Ten experts explain what they believe is the one behavior that most impedes OR efficiency.
Q: What practice or behavior is the most damaging to an OR's efficiency and why?
Mark Antoszyk, Chief CRNA, Carolinas Medical Center NorthEast (Concord, N.C.): Lack of leadership to be open to ideas from the staff and doctors doing the job. Failure of leadership to stay current with regulations, equipment and work flow issues. [Leaders] must give staff the correct tools to do the job. Also, failure to look at the whole picture when [faced with] a request for new equipment or the new tools to improve surgery and outcomes, but instead looking just at what it costs to buy.
Houtan Chaboki, MD, Plastic Surgeon, George Washington Medical Faculty Associates (Washington, D.C.): Lack of communication among team members and no repercussions to team members for inefficiency.
Steven M. Gottlieb, MD, CEO, TeamHealth Anesthesia: Failure to develop and utilize a well-managed care team is one of the most damaging practices when it comes to OR efficiency. If a surgical team is delayed from starting their next case because the anesthesiologist is still finishing up one patient or the next patient isn't ready for surgery, it creates an unnecessary roadblock that derails the surgical schedule and can leave both surgeons and patients dissatisfied. The concept of care team should also be extended to include a strategic partnership with OR leadership and care providers. For example, the anesthesia team can often partner with the OR circulating nurses to streamline throughput and reduce redundant activities. A care team approach allows anesthesiologists and OR clinicians to coordinate patient care to optimize OR time.
Sue Kozlowski, Senior Healthcare Consultant, TechSolve: Ignoring problems and not addressing them appropriately causes a major dysfunction for any team. For example, a staff member who is verbally abusive without any consequences; or poor room turnover time that is just accepted as "the way things are." A key aspect of the lean approach is to "see and solve." That is to have an accurate understanding of process and performance issues, not sweeping problems under the rug but bringing them out into the open. When that is done in a non-blaming environment, the focus changes from excusing or punishing to a conversation about what needs to happen to ensure safe, effective and timely patient care.
Joseph Livengood, MD, Acute Care Surgeon, Medical Center of the Rockies (Loveland, Colo.), Biomedical Engineer, President, Livengood Engineering: Strict adherence to service line teams. The list includes: CV, robot, GYN, ophthalmology, spine, neuro and more. Service lines are beneficial as there are unique equipment, techniques and preferences among surgeons. However, it also creates a fragmented environment in the OR that is detrimental to overall efficiency. While it is unreasonable to expect everyone to be cross-trained on all specialties, the training and use of staff outside of these strict service lines should be an objective. For example, if no hearts are on that day, the CV team should be added to the pool of staff helping out with an add-on trauma, appendectomy, hysterectomy, etc.
John Maa, MD, FACS, Assistant Professor, UCSF Department of Surgery: A major hurdle to improved efficiency is related to "block time," as ineffective scheduling, underutilization from vacations and inadequate time to release unused blocks and unrealistic estimates of operating times all result from this artificial construct.
Adam McLarney, Director; Maggie Longshore, RN, MS, CNOR, CAPA, NE-BC, Senior Consultant, Blue Jay Consulting: Apathy, lack of accountability and non-cooperation from all team members, coupled with a lack of vision and open communication. Working to build an accountable, non-blaming culture that is supported by leadership is critical to ensuring ongoing success.
Catherine Munoz, BSN, RN, CNOR, LNCC, Director of Perioperative Services, St. Vincent Medical Center (Los Angeles): Poor staff and physician behavior and attitude combined with ancient and historical routines can be the most damaging to an OR's efficiency. Breaking down cultural and "we've always done it this way" philosophies with evidence-based knowledge and data can be a slow process. Holding staff and physicians accountable to new processes is the follow-up required to keep from slipping into the past.
Joe Smith, Vice President, Perioperative Care Division, Picis: The lack of timely communication around issues and events prior to surgery results in delays or cancellations on the day of surgery, which impact the workflow of the entire surgical staff (physicians, nurses, sterile processing staff), waste OR supplies and equipment and result in unnecessary staff overtime.
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Q: What practice or behavior is the most damaging to an OR's efficiency and why?
Mark Antoszyk, Chief CRNA, Carolinas Medical Center NorthEast (Concord, N.C.): Lack of leadership to be open to ideas from the staff and doctors doing the job. Failure of leadership to stay current with regulations, equipment and work flow issues. [Leaders] must give staff the correct tools to do the job. Also, failure to look at the whole picture when [faced with] a request for new equipment or the new tools to improve surgery and outcomes, but instead looking just at what it costs to buy.
Houtan Chaboki, MD, Plastic Surgeon, George Washington Medical Faculty Associates (Washington, D.C.): Lack of communication among team members and no repercussions to team members for inefficiency.
Steven M. Gottlieb, MD, CEO, TeamHealth Anesthesia: Failure to develop and utilize a well-managed care team is one of the most damaging practices when it comes to OR efficiency. If a surgical team is delayed from starting their next case because the anesthesiologist is still finishing up one patient or the next patient isn't ready for surgery, it creates an unnecessary roadblock that derails the surgical schedule and can leave both surgeons and patients dissatisfied. The concept of care team should also be extended to include a strategic partnership with OR leadership and care providers. For example, the anesthesia team can often partner with the OR circulating nurses to streamline throughput and reduce redundant activities. A care team approach allows anesthesiologists and OR clinicians to coordinate patient care to optimize OR time.
Sue Kozlowski, Senior Healthcare Consultant, TechSolve: Ignoring problems and not addressing them appropriately causes a major dysfunction for any team. For example, a staff member who is verbally abusive without any consequences; or poor room turnover time that is just accepted as "the way things are." A key aspect of the lean approach is to "see and solve." That is to have an accurate understanding of process and performance issues, not sweeping problems under the rug but bringing them out into the open. When that is done in a non-blaming environment, the focus changes from excusing or punishing to a conversation about what needs to happen to ensure safe, effective and timely patient care.
Joseph Livengood, MD, Acute Care Surgeon, Medical Center of the Rockies (Loveland, Colo.), Biomedical Engineer, President, Livengood Engineering: Strict adherence to service line teams. The list includes: CV, robot, GYN, ophthalmology, spine, neuro and more. Service lines are beneficial as there are unique equipment, techniques and preferences among surgeons. However, it also creates a fragmented environment in the OR that is detrimental to overall efficiency. While it is unreasonable to expect everyone to be cross-trained on all specialties, the training and use of staff outside of these strict service lines should be an objective. For example, if no hearts are on that day, the CV team should be added to the pool of staff helping out with an add-on trauma, appendectomy, hysterectomy, etc.
John Maa, MD, FACS, Assistant Professor, UCSF Department of Surgery: A major hurdle to improved efficiency is related to "block time," as ineffective scheduling, underutilization from vacations and inadequate time to release unused blocks and unrealistic estimates of operating times all result from this artificial construct.
Adam McLarney, Director; Maggie Longshore, RN, MS, CNOR, CAPA, NE-BC, Senior Consultant, Blue Jay Consulting: Apathy, lack of accountability and non-cooperation from all team members, coupled with a lack of vision and open communication. Working to build an accountable, non-blaming culture that is supported by leadership is critical to ensuring ongoing success.
Catherine Munoz, BSN, RN, CNOR, LNCC, Director of Perioperative Services, St. Vincent Medical Center (Los Angeles): Poor staff and physician behavior and attitude combined with ancient and historical routines can be the most damaging to an OR's efficiency. Breaking down cultural and "we've always done it this way" philosophies with evidence-based knowledge and data can be a slow process. Holding staff and physicians accountable to new processes is the follow-up required to keep from slipping into the past.
Joe Smith, Vice President, Perioperative Care Division, Picis: The lack of timely communication around issues and events prior to surgery results in delays or cancellations on the day of surgery, which impact the workflow of the entire surgical staff (physicians, nurses, sterile processing staff), waste OR supplies and equipment and result in unnecessary staff overtime.
Related Articles on OR Efficiency:
The One Change ORs Should Make to Improve Efficiency: 9 ResponsesHow One Hospital Increased First Case On-Time Starts From 4% to 72%
How Preoperative Preparation Can Drive OR Performance