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Wake med north quality improvement initiative
- 1. Wake Med North Quality Improvement Initiative: Improving Overall Efficiency by Reducing Operating RoomTurnover Time KASEY WILLIAMS
- 2. Prompt Design a quality improvement initiative for Wake Med North addressing a specific developmental opportunity My developmental opportunity: to improve turnover time in the operating room. I used a specific study using data and recommendations from Emory University Hospital Midtown in Atlanta Looked at study recommendations and noted specific areas of potential improvement for Wake Med North
- 3. Problem Healthcare is in an era of rising costs and declining reimbursement. Essential to optimize effectiveness of the operating room. In turn, maximizing throughput of profitable cases. While also maintaining patient safety and satisfaction.
- 4. What is contributing to the problem? (causes) High variability Strictly linear processing Interaction lapses
- 5. Important Definitions to Note Call to Order (CTO) – Final pre-operative check which documents that all items having to do with patient readiness are accomplished and that the patient is cleared to be brought back to the OR. PACU – Post-Anesthesia Care Unit
- 6. High Variability High variability = Lack of clearly delineated and defined statuses/roles This variability affects proper resource planning for the OR Pre-intervention observations of turnover time ranged from 19 minutes – 2 hours & 20 minutes Most variability due to time between “stable in PACU (post anesthesia care unit)” → “call to order in pre-op” No formal definition of “room ready” – assessment of when the OR is ready to receive the next patient. This was a subjective definition which differed between staff members. Only circulating nurses were allowed to make this designation
- 7. Linear Processing 2 major processes considered in OR turnover: Preparing the OR to receive the patient Preparing the patient to be brought to the OR OR Readiness Cleaning the OR and preparing instrument cart for following case Patient Readiness Documentation (including history and physical, consent, and anesthesiologist work up) Performing the call to order
- 8. Linear Processing (continued) Preparing the OR and the patient occurred in a linear sequence Nurse waited for OR to be prepared Nurse then give “room ready” designation Then call to order process performed in pre-op area Call to order is a final check of all patient documentation This is often the first time missing documents were spotted If missing/incorrect documents were found… surgery didn’t start on time CTO was being done AFTER the “room ready designation” Average of 30 min from turnover onset to complete CTO
- 9. Interaction Lapses Many providers involved in day of surgery: Pre-op Nurse Circulating Nurse Anesthesia Attending Surgeon Physician Assistant In this study involving Emory University Hospital… The patient never saw a unified care team or witnessed formalized handoffs across providers in preoperative, intraoperative, and post operative periods I do feel that Wake Med North made a point to involve the care team in at least the preoperative and intraoperative phase. Dr. Galland typically sees patients as they are being prepped for surgery before anesthesia performs their surgical duties.
- 10. Interaction Lapses (continued) Day of surgery represents major anxiety for the patient. Anxiety levels correlated with overall patient satisfaction Anxiety stems from lack of reassurance and education from medical providers on the day of surgery Study noticed a lack of communication between nurses preparing case charts and the front desk. Central processing essential to determine approximate closure times of different operating rooms Determines preoperative waiting time for following patients This delays OR readiness and increases patient anxiety *Wake med north uses telephone communication to keep up with closure time of different surgeries to gauge when they can get the next patient started up
- 11. Solution: Redesigned Turnover Time Process Major overall guiding principles included: Horizontal integration Shared responsibility Systems based approach to care
- 12. Steps to Improving Turnover Time Developing a consistent “room ready” designation Facilitating Parallel Processing Enhancing the Call to Order (CTO) Establishing a Core Tech Position
- 13. Developing a Consistent “Room Ready” Designation Circulating nurse and anesthesia personnel educated on consistent definition of “room ready” criteria to reduce variability Room is clean Accurate case cart is in the OR 2 parties now engaged in common definition Limits subjectivity/confusion driving significant delays Shared responsibility forces active communication between the OR and pre-op team
- 14. Facilitating Parallel Processing Call to Order (CTO) moved to early in the turnover process Earlier CTO hold surgeons & anesthesiologists responsible for ensuring documentation is complete before CTO Surgeon checking for updated history and physical/consent form as the first task prior to CTO – as soon as he/she leaves the OR Anesthesiologists completing work up for next patient prior to wheels out (I believe this could significantly improve turn over time at Wake Med) Earlier CTO → earlier identification of outstanding items → items addressed quickly Earlier CTO ensures that OR and patient readiness occur simultaneously
- 15. Enhancing the CTO Replace informal verification with face-face verification between providers involved in surgery (pre-op nurse, circulating nurse, and anesthesia personnel) Wake med does a pretty good job with this depending on how busy the OR is on any given day Patient now has direct awareness and understanding of the assigned care team This increases patient satisfaction Surgical checklist and time out process intraoperatively = team interaction Leads to prevention of potential medical errors Wake med uses time out procedure consistently before operation begins… could improve on preoperative use of team communication. Feel that the surgical team could have more interaction with the patient before surgery
- 16. Consistent Surgical Teams Each surgeon has specific surgical team Enhances team oriented mentality Increases fluidity and consistency Roles more clearly delineated and remain the same for each case
- 17. Establishing a Core Tech Position Improvement of communication between sterile processing and the front desk with addition of core tech position. Core Tech would be responsible for providing the rest of the sterile processing department with real-time information on which carts are priorities Wake med could benefit from this… I have witnessed unpreparedness when it comes to availability of sterile surgical equipment Core Tech Responsibilities: Ensure accurate and complete case carts Place them with the appropriate OR Addition of Core Tech would relieve the circulating nurse of equipment duties so that they may be fully dedicated to patient readiness and charting. Core tech could be a realignment of existing staff within the sterile processing department – adding responsibility to current position rather than hiring a new staff member
- 18. Addition of Anesthetic Procedure Room Anesthetic Procedure Room would improve turn over time Enabling anesthesia personnel to start work up and sedation sooner Could occur at the same time as OR clean up is taking place.
- 19. Study Results Statistically significant reduction in mean and standard deviation of turnover time Mean turnover time reduced by about 21 minutes 46.9% reduction Standard deviation was reduced by 10 minutes and 32 seconds 0:16:24 → 0:05:52 64% reduction Incidence of a turnover time lasting ≥ 30 min was reduced from 72.5% to 11.7% Post anesthesia care unit (PACU) → CTO time Previously served as longest and most variable time component pre-intervention Reduced from 0:25:43 to 0:04:00 This is believed to be a direct reflection of moving the CTO earlier in the turnover process
- 20. Strengths/Benefits Redesigned turnover time process produced significant reductions in mean and standard deviation of turnover time. Benefit to Hospital Administration: Revenue generation Institutions with high case load + reduction in turnover time = additional caseload increasing surgeon productivity and profit Cost avoidance Reduction in turnover time = reduction in staffing costs Don’t need more staff if efficiency in improved Therefore more revenue to keep More refined process = better prediction of resources needed…. Reduction of excess inventory
- 21. Strengths/Benefits (continued) Benefit to Surgeons and OR Staff: Increased caseload and revenue Surgeons in general are drawn to institutions where the can perform efficiently with support of a system that provides fluidity, responsibility, and consistency. Improvement of reputation of institution as a whole Seen as well organized, team oriented/inclusive, and highly efficient
- 22. Strengths/Benefits (continued) Benefits to Patients: Patient focused care Reduce patient anxiety via reduced wait times and improved face to face interaction/education with surgical team Ensure positive patient experience overall Safer care with CTO enhancement and time out process within the OR and pre-op area
- 23. Weaknesses Multitude of surgical procedures and specialties. This quality improvement assessment only takes orthopedics into account Surgical procedure and times vary widely across specialties Size of hospital/institute varies results Institutes with smaller case loads may be understaffed and not necessarily benefit from turn over time improvement May not be able to afford separate room for anesthesia procedures
- 24. Redesigned Turnover Time Process Figure Visual of parallel processing model for turnover time.
- 25. References Bhatt, A. S., Carlson, G. W., & Deckers, P. J. (2014). Improving Operating Room Turnover Time: A Systems Based Approach. Journal of Medical Systems,38(12). doi:10.1007/s10916- 014-0148-4 Friedman, D. M., Sokal, S. M., Chang, Y., and Berger, D. L., Increasing operating room efficiency through parallel processing. Ann. Surg. 243(1):10–14, 2006. Krupka, D. C., and Sandberg, W. S., Operating room design and its impact on operating room economics. Curr. Opin. Anaesthesiol. 19(2):185–191, 2006. . Overdyk, F. J., Harvey, S. C., Fishman, R. L., and Shippey, F., Successful strategies for improving operating room efficiency at academic institutions. Anesth. Analg. 86(4):896–906, 1998.