Always late? Here's how to stop wasting OR time
On-time starts means happier docs, bigger bottom line
Surgeons hate to have their time wasted in the OR. Even though surgeons themselves are often tardy, and therefore responsible for scheduling lags, the Ambulatory Surgery Division of Columbia/HCA in Dallas has focused on timeliness as a way to improve physician satisfaction and overall efficiency.
Operation On Time (OOT) began with an awareness campaign. "OOT" was printed on notepads, pens, buttons, and popcorn tins, and grease boards indicated which cases started late and which were on time, says Alsie Sydness, RN, who heads the project for Columbia/HCA.
Soon, Operation On Time changed focus. Even though a study showed that 52% of cases were late because the doctor was late, Sydness and her colleagues decided to work on the other half of the problem -- the centers. "Maybe they were coming late because we were always late," says Sydness.
So the surgery centers began collecting data. They studied turnaround time from the surgeons' perspective -- from the time surgeons left the OR to the time they returned for the next patient. (The average was 16 minutes.)
They measured "Drop the Knife" time, or the minutes elapsed between the scheduled time and the moment the surgeon begins an incision (another 16 minutes). And since surgeons may perform some prep functions before the incision, centers collected data on "Surgeon's Hands on Patient" time, or the elapsed minutes from the scheduled time to the time the surgeon begins working with the patient (12 minutes). (See sample data collection form, enclosed in this issue.)
Operation On Time studied the differences in between procedures at the corporation's best and worst centers, as identified by the data collection. A list of "best practices" emerged that helped Columbia/HCA centers reduce their "Drop the Knife" time from 20.3 minutes in the first quarter of 1994 to 16.3 minutes by the fourth quarter of 1994. Even the best centers improved from 9.4 minutes to 4.9 minutes.
"The end result really should be happy doctors and growth in your business," says Lindie Slater, RN, administrator of Oklahoma (City) Surgicare and one of the most efficient centers.
Sydness and Slater provided these tips for good on-time performance:
* Make preop calls the day before surgery.
"The patient gets directions to the center, which prevents them from being late," says Slater. "We tell them to get here an hour before, which is usually more than enough time." Slater's center also asks family members to stay at least until the surgery begins. That is particularly important if the patient is a minor, and the physician needs parental approval before making changes in the planned procedure, she says.
* Be sure your scheduler is "in the know."
Some doctors take longer to perform the same procedure, yet the doctor's office may not take that into account when they tell the scheduler how much time the case requires, says Sydness.
"We ask the circulating nurse to inform the scheduler if the doctor routinely takes longer for procedures," she says.
The OR supervisor also alerts the scheduler about expected case times, she says. At Oklahoma Surgicare, times are marked on the scheduling preference cards for each surgeon and are kept in the business office.
* Keep preference cards up to date.
Nurses correct the preference cards if the surgeon changes something in his case, Slater says.
"Keeping the preference card up-to-date and accurately pulling what is on the preference card not only makes the case more efficient, but the physician perceives confidence in the OR staff," she says.
Ask for preference cards
When a new surgeon is scheduled to begin, Oklahoma Surgicare obtains preference cards from another facility. If that facility won't share the information, the center asks the doctor's office to obtain the card.
"You're ready for him before he even gets here," Slater says. "Then you verify with the physician, 'Is this correct, and is it current?'"
* Make sure equipment is available and working.
Schedulers should be informed by staff about equipment availability, and they should check preference cards to note what equipment will be needed, says Sydness. One staff nurse should be assigned the duty of verifying that the equipment is in working order, she says. The equipment also should be moved into the OR the night before it is needed in the first case, she says. At Oklahoma Surgicare, OR techs, circulators, anesthesiologists, and the nurse manager, as well as the scheduler, check for scheduling conflicts. Cases are placed on the grease board a week in advance so any staff member perusing the board can detect problems.
* Use an in-house anesthesiologist or at least one familiar with your on-time goals.
Waiting for an anesthesiologist who is taking a coffee break can bog your schedule. Oklahoma Surgicare has an in-house anesthesiologist who goes directly to the preop area to talk to the next patient after he finishes a case, says Slater.
"He understands the importance of what we're doing," she says. "He's conscientious about how he can affect Operation On Time."
* Schedule extra time for chronically late surgeons.
Slater doesn't try to reform the surgeons who don't show up on time, but sometimes subtle pressure works.
"For some, just explaining that we're actually studying [on-time results] and giving them the results of how often we're on-time is an incentive for them," Slater says. "When they realize we are on time 95% of the time, then they know if they're here, we'll start."
* Create turnaround packets to assist with room cleanup.
During the day, when staff members have a few extra minutes, they bundle the sheets and garbage bags necessary for room turnaround, Sydness says. The bundles and cleaning supplies are placed outside the room to save time when the case is complete.
* Periodically measure your on-time performance.
During the study period, a grease board sits in the hallway at Oklahoma Surgicare with a notation of cases that started on time and the running total. The Operation On Time monitoring form is attached to each patient chart, and nurses mark the times, such as the time patient entered preop or the OR. Columbia/HCA is constantly analyzing data as a way to improve performance, says Sydness.
"We need to know how we're doing before we can determine whether we need to make improvements," she says. "The first thing we need to do is measure." *
* For more information on Operation On Time, contact: Lindie Slater, Administrator, Oklahoma Surgicare, 13313 N. Meridian, Suite B, Oklahoma City, OK 73120. Telephone: (405) 755-6240.
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