Establishing an Efficient Surgical Environment
Efficiency has always been important when it comes to perioperative management, but it’s especially critical in today’s post-health care reform environment. This makes it imperative that hospitals re-examine every aspect of their OR practices and processes in an effort to increase efficiency wherever possible.
In fact, many hospitals today have adopted the principles of Lean Six Sigma in their efforts to create a more efficient surgical environment and thus reduce costs and improve the patient experience.
Lean Six Sigma was originally developed for the manufacturing industry, but its principles are just as applicable to the OR, says Christopher Powers, a Lean Six Sigma Master Black Belt and the system director of process improvement for Summa Health System in Akron, Ohio.
A Five-Step Approach
“This approach can be applied to any environment that is process-driven, whether it’s manufacturing or service oriented, and this includes the perioperative environment,” says Powers.
According to Powers, Lean Six Sigma is designed to improve the two main measurements that are inherent in all processes: efficiency and effectiveness.
“Efficiency has to do with how quickly a process is done, while effectiveness has to do with how well the process is done in relation to the customer’s — or in the OR, the patient’s — expectations.”
The biggest distinction between using Lean Six Sigma in a manufacturing verses a service environment like the OR is that service processes are driven by people, not machines.
“So behavior change management and getting buy-in from all OR personnel are both essential to getting results from Lean Six Sigma in the OR environment,” he says. “There’s an aspect of behavior change management to everything we do.”
Powers says that Summa Health System has implemented between 15 and 20 distinct efficiency-boosting initiatives based on Lean Six Sigma principles.
“These range from scheduling and billing to sterile processing and inventory management. We have examined every touch point patients have with the hospital, from the time the case is scheduled until surgery patients are discharged, in an effort to improve efficiency,” he says.
“The waste reduction principles of Lean Six Sigma are very applicable in the OR environment,” adds Jeff Peters, the president and CEO of Surgical Directions. “But if you only concentrate on using the methodology, you’ll focus too much on analysis and processes and you won’t get change. So you need to balance Lean Six Sigma principles with the application of practical, proven solutions.”
Peters believes that a big barrier to improving OR efficiency is a lack of understanding of which OR performance metrics should be monitored and managed.
“OR directors tend to focus on OR turnaround time, or the time between one patient out and the next patient in to the OR,” he says. “But that’s not what really affects profitability. More importantly, hospitals should be measuring how many cases are performed in an eight-hour block.”
Key OR Efficiency Metrics
1. Patient in
2. Anesthesia ready
3. Anesthesia start
6. Patient out
“If you focus on measuring, monitoring and managing these six metrics, you will identify opportunities to create a more efficient surgical environment,” says Peters. “You won’t see real improvements in OR efficiency until each surgeon’s performance is compared to these metrics.”
Alecia Torrance, MBA, MSN(c), BSN, BS, RN, CNOR, senior vice president for clinical operations and chief nursing executive with Surgical Directions, believes that most ORs are inefficient due to the tendency of OR team members to work in silos.
“It takes all OR team members — in particular, surgeons, perioperative nurses and anesthesiologists — working together like a finely tuned orchestra if you want to improve OR efficiency,” she says. “No single team member can do it alone — boosting efficiency requires a lot of collaboration and teamwork.”
According to Kaye Reiter, MSN, RN, vice president, surgical services with Summa Health System, culture is the biggest barrier to creating a more efficient surgical environment.
“It’s human nature that people don’t want to change,” she says.
“So we try to create buy-in and a sense of urgency among OR team members when implementing change management plans designed to boost OR efficiency,” Reiter adds. “Each member of the OR team has a part to play in improving efficiency and eliminating barriers that lead to silos in the OR.”
Reiter believes that most perioperative nurses know what they should be doing to help make the OR run efficiently.
“It’s a function of applying what they know within the right infrastructure,” she says. “Management is responsible for making sure the right processes are in place that are easy to follow and will facilitate OR efficiency.”
Parallel Instead of Sequential
Torrance says that OR nurses have traditionally worked in sequence: moving from step A to step B, then step C, and so forth. “But this doesn’t always lead to the most efficient processes,” she says. “Parallel processes are often more efficient than working sequentially.”
Standardization is another important part of most OR cost-reduction and efficiency-boosting efforts, Torrance adds.
“This makes it easier to train OR staff, reduces errors and improves clinical outcomes,” she says. “Conversely, variability in processes contributes to inefficiency and higher costs.”
One big impediment to improving OR efficiency that Torrance says many hospitals today are dealing with is the fact that the hospitals are old and have been expanded many times over the years.
“Their design leads to inefficiency — for example, it’s hard to store and access supplies when you need them. OR managers have to be creative when they’re dealing with this kind of challenge,” Torrance explains.
Another challenge is dealing with broken and worn out equipment in the OR.
“This is a significant issue as broken and worn out equipment can significantly impact OR uptime,” says Alisandra Rizzolo, vice president and general manager of customer care for Stryker Instruments Division.
Rizzolo recommends that hospitals implement a robust preventative maintenance plan for all OR equipment to reduce the number of unplanned and emergency repairs needed for such equipment.
“Some hospitals have realized reductions in downtime of as much as 32 percent by implementing an equipment repair service program,” she says, citing a recent Gallup survey conducted by Stryker ProCare.
“With equipment in good working order, ORs tend to stay on schedule,” Rizzolo adds. “This, in turn, helps decrease OR downtime, minimize patient care delays and keep the OR running at full capacity to serve patients and capitalize on revenue opportunities.”
Improved Patient Experiences
There are obviously cost-saving benefits to creating a more efficient surgical environment. However, both Torrance and Reiter emphasize that improving the patient experience by boosting efficiency is just as important as saving money.
“Patients expect their surgeries to happen on time, but there’s a balance between timeliness and safety,” says Reiter. “The more efficient your OR, the better able you are to strike the right balance.”
“In survey after survey, patients say that they hate waiting — they want to get their surgeries over with as quickly as possible,” adds Torrance. “Running a more efficient OR not only reduces patient wait times, but it also cuts down on post-op complications and readmissions since the less time patients are under anesthesia, the better the clinical outcomes.”