What is the pacemaker in a healthcare facility? Not a medical pacemaker device, but instead the process step that determines the rate of patient throughput. For most surgical hospitals, it is the operating room (OR). The number of patients in admissions, pre-op, post-op, waiting rooms, hospital beds, and on the road back home ties largely to the flow rate or patient cycle time through the operating room.
Operating room cycle time, also known as total case time
In manufacturing, cycle time is often defined as the starting point of one unit’s processing to the starting point of the next unit. In an operating room, the unit is the patient and the cycle time is referred to as total case time, from OR setup start to room clean up finish. Assuming the facility has continuous patient demand, as soon as cleanup finishes for one patient, set up for the next patient begins. Two primary components make up this metric: surgeon time and operating room turnover.
To some extent an operating procedure can be compared to a Formula 1 auto race with pit stops. The surgical procedure itself is similar to the driver racing safely along the course. The operating room turnover is similar to the pit stop; get it done as quickly as safely possible, so the main racing process can continue.
For the purpose of completing the race or the overall patient procedure the pit stop or turnover doesn’t add any value, but doing either of these slowly reduces overall effectiveness. Doing either of these unsafely can lead to serious accidents.
Historically auto race pit stops were measured in minutes; in 2017, most Formula 1 teams accomplish the task in about 2 seconds. The opportunity in OR turnover is large. A benchmark target is 25 minutes, but some teams are shortening this time significantly while maintaining safety and quality of performance.
A focus on operating room turnover
In this discussion, we’ll focus on the non-surgical part of the process, the turnover, or patient “wheels out to wheels in” of the operating room. The first step to understanding and improving this process is observing and measuring key components of the process with time stamps, such as OR scheduled start time and actual start time, start and end of sterile cleanup, timing of complete setup readiness.
A working multifunctional team will do this assessment, possibly in a rapid improvement event or Kaizen workshop, and look for ways to improve the turnover process. This work might include process flowcharting, problem solving with root cause analysis, load leveling, and many other Lean tools and methods in a continuous improvement approach. Typically the improvement teams will undertake some of these actions:
- Assign roles and responsibilities
During an OR turnover, a lot has to be done by a relatively large number of people in a small space. Assigned roles help to make sure all the work gets done efficiently without tripping over each other. A checklist helps for verification. In fact, the Association of periOperative Registered Nurses (AORN) has developed a matrix of accountabilities for RN circulator, ST/RN scrub nurse, first assistant and OR assistant during each step of operating room turnover, beginning with the start of wound closure.
- Create standard work and standards of work
Each task should have not just a standard procedure of what to do, but also a standard work method that outlines how to do it, with the right tools and techniques. This needs to be documented and included in training and retraining for staff. In addition, standards should be specified for outcomes, such as completion time and quality. In this case, when the process has extreme risk of healthcare-associated infection (HAI), the turnover quality standard must include assurance of cleanliness, with capabilities for measurement.
- Choreograph the process
Just like the pit crew, critical staff must not only know their roles, but also master the sequence and timing of their accountabilities relative to others in the room. Create a spaghetti diagram of movement around the room and look for ways to shorten steps and prevent conflicting or redundant paths. A well-run perioperative process will look like dancers smoothly flowing to a contemporary tempo.
- Practice and improve
While procedures and checklists look good on paper, the true proof of improvement is in the application. Metrics will show measured improvement. Additionally, capturing the process on video and having the team critique it can be valuable. Look for missed communications, big or small lags, errors and potential errors. Tweak the process for further improvements and apply mistake-proofing.
- Create staging
For any process with a constrained resource such as the OR, staging and kitting can be very valuable to separate tasks that must happen during the turnover from tasks that can be done before or after the availability of the resource. For example, a dedicated cart with required cleaning equipment and supplies can be parked outside the OR to be wheeled in as soon as the patient is wheeled out. Procedure-specific surgical sets can be assembled in advance to be brought in with the next patient. Some teams even leave the instruments in trays rather than lay them out on an instrument table. The same instruments and materials are verified by count to be sure nothing has been left in the patient.
- Optimize timing and preparation
Backward scheduling for the procedure and updated communications ensure everyone is ready for the process to happen. Consider these possibilities for timing issues:
- Finding out the patient had a meal or took blood thinner meds and can’t undergo anesthesia or surgery, causing a last-minute change with delays and potential for errors.
- Having cleaning staff on a break at the time of the turnover, also causing big delays impacting OR utilization.
- Not having a required piece of equipment in the room and learning mid-procedure that it is in use in another OR and no secondary choice exists.
- Utilize technology
Just as the racing pit crew has used the latest in technology to shave seconds off the pit stop, the hospital improvement team can implement developing technology to shorten OR turnover. For example, new cleaning agents might have higher disinfectant effectiveness with shorter contact time, shortening the overall turnover process. Enhanced OR surgical sheeting and transfer sheets can reduce contamination and cleanup.
- Consider overall costs and benefits
Improving operating room turnover and freeing up more time for procedures is likely to enable facility revenue increases. The team might recommend that more ancillary staff team members are needed to complete the turnover tasks quickly. Investment in kitting trays or new technology may be needed. These items should not be considered as standalone costs but should be part of the overall business case also looking at increased revenue.
- Provide change management education
Requiring changes in the way hospital staff members work is often met with individual resistance. Even after people are trained, they may tend to fall back to their favorite habits. Change management education and monitoring, including sharing of improvement results, can be very helpful.
- Ensure quality and safety
It’s worth restating that safety and quality of hospital processes, including cleaning, during the OR turnover are critical. Simply applying pressure to shave off a few minutes could result in a sharps stab, ineffective disinfection, or leaving materials inside a wound. Any cost savings on the turnover could be overwhelmed by follow-up costs for addressing the infection or its PR effect or litigation.
What about surgery improvements?
Briefly, similar efforts can be used to evaluate and improve the other part of total case time, the procedure itself. Look at such items as standard practice for surgeons’ technique, technologically simplified procedures, improved anaesthesia process and medications, optimized OR and related scheduling, and other factors. Improvements here can yield tremendous opportunity, to not only shorten total case time, but also improve positive outcomes for the patient, with lasting health benefits and patient experience enhancements.
Reducing your operating room turnover has tremendous opportunity for revenue as well as patient and staff satisfaction. Often this takes little to no capital investment.