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Studies showcase ways to improve punctuality in early-morning OR

Wednesday October 16, 2013
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Late starts to the first surgical case of the day can be improved, according to two studies presented at the annual meeting of the American Society of Anesthesiologists.

Improving efficiency potentially reduces costs, increases patient and staff satisfaction, and increases the number of cases that can be performed daily, according to a news release from the society.

“In 2011, fewer than half of the first cases of the day started on time,” Sophia van Hoff, MD, of Dartmouth Hitchcock Medical Center in Lebanon, N.H., said in the news release. “While this was not unique to our hospital, it led to dissatisfaction for both patients and staff. Correction of these delays was targeted as a high-priority improvement project.”

Dartmouth Hitchcock chose the Rapid Process Improvement Workshop to address the problem. The RPIW team included representatives from Anesthesiology, Orthopaedic Surgery, OR Nursing, Same-Day Program Nursing, ancillary staff and Pre-Anesthesia Testing staff, Laboratory Services and Radiology. The group spent five days assessing barriers to prompt first-case starts and redesigned the workflow of patient preparation.

At Vanderbilt University Medical Center in Nashville, Tenn., an initiative tied to financial incentives for staff jump-started the improvement project. The departments of Anesthesia, Surgery and Perioperative Services shared in the goal to improve first-case on-time starts, with funding going to each of the departments when they reached their goal.

“At the start of the day, operating room managers know at what time and how many surgical cases are expected that day, and how long they should take,” Vikram Tiwari, PhD, assistant professor of anesthesiology and director of surgical business analytics at Vanderbilt University Medical Center, said in the news release. “Any deviation from the planned schedule disrupts the entire schedule, and chances are that administrators will spend the rest of the day playing catch-up.”

Process improvements

The Dartmouth study improved first-case on-time starts after 16 weeks to 75%. Dartmouth then instituted a daily communication to any caregiver associated with a delayed room, and on-time starts rose further, to 82%. The average delay decreased from 7.2 minutes to four minutes.

This improvement was created by instituting nine key workflow changes. For example, on the day of surgery, certain teams were given authority for specific windows of time in the hour before the case started. OR nurse visits were implemented as the first task, rather than occurring just before patient transport. Paperwork and testing were completed prior to the day of surgery, and after 7:20 a.m. anesthesia teams no longer had to ask the OR for permission to enter the room.

The Vanderbilt study improved first-case on-time starts from less than 50% to more than 70%. The median delay time was reduced to from five minutes to two minutes. The improvements were a result of several factors, according to the researchers, including daily meetings or “huddles,” increased communications among providers and the hiring of a new administrative director.

The efficiency improvements initiated during the process redesign have been sustained even after the expiration of the incentives, indicating that the new process is working, the researchers said. This lasting effect shows a potential way of aligning resources to collaborate on shared goals, they said.

The Dartmouth case study estimated that an improvement to greater than 80% on-time starts would result in increased patient and staff satisfaction and nearly $2 million a year in combined cost savings in overtime pay, additional cases and increased revenue.

Study abstracts: http://bit.ly/15FpSF5 and http://bit.ly/1hUAEcW


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