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Over the years, UNC’s Department of Anesthesiology has established a Patient Safety/Quality Improvement (PSQI) culture that is promoted internally and respected across UNC Health Care. In early 2016, the Department found a path for developing an infrastructure-based process to execute PSQI initiatives. As one of only five UNC Health Care units chosen for its investment in PSQI, the Department was invited to participate in the Value Stream (VS) Pilot Program sponsored by UNC Heath Care’s Department of Operational Efficiency.

LEFT PHOTO – Main OR VSA Event Team with completed Process Map. Front (L to R): Peggy McNaull, Nicole Conrad / Back Row (L to R): Laura Niday, Gail Walker, David Dirito, Kim Nichols, Candra Bass, Greg Balfanz, Lavinia Kolarczyk, Marc Caruana, Nathan Woody, Paul Bednar (Operational Efficiency).

RIGHT PHOTO – Co-Leader David Dirito (center) and team conduct an anesthesia workspace improvement in an NC Medical Center 4th floor OR. Surrounding Dirito (L to R): Lavinia Kolarczyk, Aaron Lemmon, Brian Barrick, Nathan Woody, Brittney Paduchowski.

As a program participant, the Department restructured and developed a Value Stream Leadership Team (VSLT). Its makeup is comprised of Chairman Dr. David Zvara (Executive Sponsor), Vice Chair of PSQI Dr. Peggy McNaull (Process Owner), PSQI Program Manager Nathan Woody (Program Coach), and 10 other departmental faculty, CRNA and administrative leaders. The program goal was to begin establishing an infrastructure to plan, execute, and sustain departmental Q.I. efforts, in addition to developing the culture and behaviors of continuous quality improvement amongst faculty, residents, CRNAs and staff.

At a daylong retreat in summer 2016, the VSLT used Lean Six Sigma* methodology to prioritize those patient care areas where our quality improvement efforts would have the biggest impact. The initial focus areas for QI efforts included the Main OR, PreCare/Pre-Op areas, and NORA (Non-OR Anesthesia) areas. The VSLT then identified and empowered three teams to take a critical look at each of those specific areas and to identify potential quality improvement initiatives.

Each of the three teams met two days apiece. Nathan Woody led them in creating process maps for the focus areas, identifying areas of waste and inefficiency, and developing lists of potential projects.

By December 2016, five Value Stream Analysis (VSA) projects were underway. By mid-2017, two Main OR projects were completed: 1) Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™**) training for UNC Health Care perioperative providers; and 2) Streamlining the Anesthesia Workspace.

In January 2017, Main OR VSA lead Dr. Peggy McNaull and Assistant Chief CRNA Bobby Silvers oversaw development and facilitation of a one-day, multi-site perioperative provider training for 600+ UNC Health Care attendees, including 159 Department members. Cross-disciplinary “master trainer” UNC Health Care providers joined Main OR team members to refresh attendees on TeamSTEPPS™ and to introduce UNC’s three-step Surgical Safety Checklist: (“sign in”); (“time out”); and (“sign out”). The intensive, hour-long training taught tools and strategies to improve OR teamwork and communications.

The VSA pilot process showed the positive impact of reinforcing team-based communication within the UNC Health Care perioperative community. From January pre-training to late July 2017, six-month improvement in checklist compliance was greatest from pre- to post-training for two steps: 1) time out (from 28% to 98%); and 2) sign out (from 7% to 88%). These improvements, especially during sign-out, could not have been accomplished without the “all-hands-on-deck” mindset of all Department members.

Silvers noted: “Although some form of a ‘time out’ has existed for some time, incorporating TeamSTEPPS™ lends a certain structure that was missing. By encouraging closed-loop communication and hard stops, potential adverse events may be averted or minimized.”

In May 2017, the VSLT’s second resourced Main OR project, “Streamlining the Anesthesia Workspace,” executed a major set-up and work flow overhaul of the anesthesia intraoperative work space. Lacking a standardized OR supply system and multiple ergonomically unsafe power cords underfoot created provider safety issues and frustration.

After validating the ideas in UNCH’s 4th floor ORs to determine feasibility and usability, the team leaders Dr. Lavinia Kolarczyk and CRNA David Dirito wanted to lead the team in other identified areas. On a Sunday in May, 12 Department and Operational Efficiency members completed the full-scale project in 24 intraoperative workspaces. Auditing over a four-month period showed significant improvement, including: 1) increased compliance with standard OR set-up (83% ↑); 2) decreased mean time to IV kit completion: (57% ↓); and 3) improved organization of Pyxis MedStation™ automated dispensing (102%↑).

As onsite project lead, Dirito noted: “Maintaining our designed workspace has its challenges, but the improvements have been dramatic. Without the continued efforts of Nathan Woody in providing leadership, organization and structure to clinicians involved with this VSA project, it would not have been a success.”

Kolarczyk added: “This [VSA] project was one of the inaugural ones selected by the Department. Its end product reflects our team’s approach to innovative problem-solving and collaboration, and improves our daily work flow in the OR. Special thanks to [CRNA] design and planning process team members Brittney Paduchowski and Aaron Lemmon.”

The Department’s dedication to PSQI is valued by UNC’s Institute for Healthcare Quality Improvement (IHQI). IHQI Director Dr. Tina Willis stated: “Improvement work is of great importance to the Department of Anesthesiology. Leadership has embraced and invested in [PSQI] through the VSA process, and this department is leading as one of the most involved.”