7 keys to sustainable improvement in perioperative services
Most hospital leaders understand the need to boost OR performance. Payment reform is forcing surgery departments to improve quality and outcomes while reducing costs. But many CEOs hesitate to launch an aggressive OR transformation effort. After the push to improve operations, will staff revert to prior ways? Will a "misfire" frustrate surgeons? Will the OR's problems become more entrenched than ever?
These concerns are valid. Experienced hospital leaders know that process improvement is not enough. Change management is essential to achieving long-term gains. The problem is that generic change management strategies are not adequate for transforming a hospital OR.
What's different? In an OR, several powerful constituencies share an environment where the economic stakes are high and the margin of error is thin. Persuading surgeons, anesthesiologists and nurses to agree on new goals and processes is hard. Forcing them to maintain changes after the pressure is off can be next to impossible.
How can hospital leaders overcome these challenges to achieve sustainable improvement in surgical quality and outcomes while reducing costs? The key is to foster a culture change that takes into account the unique dynamics of perioperative services throughout the transformational process. Interestingly, ORs that achieve lasting improvement share seven common traits:
1. Shared governance led by physicians
Most hospital ORs are run by nursing management. Surgeons and anesthesiologists have little say in key decisions, and they are not engaged in efforts to improve OR operations. Lack of physician involvement leads to a general decline in efficiency and outcomes.
Many ORs have reversed this decline by establishing a multidisciplinary surgical services executive committee to run the operations of the OR. An SSEC includes surgeons from several specialties and representatives from anesthesia, OR nursing and hospital administration. The committee has full control over OR operations, and it is specifically empowered to make changes to improve departmental efficiency. It is not an extension of the medical executive committee or the surgical departments, but rather an administratively sponsored "board of directors" for the OR.
Why is physician-led governance effective? An SSEC's main objectives are to establish the block time schedule and enforce block rules, so the committee controls access to the OR. Rank-and-file surgeons comply readily with the decisions of the SSEC. In addition, physician governance creates strong peer pressure to conform to clinical protocols and meet utilization thresholds.
2. Engaged and collaborative anesthetists
Anesthesiologists and CRNAs are the gatekeepers of the OR. If an anesthetist does not clear a patient for surgery, the case cannot proceed. The trouble is that variation in anesthesia practice creates problems in many hospitals. Say a patient presents with a slightly abnormal EKG but is cleared for surgery by the anesthetist in preadmission testing. On the day of surgery, however, a different anesthetist orders additional testing. This significantly delays or effectively cancels the case.
To improve OR efficiency, the anesthesia department must develop consistent algorithms and lab matrices for decisions on patient clearance. This includes gaining department agreement on how to optimize patients for surgery, establishing pre-surgical testing requirements based on procedure and patient comorbidities and developing standards for evaluating abnormal lab results.
Anesthesia culture can create an obstacle to efficiency. Anesthesiologists — especially in non-academic settings — are often reluctant to "ruffle feathers" within their group by imposing standards on other peer providers. Two things are critical to overcoming this obstacle. First, the chair of anesthesia must be firmly behind efforts to establish clinical standards. A strong chair can set the expectation that all anesthesia staff will help establish department protocols and adhere to group decisions.
Second, incentives must be aligned with department protocols. The anesthesia provider contract should include either (1) productivity incentives or (2) service standards regarding efficiency and quality improvement. Under an effective contract, if an anesthetist does not want to clear a patient who falls within agreed-upon guidelines, he or she is released from the room and another provider substitutes. This approach preserves professional autonomy while creating an economic incentive to meet clinical standards.
3. Progressive nursing leadership
A strong nurse management team is essential to improving perioperative performance and maintaining gains. In many hospitals, however, nursing leaders are unwilling to rethink traditional processes. Some lack appreciation for the business dimension of surgical services. Others have a poor relationship with nursing staff or are unwilling to collaborate with surgeons. And other nurse leaders are strong but lack the support of anesthesia and/or administration, which undermines their ability to make decisions and drive change. All these situations make it difficult to move the OR forward.
I have had the privilege to work with many amazing OR nursing directors and managers. These leaders share a handful of characteristics:
- They are committed to boosting clinical quality and outcomes through continuous process improvement.
- They understand the drivers of OR financial improvement and their macro effect on the financial health of the hospital.
- They work collaboratively with physicians, hospital executives, unit leaders and ancillary managers to achieve perioperative performance goals.
The best nursing leaders are also respected for their clinical skills. OR leaders with strong frontline experience more easily secure the cooperation of nursing staff and earn the respect of surgeons and anesthesia providers.
4. Data-driven management
Transforming an OR is all about modifying behavior to deliver desired results. Staff and physicians must continuously adopt new practices and work patterns. Unfortunately, the "that's the way we've always done it here" attitude can prevent change from getting off the ground. The key to overcoming the status quo is to hold staff and physicians accountable through comprehensive performance measurement and consistent reporting.
Better-performing ORs track and report efficiency metrics such as day-of-surgery cancellation rates, late-start rates, close-to-cut times, and block and OR utilization rates. These organizations track profitability by monitoring cost per case for specialties and surgeons. Reviewing this data regularly helps instill new behaviors in nursing staff, surgeons and anesthesia providers, and sustain process changes.
An effective metric reporting program will also cover:
- Quality metrics, including Surgical Care Improvement Project measures, complication rates, length of stay and readmission rates
- Patient HCAHPS scores and surgeon and staff satisfaction survey results
- Case volume, cost per case, case mix and other financial performance measures
Leading ORs share data with the entire surgeon staff. Physicians see each other's performance on utilization, average case time, direct costs and other clinical and operational measures. Data reporting creates healthy competition, spurring surgeons to conform to best practices and strive for time- and resource-efficiency.
It is important to showcase performance improvements and provide transparent accountability, so don't be afraid of over-communicating. Share data through a balanced scorecard, a physician scorecard, a lean daily management board in the OR and a monthly newsletter.
5. Strong C-suite leadership
In better-performing hospitals, greater than two-thirds of revenue and 60 percent of margin are derived from perioperative services. Executive leaders understand the importance of surgery to the financial viability of the hospital. So when an OR transformation project begins, it's important to have a crucial conversation with the executive team.
Any significant change will generate complaints. When change affects surgeons directly, some will take their grievances straight to the CEO or others within the C-suite. Afraid of losing case volume, many CEOs will acquiesce to surgeons' demands without a clear understanding of the intended or unintended consequences. This can easily undermine OR local decision making, OR process improvement, block reform and capital spending decisions.
To achieve sustainable change, hospital executives must provide unwavering support for the SSEC. When a surgeon engages an executive in a "hallway conversation" about an OR concern, the executive must have the courage to defer the issue to the SSEC and the committee member who represents the surgeon's specialty. When surgeons see that hospital executives stand by SSEC decisions, complaints diminish and multidisciplinary OR leadership becomes even more effective.
6. Informed trustees
The same dynamic can play out in the boardroom. In most hospitals, the board of trustees or directors includes several high-profile physicians. Surgeon trustees who are dissatisfied with an SSEC decision are not above appealing directly to their fellow board members. The board then puts pressure on hospital administration to favorably resolve the surgeon's complaint or request.
To ensure progress, include trustees in the OR's change management plan. OR leaders should request time during a meeting of the hospital board (or if your facility is part of a larger health system, the system board) to explain the importance of OR transformation. Clarify the value of shared governance, how the SSEC will function and how it will help improve OR efficiency and outcomes. Most important, alert trustees to expect some turbulence in the change process. Stress the importance of referring all OR operational decisions to the SSEC for multidisciplinary discussion and resolution.
7. Solid referral platform
Perioperative improvement can collapse if the OR begins to falter within its primary or secondary market. As the economic opportunity diminishes, physician commitment can weaken. In addition, staff shift reductions can undermine staff morale and chip away at nurses' willingness to support change.
Effective business strategy is critical to sustaining an OR transformation. The foundation is a solid medical staff development plan, but physician manpower planning is just the start. Better-performing ORs use three additional strategies to build a strong referral pipeline:
Leveraging internal resources. Many ORs fail to capture potential referrals from other hospital departments and services. An occupational health program, for instance, can produce a steady stream of patient referrals for orthopedic surgery. The emergency department can generate orthopedic referrals as well as referrals for some cardiovascular procedures. Wound care can generate referrals for both vascular and general surgery procedures. OR leaders should work with these departments to create referral protocols and build the infrastructure to identify potential surgery candidates. An effective internal referral structure will also help you use employer/hospital partnerships to capture additional OR volume.
Maximizing referrals from employed physicians. In many hospitals, employed physicians send a percentage of surgery referrals outside the health system. The majority of these referrals are for surgical care available within system facilities. To capture these cases, leverage the Hawthorne Effect, whereby behavior changes as a result of observation. Require practice managers to justify all outgoing referrals in writing. Referral patterns improve dramatically when employed physicians are held accountable for unwarranted outmigration.
Optimizing referrals from community physicians. The key to connecting with private practice physicians is to create a path of least resistance for surgery referrals. First, streamline the scheduling process. Second, develop a PAT process that optimizes patients pre-surgically with minimal effort from the referring physician. Third, require surgeons to send follow-up communications to referring physicians. In addition, provide surgeons with tools to grow their practice through grassroots marketing campaigns. ORs that help busy surgeons develop their business and provide an uncomplicated referral pathway are able to attract more patients from the private medical community.
Sustaining gains
Achieving sustainable improvement in perioperative services is more important than ever. The key is to align multidisciplinary leadership, economic incentives and organizational culture. ORs that do this successfully realize lasting improvements in quality, efficiency, outcomes and costs.
Robert M. Dahl, MBA, is senior vice president and COO of Surgical Directions, a perioperative consulting firm that helps hospital ORs improve efficiency, financial performance, clinical outcomes, and patient and staff satisfaction. He can be reached at (312) 870-5600 or rdahl@surgicaldirections.com.