Improvement in Multidisciplinary Provider Rounding (Surgical Rounds) in the Pediatric Cardiac ICU: An Application of Lean Methodology*

Abstract

Provider-only, combined surgical, and medical multidisciplinary rounds ("surgical rounds") are essential to achieve optimal outcomes in large pediatric cardiac ICUs. Lean methodology was applied with the aims of identifying areas of waste and nonvalue-added work within the surgical rounds process. Thereby, the goals were to improve rounding efficiency and reduce rounding duration while not sacrificing critical patient care discussion nor delaying bedside rounds or surgical start times.

Where the Rubber Meets the Road: Lean Methodology for Improving Daily Multidisciplinary Rounds*

“…When applied to healthcare, the customer may be the patient or other healthcare professionals if the product under improvement is a tool used between professionals in the delivery of care. In the case of Brown et al (1), the product was CICU surgical rounds, and value was derived from timely completion of surgical rounds without compromising patient discussion while simultaneously not delaying bedside rounds or surgical start times. The second step, identifying the value stream, involves an assessment of "Gemba, " or the space in which work is done.…”

“…This process is rife with challenges in balancing the efficiency-thoroughness tradeoff. Brown et al (1) sought to improve the efficiency of the process of surgical rounds in response to feedback from their teams. The use of Lean methodology in the specific context of pediatric cardiac critical care multidisciplinary surgical rounds is novel.…”

“…This is vital to distinguish work as imagined from work as performed. Brown et al (1) used direct observations, surveys, and data from the electronic health record to assess the work as performed during surgical rounds. Once the team develops an understanding of the process, they create a current-state value stream map, or a visual representation of the steps involved in completing the processes and the time it takes to complete these steps.…”

“…In the case of healthcare delivery process improvements where other health professionals are the customers, establishing pull can appear in the form of rapid deployment of the process described as needed. Brown et al (1) developed a well-trained team of presenters with a rounding script, as well as moderators to ensure the process runs smoothly on a daily basis such that this “product” could be “pulled” daily. The final step of lean improvements is to strive for perfection.…”

“…The final step of lean improvements is to strive for perfection. Brown et al (1) embrace this in their description of post-intervention monitoring and ideally will continue to run this new version of their surgical rounds through the lean process. Lean experts assert that a production process must go through at least a dozen iterations of value stream mapping before most inefficiencies are identified and maximally addressed.…”