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Achieving Peak Performance in the OR

By Don Sadler

Most organizations today strive to achieve peak performance by streamlining operations and improving efficiency. Health care organizations are no exception.

But certain obstacles can hinder this goal, especially when it comes to achieving peak performance in the operating room.

“There are many variables that go into improving efficiency and streamlining processes in surgical services,” says David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC.

“It’s nearly impossible to fix only one aspect of a process without making adjustments in other areas as part of the bigger picture, or without having an effect on those areas as well,” Taylor adds.

Common Efficiency Obstacles

Linda Groah, MSN RN CNOR NEA-BC FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN), lists some of the most common obstacles to achieving peak performance in the OR, starting with incorrect case scheduling.

Groah cites a recent study examining more than 17,000 surgeries that found that booking errors occurred in 0.86 percent of the surgeries. The most common error was wrong side, which occurred in 36 percent of the booking errors, followed by incomplete labs (25 percent) and a wrong approach (17 percent).

Other common obstacles listed by Groah include:

  • Managing supplies, equipment, instruments and tissue – For example, surgeon preference cards are not accurate or up to date and instrument trays are not managed properly.
  • OR room utilization – This relates to block vs. open scheduling. “Utilization should be reviewed quarterly to assess compliance to the goal,” says Groah.
  • Patient readiness and throughput – For example, workups are not completed or patients arrive late to the facility.
  • Availability of surgical team members – “This can affect the on-time start of the surgery at the beginning of the day,” says Groah.
  • Change fatigue –  “The push to get the next patient in and out as quickly as possible can sometimes cause the surgical team to feel like they are not delivering personalized and safe care to each patient,” says Groah.

Importance of Proper Resourcing

Elbridge “Eb” Merritt, MSN, RN, CNOR, CHL, CRCST, CIS, lists a few more obstacles to achieving peak OR performance, including proper resourcing. “This includes not only supplies, equipment and infrastructure, but even more important, ensuring that appropriate human capital is present in the OR,” he says.

Merritt tells the story of when someone in human resources questioned his need for a patient transporter, saying he had “too many people as it is.”

“I had to explain to her that not having an appropriate number of patient transporters was inhibiting my ability to move patients out of the recovery room, which was backing up the ORs and crippling our productivity,” says Merritt. “Our productivity was being hamstrung by one of our lowest paying positions!”

Merritt also points to a lack of team play as a major obstacle to achieving peak OR performance.

“I’m sure no one in the OR has ever worked with someone who has a ‘I’m the center of the universe’ attitude because everyone in the OR is a team player all the time, right?” he says sarcastically.

“Getting the commitment and buy-in of all the OR team members – essentially asking them to leave their ego at the door – and getting them to contribute to a common goal can be difficult, to say the least,” Merritt adds.

Steps to Boosting Performance

The good news is that there are many steps you can take to overcome these obstacles in order to boost OR efficiency and achieve peak performance.

Taylor suggests emphasizing the importance of teamwork. “This includes not only teamwork among OR personnel, but also collaboration among departments like admissions, preoperative holding and anesthesia,” he says.

“Surgery is a team sport,” Taylor adds. “So, it’s important that each touch point is executed flawlessly to avoid costly delays or even case cancellations.”

Taylor recommends empowering front-line staff to drive the organizational changes needed to maximize performance of the surgical services department. “Who better to get the job done than the people who do the work day-in and day-out?” he asks.

Merritt believes that standardization is critical to boosting OR efficiency and performance. “This can easily be applied to processes, equipment and supplies,” he says.

He acknowledges that facilities sometimes have multiple redundant systems for the exact same procedures due to individual preferences. “However, this can have negative consequences when it comes to efficiency,” Merritt says.

“If the same system is utilized every day for the same procedure, the entire team will assimilate the knowledge of the system and begin to anticipate what’s needed five or 10 steps ahead,” says Merritt. “This can be a tremendous boost to efficiency.”

Merritt also stresses the importance of locking in OR schedules at least 48 hours in advance to make sure patients are ready on the day of their surgery.

“There should be a plan for filling up any unused blocks prior to the schedule being locked,” he says. “And there should be flexibility in the block schedule to account for emergencies and so-called ‘emergencies of convenience’ so they don’t throw the entire day’s schedule in chaos.”

Boost Efficiency By Using Analytics

Groah has more suggestions for achieving peak OR performance, starting with using descriptive, predictive and prescriptive analytics. “These will enable you to assess the problem areas, forecast what might occur and recommend actions based on the forecast,” she says.

Other efficiency-boosting ideas from Groah include:

  • Accurately determining how many ORs need to be running to meet the anticipated volume.
  • Performing quarterly assessments of surgical blocks.
  • Running pre-op clinics for patients and checking patient data the day before surgery.
  • Using electronic scheduling systems with hard stops to make sure all required data is entered.
  • Conducting pre-op briefings and post-op debriefings.
  • Using clinical pathways.

What About Concurrent Surgeries?

Right now, you might be wondering whether concurrent surgeries are an effective strategy for increasing OR efficiency. There are mixed opinions about this, especially in light of high-profile complications and patient lawsuits that have arisen recently due to the practice.

Merritt believes that concurrent surgeries can be helpful in maximizing OR efficiency as long as there are guidelines and limitations in place and this is included in the informed consent that the patient signs.

“However, the risks of performing concurrent surgery can be significant,” he says. “It’s essential to have everything spelled out in a formal policy that provides guidelines and limitations of when and how concurrent surgeries can take place.”

Taylor, however, does not think that concurrent surgeries should be practiced.

“I believe attending surgeons should be actively engaged in the surgical procedure they are consented to perform,” he says. “Surgery is complicated and each patient presents with different needs.”

Groah says that AORN’s position on concurrent surgeries is consistent with the definition by CMS and the Joint Commission, which states that “the critical portions of two surgeries performed by the same teaching physician may not take place at the same time.”

The definition continues: “If circumstances prevent the teaching physician from being immediately available during noncritical or non-key portions of the surgeries, then she/he must arrange for another qualified surgeon to be immediately available to assist with the procedure, if needed.”

AORN Seminars Discuss Efficiency

AORN’s twice-a-year Nurse Executive Leadership Seminars in 10 cities across the U.S. present an opportunity for perioperative nurses and facility leaders to discuss the rapidly changing influences that affect care delivery and OR efficiencies.

To review the fall schedule, including dates and locations, visit




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