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Industry: Email Alert RSS FeedImproving surgical services performance through changing work culture
AORN Journal, March, 2008 by Tom Schubnell, Laura Meuer, Ryan Bengtson
As in many hospitals, administrators at Children s Memorial Hospital, Chicago, Illinois, could identify a variety of opportunities to improve patient flow, efficiency, and customer satisfaction in their Surgical Services Department. Despite internal efforts to address these opportunities, however, they were unable to achieve the level of change and sustainability needed to significantly improve Surgical Services performance without some external assistance.
Children's Memorial Hospital is a 270-bed pediatric hospital with 13 ORs and four procedure suites, and more than 15,000 surgeries are performed here per year. Increased patient volume, the need to apply new and improved technology, and a major shift from inpatient to outpatient surgical procedures demanded the expansion and improvement of the organization's surgical care infrastructure. To address these obstacles, Children's Memorial Hospital opened a new surgical observation unit, a minor procedures suite, and an adjacent preoperative area. The hospital also expanded its pediatric intensive care unit to prevent denials of patient care due to space limitations and to prevent the overflow of patients into the postanesthesia care unit (PACU).
Despite its new facilities, Children's Memorial Hospital continued to experience problems with patient flow efficiency and patient, clinician, and staff member satisfaction. The hospital administrators realized that overcoming these obstacles required the creation of new work processes, tools, and training that would allow clinicians and administrators to work together effectively in the new environment. Perhaps most important, increasing patient flow efficiency and satisfaction also required an understanding of the existing work culture, how it aided or impeded performance improvement, and where changes could be made for maximum impact.
WORK ENVIRONMENT AND PERFORMANCE
Children's Memorial Hospital contends with the characteristics of a typical OR environment. Surgical care delivery involves many moving parts (ie, the coordination of the patient, surgeon, anesthesiologist, nursing staff members, supplies and equipment); many disparate functions; and groups that tend to work in "silos" (ie, physicians' offices, surgical scheduling and admitting departments, materials management, preoperative and postoperative care, patient accounting). This type of work environment limits communication across functions and groups and focuses on individual activities rather than encouraging staff members to work as part of one integrated, end-to-end surgical care delivery team. When problems arise, solutions often are implemented within a group or function with limited awareness of how a change might affect another person or activity outside of the group.
Coordinating and delivering surgical care depends on many personnel working in different organizational structures with different incentives, levels of power, and authority. Relationships may become strained and work disjointed when individual needs are not aligned. The effects of these issues can be compounded further when hospitals simultaneously attempt to meet the needs of many "customers" (ie, patients, physicians) or focus too much on one customer's needs at the expense of others.
Providing effective surgical care demands a high level of planning, scheduling, and proactive efforts to minimize delays and last-minute cancellations of surgeries or procedures. The OR is also a very fluid, fast-paced, dynamic environment that places a premium on staff members' successful reactions to the many changes that frequently occur, such as children getting sick the night before their surgery, physicians' late arrival delay ing the start of a procedure, or the addition of an emergency procedure at the last minute, all of which may back up the day's schedule. Working in an environment that simultaneously demands both proactive and reactive skills may create stress that leads to a lack of accountability when things do not run smoothly and, therefore, cause performance to suffer. It also can lead to the perception that "everything is beyond our control," rather than an effort to separate what can and cannot be controlled.
The OR environment can be emotional and intense. Patients' lives are at stake. Staff members tend to minimize risk and reduce tension by creating a comfort zone around their patients. This may include the creation of sub-teams consisting of the same team members performing the same processes every day.
Assertive and decisive people, rather than passive individuals, tend to work in this type of environment. These types of people may work independently rather than interdependently and may be resistant to change. In some cases, the opposite is true. When certain types of people primarily view work as a reaction to constant change, then change becomes the working rule. These team members successfully "go with the flow" and consider this attitude to be an asset far more valuable than asserting control, where possible, over the work environment.
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