Today, the single most important business challenge facing hospital operating rooms (ORs) is maintaining margin contribution. Meeting this challenge will be demanding, particularly in the context of an ever-increasing number of outpatient surgical centers, specialty hospitals, and physician-owned surgical hospitals.
A key issue critical to meeting the margin challenge is physician satisfaction, which is driven by several important factors:
Improvement in these three areas of perioperative services will help hospitals deal with OR margin erosion and at the same time improve patient and physician satisfaction.
By Maryann Barnes, Vice President Clinical Services, St. John Hospital & Medical Center, Detroit, MI
A poor on-time start rate for the first case of the day is recognized as the principal cause of inefficiency in the Operating Room. What is most disconcerting about this is the first case is typically the one point in the day where the greatest control can be applied. First-case delays have a cascading effect on all subsequently scheduled cases for the OR, quite often require overtime, and are a significant point of dissatisfaction among surgeons and patients.
The operating room under discussion is a moderate size OR with ten operating suites and two cystoscopy rooms. Services provided include orthopedics, neurosurgery, general surgery, vascular, and others excluding cardiac. Approximately 40% of the patients received pre-surgical screening. The on time start percentage was at 57%. The top four reasons for delay were:
Surgeons arrived late because they anticipated delays in start time. The department used an OR Information System to capture data.
A redesign team was charged to develop an action plan to improve first case starts. The team consisted of the Chief of Surgery, Chief of Anesthesia, OR Manager, Pre-op/Post Anesthesia Care Unit (PACU) manager, pre-op nurse, OR nurse, and scheduling clerk. The first action was to develop a common definition of on-time start. It was determined that the room entry time would become the start time. This was approved through the OR Committee and communicated to physicians, anesthesia, and OR staff.
The issue with late surgeons was addressed by developing a policy outlining consequences for late arrival. This was communicated to surgeons emphasizing the hospital's commitment to starting these cases on time. The Chair of the Department of Surgery was charged with administering the policy.
The unavailability of anesthesiologists was due to the scheduling of all start times at 7:30 a.m. This required an anesthesiologist to be available for two or more rooms at the same time. The start times were staggered at 7:15, 7:30, and 7:45. The anesthesia department also implemented anesthesia guidelines that allowed consistency in making decisions regarding testing needed prior to surgery.
Preoperative preparation of the patients was an area the hospital owned. In order to address the inpatients, the realignment of staff from the Pre-operating room (Pre-op)/Post Anesthesia Care Unit (PACU) area allowed the development of a pre-op facilitator role. This individual reviewed inpatient charts one to two days prior to surgery to ensure all labs and testing had been completed for surgery. If labs were not complete, the pre-op facilitator would draw them. If other studies were not complete, an order was received and scheduled. Outpatients were handled by increasing the percentage of patients seen prior to surgery to 70%. Historically patients receiving pre-surgical screening rarely caused delays. Depending on the patient's medical history and the use of anesthesia guidelines, the use of an abbreviated visit was also implemented. All charts were reviewed with relevant work-ups prior to surgery.
The issue with availability of supplies and equipment was addressed by having service specialists update preference cards. This also included an approval process for the revision of cards in the future. The afternoon and midnight shifts were responsible for having all first case procedure supplies and equipment pulled and placed in the OR for the next morning. All that was needed in the morning was a quick review and opening of supplies.
On-time starts for first case of the day became part of the Surgical Services scorecard and were reviewed monthly with the OR Committee. The management team of the OR was accountable to bring explanations and actions forward for variances from target.
The development and agreement on a standard definition for on-time start was a critical first step. This required periodic reminders with the surgeons. The staff found the process more efficient, and they no longer felt rushed and always behind throughout the day. Since several OR efficiency indicators impact overtime this initiative is not solely responsible for the savings in overtime dollars. By establishing more predictable standards of practice this OR was able to make significant change in their first case on-time start rates.
Prior Current
On-time start % 57% 85%
Pre-surgical screening 40% 70%
Physician Satisfaction no measure 71% favorable
Overtime $209,812 $152,618