Operating Room Turnover Analysis and Improvement · Slide 3 Project Client - MeritCare Health System MeritCare Health System, an entire network of care, is an integrated hospital

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Operating Room Turnover Analysis and Improvement

Reza Maleki and Melissa KramDepartment of Industrial and Manufacturing Engineering

North Dakota State University

Project Background

• Reflects the work of a team of students who, on behalf of MeritCare Health System, undertook the project “Operating Room Turnover”

• Conducted as a partial fulfillment for the Program and Project Management Capstone course

Client OverviewMeritCare Health System• Providing excellent care since 1905

• Largest practicing group in NDTwo Hospitals and 42 Supporting Clinics

• Over 1.5 million patients served a year with a service area that spans 250 miles

MeritCare Medical Center – Downtown Fargo• 380 Bed Facility

• Houses 11 surgical suites

• 2003 Surgical Department Synopsis:Over 9,400 cases and 22,400 case hours

Generated 37 million dollars in revenue

Project BackgroundNeeds Identification

Increasing efficiency of key profit center: Surgical Department

Focus on Turnover Efficiency in the Operating Room

MeritCare ContactsQuality Management Engineer

Executive Partner Surgical Services

Surgical Service Educator

CRNA Manager

Operating Room Manager

Statement of Work and Deliverables

Presentation Overview

• Project Objective

• Project Work and Research Activities

• Recommendations

• Project Benefits

• Suggestions for Future Projects

• Lessons Learned

• Questions

Project ObjectiveDetermine and propose methods to minimize the operating room downtime

Recommend ways to improve utilization by reducing turnover time

Room CleanupPatient Emergence Room Setup Patient Preparation

T u r n o v e r T i m e

Close Incision

Project Work & Research Activities

• Observations at MeritCare

• Meeting with individual staff members

• Outside discussions with professionals

• Research

• Data analysis

• Documentation

Turnover Process

Readying the RoomFinishing First Case Preparing Next Patient

Incision Closure• Incision closed• Dressing applied• Emergence from anesthesia

Patient Out of OR• Patient moved from OR table to

gurney• Patient transported to PACU

(recovery room)


Finishing First Case


Reference: Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process


OR Cleanup• Trash discarded• Case cart removed• Equipment collected for

reprocessing• OR floor & surfaces cleaned

OR Setup• Case cart delivered to OR suite• Instruments & supplies laid out• Sterile supplies opened• Missing items retrieved• Equipment positioned & Setup checked


Readying the Room

Turnover ProcessProject Work & Research Activities



Patient to OR• Patient transported to OR• Patient moved from gurney to OR

table• Patient positioned & prepped• Additional lines may be placed

Incision• Patient induced• First incision made

Preparing Next Patient


Turnover ProcessProject Work & Research Activities


Example TurnoverClockTime Event9:32 incision closed9:39 patient leaves (with CRNA & aide)9:43 room cleaned9:47 CRNA starts set up9:53 CRNA finishes set up

10:04 patient enters10:09 scrub nurse finishes room set10:23 patient prepped10:34 patient draped and incision made

Patient Waits

Staff Waits

Total Turnover Time = 62 min


Attainability of Additional CasesProject Work & Research Activities

7:308:008:309:009:30

10:0010:3011:0011:3012:0012:301:001:302:002:303:003:304:00

Overtime Overtime

Long Cases Short Cases

Case 1

Case 2

Case 3

Case 1

Case 3

Case 2

Case 4

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7


Recommendations

1. Early Patient Entry

2. Local Certified Registered Nurse Anesthetist (CRNA)

3. Front Loaded Anesthesia

4. Redefining Patient Transportation

Early Patient Entry

Time Saved

Room Cleanup

Patient in Holding Area Anesthesia Preparation

Room Setup

Patient Waits

OR Waits

TransportationInduction

Patient

OR

Recommendations

%25≈

Room Cleanup

Patient in Holding Area

Room Setup

Anesthesia Preparation TransportationInduction

Patient

OR


Early Patient EntryCurrent Process

Recommendations

Early Patient EntryProposed Process

Recommendations

Time Saved

%25≈

Early Patient Entry

• Shortened wait time experienced by both patient and operating room staff

• Balanced activities to eliminate bottlenecks in the process

• Potential to increase number of cases

Recommendations

Benefits

Recommendations





• Excluding first cases, an Anesthesiologist is responsible for completing all preoperative anesthesia evaluations

• Anesthesiologists have other equally important duties throughout the hospital

• Delays arise from varying demand

Recommendations

Local CRNA

Current Practice

Local CRNA

Delays by Department

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Surgeon Anesthesia Patient Other/ER Casein Progress

Nursing Lab/X-Ray Other

Recommendations

33%Anesthesia

Local CRNA

Recommendations

Anesthesia Delays

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Pt. Waiting

to be

seen by

Ane

s.Diff i

culty

Startin

g Line

sLin

e's in

Progres

s inHold

ing

MD Una

vaila

bleAne

sthes

ia Delay

s

CRNA Una

vaila

bleCRNA no

t ready

for Pt. Y

et.

Waiting to be seen by anesthesia

36%

Local CRNA

• Tried and true method

• Supports early patient entry

• Reduces patient and staff wait times

• Decreases delays caused by a busy anesthesiologist

• CRNA, who is more economical, is qualified to conduct the preoperative anesthesia evaluation

Recommendations

Benefits

Recommendations





• For small cases, large percentage of patients come to the OR with no anesthetic work done

• An additional task for the in-room CRNA

• Delays in the OR suite are more costly

Front Loaded Anesthesia

Recommendations

Current Practice / Issues


Anesthesia Delays

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Pt. Waiting

to be

seen by

Ane

s.Diff i

culty

Startin

g Line

sLin

e's in

Progres

s inHold

ing

MD Una

vaila

bleAne

sthes

ia Delay

s

CRNA Una

vaila

bleCRNA no

t ready

for Pt. Y

et.

Recommendations

Difficulty starting lines24%


• Reduces the impact of possible delays during the turnover process

• Limits negative effects of problem cases

• Reduces workload for in-room CRNA

Recommendations

Benefits

Recommendations





CRNA• Complete in-room setup • Transport patient into OR suite• Tasks are serial

Circulating Nurse• Usually has idle time at some point during

turnover process– After opening of supplies

Redefining Patient Transportation

Recommendations

Current Practice

Redefining Patient TransportationResource Utilization

Recommendations


• Supports early patient entry

• Frees up a crucial resource

• Assists in having the patient in the operating suite as soon they can be accommodated

Recommendations

Benefits

Example TurnoverClockTime Event9:32 surgery over9:39 patient leaves (with CRNA & aide)9:43 room cleaned9:47 CRNA starts set up9:53 CRNA finishes set up

10:04 patient enters10:09 scrub nurse finishes room set10:23 patient prepped10:34 patient draped and incision made

11 minutes

3 minutes

• Early Patient Entry

– Local CRNA

– Redefining Patient Transportation

• Front Loaded Anesthesia

Time Saved:

14 minutes – 22%

• Increased surgeon satisfaction

• Surgeon replacement costs of $20,000-$85,000

• Short-staffed one surgeon can result in lost revenue of over $100,000 monthly

Project Benefits

Project Benefits

• Costs negligible

• Possible additional cases and revenue

Potential profit could be upwards of $100,000 per suite if only one case a week is added (Source: MeritCare)

With one additional case per day, per operating room suite could translate to $4 - $7 million in annual revenue (Source: HFMA and Health Care Advisory Board)

Recommendations for Future Projects

SchedulingResearch has shown scheduling to having the largest impact on utilization and revenue

CommunicationIntegrated Information Technology Systems

First Case Start Times

SURGICAL DEPARTMENT

Lessons Learned• Work with staff & openly ask questions to learn the

complex perioperative process.

• Do not point out people or departments as problems, but instead stress the particular process as the problem.

• Keeping an open mind and recognizing the importance of compromising to ultimately reach the goal of the project.

• Make recommendations that will work and will receive buy-in from management and staff.

• Such projects provide enhanced learning opportunities for students, faculty, and business/industry clients.

Questions

Slide 1

Operating R

oom T

urnover Analysis and Im

provement

Reza M

aleki and Melissa K

ram

Departm

ent of Industrial and Manufacturing Engineering

North D

akota State University

Fargo, North D

akota 58105

Reza M

aleki, Ph.D., P.E

., C.M

fg.E.

Phone: (701) 231-8071

Fax: (701) 231-7195

Email:

Reza.M

[email protected]

http://ww

w.ndsu.edu/ndsu/m

aleki/Biography.doc

Melissa K

ram

Phone: (701) 367-4994

Email:

Melissa.K

ram@

ndsu.nodak.edu

Slide 2

This presentation reflects the work of a team

of students, who on behalf of M

eritCare H

ealth System

, undertook the project “Operating R

oom Turnover Efficiency.”

The project was also conducted as partial fulfillm

ent for the Program and Project

Managem

ent/Capstone course. The course is aim

ed at providing students with the opportunity to

work on real-w

orld projects for business/industry clients.

Slide 3

Project Client - M

eritCare H

ealth System

MeritC

are Health System

, an entire network of care, is an integrated hospital and clinical system

w

ith headquarters in Fargo, North D

akota. Established in 1905, MeritC

are has grown to be the

largest group practice in North D

akota, with 72 specialty areas of m

edicine. MeritC

are Medical

Group currently serves nearly tw

o million people a year across a service area that spans 250

miles w

est to east.

MeritC

are Health System

, in Fargo, consists of two hospitals and 42 supporting clinics. The tw

o hospital locations include M

eritCare M

edical Center (dow

ntown Fargo) and M

eritCare South

University. The M

eritCare M

edical Center has 380 adult and pediatric licensed beds.

Betw

een the two locations, there are currently tw

enty-one operating room suites. M

eritCare

Dow

ntown M

edical Center houses the m

ain operating rooms, w

hich consists of eleven suites. In 2003, the m

ain operating rooms had over 9,400 cases and over 22,400 case hours w

hich generated 37 m

illion dollars in revenue. In the fall of 2004 a twelfth suite w

as added, that is used for block scheduling part-tim

e and for add-on cases part time.

Slide 4

Like many other healthcare providers, M

eritCare m

akes every effort to better manage existing

resources, minim

ize waste, and increase the efficiency of various departm

ents. MeritC

are recognized the advantages of focusing on their key profit center – the Surgical D

epartment.

MeritC

are’s Operating R

oom Im

provement Team

had realized the potential for improvem

ents w

ith the current processes surrounding and involving the operating room suite turnover.

The project team’s first task w

as to set up and attend meetings w

ith MeritC

are contacts in order to gain as m

uch information as possible pertaining to developm

ent of the scope of the project, including learning and understanding the perioperative process. D

uring initial meetings, the

group met w

ith several mem

bers of MeritC

are Health System

staff including people from

surgical services, executive board, and quality managem

ent. Throughout these meetings, process

and project information w

as gathered and the ground rules were laid out.

After m

eetings with M

eritCare personnel and careful consideration of the needs and problem

s discussed, a statem

ent of work and deliverables w

as drafted and ultimately finalized.

Project Team

Deliverables

1. D

ocumentation of the current turnover process of the operation room

suites. 2.

Docum

ent with recom

mendations for im

proving operating room suites.

3. D

ocumentation providing cost/benefit analysis for the proposed im

provements.

4. A

n outline of recomm

endations for future projects and further improvem

ents.

Slide 5

Slide 6

The statement of w

ork included the agreed-upon project objective.

Project Objective

The objective of this project is to determine and propose m

ethods to minim

ize the operating room

downtim

e and, more specifically, recom

mend w

ays to improve utilization by reducing

turnover time.

Turnover rate, defined by MeritC

are, is the difference between the closure tim

e of one operation and the incision tim

e of the succeeding operation; including patient emergence, room

clean-up from

the previous case, suite setup and patient preparation for the subsequent case.

Slide 7

Observations / D

ata Collection

The project team’s first step tow

ards data collection was to becom

e familiar w

ith the complex

perioperative process, the medical jargon used, the job tasks of the staff, and the surgical

department environm

ent through numerous observations. C

ollecting the data was definitely the

most tim

e-consuming portion of the project. M

embers of the project team

made observations of

the turnover process between the cases occurring am

ong the 11 operating room suites. M

any tim

es, team m

embers w

ould pair up so one could watch the turnover, w

hile the other could follow

the patient from A

M adm

issions and the holding room to the surgical suite. O

ther cases involved one m

ember w

atching the turnover in the suite, while the other follow

ed the patient to the PA

CU

or recovery room. This allow

ed the team m

embers to w

itness all the processes directly related to the turnover and the associated possible delays. A

ll together, the project team

was able to accum

ulate over 25 observations and document m

ost of them. A

t first, there was a

concern with how

the staff would react to the team

mem

ber’s being present in the operating suites. H

owever, w

ith managem

ent support, that concern was never an issue. The m

anagement

of the surgical department inform

ed the staff of the team’s purpose and introduced the team

m

embers to m

any of the surgeons and anesthesiologists. Fortunately the majority of the staff

welcom

ed the team’s endless questions.

During the observation tim

e spent at MeritC

are, the observations that were taken involved m

uch m

ore than just watching the current process. The group felt that videotaping the turnover in the

room, w

ithout exposing the patient to ensure confidentiality, would be valuable for the first

observations. This allowed the team

to capture the process and have record of the observation, used to study the process and to later reference once the key factors w

ere identified. Since every operating room

suite generally performs different types of procedures, the group w

as able to observe a large variety of cases involving a num

ber of tear down, cleaning, and setting up

procedures. Since there was a variety of cases observed, team

mem

bers were able to w

itness different turnover team

s and equipment, as w

ell as the varying tasks that need to be performed

for a specific type of case.

Research

Research done prior to and during the project consisted of m

any different phases. The primary

reference used was C

lockwork Surgery, H

ardwiring E

fficiency into the Perioperative P

rocess,published by the C

linical Advisory B

oard in 2001. The book goes into great graphical detail on m

any of the aspects involved in our presentation, and also provided a template for som

e of the team

’s future recomm

endations.

Other research w

as done on the internet, particularly researching healthcare specific organizations. These resources enabled the project team

to find various methods used by

professionals working in the industry to tackle som

e of the same needs the project encom

passed.

Data A

nalysis The data and inform

ation gathered from observations, interview

s, meetings, and conversations or

emails w

ere organized into useful information to support the project team

in the development of

their recomm

endations.

Besides the data gathered by the group, the project team

was provided w

ith historical data from

previous and current projects and observations made by the client. The historical data w

as analyzed for accuracy and applicability to ensure that it w

as of use within the scope of the

project. One set of historical data w

as used to construct Pareto charts. Based on the charts, as

well as other inform

ation, the project team w

as able to identify two leading contributors to the

type of delay.

The project team also did analysis on data for room

occupancy times. A

lthough the data provided figures on the room

set-up and clean times, m

ost cases studied were not concurrent by

our definition of turnover, providing little significance.

Slide 8

A list of events that occur during each phase and factors influencing the turnover rate is com

piled and available through the reference book, C

lockwork Surgery, H

ardwiring E

fficiency into the P

erioperative Process. The team

used this resource as a guide to learn and understand the turnover process, but the process elem

ents were verified w

ith the actual process.

The T

urnover Process The operative process includes the entire turnover process that this project encom

passes. As

previously defined, operating room turnover tim

e is the difference between the closure tim

e of one operation and the incision tim

e of the succeeding operation; including patient emergence and

clean-up from the previous case along w

ith suite and patient preparation for the subsequent case.

The turnover process includes three sequential phases; finishing the first case, readying the room,

and preparing the next patient. There are a number of events that take place during each phase of

the process, along with a num

ber of factors that influence the turnover rate. There are various steps in each phase that m

ust be completed chronologically to ensure a sterile environm

ent.

Finishing First Case

The first phase of the turnover process is finishing the first case. This phase includes incision closure and transport of the patient out of the operating room

suite to the PAC

U for recovery.

Incision closure includes wound closure, dressing application, and em

ergence from anesthesia.

When transporting the patient, the patient is m

oved from the operating room

table to a transport bed and transported to the PA

CU

by the circulating nurse and anesthesia caregiver.

Slide 9

The T

urnover Process

Readying the R

oom

The second phase of the turnover process is readying the room, w

hich includes two m

ain steps; the cleanup of the previous case is com

pleted and then setup of the following case is started. The

operating room suite cleanup consists of discarding all drapes and trash, rem

oving the case cart, collecting equipm

ent for reprocessing, and cleaning the floor and surfaces (damp dusting). A

case cart is a shelving cart that holds all prepackaged supplies for the particular case. O

nce the cleaning tasks are com

plete, the staff continues by setting up for the next case. Setting up consists of delivering the case cart to the operating room

suite, laying out all supplies and instrum

ents, and opening sterile supplies. If there are any missing item

s, they are tracked down,

all the equipment is positioned, and finally, the setup is checked against the surgical preference

card for completeness.

Slide 10

The T

urnover Process

Preparing Next Patient

The third and final phase of the turnover process is preparing for the next patient. The patient is transported to the operating room

suite and moved from

the gurney to the operating room table,

where the patient is positioned and prepped for surgery. A

nesthesiology then inserts any additional lines not previously placed in the holding room

. Shortly thereafter, the patient is induced and the incision is m

ade by the surgeon. The turnover is complete.

Efficient room turnover requires careful orchestration of a large am

ount of staff mem

bers perform

ing an array of interconnected tasks. With the inherent com

plexity of the process, often tim

es a lengthy turnover is the rule rather than the exception.

Slide 11

An exam

ple of data collected during observation of the turnover process.

Slide 12

After som

e analysis of the current process, considerations to research, and discussions with key

MeritC

are personnel, it was decided that the length of case varied greatly. W

ith the timeline of

project a decision needed to be made as to the focus of the project, either shorter or longer cases.

Here, the definition of a shorter case is a case in w

hich the surgical time is an hour or less. A

s show

n in the figure, the shorter cases offer the greatest potential for attainability of additional cases. If the duration of the case is too long, the freed tim

e will be less than the tim

e it takes to perform

a case, pushing the last case into staff overtime, w

hich is not a desired effect.

Nevertheless, focusing on recom

mendations for shorter cases w

ill definitely provide the possibility of additional cases and in turn have the m

ost potential for a direct economic benefit.

Once the focus w

as determined to be the shorter cases, four m

ain recomm

endations were

formulated.

Slide 13

Recom

mendations

Based on their research, the project team

came up w

ith the following four recom

mendations:


2. Local C

ertified Registered N

urse Anesthetist (C

RN

A)

3. Front Loaded A

nesthesia 4.


Slide 14

Early Patient E

ntry

The theory behind early patient entry is to get the patient into the room as early as possible to

allow anesthetic, positioning, and preparatory w

ork to begin. Currently, there is a w

aiting period experienced by both the patient and the operating room

, but at different times throughout the

process. Since these wait tim

es are not in series, the elimination of both w

ait periods seems to be

a beneficial step.

The figure shown on this slide represents a basic exam

ple of the events taking place in the operation room

(top of the figure) and the events experienced by the patient (bottom of the

figure) prior to the surgery and after the previous patient has left the operating suite. Although

these waiting tim

es are not series in nature, they are definitely not independent. The wait

experienced by the patient when w

aiting to be transported to the room creates the w

ait in the room

while the patient is being transported.

By sim

ply moving up the tim

e that the patient transportation to the operating suite takes place, both w

ait times can

be eliminated (or at a m

inimum

reduced). The slide animation show

s the new

process and the expected time saved, for a saving in tim

e about 22% of the total average

turnover time.

Slide 15

Early Patient E

ntry

This and the next slide show the turnover process, broken dow

n by task in a Gantt chart, to m

ore specifically show

how early patient entry can benefit the turnover process.

The figure on this slide shows an exam

ple of the current process, compiled using average tim

es found during observations, from

research, and the documents provided by the client. There are

certain tasks that must follow

in a serial manner; how

ever, the current process is not taking full advantage of parallel processes w

ith a certain group of tasks. It appears that there is a lack of parallel processing w

hen it comes to the w

ork done by anesthesia in coordination with the rest of

the process tasks and employee utilization.

Slide 16

Early Patient E

ntry

The figure on this slide demonstrates w

hat the ideal process would look like. N

otice that none of the task lengths have been altered or dependencies elim

inated. Instead, by having the patient enter the room

imm

ediately when the room

is allowed to accept the patient (w

hen all supplies are opened) the overall turnover tim

e can be substantially reduced by about 25%.

The chart shows an idyllic process for turnover in the room

. In this case, the CR

NA

comes back

from the PA

CU

and begins setup almost im

mediately. Tim

e has been allotted for completing

paperwork and checking narcotics in and out. The total tw

elve minutes that the C

RN

A is show

n to be out of the room

is felt to be an adequate amount of tim

e for the average non-problematic

case.

A m

ilestone has also been added to this chart to show the im

portance of the surgeon getting to the operating suite at an appropriate tim

e. Most of the tim

e, the surgeon needs to be present to position the patient properly and check the setup. O

ne of the most difficult things about

implem

enting a new plan is having the involved personnel accept it.

In order for early patient entry to work, all personnel involved w

ith the perioperative process m

ust be adaptive to parallel processing and some support features m

ust be in place. In order for the patient to be prepared to enter the operating room

, all preoperative work m

ust be done; including tests, paperw

ork, evaluations, etc. Delays in these areas w

ill inevitably delay the start tim

e of the procedure.

Slide 17

Early Patient E

ntry

The following benefits can be realized from

implem

enting early patient entry: •

Shortened wait tim

e experienced by both patient and operating room staff

• B

alanced activities to eliminate bottlenecks in the process

• Potential to increase num

ber of cases

Slide 18

Slide 19

Local C


urse Anesthetist (C

RN

A)

One of the processes prior to transporting the patient to the operating suite is the preoperative

anesthesia evaluation process. Currently (excluding the first cases of the day) an anesthesiologist

is responsible for seeing patients in AM

admissions for the preoperative anesthesia evaluation.

AM

admissions is located on another floor, requiring the anesthesiologist to travel a noticeable

distance in the hospital. The problem w

ith this process is that anesthesiologists are also responsible for m

any other equally important activities throughout the hospital.

Observations show

ed situations where the patient in the A

M adm

issions area had to wait to be

visited by the anesthesiologist before they could proceed to the operating room area. The

anesthesiologist was late because of other tasks that they w

ere working on that could

understandably not be abandoned or delayed. So the problem becom

es how to elim

inate such delays w

ithout being a hindrance to the quality of care provided to other areas of the hospital.

Slide 20

Local C


urse Anesthetist (C

RN

A)

Historical data, w

hich was provided by the client, also supports the project team

’s observation of delays due to the patients w

aiting to be seen by the anesthesia caregiver. The figure on this slide show

s the overall delays caused by various departments. A

ccording to the figure, the anesthesia departm

ent is the second major contributor to the delays. This figure is based on the year 2003

data.Slide 21

Local C


urse Anesthetist (C

RN

A)

Further analysis of the historical data shows that the prim

ary anesthesia delay (about 36%) w

as the patient w

aiting to be seen by an anesthesiologist.

The proposed solution is to have a staff capable of doing preoperative anesthesia evaluations perm

anently located in the admissions area. In the first case scenario, there is a m

aximum

of two

CR

NA

’s or MD

A’s located in the A

M adm

issions area to see upwards of nine patients nearly

simultaneously. The first case is generally the busiest tim

e for the admissions area, so there

definitely should be no need for any more than tw

o throughout the day and there is a strong possibility that one could handle the m

ajority of the day, only having an anesthesiologist come

down to help w

hen needed.

Slide 22

Local C


urse Anesthetist (C

RN

A)

A local C

RN

A is a tried and true m

ethod at MeritC

are. This was the standard practice until

roughly five years ago when the shortage of C

RN

A’s caused m

anagement to m

ove that individual into the operating suites. N

ow that the anesthesiology departm

ent is close to their full C

RN

A staff, the C

RN

A M

anager felt that they had the capacity to fill the position in AM

A

dmissions.

This recomm

endation supports early patient entry as it will aid in reducing both patient and staff

wait tim

es. This will also decrease delays caused by a busy anesthesiologist.

Having a C

RN

A in the adm

issions area for preoperative anesthesia evaluation is a template

followed by a num

ber of different practices. One hospital system

, the University of W

ashington M

edical Center (a 450-bed com

prehensive care facility), went as far as to give nursing staff

specialty training to perform the anesthesia evaluation. Patient records and nursing assessm

ents are then review

ed then by an anesthesiologist or a nurse anesthetist prior to surgery.

Another possible benefit seen from

implem

enting a nurse anesthetist in AM

admissions is

allowing the anesthesiologists to spend m

ore of their time in the surgical departm

ent. This could possibly have a large im

pact on facilitating problem anesthetic cases and getting problem

atic lines started on tim

e. This idea opens the door to a third recomm

endation – front loaded anesthesia.

Slide 23

Slide 24

Front Loaded A

nesthesia

The current practices and issues involved with front loaded anesthesia include:

• For sm

all cases, large percentage of patients come to the O

R w

ith no anesthetic work done

• A

n additional task for the in-room C

RN

A

• D

elays in the OR

suite are more costly

Front loaded anesthesia is the practice of doing as much anesthesia w

ork as possible before the patient is brought to the operating suite. That w

ill help to reduce and/or prevent related potential delays in the operating room

. The thought behind this recomm

endation are the delays that are not the every day occurrence, but w

hen they happen, are detrimental to the turnover process and

case start times. There can be tim

es when there is difficulty starting even the basic lines, such as

IVs. If this delay occurs in the A

M adm

issions area or the holding room it is not directly

affecting the turnover time in the operating suite.

Slide 25

Front Loaded A

nesthesia

The second leading anesthesia delay is difficulty starting lines in a patient, according to the historical data from

2003. Although the causes for those delays are not w

ithin the scope of this project, rem

oving the delays from the operating room

(during the turnover process) is within the

scope of this project.

Slide 26

Front Loaded A

nesthesia

This recomm

endation can not be looked at as a cure all, as it does not apply to all cases. Once

again the primary benefits from

implem

entation will com

e from the sm

aller cases where there

seems to be a tendency to have all of the anesthesia w

ork done in the operating room, rather than

having a patient be burdened by an IV tree.

There are many interdependencies am

ong various perioperative processes and a delay in any one area w

ill cause major delays in the entire turnover. This reason alone should be enough to show

the im

portance of controlling and offloading delays that can not be eliminated.

Front loaded anesthesia would lim

it the effects of problem cases w

hen considering the total turnover tim

e. This will also reduce the w

orkload for the in-room C

RN

A, the critical resource.

This brings us to the final recomm

endation – redefining patient transportation.

Slide 27

Slide 28

Redefining Patient T

ransportation

Observations have show

n that in most occasions, the C

RN

A is responsible for retrieving the next

patient. This is another example of tying up a valuable resource. There w

ere documented

instances when the circulator, or som

etimes also an aide, w

ere waiting in the room

for the CR

NA

to finish setting up their equipm

ent so that same C

RN

A could go retrieve the patient from

the holding room

. From interview

ing staff about this situation, it was learned that patient retrieval

was not alw

ays one of the CR

NA

’s standard job tasks, but instead had become the practice over

time. Slide 29


ransportation

This slide shows the utilization of som

e of the resources during the turnover process. One can

conclude that one of the options is, where and w

hen possible, to redistribute workload for m

ore equitable use of the em

ployee resources.

The proposed idea is to have the circulating nurse retrieve the patient. Observations have show

n that in m

ost cases due to the current process, the circulating nurse has idle time right after

opening the supplies. This is also supported by the collected data during year 2000 by a M

eritCare study that charted resource usage and tim

es. You can see here in the G

antt chart w

here in the process redefining patient transportation is important.

If the circulating nurse should happen to be truly busy, a mem

ber of the holding room staff or the

operating room orderly staff w

ill be responsible for bringing the patient to the operating room.

The CR

NA

, the critical resource in the turnover process, should be leaving the room to retrieve

the patient only when it is absolutely necessary. Since the tasks perform

ed by the in-room

CR

NA

are quite serial, this will autom

atically create a delay in the process. Therefore, this option should be evaluated very carefully.

Transportation of a patient to the operating rooms from

the OR

holding room takes, on the

average, six minutes for an average shorter case, and can be upw

ards of 20 minutes if the patient

must be retrieved from

the AM

admissions area. The accum

ulation of six to twenty m

inute transports over the course of a day can add up very quickly.

Slide 30


ransportation

The benefits of redefining patient transportation include: •

Supports early patient entry •

Frees up a crucial resource •

Assists in having the patient in the operating suite as soon they can be accom

modated

Slide 31

Revisiting the E

xample T

urnover to Show E

ffects of Recom

mendations

To show you the effects of our four recom

mendations, let’s revisit the exam

ple turnover discussed earlier. There w

ere eleven minutes in this turnover w

here the patient was w

aiting to enter the operating suite and the operating room

was w

aiting for the patient to begin prep. The patient could have entered the operating suite as soon as the C

RN

A finished their set up. Y

ou can see how

early patient entry would have decreased the total turnover tim

e with the support of a

local CR

NA

and redefining of patient transportation. There was also a three m

inute delay in this case, considering the tim

e that it took the CR

NA

to place the anesthesia line. While the line w

as being placed the rest of the personnel w

ere idle. Front Loaded Anesthesia, placing the line prior

to entering the operating suite, would have elim

inated this delay in the process. These im

provements w

ould have brought about a time savings of 14 m

inutes or about 22% in the

overall process.

Slide 32

Project Benefits

As justification for the project recom

mendations, there w

ere two m

ain areas that the project team

identified as benefits to be gained from im

plementation of the recom

mendations. The first

benefit is increased surgeon and staff satisfaction. Secondly, by decreasing downtim

e of the operating room

, there is potentially room in the schedule for additional surgical cases and

income.

When it com

es to surgeon satisfaction, the truth is, it is expensive to not have one. Recruitm

ent costs for a new

surgeon can cost anywhere from

$20,000 for just recruitment costs, to upw

ards of $85,000 if a sign-on bonus is needed and a recruiter is utilized. These m

ay be one-time costs,

but the loss in revenue from being short-staffed a surgeon is even m

ore substantial since one surgeon can provide over $1 m

illion dollars in revenue every year. The costs alone make it

important to hold surgeon satisfaction as a high priority, not to m

ention the non-quantifiable effects losing a good surgeon can have on a practice as far as recognition and recruiting other quality staff.

Maintaining surgeon satisfaction is of utm

ost importance to m

anagement of m

edical facilities. Surgeons are an integral part of the healthcare com

munity and certain considerations should be

made to achieve a high satisfaction rate. A

ccording to a national survey conducted by the B

arnes-Jewish St. Peters H

ospital, 74% of surgeons rated the im

portance of surgical turnover as “very im

portant”.

It was also found by the national survey, that the ideal turnover tim

e for 54% of surgeons

surveyed is a 10-15 minute turnover tim

e. Although that short of a tim

e is rather unrealistic for m

ost cases, it shows how

important of a factor short turnover tim

es are for surgeon satisfaction, and the benefits that can be gained from

working to reduce turnover tim

es.

As a general conclusion, if surgeons are satisfied w

ith the system in w

hich they work, they w

ill be m

ore likely to stay and become an asset to the facility.

Slide 33

Project Benefits

The implem

entation costs of the recomm

endations given are negligible to MeritC

are, requiring no additional capital or labor investm

ents. The primary financial benefit w

ould be revenue generated from

additional cases. Reducing room

turnover rates alone will not guarantee tim

e for additional cases in every room

, however, the reduction of accum

ulating unproductive time

throughout the day will provide opportunity for additional cases in the room

s that hold smaller

cases and turnover time accounts for a m

ore substantial portion of the daily scheduled time.

Here again the focus of the project team

has been on the achievable smaller cases. Sm

all cases (laparoscopic gallbladders for exam

ple) that are done in the general surgery rooms have healthy

per case. These cases have actual procedure times of about 25 m

inutes, and the entire case can be facilitated in less than an hour. If an average of 15 m

inutes can be saved between at least four

successive cases in one day, it would provide am

ple room for an additional sm

all case. A

ccording to figures given by MeritC

are, the amount of profit generated w

ould be upwards of

$100,000 per room if only one case a w

eek can be added. The best case scenario of three rooms

adding one small surgery five days a w

eek would generate profit of over $1.3 m

illion dollars. A

ccording to the Healthcare Financial M

anagement A

ssociation (HFM

A) and the H

ealth Care

Advisory B

oard, improvem

ents resulting in one additional case per day per operating room suite

could translate to four to seven million dollars in annual revenue.

Slide 34

Recom

mendations for Future Projects

Based on the research and observations m

ade, the project team recom

mended a num

ber of projects that have potential to further im

prove turnover process.

The current scheduling process needs to be analyzed and improved. The current scheduling

process does not provide for efficient utilization of operation rooms. Im

proved scheduling procedure should provide for appropriate block tim

e utilization and scheduling proper length per case.

Incorporating an integrated IT system w

ould facilitate for simultaneous relay of real tim

e case data to all pertinent locations. The IT system

also allows for instantaneous changes that w

ould help in scheduling preoperative patient activities and having the patients prepared and available to go into the operating suite w

hen it becomes available.

In addition, the project team recom

mended to M

eritCare that the O

perating Room

Improvem

ent Team

continue their efforts to increase the number of on-tim

e starts for first cases.

Slide 35

Slide 36

Documents

Operating Room Turnover Analysis and Improvement · Slide 3 Project Client - MeritCare Health System MeritCare Health System, an entire network of care, is an integrated hospital