Total Productive Maintenance in the OR – A Case Study at Kadlec Regional Medical Center
Dheeraj Ahuja, MD., Ron Gullekson, and Aaron Kim
Over the last few years, Lean implementation has made a significant impact on healthcare operations. Healthcare providers now realize that to survive, they must begin looking at their institutions as businesses. Lean is a business philosophy that emphasizes the elimination of waste in order to provide better value to the customer—or patient in this case. Waste in the delivery of healthcare is particularly troubling because the United States spends far more than other industrialized countries do on healthcare, both in terms of per capita spending and as a percent of the gross domestic product (1).
The Lean business philosophy is also comprised of many interdependent tools that help an organization identify and eliminate waste. Several of these tools are now commonplace in healthcare. For example, 5S, setup reduction, and value stream mapping have successfully been transitioned to healthcare from their original manufacturing origins. As a result, healthcare providers have experienced improved outcomes such as decrease in OR turnaround time and better organization of medications and supplies.
One area of healthcare delivery that has been neglected is the effective management of equipment and tooling. Tools and equipment are usually in their correctly designated 5S location, but are often out of order or in poor working condition. This is due to the simple fact that all machinery deteriorates over time, and without proper management it fails even sooner. Fortunately, within the deep philosophy and toolset of Lean a solution exists: Total Productive Maintenance, or TPM. With TPM, the life of machinery can be greatly extended. In many cases, older equipment under a TPM program outperforms identical new equipment with no TPM program.
History of Total Productive Maintenance
The roots of TPM can be traced back to an American quality legend named Dr. W. Edwards Deming. In Japan, at a Toyota partner company called Nippondenso, he developed and instituted what was known as preventive maintenance.
Before Deming, manufacturers generally practiced what is now known as breakdown management (BM). In BM, machinery is generally run until it breaks, and breakdowns are considered inevitable and normal.
Under Deming, however, dedicated maintenance personnel were trained to prevent breakdowns. At Nippondenso, breakdowns were significantly reduced and Deming’s preventive maintenance program operated successfully until the early 1960s.
With the introduction of automated machinery, equipment became much more complex. The costs of training a growing maintenance department on progressively complex equipment became financially burdensome. To overcome this, Nippondenso began incorporating lower paid, lower skilled production workers into a comprehensive maintenance program. Simple tasks—such as tightening, lubricating, and cleaning—were easy enough for machine operators to perform.
Having operators perform basic maintenance was not necessarily intended to reduce maintenance costs. Rather, it provided three primary benefits:
- It formed a bond between operators and machinery
- It freed up highly skilled maintenance workers to perform more technically demanding tasks
- It helped operators recognize potential equipment failures long before a breakdown
The third benefit is known as autonomous maintenance. It evolved with other maintenance practices, including preventive maintenance, into the TPM program we know today.
TPM Training at Kadlec Regional Medical Center
Kadlec Regional Medical Center in Richland, Washington has been involved in a successful Lean implementation for over a year. The team has already made excellent strides using familiar Lean tools such as 5S. It was decided that equipment maintenance in operating rooms (OR) was critical because a patient’s life can depend on properly functioning equipment.
During a value stream rollout, TPM was identified as critical. The team at Kadlec began by identifying the proper scope to begin implementation. An OR can house dozens of pieces of equipment. All of the equipment was evaluated on a scoring matrix that included frequency of use, frequency of failure and the number of spare machines available. Given these criteria, four critical pieces of equipment emerged:
- Anesthesia machine
- Gas module
- Integration machine
An initial assessment of the anesthesia machine, gas module, triad and integration machine showed there was no way for clinicians to know if the equipment was in good working condition. The only way to tell if a machine was out of order was if it had a post-it note on it reading “broken.” When possible, the broken machine was removed from the OR and placed in the hallway. Often, it was then accidentally taken into other ORs to be used. This process frustrated clinicians who had believed they were receiving a working piece of equipment to replace another that was malfunctioning.
The assessment also revealed that even when equipment was properly functioning, poor equipment location and placement of cords were causing failures. Examples of poor equipment placement included:
- Countless cords crisscrossed the floor and were prone to be run over by the OR table or other mobile equipment
- Replacements were unavailable for broken or worn equipment components (and clinicians often lacked the knowledge to replace components anyway)
- The CPU of the integration machine was placed at knee level, which situated the on/off toggle in a perfect position to be inadvertently hit by the nurses’ knee; this happened from time to time and all of the images captured by the physician during the procedure would be lost
- Various pieces of equipment were located at foot level with power cords exposed. These cords were often kicked out, again cutting power during procedures
During the assessment and planning phase, the team planned for a weeklong TPM implementation event, which concluded with the creation of a list of probable action items or projects likely to be needed during the week. This included ordering critical spare equipment components and guards/fixtures which have a long lead time.
A team was assembled, consisting of representatives from clinical engineering, nursing, and anesthesiology, as well as an OR physician. During implementation week, the team was given basic lean education along with TPM-specific training. In particular, they were taught that the goals of TPM revolve around the 3 Zeroes:
- Zero defects
- Zero breakdowns
- Zero accidents
The team learned that in order to attain the 3 zeroes, nurses, anesthesia technicians and even physicians would have to learn to maintain equipment and recognize failures before they occurred. Unlike in manufacturing, the TPM evolution had yet to find its way into healthcare. As such, equipment was still run on a BM (breakdown management) methodology: equipment was run until it failed. Only after this occurred was the Clinical Engineering Department then called.
Initially, the team saw limited applicability of TPM in a healthcare setting. They also did not understand how they themselves could impact the longevity of equipment. To shift their thinking, a highly relatable “Human Machine” brainstorming session was performed. The team was asked to envision the human body as a piece of machinery. With the majority of the team being healthcare professionals, it was well understood that preventive measures were much more beneficial than allowing the body to break down thus requiring the aid of a physician.
The team was asked to provide ways to attain zero failures (illness) for the human machine using the following areas of TPM: autonomous maintenance, scheduled maintenance, skill enhancement, and equipment design changes.
Again, autonomous maintenance consists of simple maintenance items that are performed by the operator without the need of a highly skilled maintenance worker. This was equated to items we perform on our own bodies without the need for a physician’s assistance to prolong health and prevent illness. Some items on this list included a balanced diet, proper hygiene, stress management, and ample rest and exercise.
Scheduled Maintenance items are those that are set on a strict recurring frequency and generally require the aid of the maintenance department—or in our case a physician. Items on a Scheduled Maintenance list generally recur monthly, semiannually or annually. The team came up with a list that included but was not limited to annual physicals, semi-annual teeth cleanings and annual mammograms.
Skill enhancements are skills not possessed by the user today but that, if learned, can improve the health of the individual. In manufacturing, a skill enhancement can be an operator being taught how to change out worn machine components. In patients, it might be individuals being taught health related skills that go beyond common knowledge. This particularly resonated with the team. They see countless cases of serious illness and disease, which could be avoided by simple healthcare knowledge. Some of items the team listed included blood pressure measuring and monitoring, blood sugar monitoring, calorie and nutritional information for proper diet balancing and even proper care of cuts and scrapes.
Equipment and Design Enhancements
Equipment and Design enhancements are modifications to the form of the equipment. During the design phase, lessons learned from previous generations of machinery can prompt the engineering team to create stronger components to replace those that continuously failed. On existing machinery, components could be modified to last longer or make the machinery more easily maintainable. The team initially had difficulty coming up with equipment design enhancement for the human body. After some thought, the team came up with items like building up weak, injury prone muscles and stretching, which modifies the body and promotes health. The discussion even further included operations that improve health. An example of this was operating on the nasal area for those patients with frequent infections or removing the tonsils for those patients with constant inflammation.
Implementation of TPM at Kadlec
Upon completion of this exercise the team was asked to evaluate the lists and to make observations. The team correctly assessed that the autonomous maintenance list was the longest and had the most impact. Team members identified that in the human machine, most serious healthcare issues could have been prevented by the individual. Likewise, in almost all cases, the equipment user can make the most impact on the longevity of a machine. From an equipment perspective, the team agreed that much more could be done to prevent errors or correct errors prior to calling the clinical engineering department for assistance.
Earlier it was noted that there was a loose process in which clinicians used a post-it note to identify the operational status of equipment. One of the top priorities of a TPM effort is to create an environment in which machine abnormalities are easily identifiable. The team decided to create a visual control that would allow anyone to understand the status of the machine. The team designed a two-sided card, one side being green and the other being red. These cards were created for each of the four pieces of equipment and hung using a simple hook. Now the status of all equipment could be quickly and easily identified:
- Green - the machine was operating and ready for use
- Red - the machine was unfit for use and required repair
Additionally, the team designated and labeled “red tag” zones where broken equipment requiring repair would be housed. This was yet another unambiguous visual control that prevented clinicians from other operating rooms from accidentally attempting to use the broken piece of equipment.
The clinical engineering department provided data surrounding the equipment failures for the last two years on the four targeted pieces of equipment. The team painstakingly performed root cause analysis using the 5 Whys technique to determine the true cause of the failures. The 5 whys is a simple method developed by Taiichi Ohno at Toyota. Lean practitioners are trained to ask “why?” five times to problems to uncover the root cause rather than making quick assumptions.
With this list of root causes, the team determined that the overwhelming majority of issues could have been prevented or resolved at the operator (nurse, tech, or physician) level. Countermeasures to these issues were developed and printed on a list on the green side of the visual card. The green side now served as a checklist of autonomous maintenance and proper start up actions for the equipment. Operators in many cases did not know the proper sequence and procedures for problem-free equipment startups. The autonomous maintenance list now provided on the green side of the card provided a simple checklist designed to ultimately prevent equipment failures from occurring. Clinicians now follow the checklist of items at the beginning of every day to ensure the equipment is fit for use.
The list of countermeasures generated by the “5 why” root cause analysis session also provided insight into what and when scheduled maintenance should occur. The list revealed that certain components were actually more robust than originally thought, while other components needed more frequent inspection and replacement. A revised visual scheduled maintenance matrix by equipment and month was developed. The original scheduled maintenance log only gave visibility in a text heavy document one month at a time. This was not shared with the clinicians, causing conflicts with equipment usage and scheduled maintenance dates. The revised matrix gave the clinical engineering department a 12-month high-level view into approaching scheduled maintenance activates. This, along with all other documentation was placed into a TPM manual for each equipment type. The revised matrix gave clinicians a simple guide to understand when equipment would be taken out of service. This creates an environment that makes OR planning easier.
The notion of skill enhancement initially made some clinicians nervous. They had never been asked to help maintain equipment. However, the root cause analysis revealed that the tasks were manageable. In addition to these simple preventive tasks, clinicians would also be responsible for minor repairs and changing out certain equipment components. As part of the TPM manual, a troubleshooting guide was assembled. A Pareto analysis was performed on the failures using the data provided from the clinical engineering department. Those most common failures and their respective remedies were listed in the troubleshooting guide in the TPM manual. The clinical engineering team developed a guide that is very visual and contains step-by-step instructions with pictures to aid the clinician in minor repairs. These problems were re-created by the clinical engineering department for testing purposes during the event. In all cases, clinicians were able to correct these issues. These were the same issues that they would have previously called the clinical engineers to resolve. One team member commented about feeling empowered by being giving the knowledge to repair equipment issues.
The clinical engineering department perhaps benefitted the most through the implementation of TPM. Because using a post-it note with a note saying “broken” provides little information about the issue, forty-five minutes on average were spent diagnosing equipment issues per incident. This is where the red side of the visual card comes in. It lists the most common issues clinicians are likely to encounter. A convenient checklist of error codes and equipment issues provides an easy way for clinicians to communicate the issue the machine is experiencing. Diagnosing the equipment now takes virtually no time.
The quality of the data that clinical engineering collects has also dramatically improved. Prior to TPM, the clinical engineers had free reign over what was captured in the equipment database. This made data mining and analysis difficult. A standard was established so the equipment, failed component, and resolution were captured in a standard manner. The red card also provided the exact verbiage which needed to be captured in the database. This makes sorting and analyzing the data much easier.
Hospitals are doing an excellent job of quickly absorbing Lean tools that have evolved in manufacturing for over half a century. It is very encouraging to see hospitals taking a leap into more advanced Lean topics while still maintaining a strong base of stability in more common tools.
(1)Source:A CALL FOR CHANGE: THE 2011 COMMONWEALTH FUND SURVEY OF PUBLIC VIEWS OF THE U.S. HEALTH SYSTEM. Davis, Schoen, and Stremikis, Mirror, Mirror on the Wall, 2010 Update
DrDheeraj Ahuja is a Chairman and Medical Director of the Department of Anesthesiology at Kadlec Regional Medical Center in Richland, Washington.
Ron Gullekson is a technical writer at SRA International, a company that solves complex problems of global significance for clients in national security, civil government and global health.
Aaron Kim is an Associate at Joan Wellman and Associates, Inc. (JWA) - a Seattle-based Lean Healthcare Consulting Company.