Timothy Dowd, MD is managing partner and chairman of North American Partners in Anesthesia (NAPA) and CEO of NAPA Management Services Corp., the largest single-specialty anesthesia management company in the United States.
Q: What makes operating room efficiency so critical to the success of an organization?
Dr. Timothy Dowd: I don't think any organization exists in a vacuum. It exists in the context of the other health facilities it is around and what competition it has, so typically, hospitals are in competition both for patients and surgeons. That competition really focuses around the level of service the hospital is able to provide to those two constituencies.
Among the most important things to a surgical patient, and certainly a surgeon, and how they are going to judge the performance of the hospital is the performance of the OR in terms of safety, efficiency and user-friendliness — those are the three modalities I typically think about when I'm looking at the performance of an OR.
So a hospital will know its OR has to perform efficiently but really tends to do very little in terms of analyzing the performance of the OR.
Q: What do organizations need to do to undertake an effective analysis?
TD: Let's consider the safety aspect. Hospitals tend to think of things like SCHIP protocols, making sure that the antibiotic prophylaxis is delivered in a timely fashion, making sure the patients leave the OR warm — those are some of the basic components hospitals have come to acknowledge as important and things they need to look at. My suggestion is that you go significantly deeper into safety protocols.
Hospitals compare their safety to other hospitals using several different numbers and measurements, but frequently they are not comprehensibly managing the results. A hospital should want to do two things: measure these numbers and then respond and say in what way can we make them better, what are the tricks of the trade that we can use to improve the safety performance of the hospital?
Q: How should a hospital bring about such improvements?
TD: The next they need to ask is whose job is it at the hospital to look after that. It varies whose job it is. I would make the argument that the hospitals that are most successful are using people whose job it is to manage the OR. You can have what I call the "referee approach" — there's a quality assurance nurse keeping score but doesn't really understand how an OR functions and therefore although he or she is keeping score, they really aren't in a position to have an impact because it's not their job to run it. They're kind of far removed from actually pushing the levers that will make the difference.
I would make the argument that what you really want to do when you organize the OR is to have the people that are looking at the measures be the same people who are responsible for implementing and understand the changes that can be done to have an impact on those measures. That's what a well-managed OR does — you need some professional who is in the OR on a regular basis and understands how ORs function who then can figure out how to make the differences that result in getting better numbers. That is improving the safety. It's not enough to just measure it. You have to measure it and have somebody in position as a manager to respond to it. We call this person the perioperative director and it's not a universal concept.
Q: Describe a scenario when this perioperative director could bring about significant improvement?
TD: Let me use something like a SCHIP score. Say you're a quality assurance nurse and you see that 25 percent of your patients are coming out of the OR cold, that is they're coming out with a body temperature of 95 or 96 degrees. Those patients have a higher risk of infection and myocardial infarction. There's a whole series of things that are bad that can happen to patients when they're cold — some related directly to their body temperature, some of them because of the revved up metabolism they suddenly require to re-heat the body. So you're a quality assurance nurse and you're say my patients are coming out cold — now what? The typical QA nurse is not in a position to make any change in the way an operating room is run, so they have the information about patients being too cold after surgery and they can't do anything about it.
That's opposed to a physician manager as the perioperative director, for example, who is in an OR who asks what are the contributing factors to a patient coming out cold? Historically, ORs have been kept at very low temperatures. The reason is because the surgeon is in a scrub gown which, by its very nature, is very warm. The room has to be quite chilly because most of the staff members are wearing extra clothing in the OR. That's true of everybody except the patient, who is not only is not wearing clothing but is actually opened to the air — their insides are exposed. So they can lose temperature really quickly.
Some basic changes: you can increase the temperature of the room, you can provide cooling for the surgeon, you can cover the patient up with warming blankets for all areas where the surgery is not actually occurring. If the patient is intubated, the gases they're breathing can be humidified so the patient is not losing heat to the environment while breathing. The fluids the patients get while in the OR — whether they're Ringer's lactate or normal saline — those fluids can and should be heated. When a patient gets blood, the blood comes from a blood bank where it's refrigerated. It should go through a warmer where it's returned to body temperature before it goes into the patient.
A nurse who is not an experienced person in the OR doesn't really understand that what I just described is a whole series of levers that will result in the patient having a normothermic result after surgery and that normothermic result is best delivered by the folks who really understand the various reasons why the patient loses body heat. If you make that person the one who is responsible for making sure the patient is normothermic, you put the job where it belongs — you gave the power to somebody who actually understood how to do it. I think that's the key to a highly functioning OR — making it the job of somebody who actually understands how to do it to deliver the service.
Q: You described the concept of the perioperative director as a "physician manager." Does it need to be a physician?
TD: It could be a physician manager, it could be a nurse manager. I happen to think that, particularly in terms of efficiency, the physician manager is better because the physician manager is a true partner to the hospital and he or she is typically highly incented to get high volume through the OR the same way as the hospital is. In terms of professionalism — both either the nurse manager or physician manager — are okay. They're both professionals who are interested in the safety of the patient and have really trained with that as the essence of their ethic throughout their careers.
In terms of what kind of physicians should serve as perioperative director, it has to be a physician who is present in the OR because you have to be there to have the impact you want to have on the patient. If you make the director of the OR somebody who comes by once a week and sort of looks at number results but they're not regularly presence in the OR, it becomes very difficult for them to actually manage the processes on the day-to-day basis to get the results you want to get.
Consider the typical constituencies of the OR. Simplistically, there's a surgeon, there's an anesthesiologist and there's a nurse — those are the three professionals. In most private hospitals, the surgeons are virtually never full-time and there's nobody from the department of surgery who is regularly managing the OR. The surgeon, when he's in the OR, is there to operate on the patient and he doesn't see it as his job to actually manage the OR. Nurse managers are certainly there all of the time and anesthesiologists are present all of the time. There are some academic environments where there's a full-time surgeon who actually spends all day in the OR and then they can do that job quite well. It's the presence advantage rather than any special training. In non-academic environments, you have two constituencies to choose from — whether it be nursing or anesthesia. Then you look at whether you want a physician — the anesthesiologist — in this role.
A physician manager tends to result in someone who understands a little more deeply the various physiologies that have an impact on patient outcomes. That's really a medical school kind of training and that's why I think the physician manager is probably the best in the end because you're more deeply trained and educated. I think that's what makes a physician a better option, as long the physician understands that it is their job. If you say this is what I want to get out of my OR, how am I best likely to get it, it is that physician manager who is most likely going to deliver it to you.
Q: How does this physician manager work within the hospital?
TD: I think there should be assigned in every OR somebody who is the chief — we'll call them the anesthesiologist. The anesthesiologist — the chief — he's the load manager of the OR, he's the go-to person in the OR, he's the guy who is going room to room, giving anesthetics himself some of the time but he's spending a big portion of his day going in and out of the recovery room, going in and out of the holding area, going in and out of the post-ambulatory surgery area, walking in and out of the ORs so he has a true overview of how the OR is functioning. It's a position that allows him the luxury of the overview with the experience and expertise to actually manage the details right down to the management of any complicated patient.
Q: What do you think is needed for someone to perform this role effectively?
TD: We do something that is a luxury of a large group — we actually train our people in advance. You don't just throw somebody into that role. This is a role unlike any other. Can they learn it over time? They can, but then the guinea pig is the hospital OR and its patients and its surgical relationships. Rather than have a person who is completely receiving on-the-job training, we do a master/apprentice relationship with that physician so that they get taught by somebody who is senior and who has occupied this role. The apprentice learns how this role is done, what the considerations are, what are the things you always need to be thinking about.
A lot of it is also about developing relationships, so that person invariably has a very close relationship with whoever is directing the nursing team on a day-to-day basis. Beyond that it should be somebody who is a clinically superior anesthesiologist because what we do is dangerous, we work in a complex environment and there are times when there are crises that occur in an OR where having another senior physician come in and provide an extra pair of hands and an extra brain to the situation rescues a lot of patients. You want somebody who is of superior clinical skill who can, when he shows up to help another doctor, be a real addition of skill. There's a lot to that whole training program. This is going to be the physician managing all of these relationships, talking to a surgeon who is chronically late, dealing with all of the efficiencies and inefficiencies that go on in ORs, making sure the equipment is present and in working order — all of those things become the responsibility of that physician. When we're just talking about safety, it's that ability to be around, understand how the OR functions and be an overseer.
Q: We've focused our discussion on the safety aspect. How is the perioperative director involved with the other two modalities you identified: efficiency and user-friendliness?
TD: I think this specialist would see it as his job to press the levers for those other two modalities in the same way I talked about understanding the levers that result in a patient being normothermic. It is understanding an OR that is highly functioning; how do you make it efficient, what numbers do you look at and then how do you push the levers to make the numbers better? Same thing with user-friendliness — what are the things you can do to make that OR for a surgeon just a more pleasant place to work and for the patient a place of comfort in the form a well-run OR? That's the job of that perioperative director, that physician manager.
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