The new year is just around the corner, and it will bring new challenges for OR leaders as well as fresh opportunities to improve clinical, financial, and operational performance.
The typical surgery department is a “target-rich environment”: low utilization, long turnover times, inefficient charge capture, poor documentation, high supply costs, and low protocol adherence. Success in any of these areas will represent real progress for the department, so how do OR leaders choose where to focus their energy?
One common mistake is to aim for a “big win” by starting with a major efficiency problem. The trouble is that the biggest problems are usually the most complex. Performance improvement initiatives that tackle complicated issues without the right preparation usually get bogged down and lose momentum.
Instead of trying to kick off 2022 with a big win, our recommendation is to start with a quick win—a relatively straightforward project that will produce a noticeable gain in efficiency while creating forward momentum for more ambitious initiatives.
A good place to start for most hospital ORs is to improve the department’s first-case on-time start (FCOTS) rate. An FCOTS initiative can be launched quickly and produce fast results in both operational efficiency and surgeon satisfaction. Most important, it can provide a valuable template for achieving much more significant improvements in clinical and financial performance.
One advantage of starting with FCOTS is that there is only one measure of success—the patient is in the room, prepped and ready for their procedure, at the scheduled start time. No complex analysis is necessary to get started. Begin with the OR’s first-case start time and reengineer staff and patient activities as needed to make sure the process hits the target consistently.
First, one clarification: OR leadership teams that undertake an FCOTS initiative should first focus on nursing and operational processes, not on the behavior of surgeons or anesthesia providers. Why? Most surgeons arrive late to the OR because they have learned to expect that their patients will not be ready when scheduled. Before OR leaders can ask surgeons to start arriving on time, they must first demonstrate that patients will be ready on time.
The basic methodology is to work backward from the first-case start target. The timeline below lists key activities and milestones preceding “patient ready.”
Using this timeline as a basic template, the focus of an FCOTS initiative is choreographing all the staff movements, clinical activities, and information flows that contribute to first-case readiness.
OR leaders can adjust the template as needed. For example, the preoperative holding area in some hospitals is a considerable distance from the OR. These departments may need to allow more than 5 minutes for transporting patients to their surgical suite. Consider conducting a “time in motion” study to account for transit times between various locations.
Filling out the FCOTS timeline is relatively straightforward. The more challenging part is ironing out the practical wrinkles that prevent smooth process flow. Experienced OR managers have developed several tactics, strategies, and process fixes to facilitate first-case efficiency:
• Check vendor policies. Issues with vendor supplies can lead to case delays. OR leaders should revise their vendor policy to specify that all trays must be on site in the hospital 48 hours before a case. Confusion sometimes arises around sterilization. AORN guidelines require all instruments and implants to be sterilized on-site by hospital staff, not offsite as part of the vendor’s process.
• Set a hard limit on charts. Missing lab results, patient assessments, and other chart components can also cause cases to start late. Have OR staff contact surgeon offices two days before scheduled cases to follow up on any missing chart information. Notify them that if the information is not provided by 24 hours before the scheduled start time, the procedure will be moved out of the first-case time slot.
• Bring some communication in-house. Some hospitals allow surgeon offices to communicate expected arrival times to patients. This can lead to mistakes and confusion, resulting in delays. Hospitals should take this step back in house and assign it to staff in scheduling, registration, or pre-surgical testing who have access to an up-to-date OR schedule.
• Choreograph nursing check-in. Start with “arrive at bedside” times for both OR and preoperative nurses and work backwards. Like the example above, perform a simple time study tracing the actual path from punch-in to scrub-in to bedside.
• Build in extra time for patient arrival. This is probably intuitive, but ORs that want patients to register at 6 a.m. should ask them to arrive at the hospital at 5:45 a.m.
• Promote online registration. An online registration system can shave several minutes off the patient check-in process. ORs that do not use online registration should work to set up a system. If online registration exists but utilization is low, emphasize this option in patient communications.
• Enlist overnight staff. Night shift nurses can use downtime between cases to help prepare the department for a smooth morning start, which will help avoid delays due to room and equipment issues. When workload allows, overnight staff can do tasks such as validating preference cards, picking supplies, and getting started on setup for morning cases.
• Plan for “non-failure.” Many OR management teams hold a daily meeting to plan the next-day schedule. Make sure this daily huddle includes a process for identifying special patient needs and assessing their impact on patient flow. For example, patients coming to the hospital from a skilled nursing facility could easily run into transportation issues. Avoid scheduling these patients as the first case of the day. Plan for a successful start by reserving the first slot for uncomplicated procedures and patients.
There are a lot of moving parts to an FCOTS initiative, but project teams can usually get all the processes lined up and working well within a few months. When the department is consistently achieving its “patient in OR” target, the next step is to get physicians involved.
Based on best practice in well-run ORs, the tipping point is an FCOTS rate between 70% and 80%. At this level of performance, the nursing organization has solved its side of the efficiency problem. OR leaders can then reach out to surgeons and anesthesia providers to request compliance with arrival times.
In our experience, once surgeons see that their first-case patients are reliably in preoperative holding at the agreed-upon time, they will gladly adjust their arrival times to match department standards. After all, surgeons as well as anesthesia providers also want to make the most of their OR time.
Some organizations impose fines on late surgeons. This can be effective in some cases, but it tends to perpetuate an adversarial environment in the OR. Instead, we recommend a collaborative approach based on data transparency. Share individual FCOTS performance data with surgeons who are not meeting expectations. If data is validated by a collaborative governance committee (more on that below), OR leaders can also post de-identified provider timeliness data in the surgeon lounge.
The efficiency gain of a successful FCOTS project is real but relatively modest. The greatest value of starting with this initiative is that it creates a template for organizational change. OR leaders are then able to apply the same approach to bigger opportunities.
For example, an OR that has just led a successful FCOTS project could follow up with an initiative to decrease turnover time (TOT) between cases. The approach is the same: establish metrics and a performance target, convene relevant stakeholders, and choreograph activities by finetuning processes and policies.
The main challenge of a TOT initiative is that it requires the adoption of parallel workflows. This can be difficult for OR professionals who may have historically thought in terms of sequential processes.
One solution to this challenge is to start small. Do not begin by trying to fix turnover across the entire department. Launch a TOT initiative with a single specialty or even a single surgeon.
In addition, work with individuals who are personally interested in this issue and are willing to work with OR leadership to improve their TOT. These individuals are not necessarily the OR’s loudest critics or its biggest revenue generators. The ideal partner is a clinically respected surgeon who is highly visible to his or her colleagues. More bluntly, their opinion should matter to other surgeons.
Decreasing TOT for one surgeon can be a powerful starting point. From there, OR leaders can extend TOT learnings to other surgeons and divisions, creating the potential for substantial gains in department revenue.
As the entire organization gains experience with collaborative improvement, OR leaders can progressively tackle more challenging opportunities such as block utilization performance, preference card cleanup, specialty nursing team alignment, and sterile processing workflow optimization.
Regardless of what issue OR leaders are focusing on, two elements need to be in place to ensure the success of an improvement initiative.
First, the OR needs collaborative governance in some form. Every stakeholder group contributes to problems in the OR, so everyone must take part in finding solutions.
The most effective venue for collaboration is a multidisciplinary Surgical Services Executive Committee (SSEC) with representation from the surgeon staff, anesthesia providers, nursing leadership, and hospital administration. An FCOTS initiative is the ideal first step for a new SSEC because it allows the committee to learn the techniques of collaborative performance improvement on a relatively easy project.
Second, OR leaders need to establish data transparency. One of the biggest obstacles to process improvement in the OR is that different stakeholders do not look at performance in the same way. An SSEC can overcome this obstacle by establishing a common set of performance measures. This puts physicians, nurses, and administrators on the same page, giving them a shared view of operational problems and viable solutions.
As a simple example, an FCOTS initiative must be based on a shared understanding of “on time.” This concept seems uncontroversial, but in fact, some surgeons (based on their experience in other hospitals) might define timeliness as “within 10 minutes of the scheduled start time.” Similar issues affect room turnover, utilization metrics, and other OR processes.
The biggest benefit of a quick win—like a successful FCOTS initiative—is that it can jumpstart culture change. Rapid gains in first-case timeliness will demonstrate to both physicians and nurses that everyone can come together to improve OR operations.
A quick win will not fix the OR overnight, but it will help teach OR stakeholders how to tackle more complex challenges that have a major impact on clinical, financial, and operational performance.✥
Michael Besedick, MS, is director and Kartik Bhatt, MPH, is engagement manager at Surgical Directions, a healthcare consulting firm specializing in operating room transformation.