j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center Bhavani S. Kodali, MD,a Dennie Kim, BA,a Ronald Bleday, MD,b Hugh Flanagan, MD,a and Richard D. Urman, MD, MBAa,* a
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts b Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
article info
abstract
Article history:
Background: Turnover time (TOT) is one of the classic measures of operating room (OR)
Received 3 October 2013
efficiency. There have been numerous efforts to reduce TOTs, sometimes through the
Received in revised form
employment of a process improvement framework. However, most examples of process
1 November 2013
improvement in the TOT focus primarily on operational changes to workflows and sta-
Accepted 11 November 2013
tistical significance. These examples of process improvement do not detail the complex
Available online 16 November 2013
organizational challenges associated with implementing, expanding, and sustaining change.
Keywords:
Methods: TOT data for general and gastrointestinal surgery were collected retrospectively
Turnover time
over a 26-mo period at a large multispecialty academic institution. We calculated mean
OR efficiency
and median TOTs. TOTs were excluded if the sequence of cases was changed or cases were
OR management
canceled. Data were retrieved from the perioperative nursing data entry system.
OR benchmarks
Results: Using performance improvement strategies, we determined how various events and organizational factors created an environment that was receptive to change. This ultimately led to a sustained decrease in the OR TOT both in the general and gastrointestinal surgery ORs that were the focus of the study (44.8 min versus 48.6 min; P < 0.0001) and other subspecialties (49.3 min versus 53.0 min; P < 0.0001), demonstrating that the effect traveled outside the study area. Conclusions: There are obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. Awareness of the numerous variables that may support or impede a particular change effort can inform effective change implementation strategies that are “organizationally compatible.” ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Operating room (OR) efficiency continues to be a high priority for hospitals [1e4]. OR turnover time (TOT), the time from
“patient out of the OR” to “next patient into the OR,” is a common performance metric that is captured by hospitals [5]. Because it is easily measured and is subject to less patientrelated variability than other OR processes, the TOT is also
* Corresponding author. Department of Anesthesia, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. Tel.: þ1 617 732 8222; fax: þ1 617 897 0879. E-mail address: [email protected] (R.D. Urman). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.11.1081
404
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
perceived to be a useful diagnostic measure of operational efficiency [6e8]. In 2007, when Brigham and Women’s Hospital (BWH) first began routinely reporting TOT data on the hospital’s Balanced Scorecard, the average TOT across 43 ORsdas measured by the time from patient out of the OR to next patient into the ORdwas 54 min, significantly higher than national benchmarks [7,9]. Around the same time, clinical and administrative leadership assembled the Perioperative Governance Committee, a group of surgeons, anesthesiologist, nurses, and administrators who were charged with leading performance improvement initiatives to increase efficiency and predictability in the perioperative areas. TOTs quickly emerged as a leading candidate for improvement; the 54-min average was long seen as unacceptable to surgeons [10] and was significantly worse than times at other institutions. OR TOT is one of the classic measures of OR efficiency. There are numerous publications and case studies describing efforts to reduce TOTs, sometimes through the employment of a process improvement framework, such as lean or six sigma [1,11]. However, most examples of process improvement in the TOT focus primarily on operational changes to workflows and statistical significance [3,7]. These examples of process improvement do not detail the complex organizational challenges associated with implementing, expanding, and sustaining change. Similarly, many publications do not mention the obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. In the 5 y from the time when routine reporting of TOT data began, there have been three independent initiatives at BWH to reduce these times. Each initiative involved the same key components in planning: (1) Process mapping of turnover activities in a specific specialty. (2) Formulation of a revised process. (3) Piloting of the revised process by a single surgeon. (4) Development of informational materials. (5) Issue-selling to other surgeons in the specialty. (6) Implementation. Two of these initiatives, one in 2009 and another in 2010, successfully accomplished steps 1e4; a third initiative, which began in November 2011, was the only one to successfully accomplish all steps and achieve sustained improvements in the target area after more than 12 mo. Here, we describe this particular experience and investigate why this effort succeeded where others failed.
such a way that there are several well-defined geographic boundaries that divide the OR into service-specific zones or pods (Fig. 1). The geographic layout of the ORs affects travel time and also the degree to which clinical and support staffdprimarily nurses and OR assistants (ORAs)d“float” between different regions of the OR. For example, the orthopedic surgery ORs, 41e46, are isolated from the rest of the ORs so that staff working in this pod rarely work in other areas. The target area for the successful November 2011 initiative was the general and gastrointestinal (GGI) pod, which encompasses ORs 18e28. This area was chosen because the surgeon leader for this initiative was a colorectal surgeon. However, there were additional characteristics that made this an attractive target site. The GGI pod is centrally located, near the combined preoperative holding area and post-anesthesia care unit, patient transport elevators, and main OR desk, which is responsible for coordinating patient flow for all 43 ORs. ORs 18e28 are also more likely to have out-of-service casesdnon-GGIdperformed in them, meaning that additional services may be exposed to new practices. Finally, because cases performed in ORs 18e28 tend to be shorter, these ORs will be turned over 2e4 times each day. As a result, a significant proportion of turnovers (30%e40%, about 400e500 per month) occurs in this pod. The average TOT in the GGI pod was 48 min in October 2011 and 49 min in previous 12-mo period (October 2010eSeptember 2011). The institutional (hospital-wide) target for the TOT was 45 min.
3.
Methods
3.1.
Data collection and analysis
Each OR is equipped with a networked computer terminal. Circulating nurses are responsible for logging distinct time points during the course of an operation, including the time points that are used to calculate the TOTdpatient out of the OR and patient into the OR. TOTs were measured only when both the preceding and succeeding cases belonged to the same service. TOTs were excluded if the sequence of cases was changed from the initial plan or cases were canceled. Average TOTs are reported monthly for individual services and for the entire OR by an independent department in the hospital, the Center for Clinical Excellence. All data used in this study were subject to all standard exclusion criteria, as outlined previously, and a thorough quality assurance process is conducted by the Center for Clinical Excellence.
3.2.
2.
Setting
Surgery at BWHda large 793 bed academic medical centerdis organized into 13 distinct surgical specialties, or services. The hospital performs on average 28,000e30,000 operations per year. These 13 specialties delineate how ORs are allocated to surgeons and how performance metrics are analyzed and reported. There are 43 ORs at BWH, all located on the first basement level (L1) of the hospital. These ORs are laid out in
Process mapping
We mapped the activities of each member of the OR team during the TOT using previously constructed workflows and direct observation of turnovers in the GGI pod. There were four primary workflows, each representing a distinct discipline: (a) the surgical team, including the attending surgeon, fellows, and residents; (b) the anesthesia team, including attending anesthesiologists, fellows, and residents, and anesthesia technicians; (c) the nursing team, including the scrub technician and the circulating nurse; and (d) the ORAs,
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
405
Fig. 1 e BWH ORs with TOT improvement initiative target areas labeled. PACU, post-anesthesia care unit. A-H, OR pod area. (Color version of figure is available online.)
who are responsible for cleaning the OR. Processes were visually mapped and associated with average durations for each of the key tasks.
3.3.
Implementation and observation
Implementation of planned process changes was scheduled for “go live” on October 31, 2011. Initiative leaders were present in the pod for the first 2 wk of implementation to reinforce behaviors and troubleshoot any problems. Observations were shared among all change leaders through direct communication, e-mail, and biweekly
meetings with a larger patient flow task force. After January 1, 2012, direct observations were less frequent and unplanned. Additional indirect observations included close monitoring of daily TOT data and feedback from the OR personnel. At least weekly monitoring and reporting of TOT data continues to date.
3.4.
Statistical analysis
TOTs for all GGI surgery cases were analyzed for a 26-mo period (October 2010eNovember 2012). Data were imported into Microsoft Excel and this software was used to perform
406
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
basic calculations and creation of key study variables, including assigning TOT categories for distribution, determining “in pod” versus “out of pod” designation, and specifying “preintervention” and “postintervention” groups based on the operation date. All data were then imported into IBM SPSS Statistics 20 software (IBM Corporation, Armonk, NY), which was used to perform basic statistical analysis. Significance of change in turnover between relevant study periods was measured using independent samples t-tests with a 99% confidence interval.
4.
Results
4.1.
Planning phase
Process mapping revealed that a typical BWH turnover was a markedly sequential process; OR team members relied on a series of electronic cues to indicate when they should begin a particular task. This behavior was largely reinforced by the current information technology system. A centralized information technology system for all ORs used times inputted by nurses to trigger specific notifications and pages to clinical teams. For instance, surgeons and anesthesiologists would receive the “room ready” page when the circulating nurse inputted that time during a turnover. This milestone was defined by the circulating nurse as the point during turnover when all the necessary equipment for the next case was opened and accounted for in the OR. The page would then signal to the surgeon and anesthesiologist that they should bring the next patient to the OR. On the basis of the factors, such as the distance from the preoperative holding area to the target room, the status of the patient (e.g., obese, agitated, or high risk), and the readiness of the surgical team, the time from room ready to patient into the OR could range from 0e30 min. For GGI, the target service, this process took about 12 min on average. The ideal process that was determined was for patient transport and the final stages of room setup to run in parallel such that the time between room ready and patient into the OR was drastically reduced, if not eliminated. The second parallel process that was identified was to have the ORAs enter the OR to begin cleaning the room as soon as it was safe to do so, rather than waiting for the patient to first be brought out of the OR and the surgical team to leave the room. This represented a major shift in OR culture because it required proactive communication between the intraoperative team and the ORAs, who typically only enter rooms to clean them; circulating nurses would either have to indicate to ORAs that it was safe to enter or ORAs would have to don a surgical mask and inquire with the operating team. The typical delay between patient out of the OR and “clean up begin” was 2e5 min in the GGI pod. These process changes were not new discoveries. Each previous TOT initiative from 2007 also identified these same opportunities. The 2011 initiative team confirmed that these process changes were applicable to the GGI pod and investigated the feasibility of implementing both process changes in the 8 wk leading up to the proposed go live date. Ultimately, the team decided to only implement the second process change, with an expected time savings of about 3 min per
turnover, because it was determined that the first process change, although more impactful, would face more resistance from nurses and would likely require additional anesthesia staff. Additionally, the second process change was subject to less operational variability. To support the launch of this initiative, the team developed extensive communication materials to outline the details of the process change. Every discipline saw the same memos and slides to outline the rationale and objectives of the initiative. Furthermore, the team organized an interdisciplinary meeting 10 d before the scheduled go live date, where the surgeon, nurse, anesthesiologist, and ORA leaders kicked off the initiative using a joint presentation. Every leader emphasized the same messages: (1) this initiative was meant to improve teamwork and communication between clinical and nonclinical staff, and (2) any team member could stop the new process if they felt that patient safety was being compromised.
4.2.
Implementation phase
From the very beginning of the TOT improvement initiative, all stakeholders were invited to participate in both design and implementation phases. This included OR nursing leaders, OR pod leaders, and rank-and-file OR nurses. Much of the perceived resistance to change was because of typical institutional inertia common to large bureaucratic organizations. The initiative went “live” on the target date of October 31, 2012, and it encountered significant obstacles. There was a surge of negative feedback from all disciplines after the interdisciplinary kick-off meeting. Moreover, the nursing union voiced concerns about the safety of the process change. At our facility, all OR nurses are union members. According to informal inquiries about why some nurses and union representatives were initially opposed to the change had to do with legitimate concern for patient safety. Specifically, nursing leadership was concerned about the idea of parallel processingdon patient’s entry into the OR, the nurse would be counting instruments with the scrub technician and not be able to pay attention to the patient who has just entered the OR. However, we ensured that there would be an adequate number of staff (anesthesia and surgery) to initially attend to the patient until the nurse finished the necessary counts. After some deliberation, the team decided to circulate a notice announcing that the initiative would be postponed until further notice. However, the team also proceeded to identify surgeons and OR staff who were supportive of reducing the TOT to quietly implement the process changes in select ORs on the go live date. On the morning of October 31, the leadership team met in the GGI pod and monitored the implementation of the new process in the ORs where the surgeon and staff were supportive of the changes. They encouraged ORAs to enter rooms, addressed process issues, and answered questions on the spot. This on-the-ground presence continued for the first 2 wk of the initiative. During this period, average TOTs decreased from 48 min in the previous month to 41 mindan unexpectedly large decrease given that the process change was only intended to save about 3 min. Debriefing sessions were regularly held, at least once a week, involving all stakeholders,
407
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
such as ORAs, nurses, anesthesiologists, and surgeons. They proved very useful in receiving the feedback and generating new ideas for TOT improvements.
4.3.
Successful reduction in the TOT
As stated in the Methods section, BWH reports the average TOT for surgical services monthly. However, from the start of the intervention until around January 2012, we reported weekly TOTs to GGI staff (surgeons, nurses, anesthesiologists, and ORAs). Changes in the TOT were measured between October 2011 (baseline), December 2011, and October 2012 to understand what impact, if any, the intervention had on reducing the average TOT in the short-term and whether this effect was sustained after a year. Figure 2 shows the average monthly TOTs for GGI surgery in each of the 3 mo, with standard deviations. On the basis of the data, we were able to see that there was a marked decrease in December 2011 but a subsequent increase by October 2012, although it was still below the baseline level. Furthermore, to determine the significance of these changes, we performed an independent t-test with a confidence interval of 99% comparing all turnovers from each month to those in October 2011 (Table 1). The statistical analysis supports a significant difference in the average TOT between December 2011 and baseline, but not between October 2012 and baseline, indicating that the intended effects of the intervention may not have been sustained a year later.
4.4.
Sustaining change
From January 2012 to October 2012, team leaders monitored progress ad hoc. Rather than dedicating time to police processes in the GGI pod, the team used audits and carefully monitored weekly TOT data. Weekly and monthly TOT data were also reported to all OR team members in a timely manner, with no more than a 1-wk delay on weekly reports and no more than a 2-wk delay for monthly data. Although TOTs did increase slightly from the recordbreaking lows achieved in November and December 2011, the average TOT for GGI surgery never exceeded 46 min for a single month. By October 2012, the average TOT in GGI surgery
Fig. 2 e Change in GGI surgery turnover.
Table 1 e Change in the GGI surgery TOT 3 and 12 mo after intervention. Month Oct 2011 Dec 2011 Oct 2012
Cases
Median
Mean
s
P value
135 167 152
54 51 42
48.1 41.1 45.1
17.5 15.5 14.7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center Bhavani S. Kodali, MD,a Dennie Kim, BA,a Ronald Bleday, MD,b Hugh Flanagan, MD,a and Richard D. Urman, MD, MBAa,* a
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts b Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
article info
abstract
Article history:
Background: Turnover time (TOT) is one of the classic measures of operating room (OR)
Received 3 October 2013
efficiency. There have been numerous efforts to reduce TOTs, sometimes through the
Received in revised form
employment of a process improvement framework. However, most examples of process
1 November 2013
improvement in the TOT focus primarily on operational changes to workflows and sta-
Accepted 11 November 2013
tistical significance. These examples of process improvement do not detail the complex
Available online 16 November 2013
organizational challenges associated with implementing, expanding, and sustaining change.
Keywords:
Methods: TOT data for general and gastrointestinal surgery were collected retrospectively
Turnover time
over a 26-mo period at a large multispecialty academic institution. We calculated mean
OR efficiency
and median TOTs. TOTs were excluded if the sequence of cases was changed or cases were
OR management
canceled. Data were retrieved from the perioperative nursing data entry system.
OR benchmarks
Results: Using performance improvement strategies, we determined how various events and organizational factors created an environment that was receptive to change. This ultimately led to a sustained decrease in the OR TOT both in the general and gastrointestinal surgery ORs that were the focus of the study (44.8 min versus 48.6 min; P < 0.0001) and other subspecialties (49.3 min versus 53.0 min; P < 0.0001), demonstrating that the effect traveled outside the study area. Conclusions: There are obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. Awareness of the numerous variables that may support or impede a particular change effort can inform effective change implementation strategies that are “organizationally compatible.” ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Operating room (OR) efficiency continues to be a high priority for hospitals [1e4]. OR turnover time (TOT), the time from
“patient out of the OR” to “next patient into the OR,” is a common performance metric that is captured by hospitals [5]. Because it is easily measured and is subject to less patientrelated variability than other OR processes, the TOT is also
* Corresponding author. Department of Anesthesia, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. Tel.: þ1 617 732 8222; fax: þ1 617 897 0879. E-mail address: [email protected] (R.D. Urman). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.11.1081
404
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
perceived to be a useful diagnostic measure of operational efficiency [6e8]. In 2007, when Brigham and Women’s Hospital (BWH) first began routinely reporting TOT data on the hospital’s Balanced Scorecard, the average TOT across 43 ORsdas measured by the time from patient out of the OR to next patient into the ORdwas 54 min, significantly higher than national benchmarks [7,9]. Around the same time, clinical and administrative leadership assembled the Perioperative Governance Committee, a group of surgeons, anesthesiologist, nurses, and administrators who were charged with leading performance improvement initiatives to increase efficiency and predictability in the perioperative areas. TOTs quickly emerged as a leading candidate for improvement; the 54-min average was long seen as unacceptable to surgeons [10] and was significantly worse than times at other institutions. OR TOT is one of the classic measures of OR efficiency. There are numerous publications and case studies describing efforts to reduce TOTs, sometimes through the employment of a process improvement framework, such as lean or six sigma [1,11]. However, most examples of process improvement in the TOT focus primarily on operational changes to workflows and statistical significance [3,7]. These examples of process improvement do not detail the complex organizational challenges associated with implementing, expanding, and sustaining change. Similarly, many publications do not mention the obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. In the 5 y from the time when routine reporting of TOT data began, there have been three independent initiatives at BWH to reduce these times. Each initiative involved the same key components in planning: (1) Process mapping of turnover activities in a specific specialty. (2) Formulation of a revised process. (3) Piloting of the revised process by a single surgeon. (4) Development of informational materials. (5) Issue-selling to other surgeons in the specialty. (6) Implementation. Two of these initiatives, one in 2009 and another in 2010, successfully accomplished steps 1e4; a third initiative, which began in November 2011, was the only one to successfully accomplish all steps and achieve sustained improvements in the target area after more than 12 mo. Here, we describe this particular experience and investigate why this effort succeeded where others failed.
such a way that there are several well-defined geographic boundaries that divide the OR into service-specific zones or pods (Fig. 1). The geographic layout of the ORs affects travel time and also the degree to which clinical and support staffdprimarily nurses and OR assistants (ORAs)d“float” between different regions of the OR. For example, the orthopedic surgery ORs, 41e46, are isolated from the rest of the ORs so that staff working in this pod rarely work in other areas. The target area for the successful November 2011 initiative was the general and gastrointestinal (GGI) pod, which encompasses ORs 18e28. This area was chosen because the surgeon leader for this initiative was a colorectal surgeon. However, there were additional characteristics that made this an attractive target site. The GGI pod is centrally located, near the combined preoperative holding area and post-anesthesia care unit, patient transport elevators, and main OR desk, which is responsible for coordinating patient flow for all 43 ORs. ORs 18e28 are also more likely to have out-of-service casesdnon-GGIdperformed in them, meaning that additional services may be exposed to new practices. Finally, because cases performed in ORs 18e28 tend to be shorter, these ORs will be turned over 2e4 times each day. As a result, a significant proportion of turnovers (30%e40%, about 400e500 per month) occurs in this pod. The average TOT in the GGI pod was 48 min in October 2011 and 49 min in previous 12-mo period (October 2010eSeptember 2011). The institutional (hospital-wide) target for the TOT was 45 min.
3.
Methods
3.1.
Data collection and analysis
Each OR is equipped with a networked computer terminal. Circulating nurses are responsible for logging distinct time points during the course of an operation, including the time points that are used to calculate the TOTdpatient out of the OR and patient into the OR. TOTs were measured only when both the preceding and succeeding cases belonged to the same service. TOTs were excluded if the sequence of cases was changed from the initial plan or cases were canceled. Average TOTs are reported monthly for individual services and for the entire OR by an independent department in the hospital, the Center for Clinical Excellence. All data used in this study were subject to all standard exclusion criteria, as outlined previously, and a thorough quality assurance process is conducted by the Center for Clinical Excellence.
3.2.
2.
Setting
Surgery at BWHda large 793 bed academic medical centerdis organized into 13 distinct surgical specialties, or services. The hospital performs on average 28,000e30,000 operations per year. These 13 specialties delineate how ORs are allocated to surgeons and how performance metrics are analyzed and reported. There are 43 ORs at BWH, all located on the first basement level (L1) of the hospital. These ORs are laid out in
Process mapping
We mapped the activities of each member of the OR team during the TOT using previously constructed workflows and direct observation of turnovers in the GGI pod. There were four primary workflows, each representing a distinct discipline: (a) the surgical team, including the attending surgeon, fellows, and residents; (b) the anesthesia team, including attending anesthesiologists, fellows, and residents, and anesthesia technicians; (c) the nursing team, including the scrub technician and the circulating nurse; and (d) the ORAs,
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
405
Fig. 1 e BWH ORs with TOT improvement initiative target areas labeled. PACU, post-anesthesia care unit. A-H, OR pod area. (Color version of figure is available online.)
who are responsible for cleaning the OR. Processes were visually mapped and associated with average durations for each of the key tasks.
3.3.
Implementation and observation
Implementation of planned process changes was scheduled for “go live” on October 31, 2011. Initiative leaders were present in the pod for the first 2 wk of implementation to reinforce behaviors and troubleshoot any problems. Observations were shared among all change leaders through direct communication, e-mail, and biweekly
meetings with a larger patient flow task force. After January 1, 2012, direct observations were less frequent and unplanned. Additional indirect observations included close monitoring of daily TOT data and feedback from the OR personnel. At least weekly monitoring and reporting of TOT data continues to date.
3.4.
Statistical analysis
TOTs for all GGI surgery cases were analyzed for a 26-mo period (October 2010eNovember 2012). Data were imported into Microsoft Excel and this software was used to perform
406
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
basic calculations and creation of key study variables, including assigning TOT categories for distribution, determining “in pod” versus “out of pod” designation, and specifying “preintervention” and “postintervention” groups based on the operation date. All data were then imported into IBM SPSS Statistics 20 software (IBM Corporation, Armonk, NY), which was used to perform basic statistical analysis. Significance of change in turnover between relevant study periods was measured using independent samples t-tests with a 99% confidence interval.
4.
Results
4.1.
Planning phase
Process mapping revealed that a typical BWH turnover was a markedly sequential process; OR team members relied on a series of electronic cues to indicate when they should begin a particular task. This behavior was largely reinforced by the current information technology system. A centralized information technology system for all ORs used times inputted by nurses to trigger specific notifications and pages to clinical teams. For instance, surgeons and anesthesiologists would receive the “room ready” page when the circulating nurse inputted that time during a turnover. This milestone was defined by the circulating nurse as the point during turnover when all the necessary equipment for the next case was opened and accounted for in the OR. The page would then signal to the surgeon and anesthesiologist that they should bring the next patient to the OR. On the basis of the factors, such as the distance from the preoperative holding area to the target room, the status of the patient (e.g., obese, agitated, or high risk), and the readiness of the surgical team, the time from room ready to patient into the OR could range from 0e30 min. For GGI, the target service, this process took about 12 min on average. The ideal process that was determined was for patient transport and the final stages of room setup to run in parallel such that the time between room ready and patient into the OR was drastically reduced, if not eliminated. The second parallel process that was identified was to have the ORAs enter the OR to begin cleaning the room as soon as it was safe to do so, rather than waiting for the patient to first be brought out of the OR and the surgical team to leave the room. This represented a major shift in OR culture because it required proactive communication between the intraoperative team and the ORAs, who typically only enter rooms to clean them; circulating nurses would either have to indicate to ORAs that it was safe to enter or ORAs would have to don a surgical mask and inquire with the operating team. The typical delay between patient out of the OR and “clean up begin” was 2e5 min in the GGI pod. These process changes were not new discoveries. Each previous TOT initiative from 2007 also identified these same opportunities. The 2011 initiative team confirmed that these process changes were applicable to the GGI pod and investigated the feasibility of implementing both process changes in the 8 wk leading up to the proposed go live date. Ultimately, the team decided to only implement the second process change, with an expected time savings of about 3 min per
turnover, because it was determined that the first process change, although more impactful, would face more resistance from nurses and would likely require additional anesthesia staff. Additionally, the second process change was subject to less operational variability. To support the launch of this initiative, the team developed extensive communication materials to outline the details of the process change. Every discipline saw the same memos and slides to outline the rationale and objectives of the initiative. Furthermore, the team organized an interdisciplinary meeting 10 d before the scheduled go live date, where the surgeon, nurse, anesthesiologist, and ORA leaders kicked off the initiative using a joint presentation. Every leader emphasized the same messages: (1) this initiative was meant to improve teamwork and communication between clinical and nonclinical staff, and (2) any team member could stop the new process if they felt that patient safety was being compromised.
4.2.
Implementation phase
From the very beginning of the TOT improvement initiative, all stakeholders were invited to participate in both design and implementation phases. This included OR nursing leaders, OR pod leaders, and rank-and-file OR nurses. Much of the perceived resistance to change was because of typical institutional inertia common to large bureaucratic organizations. The initiative went “live” on the target date of October 31, 2012, and it encountered significant obstacles. There was a surge of negative feedback from all disciplines after the interdisciplinary kick-off meeting. Moreover, the nursing union voiced concerns about the safety of the process change. At our facility, all OR nurses are union members. According to informal inquiries about why some nurses and union representatives were initially opposed to the change had to do with legitimate concern for patient safety. Specifically, nursing leadership was concerned about the idea of parallel processingdon patient’s entry into the OR, the nurse would be counting instruments with the scrub technician and not be able to pay attention to the patient who has just entered the OR. However, we ensured that there would be an adequate number of staff (anesthesia and surgery) to initially attend to the patient until the nurse finished the necessary counts. After some deliberation, the team decided to circulate a notice announcing that the initiative would be postponed until further notice. However, the team also proceeded to identify surgeons and OR staff who were supportive of reducing the TOT to quietly implement the process changes in select ORs on the go live date. On the morning of October 31, the leadership team met in the GGI pod and monitored the implementation of the new process in the ORs where the surgeon and staff were supportive of the changes. They encouraged ORAs to enter rooms, addressed process issues, and answered questions on the spot. This on-the-ground presence continued for the first 2 wk of the initiative. During this period, average TOTs decreased from 48 min in the previous month to 41 mindan unexpectedly large decrease given that the process change was only intended to save about 3 min. Debriefing sessions were regularly held, at least once a week, involving all stakeholders,
407
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 4 0 3 e4 1 1
such as ORAs, nurses, anesthesiologists, and surgeons. They proved very useful in receiving the feedback and generating new ideas for TOT improvements.
4.3.
Successful reduction in the TOT
As stated in the Methods section, BWH reports the average TOT for surgical services monthly. However, from the start of the intervention until around January 2012, we reported weekly TOTs to GGI staff (surgeons, nurses, anesthesiologists, and ORAs). Changes in the TOT were measured between October 2011 (baseline), December 2011, and October 2012 to understand what impact, if any, the intervention had on reducing the average TOT in the short-term and whether this effect was sustained after a year. Figure 2 shows the average monthly TOTs for GGI surgery in each of the 3 mo, with standard deviations. On the basis of the data, we were able to see that there was a marked decrease in December 2011 but a subsequent increase by October 2012, although it was still below the baseline level. Furthermore, to determine the significance of these changes, we performed an independent t-test with a confidence interval of 99% comparing all turnovers from each month to those in October 2011 (Table 1). The statistical analysis supports a significant difference in the average TOT between December 2011 and baseline, but not between October 2012 and baseline, indicating that the intended effects of the intervention may not have been sustained a year later.
4.4.
Sustaining change
From January 2012 to October 2012, team leaders monitored progress ad hoc. Rather than dedicating time to police processes in the GGI pod, the team used audits and carefully monitored weekly TOT data. Weekly and monthly TOT data were also reported to all OR team members in a timely manner, with no more than a 1-wk delay on weekly reports and no more than a 2-wk delay for monthly data. Although TOTs did increase slightly from the recordbreaking lows achieved in November and December 2011, the average TOT for GGI surgery never exceeded 46 min for a single month. By October 2012, the average TOT in GGI surgery
Fig. 2 e Change in GGI surgery turnover.
Table 1 e Change in the GGI surgery TOT 3 and 12 mo after intervention. Month Oct 2011 Dec 2011 Oct 2012
Cases
Median
Mean
s
P value
135 167 152
54 51 42
48.1 41.1 45.1
17.5 15.5 14.7
