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Improving OR Efficiency
CONTINUING EDUCATION
Improving OR Efficiency 1.6
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PATRICIA VASSELL, DNP, MBA, BSN, RN, CNOR Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #16529 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme.
As a recipient of an honorarium from the Competency and Credentialing Institute for publication of this article, Patricia Vassell, DNP, MBA, BSN, RN, CNOR, has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
The contact hours for this article expire August 31, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to improving efficiency in the OR.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures
The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss the importance of improving efficiency in the OR. 2. Identify ways in which managers can evaluate OR efficiency. 3. Explain how managers can assess performance in the OR. 4. Discuss metrics used to evaluate OR efficiency.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2016.06.006 ª AORN, Inc, 2016
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PATRICIA VASSELL, DNP, MBA, BSN, RN, CNOR
ABSTRACT The high-cost/high-revenue environment of the OR requires special attention from managers to scrutinize and reduce costs. In the OR, nonlabor cost savings (ie, no staff member will be laid off or reclassified to realize cost savings) can typically be identified most readily. Operational costs in the OR are affected by start times, turnover times, cancellation rates, and adequate supplies, equipment, and staffing. Inefficiency in the OR can increase costs and lead to dissatisfied patients, physicians, and staff members. This article describes concepts that contribute to efficiency in the OR and illustrates the importance of staff member engagement in achieving desired outcomes. AORN J 104 (August 2016) 122-129. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.06.006 Key words: efficiency, cost saving, on-time starts, turnover rates, healthy work environment.
W
ith shrinking reimbursements and rising health care costs, balancing cost and quality has become a high priority to achieve sustainability in today’s health care environment.1 Operating room costs are estimated at $15 to $20 per minute for a basic surgical procedure, and approximately half of that estimate is fixed overhead costs.2 Effective use of OR time is imperative to achieve profitable margins. Close attention should be paid to practices that affect the efficiency of the OR, and managers and personnel must make efforts to decrease the amount of time it takes to perform a procedure while adhering to best practices. Significant OR time can be lost performing ancillary tasks that take away from the allotted time for surgical procedures. For example, inadequate patient preparation for procedures can contribute to delays in surgery. Patient preparation should include
obtaining consents, reviewing the results of diagnostic tests, procuring clearances for surgery, gathering needed supplies in advance of a procedure, and allocating adequate resources to perform turnover.
The lack of needed supplies and equipment during a procedure can add time and contribute to unnecessary delays. The time
saved from not having to locate missing items can significantly contribute to starting and completing procedures on time. At the conclusion of a procedure, effectively communicating to personnel that the room is ready to turn over helps reduce procedure time. Two important measures used to analyze an OR’s financial status are costs and charges.3 The amount the hospital and physician bill for a service can vary according to the complexity and duration of the procedure.2,4 Hospital time and procedure time are two OR charges that usually are captured by the hospital. It is essential to keep these low to achieve a profitable margin.
ASSESSING PERFORMANCE Donabedian’s conceptual framework has been used as a roadmap for quality measurement and improvement in health care.5 Donabedian’s structure, process, and outcome model encompasses physical, physiological, and social functions.6 One advantage of this model is its inherent flexibility, which facilitates wide application in health care. Secondary to this flexibility, the model remains in widespread use for examining health care processes. For example, the perioperative setting could be viewed as the place where the procedure occurs (ie, http://dx.doi.org/10.1016/j.aorn.2016.06.006 ª AORN, Inc, 2016
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the intraoperative phase) or it could encompass the preoperative, intraoperative, and postoperative areas. The environment must be examined closely to assess whether it is conducive to performance of the various aspects of patient care that are needed for successful surgery. Maintaining patient safety is also a major concern among nurses working in the OR, and although ensuring safety is paramount, it can affect efficiency. The OR environment requires increased work speed, enhanced productivity, and adequate staffing. Lack of adequate resources and processes can pose a threat to patient safety and OR efficiency.7 The Joint Commission has established National Patient Safety Goals that clearly outline patient safety expectations.8 It is imperative in the perioperative environment to balance speed and efficiency with patient safety. The Joint Commission’s patient safety goals promote specific improvements in patient safety and include
identifying patients correctly, improving staff member communication, using medicines safely, using alarms safely, preventing infection, identifying patient safety risks, and preventing mistakes in surgery.
Engaging physicians in improving efficiency ultimately translates into them having time to perform more procedures or to complete procedures earlier. Because there are varying models used for aligning physicians with hospital safety goals, different strategies may have to be used to assure their engagement. The two most common relationship models between physicians and hospitals are the employment model and the professionalagreement model.9 Some hospitals use both models. In many hospitals in which physicians are employees, there are financial incentives built into their agreements that pertain to organizational and departmental goals. Regardless of the model used, failure to meet some of the efficiency goals could result in a loss of either block time or the ability to schedule a first procedure of the day. Establishing a highfunctioning OR committee consisting of physician leaders, OR nursing leaders, and hospital administrators can help with creating guidelines and accountability.
METRICS FOR EVALUATING EFFICIENCY Defining the metrics used to measure efficiency helps team members understand the requirements for improving outcomes. These metrics in an OR include the percentage of on-
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time starts, turnover time, and the number of procedure cancellations and delays. Creating a dashboard to display and discuss the metrics that are being measured helps educate and engage the OR team. Some dashboards may include all the metrics being measured and others may include only the most important metrics. Table 1 presents an example of a dashboard that measures on-time start percentages, turnover time, and cancellation rates during a three-month period.
On-Time Starts According to the Association of Anesthesia Clinical Directors (AACD), OR start time is defined as the moment the patient enters the room.10 The AACD acknowledges that there is still significant debate regarding this definition and that it is important that all stakeholders are clear on the facility’s definition of start time. Determining the incidence of ontime starts requires documentation of the reasons for surgical delays, because this information can contribute significantly to process-improvement initiatives in the OR. Reasons for delays in surgery vary from patient issues (eg, the patient not being ready) to system issues (eg, blood not being available, equipment malfunctioning) to practitioner issues (eg, late physicians, incorrect scheduling). After documenting a chosen time frame, managers should identify the top three reasons for delays and develop a process-improvement plan to address them. After addressing the top three issues, the manager should also identify any remaining issues that need to be addressed. Explaining the findings to physicians and staff members is necessary to channel efforts in the appropriate direction and drive additional improvements.
Turnover Time The AACD defines turnover time as the time the previous patient leaves an OR to the time the next patient arrives for sequentially scheduled procedures.10 This period is typically described as wheels out to wheels in. Completing the turnaround process involves the entire team engaging in activities that range from cleaning the room and assembling needed supplies and equipment to ensuring the readiness of the patient, surgeon, nurses, and anesthesia professional. It is important to establish expected turnover times for different types of procedures, taking into account that some procedures require lengthy setup, whereas others do not. After turnover times have been determined, staff members should document reasons for delayed turnovers and, based on this information, implement performance-improvement plans to correct the deficiencies. Perioperative staff members and leaders must pay
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Table 1. Example of Metrics and Their Outcomes During a Three-Month Period Metric
Definition
Measure
Goal
January
February
March
On-time starts for first procedures
Patient in room at scheduled time
Percentage of procedures in which patient enters the room at the scheduled time per total number of procedures performed
85%
80%
82%
85%
Turnover time
Time from prior patient out to next patient in room
Percentage of procedures turned over in 30 minutes or less per total number of procedures performed
80%
70%
75%
78%
Procedure cancellation rate
Rate of procedures canceled within 24 hours of surgery
Number of procedures canceled within 24 hours of surgery per total number of scheduled procedures
2%
5%
3%
2%
Top three reasons for delays
N/A
N/A
careful attention to the most expedient way to achieve rapid room turnover. Some level of parallel processing may be required, whereby the tasks to be completed are performed simultaneously by different staff members.1 For example, when a nurse who functions as a facilitator helps set up rooms, assists with counts and room turnovers, provides additional supplies to the sterile field, and troubleshoots when problems arise, it frees the RN circulator to attend to the patient.
Procedure Cancellation and Delay Whenever a procedure is canceled, the reason for cancellation must be noted. A review of the total number of procedures scheduled and the total number of procedures canceled during the same time period will yield a cancellation rate. Reasons for 124 j AORN Journal
N/A
Patient with several questions Missing instrument Anesthesia professional late
Patient not ready Surgeon late Equipment unavailable
Patient late Surgeon late Equipment malfunction
cancellation include a patient in need of transportation for outpatient discharge, a patient who did not arrive for surgery, or a patient who did not meet NPO requirements.11 A 2005 study by Ferschl et al12 suggested that seeing patients in a preoperative clinic results in fewer procedure cancellations and delays on the day of surgery. High cancellation rates result in unfavorable consequences and patient and staff member dissatisfaction.12 Procedure cancellations can add unnecessary costs to the OR and waste money on unnecessary setups, instrument sterilization, and supplies. Reducing delays could free up availability on the OR schedule as well as maximize OR use.12 An examination of the myriad processes involved in the surgical experience and how they affect performance should be
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completed. For example, the act of transporting a patient into the OR and performing a procedure in a timely manner relies heavily on the processes that are in place, which should clearly identify roles and expectations of personnel. Establishing times when patients are seen by the members of the team also helps provide clarity about team expectations, facilitate flow, and identify causes of delays. An example timeline is provided here.
7:00 7:15 7:25 7:30
AM: AM: AM: AM:
Patient Patient Patient Patient
is seen by the surgeon. is seen by the anesthesia professional. is seen by the RN circulator. arrives in the OR.
Establishing such timelines aids in the appropriate documentation of delays, which can then be summarized and used to create performance-improvement plans aimed at improving efficiency in the OR. Equipment, instruments, and supply delays are easier to identify as reasons for delays if the department’s policy or practice states that the patient cannot be taken to the OR if needed items are missing. The core of these timeline expectations relies heavily on the readiness of the patient, the team, the procedure, and where the procedure occurs. For example, many organizations invest heavily in preoperative areas that ensure patient readiness before the day of surgery. The use of preoperative clinics may yield significant benefits in mitigating perioperative risks, because the patient is assessed and special needs are addressed before the day of surgery, which in turn, decreases OR delays and cancellations. Cancellations and delays negatively affect the OR financially. It may be impossible to use an empty room at the last minute, because there may be no other procedures available to take that time slot; this situation results in lost OR time. Cancellations and delays also may create nonproductive hours for personnel.11 Ultimately, preoperative preparations help to maximize the use of OR resources.13 Nurses can perform preoperative assessments either remotely or in person and use a decision tree to identify patients who need additional evaluation by a physician. During preoperative assessments, patients can receive education about their procedures as well as postoperative instructions. Nurses can obtain important patient information, such as allergies, previous surgeries, and comorbidities, and they can review and reconcile medications and provide the patient with instructions regarding what medications to withhold the morning of surgery.
Patient Satisfaction Under the Hospital Value-Based Purchasing (VBP) program of the Centers for Medicare and Medicaid Services (CMS), one measure of performance is patient satisfaction. The Hospital
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Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is the first standardized, publicly reported information regarding the patient’s perception of care received.14 The HCAHPS has created a new level of transparency that allows consumers access to informationdnamely, a facility’s HCAHPS scoredthat they can use to decide where they would like to receive care. Understanding how efficiency in the OR contributes to the patient experience is important, because unmet expectations (eg, delays) affect the patient’s experience and, subsequently, a facility’s survey results. Managing the patient’s expectations by using skillful communication techniques can help offset some of the negative consequences.14 Providing a positive patient experience and securing a good HCAHPS score are important because prospective patients making decisions about where to receive their care are able to view the patient satisfaction scores for a particular hospital and decide whether to have surgery there.14 In addition, HCAHPS scores also directly affect reimbursement for the facility. The HCAHPS score may then affect finances in two ways: loss of revenue, if patients elect to have care at another facility, and lower reimbursement from the CMS than from other payers for patient care already rendered.14 Many factors contribute to patient satisfaction with care, and nurse satisfaction is a significant variable affecting the patient’s assessment. Vahey et al15 found that nurses who had adequate staffing environments, good administrative support, and good relationships with the physicians had patients who were twice as likely to report high satisfaction with their care.15 Nurse leaders should bear this in mind in their daily work and also remember that their leadership is a significant contributing factor to the quality of the nursing work environment.
OUTCOMES Establishing goals for on-time starts, turnover time, cancellation rates, and any other desirable metric and publishing it frequently is necessary so that the team can be aware of progress. If positive outcomes are achieved, celebrate. If not, examine the data and identify where there are opportunities for improvement. The ability to retrieve good data is essential to quality improvement goals in the OR. A dashboard that highlights the outcomes of all the efforts to accomplish the established goals is a great tool to engage staff members.
REGULATIONS FOR IMPROVING EFFICIENCY Facilities have many internal reasons to improve patient care, costs, and efficiency; however, there is also external pressure AORN Journal j 125
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from accrediting and regulatory agencies for these improvements. These pressures exist for both inpatient and outpatient facilities.
Centers for Medicare & Medicaid Services The CMS have created a strategy to address issues in the American health care system. The CMS hopes to help providers provide better health care, improve the patient experience, and lower the per capita cost of care.16 Among the tools that CMS has created to achieve these goals is the VBP program. The VBP program is intended to transform Medicare from a passive payer for services to a prudent purchaser of services that pays not just for quantity of services but for quality as well.15 The four major domains for measures for a hospital’s VBP program are the patient- and caregiver-centered experience of care or care coordination, clinical care process and outcomes, efficiency and cost reduction, and safety. Some of the areas targeted by these domains are the efforts and protocols used to reduce the incidence of surgical site infections in patients undergoing colon surgery and abdominal hysterectomy, or those at risk for central lineeassociated blood stream infections or catheter-associated urinary tract infections. Effective management of the patient’s care is essential because payers, including Medicare, are refusing to pay hospitals for what may be considered preventable complications such as surgical site infections and other surgery-related infections.16 Surgical site infections are the most common type of health careeassociated infection (HAI), and they account for 31% of all HAIs among hospitalized patients. Surgical site infections contribute significantly to morbidity, prolonged hospitalization, and death.17 The CMS releases the Percentage Payment Summary Reports to hospitals every year; this documentation provides hospitals with their value-based incentive payment percentages.18 Hospitals risk losing reimbursements if infection rates are high. The HCAHPS survey contains 18 core questions about various aspects of the care provided that contributed to the patient’s experience.14 These aspects include communication with nurses and physicians, responsiveness of staff members,
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cleanliness and quietness of the hospital environment at night, pain management, communication about medicines, discharge information, overall rating of the hospital, and recommendation of the hospital to others.14 Patients receiving outpatient care typically are the ones who complete the HCAHPS survey for OR experiences. Survey results for postoperative patients who are admitted are usually reported for the area from which the patients were discharged.14
THE NURSING WORK ENVIRONMENT The American Association of Critical Care Nurses has recognized that the quality of the work environment correlates to nursing practice and patient care outcomes.19 Therefore, it is essential to understand the effects of the work environment on nursing performance and patient outcomes. Creating a healthy work environment in the OR can assist in achieving greater efficiency. The American Association of Critical Care Nurses has identified six standards that aid in sustaining a healthy work environment. The established standards are
skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership.19
Skilled Communication Effective communication is essential to providing safe care. A healthy work environment calls for skilled communication. Effective communication and teamwork can minimize stressors and decrease errors. In a study by Halverson et al,20 the researchers noted that communication failures in the OR were most frequently related to equipment and lack of updates among team members about the progress of a procedure. Such communication failures can lead to delays and inefficiency. To enhance a healthy work environment, it is important to develop collegial relationships with physicians. Engaging physicians is vital because physicians can champion initiatives to their peers if they have information about the initiatives. Identifying highly motivated physicians is key. Improving
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communication between physicians and the hospital is imperative when trying to achieve the desired organizational goals. When this responsibility is shared, there is a greater opportunity to create a culture of mutual cooperation. Organizational leaders must work on improving efficiency and decreasing costs by reducing disparities in clinical practice and creating processes and procedures with ranges of variance that are predictable. Managing costs in surgical services is of utmost importance because surgical services may contribute up to 40% of an organization’s total revenue.21 Eliminating variability in processes can be a challenging task, and it requires the engagement of the physicians to be successful.22 Standardizing physician-driven processes, such as obtaining consents, completing preoperative diagnostics, and reviewing test results before the day of surgery, helps improve efficiency outcomes.
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staffing issues. Managers usually can resolve the occasional unpredictable event; however, when every day has a high level of variability, it can lead to staff member burnout and frustration. Managers must identify trends and plan for staffing needs that will accommodate unexpected events without creating undue stress and hardship on the team. Some trends to examine include reviewing the number of rooms being used and the extent of use per day of the week during a specified time frame to determine whether there is a particular day when volume is higher, and if so, how to plan staffing accordingly. Additionally, managers should determine the frequency of add-on procedures to determine staffing levels. Mondays and Fridays may be the days that are most unpredictable for the OR because of situations that developed either before or during the weekend that require procedures to be added on one of these days. After reviewing the average numbers of procedures that are added to the schedule by day of the week, managers can plan staffing to accommodate them.
True Collaboration Collaboration and a team approach are required when caring for patients. Team members need to complete a review of patient records, instruments, equipment, and supplies before the procedure, preferably at least the day before, to help ensure everything that is needed is available. This review is essential; it helps avoid delays and procedure cancellations. True collaboration in the perioperative setting is essential to achieving a high level of functionality in the OR. To have true collaboration, however, authentic leadership must exist. Leaders who help develop a healthy work environment will create an atmosphere in which staff members are more likely to work well together to achieve the goals of the department. Perioperative nursing leaders can model collaborative behavior and also monitor the nursing work environment for improvements.
Effective Decision Making Nurses can be valued partners in creating policies and procedures, directing and evaluating care, leading organizational operations to fulfill their roles as advocates, and participating in decisions that affect patient care.19 Engaging nurses in the decision-making process in the department can support the provision of excellent, quality care.
Appropriate Staffing Staffing can be challenging because many unpredictable situations cannot be controlled (eg, procedures taking longer than expected, emergency procedures bumping scheduled procedures, equipment failures), which can create significant
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Meaningful Recognition Authentic leadership relies on leaders to engage team members and provide avenues for recognition when needed. Some examples of meaningful recognition in the OR may be creating a wall of fame where high-performing teams, services, or individuals can be recognized for achievement of the efficiency goals.
Authentic Leadership The creation of a healthy work environment is required to maintain an engaged workforce.21 Unit practice councils are an effective means to improve staff member engagement, communication, and collaboration. There are many ways frontline staff members can help the department achieve its goals and improve efficiency. Many organizations use the Lean method, which focuses on creating the most value while decreasing resource time and effort.23 Managers can use staff members to help generate ideas and can make an effort to engage frontline personnel in quality and performance improvement. Using idea systems in which staff members share ideas openly instead of using a suggestion box is helpful to the manager because personnel often identify difficult-to-spot, vital system improvements.24 The nurse leader’s role has been identified as the most prominent in the retention and job satisfaction of qualified nursing staff members.25 Staff nurses should make their expectations for support in performing duties clear to the nurse manager to help improve effective performance. Nurse managers need leadership training to master the competencies required to demonstrate
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supportive behaviors identified by staff members (eg, the staff members may state that the manager never listens to them). The demands on the manager can be overwhelming, and time management is essential to allow him or her time to interact with and support the nursing staff members. To do this, the manager could delegate clerical functions to an administrative assistant to allow him or her more time to focus on initiatives that will improve staff member morale and engagement.25 Change is a constant in the current American health care system, and nowhere is the pace of change more rapid than in the OR. Education is imperative for all team members to gain an understanding of why change needs to happen. It is the responsibility of the perioperative nursing leader to provide education to staff members. A leader must share data and seek solutions from the team, educate them on the significance of initiatives, and seek their engagement. Nursing leaders also must collect data so that they can establish a baseline for on-time start percentage and cancellation and turnover rates so that improvements can be tracked, and they must share results of the data collection with staff members as well as physicians on a regular basis. The final responsibility is for leaders to monitor and publicize data and celebrate improvements.
4. 5.
6.
7. 8.
9.
10.
11. 12.
13.
CONCLUSION Improving processes to achieve efficiency in the OR can be difficult; however, maintaining improvements can be even more challenging. Improving efficiency in the OR requires the engagement and cooperation of the entire team. Leaders must create a culture of excellence where everyone feels responsible for the outcomes. Amid the efforts to contain costs and improve efficiency, it is important for the team to know and understand that patient safety is the number one priority, and critical thinking and good judgment must prevail.
14.
15. 16.
Editor’s note: Lean is a registered trademark of Lean Enterprise Institute, Inc, Cambridge, MA. 17.
References 1. Krupka DC, Sandberg WS. Operating room design and its impact on operating room economics. Curr Opin Anaesthesiol. 2006; 19(2):185-191. 2. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233-236. 3. Gamble M. 6 cornerstones of operating room efficiency: best practices for each. Becker’s Hospital Review. http://www.beckers hospitalreview.com/or-efficiencies/6-cornerstones-of-operating
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19.
-room-efficiency-best-practices-for-each.html. Published January 18, 2013. Accessed April 22, 2016. Beck DE, Margolin DA. Physician coding and reimbursement. Ochsner J. 2007;7(1):8-15. Models of health care quality: Donabedian’s model. International Centre for Allied Health Evidence. http://implementationcentral.com/ ebponline/?page_id¼340. Accessed April 22, 2016. Mitchell PH, Ferketich S, Jennings BM. Quality health outcomes model. American Academy of Nursing Expert Panel on Quality Health Care. Image J Nurs Sch. 1998;30(1):43-46. Alfredsdottir H, Bjornsdottir K. Nursing and patient safety in the operating room. J Adv Nurs. 2008;61(1):29-37. National patient safety goals effective January 1, 2016. The Joint Commission. https://www.jointcommission.org/assets/1/6/2016_ NPSG_HAP.pdf. Accessed April 21, 2016. Hospital-physician alignment: employment vs. professional service agreement. Givens Pursley LLP. http://www.givenspursley.com/ uploads/pdf/imaarticle-hospital-physicianalignment.pdf. Accessed May 27, 2016. Procedural times glossary. Association of Anesthesia Clinical Directors. http://perioperativesummit.org/uploads/3/2/2/1/ 3221254/aacd-ptgv2013a.pdf. Accessed April 21, 2016. Haufler K, Harrington M. Using nurse-to-patient telephone calls to reduce day-of-surgery cancellations. AORN J. 2011;94(1):19-26. Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology. 2005;103(4):855-859. Kalamas AG. Preoperative evaluation and management. In: Kaye AD, Fox III CJ, Urman RD, eds. Operating Room Leadership and Management. New York, NY: Cambridge University Press; 2012:121-129. HCAHPS: patients’ perspectives of care survey. Centers for Medicare & Medicaid Services. http://www.cms.gov/Medicare/Quality-Initiati ves-Patient-Assessment-Instruments/HospitalQualityInits/Hospital HCAHPS.html. Updated September 25, 2014. Accessed April 21, 2016. Vahey DC, Aiken LH, Sloane DM, Clarke SP, Vargas D. Nurse burnout and patient satisfaction. Med Care. 2004;42(2 suppl):II57-II66. CMS makes changes to improve quality of care during hospital inpatient stay. Centers for Medicare & Medicaid Services. http:// www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2012 -Fact-Sheets-Items/2012-08-012.html. Published August 1, 2012. Accessed April 21, 2016. Surgical site infection (SSI) event. The Centers for Disease Control and Prevention. http://www.cdc.gov/nhsn/PDFs/pscManual/ 9pscSSIcurrent.pdf?agree¼yes&next¼Accept. Updated January 2016. Accessed May 27, 2016. Hospital value-based purchasing. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-initiatives-patient -assessment-instruments/hospital-value-based-purchasing/index .html. Accessed May 27, 2016. AACN standards for establishing and sustaining healthy work environments: a journey to excellence, 2nd edition. American
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20. 21.
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Association of Critical-Care Nurses. http://www.aacn.org/wd/hwe/ docs/hwestandards.pdf. Accessed April 21, 2016. Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. Romano M. Doctors make the difference. Physicians’ costs are shown to vary widely: study. Mod Healthc. 2006;36(13): 10-12. Shirey MR. Authentic leaders creating healthy work environments for nursing practice. Am J Crit Care. 2006;15(3): 256-267. What is Lean? The Lean Enterprise Academy. http://www.leanuk .org/what-is-lean.aspx. Accessed May 2, 2016. Robinson A, Schroeder D. The role of front-line ideas in Lean performance improvement. Qual Manage J. 2009;16(4): 27-40. Schmalenberg C, Kramer M. Nurse manager support: how do staff nurses define it? Crit Care Nurse. 2009;29(4):61-69.
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Patricia Vassell, DNP, MBA, BSN, RN, CNOR, is a management consultant at The First String Healthcare, Irvine, CA. As a recipient of an honorarium from the Competency and Credentialing Institute for publication of this article, Dr Vassell has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This CE meets eligibility requirements to recertify the Certified Surgical Services Manager (CSSM) credential, and eligibility requirements to apply for the CSSM exam. Learn more at cc-institute.org/CSSM.
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EXAMINATION
Continuing Education: Improving OR Efficiency 1.6
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PURPOSE/GOAL To provide the learner with knowledge specific to improving efficiency in the OR.
OBJECTIVES 1. 2. 3. 4.
Discuss the importance of improving efficiency in the OR. Identify ways in which managers can evaluate OR efficiency. Explain how managers can assess performance in the OR. Discuss metrics used to evaluate OR efficiency.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.
QUESTIONS 1. With shrinking reimbursements and rising health care costs, balancing cost and quality has become a high priority to achieve sustainability in today’s health care environment. a. true b. false 2. To improve efficiency in the OR, managers should a. restrict scheduling of procedures. b. identify physicians who inaccurately book their procedures. c. decrease the amount of time it takes to perform a procedure. d. increase staffing. 3. Important measures used to analyze an OR’s financial status include 1. costs. 2. charges. 3. insurance payments. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 4. The ________ model is often used to evaluate health care processes.
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a. Laslo c. Donabedian
b. Watson d. Maslow
5. Issues that can pose a threat to patient safety and OR efficiency include a. poor budgeting. b. lack of adequate resources and processes. c. lack of physician buy-in. d. lack of administrative support. 6. Metrics used to evaluate efficiency in an OR include 1. on-time starts. 2. turnover time. 3. procedure cancellation and delay. 4. patient satisfaction. 5. staff member satisfaction. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5 7. A study by Ferschl et al suggested that a. tracking the performance of staff members reduced cancellations and delays. b. seeing patients in a preoperative clinic results in fewer procedure cancellations and delays.
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c. no one measure affected a reduction in cancellations and delays. d. tracking the accuracy of procedure-scheduling reduced cancellations and delays. 8. An examination of the myriad processes involved in the surgical experience and how they affect performance should be completed. a. true b. false 9. Improving efficiency relies heavily on 1. the readiness of the patient. 2. the team. 3. the procedure. 4. where the procedure occurs.
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a. 1 and 3 c. 1, 2, and 4
b. 2 and 4 d. 1, 2, 3, and 4
10. Tools that the Centers for Medicare & Medicaid Services have created to provide better health care, improve the patient experience, and lower the per capita cost of care include 1. accreditation surveys. 2. the Value-Based Purchasing program. 3. the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). 4. Surgical Care Improvement Project surveys. a. 1 and 4 b. 2 and 3 c. 2, 3, 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION
Continuing Education: Improving OR Efficiency 1.6
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T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
7.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
8.
Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.)
8A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
8B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
9.
Our accrediting body requires that we verify the time you needed to complete the 1.6 continuing education contact hour (96-minute) program: _______________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss the importance of improving efficiency in the OR. Low 1. 2. 3. 4. 5. High 2.
Identify ways in which managers can evaluate OR efficiency. Low 1. 2. 3. 4. 5. High
3.
Explain how managers can assess performance in the OR. Low 1. 2. 3. 4. 5. High
4.
Discuss metrics used to evaluate OR efficiency. Low 1. 2. 3. 4. 5. High
CONTENT 5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
6.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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PATRICIA VASSELL, DNP, MBA, BSN, RN, CNOR Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #16529 Session: #0001 Fee: For current pricing, please go to: http://www.aornjournal .org/content/cme.
As a recipient of an honorarium from the Competency and Credentialing Institute for publication of this article, Patricia Vassell, DNP, MBA, BSN, RN, CNOR, has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
The contact hours for this article expire August 31, 2019. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to improving efficiency in the OR.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures
The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss the importance of improving efficiency in the OR. 2. Identify ways in which managers can evaluate OR efficiency. 3. Explain how managers can assess performance in the OR. 4. Discuss metrics used to evaluate OR efficiency.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2016.06.006 ª AORN, Inc, 2016
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PATRICIA VASSELL, DNP, MBA, BSN, RN, CNOR
ABSTRACT The high-cost/high-revenue environment of the OR requires special attention from managers to scrutinize and reduce costs. In the OR, nonlabor cost savings (ie, no staff member will be laid off or reclassified to realize cost savings) can typically be identified most readily. Operational costs in the OR are affected by start times, turnover times, cancellation rates, and adequate supplies, equipment, and staffing. Inefficiency in the OR can increase costs and lead to dissatisfied patients, physicians, and staff members. This article describes concepts that contribute to efficiency in the OR and illustrates the importance of staff member engagement in achieving desired outcomes. AORN J 104 (August 2016) 122-129. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.06.006 Key words: efficiency, cost saving, on-time starts, turnover rates, healthy work environment.
W
ith shrinking reimbursements and rising health care costs, balancing cost and quality has become a high priority to achieve sustainability in today’s health care environment.1 Operating room costs are estimated at $15 to $20 per minute for a basic surgical procedure, and approximately half of that estimate is fixed overhead costs.2 Effective use of OR time is imperative to achieve profitable margins. Close attention should be paid to practices that affect the efficiency of the OR, and managers and personnel must make efforts to decrease the amount of time it takes to perform a procedure while adhering to best practices. Significant OR time can be lost performing ancillary tasks that take away from the allotted time for surgical procedures. For example, inadequate patient preparation for procedures can contribute to delays in surgery. Patient preparation should include
obtaining consents, reviewing the results of diagnostic tests, procuring clearances for surgery, gathering needed supplies in advance of a procedure, and allocating adequate resources to perform turnover.
The lack of needed supplies and equipment during a procedure can add time and contribute to unnecessary delays. The time
saved from not having to locate missing items can significantly contribute to starting and completing procedures on time. At the conclusion of a procedure, effectively communicating to personnel that the room is ready to turn over helps reduce procedure time. Two important measures used to analyze an OR’s financial status are costs and charges.3 The amount the hospital and physician bill for a service can vary according to the complexity and duration of the procedure.2,4 Hospital time and procedure time are two OR charges that usually are captured by the hospital. It is essential to keep these low to achieve a profitable margin.
ASSESSING PERFORMANCE Donabedian’s conceptual framework has been used as a roadmap for quality measurement and improvement in health care.5 Donabedian’s structure, process, and outcome model encompasses physical, physiological, and social functions.6 One advantage of this model is its inherent flexibility, which facilitates wide application in health care. Secondary to this flexibility, the model remains in widespread use for examining health care processes. For example, the perioperative setting could be viewed as the place where the procedure occurs (ie, http://dx.doi.org/10.1016/j.aorn.2016.06.006 ª AORN, Inc, 2016
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the intraoperative phase) or it could encompass the preoperative, intraoperative, and postoperative areas. The environment must be examined closely to assess whether it is conducive to performance of the various aspects of patient care that are needed for successful surgery. Maintaining patient safety is also a major concern among nurses working in the OR, and although ensuring safety is paramount, it can affect efficiency. The OR environment requires increased work speed, enhanced productivity, and adequate staffing. Lack of adequate resources and processes can pose a threat to patient safety and OR efficiency.7 The Joint Commission has established National Patient Safety Goals that clearly outline patient safety expectations.8 It is imperative in the perioperative environment to balance speed and efficiency with patient safety. The Joint Commission’s patient safety goals promote specific improvements in patient safety and include
identifying patients correctly, improving staff member communication, using medicines safely, using alarms safely, preventing infection, identifying patient safety risks, and preventing mistakes in surgery.
Engaging physicians in improving efficiency ultimately translates into them having time to perform more procedures or to complete procedures earlier. Because there are varying models used for aligning physicians with hospital safety goals, different strategies may have to be used to assure their engagement. The two most common relationship models between physicians and hospitals are the employment model and the professionalagreement model.9 Some hospitals use both models. In many hospitals in which physicians are employees, there are financial incentives built into their agreements that pertain to organizational and departmental goals. Regardless of the model used, failure to meet some of the efficiency goals could result in a loss of either block time or the ability to schedule a first procedure of the day. Establishing a highfunctioning OR committee consisting of physician leaders, OR nursing leaders, and hospital administrators can help with creating guidelines and accountability.
METRICS FOR EVALUATING EFFICIENCY Defining the metrics used to measure efficiency helps team members understand the requirements for improving outcomes. These metrics in an OR include the percentage of on-
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time starts, turnover time, and the number of procedure cancellations and delays. Creating a dashboard to display and discuss the metrics that are being measured helps educate and engage the OR team. Some dashboards may include all the metrics being measured and others may include only the most important metrics. Table 1 presents an example of a dashboard that measures on-time start percentages, turnover time, and cancellation rates during a three-month period.
On-Time Starts According to the Association of Anesthesia Clinical Directors (AACD), OR start time is defined as the moment the patient enters the room.10 The AACD acknowledges that there is still significant debate regarding this definition and that it is important that all stakeholders are clear on the facility’s definition of start time. Determining the incidence of ontime starts requires documentation of the reasons for surgical delays, because this information can contribute significantly to process-improvement initiatives in the OR. Reasons for delays in surgery vary from patient issues (eg, the patient not being ready) to system issues (eg, blood not being available, equipment malfunctioning) to practitioner issues (eg, late physicians, incorrect scheduling). After documenting a chosen time frame, managers should identify the top three reasons for delays and develop a process-improvement plan to address them. After addressing the top three issues, the manager should also identify any remaining issues that need to be addressed. Explaining the findings to physicians and staff members is necessary to channel efforts in the appropriate direction and drive additional improvements.
Turnover Time The AACD defines turnover time as the time the previous patient leaves an OR to the time the next patient arrives for sequentially scheduled procedures.10 This period is typically described as wheels out to wheels in. Completing the turnaround process involves the entire team engaging in activities that range from cleaning the room and assembling needed supplies and equipment to ensuring the readiness of the patient, surgeon, nurses, and anesthesia professional. It is important to establish expected turnover times for different types of procedures, taking into account that some procedures require lengthy setup, whereas others do not. After turnover times have been determined, staff members should document reasons for delayed turnovers and, based on this information, implement performance-improvement plans to correct the deficiencies. Perioperative staff members and leaders must pay
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Table 1. Example of Metrics and Their Outcomes During a Three-Month Period Metric
Definition
Measure
Goal
January
February
March
On-time starts for first procedures
Patient in room at scheduled time
Percentage of procedures in which patient enters the room at the scheduled time per total number of procedures performed
85%
80%
82%
85%
Turnover time
Time from prior patient out to next patient in room
Percentage of procedures turned over in 30 minutes or less per total number of procedures performed
80%
70%
75%
78%
Procedure cancellation rate
Rate of procedures canceled within 24 hours of surgery
Number of procedures canceled within 24 hours of surgery per total number of scheduled procedures
2%
5%
3%
2%
Top three reasons for delays
N/A
N/A
careful attention to the most expedient way to achieve rapid room turnover. Some level of parallel processing may be required, whereby the tasks to be completed are performed simultaneously by different staff members.1 For example, when a nurse who functions as a facilitator helps set up rooms, assists with counts and room turnovers, provides additional supplies to the sterile field, and troubleshoots when problems arise, it frees the RN circulator to attend to the patient.
Procedure Cancellation and Delay Whenever a procedure is canceled, the reason for cancellation must be noted. A review of the total number of procedures scheduled and the total number of procedures canceled during the same time period will yield a cancellation rate. Reasons for 124 j AORN Journal
N/A
Patient with several questions Missing instrument Anesthesia professional late
Patient not ready Surgeon late Equipment unavailable
Patient late Surgeon late Equipment malfunction
cancellation include a patient in need of transportation for outpatient discharge, a patient who did not arrive for surgery, or a patient who did not meet NPO requirements.11 A 2005 study by Ferschl et al12 suggested that seeing patients in a preoperative clinic results in fewer procedure cancellations and delays on the day of surgery. High cancellation rates result in unfavorable consequences and patient and staff member dissatisfaction.12 Procedure cancellations can add unnecessary costs to the OR and waste money on unnecessary setups, instrument sterilization, and supplies. Reducing delays could free up availability on the OR schedule as well as maximize OR use.12 An examination of the myriad processes involved in the surgical experience and how they affect performance should be
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completed. For example, the act of transporting a patient into the OR and performing a procedure in a timely manner relies heavily on the processes that are in place, which should clearly identify roles and expectations of personnel. Establishing times when patients are seen by the members of the team also helps provide clarity about team expectations, facilitate flow, and identify causes of delays. An example timeline is provided here.
7:00 7:15 7:25 7:30
AM: AM: AM: AM:
Patient Patient Patient Patient
is seen by the surgeon. is seen by the anesthesia professional. is seen by the RN circulator. arrives in the OR.
Establishing such timelines aids in the appropriate documentation of delays, which can then be summarized and used to create performance-improvement plans aimed at improving efficiency in the OR. Equipment, instruments, and supply delays are easier to identify as reasons for delays if the department’s policy or practice states that the patient cannot be taken to the OR if needed items are missing. The core of these timeline expectations relies heavily on the readiness of the patient, the team, the procedure, and where the procedure occurs. For example, many organizations invest heavily in preoperative areas that ensure patient readiness before the day of surgery. The use of preoperative clinics may yield significant benefits in mitigating perioperative risks, because the patient is assessed and special needs are addressed before the day of surgery, which in turn, decreases OR delays and cancellations. Cancellations and delays negatively affect the OR financially. It may be impossible to use an empty room at the last minute, because there may be no other procedures available to take that time slot; this situation results in lost OR time. Cancellations and delays also may create nonproductive hours for personnel.11 Ultimately, preoperative preparations help to maximize the use of OR resources.13 Nurses can perform preoperative assessments either remotely or in person and use a decision tree to identify patients who need additional evaluation by a physician. During preoperative assessments, patients can receive education about their procedures as well as postoperative instructions. Nurses can obtain important patient information, such as allergies, previous surgeries, and comorbidities, and they can review and reconcile medications and provide the patient with instructions regarding what medications to withhold the morning of surgery.
Patient Satisfaction Under the Hospital Value-Based Purchasing (VBP) program of the Centers for Medicare and Medicaid Services (CMS), one measure of performance is patient satisfaction. The Hospital
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Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is the first standardized, publicly reported information regarding the patient’s perception of care received.14 The HCAHPS has created a new level of transparency that allows consumers access to informationdnamely, a facility’s HCAHPS scoredthat they can use to decide where they would like to receive care. Understanding how efficiency in the OR contributes to the patient experience is important, because unmet expectations (eg, delays) affect the patient’s experience and, subsequently, a facility’s survey results. Managing the patient’s expectations by using skillful communication techniques can help offset some of the negative consequences.14 Providing a positive patient experience and securing a good HCAHPS score are important because prospective patients making decisions about where to receive their care are able to view the patient satisfaction scores for a particular hospital and decide whether to have surgery there.14 In addition, HCAHPS scores also directly affect reimbursement for the facility. The HCAHPS score may then affect finances in two ways: loss of revenue, if patients elect to have care at another facility, and lower reimbursement from the CMS than from other payers for patient care already rendered.14 Many factors contribute to patient satisfaction with care, and nurse satisfaction is a significant variable affecting the patient’s assessment. Vahey et al15 found that nurses who had adequate staffing environments, good administrative support, and good relationships with the physicians had patients who were twice as likely to report high satisfaction with their care.15 Nurse leaders should bear this in mind in their daily work and also remember that their leadership is a significant contributing factor to the quality of the nursing work environment.
OUTCOMES Establishing goals for on-time starts, turnover time, cancellation rates, and any other desirable metric and publishing it frequently is necessary so that the team can be aware of progress. If positive outcomes are achieved, celebrate. If not, examine the data and identify where there are opportunities for improvement. The ability to retrieve good data is essential to quality improvement goals in the OR. A dashboard that highlights the outcomes of all the efforts to accomplish the established goals is a great tool to engage staff members.
REGULATIONS FOR IMPROVING EFFICIENCY Facilities have many internal reasons to improve patient care, costs, and efficiency; however, there is also external pressure AORN Journal j 125
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from accrediting and regulatory agencies for these improvements. These pressures exist for both inpatient and outpatient facilities.
Centers for Medicare & Medicaid Services The CMS have created a strategy to address issues in the American health care system. The CMS hopes to help providers provide better health care, improve the patient experience, and lower the per capita cost of care.16 Among the tools that CMS has created to achieve these goals is the VBP program. The VBP program is intended to transform Medicare from a passive payer for services to a prudent purchaser of services that pays not just for quantity of services but for quality as well.15 The four major domains for measures for a hospital’s VBP program are the patient- and caregiver-centered experience of care or care coordination, clinical care process and outcomes, efficiency and cost reduction, and safety. Some of the areas targeted by these domains are the efforts and protocols used to reduce the incidence of surgical site infections in patients undergoing colon surgery and abdominal hysterectomy, or those at risk for central lineeassociated blood stream infections or catheter-associated urinary tract infections. Effective management of the patient’s care is essential because payers, including Medicare, are refusing to pay hospitals for what may be considered preventable complications such as surgical site infections and other surgery-related infections.16 Surgical site infections are the most common type of health careeassociated infection (HAI), and they account for 31% of all HAIs among hospitalized patients. Surgical site infections contribute significantly to morbidity, prolonged hospitalization, and death.17 The CMS releases the Percentage Payment Summary Reports to hospitals every year; this documentation provides hospitals with their value-based incentive payment percentages.18 Hospitals risk losing reimbursements if infection rates are high. The HCAHPS survey contains 18 core questions about various aspects of the care provided that contributed to the patient’s experience.14 These aspects include communication with nurses and physicians, responsiveness of staff members,
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cleanliness and quietness of the hospital environment at night, pain management, communication about medicines, discharge information, overall rating of the hospital, and recommendation of the hospital to others.14 Patients receiving outpatient care typically are the ones who complete the HCAHPS survey for OR experiences. Survey results for postoperative patients who are admitted are usually reported for the area from which the patients were discharged.14
THE NURSING WORK ENVIRONMENT The American Association of Critical Care Nurses has recognized that the quality of the work environment correlates to nursing practice and patient care outcomes.19 Therefore, it is essential to understand the effects of the work environment on nursing performance and patient outcomes. Creating a healthy work environment in the OR can assist in achieving greater efficiency. The American Association of Critical Care Nurses has identified six standards that aid in sustaining a healthy work environment. The established standards are
skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership.19
Skilled Communication Effective communication is essential to providing safe care. A healthy work environment calls for skilled communication. Effective communication and teamwork can minimize stressors and decrease errors. In a study by Halverson et al,20 the researchers noted that communication failures in the OR were most frequently related to equipment and lack of updates among team members about the progress of a procedure. Such communication failures can lead to delays and inefficiency. To enhance a healthy work environment, it is important to develop collegial relationships with physicians. Engaging physicians is vital because physicians can champion initiatives to their peers if they have information about the initiatives. Identifying highly motivated physicians is key. Improving
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communication between physicians and the hospital is imperative when trying to achieve the desired organizational goals. When this responsibility is shared, there is a greater opportunity to create a culture of mutual cooperation. Organizational leaders must work on improving efficiency and decreasing costs by reducing disparities in clinical practice and creating processes and procedures with ranges of variance that are predictable. Managing costs in surgical services is of utmost importance because surgical services may contribute up to 40% of an organization’s total revenue.21 Eliminating variability in processes can be a challenging task, and it requires the engagement of the physicians to be successful.22 Standardizing physician-driven processes, such as obtaining consents, completing preoperative diagnostics, and reviewing test results before the day of surgery, helps improve efficiency outcomes.
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staffing issues. Managers usually can resolve the occasional unpredictable event; however, when every day has a high level of variability, it can lead to staff member burnout and frustration. Managers must identify trends and plan for staffing needs that will accommodate unexpected events without creating undue stress and hardship on the team. Some trends to examine include reviewing the number of rooms being used and the extent of use per day of the week during a specified time frame to determine whether there is a particular day when volume is higher, and if so, how to plan staffing accordingly. Additionally, managers should determine the frequency of add-on procedures to determine staffing levels. Mondays and Fridays may be the days that are most unpredictable for the OR because of situations that developed either before or during the weekend that require procedures to be added on one of these days. After reviewing the average numbers of procedures that are added to the schedule by day of the week, managers can plan staffing to accommodate them.
True Collaboration Collaboration and a team approach are required when caring for patients. Team members need to complete a review of patient records, instruments, equipment, and supplies before the procedure, preferably at least the day before, to help ensure everything that is needed is available. This review is essential; it helps avoid delays and procedure cancellations. True collaboration in the perioperative setting is essential to achieving a high level of functionality in the OR. To have true collaboration, however, authentic leadership must exist. Leaders who help develop a healthy work environment will create an atmosphere in which staff members are more likely to work well together to achieve the goals of the department. Perioperative nursing leaders can model collaborative behavior and also monitor the nursing work environment for improvements.
Effective Decision Making Nurses can be valued partners in creating policies and procedures, directing and evaluating care, leading organizational operations to fulfill their roles as advocates, and participating in decisions that affect patient care.19 Engaging nurses in the decision-making process in the department can support the provision of excellent, quality care.
Appropriate Staffing Staffing can be challenging because many unpredictable situations cannot be controlled (eg, procedures taking longer than expected, emergency procedures bumping scheduled procedures, equipment failures), which can create significant
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Meaningful Recognition Authentic leadership relies on leaders to engage team members and provide avenues for recognition when needed. Some examples of meaningful recognition in the OR may be creating a wall of fame where high-performing teams, services, or individuals can be recognized for achievement of the efficiency goals.
Authentic Leadership The creation of a healthy work environment is required to maintain an engaged workforce.21 Unit practice councils are an effective means to improve staff member engagement, communication, and collaboration. There are many ways frontline staff members can help the department achieve its goals and improve efficiency. Many organizations use the Lean method, which focuses on creating the most value while decreasing resource time and effort.23 Managers can use staff members to help generate ideas and can make an effort to engage frontline personnel in quality and performance improvement. Using idea systems in which staff members share ideas openly instead of using a suggestion box is helpful to the manager because personnel often identify difficult-to-spot, vital system improvements.24 The nurse leader’s role has been identified as the most prominent in the retention and job satisfaction of qualified nursing staff members.25 Staff nurses should make their expectations for support in performing duties clear to the nurse manager to help improve effective performance. Nurse managers need leadership training to master the competencies required to demonstrate
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supportive behaviors identified by staff members (eg, the staff members may state that the manager never listens to them). The demands on the manager can be overwhelming, and time management is essential to allow him or her time to interact with and support the nursing staff members. To do this, the manager could delegate clerical functions to an administrative assistant to allow him or her more time to focus on initiatives that will improve staff member morale and engagement.25 Change is a constant in the current American health care system, and nowhere is the pace of change more rapid than in the OR. Education is imperative for all team members to gain an understanding of why change needs to happen. It is the responsibility of the perioperative nursing leader to provide education to staff members. A leader must share data and seek solutions from the team, educate them on the significance of initiatives, and seek their engagement. Nursing leaders also must collect data so that they can establish a baseline for on-time start percentage and cancellation and turnover rates so that improvements can be tracked, and they must share results of the data collection with staff members as well as physicians on a regular basis. The final responsibility is for leaders to monitor and publicize data and celebrate improvements.
4. 5.
6.
7. 8.
9.
10.
11. 12.
13.
CONCLUSION Improving processes to achieve efficiency in the OR can be difficult; however, maintaining improvements can be even more challenging. Improving efficiency in the OR requires the engagement and cooperation of the entire team. Leaders must create a culture of excellence where everyone feels responsible for the outcomes. Amid the efforts to contain costs and improve efficiency, it is important for the team to know and understand that patient safety is the number one priority, and critical thinking and good judgment must prevail.
14.
15. 16.
Editor’s note: Lean is a registered trademark of Lean Enterprise Institute, Inc, Cambridge, MA. 17.
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20. 21.
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Association of Critical-Care Nurses. http://www.aacn.org/wd/hwe/ docs/hwestandards.pdf. Accessed April 21, 2016. Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. Romano M. Doctors make the difference. Physicians’ costs are shown to vary widely: study. Mod Healthc. 2006;36(13): 10-12. Shirey MR. Authentic leaders creating healthy work environments for nursing practice. Am J Crit Care. 2006;15(3): 256-267. What is Lean? The Lean Enterprise Academy. http://www.leanuk .org/what-is-lean.aspx. Accessed May 2, 2016. Robinson A, Schroeder D. The role of front-line ideas in Lean performance improvement. Qual Manage J. 2009;16(4): 27-40. Schmalenberg C, Kramer M. Nurse manager support: how do staff nurses define it? Crit Care Nurse. 2009;29(4):61-69.
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Patricia Vassell, DNP, MBA, BSN, RN, CNOR, is a management consultant at The First String Healthcare, Irvine, CA. As a recipient of an honorarium from the Competency and Credentialing Institute for publication of this article, Dr Vassell has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This CE meets eligibility requirements to recertify the Certified Surgical Services Manager (CSSM) credential, and eligibility requirements to apply for the CSSM exam. Learn more at cc-institute.org/CSSM.
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EXAMINATION
Continuing Education: Improving OR Efficiency 1.6
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PURPOSE/GOAL To provide the learner with knowledge specific to improving efficiency in the OR.
OBJECTIVES 1. 2. 3. 4.
Discuss the importance of improving efficiency in the OR. Identify ways in which managers can evaluate OR efficiency. Explain how managers can assess performance in the OR. Discuss metrics used to evaluate OR efficiency.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.
QUESTIONS 1. With shrinking reimbursements and rising health care costs, balancing cost and quality has become a high priority to achieve sustainability in today’s health care environment. a. true b. false 2. To improve efficiency in the OR, managers should a. restrict scheduling of procedures. b. identify physicians who inaccurately book their procedures. c. decrease the amount of time it takes to perform a procedure. d. increase staffing. 3. Important measures used to analyze an OR’s financial status include 1. costs. 2. charges. 3. insurance payments. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 4. The ________ model is often used to evaluate health care processes.
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a. Laslo c. Donabedian
b. Watson d. Maslow
5. Issues that can pose a threat to patient safety and OR efficiency include a. poor budgeting. b. lack of adequate resources and processes. c. lack of physician buy-in. d. lack of administrative support. 6. Metrics used to evaluate efficiency in an OR include 1. on-time starts. 2. turnover time. 3. procedure cancellation and delay. 4. patient satisfaction. 5. staff member satisfaction. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5 7. A study by Ferschl et al suggested that a. tracking the performance of staff members reduced cancellations and delays. b. seeing patients in a preoperative clinic results in fewer procedure cancellations and delays.
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c. no one measure affected a reduction in cancellations and delays. d. tracking the accuracy of procedure-scheduling reduced cancellations and delays. 8. An examination of the myriad processes involved in the surgical experience and how they affect performance should be completed. a. true b. false 9. Improving efficiency relies heavily on 1. the readiness of the patient. 2. the team. 3. the procedure. 4. where the procedure occurs.
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Improving OR Efficiency
a. 1 and 3 c. 1, 2, and 4
b. 2 and 4 d. 1, 2, 3, and 4
10. Tools that the Centers for Medicare & Medicaid Services have created to provide better health care, improve the patient experience, and lower the per capita cost of care include 1. accreditation surveys. 2. the Value-Based Purchasing program. 3. the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). 4. Surgical Care Improvement Project surveys. a. 1 and 4 b. 2 and 3 c. 2, 3, 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION
Continuing Education: Improving OR Efficiency 1.6
www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
7.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
8.
Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.)
8A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
8B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
9.
Our accrediting body requires that we verify the time you needed to complete the 1.6 continuing education contact hour (96-minute) program: _______________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss the importance of improving efficiency in the OR. Low 1. 2. 3. 4. 5. High 2.
Identify ways in which managers can evaluate OR efficiency. Low 1. 2. 3. 4. 5. High
3.
Explain how managers can assess performance in the OR. Low 1. 2. 3. 4. 5. High
4.
Discuss metrics used to evaluate OR efficiency. Low 1. 2. 3. 4. 5. High
CONTENT 5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
6.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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