Supply On Demand – Reducing Non Value-Added Time in a Large Vascular Interventional Radiology Practice

S. Prescott, R.N., S. Misra, M.D., H. Bjarnason, M.D., M. McKusick, M.D., D. Mapes, J. Klunder, T. Williams, L. Schmidt, L. Rupkalvis, E. WendorffDepartment of Radiology, Mayo Clinic, Rochester, MN

© 2009 Mayo Foundation for Medical Education and Research

Inventory management in Vascular Interventional Radiology (VIR) has been a major issue that influences the physician’s ability to provide the highest quality of patient care by having the right medical supplies at the right time. One of the most difficult aspects of the inventory man-agement process is a lack of standardization of the supplies located in the supply room and procedure rooms (this includes types of supplies, quantities, layout, and replenishment practices). This causes a signifi-cant amount of time to be wasted by both the radiology technologists and lab assistants as they search for the requested supplies, potentially causing delays in the patient’s procedure. In addition, the lack of stan-dardization has also led to increased time and effort spent training new personnel on the location of supplies.

The goal of this project was to reduce the amount of non-value added time that the lab assistants and radiology technologists spend searching for supplies in the supply and procedure rooms.

Background

DMAIC refers to a data-driven quality strategy for improving processes and is an acronym for the five interconnected phases: Define, Measure, Analyze, Improve, and Control.

Value Stream Mapping is a visual tool that helps you to see and under-stand the flow of material and information as a patient or service makes its way through the process, as well as the management and informa-tion systems that support the basic process.

Kaizen Events are structured, short cycle (usually 1 week in duration), improvement efforts with tightly scoped objectives that align with higher level project goals.

5S is a Lean tool that is used to improve the performance and safety of a process by implementing and maintaining high standards for cleanli-ness, organization, visualization, and standardization.

Visual Management is a system that makes process flow, operations standards, schedules, and problems instantly identifiable to even the casual observer. This is accomplished through the use of signs, infor-mation displays, material storage tools, color-coding, and poka-yoke or mistake proofing devices.

Methods

Measurement Process and Data Collection

Measurement Definition• NVA = Non-Value Added

• RT = Radiology Technologist

• LA = Lab Assistant

• Trainee = Someone who is not familiar with the storage locations of product in the procedure rooms and sup-ply room

• Product = Supplies or materials that are used during procedures in Vascular Interventional Radiology

Process Measures• Amount of NVA time the staff spent searching

for product in the procedure room

• Amount of NVA time the staff spent searching for prod-uct in the supply room

• Distance staff member (RT, LA, Trainee) travels to acquire product in procedure room

• Distance staff member (RT, LA, Trainee) travels to acquire product in supply room

Measurement ProcessBaseline data was collected on day 1 of the kaizen event. One representative from each staff position (RT, LA, trainee) was given the same list of 8 items to locate within the pro-cedure room and 8 items to locate in the supply room. The duration of time spent searching for the 8 items in each loca-tion was measured using a stopwatch. The distance trav-eled while searching for the 8 items in each location was measured using a surveyor’s wheel.

This same measurement process was duplicated after the kaizen interventions in order to measure change in the pri-mary process measures.

Measurement

Figure 1: Vascular Interventional Radiology – High Level Process Mapping

VIQI Current State Value Stream Map1-Aug-07

ProceduralistGonda 2Cath LabSurgery

Supply Room

Lab Tech

- Retrieves Item- Scans Item- Responsible for removing expired product

PT = 1-5 min.FTQ = 85-95%

2

I

Waiting for procedure end

30min.-3hrs

Lab Tech

- Check supply list and mark ready to audit

PT = 2-5 min.FTQ = 95%

2

I

Waiting for audit to be completed

1-6 hrs

Lab Tech

- Audit Supply List

PT = 5-10 min.FTQ = 80-90%

6-12

I

Waiting for PO to be generated.

< 1hr - 53 hrs

SIMS - LAWSON

- Interface to check re-order point and order item.

PT = 15-60 minFTQ = 98%

I

Product Lead Time1 day - 6 wks

MICS - Baldwin Shipping

- PO's are received and then shipped to Alfred 6.

PT = ?FTQ = ?

I

Items waiting to be put away

30 min - 2 hrs

MICS - Baldwin Shipping

- PO's are received and then shipped to Alfred 6.

PT = 15min - 1hrFTQ = 80-90%

1-25

Supply Room

Standardization

- Frequency of Delivery

- Obsolecent Product- Reorder pts for new technology

- No target

- No FIFO- NO Visual Management- No Standard

- Why do we audit?- Products not in SIMS borrowed from another dept.

- Back Order SOL

- No FIFO- Rooms not standardized

SIMS Lawson Tammy

VIQI Future State Value Stream Map

lo hi0.5 3 1 53 24 1008 0.5 2 26 1066

2 580.55 2.15

0.05 0.05 0.1 0.1 0.1 1 0.3 1 2.12% 0.20%27.50% 3.71%

12-Oct-07

NVA time (with supplier lead time)

%VA (without supplier lead time)%VA (with supplier lead time)VA timeNVA time (with out supplier lead time)

time shown in hours

ProceduralistGonda 2Cath LabSurgery

Supply Room

Lab Tech

- Retrieves Item- Scans Item* No method to ensure FIFO

PT = 1-5 min.FTQ = 85-95%

2

I

Waiting for procedure end

30min.-3hrs

Lab Tech

- Bring unused supplies back to supply room - Check supply list and audit and close case

PT = 3-7 min.FTQ = 95%

2

I

Waiting for PO to be generated.

< 1hr - 53 hrs

SIMS - LAWSON

- Interface to check re-order point and order item.

PT = 15-60 minFTQ = 98%

I

Product Lead Time1 day - 6 wks

MICS - Baldwin Shipping

- PO's are received and then shipped to Alfred 6.

PT = ?FTQ = ?

I

Items waiting to be put away

30 min - 2 hrs

Lab Tech Restocks

- Verify packing slips- Right Quantity- Rigth Product

PT = 15min - 1hrFTQ = 80-90%

1-25

Supply Room

Standardization of how new product is brought in.

SIMS Lawson Tammy

Kaizen Event - 5S & Standardization in Supply room and Procedure Room

New Standard Process - Delay in audit eliminated

Lawson Tammy

Future State Value Stream Map -

Improvement opportunities identified

• 5S procedure rooms and supply room

• Implement visual management system for supplies

Current state Value Stream Map -

Problem areas identified

• Procedure rooms not standardized (wasted time searching for products)

• Staff has to leave room during procedure to locate supplies requested by Radiologist (increased procedure time)

• Stock not rotated in procedure rooms

Figure 4: Bias for Action and Real-time Change

Store Room

All changes implemented within 4-day kai-zen event. Visual management: larger font can be read from any point in room, color coding matches supply locations in proce-dure and supply rooms for easier acquisi-tion. Storage locations closest to the point of use were prioritized for highest usage items, as well as items that needed to be acquired quickly.

Procedure Room

Figure 2: Identify Current State

Team determined baseline performance by having various staff search for 8 items in the procedure room and supply rooms. Search time and travel distance to find each item was recorded.

Figure 2: Identify Current State

Team determine baseline performance by having various staff search for 8 items in the procedure room and supply rooms. Search time and travel distance to find each item was recorded.

Figure 3: Red-tagging and Organizing

Day 1 & 2 – Red Tagging (determine disposition) of items with little or no use. Identify and label home locations for supplies.

Critical Success Factors for Kaizen Event:• Aligns with Department / Institution goals • Improvement need felt by management and team members• Existing process: defined, documented, routine and stable• Accessible, actionable and self-contained process• Sponsor who is supportive, active, and engaged is identified to champion

event (Physician participation)• Project team of 6-10 process experts, including a department co-lead and

expert facilitator• Empowerment given to Kaizen team• Management commitment and presence (should be at daily report outs)• Workforce involvement • Communication of purpose and benefits• Dedicated resources (full-time participation with probable overtime).

No observers!!!• Dedicated workspace for team, close to work location, for duration of event• Budget for event from department for small supplies, food, overtime, and

team recognition• Support services (facilities, IT, materials, etc.) are available and empowered

to make REAL TIME changes per team needs identified during try-storming

Discussion

Standardization of supplies in the procedure rooms and the storeroom, in addi-tion to color-coded labeling has resulted in quicker retrieval of supplies, a more efficient method of restocking supplies, and an increase in material flow.

Quotes from team members and staff“I learned to appreciate the stress the lab assistants, techs and radiologists have had over supply issues. We have tunnel vision as far as our own jobs and do not realize the entire picture.” (RN)

“I really like the layout of the storeroom now. There are a lot less wasted steps.” (LA)

“The task at the beginning of the Kaizen event seemed overwhelming but it was won-derful to see it together in the end.” (Supply Management Coordinator)

Conclusion

Figure 5: RESULTS (Verify, Sustain, Diffuse)

On last day of kaizen event, the team repeated the measurements taken on day 1 to confirm the improvements made during the kaizen event. This was also repeated 30 days after the event to ensure original improvements were sustained. Visual man-agement system was quickly replicated in the remaining procedure rooms.

Retrieval Time in Procedure Room

0

2

4

6

8

10

12

Pre-event Event 30 day post

Procedure RoomLocation

Tim

e (m

inut

es)

LA RT Trainee GOAL = < 3 minutes

Goal < 3 minutes

Retrieval Time in Storeroom

0

2

4

6

8

10

12

14

Tim

e (M

inut

es)

Goal < 3 minutes

LA RT Trainee GOAL = < 3 minutes

Pre-event Event 30 day post

Store RoomLocation

Distance traveled in Procedure Room

0

50

100

150

200

250

Dis

tanc

e (f

t)

Goal = < 50ft

LA RT Trainee GOAL = < 50 feet

Pre-event Event 30 day post

Procedure RoomLocation

Distance Traveled in Storeroom

0

50

100

150

200

250

300

Dis

tanc

e (f

t)

Goal = < 100ft

LA RT Trainee GOAL = < 100 feet

Pre-event Event 30 day post

Store RoomLocation

# of IR Rooms with Standardized Supply Locations

0

1

2

3

4

5

11/1

/200

7

11/8

/200

7

11/1

5/20

07

11/2

2/20

07

11/2

9/20

07

12/6

/200

7

12/1

3/20

07

12/2

0/20

07

12/2

7/20

07

1/3/

2008

1/10

/200

8

1/17

/200

8

1/24

/200

8

1/31

/200

8

2/7/

2008

2/14

/200

8

2/21

/200

8

2/28

/200

8

3/6/

2008

3/13

/200

8

3/20

/200

8

3/27

/200

8

Date

# of

room

s

# of Standardized Rooms Goal