What is SMED!?
Have you heard of SMED previously? (I did not encounter this useful tool until coursework in Lean and Six Sigma methodology.) Like the link above described, the essence of SMED as reducing changeover time by converting elements in the changeover process to elements that can happen before the machine is shut down for actual changeover.
Let’s extend this analogy to our typical Trauma and Acute Care Surgery service line: what is the “machine”? The machine, here, is the service that we render to patients or that time when the service is up and running / available. What is the “changeover” here? That’s the morning handoff. The key with handoffs is to ensure fidelity of information transfer (accurate information is transferred) and that the required information to render excellent clinical care (the “right” info) is transmitted. It need not be all info including what flavor of soda a patient likes (unless that’s somehow important for their care) and it does need to happen in a reasonable amount of time.
How many times have you participated in a morning signout that (A) took way too long (B) didn’t get you the information you or the team needed (C) was more about unstated social agendas than actual patient care (D) missed teaching points that were important for the group or even (E) focused on so many teaching points that the essence of the signout was lost and it took way too long? If you ever have then you, my colleague, have the opportunity to deploy SMED to improve your turnovers. Let’s talk about how.
Use Video to Be the Most Effective
One of the useful ways I’ve deployed SMED previously includes videotaping the signout or turnover. Usually we tell everyone that in the next few weeks, we’ll be recording signout in order to improve signout and NOT to get any provider in trouble. My recommendation: let some time elapse between when you tell the group you will record signout and when you do record signout. That may help minimize the Hawthorne effect. Also, note patient confidentiality will be preserved as the video will be reviewed then destroyed. This is part of a quality improvement study, and so usually expedited Institutional Review Board (IRB) standards apply as do routine HIPAA protections.
One day in the weeks that follow we record the signout process starting exactly at the time at which the signout is scheduled to start. (Usually the first few minutes of the tape includes people milling around for about 5 to 10 minutes beyond the official start time.) We let the tape run until the room has cleared and often this is 5 to 10 minutes beyond the scheduled end time.
Next, we spend some time with the group talking about what makes for a good signout. What are the characteristics we want as a group in our signout? This helps make the entire team accountable and focused on how we want our system to look. Next, we review the tape without the larger group so we can have a sense of what exactly is recorded and begin to apply SMED methodology. We label elements of the signout as essential to changeover or as candidates to move externally, eg: how many times have you waited for radiology films to load during signout? Is there any reason those can’t be loaded and waiting beforehand? How about bringing up labs?
So, in particular, we are looking for any steps that make signout less effective, slow it down, or otherwise get in the way and we look to make these external relative to the signout process. Commonly, labs can be brought up ahead of time, radiologic films can be ready and waiting, and a teaching point of the day can be prepared from the night’s events, typed, and printed for discussion. In this way the team is focused on the single, relevant message for the day instead of thirty ad-hoc teaching points.
Next, we review the video with the larger team and make sure to highlight with them the internal versus external parts of the process. We review SMED methods and frequently restate: how do NASCAR teams take a 15 minute process of changing a tire and make it take 15 seconds? They use SMED techniques. (The lean manufacturing link above uses the same analogy.)
Next, along with the team, we redesign signout and see what should be made an external process. (We’ve described several of the candidate portions of signout that can usually be made external in the work above.) Then we usually highlight that the first several times we try the new process, there will be friction–after all it’s new! So we have to push through the process to get to the new normal signout that we all want. After all, no doubt the first time we try the new process a trauma activation will be called just as the prep work is starting.
Don’t be TOO lean…
We usually try to build in a little redundancy or robustness into the process. For example: perhaps the in house, on call person doesn’t need to be the one to prepare a teaching point (when the group decides they want a daily teaching point in the process). Perhaps someone who is not in house and on call can prepare the teaching point the night before and bring that to signout ready to discuss. That way, the whole new SMED signout doesn’t rely on someone who may become busy during prep time. Even though the person who is not in house may not want the homework, we usually focus on how much better signout will be and how much more they will enjoy the signout. The teaching point may rotate among the different providers. These ideas usually help us get the group behind the idea.
Last, we pilot the new turnover process for about a week. The kinks slowly work themselves out, and after about a week we videotape a typical signout again. We then compare the signout videos with the group in a followup meeting. It really drives home how SMED improves the signout / turnover process for Trauma and Acute Care Surgery. Last, remember to destroy the tapes after you’ve recorded the improvements noted by the team in terms of total time spent in signout, signout effectiveness, or any other endpoints you select. Remember, you can even create and validate a Likert Scale for signout quality as measured by the physician receiving report.
SMED, in the end, is a useful technique to apply to your turnover meetings in Trauma and Acute Care Surgery. Healthcare colleagues: let’s NOT re-invent the wheel! The Single Minute Exchange of Die, although initially created for manufacturing, is a tool for which many of us in healthcare are searching to improve turnovers in terms of time spent and quality of signout. Making a robust process where certain work is done before signout begins allows us to maximize quality in the turnover situation. Hope you enjoy and deploy SMED in your practice and remember: many of the quality opportunities we have in healthcare have already been addressed–there are validated tools out there already!