Dr. Lewis Lefkowitz talks with Dr. Deborah C. German, senior associate dean for medical education, at the reception. (photo by Dana Johnson)
Change efforts pay off in the OR
For the past several months, surgeons, anesthesiologists and operative services staff have engaged in sweeping efforts to improve operating room efficiency. The ongoing project, known as OR Rapid Redesign, is focused on accommodating increased patient volume by eliminating unnecessary lag between surgical cases and preventing cases from running unnecessarily long.
“Surgical procedures often take longer here than at non-teaching hospitals,” said Nancye Feistritzer, administrative director of the perioperative patient care center and a co-leader for OR Rapid Redesign. “There’s a presumption that, because we’re academic, we are inherently slower. But the reality is that payers don’t acknowledge this difference when they reimburse providers. The challenge is to continue our educational mission under these tightening financial constraints.”
OR redesign is a complex undertaking with different committees converging from various directions: preoperative process, intraoperative process, holding and recovery areas, supplies and equipment, sterile instrument processing. The overall goals take shape in a steering committee but staff and faculty carry out the changes.
“The redesign effort is bearing fruit,” Feistritzer said. For the first six months of this fiscal year, OR patient volume was up 10 percent (compared to the first six months of the previous year). In budget terms, the volume increase has helped operative services go from being one of the hospital’s worst performing departments to one of its best. Operating room utilization (hours of surgery divided by total staffed OR time) has risen from 70 percent to 83 percent over the past seven months. (A utilization rate of 85 percent is considered optimum; anything higher tends to create a bottleneck.) Rising OR utilization helps to lower per case fixed costs such as labor and capital equipment. Supply costs, however, are on the rise. “Increased emphasis on reducing cost of product utilization will be forthcoming,” Feistritzer said.
New ways of working
To promote accurate scheduling, the OR is tracking how long it takes on average for a given doctor to perform a given procedure. As a surgeon schedules a procedure the system will immediately flag any significant discrepancy between the scheduled duration and the surgeon’s historical average time for the procedure. This upgrade may be available as early as May.
A new policy prevents cases from being scheduled without a medical record number and the patient information needed for insurance precertification.
A new chart manager position was created to check charts a few days prior to surgery to ensure that lab results and all other documentation is in hand by the start of the case.
As of Jan. 22 the main OR has been functioning as four distinct specialty areas or pods. Giving surgeons their own turf in the OR will allow improved efficiency and quicker room turnaround. Within each pod a lead anesthesiologist and a patient care manager work together to ensure optimum patient flow.
VMG anesthesiologists now tread a quicker circuit from holding room to OR to recovery room. Their former zigzag route involved twice the number of stops in the OR. This new work flow solution should shave minutes off OR turnaround.
The Vanderbilt Perioperative Information Management System (VPIMS) is now at least partially deployed in all five Vanderbilt operative services suites. The system will be indispensable for ongoing OR redesign: It gives an up to the minute view of what’s happening across the OR and produces data to help identify bottlenecks and opportunities for improved efficiency. Developed by anesthesiology, the system supports medical management and detailed tracking of OR patients, as well as outcomes research.
As a patient advances through the OR, nurses use VPIMS to note beginning and end times for each stage of care. Through a link to the OR scheduling system, VPIMS will be upgraded to recognize automatically when a given stage of an OR case has exceeded its expected duration. Users will be prompted to register the causes of the delay, allowing yet closer analysis of the work of the OR.
Perhaps the greatest work redesign changes have occurred in the holding room, recovery room and stage II recovery. Through staff training and reassignment, these areas became practically interchangeable in December. Cardiothoracic patients now finish preparation for surgery in the stage II recovery area, where staff have learned to assist placement of cardiac monitoring lines. At the busy start of the day the recovery room and stage II function as an extension of the holding room.
It’s no longer acceptable to allow the recovery room and stage II to back up the surgery schedule. Daily surgical bed management meetings are helping to solve the postsurgical bottleneck. The meetings bring together nurses from admitting, the OR and surgical care units of the hospital.
The stage II recovery area now has the capacity to keep patients overnight as need arises – yet another strategy for accommodating greater surgical patient volume.
The supply side
Eighteen months ago operative services turned its supplies intake and distribution activity over to central supply, a branch of medical center support services. Other VUMC groups, including radiology, respiratory services and Vanderbilt Medical Group, are following the OR’s lead, turning over supplies handling to medical center support services.
The VUH case cart fill rate measures how successful the hospital is at having supplies on hand in anticipation of the needs of surgical teams. In the past year the case cart fill rate has risen from 85 percent to 99.5 percent. There’s now same-day reshelving of unused supplies returning from the OR, which helps keep inventory records up to the minute. Inventory has been reduced by $425,000, and further reductions are planned. The goal is to reduce the OR’s current $4.2 million inventory by 50 percent.
There’s a renewed push underway to exploit volume pricing opportunities and improve efficiency through greater standardization of OR supplies and equipment. Requests for new supplies are no longer granted automatically but are instead funneled through various committees, and groups of surgeons at the division level are beginning to review colleagues’ supplies requests.
Over the last few years materials management computer programmers have rebuilt the house-wide supplies database, helping to improve charge capture and OR revenue and allowing more efficient management of OR supplies. VUH and OR supplies are now massed in a single database and storeroom.
In the past 10 months, at a cost of more than $2 million, the OR has increased the number of surgical instrument sets by 11 percent. Having more sets helps eliminate lags between cases. Streamlining has recently reduced turnaround of sterile instrument sets from five hours to two hours. The quicker processing of instruments is achieved with the help of OR scrub nurses, who ensure that instruments are put back in the same sets in which they arrived from sterile processing.
“As we’ve moved to implement the key redesign initiatives, we’ve learned the importance of working in small groups to identify and overcome process barriers,” said Stephanie Randa, director of the main OR. With assistance from the center for clinical improvement, newer elements of OR redesign are taking shape specifically within cardiothoracic surgery, which has a network of committees focused on surgical cost containment. Randa said other surgical specialties are now launching similar efforts of their own.