Total Joint Replacement- Improving Day of Surgery Efficiency and Throughput


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Organic growth of total joint replacement volume is growing at 3-4% per year as the number of physicians entering orthopedic residency programs is in decline. Cuts in Medicare reimbursement for total joints is forecast every year producing stressors for the surgeon to perform more surgery just to tread water financially. Increasing surgical volume without increasing time in the day requires a team approach to process improvements. By taking a fresh look at operating room processes, it’s possible to accomplish this goal.

Discussion points include:
• Pre-op patient preparedness
• Resolving inherent conflicts
• Surgical case order
• Tracking case efficiency
• Surgical tray streamlining

About the Speaker:
Sandy Nettrour has specialized in orthopedics for 30 years. She is the Neurosurgery and Orthopedic Service Line Coordinator for Butler Health System, providing oversight of the business aspects of Neurosurgery and Orthopedics, while continuing to first assist in the operating room and provide patient care at the bedside.
Sandy graduated from Alderson Broaddus College in 1980 with a Physician Assistant degree. She has been awarded the Distinguished Fellow Recognition by the American Academy of Physician Assistants, the Hu C. Myers Award for lifetime professional achievement and community service, and the Pennsylvania Society of Physician Assistants Humanitarian of the Year 2013. She was a Round Table Participant in Orthopedics Today June 2012′s “Effective and Efficient Joint Replacement Programs Need Constant Review and Renewal of Processes.”

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Total Joint Replacement- Improving Day of Surgery Efficiency and Throughput

  1. 1. ThePatientJourney A Guided CarePath helps automate patient preparation and follow-up activities through the entire journey of a total joint replacement.
  2. 2. Total Joint Replacement Improving Day of Surgery Efficiency and Throughput Sandy Nettrour, PA-C
  3. 3. Let’s get acquainted
  4. 4. Did you know? On average, hospital surgical suites waste over 30% of their capacity due to inefficient processes. The average costs in the peri-operative services are 20% higher than they should be due to poor utilization of staff, equipment and supplies CMS has reduced total joint surgeon’s professional fees by 36% since 1991 Total knee replacement surgery is projected to triple over the next 15 years, while the number of total joint surgeons is in decline
  5. 5. Why is the surgeon grumpy? The average surgeon only spends 60% of their time performing surgery while in the OR On average, only 70% of first surgical cases start on time #1 surgeon complaint: Lack of a collaborative surgical environment
  6. 6. Universal Issues Inherent Conflicts Patient Preparedness Surgical Start Time Case Efficiency Turn Over Time One Room or Two Rooms?
  7. 7.  Inherent Conflicts- The Hospital Salute • Pre-op Staff • OR Team • Anesthesia Team • Surgeon • Central Sterile • Housekeeping • Post-op Staff • Product Rep • Administration Each person has the power to de-rail the day
  8. 8. Resolving Conflicts-Create an Operations Team • All team members sit at the same table • Each team member’s opinion is valuable • Goals must be defined and understood • Champions are empowered to institute changes • Accountability is clear
  9. 9.  Patient Preparedness • Patients with many questions slow the process. • Assure that the patient is well informed and knows what to expect • Everybody sings the same song • Don’t do anything on the day of surgery that you can do ahead of time.
  10. 10.  Surgical Start Time • You will NEVER make up lost time • How is surgical start time defined? • Does everyone agree? • Paralysis by analysis • Capitalize on your data On time start decreases end of day overtime costs, case length, and need to use staff with a different skill set
  11. 11. Surgical Start Time Pre-Op and Anesthesia drive the day’s success Anesthesia needs to contribute to case order
  12. 12. Case Order can make or break the day
  13. 13.  Case Efficiency Teams should know their numbers Track case efficiency: • On time start accuracy • In room to incision • Turn over times • Average case times • Case volumes • Block utilization Hard data tells the story: • Finger pointing doesn’t work • Each OR team member must own their contribution • Where are the roadblocks? • Who needs help?
  14. 14. Turn Over Time Don’t make a mess Start clean up during closure Key team members take breaks during closure Enlist help Allow tandem work
  15. 15. Streamline your trays Before SPD collaboration After SPD collaboration
  16. 16. SPD cost savings= $105,000 annually • Average cost to process a tray: $35.00 • 60% of the costs are related to labor • Sample model • 500 total joint replacement cases per year • Reduction from 10 trays to 4 trays Time and Efficiency = More cases
  17. 17. Post-op and Floor Staff- play a part in OR efficiency • Use only one order set • Consistent block duration to decrease stay in PACU • Beds sent from the floor • Ice packs sent to the floor • Consistent floor discharge time (11:00am) to prevent backups in PACU
  18. 18.  To Swing or Not to Swing? Established criteria for swing rooms: Surgeon has to increase 10% within first year 75% utilization of their current block Partner or first assist available to close case Patient safety not compromised Top 50% of their service line (volume)
  19. 19. Typical OR Day- One Surgeon, One Room Start time Case Turn Over time 0724 Knee Arthroscopy 14 min 0805 Knee Arthroscopy 11 min 0906 Total Hip 24 min 1100 Total Knee 21 min 1305 Total Knee Day end: 14:45
  20. 20. Typical O.R. Day- One Surgeon, Two Rooms Room 1 • 7:30: Knee scope • 8:50: TKA • 11:00: TKA • 1:15: TKA Room 2 • 7:45: TKA • 9:55: TKA • 12:10: TKA • 2:20: Hip fracture Done at 2:50 Total Count for Day: 1 Knee scope, 6 Primaries, 1 Hip fracture
  21. 21. Swing Room Model TIME 6:00 6:30 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 PRE-OP Prep/Block 1 Prep/Block 2 Prep/Block 3 Prep/Block 4 Prep/Block 5 Prep/Block 6 Prep/Block 7 ANESTHESIA Anesthesia 1 Anesthesia 2 Anesthesia 3 Anesthesia 4 Anesthesia 5 Anesthesia 6 Anesthesia 7 SURGEON Marks, Completes Rounds Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 family 1 family 2 family 3 family 4 family 5 family 6 Postops OR STAFF Open Case 1 Open Case 2 Open 3 Open 4 Open 5 Open 6 Open 7 Every team member knows their role and proceeds without prompting
  22. 22. Team Building • Each person can be the problem or part of the solution • Every person has a contribution • Each contribution has value • Use a carrot instead of a stick- Incentivize your staff Delayed surgeon
  23. 23. Team Building-What works? Are you kidding?!? • Milkshake races • Song games • Pizza for Central Sterile, O.R. • Mop stealing • Floor Staff (every shift) • Muzzy Monday- Cookies • Tropical Tuesday- Fresh fruit • Wacky Wednesday- Candy • Thirsty Thursday- Soft drinks • Souper Friday- Soup/rolls
  24. 24. In Conclusion • O.R. efficiency is a collaboration • Empower team members to find solutions- recognize their efforts • Break down barriers by leveling the playing field • Find a way to work smarter not harder • Everyone wants to do a good job and be appreciated
  25. 25. THANK YOU Chautauqua Lake, New York