Improving an operating room's efficiency may seem daunting due to the number of factors involved, such as timing, patient safety, leadership and OR group cooperation. The following experts offer their opinions on the one change ORs should focus on to improve efficiency.
Q: What is the single most effective change an OR can make to improve efficiency and why?
Mark Antoszyk, Chief CRNA, Carolinas Medical Center NorthEast (Concord, N.C.): Leadership — without good leadership that has direct contact and respect, [the OR] will run by itself for a while, but not long.
Houtan Chaboki, MD, Plastic Surgeon, George Washington Medical Faculty Associates (Washington, D.C.): Make each team member responsible and accountable. For example, don't allow surgeons to schedule for desired times if they are consistently inefficient.
Steven M. Gottlieb, MD, CEO, TeamHealth Anesthesia: The change that we've found to be most successful in improving OR efficiency has to do with leadership and reconsidering who is "conducting the orchestra" when it comes to managing perioperative care. That is, instead of having a nurse manager or other staff member oversee the continuum of care, the anesthesia team should take the lead for OR operations. Given that these physicians are the ones responsible for tracking the comfort and well-being of patients throughout their surgical stay, anesthesiologists are in a unique position to handle:
1. Pre-admission testing. One key factor to keeping surgeries running on time is making sure all patients' pre-admission tests are completed prior to the date of surgery. In many hospitals, all patients are asked to arrive two hours before their procedures. For some, that may be too much time, for others the admit team may find the patient needs a complex work-up like a cardiology consult that cannot be completed in the allotted time.
Anesthesiologists should take ownership of managing this process. Instead of visiting the patient in the two-hour window before surgery, they should facilitate a process in which all pre-admission testing is completed at least 72 hours before the scheduled surgery time. This allows the physician to ensure the highest quality outcomes and avoid needless surgical case delays or cancellations.
2. First case start time accuracy. Starting the first case(s) on time is key to adhering to the OR schedule for the balance of the day. If just one or two cases start late, those delays can have sufficient ripple effects to cause a number of other problems or backups later in the day. For example, physicians performing the delayed surgeries are detained from their next appointment or engagement — which could be rounding on other patients, doing examinations in their offices, etc. That means the physicians may run late all day, potentially affecting the schedules of other providers and patients, creating conflicts in resource and equipment ability, and other issues.
An effective anesthesia team recognizes these pitfalls and will implement processes — including the pre-admission testing discussed above — to assure first case start time accuracy.
3. OR turnaround times. Operating room turnaround times are paramount to the efficiency of a hospital's perioperative program. Needlessly idle ORs are a missed revenue opportunity and can frustrate clinicians and patients, affecting satisfaction scores. To combat these issues, a hospital's anesthesia partner should have a protocol in place for shortening the time between cases — the most effective of which is properly utilizing an anesthesia care team model, which groups an anesthesiologist with one or more certified registered nurse anesthetists (CRNAs). This model allows the physician to care for more than one patient at a time throughout the perioperative continuum. This can significantly decrease turnaround times, often reducing overtime costs and freeing up additional time for extra procedures.
Sue Kozlowski, Senior Healthcare Consultant, TechSolve: Tracking the patient experience through all the phases of their service and posting those metrics for staff to observe can make a huge change in the way OR teams view their process. Rather than "holding people accountable" for not meeting expectations, leaders can use the tracking metrics as part of a lean approach to ask the right questions — what is happening in our process to cause this issue? If we're not meeting targets, what's the impact on our customers? OR staff can see how they're doing rather than waiting for patient complaints. Together with a team-based approach to problem-solving, this one change can have a huge impact on the way OR teams work together to solve problems.
Joseph Livengood, MD, Acute Care Surgeon, Medical Center of the Rockies (Loveland, Colo.), Biomedical Engineer, President, Livengood Engineering: Employee participation in a "team" mentality throughout the OR and perioperative areas. There are a number of factors that can play a role in efficiency, but without question, the single most critical factor is the staff. The team approach needs to include the entire OR and perioperative staff and not be limited to service lines. I have had the privilege of working in ORs where staff routinely step outside of their duties and their assigned rooms to help keep rooms moving. Far more than helping with room turnover, the benefits are seen in finding equipment and supplies and keeping communication open. With a constant team approach to operations, the entire OR staff contributes to adapting to the inevitable ever-changing schedule throughout the day.
John Maa, MD, FACS, Assistant Professor, UCSF Department of Surgery: The single most helpful thing for ORs to do to enhance efficiency is to create an operating room suite dedicated for emergency procedures to accelerate hospital throughput, shorten hospital waits and reduce cancellations from a lack of inpatient beds. In many other countries the typical hospital OR allocates two-thirds of its ORs for elective procedures and one-third for emergency procedures during the daytime.
Adam McLarney, Director; Maggie Longshore, RN, MS, CNOR, CAPA, NE-BC, Senior Consultant, Blue Jay Consulting: Any OR should develop a vision by involving key stakeholders from nursing, physicians and administration. Leadership should effectively communicate the "why" for the improvements that are being proposed. Internal champions should be identified to support the change process and communicate to peers. The department should strive to establish an environment of trust with transparency of information and open, honest communication. Efficiency is dependent on everyone on the team supporting the initiative. To be successful and sustain efficiency initiatives must be approached and driven by a team concept.
Catherine Munoz, BSN, RN, CNOR, LNCC, Director of Perioperative Services, St. Vincent Medical Center (Los Angeles): Improving the pre-admitting and patient access processes are the key steps to reducing "day of surgery" delays and cancellations. Finding out the individualized needs of each patient and operating physician in advance can make the difference in getting those first cases of the day onto the operating room table on time. "First start," or first case of the day in each OR's scheduled line-up sets the tone for staying on time, which is the best indicator of efficiency and customer satisfaction.
Joe Smith, Vice President, Perioperative Strategy, Picis: Surgery delays and cancellations are the most disruptive and expensive issue impacting OR efficiency. Meeting the goals of an OR schedule requires both preoperative checklists and "day-of" surgery patient tracking solutions. The pre-op checklist needs to be easily accessed and proactively reviewed for completeness (i.e. consent form is on file, implants have been ordered and received, pre-op diagnostic testing is complete, patient has been given pre-op teaching instructions, etc). The "day-of" surgery tracking feature should combine patient monitoring with a communication mechanism that notifies the proper people of completed or pending events (i.e. let the surgeon know the patient has changed rooms, let the surgeon and anesthesiologist know a patient is ready for surgery, let the circulating nurse know that a patient is late arriving at registration, etc.).
American College of Surgeons, 20 Others Offer Guide on Operations Requiring Physicians as Assistants
OR Resource Nurses Play Important Role in Scheduling, Patient Safety
Q: What is the single most effective change an OR can make to improve efficiency and why?
Mark Antoszyk, Chief CRNA, Carolinas Medical Center NorthEast (Concord, N.C.): Leadership — without good leadership that has direct contact and respect, [the OR] will run by itself for a while, but not long.
Houtan Chaboki, MD, Plastic Surgeon, George Washington Medical Faculty Associates (Washington, D.C.): Make each team member responsible and accountable. For example, don't allow surgeons to schedule for desired times if they are consistently inefficient.
Steven M. Gottlieb, MD, CEO, TeamHealth Anesthesia: The change that we've found to be most successful in improving OR efficiency has to do with leadership and reconsidering who is "conducting the orchestra" when it comes to managing perioperative care. That is, instead of having a nurse manager or other staff member oversee the continuum of care, the anesthesia team should take the lead for OR operations. Given that these physicians are the ones responsible for tracking the comfort and well-being of patients throughout their surgical stay, anesthesiologists are in a unique position to handle:
1. Pre-admission testing. One key factor to keeping surgeries running on time is making sure all patients' pre-admission tests are completed prior to the date of surgery. In many hospitals, all patients are asked to arrive two hours before their procedures. For some, that may be too much time, for others the admit team may find the patient needs a complex work-up like a cardiology consult that cannot be completed in the allotted time.
Anesthesiologists should take ownership of managing this process. Instead of visiting the patient in the two-hour window before surgery, they should facilitate a process in which all pre-admission testing is completed at least 72 hours before the scheduled surgery time. This allows the physician to ensure the highest quality outcomes and avoid needless surgical case delays or cancellations.
2. First case start time accuracy. Starting the first case(s) on time is key to adhering to the OR schedule for the balance of the day. If just one or two cases start late, those delays can have sufficient ripple effects to cause a number of other problems or backups later in the day. For example, physicians performing the delayed surgeries are detained from their next appointment or engagement — which could be rounding on other patients, doing examinations in their offices, etc. That means the physicians may run late all day, potentially affecting the schedules of other providers and patients, creating conflicts in resource and equipment ability, and other issues.
An effective anesthesia team recognizes these pitfalls and will implement processes — including the pre-admission testing discussed above — to assure first case start time accuracy.
3. OR turnaround times. Operating room turnaround times are paramount to the efficiency of a hospital's perioperative program. Needlessly idle ORs are a missed revenue opportunity and can frustrate clinicians and patients, affecting satisfaction scores. To combat these issues, a hospital's anesthesia partner should have a protocol in place for shortening the time between cases — the most effective of which is properly utilizing an anesthesia care team model, which groups an anesthesiologist with one or more certified registered nurse anesthetists (CRNAs). This model allows the physician to care for more than one patient at a time throughout the perioperative continuum. This can significantly decrease turnaround times, often reducing overtime costs and freeing up additional time for extra procedures.
Sue Kozlowski, Senior Healthcare Consultant, TechSolve: Tracking the patient experience through all the phases of their service and posting those metrics for staff to observe can make a huge change in the way OR teams view their process. Rather than "holding people accountable" for not meeting expectations, leaders can use the tracking metrics as part of a lean approach to ask the right questions — what is happening in our process to cause this issue? If we're not meeting targets, what's the impact on our customers? OR staff can see how they're doing rather than waiting for patient complaints. Together with a team-based approach to problem-solving, this one change can have a huge impact on the way OR teams work together to solve problems.
Joseph Livengood, MD, Acute Care Surgeon, Medical Center of the Rockies (Loveland, Colo.), Biomedical Engineer, President, Livengood Engineering: Employee participation in a "team" mentality throughout the OR and perioperative areas. There are a number of factors that can play a role in efficiency, but without question, the single most critical factor is the staff. The team approach needs to include the entire OR and perioperative staff and not be limited to service lines. I have had the privilege of working in ORs where staff routinely step outside of their duties and their assigned rooms to help keep rooms moving. Far more than helping with room turnover, the benefits are seen in finding equipment and supplies and keeping communication open. With a constant team approach to operations, the entire OR staff contributes to adapting to the inevitable ever-changing schedule throughout the day.
John Maa, MD, FACS, Assistant Professor, UCSF Department of Surgery: The single most helpful thing for ORs to do to enhance efficiency is to create an operating room suite dedicated for emergency procedures to accelerate hospital throughput, shorten hospital waits and reduce cancellations from a lack of inpatient beds. In many other countries the typical hospital OR allocates two-thirds of its ORs for elective procedures and one-third for emergency procedures during the daytime.
Adam McLarney, Director; Maggie Longshore, RN, MS, CNOR, CAPA, NE-BC, Senior Consultant, Blue Jay Consulting: Any OR should develop a vision by involving key stakeholders from nursing, physicians and administration. Leadership should effectively communicate the "why" for the improvements that are being proposed. Internal champions should be identified to support the change process and communicate to peers. The department should strive to establish an environment of trust with transparency of information and open, honest communication. Efficiency is dependent on everyone on the team supporting the initiative. To be successful and sustain efficiency initiatives must be approached and driven by a team concept.
Catherine Munoz, BSN, RN, CNOR, LNCC, Director of Perioperative Services, St. Vincent Medical Center (Los Angeles): Improving the pre-admitting and patient access processes are the key steps to reducing "day of surgery" delays and cancellations. Finding out the individualized needs of each patient and operating physician in advance can make the difference in getting those first cases of the day onto the operating room table on time. "First start," or first case of the day in each OR's scheduled line-up sets the tone for staying on time, which is the best indicator of efficiency and customer satisfaction.
Joe Smith, Vice President, Perioperative Strategy, Picis: Surgery delays and cancellations are the most disruptive and expensive issue impacting OR efficiency. Meeting the goals of an OR schedule requires both preoperative checklists and "day-of" surgery patient tracking solutions. The pre-op checklist needs to be easily accessed and proactively reviewed for completeness (i.e. consent form is on file, implants have been ordered and received, pre-op diagnostic testing is complete, patient has been given pre-op teaching instructions, etc). The "day-of" surgery tracking feature should combine patient monitoring with a communication mechanism that notifies the proper people of completed or pending events (i.e. let the surgeon know the patient has changed rooms, let the surgeon and anesthesiologist know a patient is ready for surgery, let the circulating nurse know that a patient is late arriving at registration, etc.).
Related Articles on OR Efficiency:
NAPA Releases White Paper on Improving OR Efficiencies Through Perioperative LeadershipAmerican College of Surgeons, 20 Others Offer Guide on Operations Requiring Physicians as Assistants
OR Resource Nurses Play Important Role in Scheduling, Patient Safety