Michael Simon, MD, North American Partners in American anesthesiologist, director of cardiothoracic anesthesia at Vassar Brothers Medical Center, chairman of anesthesia at UPMC Hamot Medical Center and president-elect of the New York State Society of Anesthesiologists says improving operating room efficiency is at the top of the list of priorities for all hospital ORs.
"There are multiple reasons as to why hospitals look to increase OR efficiencies, whether it is due to the pressures from surgeons, government or payors," Dr. Simon says. "With that being said, hospitals need more than ever for all of their staff and service providers to be aligned with their goals to ensure and sustain success. As anesthesiologists, it's just a mindset that we have to provide quality patient care, while working in conjunction with other important stakeholders to form a team dedicated to constant improvement."
There are a few critical elements to achieve OR efficiency, he says. First and foremost, strong perioperative leadership needs to be put in place.
"When you don't have an accountable, point person who runs the OR, manages scheduling, vacation coverage and effectively communicates with the surgical team, things just kind of fall apart," he says. "It is imperative that the perioperative director has a strong understanding as to how each function within the hospital impacts the other functions interacting with the OR in order to get them on the same page.
"This involves developing a supportive and responsive work environment that promotes a positive working relationship between leadership and the staff members to ensure that daily activities are effectively carried out," Dr. Simon continues. "Otherwise, with a lack of communication, you have people running around in different directions, all with different motivators and different mindsets with how things get done. Through various exercises in team training and keeping everyone abreast of what the common theme is; you really are able to maximize efficiencies throughout the day.
"In addition to the placement of an effective perioperative leader, tracking and measuring data on each case will help to prove results and drive improvement in the OR," he says.
Dr. Simon identifies the following seven metrics as some the most important for measuring OR efficiency:
1. First case starts. This metric measures the start time for the first case of the day and shows how often a facility actually brings patients into the OR at their scheduled time.
"Although we all like to think we're really good at that, in essence we're not," Dr. Simon says. "A good OR that runs really well is pleased when it gets that number up to 90 percent or above, which comes with much hardship and preparation. That just doesn't happen because the names appear on the schedule for a first case start."
To achieve a high success rate for achieving on-time first case starts, he says an organization must be diligent about looking at the reasons why patients do not arrive in the OR at scheduled times. When you can get to the heart of that matter and fix the problems causing the delays, it will make all of the hospital's customers happier.
"Patient satisfaction will increase due to the fact that the patient will now go into the OR when they're supposed to [and] surgeon satisfaction will increase as a result of their patient actually being present in the OR when they arrive for the case," Dr. Simon says. "This also in turn makes the hospital happy as this produces the huge benefit of minimizing wasted OR time, which affects the outcomes of other metrics such as turnover time."
2. Turnover times. There are many factors that drive turnover time, also known as the length of time between wheels out of the OR to wheels in. This can include an inefficient central processing of instruments or can be a result of a multidisciplinary problem involving nursing, anesthesia, housekeeping and the turnover team staff not working in sync.
Dr. Simon says most hospitals will have turnover times somewhere in the neighborhood of 25-35 minutes, depending upon the size of the case. A really efficient OR is when you can turn the room over in about 12 minutes for a major general surgery case. This all goes back to having an effective perioperative leader to ensure patient flow is managed, he says.
3. Percent of locations used and what times are they used. "It's very important to have a handle on exactly how many anesthetizing locations are in a facility," Dr. Simon says. "Whether those be ORs, GI labs, EP labs, cath labs, obstetrics, labor rooms — all of those places need to be taken into consideration when you talk about anesthetizing locations."
After determining the number of anesthetizing locations in your facility, you should determine how often and at what times they're used. By tracking this, you can maximize your personnel and move people around strategically, which will work out much more efficiently as far as staff usage.
For example, if you learn through tracking your data that every Tuesday and Thursday you usually have a few anesthesia providers that are not needed in ORs in the afternoon, you can plan to provide anesthesia to locations outside of the OR during these times.
"Proceduralists who are not in the OR love that because it provides them with regularity as to when anesthesia is available for their services so that they can schedule accordingly," Dr. Simon says. "It takes out that unknown element for them."
4. Complications. Dr. Simon says an organization should track untoward events and complicating factors in order to determine which complications occur frequently, why they occur regularly and develop a solution to counteract these issues.
"Is it a fault of the system, is it a fault of the people involved, is it something beyond your control," he says. "When you have complications you can actually do something about, that only serves to enhance the whole process. But you have to have a handle on that. So you have to have an accurate means of tracking those complications and knowing what your outcomes actually are. That goes to the heart of what a good anesthesia group will do as part of the service they provide."
Dr. Simon also notes that complications can be for less acute issues, such as meeting core SCIP measures. "We have to have antibiotics in within an hour, we have to have patients brought out at a certain temperature and we will have to do more and more of those [requirements] every year," Dr. Simon says. "You have to have a handle on how well you do those things not only to ensure you're providing the highest quality of care to the patient but also to take into account that if you don't give patients their antibiotics on time, you're going to find that Medicare starts docking reimbursement to the hospital and eventually to the providers in a very methodical way"
5. Value-based purchasing. You also want to make sure that in working to improve efficiencies, you also track other important elements of a successful OR's operations. One such element is value-based purchasing in the perioperative setting and the associated metrics organizations must now meet. "You need to make sure that all value-based purchasing goals are being met as you also try to tackle these other goals in improving efficiency," says Simon.
6. Consistency of service. While this is not a metric per se, it is a component that is very important in maximizing the flow of the OR.
"That's something surgeons always talk about — they want to have a consistency of service from all constituents in the OR," Dr. Simon says. "Nothing bothers a surgeon or proceduralist more than having different providers give different levels of service. That really ends up slowing down a day, slowing down a provider and it's really [wasted] resources when you don't have a consistent service at all times."
7. Outcomes. When you look at outcomes, you are able to determine how well your providers deliver a certain service and make the necessary adjustments for improvement. For example, how well do they prevent PONV?
"If you track complications of all types, such as nausea and vomiting, you can conclude why certain providers bring patients out who tend to be much more nauseous and need to spend much more time in the recovery room," Dr. Simon says. "Perhaps some providers like to use more narcotics or some don't like to use anti-emetics. This arms you for a discussion with those providers about how they do things a little differently in comparison to their colleagues with lower rates in that area. "
By tracking outcomes by provider, you can gain a better understanding of the consistency of service and can bring about change in the other metrics you are tracking and working to improve.
Learn more about North American Partners in Anesthesia.
More Articles Featuring North American Partners in Anesthesia:
Assessing the Financial Viability of Anesthesia Coverage for a New Service
NAPA Anesthesiologist Pens Column on Anesthesia for Reconstructive Surgery After Massive Weight Loss
How to Determine Quality Indicators to Track