Happy Birthday Frank Gilbreth; Reducing Waste in Hospitals… Green is Lean

Today, July 7, is the birthday of Frank Gilbreth, born this day in 1868. While some of his methods arguably ranked low on the “respect for people” scale (calling doctors “boobs” for doing things wastefully), he was an innovator in terms of identifying waste and driving process improvement in healthcare.

It was Gilbreth's idea, based on O.R. observation and filming, that surgeon's shouldn't waste their time searching for instruments, that they should instead have a “surgical caddy” to hand them a scalpel when they need a scalpel (as anyone has seen portrayed on TV). Ironically, it took 15 years for the American Medical Association to officially approve Gilbreth's idea as a best practice (or thereabout that time).

Fast forward to 2010 and there's still a lot of waste – wasted time, wasted cost, wasted materials in hospitals and operating rooms, some of newly generated by the trend toward single-use items, as written about in the New York Times.

The article, “In a World of Throwaways, Making a Dent in Medical Waste,” talks about the trend toward single-use items as a strategy for preventing the spread of HIV and other infections that resulted from improper sterilization of re-usable items. Hat tip to Karthik for sending me the article.

From the article:

No organization currently tracks how much medical trash the United States produces… the last known estimate, from the early 1990s, was two million tons a year.

Only recently has the industry begun grappling with the amount of waste it generates, and one reason is that financially stressed hospitals are seeking ways to cut costs.

Although the single-use materials had good intentions, much of the evidence now seems to indicate that many single-use items can indeed be safely sterilized and prepared to be used again. The focus here is SAFELY.

The idea of properly sterilizing supplies thought to be “single use only” isn't mindless cost-cutting or corner cutting. We have to do things safely, of course. This isn't the same as the cases where doctors were improperly re-using items like syringes, creating health risks for patients (as I wrote about in 2007).

This is about scientific data that shows it's OK to sterilize and re-use, if done properly (with work done, in part, by one of my favorite healthcare safety leaders, Dr. Peter Pronovost). Who is opposed to this (for obvious financial reasons)? The medical device makers. They can claim “our only concern is safety, hospitals shouldn't be needlessly cheap” (my paraphrasing) and seem like they're taking the high road. But the NYT article gives a lot of evidence that shows it's OK to sterilize and re-use, when appropriate based on the item and (again) when done properly.

One company that re-processes items:

… estimates that its 1,800 hospital clients diverted 2,650 tons of garbage from landfills in 2009; one major customer, the Hospital Corporation of America, which owns 163 hospitals, eliminated 94 tons of waste last year through reprocessing.

While people are arguing about whether items should be trashed or properly re-used, it begs this question: How about NOT creating the wastage to begin with?

From the article:

Now, a new movement is taking aim at one of the biggest sources of medical refuse” —  the operating room, which churns out roughly 20 to 30 percent of a hospital's waste.

…

Dr. Makary stared into a trash bin in the operating room after performing routine laparoscopic “keyhole” surgery. As is typical in most hospitals, the wastebasket was full of “perfectly good equipment, much of which was either barely used or never used,” he recalled. The unused devices came from sterilized surgical kits that were opened for the operation; no longer sterile, they got tossed.

When surgical packs and case carts have unnecessary items, that's a form of waste – the waste of overproduction, you might say… overproducing the items that go into the cart.

People might say, “But, wait, we MIGHT need those items! We don't want to go running out of the O.R. to get them!”

OK, I can see the other side of that argument. Walking is waste and running out to get supplies might prolong a procedure, which isn't good for the patient or the surgical schedule. But some hospitals are getting more creative, using Lean and other improvement methods, to rethink the packs. Instead of one pack that's open (thereby exposing everything), you can create one pack that has everything you WILL need and other items can be in an “if needed” pack or they can be stored in a cabinet in the O.R.

One hospital that has used Lean for many years, Fairview in Minneapolis, had a “green team” that I suspect was also using the Lean methodology that's very much the same approach.

For now, another approach is to cut back the use of disposables at the source by streamlining packaged surgical kits. Last year, Dr. Andrade and a nurse, Lynn Thelen, started an “O.R. green team” at Fairview. With input from colleagues, they scrutinized 38 types of operating room packs, figured out which supplies were never used (like plastic basins, catheters, syringes and dressings), and asked their medical product vendor to remove them.

One kit for implanting an intravenous port in  chemotherapy patients contained 44 items, but the green team downsized it to 27 items and swapped disposable gowns and linens for reusable ones. That trimmed a pound of trash and $50 in supply costs per procedure. So far, Ms. Thelen said, the various kit reformulations have prevented 7,792 pounds of waste and saved $104,658.

That sounds very Lean to me: getting staff input, looking at data and the details of the process, and using a 5S-type process to prioritize what's really needed or not.

Green is Lean. Reducing waste is a good thing, regardless of what we call it. Reducing costs in way that does not jeopardize safety or quality, those are the staff-driven solutions we are looking for. Why do those items go in the pack?   “Because we've always built them that way” — there's a red-flag clue that maybe things can change.

Is your hospital doing work in this area, regardless of a Lean label being there or not?

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