Old habits crumble under gentle pressure
Cherished customs went by the wayside as people questioned the value of existing perioperative practices at the Palmetto Baptist Medical Center in Columbia, SC. Four QI teams met bi-weekly starting in late 1996. The degree of success on individual process changes correlated directly with how well the team members communicated with peers who were affected by the proposed changes.
Within months, the teams made dramatic gains in their aim to meet and exceed patient and physician expectations for value in quality and cost of the perioperative services.
Key practice changes resulting from the project include:
1. Existing practice. A nurse left the operating room to read the chart and greet and roll in the next patient. "This could mean a 10-minute absence from the back where the nurse could assist with room preparations," explains Lynn Wythe, RN, MSN, nursing director of Perioperative Services. But, she adds, the nurses enjoyed the patient contact.
• New practice. The anesthesiologist reads the chart and greets and rolls in next patient. The nurse assists with room change. On the way through the door, the anesthesiologist briefs the nurse.
• Results. Average room turnover time has decreased 11% (18 minutes to 16 minutes). Staffed utilization of operating room has increased 36%.
2. Existing practice. Fewer than 5% of presurgical nurse-patient interviews were conducted by phone. Fewer than 50% of patients were preregistered prior to day of surgery.
• New practice. Twenty-eight percent of nurse-patient interviews and 98% of preregistrations are conducted by phone prior to the day of surgery.
• Results. Savings represent a half day of personal or corporate time. "I haven’t heard any complaints about long waits," Wythe notes. For in-person interviews of patients with cardiac conditions or co-morbidities, the target wait is 15 minutes, actual average, 32. In a way, explains Wythe, the target is based on the Golden Rule: "[Staff] looked at our personal experience on doctor’s appointments. After 15 minutes in the waiting room, we start looking at our watches."
3. Existing practice. On the day of surgery, patients routinely arrived at 6:30 a.m. hoping to beat the admitting department rush.
• New practice. Patients go directly to pre-op and complete everything there.
• Results. Pre-op unit hired and cross-trained extra nurse technicians to do EKGs in perioperative area instead of sending patients to another floor. Patients love the convenience and time savings.
4. Existing practice. The rate of on-time surgery starts (making the incision) was described as abysmal by Wythe, most often due to late arrival by surgeons. "Instead of beating people up, which doesn’t work with doctors anyway, we asked them if they value making the first incision at 7:30 a.m."
• New practice. Ten doctors agreed to arrive at 7:10 a.m. to achieve "early starts." In separate initiative on intra-operative processes, several high-performance operating room teams paired with high-volume surgeons who operate on cases back to back or handle several consecutively.
• Results. For the past six months, 29 surgeons have sustained an 80% to 85% early-start rate. Room turnover for high-performance groups, 14 minutes, 22% above pre-initiative rates. Some high-performance groups have built volume to an extra case per day.
One surgeon quipped that he has to fight the 5:00 p.m. rush hour for the first time in years. He used to miss it because he didn’t leave the operating room until 6:00 p.m.
Need More Information?
For more on rapid-cycle change within perioperative services, contact:
- Lynn Wythe, Nursing Director of Perioperative Services, Palmetto Baptist Medical Center, Taylor at Marion Street, Columbia, SC 29220. Telephone: (803) 296-5309. E-mail: LBWythe @bhsc.hbocvan.com
On process improvements within not-for-profit health care organizations, contact:
- VHA Inc., 220 E. Las Colinas Blvd., Irving, TX 75039-5500. Telephone: (972) 830-0000. Web site: www.vha.com.
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