World-class OR turnaround times: secrets uncovered

John Olmstead

When nurses enter a career in the perioperative area, they quick-learn that the three aspects of OR service most important to surgeons are availability of convenient OR times, quality surgical equipment, and fast OR turnaround times. If service on these three vital issues cannot be met, the hospital risks losing the surgical procedures and revenue gained from these physician customers to competing hospitals or ambulatory surgery centers (ASCs). It is especially frustrating for perioperative RNs that the OR team can only affect one of these three vital service functions--OR turnaround times--because the other two service functions are controlled by hospital administrative personnel.

In improving the service provided to physicians, a perioperative nurse's attention is focused mainly on ensuring efficient OR turnaround times. Simple improvements, such as having a housekeeping turnover team available, can be implemented easily. Occasionally, a surgeon will request the use of two separate ORs with two separate OR teams so that when the surgeon finishes a procedure in the first OR, he or she may immediately begin a procedure in the second OR, effectively eliminating turnaround time. Although this approach can be very effective, it also is extremely expensive and unrealistic and is not mentioned in current literature as an effective technique for reducing turnaround times.

Better coordination of the OR team's specific duties can greatly reduce turnaround times. The process used at the Community Hospital, Munster, Ind, by the OR team working with one surgeon, Martin Hall, MD, SC, has consistently produced cost-effective, ASC-like turnaround times in a community hospital setting.

The Community Hospital is a 350-bed, acute care hospital serving the northwest Indiana region. The hospital performs more than 9,000 surgeries annually, and more than 70% of these are inpatient procedures. Another 8,000 outpatient procedures are performed annually in a physician/hospital joint venture ASC physically connected to the hospital.

Dr Hall is an orthopedic surgeon who has been practicing at the Community Hospital since the late 1980s. As his practice increased in volume over the years, Dr Hall worked with anesthesia care providers and perioperative staff members in the Community Hospital surgery department to improve OR turnaround times by continually modifying their approach to turning over an OR. Although the OR team for Dr Hall views their current turnaround approach as routine, the results are impressive (Table 1). The average turnaround time for Dr Hall's procedures (ie, 12 minutes) is faster than that for all other orthopedic surgeons in the hospital; the next fastest average turnaround time for an orthopedic surgeon is 24 minutes. In fact, the only surgeon able to consistently generate faster turnaround times is an oral surgeon whose procedures involve minimal clean-up and set-up time.

TURNAROUND PROCESSES

Most surgeons at the Community Hospital use the traditional turnaround process (Figure 1). At best, this process delivers average turnaround times ranging from 20 to 40 minutes. Common factors that slow the traditional turnaround process include the following.

* Physicians often do not remain in OR area, causing staff members to spend time locating surgeons to alert them that the OR is ready for their next procedure.

* The process leaves no opportunity for parallel processing, which has been identified as a key factor in quick turnaround time. (1,2)

[FIGURE 1 OMITTED]

The turnaround process used by Dr Hall is parallel processing, which allows different members of the team to perform various functions simultaneously (Figure 2). In the traditional OR turnaround process, only one function is performed at a time. For example, most perioperative RNs can relate to this scenario:

   The perioperative team anxiously
   waits in the wings as the surgeon,
   who has just finished speaking with
   the family of patient #1, speaks with
   patient #2 in the preoperative holding
   area. After the surgeon's inter
   view with the patient is complete, the
   perioperative RN and anesthesia care
   provider rush in to complete their interviews,
   then rush back to the OR to
   ensure room readiness, then rush out
   to gather the patient, then once again
   return to the OR so anesthetic induction
   can begin.

[FIGURE 2 OMITTED]

Even when performed as quickly as possible, this one-step-at-a-time process can only be performed as fast as each separate step can be completed. Parallel processing arrangements, on the other hand, allow for several steps to be completed simultaneously. This coordination results in dramatic reductions in turnaround times.

STRENGTHS OF THE EFFICIENT OR TURNAROUND PROCESS

The impressive outcomes from the parallel process used to turn over ORs for Dr Hall are derived from a study of every step involved in the perioperative process. Focus on the various perioperative roles, order for scheduling procedures, and traits exhibited by members of the perioperative team has led to identification of the strengths that enable this perioperative team to perform efficient surgical procedures and quick OR turnarounds.

THE RN AND SURGICAL TECHNOLOGIST (ST) ROLES. Processes that ensure efficient OR turnarounds for a day of surgery begin the day before. While staff members in the Central Sterile/Receiving (CSR) Department at the Community Hospital pull case carts, members of the perioperative team (ie, RNs, STs) double-check all supplies, equipment, and implants needed for the next day's surgical procedures. Missing items are located. If the next day's caseload will require quick sterilization of specific equipment for procedures scheduled later in the day, arrangements are made and verified in advance.

The team believes this step enables smooth performance of the surgical procedures. No time is wasted between procedures searching for missing supplies or making equipment arrangements with CSR staff members. The perioperative team can move from one case to the next without delay.

The most important aspect of the perioperative RN or ST role in a quick turnaround is that the RNs and STs involved have a clear understanding of which specific job functions they will be performing at any given moment. Much time is saved by avoiding the repeated discussion of which tasks need to be performed and who will perform each task. The importance of team member consistency also cannot be over-emphasized. The members of Dr Hall's perioperative team have been working with each other for a long time, and each team member understands the entire surgical procedure flow and performs his or her tasks step-by-step and without delay.

THE SURGEON'S ROLE. The surgeon plays a central role up front in the efficient performance of a day's surgical procedures. Specifically, the surgeon needs to consistently schedule patients for preadmission testing well in advance of their procedures and obtain cardiac clearance for all patients who require this. The routine performance of this step allows the anesthesia care providers to consistently and quickly review a patient's chart and sign off on an anesthetic plan of care.

After completing a surgical procedure, the surgeon controls some key steps that make a major difference in turnaround times for the efficient, parallel process compared to the traditional process.

* Immediately after the procedure, the surgeon dictates the completed case, preferably in the hallway immediately outside the OR.

* The surgeon then interviews the next patient instead of first speaking with the previous patient's family members. This step allows the perioperative team to escort the next patient back to the OR and begin anesthesia induction more quickly than they would in the traditional process.

* Finally, the surgeon speaks with the first patient's family about the completed procedure. This step can require an unpredictable amount of time, so if the second patient is not released by the surgeon to be taken to the OR, turnaround times can be greatly lengthened if the first patient's family members have many questions about their loved one's procedure.

Another important factor for fast turnarounds is that after finishing with the previous patient's family, the surgeon should remain in the OR area. If the surgeon is immediately available so that the next case can start without delay, turnaround times are much improved. If the team becomes accustomed to stopping the process to search for a missing surgeon, however, the goal of efficient turnaround times is severely hampered. Staff members then may get the impression that expedient turnaround times are not as highly valued by the surgeon as was previously thought. A vicious cycle may begin: the surgeon leaves the OR area because of lengthy turnaround times, thus decreasing team efficiency and increasing turnaround times even more. For this key reason, surgeon proximity to the OR area is vital to increasing OR turnaround efficiency.

SCHEDULING PROCEDURES. Dr Hall's approach to scheduling surgical procedures also is an integral factor in generating successful turnaround time averages. Procedures with predictable case lengths are scheduled first, despite suggestions in the literature that quick turnaround time averages are gained by scheduling shorter cases first? Dr Hall's patients are highly conscious of their scheduled start times, and he has organized his daily schedule accordingly. The physician's office schedules procedures to begin in the following order:

* predictable, larger procedures first (eg, routine total joint replacements);

* predictable, shorter procedures next (eg, arthroscopies); and

* procedures with unpredictable duration last (eg, anterior cruciate ligament repairs, hip procedures with patients who have complications).

In addition, patients are scheduled according to laterality. When possible, all left-sided procedures are scheduled first, then right-sided procedures, limiting the need for OR equipment to be moved during turnarounds.

Unlike other surgeons pursuing quick turnaround times, Dr Hall does not request the use of two ORs, which theoretically could minimize turnaround times by allowing the physician to switch back and forth between clean ORs. Dr Hall believes that this arrangement actually slows turnaround times as a result of equipment jostling and unfocused team movement.

TEAM MEMBER TRAITS. The members of Dr Hall's perioperative team have several personal traits that help speed efficiency in the OR turnaround process. The staff members are highly experienced and skilled orthopedic perioperative RNs and STs who have been consistently scheduled with Dr Hall for years. There is a seamless workflow among the members of Dr Hall's team; for example, during routine procedures, there is little need for spoken communication to facilitate quick completion of the surgical procedure. In addition. the perioperative RNs and STs are personally dedicated to Dr Hall and the successful completion of his surgical procedures. These staff members have stated that though they know they will work harder when they are in Dr Hall's OR because more procedures are completed with Dr Hall than with other surgeons, they appreciate working as part of his high-quality OR team.

Dr Hall himself has several traits that contribute to an efficient surgical procedure and OR turnaround process. His practice has a large surgical case volume, and his weekly block time from 7:30 AM to 1 PM is consistently filled 100% of the time. In regard to his surgical practice traits, he

* has uncommonly quick surgical technique (eg, arthroscopies can be completed in 12 minutes, total knee procedures are completed in an average of 60 minutes);

* consistently arrives at the hospital campus early for the first scheduled surgical procedure;

* does not leave the OR area between surgical procedures; and

* consistently ensures that preadmission testing and assessment are completed well in advance of a scheduled procedure, reducing the incidence of cancellations on the day of the procedure.

In addition, Dr Hall's personality traits have a positive effect on his perioperative team members. He is a strong advocate of teamwork and leads by example; before the start of a procedure, he will assist the RNs and STs in small tasks that will help speed up the patient preparation process (eg, tying up surgical gowns, assisting in positioning patients, picking up linen from the OR floor). According to the perioperative staff members, however, the most important traits Dr Hall has that affect turnaround times are that he is helpful, polite, dedicated, and respectful to the OR staff members.

OUTCOMES OF THE EFFICIENT PROCESS

The costs associated with the efficient OR turnaround process are minimal compared to the increased revenue. The other, less-tangible benefits of this process also provide strong advantages for the hospital administration, surgeon, and staff members.

COSTS. Although the current model used by Dr Hall's team includes two RNs to help expedite the process, the extra RN and full-time equivalent cost is not mandatory to the efficient turnaround process. For many years, the perioperative team and Dr Hall utilized only one RN and still obtained excellent results. The team currently utilizes two RNs whenever possible, but it often relies on only one RN when department caseload necessitates reallocation of staff members.

The service provided by the floating anesthesiologist, though helpful, is not responsible for the bulk of the increased efficiency. For many years, no floating anesthesiologist was used. This extra position was added to allow breaks for anesthesia personnel and was not added specifically for Dr Hall. Thus, although this additional service is indeed helpful, the costs of employing the floating anesthesiologist are not factored into this model because they were incurred independently of the development of the efficient OR turnaround process. In addition, no extra equipment or supplies were required to produce faster turnaround times, so there were no additional equipment costs associated with this process.

BENEFITS. The increased efficiency of the OR turnaround process allows Dr Hall to schedule more procedures than other orthopedic surgeons in the same amount of time, resulting in increased revenue for the hospital (Table 2). Dr Hall routinely schedules six procedures each day in his reserved block time; other orthopedic surgeons schedule an average of three procedures a day in their respective block times. On average, Dr Hall's surgical team delivers $30,000 more revenue to the surgical department than other orthopedic surgical teams in the same amount of time. This efficiency benefits the surgeon as well as the hospital. Dr Hall is able to complete his surgical procedures by 1 PM and return to his office to see a full schedule of patients.

In this competitive age, surgeons have a plethora of hospitals and surgery centers vying for their business. Dr Hall has consistently filled block time at the Community Hospital, despite numerous increases in available OR centers in the area. The commitment of staff members and resources to ensuring an efficient process has helped greatly in the development of the long-term relationship between Dr Hall and the Community Hospital.

In addition, staff members take pride in providing high-quality patient care and working as part of Dr Hall's team. Although staff members know they will work harder in Dr Hall's OR than in other surgeons' ORs, they have stated that they have a higher sense of job satisfaction on the days they work with Dr Hall.

FUTURE STUDY

The results of this efficient turnaround process run counter to conventional wisdom, which states that improvements in OR turnaround times cannot create sufficient additional time to perform more procedures or reduce staffing costs/In addition, the efficient OR turnaround model at the Community Hospital shows that highly efficient turnaround times can be generated without incurring expensive capital equipment and construction costs, disproving another widely held belief. (1,2)

The benefits of the efficient OR turnaround process are evident. The staff members at the Community Hospital OR now are focusing on finding out if these outcomes can be reproduced with other surgeons. They want to determine whether this process can be adopted by a second OR team to consistently produce these impressive results. This study currently is ongoing. The surgeon and staff member traits listed previously are being used as a template from which to build the next great success story at the Community Hospital.

RESOURCE

Mangum SS, Cutler K. increased efficiency through OR redesign and process simplification. AORN J. 2002;76:1041-1046.

REFERENCES

(1.) Sandberg WS, Daily B, Egan M, et al. Deliberate perioperative systems design improves operating room throughput. Anesthesiology. 2005;103:406-418.

(2.) Friedman DM, Sokal SM, Change Y, Berger DL. Increasing operating, room efficiency through parallel processing. Ann Surgery. 2006;243:10-14.

(3.) Lebowitz P. Schedule the short procedure first to improve OR efficiency. AORN J. 2003;78:651-659.

(4.) Dexter F, Abouleish AE, Epstein RH, Whitten CW, Lubarsky DA. Use of operating room information system data to predict the impact of reducing turnover times on staffing costs. Anesth Analg. 2003;97: 1119-1126.

John Olmstead, RN; Peggy Coxon, RN; Deborah Falcone, RN; Lisa Ignas, RN; Pam Foss

John Olmstead, RN, MBA, FACHE, is the director of surgical services at the Community Hospital, Munster, Ind.

Peggy Coxon, RN, is a perioperative nurse at the Community Hospital, Munster, Ind.

Deborah Falcone, RN, is the OR manager at the Community Hospital, Munster, Ind.

Lisa Ignas, RN, is a perioperative nurse at the Community Hospital, Munster, Ind.

Pare Foss, CST, is a surgical technologist at the Community Hospital, Munster, Ind.

TABLE 1
Average Turnaround Times for
Physicians with the 10 Fastest
Turnaround Times at the
Community Hospital *

                              Average
                            turnaround
Specialty      Physician     times **

Dental             #1       11 minutes
Orthopedics     Dr Hall     12 minutes
Gynecology         #3       19 minutes
Gynecology         #4       19 minutes
Urology            #5       20 minutes
Gynecology         #6       20 minutes
Spine              #7       21 minutes
Gynecology         #8       22 minutes
Gynecology         #9       22 minutes
General           #10       22 minutes

* Measurements taken from December 2005 to Map 2006.

** The Community Hospital defines turnaround times as the interval
between the previous patient's departure from the OR and the next
patient's arrival in the OR.

TABLE 2
Average Surgical Department
Charges for Orthopedic Procedures
at the Community Hospital

                           Average
Procedure                   charge

Arthroscopies               $4,200
Total hip replacements     $22,000
Total knee replacements    $19,000

COPYRIGHT 2007 Association of Operating Room Nurses, Inc.
COPYRIGHT 2008 Gale, Cengage Learning