Quick Changeover in the OR
The time was the late 1950's.
Struggling to survive after near-bankruptcy in the early part of the decade, the Toyota Motor Company had dedicated itself to rebuilding, and to the ideal of "kaizen" or continuous improvement in all of its processes.
One of the challenges they faced was excessively long changeover times on their large presses, the machines that stamp out body parts.
They had discovered that one of their competitors was able to change over the identical machine in three hours from one part to another, as compared to Toyota's current best time of six hours.
They had assigned the task of reducing the time to at least equal the competition to a young engineer named Shigeo Shingo, and after several months of team effort he was ready to report the results.
"We had achieved our goal," Shingo reported in his autobiography, "and we were proud to be able to report success.
However, after the initial congratulations from the plant manager, he gave us our next assignment.
What I want you to do, he said, is to now reduce the time from three hours to three minutes.
We all thought he was literally crazy.
" After the initial shock wore off, and because he couldn't say no, the wheels began to turn in Shingo's mind, and the light bulb went on when he realized that the goal was not to eliminate three hours of labor time, but to reduce the time that the expensive piece of equipment was unavailable for use.
This insight was the beginning of what we now call SMED, Single Minute Exchange of Dies, or quick changeover in less than 10 minutes.
So what, after this long-winded introduction, does this have to do with the OR? What does an OR have in common with a large Japanese stamping machine? Let's ask, and answer, a series of questions.
1.
Are OR changeovers within the single-minute range? No.
2.
Is the operating room an expensive asset that we'd like to utilize as much as possible? Yes.
3.
Does an OR require an extensive and complex changeover time between procedures? Yes.
4.
Can this changeover time be reduced, without compromising safety and patient care? Almost certainly yes.
From this initial assessment, it is clear that quick changeovers in the OR are not only beneficial, they are also very feasible.
The chief benefit for a hospital in reducing changeover time is to increase the potential utilization of this resource, to have more intra-operative time to perform proper checklist-driven time-outs or meticulous instrument counts, schedule more procedures with the same number of rooms, and avoid highly expense construction of new ORs.
So how might SMED be applied to an OR environment? Let's introduce the topic of SMED by stating clearly that quick changeover does not include any reduction in standards or quality.
Quick Changeover does not mean rushing, hence increasing the number of errors.
If anything our expectation is to improve the quality of work done, not reduce it.
Step one in the SMED process is called Separate Internal from External.
This means that anything that can be done while the prior procedure is still going should be done ahead of time.
By "external" we mean a work step or action that can be done outside or external to the procedure.
For example, if you start to search forthat C-Arm or Harmonic Scalpel when the prior procedure is already completed, you are consuming "internal" time and lengthening the changeover time.
If, on the other hand, the equipment is located and staged while the prior procedure is still going on, you have reduced the changeover time.
This step may seem to be common sense, but as we know, common sense things are not always done.
The second step in the SMED process requires more creativity: Convert Internal to External.
Step one was the easy stuff, but in step two you actually look for way to change the existing process so that you can do what are currently internal step as external steps.
At Toyota the breakthrough was to do the changeover work on a removable fixture, outside of the press.
When it came time to change from one part to another, the old die could be quickly removed and the new die installed and locked into place within a few minutes.
In an OR you would look for similar opportunities to move preparation work ahead of time, by mixing desinfectants outside the room and staging them or by maintaining duplicate sets of the most common - least expensive - equipment, for example.
There may be some investment required, but that cost would have to be justified by significant additional utilization gained in the OR.
The third and final step in the SMED process for ORs is called Streamlining.
This simply means doing what you do more efficiently.
Standard Lean tools like 7S (5S +2), Kanban, and Waste Elimination are valuable here.
In a recent OR quick changeover project that we worked on, 20 minutes of time that had been spent "looking for things" was eliminated through a robust 7S and Kanban effort.
Streamlining can be applied to both internal and external steps, with a priority on reducing internal steps first.
The recommended starting point for a SMED initiative is train your team in the process.
You can then move to understanding and documenting in detail the current state, where you are today, warts and all.
Videotaping is a valuable aid in doing a detailed analysis, since both the work steps and times can be capture simultaneously.
Write down each discrete work step, along with the work minutes and the resource needed.
As a team-based effort you can then apply the SMED process starting with separating internal from external steps.
How much can you expect to reduce OR changeover time? If, like the Toyota stamping plant, you set ambitious goals for yourself, and don't give up, then great improvements can be expected.
Given the cost of today's OR resources, however, even modest time gains are well worth the effort as they are likely to yield great benefits for the patient and for the hospital.
Struggling to survive after near-bankruptcy in the early part of the decade, the Toyota Motor Company had dedicated itself to rebuilding, and to the ideal of "kaizen" or continuous improvement in all of its processes.
One of the challenges they faced was excessively long changeover times on their large presses, the machines that stamp out body parts.
They had discovered that one of their competitors was able to change over the identical machine in three hours from one part to another, as compared to Toyota's current best time of six hours.
They had assigned the task of reducing the time to at least equal the competition to a young engineer named Shigeo Shingo, and after several months of team effort he was ready to report the results.
"We had achieved our goal," Shingo reported in his autobiography, "and we were proud to be able to report success.
However, after the initial congratulations from the plant manager, he gave us our next assignment.
What I want you to do, he said, is to now reduce the time from three hours to three minutes.
We all thought he was literally crazy.
" After the initial shock wore off, and because he couldn't say no, the wheels began to turn in Shingo's mind, and the light bulb went on when he realized that the goal was not to eliminate three hours of labor time, but to reduce the time that the expensive piece of equipment was unavailable for use.
This insight was the beginning of what we now call SMED, Single Minute Exchange of Dies, or quick changeover in less than 10 minutes.
So what, after this long-winded introduction, does this have to do with the OR? What does an OR have in common with a large Japanese stamping machine? Let's ask, and answer, a series of questions.
1.
Are OR changeovers within the single-minute range? No.
2.
Is the operating room an expensive asset that we'd like to utilize as much as possible? Yes.
3.
Does an OR require an extensive and complex changeover time between procedures? Yes.
4.
Can this changeover time be reduced, without compromising safety and patient care? Almost certainly yes.
From this initial assessment, it is clear that quick changeovers in the OR are not only beneficial, they are also very feasible.
The chief benefit for a hospital in reducing changeover time is to increase the potential utilization of this resource, to have more intra-operative time to perform proper checklist-driven time-outs or meticulous instrument counts, schedule more procedures with the same number of rooms, and avoid highly expense construction of new ORs.
So how might SMED be applied to an OR environment? Let's introduce the topic of SMED by stating clearly that quick changeover does not include any reduction in standards or quality.
Quick Changeover does not mean rushing, hence increasing the number of errors.
If anything our expectation is to improve the quality of work done, not reduce it.
Step one in the SMED process is called Separate Internal from External.
This means that anything that can be done while the prior procedure is still going should be done ahead of time.
By "external" we mean a work step or action that can be done outside or external to the procedure.
For example, if you start to search forthat C-Arm or Harmonic Scalpel when the prior procedure is already completed, you are consuming "internal" time and lengthening the changeover time.
If, on the other hand, the equipment is located and staged while the prior procedure is still going on, you have reduced the changeover time.
This step may seem to be common sense, but as we know, common sense things are not always done.
The second step in the SMED process requires more creativity: Convert Internal to External.
Step one was the easy stuff, but in step two you actually look for way to change the existing process so that you can do what are currently internal step as external steps.
At Toyota the breakthrough was to do the changeover work on a removable fixture, outside of the press.
When it came time to change from one part to another, the old die could be quickly removed and the new die installed and locked into place within a few minutes.
In an OR you would look for similar opportunities to move preparation work ahead of time, by mixing desinfectants outside the room and staging them or by maintaining duplicate sets of the most common - least expensive - equipment, for example.
There may be some investment required, but that cost would have to be justified by significant additional utilization gained in the OR.
The third and final step in the SMED process for ORs is called Streamlining.
This simply means doing what you do more efficiently.
Standard Lean tools like 7S (5S +2), Kanban, and Waste Elimination are valuable here.
In a recent OR quick changeover project that we worked on, 20 minutes of time that had been spent "looking for things" was eliminated through a robust 7S and Kanban effort.
Streamlining can be applied to both internal and external steps, with a priority on reducing internal steps first.
The recommended starting point for a SMED initiative is train your team in the process.
You can then move to understanding and documenting in detail the current state, where you are today, warts and all.
Videotaping is a valuable aid in doing a detailed analysis, since both the work steps and times can be capture simultaneously.
Write down each discrete work step, along with the work minutes and the resource needed.
As a team-based effort you can then apply the SMED process starting with separating internal from external steps.
How much can you expect to reduce OR changeover time? If, like the Toyota stamping plant, you set ambitious goals for yourself, and don't give up, then great improvements can be expected.
Given the cost of today's OR resources, however, even modest time gains are well worth the effort as they are likely to yield great benefits for the patient and for the hospital.
Source...