Quality Improvement Proposal: Increasing OR Efficiency

Quality Improvement Proposal: Increasing OR Efficiency

Grand Canyon University

HLT 362 V

Quality Improvement Proposal: Increasing OR Efficiency

When looking at increasing surgical volumes and patient access, improving surgical efficiency is a multi-faceted collaborative quality improvement initiative. The operating room is one of the hospitals most costly resources. The design, staffing and utilization of this resource are important to patient safety and financial productive efficiency. Inefficiencies within the perioperative setting have a negative financial impact on an institution and cause patient and staff dissatisfaction. Numerous factors affect operating room productivity and efficiency including patient scheduling, patient through-put, operating room staffing practices, equipment resource allocation, patient problems, and unexpected events. Efforts to increase operating room productivity and efficiency must be balanced with patient satisfaction and safety to provide for optimal patient outcomes (Tagge, Thirumoorthi, Garberoglio, & Mitchell, 2017).

A study from Sao Paolo Brazil highlighted the use of Lean Six Sigma concepts to develop quality improvement strategies to increase operating room efficiency. This hospital started with first case on-time start or first case tardiness. Using the standard Lean Six Sigma framework of define, measure, analyze, improve, and control (DMAIC), the hospital compared the previous year case start times to the two groups established for the study. Within the study, the hospital implemented identified changes in one group and the second group remained with the current processes. The primary outcome measures were the proportion of late starts and the mean tardiness in minutes. Other identified outcomes were operating room utilization and cases running after regular hours. The findings were a significant decrease in the proportion of late starts and mean tardiness post implementation of the identified strategies. Surgical cases starting late decreased from 62% to 31%, and mean tardiness decreased from 56 minutes to 34 minutes. This hospital also realized a block utilization increase of 3% and a decrease in cases running late by 2%, clearly identifying the need and efficacy of the quality improvement initiative (Ramos et al., 2016).

A second study is a retrospective look at a single physician caseload over a six month period at a children’s hospital. Four parameters were identified to include, patient enters the room to procedure start (T1), procedure start to procedure end (T2), procedure ends to patient exits the room (T3), and patient exits the room to the next patient enters the room (T4). These findings were compared to current literature and results presented to stakeholders. Findings from the study of 180 otolaryngology cases revealed efficiency in the T2 and T3 areas and marked inefficiency in the T1 and T4 areas. The study recorded results of time in minutes with a mean and standard deviation, and interquartile range. The T4 or room turnover time observed a mean of 31.09 with a standard deviation of 16.09 and median of 26 with IQR of 20 to 33. Benchmark for room turnover is noted to be a median of 9 (Perkins, Chiang, Ruiz, & Prager, 2014). This institution was able to compare with other benchmark studies to demonstrate the need for further quality improvement strategies to improve operating room efficiency.

The third study took an interdisciplinary approach and formed a governance committee to oversee the quality improvement project. Through this committee, four more committees were formed to look at the inefficiencies by utilizing lean six sigma strategies. These teams included employees from surgical scheduling, operating room, pre-operative and post-operative nurses, sterile processing technicians, patient care technicians, anesthesia technicians, and supply technicians. Through the identification of inefficiencies and the subsequent implementation of solutions, this facility increased operating room utilization from 68% to 74%, an increase in first case on-time starts from 32% to 73% (a 128% increase), and a decrease in after-hours room use by 50%. This facilities approach led to marked improvements in patient access, surgical volumes, efficiency, staff satisfaction, and financial performance (Bender et al., 2015).

Beginning work on a quality improvement project starts with defining the problem. In this case, on-time first case starts in the operating room. The questions to ask are; will improving on-time first case starts increase operating room efficiency? What are the barriers to on-time first case starts? How will the data be measured? To begin collecting data, the formulation of a committee involving all areas that affect the operating room are to be included to garner different perspectives from each area. An oversight committee of management will help to steer each committee. Using a lean six sigma approach in each area, the teams will map out their part of the process for patient throughput from registration to preoperative care unit to operating room to recovery room and discharge either home or to a unit. A separate team will look at the barriers to inpatients coming to the preoperative unit for surgical procedures. Through mapping out the processes, each team will define the areas that cause a problem in patient flow. These are called “pain points” to patient care. For the first phase of the improvement project, one identified variable will be addressed per area. Specific definitions for on-time first case starts will be defined by the managing committee and are usually defined as “wheels in the room”. The process and data collection occurs over many months but is evaluated monthly throughout the process.

Data to be gathered will include the time the patient registers in admitting to the time the patient is placed in a bed in the preoperative unit. The time the patient reaches the preoperative unit to the time into the operating room, along with the surgical schedule estimated time for the surgical procedure. The latter time is used to determine the validity of the schedules automated surgical procedure length. The length of time the patient is in the operating room to determine surgeon block utilization and room utilization. The time the patient leaves the operating room to the next patient arriving in the operating room to determine room turnover times. Time the patient arrives in the recovery room to discharge from the recovery room. All times are recorded in minutes for each operating room, surgeon, and patient. Mean, median, and standard deviations will be calculated for each operating room, surgeon, and patient. To calculate operating room utilization, OR utilization will equal the sum of time the OR is used by patients divided by the sum of OR block time available times 100%. All results will be compared to a same size and type facility, meaning the same type of surgical procedures for example, a level II trauma center to a level II trauma center, for benchmarking. Results noted to be within the mean and standard deviation is considered normal and will require little to no changes in practice. To test the hypothesis of improving first case on-time starts increase operating room efficiency, calculation of OR efficiency equals the sum of operative time divided by the sum of case process time times 100%. Comparisons will be made within the facilities monthly data as a percentage increase or decrease over time.

The variables likely to be seen include, insurance precertification issues and late arriving patients in the admitting area. Confusing or overlapping orders, patient did not receive preoperative testing prior to day of surgery, late surgeon, and no clear indication that a patient is ready for surgery may be seen in the preoperative area. Variables in the operating room may include late arriving staff, scheduling resource conflicts, lack of leadership to move the schedule, previous case running late or an emergency case using the operating room, and missing paperwork missed by the preoperative nurse. Recovery room variables include extended recovery time, use of recovery room for non-recovery patient care, and unavailable anesthesiologist for patient discharge.

Implementation of the quality improvement initiative is staff driven with management oversight and guidance. In the admitting area, placing one admitting clerk on working the schedule 96 hours ahead helps to decrease the number of patients cancelled day of surgery due to pre-certification issues. Utilizing a system such as “red light”, “yellow light”, and “green light” will enable the department to monitor those patients with pre-certification issues that need to be referred back to the surgeon’s office for further paperwork. In the preoperative area, identifying those patients requiring extensive work-up prior to surgery and collaborating with anesthesia to develop pre-admission testing criteria to have these issues rectified prior to arrival will decrease delays in readying the patient for surgery. For the operating room, a complete review of surgeon preference cards for accuracy is the first step for ensuring that the caseload for the day is put together with necessary supplies and equipment to decrease staff needing to search for items. Along with this, a complete inventory of equipment and needs will be communicated to the surgery scheduling office to “flag” over-booking of equipment resources. Evaluation of post anesthesia care criteria is reviewed with the recovery room staff and anesthesia team to define redundant or confusing orders and discharge criteria.

As the data is continually analyzed and issues identified and corrected, on-time first case starts will improve along with block utilization, day of surgery case cancellations, operating room turnover times, supply and resource utilization, and patient, surgeon, and staff satisfaction. The financial gains noticed through this initiative could increase substantially based on the hospital and payer mix. This is a continual quality improvement initiative that essentially has no end date and requires constant evaluation of the metrics through a dashboard that allows for real-time data analysis.

References

Bender, J. S., Nicolescu, T. O., Hollingsworth, S. B., Murer, K., Wallace, K. R., & Ertl, W. J. (2015, March). Improving operating room efficiency via an interprofessional approach. The American Journal of Surgery, 209, 447-450. https://doi.org/10.1016/j.amjsurg.2014.12.007

Perkins, J. N., Chiang, T., Ruiz, A. G., & Prager, J. D. (2014, May). Auditing of operating room times: A quality improvement project. International Journal of Otorhinolaryngology, 78, 782-786. https://doi.org/10.1016/j.ijporl.2014.02.010

Ramos, P., Bonfa, E., Goulart, P., Medeiros, M., Cruz, N., Puech-Leao, P., & Feiner, B. (2016, December). First-case tardiness reduction in a tertiary academic medical center operating room: A lean six sigma perspective. Perioperative Care and Operating Room Management, 5(), 7-12. https://doi.org/10.1016/j.pcorm.2016.12.001

Tagge, E. P., Thirumoorthi, A. S., Garberoglio, C., & Mitchell, K. W. (2017). Improving operating room efficiency in academic children’s hospital using Lean Six Sigma methodology. Journal of Pediatric Surgery, 52, 1040-1044. https://doi.org/10/1016/j.jpedsurg.2017.03.035