Surgical Delays Before and After Perioperative Initiative
1996 1997 Percent change
Total cases 705 459 35%
Total hours 363 204 44%
Revenues involved $21,780 $12,240 43%
Number of surgeons 24 20 16%
performing 50% of volume
Source: Palmetto Baptist Medical Center, Columbia, SC.
The improvement initiative began with a formal satisfaction assessment among the surgeons and proceeded to effect changes throughout the surgical service from pre-admission to discharge.
Within one year, surgical volume increased 4%; patient complaints plummeted to near zero; operating room utilization increased from 54% to 72%. (To learn more about practice improvements resulting from the effort, see table, above.)
Another hallmark of the 1996 initiative was the disappearance of the word change from the organization’s QI vocabulary. "People resist the heck out of it when you use the word change," Wythe notes. The operative word now is pilot. It raises less resistance, she reports."We made suggestions like let’s try this for two weeks, and we’re not stuck with it. We can go back or try something different if it doesn’t work.’"
If a pre-op process change did not work well, the team defined it as a success for its educational value, so failure lost its sting. "This approach lit the fire for excitement and openness about trying new things," she observes.
Each step of the perioperative process was mapped and questioned. Positive results emerged almost overnight and resistance gave way to excitement. "After the first two weeks," she recalls, "we had no major obstacles." A project steering committee included representatives from top administration and chiefs of the medical staff. VHA consultants supported each aspect of the change. Four staff-level teams, working simultaneously in rapid-cycle fashion, took one process apiece:
1. Preoperative;
2. Intraoperative (operating room);
3. Postoperative (recovery room);
4. Scheduling, where the admitting department interfaced with physicians’ office staffs.
Team membership included:
• a surgeon;
• an anesthesiologist;
• PBMC clinical and administrative staff;
• representatives from admitting and physicians’ offices, as needed.
VHA consultants recorded and distributed minutes, provided literature and data backup for completing individual assignments and handled communications among project teams. "When you have physicians coming in for 6:00 a.m. meetings, you obviously want to be respectful of their time," Wythe says.
Commitment from the medical staff ran high, buoyed by the precision with which the consultants orchestrated the project. One anesthesiologist came in at 5:00 a.m. for nearly a month to help improve patient flow from the pre-op area into the operating room.
In hindsight, Wythe notes that inter-team and intra-team communication was superb. "But if I were to take on something of this magnitude again. "I would do a better job of communicating with our 200-plus nurses and support staff in the perioperative area who would be affected by the changes." Besides the white boards and memos employed in this initiative, Wythe says she might issue a weekly or biweekly newsletter to chronicle progress in each of the perioperative services.
Award feeds the excitement
The perioperative improvement initiative won a VHA Leadership Award for improving organizational management. Wythe deems it "a wonderful thing in many ways." It acknowledged the dedication of the improvement teams. The publicity enhanced PBMC’s prestige among the medical staff. Other departments caught the spirit and have applied techniques tested in the perioperative effort.
Most notably, though, the initiative and subsequent award stripped away the dread of change that pervaded the perioperative unit — as it does most other systems nationwide. "The old way was to study something completely before making a change. The enthusiasm is gone before the actual change goes live," Wythe observes. "Since this project, we take little bites; pilot change has become a permanent strategy."
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