Information changes everything — New OR systems capabilities
Turning to the large flat-panel computer monitor perched on his desk, Dr. Mike Higgins pulls up a slide presentation and begins reading aloud from an old list of proposals for operating room information systems upgrades. Vanderbilt’s five OR suites run on electronic information and the OR’s administrative to-do list never lacks for proposals to enhance information systems. Higgins, associate professor of Anesthesiology and Surgery, leads the OR Informatics Steering Committee. Reading rapidly through the old list of proposed upgrades, he pauses for a second to deliver a mock aside, “Whoa! We’ve actually done some of this stuff.”
Self-deprecating humor notwithstanding, information systems development has played a critical role over the last three years as the OR has intensively reorganized and redesigned work processes to improve efficiency.
Nancye Feistritzer, director of the Perioperative Patient Care Center, recalls the November 1999 retreat marking the start of the OR redesign effort. “We found ourselves not having real-time information from which to manage,” she said.
Information systems offered only a scanty representation of work as it occurred in the OR. Useful details were lacking. The same was true of the back-end reports used to evaluate performance. Electronic case documentation was inadequate for locating causes of OR delays. If cases often ran longer than scheduled, it was in part because there was no historical data that would allow more accurate prediction of case times. Finally, delivery of OR supplies and equipment was considered improvable through electronic inventory management and instrument tracking. All these issues and more have been addressed through system upgrades that today help the OR run more smoothly and efficiently.
Patient tracking
To help them manage workflow and OR capacity, managers and charge nurses can now turn to an electronic white board to survey activity as it’s occurring in the OR. The board also provides a summary of patient arrivals.
The white board is powered by the Vanderbilt Perioperative Information Management System, or VPIMS. Even before the start of redesign, the OR had turned to Higgins and anesthesiology for development of a system to help manage work more efficiently. VPIMS supports intraoperative medical documentation, patient tracking, anesthesia/OR quality improvement programs, and analysis of workflow and efficiency. The application was recently licensed for commercial development by a new Vanderbilt subsidiary, Intelligent Healthcare Informatics.
VPIMS patient tracking begins at the front door of the hospital as guest services representatives greet arriving surgical patients. Greeters check off arrivals using a special interface on a hand-held computer. The hand-helds were introduced last year for the main OR and this summer use was expanded to all five OR suites. By immediately registering arrivals in the system, the OR is in a position to adjust the admitting queue as operating rooms become available. Detailed patient tracking continues in VPIMS until the patient leaves recovery.
Performance feedback
Objective performance comparisons help greatly to communicate institutional goals to faculty and staff. Feedback on performance was near the top of the informatics wish list developed at the November ‘99 redesign retreat.
“People want to do well on report cards – it’s virtually ingrained in competitive people,” Higgins said.
Since August VPIMS has generated detailed reports on OR practice patterns – reports by individual surgeon, by surgical service, by procedure and by OR suite. At every stage of VPIMS patient tracking, nurses use the system to document the reasons for any delay. The documentation is categorical, lodging directly in a database for easy reporting and analysis. The reports are distributed to surgical department chiefs and to OR suite managers.
The reports for surgeons include accuracy of case scheduling, frequency of delays caused by surgeons, preoperative documentation completion rate (patient consent, history and physical), and percentage of adult cases seen first by the preoperative evaluation center (the center is seeking to evaluate all adult preop patients). Surgeons are ranked both within their service and within the section of surgical sciences as a whole.
For OR suite administrators and staff, reports include data on 48 categories of case delays, as well as room turnover time, and performance in getting patients into their OR rooms on time.
VPIMS also incorporates reports of patient satisfaction with anesthesiologists, nurses and surgeons.
VPIMS reports will be used to drive work redesign in the OR suites and the Perioperative Executive Committee will use the reports as it periodically refines how OR block time is allotted among the various surgical services.
Anesthesiology has instituted faculty salary incentives based on performance on certain efficiency measures.
Historic case scheduling
When cases run over schedule other cases are delayed and OR efficiency suffers. In the last fiscal year only 30 percent of cases finished within 15 percent of their scheduled length. Some overruns are due to medical variability while others are a matter of poor scheduling. In partnership with an outside vendor the OR recently upgraded its management information system, used for case scheduling, instrument control, billing and cost analysis. One of the benefits of the upgrade is improved ability to view a scheduled case against previous case durations for a given surgeon and a given procedure or combination of procedures. The system gives an alert when the scheduled time is out of line with the historical record, prompting the patient care manager, scheduling supervisor and anesthesiologist to get involved with scheduling of the case.
The OR has adopted a new goal: to finish 80 percent of cases within 15 percent of the scheduled case length. The system will also allow eventual case-length benchmark reporting to support standardizing case lengths.
Instrument control
Vanderbilt recently outgrew its on-site sterilization facility, and Feistritzer said the introduction earlier this year of off-site sterilization by an outside vendor has created some difficulties. The recent management system upgrade is expected to help fix the problems, allowing greater assurance that instruments will be available when and where they’re needed. Once the OR takes a full inventory of its instruments, as each new case is scheduled, conflict checking will assure that there are enough instruments to go around. The system will also track instruments as they cycle between use in the OR and sterilization at the vendor’s off-site facility. With more than 10 bar code scanning points along the instrument processing route, the OR will know precisely where its instruments are at any moment. The tracking system will be implemented in January.
Surgeon preference management and easier cost analysis
In the interest of efficiency the OR has for years worked with surgeons to standardize the supplies and equipment used for a given procedure. The recent management system upgrade gave added impetus to standardization of these surgeon preferences. It’s now easier to spot any preferences that vary from the standard. In addition, charges for supplies and OR rooms are now generated by the same system. All this means that automated OR cost reporting is possible for the first time. Reporting has begun by surgeon, surgical procedure and surgical service.
Preop checklist
Lack of complete preoperative documentation is a perennial source of delay and inefficiency in the OR. The often missing documents include the preoperative history and physical, patient consent for the procedure and notice of insurance authorization. “There are a large number of delays due to incomplete documentation and unresolved insurance issues,” Higgins said.
As surgical clinics automate under the E3 initiative, preop documents will either be created electronically or scanned into the system and indexed to the medical record. The informatics center has created a preoperative checklist in StarPanel, viewable by patient, by date, by surgeon or by surgical service. This white board will allow surgical services to survey the status of documentation. “Performance of the checklist will create a huge return for the OR,” Higgins said.