Machiavelli famously said to the prince: "It is better to be both loved and feared but if you can only be one, be feared". I've been wondering what Machiavelli would...
A hospital’s operating room powers the hospital’s financial margin. But for the OR to be truly effective, it has to be efficient. In order to be efficient, you have to know what data to analyze and how to interpret that data. For this post, I want to focus on 2 metrics: (1) first case start times and (2) operating room turn over times.
At our hospital, we are very fortunate to have an outstanding Medical Director of Perioperative Services who understands efficiency and works well to build consensus among the surgeons, anesthesiologists and OR staff to create an efficient environment with a focus on optimizing the patient’s experience. One of the first areas he addressed was whether the first cases of the day started at the time that they were scheduled to start. The operating room schedule is just like an outpatient office schedule: if you start the first patient 30 minutes late, you are going to be late by 30 minutes for all of the rest of the patients for that day and then you are going to have to pay your staff overtime for 30 minutes when they finally finish up their day 30 minutes later than anticipated. In order to start on time, several things are required:
- The room has to be ready for the patient
- The patient has to be ready for the room
- The OR staff have to be in the room
- The anesthesiologist has to be in the room
- The surgeon has to be in the room.
If any one of these are not in place at the time of the first scheduled case, then everyone gets delayed for the rest of the day. If your operating room first cases are not starting on time, the next step is to drill down to determine which of these 5 variables is the culprit and then take steps to rectify the situation
Room turn over time is more complex. At our medical center, The Medical Director of Ambulatory Surgery, Associate Professor of Anesthesiology Dr. Mike Guertin, has done a very detailed analysis of room turn over and I’ll credit him with my understanding of room turn over.
The number of minutes it takes to turn an operating room over can vary depending on the surgical case. For example, surgeries that use a basic surgical instrument set and minimum number of OR staff (for example, cataract removal) can have short room turn-overs, say, 20 minutes. On the other hand, a surgery that uses a large number of specialized instrument sets plus a larger number OR staff (for example, hip replacements) will need a longer time to turn the room over, say 40 minutes. For a wide spectrum of different types of surgeries, a good average to shoot for is 80% of the room turnovers taking less than 30 minutes.
There are 4 key parts of an operating room turnover:
- The time from incision closure to the first patient leaving the room
- The time from when the first patient leaves the room until the room is ready for the second patient
- The time from when the room is ready until the second patient is ready in that room
- The time that the second patient is ready in the room until the the incision is made
Although on the surface, this sounds simple, in reality this is a supremely complex human behavioral engineering challenge. Here are some ways to address the common causes of delay in room turnover:
Standardize work flows. The staff should not have to be called to do routine parts of the room turnover, they should do it automatically. For example, cleaning the floor of the room in between cases should be hard-wired into the staffing and it should not require the OR charge nurse to page housekeeping.
Improve communication. The fewer phone calls and pages that the staff have to make, the fewer minutes it takes to turn the room over. The solution may be different for different hospitals and could involve an overhead paging system, an auto-page triggered electronically to staff pagers or cellphones, patient flow monitor screens placed throughout the OR area, or microphone headsets for use by the staff.
Optimize pre-admission evaluation processes. Dr. Guertin found that in nearly half of cases, patients are not ready to go back to the operating room when the operating room is ready for them. More effective pre-admission evaluation and testing was able to have patients better prepared for surgery and have all of the proper documentation in order with fewer “unexpected surprises” on the day of surgery in our ambulatory surgery center. Not only does this improve patient flow and reduce day-of-surgery cancellations but it also significantly improves patient satisfaction. Outpatient pre-admission testing programs that use healthcare professionals at the top of their license capabilities (office assistants, medical assistants, RNs, CNPs/PAs, and physicians) can improve throughput of patients later when at the arrive to the hospital for their surgery.
Avoid a culture of defeat. Improving operating room efficiency can seem like an insurmountable task for the OR staff, physicians, and hospital administration. By following regular report metrics on room turnover and first start times, it can be much easier to show the OR staff small incremental changes of just 1-2 minutes and this is sometimes the positive reinforcement that is needed to maintain the culture of optimization.
Operating room time is expensive, typically $18-19/minute so even shaving a few minutes off of room turn over time can result in dramatic financial rewards. Reducing room turnover time by 10-15 minutes can allow for an additional surgical case per room each day. Equally important, a maximally efficient operating room with on-time first-starts each morning and shorter room turnover time will improve the patient experience and improve patient satisfaction. In the spirit of the Ohio State University Wexner Medical Center, Dr. Guertin refers to the process as “OSUWMC2”: “Optimal Surgical Utilization With Minimal Complications & Cancellations”.
The key message is that operating room optimization starts not when the patient arrives in the hospital on the day of surgery but instead starts when the patient first decides to have a surgery. There are no losers with operating room optimization, only winners.
July 31, 2016