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1 Operating Room Turnover Analysis and Improvement Click to edit Master title style Click to edit Master subtitle style Reza Maleki and Melissa Kram Department of Industrial and Manufacturing Engineering North Dakota State University

2 Project Background Reflects the work of a team of students who, on behalf of MeritCare Health System, undertook the project Operating Room Turnover Conducted as a partial fulfillment for the Program and Project Management Capstone course

3 Client Overview MeritCare Health System Providing excellent care since 1905 Largest practicing group in ND Two Hospitals and 42 Supporting Clinics Over 1.5 million patients served a year with a service area that spans 250 miles MeritCare Medical Center Downtown Fargo 380 Bed Facility Houses 11 surgical suites 2003 Surgical Department Synopsis: Over 9,400 cases and 22,400 case hours Generated 37 million dollars in revenue

4 Project Background Needs Identification Increasing efficiency of key profit center: Surgical Department Focus on Turnover Efficiency in the Operating Room MeritCare Contacts Quality Management Engineer Executive Partner Surgical Services Surgical Service Educator CRNA Manager Operating Room Manager Statement of Work and Deliverables

5 Presentation Overview Project Objective Project Work and Research Activities Recommendations Project Benefits Suggestions for Future Projects Lessons Learned Questions

6 Project Objective Determine and propose methods to minimize the operating room downtime Recommend ways to improve utilization by reducing turnover time T u r n o v e r T i m e Close Incision Patient Emergence Room Cleanup Room Setup Patient Preparation

7 Project Work & Research Activities Observations at MeritCare Meeting with individual staff members Outside discussions with professionals Research Data analysis Documentation

8 Project Work & Research Activities Turnover Process Finishing First Case Readying the Room Preparing Next Patient Finishing First Case Incision Closure Incision closed Dressing applied Emergence from anesthesia Patient Out of OR Patient moved from OR table to gurney Patient transported to PACU (recovery room) Reference: Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process

9 Project Work & Research Activities Turnover Process Finishing First Case Readying the Room Preparing Next Patient Readying the Room OR Cleanup Trash discarded Case cart removed Equipment collected for reprocessing OR floor & surfaces cleaned OR Setup Case cart delivered to OR suite Instruments & supplies laid out Sterile supplies opened Missing items retrieved Equipment positioned & Setup checked Reference: Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process

10 Project Work & Research Activities Turnover Process Finishing First Case Readying the Room Preparing Next Patient Preparing Next Patient Patient to OR Patient transported to OR Patient moved from gurney to OR table Patient positioned & prepped Additional lines may be placed Incision Patient induced First incision made Reference: Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process

11 Project Work & Research Activities Example Turnover Patient Waits Staff Waits Clock Time Event 9:32 incision closed 9:39 patient leaves (with CRNA & aide) 9:43 room cleaned 9:47 CRNA starts set up 9:53 CRNA finishes set up 10:04 patient enters 10:09 scrub nurse finishes room set 10:23 patient prepped 10:34 patient draped and incision made Total Turnover Time = 62 min

12 Project Work & Research Activities Attainability of Additional Cases 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 Long Cases Case 1 Case 1 Case 2 Case 2 Case 3 Case 3 Overtime Case 4 Short Cases Case 1 Case 1 Case 2 Case 2 Case 3 Case 3 Case 4 Case 4 Case 5 Case 5 Case 6 Case 6 Case 7 Overtime Reference: Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process

13 Recommendations 1. Early Patient Entry 2. Local Certified Registered Nurse Anesthetist (CRNA) 3. Front Loaded Anesthesia 4. Redefining Patient Transportation

14 Recommendations Early Patient Entry OR Patient Room Cleanup Patient in in Holding Area Room Setup Anesthesia Preparation Transportation Patient Waits OR Waits Induction Transportation Induction Time Saved 25% Reference: Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process

15 Recommendations Early Patient Entry Current Process

16 Recommendations Early Patient Entry Proposed Process Time Saved 25%

17 Recommendations Early Patient Entry Benefits Shortened wait time experienced by both patient and operating room staff Balanced activities to eliminate bottlenecks in the process Potential to increase number of cases

18 Recommendations 1. Early Patient Entry 2. Local Certified Registered Nurse Anesthetist (CRNA) 3. Front Loaded Anesthesia 4. Redefining Patient Transportation

19 Recommendations Local CRNA Current Practice Excluding first cases, an Anesthesiologist is responsible for completing all preoperative anesthesia evaluations Anesthesiologists have other equally important duties throughout the hospital Delays arise from varying demand

20 Recommendations Local CRNA 40.00% 35.00% 33% Anesthesia Delays by Department 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Surgeon Anesthesia Patient Other/ER Case in Progress Nursing Lab/X-Ray Other

21 CRNA Unavailable CRNA not ready for Pt.Yet. Recommendations 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Local CRNA Anesthesia Delays Line's in Progress inholding MD Unavailable Anesthesia Delays 36% Waiting to be seen by anesthesia Pt. Waiting to be seen by Anes. Difficulty Starting Lines

22 Recommendations Local CRNA Benefits Tried and true method Supports early patient entry Reduces patient and staff wait times Decreases delays caused by a busy anesthesiologist CRNA, who is more economical, is qualified to conduct the preoperative anesthesia evaluation

23 Recommendations 1. Early Patient Entry 2. Local Certified Registered Nurse Anesthetist (CRNA) 3. Front Loaded Anesthesia 4. Redefining Patient Transportation

24 Recommendations Front Loaded Anesthesia Current Practice / Issues For small cases, large percentage of patients come to the OR with no anesthetic work done An additional task for the in-room CRNA Delays in the OR suite are more costly

25 Recommendations Front Loaded Anesthesia 40.00% 35.00% Anesthesia Delays 24% Difficulty starting lines 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Pt. Waiting to be seen by Anes. Difficulty Starting Lines Line's in Progress inholding MD Unavailable Anesthesia Delays CRNA Unavailable CRNA not ready for Pt.Yet.

26 Recommendations Front Loaded Anesthesia Benefits Reduces the impact of possible delays during the turnover process Limits negative effects of problem cases Reduces workload for in-room CRNA

27 Recommendations 1. Early Patient Entry 2. Local Certified Registered Nurse Anesthetist (CRNA) 3. Front Loaded Anesthesia 4. Redefining Patient Transportation

28 Recommendations Redefining Patient Transportation Current Practice CRNA Complete in-room setup Transport patient into OR suite Tasks are serial Circulating Nurse Usually has idle time at some point during turnover process After opening of supplies

29 Recommendations Redefining Patient Transportation Resource Utilization

30 Recommendations Redefining Patient Transportation Benefits Supports early patient entry Frees up a crucial resource Assists in having the patient in the operating suite as soon they can be accommodated

31 Example Turnover 11 minutes 3 minutes Clock Time Event 9:32 surgery over 9:39 patient leaves (with CRNA & aide) 9:43 room cleaned 9:47 CRNA starts set up 9:53 CRNA finishes set up 10:04 patient enters 10:09 scrub nurse finishes room set 10:23 patient prepped 10:34 patient draped and incision made Time Saved: 14 minutes 22% Early Patient Entry Front Loaded Anesthesia Local CRNA Redefining Patient Transportation

32 Project Benefits Increased surgeon satisfaction Surgeon replacement costs of $20,000-$85,000 Short-staffed one surgeon can result in lost revenue of over $100,000 monthly

33 Project Benefits Costs negligible Possible additional cases and revenue Potential profit could be upwards of $100,000 per suite if only one case a week is added (Source: MeritCare) With one additional case per day, per operating room suite could translate to $4 - $7 million in annual revenue (Source: HFMA and Health Care Advisory Board)

34 Recommendations for Future Projects SURGICAL DEPARTMENT Scheduling Research has shown scheduling to having the largest impact on utilization and revenue Communication Integrated Information Technology Systems First Case Start Times

35 Lessons Learned Work with staff & openly ask questions to learn the complex perioperative process. Do not point out people or departments as problems, but instead stress the particular process as the problem. Keeping an open mind and recognizing the importance of compromising to ultimately reach the goal of the project. Make recommendations that will work and will receive buy-in from management and staff. Such projects provide enhanced learning opportunities for students, faculty, and business/industry clients.

36 Questions

37 Slide 1 Operating Room Turnover Analysis and Improvement Reza Maleki and Melissa Kram Department of Industrial and Manufacturing Engineering North Dakota State University Fargo, North Dakota Reza Maleki, Ph.D., P.E., C.Mfg.E. Phone: (701) Fax: (701) Reza.Maleki@ndsu.nodak.edu Melissa Kram Phone: (701) Melissa.Kram@ndsu.nodak.edu Slide 2 This presentation reflects the work of a team of students, who on behalf of MeritCare Health System, undertook the project Operating Room Turnover Efficiency. The project was also conducted as partial fulfillment for the Program and Project Management/Capstone course. The course is aimed at providing students with the opportunity to work on real-world projects for business/industry clients. Slide 3 Project Client - MeritCare Health System MeritCare Health System, an entire network of care, is an integrated hospital and clinical system with headquarters in Fargo, North Dakota. Established in 1905, MeritCare has grown to be the largest group practice in North Dakota, with 72 specialty areas of medicine. MeritCare Medical Group currently serves nearly two million people a year across a service area that spans 250 miles west to east. MeritCare Health System, in Fargo, consists of two hospitals and 42 supporting clinics. The two hospital locations include MeritCare Medical Center (downtown Fargo) and MeritCare South University. The MeritCare Medical Center has 380 adult and pediatric licensed beds.

38 Between the two locations, there are currently twenty-one operating room suites. MeritCare Downtown Medical Center houses the main operating rooms, which consists of eleven suites. In 2003, the main operating rooms had over 9,400 cases and over 22,400 case hours which generated 37 million dollars in revenue. In the fall of 2004 a twelfth suite was added, that is used for block scheduling part-time and for add-on cases part time. Slide 4 Like many other healthcare providers, MeritCare makes every effort to better manage existing resources, minimize waste, and increase the efficiency of various departments. MeritCare recognized the advantages of focusing on their key profit center the Surgical Department. MeritCare s Operating Room Improvement Team had realized the potential for improvements with the current processes surrounding and involving the operating room suite turnover. The project team s first task was to set up and attend meetings with MeritCare contacts in order to gain as much information as possible pertaining to development of the scope of the project, including learning and understanding the perioperative process. During initial meetings, the group met with several members of MeritCare Health System staff including people from surgical services, executive board, and quality management. Throughout these meetings, process and project information was gathered and the ground rules were laid out. After meetings with MeritCare personnel and careful consideration of the needs and problems discussed, a statement of work and deliverables was drafted and ultimately finalized. Project Team Deliverables 1. Documentation of the current turnover process of the operation room suites. 2. Document with recommendations for improving operating room suites. 3. Documentation providing cost/benefit analysis for the proposed improvements. 4. An outline of recommendations for future projects and further improvements. Slide 5 Slide 6 The statement of work included the agreed-upon project objective. Project Objective The objective of this project is to determine and propose methods to minimize the operating room downtime and, more specifically, recommend ways to improve utilization by reducing turnover time.

39 Turnover rate, defined by MeritCare, is the difference between the closure time of one operation and the incision time of the succeeding operation; including patient emergence, room clean-up from the previous case, suite setup and patient preparation for the subsequent case. Slide 7 Observations / Data Collection The project team s first step towards data collection was to become familiar with the complex perioperative process, the medical jargon used, the job tasks of the staff, and the surgical department environment through numerous observations. Collecting the data was definitely the most time-consuming portion of the project. Members of the project team made observations of the turnover process between the cases occurring among the 11 operating room suites. Many times, team members would pair up so one could watch the turnover, while the other could follow the patient from AM admissions and the holding room to the surgical suite. Other cases involved one member watching the turnover in the suite, while the other followed the patient to the PACU or recovery room. This allowed the team members to witness all the processes directly related to the turnover and the associated possible delays. All together, the project team was able to accumulate over 25 observations and document most of them. At first, there was a concern with how the staff would react to the team member s being present in the operating suites. However, with management support, that concern was never an issue. The management of the surgical department informed the staff of the team s purpose and introduced the team members to many of the surgeons and anesthesiologists. Fortunately the majority of the staff welcomed the team s endless questions. During the observation time spent at MeritCare, the observations that were taken involved much more than just watching the current process. The group felt that videotaping the turnover in the room, without exposing the patient to ensure confidentiality, would be valuable for the first observations. This allowed the team to capture the process and have record of the observation, used to study the process and to later reference once the key factors were identified. Since every operating room suite generally performs different types of procedures, the group was able to observe a large variety of cases involving a number of tear down, cleaning, and setting up procedures. Since there was a variety of cases observed, team members were able to witness different turnover teams and equipment, as well as the varying tasks that need to be performed for a specific type of case. Research Research done prior to and during the project consisted of many different phases. The primary reference used was Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process, published by the Clinical Advisory Board in The book goes into great graphical detail on many of the aspects involved in our presentation, and also provided a template for some of the team s future recommendations. Other research was done on the internet, particularly researching healthcare specific organizations. These resources enabled the project team to find various methods used by professionals working in the industry to tackle some of the same needs the project encompassed.

40 Data Analysis The data and information gathered from observations, interviews, meetings, and conversations or s were organized into useful information to support the project team in the development of their recommendations. Besides the data gathered by the group, the project team was provided with historical data from previous and current projects and observations made by the client. The historical data was analyzed for accuracy and applicability to ensure that it was of use within the scope of the project. One set of historical data was used to construct Pareto charts. Based on the charts, as well as other information, the project team was able to identify two leading contributors to the type of delay. The project team also did analysis on data for room occupancy times. Although the data provided figures on the room set-up and clean times, most cases studied were not concurrent by our definition of turnover, providing little significance. Slide 8 A list of events that occur during each phase and factors influencing the turnover rate is compiled and available through the reference book, Clockwork Surgery, Hardwiring Efficiency into the Perioperative Process. The team used this resource as a guide to learn and understand the turnover process, but the process elements were verified with the actual process. The Turnover Process The operative process includes the entire turnover process that this project encompasses. As previously defined, operating room turnover time is the difference between the closure time of one operation and the incision time of the succeeding operation; including patient emergence and clean-up from the previous case along with suite and patient preparation for the subsequent case. The turnover process includes three sequential phases; finishing the first case, readying the room, and preparing the next patient. There are a number of events that take place during each phase of the process, along with a number of factors that influence the turnover rate. There are various steps in each phase that must be completed chronologically to ensure a sterile environment. Finishing First Case The first phase of the turnover process is finishing the first case. This phase includes incision closure and transport of the patient out of the operating room suite to the PACU for recovery. Incision closure includes wound closure, dressing application, and emergence from anesthesia. When transporting the patient, the patient is moved from the operating room table to a transport bed and transported to the PACU by the circulating nurse and anesthesia caregiver. Slide 9

41 The Turnover Process Readying the Room The second phase of the turnover process is readying the room, which includes two main steps; the cleanup of the previous case is completed and then setup of the following case is started. The operating room suite cleanup consists of discarding all drapes and trash, removing the case cart, collecting equipment for reprocessing, and cleaning the floor and surfaces (damp dusting). A case cart is a shelving cart that holds all prepackaged supplies for the particular case. Once the cleaning tasks are complete, the staff continues by setting up for the next case. Setting up consists of delivering the case cart to the operating room suite, laying out all supplies and instruments, and opening sterile supplies. If there are any missing items, they are tracked down, all the equipment is positioned, and finally, the setup is checked against the surgical preference card for completeness. Slide 10 The Turnover Process Preparing Next Patient The third and final phase of the turnover process is preparing for the next patient. The patient is transported to the operating room suite and moved from the gurney to the operating room table, where the patient is positioned and prepped for surgery. Anesthesiology then inserts any additional lines not previously placed in the holding room. Shortly thereafter, the patient is induced and the incision is made by the surgeon. The turnover is complete. Efficient room turnover requires careful orchestration of a large amount of staff members performing an array of interconnected tasks. With the inherent complexity of the process, often times a lengthy turnover is the rule rather than the exception. Slide 11 An example of data collected during observation of the turnover process. Slide 12 After some analysis of the current process, considerations to research, and discussions with key MeritCare personnel, it was decided that the length of case varied greatly. With the timeline of project a decision needed to be made as to the focus of the project, either shorter or longer cases.

42 Here, the definition of a shorter case is a case in which the surgical time is an hour or less. As shown in the figure, the shorter cases offer the greatest potential for attainability of additional cases. If the duration of the case is too long, the freed time will be less than the time it takes to perform a case, pushing the last case into staff overtime, which is not a desired effect. Nevertheless, focusing on recommendations for shorter cases will definitely provide the possibility of additional cases and in turn have the most potential for a direct economic benefit. Once the focus was determined to be the shorter cases, four main recommendations were formulated. Slide 13 Recommendations Based on their research, the project team came up with the following four recommendations: 1. Early Patient Entry 2. Local Certified Registered Nurse Anesthetist (CRNA) 3. Front Loaded Anesthesia 4. Redefining Patient Transportation Slide 14 Early Patient Entry The theory behind early patient entry is to get the patient into the room as early as possible to allow anesthetic, positioning, and preparatory work to begin. Currently, there is a waiting period experienced by both the patient and the operating room, but at different times throughout the process. Since these wait times are not in series, the elimination of both wait periods seems to be a beneficial step. The figure shown on this slide represents a basic example of the events taking place in the operation room (top of the figure) and the events experienced by the patient (bottom of the figure) prior to the surgery and after the previous patient has left the operating suite. Although these waiting times are not series in nature, they are definitely not independent. The wait experienced by the patient when waiting to be transported to the room creates the wait in the room while the patient is being transported. By simply moving up the time that the patient transportation to the operating suite takes place, both wait times can be eliminated (or at a minimum reduced). The slide animation shows the new process and the expected time saved, for a saving in time about 22% of the total average turnover time.

43 Slide 15 Early Patient Entry This and the next slide show the turnover process, broken down by task in a Gantt chart, to more specifically show how early patient entry can benefit the turnover process. The figure on this slide shows an example of the current process, compiled using average times found during observations, from research, and the documents provided by the client. There are certain tasks that must follow in a serial manner; however, the current process is not taking full advantage of parallel processes with a certain group of tasks. It appears that there is a lack of parallel processing when it comes to the work done by anesthesia in coordination with the rest of the process tasks and employee utilization. Slide 16 Early Patient Entry The figure on this slide demonstrates what the ideal process would look like. Notice that none of the task lengths have been altered or dependencies eliminated. Instead, by having the patient enter the room immediately when the room is allowed to accept the patient (when all supplies are opened) the overall turnover time can be substantially reduced by about 25%. The chart shows an idyllic process for turnover in the room. In this case, the CRNA comes back from the PACU and begins setup almost immediately. Time has been allotted for completing paperwork and checking narcotics in and out. The total twelve minutes that the CRNA is shown to be out of the room is felt to be an adequate amount of time for the average non-problematic case. A milestone has also been added to this chart to show the importance of the surgeon getting to the operating suite at an appropriate time. Most of the time, the surgeon needs to be present to position the patient properly and check the setup. One of the most difficult things about implementing a new plan is having the involved personnel accept it. In order for early patient entry to work, all personnel involved with the perioperative process must be adaptive to parallel processing and some support features must be in place. In order for the patient to be prepared to enter the operating room, all preoperative work must be done; including tests, paperwork, evaluations, etc. Delays in these areas will inevitably delay the start time of the procedure. Slide 17

44 Early Patient Entry The following benefits can be realized from implementing early patient entry: Shortened wait time experienced by both patient and operating room staff Balanced activities to eliminate bottlenecks in the process Potential to increase number of cases Slide 18 Slide 19 Local Certified Registered Nurse Anesthetist (CRNA) One of the processes prior to transporting the patient to the operating suite is the preoperative anesthesia evaluation process. Currently (excluding the first cases of the day) an anesthesiologist is responsible for seeing patients in AM admissions for the preoperative anesthesia evaluation. AM admissions is located on another floor, requiring the anesthesiologist to travel a noticeable distance in the hospital. The problem with this process is that anesthesiologists are also responsible for many other equally important activities throughout the hospital. Observations showed situations where the patient in the AM admissions area had to wait to be visited by the anesthesiologist before they could proceed to the operating room area. The anesthesiologist was late because of other tasks that they were working on that could understandably not be abandoned or delayed. So the problem becomes how to eliminate such delays without being a hindrance to the quality of care provided to other areas of the hospital. Slide 20 Local Certified Registered Nurse Anesthetist (CRNA) Historical data, which was provided by the client, also supports the project team s observation of delays due to the patients waiting to be seen by the anesthesia caregiver. The figure on this slide shows the overall delays caused by various departments. According to the figure, the anesthesia department is the second major contributor to the delays. This figure is based on the year 2003 data. Slide 21 Local Certified Registered Nurse Anesthetist (CRNA)

45 Further analysis of the historical data shows that the primary anesthesia delay (about 36%) was the patient waiting to be seen by an anesthesiologist. The proposed solution is to have a staff capable of doing preoperative anesthesia evaluations permanently located in the admissions area. In the first case scenario, there is a maximum of two CRNA s or MDA s located in the AM admissions area to see upwards of nine patients nearly simultaneously. The first case is generally the busiest time for the admissions area, so there definitely should be no need for any more than two throughout the day and there is a strong possibility that one could handle the majority of the day, only having an anesthesiologist come down to help when needed. Slide 22 Local Certified Registered Nurse Anesthetist (CRNA) A local CRNA is a tried and true method at MeritCare. This was the standard practice until roughly five years ago when the shortage of CRNA s caused management to move that individual into the operating suites. Now that the anesthesiology department is close to their full CRNA staff, the CRNA Manager felt that they had the capacity to fill the position in AM Admissions. This recommendation supports early patient entry as it will aid in reducing both patient and staff wait times. This will also decrease delays caused by a busy anesthesiologist. Having a CRNA in the admissions area for preoperative anesthesia evaluation is a template followed by a number of different practices. One hospital system, the University of Washington Medical Center (a 450-bed comprehensive care facility), went as far as to give nursing staff specialty training to perform the anesthesia evaluation. Patient records and nursing assessments are then reviewed then by an anesthesiologist or a nurse anesthetist prior to surgery. Another possible benefit seen from implementing a nurse anesthetist in AM admissions is allowing the anesthesiologists to spend more of their time in the surgical department. This could possibly have a large impact on facilitating problem anesthetic cases and getting problematic lines started on time. This idea opens the door to a third recommendation front loaded anesthesia. Slide 23 Slide 24 Front Loaded Anesthesia

46 The current practices and issues involved with front loaded anesthesia include: For small cases, large percentage of patients come to the OR with no anesthetic work done An additional task for the in-room CRNA Delays in the OR suite are more costly Front loaded anesthesia is the practice of doing as much anesthesia work as possible before the patient is brought to the operating suite. That will help to reduce and/or prevent related potential delays in the operating room. The thought behind this recommendation are the delays that are not the every day occurrence, but when they happen, are detrimental to the turnover process and case start times. There can be times when there is difficulty starting even the basic lines, such as IVs. If this delay occurs in the AM admissions area or the holding room it is not directly affecting the turnover time in the operating suite. Slide 25 Front Loaded Anesthesia The second leading anesthesia delay is difficulty starting lines in a patient, according to the historical data from Although the causes for those delays are not within the scope of this project, removing the delays from the operating room (during the turnover process) is within the scope of this project. Slide 26 Front Loaded Anesthesia This recommendation can not be looked at as a cure all, as it does not apply to all cases. Once again the primary benefits from implementation will come from the smaller cases where there seems to be a tendency to have all of the anesthesia work done in the operating room, rather than having a patient be burdened by an IV tree. There are many interdependencies among various perioperative processes and a delay in any one area will cause major delays in the entire turnover. This reason alone should be enough to show the importance of controlling and offloading delays that can not be eliminated. Front loaded anesthesia would limit the effects of problem cases when considering the total turnover time. This will also reduce the workload for the in-room CRNA, the critical resource. This brings us to the final recommendation redefining patient transportation. Slide 27

47 Slide 28 Redefining Patient Transportation Observations have shown that in most occasions, the CRNA is responsible for retrieving the next patient. This is another example of tying up a valuable resource. There were documented instances when the circulator, or sometimes also an aide, were waiting in the room for the CRNA to finish setting up their equipment so that same CRNA could go retrieve the patient from the holding room. From interviewing staff about this situation, it was learned that patient retrieval was not always one of the CRNA s standard job tasks, but instead had become the practice over time. Slide 29 Redefining Patient Transportation This slide shows the utilization of some of the resources during the turnover process. One can conclude that one of the options is, where and when possible, to redistribute workload for more equitable use of the employee resources. The proposed idea is to have the circulating nurse retrieve the patient. Observations have shown that in most cases due to the current process, the circulating nurse has idle time right after opening the supplies. This is also supported by the collected data during year 2000 by a MeritCare study that charted resource usage and times. You can see here in the Gantt chart where in the process redefining patient transportation is important. If the circulating nurse should happen to be truly busy, a member of the holding room staff or the operating room orderly staff will be responsible for bringing the patient to the operating room. The CRNA, the critical resource in the turnover process, should be leaving the room to retrieve the patient only when it is absolutely necessary. Since the tasks performed by the in-room CRNA are quite serial, this will automatically create a delay in the process. Therefore, this option should be evaluated very carefully. Transportation of a patient to the operating rooms from the OR holding room takes, on the average, six minutes for an average shorter case, and can be upwards of 20 minutes if the patient must be retrieved from the AM admissions area. The accumulation of six to twenty minute transports over the course of a day can add up very quickly. Slide 30

48 Redefining Patient Transportation The benefits of redefining patient transportation include: Supports early patient entry Frees up a crucial resource Assists in having the patient in the operating suite as soon they can be accommodated Slide 31 Revisiting the Example Turnover to Show Effects of Recommendations To show you the effects of our four recommendations, let s revisit the example turnover discussed earlier. There were eleven minutes in this turnover where the patient was waiting to enter the operating suite and the operating room was waiting for the patient to begin prep. The patient could have entered the operating suite as soon as the CRNA finished their set up. You can see how early patient entry would have decreased the total turnover time with the support of a local CRNA and redefining of patient transportation. There was also a three minute delay in this case, considering the time that it took the CRNA to place the anesthesia line. While the line was being placed the rest of the personnel were idle. Front Loaded Anesthesia, placing the line prior to entering the operating suite, would have eliminated this delay in the process. These improvements would have brought about a time savings of 14 minutes or about 22% in the overall process. Slide 32 Project Benefits As justification for the project recommendations, there were two main areas that the project team identified as benefits to be gained from implementation of the recommendations. The first benefit is increased surgeon and staff satisfaction. Secondly, by decreasing downtime of the operating room, there is potentially room in the schedule for additional surgical cases and income. When it comes to surgeon satisfaction, the truth is, it is expensive to not have one. Recruitment costs for a new surgeon can cost anywhere from $20,000 for just recruitment costs, to upwards of $85,000 if a sign-on bonus is needed and a recruiter is utilized. These may be one-time costs, but the loss in revenue from being short-staffed a surgeon is even more substantial since one surgeon can provide over $1 million dollars in revenue every year. The costs alone make it important to hold surgeon satisfaction as a high priority, not to mention the non-quantifiable effects losing a good surgeon can have on a practice as far as recognition and recruiting other quality staff.

49 Maintaining surgeon satisfaction is of utmost importance to management of medical facilities. Surgeons are an integral part of the healthcare community and certain considerations should be made to achieve a high satisfaction rate. According to a national survey conducted by the Barnes-Jewish St. Peters Hospital, 74% of surgeons rated the importance of surgical turnover as very important. It was also found by the national survey, that the ideal turnover time for 54% of surgeons surveyed is a minute turnover time. Although that short of a time is rather unrealistic for most cases, it shows how important of a factor short turnover times are for surgeon satisfaction, and the benefits that can be gained from working to reduce turnover times. As a general conclusion, if surgeons are satisfied with the system in which they work, they will be more likely to stay and become an asset to the facility. Slide 33 Project Benefits The implementation costs of the recommendations given are negligible to MeritCare, requiring no additional capital or labor investments. The primary financial benefit would be revenue generated from additional cases. Reducing room turnover rates alone will not guarantee time for additional cases in every room, however, the reduction of accumulating unproductive time throughout the day will provide opportunity for additional cases in the rooms that hold smaller cases and turnover time accounts for a more substantial portion of the daily scheduled time. Here again the focus of the project team has been on the achievable smaller cases. Small cases (laparoscopic gallbladders for example) that are done in the general surgery rooms have healthy per case. These cases have actual procedure times of about 25 minutes, and the entire case can be facilitated in less than an hour. If an average of 15 minutes can be saved between at least four successive cases in one day, it would provide ample room for an additional small case. According to figures given by MeritCare, the amount of profit generated would be upwards of $100,000 per room if only one case a week can be added. The best case scenario of three rooms adding one small surgery five days a week would generate profit of over $1.3 million dollars. According to the Healthcare Financial Management Association (HFMA) and the Health Care Advisory Board, improvements resulting in one additional case per day per operating room suite could translate to four to seven million dollars in annual revenue. Slide 34 Recommendations for Future Projects Based on the research and observations made, the project team recommended a number of projects that have potential to further improve turnover process.

50 The current scheduling process needs to be analyzed and improved. The current scheduling process does not provide for efficient utilization of operation rooms. Improved scheduling procedure should provide for appropriate block time utilization and scheduling proper length per case. Incorporating an integrated IT system would facilitate for simultaneous relay of real time case data to all pertinent locations. The IT system also allows for instantaneous changes that would help in scheduling preoperative patient activities and having the patients prepared and available to go into the operating suite when it becomes available. In addition, the project team recommended to MeritCare that the Operating Room Improvement Team continue their efforts to increase the number of on-time starts for first cases. Slide 35 Slide 36