- Email: [email protected]
Efficiency improvement in the operating room
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
Available online at www.sciencedirect.com
1 2 3 4 5 6 journal homepage: www.JournalofSurgicalResearch.com 7 8 9 10 Research review 11 12 13 14 15 Q13 a,b 16 Meghan Smith,a,c and Alexander Langermana,c,* Q2 Abigail J. Fong, 17 Q3 18 Q4 a University of Chicago Operative Performance Research Institute b 19 Pritzker School of Medicine c 20 Department of Surgery, Section of OtolaryngologydHead and Neck Surgery 21 22 23 abstract Q12 a r t i c l e i n f o 24 25 Background: In the changing health care environment, health systems, hospitals, and Article history: 26 health care providers must focus on improving efficiency to meet an increasing demand for Received 23 August 2015 27 high-quality, low-cost health care. Much has been written about strategies and efforts to Received in revised form 28 improve efficiency in the perioperative periods, yet the time when the patient is in the 15 March 2016 29 operating roomdthe intraoperative perioddhas received less attention. Yet, this is the Accepted 20 April 2016 30 period in which surgeons may have the most influence. Available online xxx 31 32 Study Design: Systematically review published efforts to improve intraoperative efficiency; 33 assess the outcomes of these efforts, and propose standardized reporting of future studies. Keywords: 34 Results: A total of 39 studies were identified that met inclusion criteria. These divided Efficiency 35 naturally into small (single operative team), medium (multi-operative team), and large Operating room 36 (institutional) interventions. Most studies used time or money as their metric for efficiency, Surgery 37 though others were used as well. Intraoperative 38 Conclusions: There is substantial opportunity to enhance operating room efficiency during Lean 39 the intraoperative period. Surgeons may have a particular role in procedural efficiency, Six sigma 40 which has been relatively unstudied. Common themes were standardizing tasks, collecting Total quality improvement 41 and using actionable data, and maintaining effective team communication. Process mapping 42 ª 2016 Elsevier Inc. All rights reserved. 43 44 45 46 Introduction Most surgical dollars are spent in the OR,2 making this 47 48 a high-priority target for efficiency efforts. As the public 49 Hospitals and health systems must focus on improving effibecomes more aware of differences in health care 50 ciency to meet the increasing demands for high-quality, lowspending,3,4 hospitals may hold surgeons more responsible 51 for controlling variable OR costs.5,6 Beyond this, surgeons cost care. Although much has been written about the need 52 have additional incentives for OR efficiencydtime savings and strategies to improve efficiency of the preoperative and 53 may translate to an earlier finish or the opportunity to post and/or interoperative periods,1 the intraoperative peri54 perform more cases during the same block time. oddwhen the patient is in the operating room (OR)dhas 55 Because surgeons direct and perform surgical care on received less attention. Yet, the intraoperative period is the 56 behalf of their patients, they are in the ideal position to primary OR experience, the basis for procedure billing, and the 57 ensure that efficiency improvements do not threaten period of time over which surgeons may have the most 58 59 patient care. influence. 60 61 * Corresponding author. Department of Otolaryngology, Vanderbilt University, 7209 Medical Center East, South Tower, Nashville, TN 62 37232-8605. Tel.: þ1 615 322 9598; fax: þ1 615 936 2887. 63 E-mail address: [email protected] (A. Langerman). 64 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. 65 http://dx.doi.org/10.1016/j.jss.2016.04.054
ScienceDirect
Efficiency improvement in the operating room
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
2
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
To raise surgeon awareness of OR efficiency (as has been previously done for quality7), this article summarizes currently published studies of intraoperative efficacy improvement, examines the outcomes of these efforts, and proposes standardization of reporting future efforts in the surgical literature.
Methods Key search terms were determined by background reading on health care and manufacturing efficiency.8-11 We queried PubMed in April 2015 via the following search: [“operating room” OR “surgery” OR “surgical”] AND [“Efficiency” OR “Lean” OR “Six Sigma” OR “parallel processing” OR “process mapping” OR “process map” OR “value stream mapping” OR “value stream map” OR “total quality improvement”]. We excluded nonrelevant search results and articles not in English and then manually screened the remaining abstracts and their references for appropriate articles. “Efficiency” is a widely used word in health care with multiple definitions8; for this study, we focused on efforts to produce improvements in time, costs, or their proxies. We defined our inclusion criteria as any article describing a method to improve intraoperative efficiency and reporting results of an outcome measure. We defined the intraoperative time period to be that when the patient is in the operating room, including anesthesia time but not patient transport or room changeover time (“interoperative” time). Articles solely reporting preoperative, postoperative, or interoperative efficiency were excluded as were articles solely regarding ontime starts, scheduling, ergonomics, cancellations, training, admissions, room change-overs, room airflow, quality measures, and work-life balance. Each author independently selected articles based on inclusion criteria, and disagreements were settled with consensus. References of included articles were scanned for additional articles. After this iterative process was exhausted, the resultant articles were surveyed and categorized by focus and methodology. Level of evidence was assigned as a group from these articles based on the Agency for Healthcare Research and Quality National Guideline Clearinghouse guidelines. Two authors (A.F. and A.L.) then abstracted results from these studies and grouped them into the categories presented in the results.
Results The initial search generated 26,798 results. Of these, 3602 remained after initial screening, and 182 articles and their references were screened individually for relevance. Of these, 37 studies were identified by all authors as meeting inclusion criteria; an additional eight articles were identified by at least one author, and of these, two were added based on consensus review for a total of 39 articles (Table). The PRISMA flowchart and the stratification for focus on intraoperative efficiency are summarized in Figure 1. For explanatory and supportive purposes, we also have cited an additional 49 review, analytical, and nonintervention descriptive articles in this article.
Of the 39 intervention articles, 29 (74%) used time as their metric for efficiency, 9 (23%) used financial measures, and 12 (31%) studies used other metrics such as tool reduction, case number, delays, and steps. Some studies used more than one metric and some included quality metrics as well. The most common factors studied were parallel processing (n ¼ 7), lean management (n ¼ 2), value stream/process mapping (n ¼ 5), checklists (n ¼ 2), OR redesign and environment (n ¼ 2), six sigma (n ¼ 2), and total quality management (n ¼ 2). Most articles focused on the OR space or the surgical team and did not examine efficiency of the operative procedure itself. Interventions were naturally partitioned into three categories based on scale: small (those that could be implemented in a single operating room potentially by a single surgeon or team); medium (those that require a surgical group or floor cooperation); and large (those that require major institutional buy-in, support and change). Common themes across these interventions were standardization, collecting and using actionable data, and maintaining effective communication.
Small-scale efficiency interventions “Small” interventions can be implemented relatively quickly and can be considered first-line approaches to improving OR efficiency. A single surgeon or small groups of surgeons might initiate these interventions, which include:
Surgical workflow redesign Attarian used interoperative and intraoperative workflow analysis to make multiple changes in staff behaviors and generate a case increase of 29% for total joint arthroplasties (from 2.35 to 3.04 average cases per OR per day12). Krasner standardized setup and introduced parallel task completion to reduce coronary bypass procedure time an average of 22 min (18%), anesthesia time 10 min (38%), and total OR time 67 min (21% of the initial average time of 314 min13). Such time savings may allow more cases to be completed if they are shorter (more revenue per OR day) or allow longer cases to be completed within standard shifts to avoid overtime (lower costs per OR day). Bender managed to accomplish both of these goals in a large academic medical center using a six sigma approach that included input from members of the surgical team and administration; cases increased by 9% and overtime decreased from 7% to 4%, resulting in a 14% decrease in personnel costs and a 19% increase in OR revenue.14 Three studies applied process-mapping surgical procedures, which outline every step of the case and expected team tasks to decrease staff uncertainty and encourage anticipatory preparation. Chalian reduced operative time by 12% in 21 head and neck cancer resection cases by designating intraoperative pathways and standardizing planned instrumentation.15 Casaletto reduced operative time by 20% and reduced the number of surgical steps from 66 to 37 in eight carpal tunnel decompression cases.16 Lee mapped the intraoperative process of deep inferior epigastric perforator flap breast reconstruction and instituted simultaneous flap harvest and breast resection (parallel processing, Fig. 2). This change resulted in an average case length reduction of 16% (8.2 to 6.9 h for unilateral and 12.8 to 10.6 h for bilateral reconstruction) and reduced operative costs by 5%-12%.17
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260
3
fong et al ---
261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325
Table e Intraoperative efficiency articles identified for this review. Scale of the intervention Small
Medium
Author
Method
Study design
Outcome
Attarian
Process redesign
Time interrupted cohort. Level of evidence II
Number of cases increased by 29%
Bender
Six sigma
Nonrandomized trial, 24,193 cases over 2 y; level of evidence II
Number of cases increased by 9%, overtime decreased by 3%, 19% increase in OR revenue
Casaletto
Process mapping/ redesign
Nonrandomized trial. Eight cases. Level of evidence II
Reduced operative time by 20% and reduced the number of surgical steps from 66 to 37 in eight carpal tunnel decompression cases
Cassera
Team familiarity
Cohort; 360 cases. Level of evidence III
Addition of 1 team member increased procedure time by predicted 15.4 min
Chalian
Pathway redesign
Nonrandomized trial; 21 cases. Level of evidence II
12% operative time decrease
Chin
Tool reduction
Cross-sectional study: 226 instrument trays, level of evidence II
Average instrument utilization rate found to be 27.8%, able to reduce instruments on trays by 57%
Engelmann Standardized breaks
Randomized controlled trial; 51 Frequent intraoperative breaks of 5 min every cases. Level of evidence I half hour did not increase operative time, and decreased adverse outcomes as well as surgeon cortisol levels.
Farrokhi
Lean methodology, 5s tool reduction
Nonrandomized controlled trial; 2766 cases. Level of evidence II
Reduction of surgical trays for minimally invasive spine surgery by 70% (197 tools to 58) and decrease operative time by 7 min
He
Team familiarity
Retrospective cohort; 1900 cases. Level of evidence III
Addition of one team member increased procedure time by predicted 34.7 min
Krasner
Parallel processing and standardization
Cohort; 549 cases. Level of evidence III
22-min surgical time saved; 10-min anesthesia time
Lain
IHI collaborative improvement, standardization, tool reduction, cycle time reduction
Cohort; 805 cardiac surgeries. Level of evidence III
26% cost reduction in coronary bypass DRG
Lee
Process mapping/ redesign
Nonrandomized controlled trial; 150 patients, 100 before intervention. Level of evidence II
Unilateral group cost decrease of 10.2% and decreases of 1.3 h; bilateral group time decreases of 2.2 h
Lunardini
Tool reduction
Cross-sectional study: 38 instrument trays, level of evidence II
42% of instruments unused, 41% removed from tray with projected savings of $41,000 per year
Morris
Root cost analysis, process mapping
Retrospective cohort; 419 cases. Decreased instruments by 23%, decreased in Level of evidence III OR non-operating time by 9 min (20%)
Ngu
Planning, streamlined supply chain and instrument trays, team building
Nonrandomized controlled Instrumentation reduced from 113 to 72; trial; one surgical team. Level of doubling surgical volume per time evidence II.
Nundy
Checklists
Nonrandomized controlled trial; 422 survey respondents. Level of evidence II
11% decrease in intraoperative delays, 15% decrease in communication breakdowns
Porta
Checklists (team assessment)
Cross-sectional survey; 11,342 cases. Level of evidence IV
9% decrease in mean delays, 39% decreased wasted time
Stockert
Tool reduction
Cross-sectional study: 49 procedures, 237 instrument trays, level of evidence II
Utilization rate for instruments was 13%-22%
Zheng
Team familiarity
Retrospective cohort; 587 cases. Addition of 1 team member increased Level of evidence III procedure time by predicted 7 min
Al-Hakim
Tracking delay
Cross-sectional study; 31 cases. Approximately 25% of the time observed was Level of evidence IV spent on preventable disruption and 60% of that preventable disruption was on nonvalue added activities (continued)
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390
4
391 392 393 394 395Q1 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
Table e (continued ) Scale of the intervention
Large
Author
Method
Study design
Outcome
Doherty
Standardization of team
Retrospective cohort; 101 cases. Standardize personnel on the operative team reduce procedure time by 47.1 min Level of evidence III
Gitelis
Cost awareness
Non-randomized trial; 1014 10% decrease in disposable costs for cases (586 pre 428 post) level of laparoscopic cholecystectomy, an annual evidence II savings of $27,000
Morris
Root cost analysis, process mapping
Retrospective cohort; 419 cases. Decreased instruments by 23%, decreased in Level of evidence III OR non-operating time by 9 min (20%)
Overdyke
Tracking delays, education intervention
Cross-sectional survey. 1881 cases. Level of evidence IV
Perkins
Timing auditing, tracking delays
Retrospective cohort; 180 cases. In OR to procedure start and turnover time Level of evidence III identified as weaknesses
Stepaniak
Consistent team and type of procedure
Randomized controlled trial; 94 Fixed teams and scheduling similar cases. Level of evidence I procedures sequentially reduces procedural time by an average of 10 min in the 94 hernia repair and laparoscopic cholecystectomies they observed
Stepaniak
Consistent team and type of procedure
Non-randomized control trial, 2 1387 bariatric procedures observed. Fixed medical centers 1387 cases, teams reduced procedure duration by 10.8% level of evidence II or 4-13 min
Xu
Team familiarity
Cohort study: 754 procedures, 223 teams, 8 surgeons. Level of evidence III
Surgical team familiarity accounted for 16 min decrease in operative time after 10 collaborations
Althausen
Specialized team
Retrospective review; 2076 cases. Level of evidence III
Specialized traumatologist decreased procedure time 20 min and cost about $600 versus general orthopedic surgeons
Friedman
Parallel processing
Nonrandomized trial; 66 case studies, 72 controls. Level of evidence level II
Saved on average 9.6 min in sedate, block, and prep time
Hanss
Parallel processing
Non-randomized trial; 335 cases. Level of evidence II
Nonoperative time decreased 11 min, one extra case possible per day with two ORs participating, with three ORs 2 extra cases possible
Harders
Parallel processing, multidisciplinary process redesign
Non-randomized trial; 239 cases, 23 surgeons. Level of evidence II
Decreased non-operative time by 23 min, decreased anesthesia time by 5 min
Kehoe
Supply chain management, lean
Case report; 1 hospital with 22 ORs. Level of evidence IV
Improved tray accuracy to over 99%
Rosenblatt
Supply chain management
Time interrupted cohort; 1318 (pre-intervention); 1367 cases (post-intervention). Level of evidence II
45% reduction in mean per case overage in comparable study periods
Small
Specialized OR
Randomized controlled trial; 1004 cases. Level of evidence I
7 min of operative time savings and a total savings of 19 min per procedure by using a specialized orthopedic OR
Smith
Parallel processing
Non-randomized controlled Non operative time decreased 36 min, trial. 608 historical controls, 905 operative time decreased 14 min post-intervention cases, level of evidence II
Stahl
Specialized OR; parallel processing
Case-control; 182 specialized Decreased procedure time by 14 min, and OR cases, 193 matched controls, total patient OR flow time by 29 min, this level of evidence II allowed for two additional cases per day
Torkkai
Parallel processing
Case-controlled; 57 cases preintervention, 77 cases postintervention. Level of evidence III
Non operative time decreased 45.6%, additional case was able to be added per day
Varu
Specialized OR
Case-controlled; 109 cases. Level of evidence III
Hybrid fixed-image fluoroscopy equipped ORs reduced contrast usage by 30 mL and operative time by 30 min on average in the 109 endovascular aneurysm repairs observed.
Reporting delays leads to less delays
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520
fong et al ---
521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585
5
shown to help prevent mental fatigue. One study involving complex laparoscopic procedures found that in the 51 cases they studied, frequent intraoperative breaks of 5 min every half hour did not increase operative time and did decrease adverse outcomes and surgeon stress (as measured by cortisol levels18). No-handoff zones are time periods in a procedure in which the staff cannot change. In Lee’s study,17 the no-handoff zone started with the moment of flap harvest through the microvascular anastomosis (the flap ischemia time). Three studies each found that increased handoffs (as measured by team size) predicted increased operative time.19-21 These handoffs are primarily nurse-nurse (or nurse-tech) rather than surgeons. Studies examining surgeon handoffs are in conflict; He et al. found surgeon handoffs contributed to increased surgical time, whereas Cassera et al. found no effect.19,20 Regardless of the personnel who hand off, surgeons must determine the periods of the case during which handoffs will be most and least detrimental to case flow.
Standardizing instruments and supplies Standardizing and reducing supplies and durable instruments have benefits outside and inside the OR by reducing operative costs, setup time, counting time, and turnover time. Farrokhi applied lean methodology to reduce surgical trays for minimally invasive spine surgery by 70% (197 tools to 58) and decrease operative time by 7 min.22 Lunardini held an “instrument fair” to discuss utilization of spine instruments, ultimately leading to a reduction of 41% and an estimated savings of $41,000 per y.23 Multiple other studies have reduced instruments by 19%-57%, leading to less clutter in the operating room, improved setup time, and reduced reprocessing costs.24-26 Our own study found that across multiple specialties, the utilization rate of instruments was 13%-22%,27 suggesting ample room for improvement.
Team huddles Before and after each case, surgeons can use team huddles to improve efficiency. By reviewing the OR plan, goals, anticipated flow, and supply needs with the surgical team at the onset of the case, 11 surgeons at Johns Hopkins University reduced unexpected surgical delays from 36% to 25% in over 400 cases.28 Porta assessed the team’s performance after a case to understand intraoperative delays. This added no operative time and led to a 9% decrease in average delay and a 39% decrease in wasted OR time.29 Makary published a tutorial on these postoperative debriefings and suggested their use in identifying trouble areas.30 Fig. 1 e PRISMA diagram of literature search: (NB: The numbers listed for each exclusion type in “exclusion by inclusion criteria” add up to greater than total of 147 because some articles were excluded for multiple reasons.).
Medium-scale interventions
In addition to parallel processing, Lee’s process map included planned breaks and “no-handoff zones.” Planned breaks create a moment of rest during long cases and have been
Checklists
“Medium” interventions require a whole OR floor or group to participate to see benefits. Data are collected across multiple practitioners and teams to identify outliers in need of improvement. These interventions require more staff buy-in to implement.
The most widespread use of checklists in the OR today tends to focus on immediate preprocedural and postprocedural
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650
6
651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
Fig. 2 e Parallel processing: (A) induction and room turnover occur simultaneously and (B) two portions of a procedure occur simultaneously, (diagram design by Tomoko Ichikawa and Marcie Cooperman, IIT Institute of Design).
checks31-34 but extending them throughout the procedure is possible. Buzink piloted the Pro/cheQ, an interactive surgical workflow tool that displays checklists for each step of a
laparoscopic cholecystectomy and found a 65% decrease in risk-sensitive events in 15 observed cases.32 Over time, however, they had difficulties with staff engagement; in their article,
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
Q10
716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780
fong et al ---
781 782 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845
7
Fig. 3 e Dynamic operational map (DOM): This simplified diagram demonstrates the relational coordination of surgical team members and the discreet steps of an operation. Contingencies are diagrammed as diverging branches and decision nodes as converging branches. This method can be used as a framework for examining workflow in complex operations. Tools needed, scheduled breaks, and no-handoff zones can be added based on case requirements. Data on value added, cost, time, and inefficiencies can be organized based on these discreet steps. (Diagram design by Tomoko Ichikawa and Marcie Cooperman, IIT Institute of Design).
they address the need to embed such checklists in the OR routine for a sustainable benefit. Russ reported on the development and validation of an observer-administered checklist (“METEOR”) that assesses completion of key efficiency-related OR tasks during each stage of general surgical procedures.35 Although this was a research tool, it highlights key intraoperative tasks that could be targeted with a checklist.
16-min reduction in operative time after 10 team collaborations.38 Similarly, Doherty reduced average procedure time by 47.1 min by standardizing the nursing staff over 49 complex head and neck cases,39 and Morris found working with familiar teams resulted in an average 20% (9 min) reduction in nonoperative in-room time per case.26
Data tracking Teaming When surgeons regularly work with the same teams, cases run more efficiently due to nurses’ familiarity with tools and nomenclature, knowledge of preferences, and ability to anticipate needs. Stepaniak maintained fixed teams and scheduled similar procedures sequentially to reduce procedural time by an average of 10 min per case over 94 hernia repairs and laparoscopic cholecystectomies36 and in a separate study found that fixed teams and similar schedules reduced bariatric surgery duration by 10.8% or 4-13 min.37 Xu examined 754 cases of bilateral reduction mammoplasty procedures and found that surgical team familiarity with one another accounted for about
Perkins et al. tracked their operating room times for 180 pediatric otolaryngology cases to look for efficiency intervention targets. By comparing granular results on timing for each component of patient throughput (i.e., patient in-room to procedure start, procedure time, procedure end to room-out, and turnover time) to published benchmarks, they were able to focus their efficiency efforts only on the components that were prolonged.40 Overdyke et al. tracked specific interoperative and intraoperative delays to identify the most common sources of inefficiency for total quality improvement.41 They found decreased delays after their interventions, many of which
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910
8
911 912 913 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
Fig. 4 e Framework for OR efficiency innovations. (Diagram design by Tomoko Ichikawa and Marcie Cooperman, IIT Institute of Design). *Jimmerson details a common technique for this called “value stream mapping”.80 **Sensors are becoming ubiquitous in health care settings. In the OR, this commonly includes radiofrequency identification tracking of patients, supplies, and personnel but could also be envisioned to include computer vision, audio, and wearables that track
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
Q11
976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040
fong et al ---
1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062 1063 1064 1065 1066 1067 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105
involved simply notifying the right people of their performance. Al-Hakim and Gong found by tracking delays in the OR that about 25% of intraoperative delay time was spent on preventable disruption and 60% of those disruptions were for unnecessary activities or those that should have been performed before the procedure.42
Awareness of costs Gitelis found that educating surgeons about the price of disposable tools resulted in a 10% decrease in disposable costs for laparoscopic cholecystectomy for an annual savings of $27,000.43 Our own institutional experience has been even more significant, with a decrease in >$500,000 in annual costs of disposable instruments due to a cost-awareness campaign across just four surgical specialties.
Large-scale interventions “Large” interventions require institutional cooperation and major investment to implement. These include reorganizing supply-chain management, creating designated teams for specialized tasks, and redesigning the OR space itself.
Supply chain management Supplies are a voluminous and costly component of surgical work; hospitals may spend 50% of OR budgets on supplies,44 and this has prompted several studies aimed at reducing supply-related costs and delays. Intraoperatively ensuring that the right items are available and that unnecessary items remain unopened has the potential to reduce OR equipment delays, decrease labor costs to pull and restock unused items, and improve doctors’ and nurses’ focus on clinical care.44-47 To reduce the presence of unnecessary items, the surgical team can estimate instrument needs from past cases46 and can track wasted (opened-but-unused) supplies.48 Using this information to revise pick lists and standardize OR setups led Rosenblatt to decrease wasted material costs by 45% in 1367 postintervention cases.49 Tracking supplies with barcodes or radiofrequency identification (RFID) enhances the speed and accuracy of data collection for efficiency interventions by linking supplies with specific patients and providers and generating actual utilization data.50-55 This tracking technology can continuously monitor supplies and deliver case carts “just-in-time” to reduce operative waiting time as well as holding costs related to excess inventory.44 Such tracking software can also be used on durable instruments, to maintain tray accuracy and eliminate delays due to missing instruments56 and on personnel, to drive insights on workflow.57
Specialization Some groups have implemented specialized personnel, programs, instruments, and ORs to improve efficiency.58-61 Such interventions are only possible at medical centers with justifiable volume but have the potential to greatly
9
improve time and cost savings. Small reduced operative time by 7 min and total room time by 19 min per procedure by using a specialized 6-room orthopedic OR unit with dedicated teams.58 Althausen examined the effect of a specialized traumatologist for surgical fracture care compared to a general orthopedic surgeon at a level II trauma center. In the 2076 cases, they studied, the outcomes were comparable, but the truamatologist’s procedures were shorterdby approximately 20 min (P ¼ 0.0001)dand demanded fewer labor, supply, and implant costs.60
Space redesign and parallel processing Perhaps, the largest approach to improving efficiency is to physically redesign the OR. Massachusetts General Hospital built its OR of the Future (ORF) to study the effect of space interventions on efficiency.62 In the ORF induction and earlyrecovery rooms adjoin to improve patient flow; monitors and sensors help with easy reconfiguration. To improve throughput, specialized gurneys double as patient beds, thereby eliminating transfers. Although ORF requires an additional staff member, the workflow redesign generated enough capacity to perform two additional procedures daily.62,63 The capacity increase was due to reductions in nonoperative time by about 30 min per case by parallel processing OR turnover with patient recovery and the next patient’s induction (Fig. 2). Multiple studies have examined the effect of parallel processing on efficiency in the OR and found a savings of 5-36 min from in-room anesthesia or nonoperative time. Freidman saved an average 9.6 min in sedation, blocking, and prep time,64 Smith saved an average 36 min of nonoperative time (a 50% savings),65 and Harders saved 23 min of non-operative time and 5 min in anesthesia time.66 Importantly, this time reduction does not seem to affect anesthesia quality and may actually allow for a less hurried induction while still saving overall time.67 These time savings result in real additional capacity (which can translate to revenue increase). Torkki and Hanss each found that a separate induction room allowed an additional case to be added to a normal surgical day.68,69 Hanss also showed that this effect was more powerful when more ORs participated in parallel processing (going from two to three participating ORs resulted in an increase from one to two additional surgical procedures being possible in a standard day with the same procedural mix).68 The number of additional personnel needed to run these parallel induction rooms was 1.569 to 2.68 The benefits of additional capacity are balanced against the combined upfront capital investment in space redesign and ongoing costs of additional personnel. Marjamaa found that infrastructure costs can be avoided by performing parallel induction techniques within existing space70 and also that efficiency savings hold even in scenarios with centralized induction areas.71
= elements such as instrument use, economy of motion, or stress. ***Interventions may affect certain parts of the procedure more than others. Defining these discreet elements is important. See Fig. 3. ****Although patient is anesthetized but surgical team is not actively operating due to a disruption or delay. 5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118 1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 1153 1154 1155 1156 1157 1158 1159 1160 1161 1162 1163 1164 1165 1166 1167 1168 1169 1170
10
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
However, saving a few minutes of OR time may not always 1171 translate to additional cases.72 Using a mathematical model 1172 based on cases in the ORF and normal ORs, Sokal found that 1173 parallel processing would save enough time for additional 1174 procedures in only 26% of potential surgeon-case combina1175 1176 Q5 tions.73 Furthermore, they noted that without increased PACU 1177 space, increased OR turnover can lead to shifting the bottle1178 neck in efficiency.73 1179 In addition to parallel processing, whereby tasks are 1180 moved outside the OR, space redesign can also introduce new 1181 functions into the OR. “Hybrid rooms” can include fluoros1182 copy, magnetic resonance imaging, and computed tomogra1183 phy imaging capabilities to reduce wait time and eliminate the 1184 need for patient transportation during procedures.74-77 For 1185 instance, Varu found fixed-image fluoroscopyeequipped ORs 1186 reduced operative time by an average 30 min in 109 endo1187 1188 vascular aneurysm repairs.77 1189 1190 1191 1192 Discussion 1193 1194 Although much of the money spent in surgical care occurs in 1195 the OR,2,78 few published studies focus on this portion of the 1196 workflow. It may be that the preoperative, postoperative, and 1197 interoperative periods are more standardized, easier to track, 1198 1199 and represent the “low hanging fruit” for efficiency improve1200 ment. Surgery is highly human and must respond to patients’ 1201 anatomy, physiology, and pathology. This variability is a 1202 roadblock to efficiency improvement and highlights the need 1203 for more surgeons to get involved in efficiency interventions; 1204 surgeons have firsthand insight into the effect that any 1205 intervention has on the care of individual patients. 1206 The timepoints, cost methodology, and outcomes mea1207 sures were inconsistent across the studies in this review, and 1208 most reports lacked details that would facilitate replication in 1209 other centers. Nicolay found similar deficiencies in studies on 1210 1211 quality improvement in the OR.7 Nevertheless, articles cited in 1212 this review give important clues as to how manufacturing 1213 techniques can be useful tools for the OR. 1214 Standardization has long been an approach to improving 1215 workflow in manufacturing because it improves consistency 1216 and speed with repetition. Although patients may vary, the 1217 major steps of a given procedure are usually consistent and 1218 outlining even these can help team efficiency and reveal im1219 mediate opportunities for time savings.12-17 Designating “no1220 handoff zones”17 can further improve the continuity of care 1221 1222 and eliminate time spent transferring information between 1223 surgeons and staff during critical moments. Efficiency and 1224 safety checks could also be introduced for key moments of a 1225 procedure (rather than only at the bookends), enhancing team 1226 awareness and ushering in a paradigm shift in surgical 1227 quality. 1228 Instrument reduction is another way for surgeons to get 1229 immediate efficiency improvements22-26dnurses will need 1230 less time to prepare a room, and necessary instruments can be 1231 more evident when the OR table is less cluttered. When 1232 reduction is applied across service lines, institutions 1233 1234 can realize reduced labor-replacement and instrument1235 replacement costs.
Working with the same team leads to efficiency benefits26,36-39 and may possibly supersede many other workflow efforts. However, working with the same, experienced team is not always possible, and enhancing performance in the setting of inconsistent teams is an important area for future research. Potential avenues include using team-based communication techniques such as scripting (standardized verbal exchanges79) and implementation of intraoperative checklists and team huddles to better acclimate novices. A good first step for a surgeon looking to improve the efficiency of his or her own OR might be to map the standard workflow and contingences of their procedures (Fig. 3). This can allow areas of inefficiency or special scenarios requiring tight team coordination to be identified.80 It is possible (and perhaps desirable) for surgeons to adopt “standard operating procedures” for routine cases that are consistent across different practitioners and institutions. This would allow for greater consistency of operations and planning for the entire operative team and can help control for potential confounding variables when comparing surgical teams or comparing surgery to other interventions.81 Whatever intervention is created, there are common elements throughout all of them: 1) Data is Paramount. All efficiency improvement efforts must begin with a data plan that includes the metrics to be collected, the means of collecting them, and the definition of success.15,66,82 Time savings may not directly relate to cost savings83 nor patient outcomes, so data plans should consider the relative impact of each of these metrics on the success of a proposed intervention. 2) Communication drives the operating room. Teamwork is the cornerstone of successful surgery, and the voices of all team members (surgeons, nurses, staff, and anesthesiologists) should be heard when planning interventions to ensure that all opportunities are considered.84,85 This also engenders ownership and buy-in of team members in proposed solutions.86 3) The OR is not an Island. Although we intentionally focused on intraoperative efficiencies, the overall patient-care pathway and distal patient-care outcomes should be tracked.87 Money and time saved in the OR that leads to longer hospital stays and poor outcomes is a fools’ economy88 and is antithetical to surgical improvement. Figure 4 outlines the steps for designing and implementing an OR efficiency intervention, as well as the key reporting measures for future publications. As more studies of OR efficiency are conducted, ensuring complete and standardized reporting can allow for cross-study comparisons, metaanalyses, and more reliable inference from data produced by multiple institutions.
Limitations Data used to assess efficiency do not tell the whole story. A simultaneous focus on improving or maintaining the quality of care must occur in any health care efficiency intervention. Our choice to focus only on the intraoperative period means that we have excluded many successful
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1236 1237 1238 1239 1240 1241 1242 1243 1244 1245 1246 1247 1248 1249 1250 1251 1252 1253 1254 1255 1256 1257 1258 1259 1260 1261 1262 1263 1264 1265 1266 1267 1268 1269 1270 1271 1272 1273 1274 1275 1276 1277 1278 1279 1280 1281 1282 1283 1284 1285 1286 1287 1288 1289 1290 1291 1292 1293 1294 1295 1296 1297 1298 1299 1300
fong et al ---
1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 1315 1316 1317 1318 1319 1320 1321 1322 1323 1324 1325 1326 1327 1328 1329 1330 1331 1332 1333 1334 1335 1336 1337 1338 1339 1340 1341 1342 1343 1344 1345 1346 1347 1348 1349 1350 1351 1352 1353 1354 1355 1356 1357 1358 1359 1360 1361 1362 Q6 1363 1364 1365
workflow-improvement solutions. We refer the reader to other sources for this information.7,78 We have also likely not captured all of the innovative intraoperative workflow solutions that have been introduced and tested. Publication bias limits reporting of unsuccessful efforts or replications of previously successful interventions. OR administrators, who drive many of these interventions, may not have the same incentive to publish as physicians or nurses. Some institutions may also consider workflow innovations to confer a competitive advantage in a marketplace of dwindling reimbursement. Others, such as the Cleveland Clinic58,88 and the Center for Integration of Medicine & Integrative Technology at the Massachusetts General Hospital,62 have been transparent about their innovations. Our hope is that by shedding light on and describing standards for intraoperative efficiency research, more individuals and institutions will be encouraged to share their experiences.
5. 6.
7.
8.
9. 10.
11.
Conclusion Approaches to improving intraoperative efficiency can occur on many levels based on the required level of resources and institutional support. Data transparency and communication are critical to intraoperative improvements, and any intervention should be conducted in the context of overall patient care. Intraoperative efficiency is an emerging science that must balance workflow standardization with individual patient care, and surgeons must therefore play a central role in developing future efficiency innovations.
12.
13.
14.
15.
16.
Acknowledgment The authors wish to thank Tomoko Ichikawa and Marcie Cooperman, both of the Illinois Institute of Technology Institute of Design, Chicago, IL, for preparation of Figures 2-4. Author contributions: All authors contributed to the design, research, analysis, and writing of this work.
17.
18.
19.
Financial disclosures The authors have no disclosures.
20.
references
21.
22. 1. Mason SE, Nicolay CR, Darzi A. The Use of lean and six sigma methodologies in surgery: a Systematic review. Surgeon. 2015;13:91e100. 2. Barbagallo S, Corradi L, Goyet JV, et al. Optimization and planning of operating room theatre activities: an original definition of pathways and process modeling. BMC Med Inform Decis Mak. 2015;15:38. 3. Ubel P. Doctor, first tell me what it costs. New York Times; 2013:A25. 4. Adamopoulos H. Survey: most patients paying attention to healthcare costs. Beckers Hosp Rev. 2013;21. Available at:
23.
24. 25.
11
http://www.beckershospitalreview.com/finance/surveymost-patients-paying-attention-to-healthcare-costs.html. Q7 Ruggieri P. Surgeons need to be more cost-conscious, and be rewarded for it. Gen Surg News. 2015;42:10. Panza W, Dahl R. What hospital CEOs need to know about surgical services. Beckers Hosp Rev. 2013;17. Available at: http://www.beckershospitalreview.com/ hospital-management-administration/what-hospital-ceosneed-to-know-about-surgical-services-4-strategies-forprotecting-or-revenue.html. Nicolay CR, Purkayastha S, Greenhalgh a, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg. 2012;99:324e335. Arakelian E, Gunningberg L, Larsson J. How operating room efficiency is understood in a surgical team: a qualitative study. Int J Qual Health Care. 2011;23:100e106. Berlet GC, Weil LS, Fooman A, Miller JM. Contemporary trends in operating room efficiency. Foot Ankle Spec. 2013;6:125e131. Fixler T, Wright JG. Comment on “Identification and use of operating room efficiency indicators: the problem of definition”. Can J Surg. 2013;56:E104. Poksinska B. The current state of Lean implementation in health care: literature review. Qual Manag Health Care. 2010;19:319e329. Attarian DE, Wahl JE, Wellman SS, Bolognesi MP. Developing a high-efficiency operating room for total joint arthroplasty in an academic setting. Clin Orthop Relat Res. 2013;471:1832e1836. Krasner H, Connelly NR, Flack J, Weintraub A. A multidisciplinary process to improve the efficiency of cardiac operating rooms. J Cardiothorac Vasc Anesth. 1999;6:661e665. Bender J, Nicolescu S, Hollingsworth S, et al. Improving operating room efficiency via an interprofessional approach. Am J Surg. 2015;209:447e450. Chalian AA, Kagan SH, Goldberg AN, et al. Design and impact of intraoperative pathways for head and neck resection and reconstruction. Arch Otolaryngol Head Neck Surg. 2002;128:892e896. Casaletto JA, Rajaratnam V. Surgical process Re-Engineering: carpal tunnel decompression: a model. Hand Surg. 2004;9:19e27. Lee BT, Tobias AM, Yueh JH, et al. Design and impact of an intraoperative pathway: a new operating room model for team-based practice. J Am Coll Surg. 2008;207:865e873. Engelmann C, Schneider M, Kirschbaum C, et al. Effects of intraoperative breaks on mental and somatic operator fatigue: a randomized clinical trial. Surg Endosc. 2011;25:1245e1250. Cassera M a, Zheng B, Martinec DV, et al. Surgical time independently affected by surgical team size. Am J Surg. 2009;198:216e222. He W, Ni S, Chen G, et al. The composition of surgical teams in the operating room and its impact on surgical team performance in China. Surg Endosc. 2014;28:1473e1478. Zheng B, Panton ON, Al-Tayeb TA. Operative length independently affected by surgical team size: data from 2 Canadian hospitals. Can J Surg. 2012;55:371e376. Farrokhi FR, Gunther M, Williams B, Blackmore CC. Application of lean methodology for improved quality and efficiency in operating room instrument availability. J Healthc Qual. 2013;00:1e10. Lunardini D, Arington R, Canacari E, et al. Lean principles to optimize instrument utilization for spine surgery in an academic medical center. Spine. 2014;39:1714e1717. Ngu JC. Improving OR efficiency in a university medical center arthroplastic surgery service. AORN J. 2010;92:425e435. Chin C, Sowerby L, John-Baptiste A, et al. Reducing otolaryngology surgical inefficiency via assessment of tray Redundancy. J Otolaryngol Head Neck Surg. 2014;43:46e49.
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1366 1367 1368 1369 1370 1371 1372 1373 1374 1375 1376 1377 1378 1379 1380 1381 1382 1383 1384 1385 1386 1387 1388 1389 1390 1391 1392 1393 1394 1395 1396 1397 1398 1399 1400 1401 1402 1403 1404 1405 1406 1407 1408 1409 1410 1411 1412 1413 1414 1415 1416 1417 1418 1419 1420 1421 1422 1423 1424 1425 1426 1427 1428 1429 1430
12
1431 1432 1433 1434 1435 1436 1437 1438 1439 1440 1441 1442 1443 1444 1445 1446 1447 1448 1449 1450 1451 1452 1453 1454 1455 1456 1457 1458 1459 1460 1461 1462 1463 1464 1465 1466 1467 1468 1469 1470 1471 1472 1473 1474 1475 1476 1477 1478 1479 1480 1481 1482 1483 1484 1485 1486 1487 1488 1489 1490 1491 1492 1493 1494 1495
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
26. Morris L, Romero Arenas M, Cerny J, et al. Streamlining variability in hospital charges for standard thyroidectomy: developing a strategy to decrease waste. Surgery. 2014;156:1441e1449. 27. Stockert E, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg. 2014;219:646e655. 28. Nundy S, Mukherjee A, Sexton JB, et al. Impact of preoperative Briefings on operating room delays. Arch Surg. 2014;143:1068e1072. 29. Porta CR, Foster A, Causey MW, et al. Operating room efficiency improvement after implementation of a postoperative team assessment. J Surg Res. 2013;180:15e20. 30. Makary MA, Holzmueller CG, Sexton JB, et al. Operating room debriefings. Jt Comm J Qual Patient Saf. 2006;32:407e410, 357. 31. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491e499. 32. Buzink SN, van Lier L, de Hingh IH, Jakimowicz JJ. Risksensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool. Surg Endosc. 2010;24:1990e1995. 33. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12e17. discussion 18. 34. Stanton BC. Management connections: checklist offers improved efficiency for MIS cases. AORN J. 2011;93:C7eC10. 35. Russ S, Arora S, Wharton R, et al. Measuring safety and efficiency in the operating room: development and validation of a metric for evaluating task execution in the operating room. J Am Coll Surg. 2013;216:472e481. 36. Stepaniak PS, Vrijland WW, de Quelerij M, et al. Working with a fixed operating room team on consecutive similar cases and the effect on case duration and turnover time. Arch Surg. 2010;145:1165e1170. 37. Stepaniak PS, Heij C, Buise MP. Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration. Anesth Analg. 2012;115:1384e1392. 38. Xu R, Carty MJ, Orgill DP, et al. The teaming Curve. Ann Surg. 2013;258:953e957. 39. Doherty C, Nakoneshny SC, Harrop AR, et al. A standardized operative team for major head and neck Cancer Ablation and reconstruction. Plast Reconstr Surg. 2012;130(1):82e88. 40. Perkins J, Chiang T, Ruiz A, et al. Auditing of operating room times: a quality improvement Project. Int J Pediatr Otorhinolaryngol. 2014;78:782e786. 41. Overdyke F, Harvey S, Fishman R, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg. 1999;88:963. 42. Al-Hakim L, Gong XY. On the day of surgery: how long does preventable disruption prolong the patient journey? Int J Health Care Qual Assur. 2012;25:322e342. 43. Gitelis M, Vigneswaran Y, Ujiki M, et al. Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a Regional health System’s experience. Am J Surg. 2015;209:488e492. 44. Park KW, Dickerson C. Can efficient supply management in the operating room save millions? Curr Opin Anaesthesiol. 2009;22:242e248. 45. Supply chain efficiencies could save Billions. OR Manager. 1997;13:24. 46. Kanich DG, Byrd JR. How to increase efficiency in the operating room. Surg Clin North Am. 1996;76:1e11.
47. King J, Joan M, Valerie Z, et al. Can supply chain software really deliver more nurses? St. Michael’s hospital in Toronto Knows it can. Healthc Q. 2005;8:125e127. 48. Rosenblatt WH, Silverman DG. Issues in cost Containment cost-effective Use of operating room supplies based on the REMEDY: Database of recovered unused materials. J Clin Anesth. 1994;6:400e404. 49. Rosenblatt WH, Chavez A, Tenney D, Silverman DG. Assessment of the economic impact of an overage reduction program in the operating room. J Clin Anesth. 1997;9:478e481. 50. Bilyk C. Importance of supply chain management in the operating room. Can Oper Room Nurs J. 2008;26:21e34. 51. Greene J. Gaining efficiency with instrument tracking. OR Manager. 2004;20:17e19, 21e2. 52. Torner N. Instrument tracking begets efficiency. Mater Manag Health Care. 2007;16:40e42. 53. Bendavid Y, Boeck H, Philippe R. RFID-enabled traceability system for consignment and high value products: a case study in the healthcare sector. J Med Syst. 2012;36:3473e3489. 54. Points K. Bar codes help improve safety in operating room. Healthcare Benchmarks Qual Improv. 2008;15:77e78. 55. Rogers a, Jones E, Oleynikov D. Radio frequency identification (RFID) applied to surgical sponges. Surg Endosc. 2007;21:1235e1237. 56. Kehoe B. Improving quality from the bottom up. Hosp Health Netw. 2010;84:28, 30. 57. Longe K. Bar coding in the OR: it’s more than just inventory control. Mater Manag Health Care. 1995;4:40e42. 58. Small TJ, Gad BV, Klika AK, et al. Dedicated orthopedic operating room unit improves operating room efficiency. J Arthroplasty. 2013;28:1066e1071.e2. 59. Kpodonu J. Hybrid cardiovascular suite: the operating room of the future. J Card Surg. 2010;25:704e709. 60. Althausen PL, Kauk JR, Shannon S, et al. Operating room efficiency: benefits of an Orthopaedic traumatologist at a level II trauma center. J Orthop Trauma. 2014;28:e101ee106. 61. Seim AR, Dahl DM, Sandberg WS. Small changes in operative time can yield discrete increases in operating room throughput. J Endourol. 2007;21:703e708. 62. Serb BY. OR of the future: hospitals & health networks/AHA. 82. 2002:36e39. Q8 63. Stahl JE, Sandberg WS, Daily B, et al. Reorganizing patient care and workflow in the operating room: a cost-effectiveness study. Surgery. 2006;139:717e728. 64. Friedman DM, Sokal SM, Chang Y, Berger DL. Increasing operating room efficiency through parallel processing. Ann Surg. 2006;243:10e14. 65. Smith MP, Sandberg WS, Foss J, et al. High-throughput operating room system for joint arthroplasties durably outperforms routine processes. Anesthesiology. 2008;109:25e35. 66. Harders M, Malangoni M a, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery. 2006;140:509e514. discussion 514e6. 67. Seim AR, Meyer M, Sandberg WS. Does parallel workflow impact anesthesia quality? AMIA Annu Symp Proc. 2005:1053. Q9 68. Hanss R, Buttgereit B, Tonner PH, et al. Overlapping induction of anesthesia: an analysis of benefits and costs. Anesthesiology. 2005;103:391e400. 69. Torkki PM, Marjamaa RA, Torkki MI, et al. Use of anesthesia induction rooms can increase the number of urgent orthopedic cases completed within 7 hours. Anesthesiology. 2005;103:401e405. 70. Marjamaa R, Vakkuri A, Kirvela¨ O. Operating room management: why, how and by whom? Acta Anaesthesiol Scand. 2008;52:596e600.
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1496 1497 1498 1499 1500 1501 1502 1503 1504 1505 1506 1507 1508 1509 1510 1511 1512 1513 1514 1515 1516 1517 1518 1519 1520 1521 1522 1523 1524 1525 1526 1527 1528 1529 1530 1531 1532 1533 1534 1535 1536 1537 1538 1539 1540 1541 1542 1543 1544 1545 1546 1547 1548 1549 1550 1551 1552 1553 1554 1555 1556 1557 1558 1559 1560
fong et al ---
1561 1562 1563 1564 1565 1566 1567 1568 1569 1570 1571 1572 1573 1574 1575 1576 1577 1578 1579 1580 1581 1582 1583 1584 1585 1586 1587
71. Marjamaa RA, Torkki PM, Hirvensalo EJ, Kirvela¨ OA. What is the best workflow for an operating room? A simulation study of five scenarios. Health Care Manag Sci. 2008;12:142e146. 72. Dexter F, Coffin S, Tinker JH. Decrease in anesthesiaControlled time cannot Permit one additional surgical operation to be reliably scheduled during the Workday. Anesth Analg. 1995;81:1263e1268. 73. Sokal SM, Craft DL, Chang Y, et al. Maximizing operating room and recovery room capacity in an era of constrained resources. Arch Surg. 2006;141:389e393. discussion 393e5. 74. Starke RM, Dumont AS. Intraoperative imaging and assessment of Cerebral Blood flow in Cerebrovascular surgery: hybrid operating rooms, intraoperative angiography and MRI, Doppler Ultrasound, Cerebral Blood flow Probes, Endoscopic Assistance, Indocyanine green Videography, and Laser Contrast imaging. World Neurosurg. 2013;82:e693ee696. 75. Stockburger WT. Image display in the operating room: eliminating the barriers in the transition to filmless radiology. Radiol Manage. 2005;27:18e20, 22, 24e5. 76. Uhl E, Zausinger S, Morhard D, et al. Intraoperative computed tomography with integrated navigation system in a multidisciplinary operating suite. Neurosurgery. 2009;64:231e239. discussion 239e40. 77. Varu VN, Greenberg JI, Lee JT. Improved efficiency and safety for EVAR with utilization of a hybrid room. Eur J Vasc Endovasc Surg. 2013;46:675e679.
13
78. Guerriero F, Guido R. Operational research in the operating theatre: a survey. Health Care Manag Sci. 2011;14:89e114. 79. Webster JL, Cao CG. Lowering communication barriers in operating room technology. Hum Factors. 2006;48:747e758. 80. Jimmerson C. Value stream mapping for healthcare made easy. Boca Raton, FL: CRC Press; 2009. 81. Attwood SEA, Lundell L, Ell C, et al. Standardization of surgical technique in antireflux surgery: the LOTUS Trial experience. World J Surg. 2008;32:995e998. 82. Agnoletti V, Buccioli M, Padovani E, et al. Operating room data management: improving efficiency and safety in a surgical block. BMC Surg. 2013;13:7. 83. Dexter F. Reductions in non-operative times, not increases in operating room efficiency. Surgery. 2007;141:544. 84. Lain J, Young C, Dworkin G, Rackstein A. Improving efficiencies and reducing costs in adult cardiac surgery: a team approach. Qual Manag Health Care. 1998;6:37e41. 85. Malagoni M. Assessing operating room efficiency and parallel processing. Ann Surg. 2006;243:15e16. 86. Mosbacher K, Raeford D. Performance art. Mater Manag Health Care. 1999;8:20e22. 87. Traverso LW. The laparoscopic surgical value package and how surgeons can influence costs. Surg Clin North Am. 1996;76(3). 88. Butler V, Clinton C, Sagi H, et al. Applying science and strategy to operating room workforce management. Nurs Econ. 2012;30:275e281.
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1588 1589 1590 1591 1592 1593 1594 1595 1596 1597 1598 1599 1600 1601 1602 1603 1604 1605 1606 1607 1608 1609 1610 1611 1612 1613 1614
Available online at www.sciencedirect.com
1 2 3 4 5 6 journal homepage: www.JournalofSurgicalResearch.com 7 8 9 10 Research review 11 12 13 14 15 Q13 a,b 16 Meghan Smith,a,c and Alexander Langermana,c,* Q2 Abigail J. Fong, 17 Q3 18 Q4 a University of Chicago Operative Performance Research Institute b 19 Pritzker School of Medicine c 20 Department of Surgery, Section of OtolaryngologydHead and Neck Surgery 21 22 23 abstract Q12 a r t i c l e i n f o 24 25 Background: In the changing health care environment, health systems, hospitals, and Article history: 26 health care providers must focus on improving efficiency to meet an increasing demand for Received 23 August 2015 27 high-quality, low-cost health care. Much has been written about strategies and efforts to Received in revised form 28 improve efficiency in the perioperative periods, yet the time when the patient is in the 15 March 2016 29 operating roomdthe intraoperative perioddhas received less attention. Yet, this is the Accepted 20 April 2016 30 period in which surgeons may have the most influence. Available online xxx 31 32 Study Design: Systematically review published efforts to improve intraoperative efficiency; 33 assess the outcomes of these efforts, and propose standardized reporting of future studies. Keywords: 34 Results: A total of 39 studies were identified that met inclusion criteria. These divided Efficiency 35 naturally into small (single operative team), medium (multi-operative team), and large Operating room 36 (institutional) interventions. Most studies used time or money as their metric for efficiency, Surgery 37 though others were used as well. Intraoperative 38 Conclusions: There is substantial opportunity to enhance operating room efficiency during Lean 39 the intraoperative period. Surgeons may have a particular role in procedural efficiency, Six sigma 40 which has been relatively unstudied. Common themes were standardizing tasks, collecting Total quality improvement 41 and using actionable data, and maintaining effective team communication. Process mapping 42 ª 2016 Elsevier Inc. All rights reserved. 43 44 45 46 Introduction Most surgical dollars are spent in the OR,2 making this 47 48 a high-priority target for efficiency efforts. As the public 49 Hospitals and health systems must focus on improving effibecomes more aware of differences in health care 50 ciency to meet the increasing demands for high-quality, lowspending,3,4 hospitals may hold surgeons more responsible 51 for controlling variable OR costs.5,6 Beyond this, surgeons cost care. Although much has been written about the need 52 have additional incentives for OR efficiencydtime savings and strategies to improve efficiency of the preoperative and 53 may translate to an earlier finish or the opportunity to post and/or interoperative periods,1 the intraoperative peri54 perform more cases during the same block time. oddwhen the patient is in the operating room (OR)dhas 55 Because surgeons direct and perform surgical care on received less attention. Yet, the intraoperative period is the 56 behalf of their patients, they are in the ideal position to primary OR experience, the basis for procedure billing, and the 57 ensure that efficiency improvements do not threaten period of time over which surgeons may have the most 58 59 patient care. influence. 60 61 * Corresponding author. Department of Otolaryngology, Vanderbilt University, 7209 Medical Center East, South Tower, Nashville, TN 62 37232-8605. Tel.: þ1 615 322 9598; fax: þ1 615 936 2887. 63 E-mail address: [email protected] (A. Langerman). 64 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. 65 http://dx.doi.org/10.1016/j.jss.2016.04.054
ScienceDirect
Efficiency improvement in the operating room
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
2
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
To raise surgeon awareness of OR efficiency (as has been previously done for quality7), this article summarizes currently published studies of intraoperative efficacy improvement, examines the outcomes of these efforts, and proposes standardization of reporting future efforts in the surgical literature.
Methods Key search terms were determined by background reading on health care and manufacturing efficiency.8-11 We queried PubMed in April 2015 via the following search: [“operating room” OR “surgery” OR “surgical”] AND [“Efficiency” OR “Lean” OR “Six Sigma” OR “parallel processing” OR “process mapping” OR “process map” OR “value stream mapping” OR “value stream map” OR “total quality improvement”]. We excluded nonrelevant search results and articles not in English and then manually screened the remaining abstracts and their references for appropriate articles. “Efficiency” is a widely used word in health care with multiple definitions8; for this study, we focused on efforts to produce improvements in time, costs, or their proxies. We defined our inclusion criteria as any article describing a method to improve intraoperative efficiency and reporting results of an outcome measure. We defined the intraoperative time period to be that when the patient is in the operating room, including anesthesia time but not patient transport or room changeover time (“interoperative” time). Articles solely reporting preoperative, postoperative, or interoperative efficiency were excluded as were articles solely regarding ontime starts, scheduling, ergonomics, cancellations, training, admissions, room change-overs, room airflow, quality measures, and work-life balance. Each author independently selected articles based on inclusion criteria, and disagreements were settled with consensus. References of included articles were scanned for additional articles. After this iterative process was exhausted, the resultant articles were surveyed and categorized by focus and methodology. Level of evidence was assigned as a group from these articles based on the Agency for Healthcare Research and Quality National Guideline Clearinghouse guidelines. Two authors (A.F. and A.L.) then abstracted results from these studies and grouped them into the categories presented in the results.
Results The initial search generated 26,798 results. Of these, 3602 remained after initial screening, and 182 articles and their references were screened individually for relevance. Of these, 37 studies were identified by all authors as meeting inclusion criteria; an additional eight articles were identified by at least one author, and of these, two were added based on consensus review for a total of 39 articles (Table). The PRISMA flowchart and the stratification for focus on intraoperative efficiency are summarized in Figure 1. For explanatory and supportive purposes, we also have cited an additional 49 review, analytical, and nonintervention descriptive articles in this article.
Of the 39 intervention articles, 29 (74%) used time as their metric for efficiency, 9 (23%) used financial measures, and 12 (31%) studies used other metrics such as tool reduction, case number, delays, and steps. Some studies used more than one metric and some included quality metrics as well. The most common factors studied were parallel processing (n ¼ 7), lean management (n ¼ 2), value stream/process mapping (n ¼ 5), checklists (n ¼ 2), OR redesign and environment (n ¼ 2), six sigma (n ¼ 2), and total quality management (n ¼ 2). Most articles focused on the OR space or the surgical team and did not examine efficiency of the operative procedure itself. Interventions were naturally partitioned into three categories based on scale: small (those that could be implemented in a single operating room potentially by a single surgeon or team); medium (those that require a surgical group or floor cooperation); and large (those that require major institutional buy-in, support and change). Common themes across these interventions were standardization, collecting and using actionable data, and maintaining effective communication.
Small-scale efficiency interventions “Small” interventions can be implemented relatively quickly and can be considered first-line approaches to improving OR efficiency. A single surgeon or small groups of surgeons might initiate these interventions, which include:
Surgical workflow redesign Attarian used interoperative and intraoperative workflow analysis to make multiple changes in staff behaviors and generate a case increase of 29% for total joint arthroplasties (from 2.35 to 3.04 average cases per OR per day12). Krasner standardized setup and introduced parallel task completion to reduce coronary bypass procedure time an average of 22 min (18%), anesthesia time 10 min (38%), and total OR time 67 min (21% of the initial average time of 314 min13). Such time savings may allow more cases to be completed if they are shorter (more revenue per OR day) or allow longer cases to be completed within standard shifts to avoid overtime (lower costs per OR day). Bender managed to accomplish both of these goals in a large academic medical center using a six sigma approach that included input from members of the surgical team and administration; cases increased by 9% and overtime decreased from 7% to 4%, resulting in a 14% decrease in personnel costs and a 19% increase in OR revenue.14 Three studies applied process-mapping surgical procedures, which outline every step of the case and expected team tasks to decrease staff uncertainty and encourage anticipatory preparation. Chalian reduced operative time by 12% in 21 head and neck cancer resection cases by designating intraoperative pathways and standardizing planned instrumentation.15 Casaletto reduced operative time by 20% and reduced the number of surgical steps from 66 to 37 in eight carpal tunnel decompression cases.16 Lee mapped the intraoperative process of deep inferior epigastric perforator flap breast reconstruction and instituted simultaneous flap harvest and breast resection (parallel processing, Fig. 2). This change resulted in an average case length reduction of 16% (8.2 to 6.9 h for unilateral and 12.8 to 10.6 h for bilateral reconstruction) and reduced operative costs by 5%-12%.17
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260
3
fong et al ---
261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325
Table e Intraoperative efficiency articles identified for this review. Scale of the intervention Small
Medium
Author
Method
Study design
Outcome
Attarian
Process redesign
Time interrupted cohort. Level of evidence II
Number of cases increased by 29%
Bender
Six sigma
Nonrandomized trial, 24,193 cases over 2 y; level of evidence II
Number of cases increased by 9%, overtime decreased by 3%, 19% increase in OR revenue
Casaletto
Process mapping/ redesign
Nonrandomized trial. Eight cases. Level of evidence II
Reduced operative time by 20% and reduced the number of surgical steps from 66 to 37 in eight carpal tunnel decompression cases
Cassera
Team familiarity
Cohort; 360 cases. Level of evidence III
Addition of 1 team member increased procedure time by predicted 15.4 min
Chalian
Pathway redesign
Nonrandomized trial; 21 cases. Level of evidence II
12% operative time decrease
Chin
Tool reduction
Cross-sectional study: 226 instrument trays, level of evidence II
Average instrument utilization rate found to be 27.8%, able to reduce instruments on trays by 57%
Engelmann Standardized breaks
Randomized controlled trial; 51 Frequent intraoperative breaks of 5 min every cases. Level of evidence I half hour did not increase operative time, and decreased adverse outcomes as well as surgeon cortisol levels.
Farrokhi
Lean methodology, 5s tool reduction
Nonrandomized controlled trial; 2766 cases. Level of evidence II
Reduction of surgical trays for minimally invasive spine surgery by 70% (197 tools to 58) and decrease operative time by 7 min
He
Team familiarity
Retrospective cohort; 1900 cases. Level of evidence III
Addition of one team member increased procedure time by predicted 34.7 min
Krasner
Parallel processing and standardization
Cohort; 549 cases. Level of evidence III
22-min surgical time saved; 10-min anesthesia time
Lain
IHI collaborative improvement, standardization, tool reduction, cycle time reduction
Cohort; 805 cardiac surgeries. Level of evidence III
26% cost reduction in coronary bypass DRG
Lee
Process mapping/ redesign
Nonrandomized controlled trial; 150 patients, 100 before intervention. Level of evidence II
Unilateral group cost decrease of 10.2% and decreases of 1.3 h; bilateral group time decreases of 2.2 h
Lunardini
Tool reduction
Cross-sectional study: 38 instrument trays, level of evidence II
42% of instruments unused, 41% removed from tray with projected savings of $41,000 per year
Morris
Root cost analysis, process mapping
Retrospective cohort; 419 cases. Decreased instruments by 23%, decreased in Level of evidence III OR non-operating time by 9 min (20%)
Ngu
Planning, streamlined supply chain and instrument trays, team building
Nonrandomized controlled Instrumentation reduced from 113 to 72; trial; one surgical team. Level of doubling surgical volume per time evidence II.
Nundy
Checklists
Nonrandomized controlled trial; 422 survey respondents. Level of evidence II
11% decrease in intraoperative delays, 15% decrease in communication breakdowns
Porta
Checklists (team assessment)
Cross-sectional survey; 11,342 cases. Level of evidence IV
9% decrease in mean delays, 39% decreased wasted time
Stockert
Tool reduction
Cross-sectional study: 49 procedures, 237 instrument trays, level of evidence II
Utilization rate for instruments was 13%-22%
Zheng
Team familiarity
Retrospective cohort; 587 cases. Addition of 1 team member increased Level of evidence III procedure time by predicted 7 min
Al-Hakim
Tracking delay
Cross-sectional study; 31 cases. Approximately 25% of the time observed was Level of evidence IV spent on preventable disruption and 60% of that preventable disruption was on nonvalue added activities (continued)
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390
4
391 392 393 394 395Q1 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
Table e (continued ) Scale of the intervention
Large
Author
Method
Study design
Outcome
Doherty
Standardization of team
Retrospective cohort; 101 cases. Standardize personnel on the operative team reduce procedure time by 47.1 min Level of evidence III
Gitelis
Cost awareness
Non-randomized trial; 1014 10% decrease in disposable costs for cases (586 pre 428 post) level of laparoscopic cholecystectomy, an annual evidence II savings of $27,000
Morris
Root cost analysis, process mapping
Retrospective cohort; 419 cases. Decreased instruments by 23%, decreased in Level of evidence III OR non-operating time by 9 min (20%)
Overdyke
Tracking delays, education intervention
Cross-sectional survey. 1881 cases. Level of evidence IV
Perkins
Timing auditing, tracking delays
Retrospective cohort; 180 cases. In OR to procedure start and turnover time Level of evidence III identified as weaknesses
Stepaniak
Consistent team and type of procedure
Randomized controlled trial; 94 Fixed teams and scheduling similar cases. Level of evidence I procedures sequentially reduces procedural time by an average of 10 min in the 94 hernia repair and laparoscopic cholecystectomies they observed
Stepaniak
Consistent team and type of procedure
Non-randomized control trial, 2 1387 bariatric procedures observed. Fixed medical centers 1387 cases, teams reduced procedure duration by 10.8% level of evidence II or 4-13 min
Xu
Team familiarity
Cohort study: 754 procedures, 223 teams, 8 surgeons. Level of evidence III
Surgical team familiarity accounted for 16 min decrease in operative time after 10 collaborations
Althausen
Specialized team
Retrospective review; 2076 cases. Level of evidence III
Specialized traumatologist decreased procedure time 20 min and cost about $600 versus general orthopedic surgeons
Friedman
Parallel processing
Nonrandomized trial; 66 case studies, 72 controls. Level of evidence level II
Saved on average 9.6 min in sedate, block, and prep time
Hanss
Parallel processing
Non-randomized trial; 335 cases. Level of evidence II
Nonoperative time decreased 11 min, one extra case possible per day with two ORs participating, with three ORs 2 extra cases possible
Harders
Parallel processing, multidisciplinary process redesign
Non-randomized trial; 239 cases, 23 surgeons. Level of evidence II
Decreased non-operative time by 23 min, decreased anesthesia time by 5 min
Kehoe
Supply chain management, lean
Case report; 1 hospital with 22 ORs. Level of evidence IV
Improved tray accuracy to over 99%
Rosenblatt
Supply chain management
Time interrupted cohort; 1318 (pre-intervention); 1367 cases (post-intervention). Level of evidence II
45% reduction in mean per case overage in comparable study periods
Small
Specialized OR
Randomized controlled trial; 1004 cases. Level of evidence I
7 min of operative time savings and a total savings of 19 min per procedure by using a specialized orthopedic OR
Smith
Parallel processing
Non-randomized controlled Non operative time decreased 36 min, trial. 608 historical controls, 905 operative time decreased 14 min post-intervention cases, level of evidence II
Stahl
Specialized OR; parallel processing
Case-control; 182 specialized Decreased procedure time by 14 min, and OR cases, 193 matched controls, total patient OR flow time by 29 min, this level of evidence II allowed for two additional cases per day
Torkkai
Parallel processing
Case-controlled; 57 cases preintervention, 77 cases postintervention. Level of evidence III
Non operative time decreased 45.6%, additional case was able to be added per day
Varu
Specialized OR
Case-controlled; 109 cases. Level of evidence III
Hybrid fixed-image fluoroscopy equipped ORs reduced contrast usage by 30 mL and operative time by 30 min on average in the 109 endovascular aneurysm repairs observed.
Reporting delays leads to less delays
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520
fong et al ---
521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585
5
shown to help prevent mental fatigue. One study involving complex laparoscopic procedures found that in the 51 cases they studied, frequent intraoperative breaks of 5 min every half hour did not increase operative time and did decrease adverse outcomes and surgeon stress (as measured by cortisol levels18). No-handoff zones are time periods in a procedure in which the staff cannot change. In Lee’s study,17 the no-handoff zone started with the moment of flap harvest through the microvascular anastomosis (the flap ischemia time). Three studies each found that increased handoffs (as measured by team size) predicted increased operative time.19-21 These handoffs are primarily nurse-nurse (or nurse-tech) rather than surgeons. Studies examining surgeon handoffs are in conflict; He et al. found surgeon handoffs contributed to increased surgical time, whereas Cassera et al. found no effect.19,20 Regardless of the personnel who hand off, surgeons must determine the periods of the case during which handoffs will be most and least detrimental to case flow.
Standardizing instruments and supplies Standardizing and reducing supplies and durable instruments have benefits outside and inside the OR by reducing operative costs, setup time, counting time, and turnover time. Farrokhi applied lean methodology to reduce surgical trays for minimally invasive spine surgery by 70% (197 tools to 58) and decrease operative time by 7 min.22 Lunardini held an “instrument fair” to discuss utilization of spine instruments, ultimately leading to a reduction of 41% and an estimated savings of $41,000 per y.23 Multiple other studies have reduced instruments by 19%-57%, leading to less clutter in the operating room, improved setup time, and reduced reprocessing costs.24-26 Our own study found that across multiple specialties, the utilization rate of instruments was 13%-22%,27 suggesting ample room for improvement.
Team huddles Before and after each case, surgeons can use team huddles to improve efficiency. By reviewing the OR plan, goals, anticipated flow, and supply needs with the surgical team at the onset of the case, 11 surgeons at Johns Hopkins University reduced unexpected surgical delays from 36% to 25% in over 400 cases.28 Porta assessed the team’s performance after a case to understand intraoperative delays. This added no operative time and led to a 9% decrease in average delay and a 39% decrease in wasted OR time.29 Makary published a tutorial on these postoperative debriefings and suggested their use in identifying trouble areas.30 Fig. 1 e PRISMA diagram of literature search: (NB: The numbers listed for each exclusion type in “exclusion by inclusion criteria” add up to greater than total of 147 because some articles were excluded for multiple reasons.).
Medium-scale interventions
In addition to parallel processing, Lee’s process map included planned breaks and “no-handoff zones.” Planned breaks create a moment of rest during long cases and have been
Checklists
“Medium” interventions require a whole OR floor or group to participate to see benefits. Data are collected across multiple practitioners and teams to identify outliers in need of improvement. These interventions require more staff buy-in to implement.
The most widespread use of checklists in the OR today tends to focus on immediate preprocedural and postprocedural
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650
6
651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
Fig. 2 e Parallel processing: (A) induction and room turnover occur simultaneously and (B) two portions of a procedure occur simultaneously, (diagram design by Tomoko Ichikawa and Marcie Cooperman, IIT Institute of Design).
checks31-34 but extending them throughout the procedure is possible. Buzink piloted the Pro/cheQ, an interactive surgical workflow tool that displays checklists for each step of a
laparoscopic cholecystectomy and found a 65% decrease in risk-sensitive events in 15 observed cases.32 Over time, however, they had difficulties with staff engagement; in their article,
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
Q10
716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780
fong et al ---
781 782 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845
7
Fig. 3 e Dynamic operational map (DOM): This simplified diagram demonstrates the relational coordination of surgical team members and the discreet steps of an operation. Contingencies are diagrammed as diverging branches and decision nodes as converging branches. This method can be used as a framework for examining workflow in complex operations. Tools needed, scheduled breaks, and no-handoff zones can be added based on case requirements. Data on value added, cost, time, and inefficiencies can be organized based on these discreet steps. (Diagram design by Tomoko Ichikawa and Marcie Cooperman, IIT Institute of Design).
they address the need to embed such checklists in the OR routine for a sustainable benefit. Russ reported on the development and validation of an observer-administered checklist (“METEOR”) that assesses completion of key efficiency-related OR tasks during each stage of general surgical procedures.35 Although this was a research tool, it highlights key intraoperative tasks that could be targeted with a checklist.
16-min reduction in operative time after 10 team collaborations.38 Similarly, Doherty reduced average procedure time by 47.1 min by standardizing the nursing staff over 49 complex head and neck cases,39 and Morris found working with familiar teams resulted in an average 20% (9 min) reduction in nonoperative in-room time per case.26
Data tracking Teaming When surgeons regularly work with the same teams, cases run more efficiently due to nurses’ familiarity with tools and nomenclature, knowledge of preferences, and ability to anticipate needs. Stepaniak maintained fixed teams and scheduled similar procedures sequentially to reduce procedural time by an average of 10 min per case over 94 hernia repairs and laparoscopic cholecystectomies36 and in a separate study found that fixed teams and similar schedules reduced bariatric surgery duration by 10.8% or 4-13 min.37 Xu examined 754 cases of bilateral reduction mammoplasty procedures and found that surgical team familiarity with one another accounted for about
Perkins et al. tracked their operating room times for 180 pediatric otolaryngology cases to look for efficiency intervention targets. By comparing granular results on timing for each component of patient throughput (i.e., patient in-room to procedure start, procedure time, procedure end to room-out, and turnover time) to published benchmarks, they were able to focus their efficiency efforts only on the components that were prolonged.40 Overdyke et al. tracked specific interoperative and intraoperative delays to identify the most common sources of inefficiency for total quality improvement.41 They found decreased delays after their interventions, many of which
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910
8
911 912 913 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
Fig. 4 e Framework for OR efficiency innovations. (Diagram design by Tomoko Ichikawa and Marcie Cooperman, IIT Institute of Design). *Jimmerson details a common technique for this called “value stream mapping”.80 **Sensors are becoming ubiquitous in health care settings. In the OR, this commonly includes radiofrequency identification tracking of patients, supplies, and personnel but could also be envisioned to include computer vision, audio, and wearables that track
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
Q11
976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040
fong et al ---
1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062 1063 1064 1065 1066 1067 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105
involved simply notifying the right people of their performance. Al-Hakim and Gong found by tracking delays in the OR that about 25% of intraoperative delay time was spent on preventable disruption and 60% of those disruptions were for unnecessary activities or those that should have been performed before the procedure.42
Awareness of costs Gitelis found that educating surgeons about the price of disposable tools resulted in a 10% decrease in disposable costs for laparoscopic cholecystectomy for an annual savings of $27,000.43 Our own institutional experience has been even more significant, with a decrease in >$500,000 in annual costs of disposable instruments due to a cost-awareness campaign across just four surgical specialties.
Large-scale interventions “Large” interventions require institutional cooperation and major investment to implement. These include reorganizing supply-chain management, creating designated teams for specialized tasks, and redesigning the OR space itself.
Supply chain management Supplies are a voluminous and costly component of surgical work; hospitals may spend 50% of OR budgets on supplies,44 and this has prompted several studies aimed at reducing supply-related costs and delays. Intraoperatively ensuring that the right items are available and that unnecessary items remain unopened has the potential to reduce OR equipment delays, decrease labor costs to pull and restock unused items, and improve doctors’ and nurses’ focus on clinical care.44-47 To reduce the presence of unnecessary items, the surgical team can estimate instrument needs from past cases46 and can track wasted (opened-but-unused) supplies.48 Using this information to revise pick lists and standardize OR setups led Rosenblatt to decrease wasted material costs by 45% in 1367 postintervention cases.49 Tracking supplies with barcodes or radiofrequency identification (RFID) enhances the speed and accuracy of data collection for efficiency interventions by linking supplies with specific patients and providers and generating actual utilization data.50-55 This tracking technology can continuously monitor supplies and deliver case carts “just-in-time” to reduce operative waiting time as well as holding costs related to excess inventory.44 Such tracking software can also be used on durable instruments, to maintain tray accuracy and eliminate delays due to missing instruments56 and on personnel, to drive insights on workflow.57
Specialization Some groups have implemented specialized personnel, programs, instruments, and ORs to improve efficiency.58-61 Such interventions are only possible at medical centers with justifiable volume but have the potential to greatly
9
improve time and cost savings. Small reduced operative time by 7 min and total room time by 19 min per procedure by using a specialized 6-room orthopedic OR unit with dedicated teams.58 Althausen examined the effect of a specialized traumatologist for surgical fracture care compared to a general orthopedic surgeon at a level II trauma center. In the 2076 cases, they studied, the outcomes were comparable, but the truamatologist’s procedures were shorterdby approximately 20 min (P ¼ 0.0001)dand demanded fewer labor, supply, and implant costs.60
Space redesign and parallel processing Perhaps, the largest approach to improving efficiency is to physically redesign the OR. Massachusetts General Hospital built its OR of the Future (ORF) to study the effect of space interventions on efficiency.62 In the ORF induction and earlyrecovery rooms adjoin to improve patient flow; monitors and sensors help with easy reconfiguration. To improve throughput, specialized gurneys double as patient beds, thereby eliminating transfers. Although ORF requires an additional staff member, the workflow redesign generated enough capacity to perform two additional procedures daily.62,63 The capacity increase was due to reductions in nonoperative time by about 30 min per case by parallel processing OR turnover with patient recovery and the next patient’s induction (Fig. 2). Multiple studies have examined the effect of parallel processing on efficiency in the OR and found a savings of 5-36 min from in-room anesthesia or nonoperative time. Freidman saved an average 9.6 min in sedation, blocking, and prep time,64 Smith saved an average 36 min of nonoperative time (a 50% savings),65 and Harders saved 23 min of non-operative time and 5 min in anesthesia time.66 Importantly, this time reduction does not seem to affect anesthesia quality and may actually allow for a less hurried induction while still saving overall time.67 These time savings result in real additional capacity (which can translate to revenue increase). Torkki and Hanss each found that a separate induction room allowed an additional case to be added to a normal surgical day.68,69 Hanss also showed that this effect was more powerful when more ORs participated in parallel processing (going from two to three participating ORs resulted in an increase from one to two additional surgical procedures being possible in a standard day with the same procedural mix).68 The number of additional personnel needed to run these parallel induction rooms was 1.569 to 2.68 The benefits of additional capacity are balanced against the combined upfront capital investment in space redesign and ongoing costs of additional personnel. Marjamaa found that infrastructure costs can be avoided by performing parallel induction techniques within existing space70 and also that efficiency savings hold even in scenarios with centralized induction areas.71
= elements such as instrument use, economy of motion, or stress. ***Interventions may affect certain parts of the procedure more than others. Defining these discreet elements is important. See Fig. 3. ****Although patient is anesthetized but surgical team is not actively operating due to a disruption or delay. 5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118 1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 1153 1154 1155 1156 1157 1158 1159 1160 1161 1162 1163 1164 1165 1166 1167 1168 1169 1170
10
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
However, saving a few minutes of OR time may not always 1171 translate to additional cases.72 Using a mathematical model 1172 based on cases in the ORF and normal ORs, Sokal found that 1173 parallel processing would save enough time for additional 1174 procedures in only 26% of potential surgeon-case combina1175 1176 Q5 tions.73 Furthermore, they noted that without increased PACU 1177 space, increased OR turnover can lead to shifting the bottle1178 neck in efficiency.73 1179 In addition to parallel processing, whereby tasks are 1180 moved outside the OR, space redesign can also introduce new 1181 functions into the OR. “Hybrid rooms” can include fluoros1182 copy, magnetic resonance imaging, and computed tomogra1183 phy imaging capabilities to reduce wait time and eliminate the 1184 need for patient transportation during procedures.74-77 For 1185 instance, Varu found fixed-image fluoroscopyeequipped ORs 1186 reduced operative time by an average 30 min in 109 endo1187 1188 vascular aneurysm repairs.77 1189 1190 1191 1192 Discussion 1193 1194 Although much of the money spent in surgical care occurs in 1195 the OR,2,78 few published studies focus on this portion of the 1196 workflow. It may be that the preoperative, postoperative, and 1197 interoperative periods are more standardized, easier to track, 1198 1199 and represent the “low hanging fruit” for efficiency improve1200 ment. Surgery is highly human and must respond to patients’ 1201 anatomy, physiology, and pathology. This variability is a 1202 roadblock to efficiency improvement and highlights the need 1203 for more surgeons to get involved in efficiency interventions; 1204 surgeons have firsthand insight into the effect that any 1205 intervention has on the care of individual patients. 1206 The timepoints, cost methodology, and outcomes mea1207 sures were inconsistent across the studies in this review, and 1208 most reports lacked details that would facilitate replication in 1209 other centers. Nicolay found similar deficiencies in studies on 1210 1211 quality improvement in the OR.7 Nevertheless, articles cited in 1212 this review give important clues as to how manufacturing 1213 techniques can be useful tools for the OR. 1214 Standardization has long been an approach to improving 1215 workflow in manufacturing because it improves consistency 1216 and speed with repetition. Although patients may vary, the 1217 major steps of a given procedure are usually consistent and 1218 outlining even these can help team efficiency and reveal im1219 mediate opportunities for time savings.12-17 Designating “no1220 handoff zones”17 can further improve the continuity of care 1221 1222 and eliminate time spent transferring information between 1223 surgeons and staff during critical moments. Efficiency and 1224 safety checks could also be introduced for key moments of a 1225 procedure (rather than only at the bookends), enhancing team 1226 awareness and ushering in a paradigm shift in surgical 1227 quality. 1228 Instrument reduction is another way for surgeons to get 1229 immediate efficiency improvements22-26dnurses will need 1230 less time to prepare a room, and necessary instruments can be 1231 more evident when the OR table is less cluttered. When 1232 reduction is applied across service lines, institutions 1233 1234 can realize reduced labor-replacement and instrument1235 replacement costs.
Working with the same team leads to efficiency benefits26,36-39 and may possibly supersede many other workflow efforts. However, working with the same, experienced team is not always possible, and enhancing performance in the setting of inconsistent teams is an important area for future research. Potential avenues include using team-based communication techniques such as scripting (standardized verbal exchanges79) and implementation of intraoperative checklists and team huddles to better acclimate novices. A good first step for a surgeon looking to improve the efficiency of his or her own OR might be to map the standard workflow and contingences of their procedures (Fig. 3). This can allow areas of inefficiency or special scenarios requiring tight team coordination to be identified.80 It is possible (and perhaps desirable) for surgeons to adopt “standard operating procedures” for routine cases that are consistent across different practitioners and institutions. This would allow for greater consistency of operations and planning for the entire operative team and can help control for potential confounding variables when comparing surgical teams or comparing surgery to other interventions.81 Whatever intervention is created, there are common elements throughout all of them: 1) Data is Paramount. All efficiency improvement efforts must begin with a data plan that includes the metrics to be collected, the means of collecting them, and the definition of success.15,66,82 Time savings may not directly relate to cost savings83 nor patient outcomes, so data plans should consider the relative impact of each of these metrics on the success of a proposed intervention. 2) Communication drives the operating room. Teamwork is the cornerstone of successful surgery, and the voices of all team members (surgeons, nurses, staff, and anesthesiologists) should be heard when planning interventions to ensure that all opportunities are considered.84,85 This also engenders ownership and buy-in of team members in proposed solutions.86 3) The OR is not an Island. Although we intentionally focused on intraoperative efficiencies, the overall patient-care pathway and distal patient-care outcomes should be tracked.87 Money and time saved in the OR that leads to longer hospital stays and poor outcomes is a fools’ economy88 and is antithetical to surgical improvement. Figure 4 outlines the steps for designing and implementing an OR efficiency intervention, as well as the key reporting measures for future publications. As more studies of OR efficiency are conducted, ensuring complete and standardized reporting can allow for cross-study comparisons, metaanalyses, and more reliable inference from data produced by multiple institutions.
Limitations Data used to assess efficiency do not tell the whole story. A simultaneous focus on improving or maintaining the quality of care must occur in any health care efficiency intervention. Our choice to focus only on the intraoperative period means that we have excluded many successful
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1236 1237 1238 1239 1240 1241 1242 1243 1244 1245 1246 1247 1248 1249 1250 1251 1252 1253 1254 1255 1256 1257 1258 1259 1260 1261 1262 1263 1264 1265 1266 1267 1268 1269 1270 1271 1272 1273 1274 1275 1276 1277 1278 1279 1280 1281 1282 1283 1284 1285 1286 1287 1288 1289 1290 1291 1292 1293 1294 1295 1296 1297 1298 1299 1300
fong et al ---
1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 1315 1316 1317 1318 1319 1320 1321 1322 1323 1324 1325 1326 1327 1328 1329 1330 1331 1332 1333 1334 1335 1336 1337 1338 1339 1340 1341 1342 1343 1344 1345 1346 1347 1348 1349 1350 1351 1352 1353 1354 1355 1356 1357 1358 1359 1360 1361 1362 Q6 1363 1364 1365
workflow-improvement solutions. We refer the reader to other sources for this information.7,78 We have also likely not captured all of the innovative intraoperative workflow solutions that have been introduced and tested. Publication bias limits reporting of unsuccessful efforts or replications of previously successful interventions. OR administrators, who drive many of these interventions, may not have the same incentive to publish as physicians or nurses. Some institutions may also consider workflow innovations to confer a competitive advantage in a marketplace of dwindling reimbursement. Others, such as the Cleveland Clinic58,88 and the Center for Integration of Medicine & Integrative Technology at the Massachusetts General Hospital,62 have been transparent about their innovations. Our hope is that by shedding light on and describing standards for intraoperative efficiency research, more individuals and institutions will be encouraged to share their experiences.
5. 6.
7.
8.
9. 10.
11.
Conclusion Approaches to improving intraoperative efficiency can occur on many levels based on the required level of resources and institutional support. Data transparency and communication are critical to intraoperative improvements, and any intervention should be conducted in the context of overall patient care. Intraoperative efficiency is an emerging science that must balance workflow standardization with individual patient care, and surgeons must therefore play a central role in developing future efficiency innovations.
12.
13.
14.
15.
16.
Acknowledgment The authors wish to thank Tomoko Ichikawa and Marcie Cooperman, both of the Illinois Institute of Technology Institute of Design, Chicago, IL, for preparation of Figures 2-4. Author contributions: All authors contributed to the design, research, analysis, and writing of this work.
17.
18.
19.
Financial disclosures The authors have no disclosures.
20.
references
21.
22. 1. Mason SE, Nicolay CR, Darzi A. The Use of lean and six sigma methodologies in surgery: a Systematic review. Surgeon. 2015;13:91e100. 2. Barbagallo S, Corradi L, Goyet JV, et al. Optimization and planning of operating room theatre activities: an original definition of pathways and process modeling. BMC Med Inform Decis Mak. 2015;15:38. 3. Ubel P. Doctor, first tell me what it costs. New York Times; 2013:A25. 4. Adamopoulos H. Survey: most patients paying attention to healthcare costs. Beckers Hosp Rev. 2013;21. Available at:
23.
24. 25.
11
http://www.beckershospitalreview.com/finance/surveymost-patients-paying-attention-to-healthcare-costs.html. Q7 Ruggieri P. Surgeons need to be more cost-conscious, and be rewarded for it. Gen Surg News. 2015;42:10. Panza W, Dahl R. What hospital CEOs need to know about surgical services. Beckers Hosp Rev. 2013;17. Available at: http://www.beckershospitalreview.com/ hospital-management-administration/what-hospital-ceosneed-to-know-about-surgical-services-4-strategies-forprotecting-or-revenue.html. Nicolay CR, Purkayastha S, Greenhalgh a, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg. 2012;99:324e335. Arakelian E, Gunningberg L, Larsson J. How operating room efficiency is understood in a surgical team: a qualitative study. Int J Qual Health Care. 2011;23:100e106. Berlet GC, Weil LS, Fooman A, Miller JM. Contemporary trends in operating room efficiency. Foot Ankle Spec. 2013;6:125e131. Fixler T, Wright JG. Comment on “Identification and use of operating room efficiency indicators: the problem of definition”. Can J Surg. 2013;56:E104. Poksinska B. The current state of Lean implementation in health care: literature review. Qual Manag Health Care. 2010;19:319e329. Attarian DE, Wahl JE, Wellman SS, Bolognesi MP. Developing a high-efficiency operating room for total joint arthroplasty in an academic setting. Clin Orthop Relat Res. 2013;471:1832e1836. Krasner H, Connelly NR, Flack J, Weintraub A. A multidisciplinary process to improve the efficiency of cardiac operating rooms. J Cardiothorac Vasc Anesth. 1999;6:661e665. Bender J, Nicolescu S, Hollingsworth S, et al. Improving operating room efficiency via an interprofessional approach. Am J Surg. 2015;209:447e450. Chalian AA, Kagan SH, Goldberg AN, et al. Design and impact of intraoperative pathways for head and neck resection and reconstruction. Arch Otolaryngol Head Neck Surg. 2002;128:892e896. Casaletto JA, Rajaratnam V. Surgical process Re-Engineering: carpal tunnel decompression: a model. Hand Surg. 2004;9:19e27. Lee BT, Tobias AM, Yueh JH, et al. Design and impact of an intraoperative pathway: a new operating room model for team-based practice. J Am Coll Surg. 2008;207:865e873. Engelmann C, Schneider M, Kirschbaum C, et al. Effects of intraoperative breaks on mental and somatic operator fatigue: a randomized clinical trial. Surg Endosc. 2011;25:1245e1250. Cassera M a, Zheng B, Martinec DV, et al. Surgical time independently affected by surgical team size. Am J Surg. 2009;198:216e222. He W, Ni S, Chen G, et al. The composition of surgical teams in the operating room and its impact on surgical team performance in China. Surg Endosc. 2014;28:1473e1478. Zheng B, Panton ON, Al-Tayeb TA. Operative length independently affected by surgical team size: data from 2 Canadian hospitals. Can J Surg. 2012;55:371e376. Farrokhi FR, Gunther M, Williams B, Blackmore CC. Application of lean methodology for improved quality and efficiency in operating room instrument availability. J Healthc Qual. 2013;00:1e10. Lunardini D, Arington R, Canacari E, et al. Lean principles to optimize instrument utilization for spine surgery in an academic medical center. Spine. 2014;39:1714e1717. Ngu JC. Improving OR efficiency in a university medical center arthroplastic surgery service. AORN J. 2010;92:425e435. Chin C, Sowerby L, John-Baptiste A, et al. Reducing otolaryngology surgical inefficiency via assessment of tray Redundancy. J Otolaryngol Head Neck Surg. 2014;43:46e49.
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1366 1367 1368 1369 1370 1371 1372 1373 1374 1375 1376 1377 1378 1379 1380 1381 1382 1383 1384 1385 1386 1387 1388 1389 1390 1391 1392 1393 1394 1395 1396 1397 1398 1399 1400 1401 1402 1403 1404 1405 1406 1407 1408 1409 1410 1411 1412 1413 1414 1415 1416 1417 1418 1419 1420 1421 1422 1423 1424 1425 1426 1427 1428 1429 1430
12
1431 1432 1433 1434 1435 1436 1437 1438 1439 1440 1441 1442 1443 1444 1445 1446 1447 1448 1449 1450 1451 1452 1453 1454 1455 1456 1457 1458 1459 1460 1461 1462 1463 1464 1465 1466 1467 1468 1469 1470 1471 1472 1473 1474 1475 1476 1477 1478 1479 1480 1481 1482 1483 1484 1485 1486 1487 1488 1489 1490 1491 1492 1493 1494 1495
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e1 3
26. Morris L, Romero Arenas M, Cerny J, et al. Streamlining variability in hospital charges for standard thyroidectomy: developing a strategy to decrease waste. Surgery. 2014;156:1441e1449. 27. Stockert E, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg. 2014;219:646e655. 28. Nundy S, Mukherjee A, Sexton JB, et al. Impact of preoperative Briefings on operating room delays. Arch Surg. 2014;143:1068e1072. 29. Porta CR, Foster A, Causey MW, et al. Operating room efficiency improvement after implementation of a postoperative team assessment. J Surg Res. 2013;180:15e20. 30. Makary MA, Holzmueller CG, Sexton JB, et al. Operating room debriefings. Jt Comm J Qual Patient Saf. 2006;32:407e410, 357. 31. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491e499. 32. Buzink SN, van Lier L, de Hingh IH, Jakimowicz JJ. Risksensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool. Surg Endosc. 2010;24:1990e1995. 33. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12e17. discussion 18. 34. Stanton BC. Management connections: checklist offers improved efficiency for MIS cases. AORN J. 2011;93:C7eC10. 35. Russ S, Arora S, Wharton R, et al. Measuring safety and efficiency in the operating room: development and validation of a metric for evaluating task execution in the operating room. J Am Coll Surg. 2013;216:472e481. 36. Stepaniak PS, Vrijland WW, de Quelerij M, et al. Working with a fixed operating room team on consecutive similar cases and the effect on case duration and turnover time. Arch Surg. 2010;145:1165e1170. 37. Stepaniak PS, Heij C, Buise MP. Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration. Anesth Analg. 2012;115:1384e1392. 38. Xu R, Carty MJ, Orgill DP, et al. The teaming Curve. Ann Surg. 2013;258:953e957. 39. Doherty C, Nakoneshny SC, Harrop AR, et al. A standardized operative team for major head and neck Cancer Ablation and reconstruction. Plast Reconstr Surg. 2012;130(1):82e88. 40. Perkins J, Chiang T, Ruiz A, et al. Auditing of operating room times: a quality improvement Project. Int J Pediatr Otorhinolaryngol. 2014;78:782e786. 41. Overdyke F, Harvey S, Fishman R, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg. 1999;88:963. 42. Al-Hakim L, Gong XY. On the day of surgery: how long does preventable disruption prolong the patient journey? Int J Health Care Qual Assur. 2012;25:322e342. 43. Gitelis M, Vigneswaran Y, Ujiki M, et al. Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a Regional health System’s experience. Am J Surg. 2015;209:488e492. 44. Park KW, Dickerson C. Can efficient supply management in the operating room save millions? Curr Opin Anaesthesiol. 2009;22:242e248. 45. Supply chain efficiencies could save Billions. OR Manager. 1997;13:24. 46. Kanich DG, Byrd JR. How to increase efficiency in the operating room. Surg Clin North Am. 1996;76:1e11.
47. King J, Joan M, Valerie Z, et al. Can supply chain software really deliver more nurses? St. Michael’s hospital in Toronto Knows it can. Healthc Q. 2005;8:125e127. 48. Rosenblatt WH, Silverman DG. Issues in cost Containment cost-effective Use of operating room supplies based on the REMEDY: Database of recovered unused materials. J Clin Anesth. 1994;6:400e404. 49. Rosenblatt WH, Chavez A, Tenney D, Silverman DG. Assessment of the economic impact of an overage reduction program in the operating room. J Clin Anesth. 1997;9:478e481. 50. Bilyk C. Importance of supply chain management in the operating room. Can Oper Room Nurs J. 2008;26:21e34. 51. Greene J. Gaining efficiency with instrument tracking. OR Manager. 2004;20:17e19, 21e2. 52. Torner N. Instrument tracking begets efficiency. Mater Manag Health Care. 2007;16:40e42. 53. Bendavid Y, Boeck H, Philippe R. RFID-enabled traceability system for consignment and high value products: a case study in the healthcare sector. J Med Syst. 2012;36:3473e3489. 54. Points K. Bar codes help improve safety in operating room. Healthcare Benchmarks Qual Improv. 2008;15:77e78. 55. Rogers a, Jones E, Oleynikov D. Radio frequency identification (RFID) applied to surgical sponges. Surg Endosc. 2007;21:1235e1237. 56. Kehoe B. Improving quality from the bottom up. Hosp Health Netw. 2010;84:28, 30. 57. Longe K. Bar coding in the OR: it’s more than just inventory control. Mater Manag Health Care. 1995;4:40e42. 58. Small TJ, Gad BV, Klika AK, et al. Dedicated orthopedic operating room unit improves operating room efficiency. J Arthroplasty. 2013;28:1066e1071.e2. 59. Kpodonu J. Hybrid cardiovascular suite: the operating room of the future. J Card Surg. 2010;25:704e709. 60. Althausen PL, Kauk JR, Shannon S, et al. Operating room efficiency: benefits of an Orthopaedic traumatologist at a level II trauma center. J Orthop Trauma. 2014;28:e101ee106. 61. Seim AR, Dahl DM, Sandberg WS. Small changes in operative time can yield discrete increases in operating room throughput. J Endourol. 2007;21:703e708. 62. Serb BY. OR of the future: hospitals & health networks/AHA. 82. 2002:36e39. Q8 63. Stahl JE, Sandberg WS, Daily B, et al. Reorganizing patient care and workflow in the operating room: a cost-effectiveness study. Surgery. 2006;139:717e728. 64. Friedman DM, Sokal SM, Chang Y, Berger DL. Increasing operating room efficiency through parallel processing. Ann Surg. 2006;243:10e14. 65. Smith MP, Sandberg WS, Foss J, et al. High-throughput operating room system for joint arthroplasties durably outperforms routine processes. Anesthesiology. 2008;109:25e35. 66. Harders M, Malangoni M a, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery. 2006;140:509e514. discussion 514e6. 67. Seim AR, Meyer M, Sandberg WS. Does parallel workflow impact anesthesia quality? AMIA Annu Symp Proc. 2005:1053. Q9 68. Hanss R, Buttgereit B, Tonner PH, et al. Overlapping induction of anesthesia: an analysis of benefits and costs. Anesthesiology. 2005;103:391e400. 69. Torkki PM, Marjamaa RA, Torkki MI, et al. Use of anesthesia induction rooms can increase the number of urgent orthopedic cases completed within 7 hours. Anesthesiology. 2005;103:401e405. 70. Marjamaa R, Vakkuri A, Kirvela¨ O. Operating room management: why, how and by whom? Acta Anaesthesiol Scand. 2008;52:596e600.
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1496 1497 1498 1499 1500 1501 1502 1503 1504 1505 1506 1507 1508 1509 1510 1511 1512 1513 1514 1515 1516 1517 1518 1519 1520 1521 1522 1523 1524 1525 1526 1527 1528 1529 1530 1531 1532 1533 1534 1535 1536 1537 1538 1539 1540 1541 1542 1543 1544 1545 1546 1547 1548 1549 1550 1551 1552 1553 1554 1555 1556 1557 1558 1559 1560
fong et al ---
1561 1562 1563 1564 1565 1566 1567 1568 1569 1570 1571 1572 1573 1574 1575 1576 1577 1578 1579 1580 1581 1582 1583 1584 1585 1586 1587
71. Marjamaa RA, Torkki PM, Hirvensalo EJ, Kirvela¨ OA. What is the best workflow for an operating room? A simulation study of five scenarios. Health Care Manag Sci. 2008;12:142e146. 72. Dexter F, Coffin S, Tinker JH. Decrease in anesthesiaControlled time cannot Permit one additional surgical operation to be reliably scheduled during the Workday. Anesth Analg. 1995;81:1263e1268. 73. Sokal SM, Craft DL, Chang Y, et al. Maximizing operating room and recovery room capacity in an era of constrained resources. Arch Surg. 2006;141:389e393. discussion 393e5. 74. Starke RM, Dumont AS. Intraoperative imaging and assessment of Cerebral Blood flow in Cerebrovascular surgery: hybrid operating rooms, intraoperative angiography and MRI, Doppler Ultrasound, Cerebral Blood flow Probes, Endoscopic Assistance, Indocyanine green Videography, and Laser Contrast imaging. World Neurosurg. 2013;82:e693ee696. 75. Stockburger WT. Image display in the operating room: eliminating the barriers in the transition to filmless radiology. Radiol Manage. 2005;27:18e20, 22, 24e5. 76. Uhl E, Zausinger S, Morhard D, et al. Intraoperative computed tomography with integrated navigation system in a multidisciplinary operating suite. Neurosurgery. 2009;64:231e239. discussion 239e40. 77. Varu VN, Greenberg JI, Lee JT. Improved efficiency and safety for EVAR with utilization of a hybrid room. Eur J Vasc Endovasc Surg. 2013;46:675e679.
13
78. Guerriero F, Guido R. Operational research in the operating theatre: a survey. Health Care Manag Sci. 2011;14:89e114. 79. Webster JL, Cao CG. Lowering communication barriers in operating room technology. Hum Factors. 2006;48:747e758. 80. Jimmerson C. Value stream mapping for healthcare made easy. Boca Raton, FL: CRC Press; 2009. 81. Attwood SEA, Lundell L, Ell C, et al. Standardization of surgical technique in antireflux surgery: the LOTUS Trial experience. World J Surg. 2008;32:995e998. 82. Agnoletti V, Buccioli M, Padovani E, et al. Operating room data management: improving efficiency and safety in a surgical block. BMC Surg. 2013;13:7. 83. Dexter F. Reductions in non-operative times, not increases in operating room efficiency. Surgery. 2007;141:544. 84. Lain J, Young C, Dworkin G, Rackstein A. Improving efficiencies and reducing costs in adult cardiac surgery: a team approach. Qual Manag Health Care. 1998;6:37e41. 85. Malagoni M. Assessing operating room efficiency and parallel processing. Ann Surg. 2006;243:15e16. 86. Mosbacher K, Raeford D. Performance art. Mater Manag Health Care. 1999;8:20e22. 87. Traverso LW. The laparoscopic surgical value package and how surgeons can influence costs. Surg Clin North Am. 1996;76(3). 88. Butler V, Clinton C, Sagi H, et al. Applying science and strategy to operating room workforce management. Nurs Econ. 2012;30:275e281.
5.4.0 DTD YJSRE13772_proof 12 May 2016 2:38 pm ce
1588 1589 1590 1591 1592 1593 1594 1595 1596 1597 1598 1599 1600 1601 1602 1603 1604 1605 1606 1607 1608 1609 1610 1611 1612 1613 1614