OR Manager Vol. 25 No.

3 March 2009

Process improvement

Set the clock for OR on-time starts

chieving on-time starts can be elusive for OR leaders, including those at Memorial University Medical Center (MUMC) in Savannah, Georgia. Faced with a dismal 27% on-time starts for the first cases of the day in their 21-room OR, the leaders applied Six Sigma principles to the process. The result? A jump in on-time starts to 83%. Heres how they did it.

The Six Sigma process consists of these steps: define, measure, analyze, improve, and control. It takes the right team to work with this process. At MUMC, Kelli Porzio, RN, Six Sigma Black Belt, process excellence consultant; and then-perioperative clinical practice manager Cindy Beauvais, RN, BSN, CPAN, CAPA, facilitated the core project team for on-time starts. Core team members included managers of the OR, postanesthesia care unit (PACU), day surgery, surgical scheduling, and presurgical testing; chief anesthetist; perioperative data analyst; and staff members from OR, PACU, and day surgery. An ad hoc team, which provided additional support and consultation, included the physician chair of the OR committee (the major governing body of the OR), chief medical officer, department of anesthesia chair, and surgeon representative. The project team set a goal to increase on-time starts from 27% to 80% by December 31, 2007. After a business analysis of the current situation, which showed significant loss of revenue from late starts ($1.7 million in 2006), the team was ready to measure and analyze data. We created high-level process maps that looked at our processes from beginning to end, says Porzio. The maps define suppliers, input, process, output, and criteria for quality. Its like a big puzzle; you have to know everyone whos involved and what they do, says Porzio. The maps helped the team determine the boundaries of the project and identify their customerssurgeons, anesthesiologists, patients, families, staff, and ancillary departments. We then went to those customers to determine what is critical to quality for them, says Porzio. Answers varied. For the OR staff, a correctly scheduled case with no equipment conflicts and an OR that was set up correctly by the night staff were critical. For physicians, it was that patients were ready to go to the OR, and for anesthesia providers it was that diagnostic test results were available.

Choose the right team

Measure twice to verify

Analyze root causes

The team then analyzed data from the NaviCare dashboard system from HillRom to determine causes of delays but realized the method was potentially flawed. Were all the reasons for delay captured? Was there bias in entering the data; for example, surgeons changing the reason for delays to shift blame to the OR? To answer these and other questions, the team collected manual feedback for 2 weeks and compared it with the automated data. They found additional reasons for delay, including staff arriving late to work, ORs set up incorrectly by the night shift, and

OR Manager Vol. 25 No. 3 March 2009

equipment conflicts that werent discovered until the morning of surgery. Next, the team identified potential root causes and created a fishbone diagram to identify the most critical causes. Based on their analysis, Beauvais, now clinical manager of the endoscopic procedure center, says the committee determined the OR needed a clear definition of surgery start time, clarification of roles, more accountability, implementation of specific processes, and ongoing oversight to ensure adherence to the processes. Porzio emphasizes the need to take time for measurement and analysis. Dont be quick to jump to improvement, she says. You must examine your processes and root causes carefully. Improvements included a staff reward system, a service level agreement that defined responsibilities and set up accountability, and changes in communication processes. It can be a slow and arduous process, says Debbie Hattrich, RN, director of perioperative services, of achieving on-time starts. I wore a lot of flak jackets. To take it to the next level, the hospital invested in a rewards system. The operations coordinator takes the schedule and goes room to room to determine who started on time. The ones who do get a gold star on the door, and everyone in the room gets a ticket, says Beauvais. Each ticket is worth $2 and can be used to purchase uniforms or make purchases in the gift shop or can be saved to earn a day off (10 tickets equal 1 hour of time off). If the doctor is late, no one in the room gets a ticket. Its an all-or-none principle, says Beauvais. Hattrich says the surgical technologists (STs) were key. Reward and recognize your techsthey pushed us over the top for on-time starts, she says. STs pressured the surgeons, who recognized they were in for a long day in the OR if their team wasnt happy because he or she was late, which meant no coupons. I had surgeons begging me to give their teams coupons, says Hattrich. Hattrich estimates she spends about $1,000 each month for gifts, averaging about $400 per year per employee. Interestingly, no staff members have used the time-off option. Of course, achieving on-time starts is a team effort. It starts with cases being posted correctly, and the charts being complete and ready for the day of surgery, says Beauvais. Day surgery and holding area staff play just as important a role as the OR staff. For some departments, alternative rewards had to be found. For example, the manager of day surgery gives each staff member working that day a ticket if the overall average for on-time starts for first cases is 80% or better. The OR scheduling manager rewards schedulers with tickets if the overall on-time starts are 80% or greater. The money for rewards is now included in departmental budgets. A potential downside is concern that the staff reward program has become an entitlement. The project team discussed changing the program to a lottery, where tickets would go into a box and names would be drawn monthly for prizes, but the current program was deemed too valuable as a morale booster to change. The project team developed a service level agreement (SLA) for staff, surgeons, allied health providers, and anesthesia providers. The agreement includes the ontime start definitions, duties and responsibilities for each role, and consequences for not adhering to the agreement. The COO and the chief medical officer approved the SLA. The chief medical officer and Hattrich explained the agreement at each surgical specialty meeting. Members of the project team attended as availability permitted. The medical staff

Invest in rewards

Service level agreement

OR Manager Vol. 25 No. 3 March 2009

office mailed the agreement and collected the signed ones. Although surgeons were not required to sign the SLA, most did, says Beauvais. The team learned a valuable lesson when they first launched the SLA. Surgeons were furious about the service level agreement, saying, Youre going to use it against me for credentialing, says Hattrich. In retrospect, the team realized the cover letter was too stern and modified it. As the team worked together more and on-time starts improved, surgeons were more willing to sign. New physicians are now asked to sign when they start at the hospital. The SLA has teeth. If surgeons have more than 20% late starts, they receive first a verbal warning, then a written one. Surgeons who continue to be late for an entire quarter after notification lose the ability to schedule first cases of the day for the following quarter. The OR committee makes that decision. You have to take a peer-topeer approach, says Beauvais. Staff who dont fulfill the SLA face disciplinary action.

Peer pressure

Daily and weekly first-case starts were posted for the OR staff. Physicians were also kept in the loop. We posted results every month, first by physician numbers, says Beauvais. After 3 months, surgeon names were used. Peer pressure took over, with surgeons vying to be at the top of the list. When the OR met its goal of on-time starts, staff held a physician appreciation day. Beauvais and Porzio cite the success story of how a surgeon who was always at the bottom for on-time starts became the best. Staff rewarded him with a cake. Its important not to underestimate the need for physician rewards, too, says Porzio.

The project team implemented an automated staff assignment phone line to facilitate flexing of staff. Staff call in the day before to see what time they need to arrive for the first case. Another initiative was a daily interdisciplinary meeting to review the schedule for the next day, which helps prevent instrument and equipment conflicts. The surgery scheduling manager, OR manager, OR coordinators, and day surgery senior staff nurse comprise the team. The meeting takes place at 1:30 pm so the day surgery staff can start calling patients to notify them of their arrival times for surgery. After 5 pm, only urgent cases can be scheduled. It took a bit longer than expected, but in February 2008, on-time starts reached 83% and are hovering around 80%. Although the hospital didnt have a way to specifically measure the results in financial terms, the team saw a decrease in overtime and a more efficient schedule, which likely resulted in more cases and more revenue. In addition, physician, staff, and patient satisfaction are all up. Porzio emphasizes the need for a feedback loop that includes ongoing monitoring. We have a thermometer where we mark on-time starts every day. The perioperative director and the chair of the OR committee continue to monitor SLAs and take action as needed. The project team still has quarterly meetings to keep addressing problems. This project will never end, says Beauvais. It must always be a priority. O Cynthia Saver, RN, MS Cynthia Saver is a freelance writer in Columbia, Maryland.

New communication initiatives

Goal met!

OR Manager Vol. 25 No. 3 March 2009

Six Sigma process

Define
Develop project charter. Map high-level processes. Determine customers and what is critical to quality.

Measure

Establish baseline measurement. Plan for data collection. Validate measurement system. Identify possible root causes.

Analyze

Identify critical root causes.

Improve

Develop solution alternatives. Implement solutions. Assess effectiveness.

Control

Develop feedback loops. Develop process control plan to hold the gains.

Surgical time definitions

Start time

Here are definitions the MUMC project team developed.

The time the case is posted on the surgery schedule. This time is considered the patient induction time.

Induction time

The beginning of IV sedation for patients receiving general anesthesia, monitored anesthesia care, or moderate sedation, or the time of local anesthetic injection for local patients.

Surgery late time

Surgery is considered late if induction time is more than 5 minutes after the scheduled start time.

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