Several comments were made suggesting that there is a lack of standardization between the OR supply cabinets and the stock areas of the different cores. A summary of the results of the Time study can be seen in Table 1 below. This table shows that when operating in OR 13, Circulators had to leave the room during surgery significantly less often. The table also shows that Circulators working in Core C went to Core B more often when making a run, compared to the number of times Circulators working in OR 13 and Core B made runs to Core C. This suggests that Core B is better prepared to accommodate General Surgery. Table 1: Summary of Time Study Findings
OR 13 Core B Core C
Average # of Runs 4.43 6.20 6.25
% of runs to Core C 6 9 -
% of runs to Core B 18
The analysis of the ORMIS data showed no correlation between which room a surgery occurred in and the overall surgery time. While some specific surgery types indicated that operating room location had some impact on surgery time, the team was not able to draw any overriding correlation across surgeries. Conclusions IOE 481 Team 6 concluded that operating in a dedicated OR will reduce the Circulator workload by having a less need to leave the room as often and spend shorter amount of times out of the room. However, operating in a dedicated OR will not impact the overall time of the surgery. It was also concluded that the supply stock area in Core B is better prepared for General Surgery than the supply stock area in Core C.
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Recommendations Group 6 has the following recommendations for improvement in General Surgery • Implement ‘5S’ techniques to standardize the supply stock between cores and supply cabinets in ORs. Standardizing will create a better organization in the supply stock areas, reducing misplacements and the absence of items. As a result, this will eliminate unnecessary delays by reducing the amount of time the Circulators search or retrieve an item. • Conduct supply studies to determine most common supplies retrieved out of OR during surgery. These studies will provide a more detailed picture of which supplies Circulators are going to get during surgery. By locating these supplies closer to the types of surgeries they are needed in, the amount of time spent out of the room by the Circulator can be further reduced. • After implementation of previous recommendations conduct time studies on Circulators to determine effectiveness of standardization. Following the implementation of the previous two recommendations, this will allow any improvements to be quantified and provide an idea of what can still be improved in the General Surgery Operating rooms.
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Introduction The University of Michigan Hospital Operating Room (OR) has 26 operating rooms grouped into three cores (A, B, and C). Currently, the General Surgery Service is assigned to core B, but due to a lack of consistent room placement, general surgeries could take place in any of the three cores. Also, General Surgery has only one dedicated “home room” (Operating Room 13) located in core B. A dedicated “home room” is an operating room in which only one type of surgery is regularly scheduled, allowing for frequently used items to be stocked and available. Historically, the operating rooms store service-specific instrumentation near the designated operating rooms to decrease out-of-room time, when additional instrumentation is needed. However, General Surgery’s lack of designated procedure rooms has resulted in needed instrumentation being stored in multiple cores. This current setup causes problems for Scrubs (RN or Tech) and Circulators (RN only) who prepare each room for surgery, and frequently results in a Circulator having to leave the room during the surgical procedure to retrieve items that were not set up before surgery. The Circulator having to leave the room results in inefficiencies and delays to the surgical procedure and causes frustration for the Circulators and Scrubs. The OR Core B manager requested that the IOE 481 student team observe the current daily process of preparing the ORs for surgery. Additionally, the Core B manager is interested in identifying the tasks the Circulators perform during surgery and identifying delays directly related to them. Therefore, the purpose of this project was to analyze the Scrub and Circulator activities in the General Surgery Service at the University of Michigan Hospital, including the pre-operation preparation of the operating rooms and the associated workload of the Scrubs and Circulators pre, post and intra operatively and to recommend improvements in these processes. This report presents the project methods, findings, conclusions, recommendations, and supporting documentation.
Background The General Surgery Service at the University of Michigan Hospital does not currently operate out of a specified core of operating rooms. The hospital has 26 operating rooms, which are currently set up into Core A, Core B and Core C. Core A has 8 operating rooms dedicated to Otolaryngology, Neurology and Orthopedic surgeries. Core B has 9 operating rooms, which are divided between General, Orthopedic (Sports medicine), Orthopedic, Oral and Plastic surgeries. Core C has 9 operating rooms used for Urology, Gynecology, Trauma and Endoscopic surgeries. The General Surgery Service currently has only 1 “home room” dedicated to general surgeries. All other general surgeries take place in whichever room is available in Core B or Core C. Each surgery is staffed by a Scrub, who directly assists the surgeon with supplies and instruments during surgery, and a Circulator, who acts as the patient advocate, charts patient information, and obtains additional supplies needed by the surgical team. Supplies, as previously noted, may be located either in the stock cabinet in the room, in the sterile cores, or in the stock carts in adjacent hallways. Circulators and Scrubs are staffed by the core designated for their branch of surgery. General Surgery is staffed by Core B; however, due to the changes in OR room designations, staff frequently work in cores other than their own. Unfamiliarity with stock 9
location and core set up leads to delays and frustration when additional supplies are needed. In addition, lack of a central service supply area increases the distance between the assigned OR and the supplies necessary for the scheduled surgery. To prepare a room for surgery, Scrubs and Circulators set up the room with the equipment, instruments, and supplies needed. The general surgery equipment is located in the hallway between Core B and Core C. Instruments and sterile supplies are located in Cores B, C and mini C. Scrubs and Circulators are required to move the equipment, instruments and supplies from these multiple areas to the operating room assigned that day. However, needed supplies may be from any of the three core’s stock. The need to move the equipment, instruments, and supplies increases the distance that the Scrubs and Circulators walk. In addition, the supply stock areas within each core are not set up the same, which makes it difficult for Scrubs or Circulators to find supplies in a different core. Lastly, since general surgery supplies are not stocked in the OR, with the exception of OR 13, Circulators often need to leave the OR during surgery to retrieve unforeseen supplies. These circumstances are frustrating Scrubs and Circulators and the current setup is believed to waste the hospital’s resources, including time and money.
Goals and Objectives To identify the root causes of waste and delay in the activities of the Scrubs and Circulators in the General Surgery Service of the University of Michigan Hospital system, the team achieved the following tasks: • •
Observed current processes and conducted time and motion studies on general surgery preparation and Circulators’ tasks during surgery. Quantified the waste and delays of preparing a non-dedicated operating room for surgery, in terms of time.
With this information, the team: • • • • •
Determined if working in a dedicated OR saves time during surgery. Determined if room allocation corresponds to waste and delays, and if so, recommended a better room allocation. Determined if equipment and supply needs correlate with any delays. Determined if the supply stock locations affect the procedure efficiency of the Circulator’s tasks, and if so, recommended an improved stock location. Developed recommendations intended to improve Circulator and Scrub satisfaction.
Project Scope This project included the preparation of general surgery operating rooms and the tasks of locating unforeseen supplies during surgery. It addressed the tasks and activities of the Circulators and the Scrubs. This project included observing the tasks and activities of the 10
Service Leads in preparing a room for surgery, since they are correlated with the tasks and activities of the Circulators and Scrubs; however, this project was not concerned with the overall tasks and activities of the Service Leads. This project was not concerned with the other activities that occur in the general surgery operating rooms, such as the activities performed by the surgeons and the residents. In addition, the project was not concerned with the functions of the operating rooms designated to branches of surgery other than general surgery.
Shadowing The team shadowed the Circulators, Scrubs, and Service Leads to identify the process and main steps of preparing a room for surgery and to identify the Circulator’s tasks during surgery. Data Collection The team shadowed the Service Leads as they began their day and prepared each room for surgery, beginning at 6 A.M. The team also shadowed the Circulators and observed the Scrubs, beginning at 7 A.M., as they prepared a room for surgery, changed over a room after surgery, and performed their tasks during the surgery. The team observed a total of 15 general surgeries in OR 13, the “home room”, other ORs in Core B, and ORs in Core C. During each surgery and the preparation of the OR for that surgery, the team member observed the tasks that the Circulator, Scrub, or Service Lead was performing and asked them questions regarding their activities. While the Service Leads were not directly included in the scope of this project, the impact of the Service Lead on the jobs of the Scrubs and Circulators was important to understand. During the shadowing process, the team members also asked the Circulators, only when the Circulators had available time, for their opinions of the OR preparation and surgery process. Findings From the team’s shadowing sessions, we came to several key conclusions. It was found that Circulators do not always know the exact locations of supplies in core stock areas. This was especially apparent when surgeries were being conducted in Core C, which was observed to be caused by a lack of familiarity with the layout of the Core C supply stock. The team also found that when working in Core C, Circulators often have to go to Core B to get necessary supplies, whereas when working in Core B, Circulators have to leave the core less often. Lastly, the team found that when a surgery was being conducted in OR 13, supplies are found within the room more often than in other ORs. This finding was based on observations of how often a Circulator could get the necessary supply from the cabinets within the room.
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Surveys The team distributed a survey to the Circulators, Scrubs, and Service Leads to better understand the frustrations and problems in the General Surgery Service. Data Collection The team developed a survey containing 11 questions. These questions ranged from multiple choice questions asking the participant’s level of agreement with certain frustrations, to written response questions asking the participant’s opinions on certain problems in the General Surgery Service. The survey can be seen in Appendix A. The survey was distributed both on paper and online through www.surveymonkey.com. The team collected a total of 7 surveys. Findings From the surveys that the team collected, the comprehensive results were very similar. 71% of the responses strongly agreed with being frustrated with the equipment storage location, while 29% agreed. 67% of the responses strongly agreed with being frustrated with the setup of the supply stock, while 33% agreed. 71% of the responses strongly agreed with being frustrated about having to work outside of Core B, while 29% agreed. None of the responses strongly disagreed, disagreed, or felt neutral about any of these aforementioned frustrations. 86% of the responses felt that Core B supply stock is better set up than the other cores’ supply stock. 100% of the responses specified that they notice a difference in preparing OR 13 for General Surgery as opposed to other ORs, as well as preparing an OR in Core B as opposed to Core C. All of the responses felt that OR 13 is better equipped and requires fewer trips out of the room. Also, all of the responses felt that General Surgery needs more dedicated rooms grouped together within one core. Lastly, some of the responses felt less comfortable and familiar with working in Core C. The detailed results of the survey are included in Appendix A. The results of these surveys indicate that the Circulators, Scrubs, and Service Leads are very frustrated with the General Surgery services current situation.
Observing Stock The team observed the supply stock in Cores B and C and the supply stock in the OR cabinets in OR 9, OR 13, and OR 20 to assess any differences between them. Data Collection The team examined the supply stock in the cores and in the OR cabinets and took note of location of supplies. In addition, with the OR Core B manager’s permission, we photographed the OR 9, OR 13, and OR 20 cabinets to assist in the analysis. Data Analysis The team entered the supplies from the OR cabinets in a table to make comparisons between OR 9, OR 13, and OR 20. This table can be seen in Appendix B. The cabinets in OR 9 and OR 13 12
have four cabinet sections with shelves above and two drawers below, for a total of eight drawers. The cabinet in OR 20, however, has three cabinet sections with shelves above and three drawers below, for a total of nine drawers. To assess the differences between the OR’s cabinets, the team compared the first cabinet section shelves and two drawers in OR 9 and OR 13 with each other and with the first cabinet section shelves and three drawers in OR 20. The same comparisons were made for the second, third, and fourth cabinet sections. Lastly, some ORs are mirrored layouts of each other, so the location of the supplies within the OR cabinets were compared to the orientation of the room, not to the direction within the OR. Findings The team found that the OR cabinets in OR 9 and OR 13 are mainly set up the same with the same supplies in the same locations, except for the two drawers in the fourth cabinet section. In OR 13 these two drawers have common general surgery supplies, such as hernia needles, ball electrodes, hemorrhoid bands, etc. In OR 9, however, these two drawers are mostly empty and are not labeled to contain any supplies within them. These findings can be seen in a visual in Appendix B1. In OR 20, the team found that while there are some similarities in the location of supplies with OR 9 and OR 13, there is still a reasonable amount of lack of standardization. In addition, the drawers in OR 20 are not labeled as effectively as the drawers in OR 9 and OR 13, which make it difficult for a Circulator who is not familiar with the room to find supplies. Lastly, through the team’s observations of the supply stock in Cores B and C, we noticed a great lack of standardization between the cores. Certain general surgery supplies are only located in Core B or Core C, and not divided between the two cores, causing the Circulator to walk back and forth between the cores to retrieve certain supplies. Common supplies for surgeries are located in different areas within Core B and Core C, which results in the Circulators not being familiar with Core C stock and taking longer to locate supplies.
Spaghetti Diagrams The team created spaghetti diagrams documenting the motion patterns of the Circulator during surgery to compare the differences between ORs. Data Collection While in the OR, the team created spaghetti diagrams for SGI surgeries in three locations: OR 13, OR 9, and OR 20. These three spaghetti diagrams can be seen in Appendix C. The team created these three different spaghetti diagrams to compare the differences in the Circulator’s workload when working in OR 13, the “homeroom”, other ORs in Core B, and ORs in Core C. Findings From these spaghetti diagrams, the team found that the OR that the Circulator works in affects the Circulator’s workload. When working in OR 13, the Circulator mainly had to just step right outside of the room to the General Surgery supply stock right by OR 13. There were a couple of times that the Circulator had to walk halfway across Core B, near OR 11 and OR 15, and one 13
time that the Circulator had to walk to Core C, which is not that far from OR 13. When working in OR 9, the Circulator had to always walk at least halfway across Core B to retrieve supplies, as there are not any supplies located in the stock near OR 9 that are needed for general surgeries. When working in OR 20, the Circulator had to retrieve supplies within Core C, however there was also multiple times that the Circulator had to go to Core B, either near OR 13 or halfway across Core B. From these findings, the team concluded that the distances that the Circulator needs to walk to retrieve supplies when working in Core C is much greater than when working in Core B, thus increasing the Circulator’s workload. In addition, the Circulator’s workload is increased when working in the opposite end in Core B of OR 13, such as OR 9 and OR 10, than when working in OR 13, since most of the General Surgery supplies are located near OR 13.
Time Studies The team collected data on the tasks of the Circulators when they left the OR during surgery, in order to compare the differences in the total number of times and total time out of the OR between OR 13, ORs in Core B excluding OR 13, and ORs in Core C. The team then compiled and analyzed the data, and established findings based on the results from the analysis. Data Collection To collect data on the times of the Circulators when they left the OR during surgery, the team developed time study cards to document: • • • • •
General case information The total time out of the room each time the Circulator left The reason for leaving A description of the specific item retrieved The location that the Circulator went to retrieve the item
The time study card can be seen in Figure D1 in Appendix D1. These time study cards were distributed to the Circulators for them to fill out during surgery, if they chose to do so. Also, stop watches were distributed to the Circulators to aid them when recording the time they spent out of the room. The time study cards were available to the Circulators for a period of 2 weeks. The team collected a total of 15 time study cards from the Circulators. In addition, the team collected time study data by shadowing the Circulator, and we collected a total of 5 time study cards. Data Analysis The team compiled the time study data collected and divided into OR 13, ORs in Core B excluding OR 13, and ORs in Core C. For each of these three different locations, the team first computed the average total time that the Circulator spent out of the OR during surgery. These results can be seen in Figure 1. 14
Figure 1: Average Total Time Out of OR During Surgery for OR 13, Core B & Core C
As seen in Figure XX, Circulators spent the least amount of total time out of the OR during surgery in OR 13, with an average of approximately 304 seconds, and the most time in Core C, with an average of approximately 560 seconds. The team then analyzed the average number of runs that the Circulators took out of the OR during surgery and the amount of time spent for each run for OR 13, Core B, and Core C. The average number of runs out of the OR for the three locations can be seen in Figure 2. Figure 2: Average Number of Runs Out of OR for OR 13, Core B & Core C
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As seen in Figure 2, when working in OR 13, the Circulators leave the OR less, with an average of approximately 4 runs out per surgery, compared to working in other ORs in Core B and ORs in Core C, with an average of approximately 6 runs out per surgery. The team analyzed the amount of time the Circulators spent out of the OR for each run through a boxplot comparing the three different locations. These results can be seen in Figure 3. Figure 3: Boxplot of Time of Each Run Out of OR for OR 13, Core B & Core C Boxplot of Time of Each Run Out of OR 400
Time (sec)
300
200
100
0 OR 13
Core B Location
Core C
As seen in Figure 3, the average time spent out of the OR for each run for OR 13 and other ORs in Core B is approximately the same, with 68.68 and 71.29 seconds. In Core C, however, the average time spent out of the OR for each run is greater, with 89.58 seconds. In addition, Core C has a greater variability with a couple of large outliers. This is due to the fact that while working in Core C, the Circulators went to Core B more often than they went to Core B while working in Core B. As computed by the team, when working in Core C, the Circulators went to Core B approximately 18% of the time, whereas when working in Core B, the Circulators only went to Core C approximately 9% of time and when working in OR 13, the Circulators only went to Core C approximately 6% of the time. The complete percentages of times that the Circulators spent going to different location for the three different locations can be seen in Appendix D2. Findings Based on the results from our analysis, the team concluded that there is a significant difference on the Circulators’ workload during surgery when working in OR 13, other ORs in Core B excluding OR 13, and ORs in Core C. The Circulators make more runs out of the OR to retrieve items when working in Core C and Core B than they do when working in the “homeroom”, OR 13. However, when working in Core C, the Circulators spend a significantly greater amount time for each run out of the OR than they do when working in Core B or OR 13.
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Motion Studies The team conducted motion studies using pedometers to assess the distances the Circulators walk to prepare a room, as well as the distances the Circulators walk during surgery. This data provides insight into how much additional movement is required when assisting in a surgery not located in the General Surgery homeroom. The motion studies also allow the team to observe differences between the number of steps taken in OR 13, Core B, and Core C. Data Collection The team distributed pedometers to the Circulators and they were asked to wear the pedometers on the waistband of their pants and to record the readings of the pedometers at specific intervals. To record the data, the team developed pedometer study cards to document the number of runs out of the OR and the pedometer readings for the following different intervals of the entire case: • • • • • •
Pre-set up before room Initial set up in room (prior to patient in room) Patient Induction/Prep/Positioning Surgery/Procedure Closing to patient out Post case
After each stage, the Circulators recorded the pedometer reading for that stage. The pedometer study card can be seen in Figure E1 in Appendix E. A total of 17 pedometer study cards were collected. Data Analysis This study did not return sufficient data for analysis. While there were 17 cards collected, there were significant variations between cards and many cards were not completely filled out, preventing an analysis of the data. The variation between the cards was attributed to inaccuracies of the pedometers used to obtain the data.
ORMIS Data Operating Room Management Information System (ORMIS) is a database of all surgeries that take place at the University of Michigan Hospital. The ORMIS data includes the following: important surgery information, including the type of surgery and what department the surgery was conducted by; the location of the surgery, including the room number; and significant times during surgery, such as when the Circulator arrives in the operating room before surgery, when surgery began and ended, and when the Circulator leaves the room following the completion of the surgery.
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Data Collection The team received ORMIS data spanning from May, 2008 to February, 2009 from our coordinator. This data covers all surgeries that took place at the University of Michigan Hospital within this timeframe. The team received this data to determine any time differences between OR 13, other ORs in Core B, and ORs in Core C within the same types of general surgery. Data Analysis The team analyzed the ORMIS data for common procedures in GSE, SON, and SGI. These surgeries were: • • • • • •
Total Thyroidectomy (235 cases) Parathyroidectomy (155 cases) Exploratory Laparotomy (124 cases) Colectomy (80 cases) Wire Localized Breast Biopsy (80 cases) Laparoscopic Cholecystectomy (103 cases)
We examined each of these surgeries for OR 13, ORs in Core B excluding OR 13, and ORs in Core C. We used the key surgery times provided in the ORMIS data and split each surgery into the four following key surgery phases: • Room set up (Circulator In to Room Start) • Induction/prep/positioning (Room Start to Surgery Start) • Surgery (Surgery Start to Surgery Stop) • Closing to patient out (Surgery Stop to Room Stop). The times of each of these phases were used to determine the mean times for each surgery. The data was also used in creating box plots to analyze whether which OR a surgery took place in correlated to any significant differences between the times of these phases, as well as total case time, from room set up to closing to patient out. The detailed results of this analysis are located in Appendix C. Findings Total Thyroidectomy: There was no correlation between OR location and mean time in any of the four phases of surgery, or in overall case time. The detailed analysis is in Appendix C1. Parathyroidectomy: There was no correlation between OR location and mean time in any of the four phases of surgery, or in overall case time. The detailed analysis is in Appendix C2. Exploratory Laparotomy: There was some variation between locations in the times of the Surgery phase. The data showed a longer surgery time for Core C, than for OR13 and Core B. This was attributed to the high variability of the Exploratory Laparotomy. This procedure 18
includes many different types of surgeries, which vary greatly in time. The detailed analysis is in Appendix C3. Colectomy: There was some variation between locations in the times of the Surgery phase. The data showed significantly shorter surgery times in OR 13 than in Core B, and greater surgery times in Core C. This was attributed to a small sample size and several outliers in the data. The detailed analysis is in Appendix C4. Wire Localized Breast Biopsy: There was some variation between locations in all phases of the Surgery, however here was no consistent correlation between location and time. The variation was attributed to a small sample size and variability in the procedure. Laparoscopic Cholecystectomy: There was variation in time between locations for the Surgery phase of the analysis. This variation was attributed to a small sample size and variation in the procedure. Overall, the analysis of the ORMIS data did not show any significant correlation between which OR a surgery was occurring in and the time of the different phases, as well as total case time. While there was some variation in times between locations, the variations were not consistent between surgeries, and could therefore not be attributed to location.
Conclusions From the analysis and findings of the shadowing, surveys, spaghetti diagrams, observations of stock, ORMIS data and time studies, the team came to some consistent conclusions about the differences between working in a dedicated OR and working elsewhere. The first conclusion taken from the project was that operating in a dedicated OR reduces Circulator workload by reducing the number of times the Circulator must leave the room during surgery, as well as the amount of time that each run takes. This conclusion was based on the findings of the shadowing process, spaghetti diagrams, survey results and the time studies. The time studies show that when working in dedicated OR 13, Circulators have to leave the room an average of 1.77 fewer times during surgery than when working in Core B and an average of 1.82 times fewer than when working in Core C. The time studies also showed that the length of time that the Circulator spent out of the room during surgery was significantly less when working in OR 13, than when working in other ORs in Cores B or ORs in Core C. The second conclusion that the team drew from the data was that General Surgeries taking place in Core C require the Circulator to be out of room for more time during surgery. This result is due to a lack of standardization of the supply stock between Cores B and C. The team arrived at this conclusion based primarily on the results of the shadowing process and the time studies. The time studies concluded that there was a significant difference, in the total time that the Circulator spent out of the room during surgery, between Cores B and C. From the results of the shadowing process, this difference in time can be attributed to the Circulators lack of familiarity 19
with the layout of the Core C supply stock. This is due to the lack of standardization between the supply stocks of the two cores, which the team saw while observing the supply stock. The final conclusion drawn from the data was that operating in a dedicated OR, such as OR 13, does not significantly impact overall case time. This conclusion was taken from the analysis of the ORMIS data. Although this conclusion goes against some of the results of the survey, no consistent correlation between OR location and case time could be drawn from the ORMIS data, therefore, there was no analytical backing of the survey results. Overall, the final conclusion that the team came to can be summarized as: While which operating room a surgery occurs in does not impact overall case time, it does impact the Circulator workload by increasing frequency and length of time spent out of the OR.
Recommendations Based on the findings and conclusions of our project, the team suggests that the General Surgery service at the University of Michigan Hospital implement the following recommendations. • • • •
Implement ‘5S’ techniques to standardize common supply stock between cores and supply cabinets in ORs Create partnerships with other surgery services in shared rooms (OR 17 & 20) Conduct supply studies to determine most common supplies retrieved out of the OR during surgery After implementing these recommendations conduct new time and motion studies to observe changes
For the first recommendation, implementing ‘5S’ techniques, refers to the practice of Sort, Set in Order, Shine, Standardize, and Sustain. This methodology will help ensure that all Circulators and Scrubs know the location of any supplies they may need, regardless of which operating room they are working in. By making all ORs as similar as possible, the amount of time spent looking for supplies will be minimized. The second recommendation, creating partnerships with other surgery services, is similar to the first recommendation. By creating these partnerships, General Surgery will be able to gain some ownership of the rooms in which they most frequently operate. In the case of ORs 17 and 20, General Surgery operates in these rooms more often than the services with which the rooms are shared. These rooms should be better prepared for General Surgery, by being stocked with supplies more specific to General Surgeries needs. The third recommendation, conducting supply studies, will allow for the core supply stock areas to be laid out in the most effective ways for all surgery types. Supplies being most frequently used by the General Surgery Service should be located closest to the rooms in which General Surgery most often operates. These studies would look at which supplies are being taken from the core areas and which surgery is taking them. Some data that could be recorded by the study 20
include which supplies were most often needed during surgery and which surgery needed them, and if common supplies were stocked near each other. Over time, this data could be analyzed and the supply distributions could be observed. The final recommendation, future time and motion studies, refers to another look at the time that Circulators spend out of the room during surgery. If this study is conducted again, after the previous recommendations have been implemented, it could determine if any improvements are being made.
Expected Impact The expected impact of this project, and the recommendations developed from it, include reducing Circulator workload and increasing General Surgery staffs’ familiarity with the supply stock both in the Core and OR in which they are working. These results should in turn reduce the overall level of frustration felt by the General Surgery staff.
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Appendix A: Survey Results
General Surgery Survey Instructions: Please answer the following questions regarding General Surgery. Please consider only General Surgery when responding. Please note that this survey is anonymous. After completion, please return the survey to Gladys’ office.
1) What is your position in General Surgery? (Please check all that apply) ___ Scrub 71%
___ Circulator 86%
___ Service Lead 14%
2) I am frustrated with the equipment storage location. (Please circle one) Strongly Disagree 0%
Disagree 0%
Neutral 0%
Agree 29%
Strongly Agree 71%
3) I am frustrated with the setup of the supply stock. (Please circle one) Strongly Disagree 0%
Disagree 0%
Neutral 0%
Agree 33%
Strongly Agree 67%
4) Is there a supply stock area you feel is better set up than others? Core A 0%
Core B 86%
Core C 0%
None of them 14%
5) I am frustrated about having to work outside of Core B. (if applicable) Strongly Disagree 0%
Disagree 0%
Neutral 0%
Agree 29%
Strongly Agree 71%
6) Circulators only: On average how many times do you leave the OR during surgery? 0 0%
1 0%
2–4 0%
5–7 0%
8 – 10 43%
11 – 15 29%
More than 15 29%
7) Circulators only: On average how many times do you leave the OR during surgery to get supplies? 0 0%
1 0%
2–4 0%
5–7 0%
8 – 10 43%
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11 – 15 43%
More than 15 14%
8) Do you notice a difference in preparing OR 13 for a General Surgery as opposed to other ORs? Yes No 100% 0% If so, what? ______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 9) Do you notice a difference in preparing an OR for a General Surgery in Core B as opposed to Core C? Yes 100%
No 0%
If so, what? ______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
10) What do you feel are the main problems with General Surgery? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 11) How do you feel that these problems could be improved? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 23
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Thank you for your participation!
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Written Responses 8) Do you notice a difference in preparing OR 13 for a General Surgery as opposed to other ORs? -
Supplies are in 13 and close by. You have to leave less often. Always better stocked. We have more supplies in 13, if we need to run and get something our core supplies are closer. Simpler, readily available supplies. B Core PT's are more willing to help us gather equipment, open supplies, restock rooms, remove equipment after cases, etc. Stocked better, have our commonly used Suture closer to littler supplies like staplers, pediatric feeding tubes, etc. Room 13 has some of our basic G.S. things already in the room. Equipment is usually close by in hall or core.
9) Do you notice a difference in preparing an OR for a General Surgery in Core B as opposed to Core C? -
-
Supplies are close by. Yes, a lot of running. I usually can't find anything and have to run to B core to get supplies. OR #20 is not well stocked. You always have to run for something. Most of the time it is supplies that are not kept in B Core. I walk back & forth to B core several times. Core C PTs are not willing to help with General Surgery cases AT ALL. They resent us being there; the only help they provide is bringing blood from the front desk and cleaning the rooms. They NEVER help open to get cases started, restock rooms, etc. Specifically, I am referring to *** and ***. They consider themselves members of other teams. Same as above question, plus the B Core PT's usually write name & pager on board & they are more available to use. They don't hide out by the windows as much. Today I spent 1/2 hour setting up only room 28. This was in addition to 1-2 other staff. This involved removing equipment and moving them (not just pushing outside room), bringing equipment/supplies and traveling.
10) What do you fell are the main problems with general surgery? -
Spread out all over the place. Equipment missing. Supplies far away. Everything is everywhere. There is no basic area to go for supplies. When you’re in C, you go to B core constantly. We have too many rooms in different cores. There are different cases in the rooms so proper supplies are not stocked. We should be contained to one core, cases & supplies. One main problem is not having any dedicated rooms for General Surgery. Sometimes we are in A, B and C cores on the same day. Our instruments are all over the place in B 25
-
-
and C Cores. Much time is wasted, cases are delayed and surgeons are kept waiting during surgery while we go search for supplies and equipment. We can barely fit all the necessary equipment in Room 20 to do a case, and then there is not enough room to walk and we cannot move large equipment such as the ultrasound machine and the cust machine Constantly looking for supplies & equipment & restocking rooms, no other rooms besides OR 13 designated to Gen. Surgery, have available rarely picked or separated from the open supplies. There is only one steady consistent room (OR #13), Our equipment supplies flow s. We have 4 traveling carts. 1 open available cart that travels, Laparoscopic cart that travels. We are spread out between core A, B, & C!
11) How do you feel that these problems could be fixed? -
-
We need our own rooms again. More rooms for the service. If the supplies were all in one basic location. We should be contained to one core only. These problems could be improved by giving general surgery some dedicated rooms in B core. Also moving our supplies and equipment to B core would help. A suggestion would be to move oral surgery out of B core and putting General Surgery in that space. A door between rooms 21 & 22 that connected C Core to the hallway outside of Rooms 28 & 29 would help decrease wasted steps. Getting the PT's to do their jobs would help. The situation was much better when General Surgery was in B Core. Designated rooms, PT's held accountable for case not being picked. Case picked right the first time, PT's available to help run for supplies. We need 3-4 dedicated General Surgery rooms to eliminate the traveling!! Frustration, burnout, wear & tear!! We need bigger rooms, more storage space, more general surgery team staff, dedicated room PT's that pick cases correctly, set-up rooms appropriately. Places to store special instruments so they may be routinely found. Accountability with instruments!
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Appendix B: Observing Stock Table B1: Summary of OR Supply Stock
OR 13
Shelving 1 Shelving 2 Shelving 3 Shelving 4 Drawer 1 Drawer 2 gloves sutures sutures gowns aseptos alcohol wipes laps parathyroid scale padding bovie supplies blades drain sponges buckets suction supplies needles & syringes tisseal abdominal fistula catheter
OR 9
gloves sutures laps GIA staplers drain sponge dressings
OR 20
gloves laps
sutures
sutures staplers ligaclip cartridges dressings gowns towels
towels sleeves drape sheets table covers plastic mayo covers junk scissors detachol surgilube betadine solution duraprep remover lotion specimen containers
aseptos alcohol wipes bovie supplies blades suction supplies needles & syringes
bovie supplies needles lite glove covers syringes
Drawer 3
Drawer 4 bowel clamp covers lite gloves suture boots umbilical tape vessel loops kittners markers penrose
Drawer 5 Drawer 6 Drawer 7 Drawer 8 Drawer 9 Drawer 10 Drawer 11 blood tubes & culture suplies surgi‐kits catheters hernia needles hemorrhoid bands clipper heads ioban 6650 drapes (Red Robinson) micro pins mersilene mesh steri‐strips kerlix ligaclips purple‐top tubes tape PE tubing ball electrodes misc. tincober, mastisol, dermaband taper needle
bowel clamp covers lite gloves suture boots umbilical tape vessel loops kittners markers penrose
blood tubes & culture suplies steri‐strips tape tincober, mastisol, dermaband
blades steri strips blood/lab tubes sunction tubing tincomen/mastisol suction tips suture boots kittners penrose drains
27
surgi‐kits catheters ioban 6650 drapes (Red Robinson) kerlix PE tubing
tape surgikits detachol ioban new skin
catheters
no labels no labels (mostly empty) (mostly empty)
steridrapes
Appendix B1: Supply Stock Photographs Figure B1.A: OR 13 Supply Stock
Hernia needles Micro pins Ligaclips Ball electrodes Taper needle
Aseptos Bovie supplies Suction supplies
Hemorrhoid bands Mersilene mesh Purple-top tubes Misc.
Alcohol wipes Blades Needles & syringes
Figure B1.B: OR 9 Supply Stock
Aseptos Bovie supplies Suction supplies
Alcohol wipes Blades Needles & syringes
No labels (mostly empty) 28
Appendix C: Spaghetti Diagrams
Figure C.1: SGI Surgery in OR 13 29
Figure C.2: SGI Surgery in OR 9, Core B 30
Figure C.3: SGI Surgery in OR 20, Core C
31
Appendix D1: Time Study Data Collection Figure D1: Example Time Study Data Collection Card General Surgery Analysis: Circulator Time Study Date: Case #: Patient # & Initials:
Circulator: Room #: Procedure:
Circulator Time out of OR: # Total Time Out of Room Reason # Description 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
32
Location 0 1 2 3 4 5 6
Reason Get supply Get instrument Get paperwork Get equipment Return equipment Take specimen to Pathology Other (please specify)
0 1 2 3 4
Location Core A Core B Core C Pathology Other (Please Specify)
Appendix D2: Time Study Analysis Results Figure D2.A: Pie Chart of OR 13 Run Locations
Figure D2.B: Pie Chart of Core B Run Locations
33
Figure D2.C: Pie Chart of Core C Run Locations
34
Appendix E: Motion Study Figure E1: Example Motion Study Data Collection Card General Surgery Circulator & Scrub Pedometer Study Date: Circulator or Scrub? Case #: Patient # & Initials:
Room Setup Start Time: Name: Room #: Procedure: Put / for Each Run
For Pre‐Set Up before Room For Initial Set Up In Room (Prior to Patient In Room) For Induction/Prep/Positioning For Surgery/Procedure For Closing to Patient Out For Post Case
35
Pedometer Reading
Appendix F: ORMIS Analysis Results
Table F.1 ORMIS Data Analysis: Average Times by Surgery ORMIS Data Analysis: Average Times by Surgery Surgery Type Total Thyroidectomy
Room Set up Induction/Positioning Surgery Closing ‐ Patient Out Room 13 Other Core B Core C Room 13 Other Core B Core C Room 13 Other Core B Core C Room 13 Other Core B Core C Average(min) 25 24 26 31 33 30 102 108 111 10 11 11 Standard Deviation(min) 12 10 10 8 9 7 35 42 50 6 6 4 Coefficient of Variation 0.48 0.416666667 0.3846 0.25806 0.272727273 0.2333 0.34314 0.388888889 0.4505 0.6 0.545454545 0.3636 Sample Size 100 101 34
Parathyroidectomy
Average(min) Standard Deviation(min) Coefficient of Variation Sample Size
28 29 30 28 11 14 11 6 0.39286 0.482758621 0.3667 0.21429 62 68 25
Exploratory Laparotomy
Average(min) Standard Deviation(min) Coefficient of Variation Sample Size
52 36 0.69231 25
Colectomy
Average(min) Standard Deviation(min) Coefficient of Variation Sample Size
32 35 41 34 35 39 139 181 204 12 15 11 21 19 11 10 63 88 108 7 0.46875 0.314285714 0.5122 0.55882 0.314285714 0.2564 0.45324 0.486187845 0.5294 0.58333 29 19 32
Wire Localized Breast Biopsy
Average(min) Standard Deviation(min) Coefficient of Variation Sample Size
37 27 30 23 21 15 22 3 0.56757 0.555555556 0.7333 0.13043 18 28 34
LAPAROSCOPIC CHOLECYSTECTOMY Average(min) Standard Deviation(min) Coefficient of Variation Sample Size
50 45 32 22 0.64 0.4889 47 52
30 37 34 17 20 23 0.56667 0.540540541 0.6765 28 30 45
29 30 7 7 0.24137931 0.2333
10 5 0.5
158 157 159 54 42 42 0.341772 0.267515924 0.264151
35 36 35 112 102 144 15 12 13 14 16 11 69 59 112 10 8 7 0.4 0.444444444 0.3143 0.61607 0.578431373 0.7778 0.66667 0.666666667 0.5385
216 199 237 83 72 114 0.384259 0.361809045 0.481013
21 24 36 43 42 4 5 13 16 13 0.19047619 0.2083 0.36111 0.372093023 0.3095
10 7 0.7
10 11 5 6 0.5 0.5455
296 111 0.375
103 99 104 28 22 35 0.271845 0.222222222 0.336538
25 30 32 86 112 95 9 9 9 7 8 11 24 60 40 6 6 4 0.28 0.266666667 0.3438 0.27907 0.535714286 0.4211 0.66667 0.666666667 0.4444
158 190 171 56 74 55 0.35443 0.389473684 0.321637
36
6 6 3 4 0.5 0.666666667
219 262 70 83 0.319635 0.316793893
7 7 1
92 86 89 9 46 36 38 5 0.5 0.418604651 0.427 0.55556
Total Surgery Time Room 13 Other Core B Core C 170 179 180 42 49 54 0.247059 0.273743017 0.3
Appendix F1: Total Thyroidectomy Analysis Figure F1.A Graph of Average Total Thyroidectomy Times
Figure F1.B Boxplot of Total Thyroidectomy Room Set up Times by OR Boxplot of Room Setup Times for Total Thyroidectomy 90 80
Time (minutes)
70 60 50 40 30 20 10 0 OR13
CoreB Location
37
Core
Figure F1.C Boxplot of Total Thyroidectomy Induction/Positioning Times by OR Boxplot of Induction/Positioning Times for Total Thyroidectomy 90 80
Time (minutes)
70 60 50 40 30 20 10 0 OR13
CoreB Location
CoreC
Figure F1.D Boxplot of Total Thyroidectomy Surgery Times by OR Boxplot of Surgery Times for Total Thyroidectomy 350 300
Time (minutes)
250 200 150 100 50 0 OR13
CoreB Location
38
CoreC
Figure F1.E Boxplot of Total Thyroidectomy Closing- Patient Out Times by OR Boxplot of Closing - Patient Out Times for Total Thyroidectomy 35 30 25
Data
20 15 10 5 0 OR13
CoreB Location
CoreC
Figure F1.F Boxplot of Total Thyroidectomy Overall Surgery Times by OR Boxplot of Total Thyroidectomy Total Times 400
Time (minutes)
350 300 250 200 150 100 OR13
CoreB Location
39
CoreC
Appendix F2: Parathyroidectomy Analysis Figure F2.A Graph of Average Parathyroidectomy Times
Figure F2.B Boxplot of Parathyroidectomy Room Set up Times by OR Boxplot of Room Setup Times for Parathyroidectomy 120
Time (minutes)
100 80 60 40 20 0 OR13
CoreB Location
40
CoreC
Figure F2.C Boxplot of Parathyroidectomy Induction/Positioning Times by OR Boxplot of Induction/ Positioning Times for Parathyroidectomy 60
Time (minutes)
50
40
30
20
10 OR13
CoreB Location
CoreC
Figure F2.D Boxplot of Parathyroidectomy Surgery Times by OR Boxplot of Surgery Times for Parathyroidectomy 250
Time (minutes)
200
150
100
50
0 OR13
CoreB Location
41
CoreC
Figure F2.E Boxplot of Parathyroidectomy Closing- Patient Out Times by OR Boxplot of Closing - Patient Out Times for Parathyroidectomy 50
Time (minutes)
40
30
20
10
0 OR13
CoreB Location
CoreC
Figure F2.F Boxplot of Parathyroidectomy Overall Surgery Times by OR Boxplot of Parathyroidectomy Total Times 350
Time (minutes)
300
250
200
150 100 OR13
CoreB Location
42
CoreC
Appendix F3: Exploratory Laparotomy Analysis Figure F3.A Graph of Average Exploratory Laparotomy Times
Figure F3.B Boxplot of Exploratory Laparotomy Room Set up Times by OR Boxplot of Exploratory Laparotomy Room Setup Times
Time (minutes)
200
150
100
50
0 OR13
CoreB Location
43
CoreC
Figure F3.C Boxplot of Exploratory Laparotomy Induction/Positioning Times by OR Boxplot of Induction/Positioning Times for Exploratory Laparotomy 120
Time (minutes)
100 80 60 40 20 0 OR13
CoreB Location
CoreC
Figure F3.D Boxplot of Exploratory Laparotomy Surgery Times by OR Boxplot of Surgery Times for Exploratory Laparotomy 700 600
Time (minutes)
500 400 300 200 100 0 OR13
CoreB Location
44
CoreC
Figure F3.E Boxplot of Exploratory Laparotomy Closing- Patient Out Times by OR Boxplot of Closing - Patient Out Times for Exploratory Laparotomy 40
Time (minutes)
30
20
10
0 OR13
CoreB Location
CoreC
Figure F3.F Boxplot of Exploratory Laparotomy Overall Surgery Times by OR Boxplot of Exploratory Laparotomy Total Times 800 700
Time (minutes)
600 500 400 300 200 100 0 OR13
CoreB Location
45
CoreC
Appendix F4: Colectomy Analysis Figure F4.A Graph of Average Colectomy Times
Figure F4.B Boxplot of Colectomy Room Set up Times by OR Boxplot of Colectomy Room Setup Times 100
Time (minutes)
80
60
40
20
0 OR13
CoreB Location
46
CoreC
Figure F4.C Boxplot of Colectomy Induction/Positioning Times by OR Boxplot of Induction/Positioning Times for Colectomy 120
Time (minutes)
100 80 60 40 20 0 OR13
CoreB Location
CoreC
Figure F4.D Boxplot of Colectomy Surgery Times by OR Boxplot of Surgery Times for Colectomy 600
Time (minutes)
500 400 300 200 100 0 OR13
CoreB Location
47
CoreC
Figure F4.E Boxplot of Colectomy Closing- Patient Out Times by OR Boxplot of Closing - Patient Out Times for Colectomy 40
Time (minutes)
30
20
10
0 OR13
CoreB Location
CoreC
Figure F4.F Boxplot of Colectomy Overall Surgery Times by OR Boxplot of Colectomy Total Times 500
Time (minutes)
400
300
200
100 OR13
CoreB Location
48
CoreC
Appendix F5: Wire Localized Breast Biopsy Analysis Figure F5.A Graph of Average Wire Localized Breast Biopsy Times
Figure F5.B Boxplot of Wire Localized Breast Biopsy Room Set up Times by OR Boxplot of Room Setup Times for Wire Localized Breast Biopsy 100
Time (minutes)
80
60
40
20
0 OR13
CoreB Location
49
CoreC
Figure F5.C Boxplot of Wire Localized Breast Biopsy Induction/Positioning Times by OR Boxplot of Induction/Positioning Times for Wire Localized Breast Biopsy 35
Time (minutes)
30 25 20 15 10
OR13
CoreB Location
CoreC
Figure F5.D Boxplot of Wire Localized Breast Biopsy Surgery Times by OR Boxplot of Surgery Times for Wire Localized Breast Biopsy 110 100
Time (minutes)
90 80 70 60 50 40 30 20 OR13
CoreB Location
50
CoreC
Figure F5.E Boxplot of Wire Localized Breast Biopsy Closing- Patient Out Times by OR Boxplot of Closing - Patient Out Times for Wire Localized Breast Biopsy 40
Time (minutes)
30
20
10
0 OR13
CoreB Location
CoreC
Figure F5.F Boxplot of Wire Localized Breast Biopsy Overall Surgery Times by OR Boxplot of Wire Localized Breast Biopsy Total Times 225 200
Time (minutes)
175 150 125 100 75 50 OR13
CoreB Location
51
CoreC
Appendix F6: Laparoscopic Cholecystectomy Analysis Figure F6.A Graph of Average Laparoscopic Cholecystectomy Times
Figure F6.B Boxplot of Laparoscopic Cholecystectomy Room Set up Times by OR Boxplot of Room Setup Times for Laparoscopic Cholecystectomy 160 140
Time (minutes)
120 100 80 60 40 20 0 OR13
CoreB Location
52
CoreC
Figure F6.C Boxplot of Laparoscopic Cholecystectomy Induction/Positioning Times by OR Boxplot of Induction/Positioning Times for Laparoscopic Cholecystectomy 80
Time (minutes)
70 60 50 40 30 20 10 OR13
CoreB Location
CoreC
Figure F6.D Boxplot of Laparoscopic Cholecystectomy Surgery Times by OR Boxplot of Surgery Times for Laparoscopic Cholecystectomy 350
Time (minutes)
300 250 200 150 100 50 0 OR13
CoreB Location
53
CoreC
Figure F6.E Boxplot of Laparoscopic Cholecystectomy Closing- Patient Out Times by OR Boxplot of Closing - Patient Out Times for Laparoscopic Cholecystectomy 30
Time (minutes)
25 20 15 10 5 0 OR13
CoreB Location
CoreC
Figure F6.F Boxplot of Laparoscopic Cholecystectomy Overall Surgery Times by OR Boxplot of Laparoscopic Cholecystectomy Total Times 500
Time (minutes)
400
300
200
100 OR13
CoreB Location
54
CoreC
