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Original Investigation | Association of VA Surgeons

Effect of Lean Processes on Surgical Wait Times and Efficiency in a Tertiary Care Veterans Affairs Medical Center ONLINE FIRST

Nakul P. Valsangkar, MD1; Andrew C. Eppstein, MD1,2; Rick A. Lawson, BSEE3; Amber N. Taylor, MHA2
[+] Author Affiliations
1Section of General Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis
2Surgery Service, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
3Systems Redesign Service, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
JAMA Surg. Published online September 07, 2016. doi:10.1001/jamasurg.2016.2808
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Importance  There are an increasing number of veterans in the United States, and the current delay and wait times prevent Veterans Affairs institutions from fully meeting the needs of current and former service members. Concrete strategies to improve throughput at these facilities have been sparse.

Objective  To identify whether lean processes can be used to improve wait times for surgical procedures in Veterans Affairs hospitals.

Design, Setting, and Participants  Databases in the Veterans Integrated Service Network 11 Data Warehouse, Veterans Health Administration Support Service Center, and Veterans Information Systems and Technology Architecture/Dynamic Host Configuration Protocol were queried to assess changes in wait times for elective general surgical procedures and clinical volume before, during, and after implementation of lean processes over 3 fiscal years (FYs) at a tertiary care Veterans Affairs medical center. All patients evaluated by the general surgery department through outpatient clinics, clinical video teleconferencing, and e-consultations from October 2011 through September 2014 were included. Patients evaluated through the emergency department or as inpatient consults were excluded.

Exposures  The surgery service and systems redesign service held a value stream analysis in FY 2013, culminating in multiple rapid process improvement workshops. Multidisciplinary teams identified systemic inefficiencies and strategies to improve interdepartmental and patient communication to reduce canceled consultations and cases, diagnostic rework, and no-shows. High-priority triage with enhanced operating room flexibility was instituted to reduce scheduling wait times. General surgery department pilot projects were then implemented mid-FY 2013.

Main Outcomes and Measures  Planned outcome measures included wait time, clinic and telehealth volume, number of no-shows, and operative volume. Paired t tests were used to identify differences in outcome measures after the institution of reforms.

Results  Following rapid process improvement workshop project rollouts, mean (SD) patient wait times for elective general surgical procedures decreased from 33.4 (8.3) days in FY 2012 to 26.0 (9.5) days in FY 2013 (P = .02). In FY 2014, mean (SD) wait times were half the value of the previous FY at 12.0 (2.1) days (P = .07). This was a 3-fold decrease from wait times in FY 2012 (P = .02). Operative volume increased from 931 patients in FY 2012 to 1090 in FY 2013 and 1072 in FY 2014. Combined clinic, telehealth, and e-consultation encounters increased from 3131 in FY 2012 to 3460 in FY 2013 and 3517 in FY 2014, while the number of no-shows decreased from 366 in FY 2012 to 227 in FY 2014 (P = .02).

Conclusions and Relevance  Improvement in the overall surgical patient experience can stem from multidisciplinary collaboration among systems redesign personnel, clinicians, and surgical staff to reduce systemic inefficiencies. Monitoring and follow-up of system efficiency measures and the employment of lean practices and process improvements can have positive short- and long-term effects on wait times, clinical throughput, and patient care and satisfaction.

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Figure 1.
Methods Used During the Implementation of General Surgery Department Pilot
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Figure 2.
Average Surgical Wait Time for General Surgery Department Patients

The average wait time for patients decreased from the time of the implementation of the value stream analysis. These differences were statistically significant. The mean (SD) wait times in fiscal year (FY) 2012 were 33.4 (8.3) days, 26.0 (9.5) days in FY 2013 (P = .02 compared with FY 2012), and 12.0 (2.1) days in FY 2014 (P = .02 compared with FY 2012).

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Figure 3.
Results of the General Surgery Department Pilot

Clinical video teleconferencing was not previously available in fiscal year (FY) 2012.

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Figure 4.
Clinic No-shows
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