Continuous quality improvement analysis of operating room turnover time

Continuous quality improvement analysis of operating room turnover time

Continuous of operating quality room improvement turnover time analysis Cheryl Kurtz, RN Carol Cove& RN, MS The continuous quality improvement pro...

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Continuous of operating

quality room

improvement turnover time

analysis Cheryl Kurtz, RN Carol Cove& RN, MS

The continuous quality improvement process reminds us how recognizing opportunity for growth enhances the provision of quality patient care. (Insight 1999;24:40-4)

Editor’s note: This manuscript is based on a scientific free paper delivered at the 7 998 ASORN Annual Meeting in New Orleans, la. Cheryl Kurtz, RN, SSN, is staff nurse, operating room, Massachusetts Eye and Ear Infirmary, Boston. She joined ASORN in 7 998. Carol Cove/l, RN, MS, is senior vice president for patient services, Massachusetts Eye and Ear Infirmary, Boston. She joined ASORN in 7 986. Reprint requests: Cheryl Kurtz, RN, 47 Arborwood Dr, Burlington, MA 08703. Copyright 0 7 999 by the American Society of Ophthalmic Registered Nurses. 7 060- 7 35X/99 72/l/96690 40

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t our facility, a multidisciplinary team of 12 employees, all trained in continuous quality improve_*merit (CQI) principles, was organized to analyze and improve operating room (OR) turnover time. As indicated in an article by Robinson,’ “Many health care practitioners today are striving to enact continuous quality improvement (CQI) as a sound and effective processfor solving time-management problems.” According to Morton,2 CQI “identifies the response mechanism initiated to correct problems or take advantage of opportunities as the actual improvement process.” Members of the CQI or Turnover Time Team included the following: Vice president of patient services (Team facilitator) Anesthesiologist Ophthalmologist Otolaryngologist Certified registerednurse anesthetist OR nurse manager Surgicenter clinical leader OR hall coordinator OR staff nurse OR holding areanurse Instrument room technician Orderly A marked perceptual difference of start times and turnover times generally exists among anesthesiologists,OR nurses, and surgeonsbecauseof a lack of a standardl

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ized definition of these times.3 The Association of Operating Room Nursesis not aware of any standard or averageOR turnover time. In fact, a standard or averageturnover time would be meaningless becauseof the impossibility of comparing facilities with different physical constraints, staffing complements, patient populations, and so forth.4 Robinson1 defines turnover time as the period between one patient’s departure from the OR suite and the next patient’s arrival. According to Mazzei,3room turnover time is the time from patient in to patient out, and patient turnover time is the time from the end of surgeryfor one patient to the end of induction of the next patient. At the initial meeting, our CQI Team defined turnover time as the downtime between patients, or from the time one patient leavesthe OR to the time another patient enters the OR. A brainstorming session was conducted to identify the factors affecting turnover time that would be most beneficial and appropriate to analyze, and subsequent meetings focused on analyzing these factors. According to Morton,2 effective problem solving and decision making require both criticism and new ideas; separation of the idea-generation process from the critique processenhances creativity and participation. To enhance our understanding of factors affecting turnover time, a cause-and-effect

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Kurtz and Cove11 diagram developedby a previous CQI OR team was distributed to members of the current team. The diagram describedinefficiencies identified in processingpatients asthey were transferredfrom the ambulatory unit to the OR. Delay log statisticspreparedby the nurse manager of the ambulatory unit showed that the number 1 delay on the ambulatory unit was medically compromised patients who required further clearance.The current team found this work very beneficial in helping them identify factors that affect turnover time in our facility. The group summarized an analysis of delay factors and then categorizedthem into 4 groups of factors: patient, people, process,and instrument/equipment. The CQI Team decided to continue to review issuesand prioritize them further. The following factors were identified: Factorsrelated to patients: Arrival time at the hospital Complexity of cases Tardinessto the OR’sschedule becauseof a previouscaserunning late or a patient late in arriving at the OR Anesthesiaconsults for pediatric and adult patients Factorsrelated to people: Number or availability of orderlies in ambulatory area Number of anesthesiologistsavailable Availability of appropriate preoperative consultation area Coffee breaks for staff Surgeonsleaving the floor between cases Availability of cross-trainedpersonnel Preoperativeassessmentdone by certified registerednurse anesthetists instead of anesthesiologists Factors related to process: Compliance with the 48-hour rule Pre-admission testing Transport of patients to and from the OR Stretcherbed/crib availability Major casepreparation/major IV lines (eg,A line) Timeliness of starting intravenous lines Laboratory test results Transportation of patient from holding area to OR l l l

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INSIGHT

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Communication Review of chart Duplication of effort Cost-accounting system Factorsrelated to instruments/equipment: Delays in the OR resulting from broken or lost instruments and equipment Redesignof instrument room required for better efficiency Availability of nitrous tanks Availability of instrument technician Appropriate instrument inventory The Team invited experts to attend CQI sessionsas gueststo provide explanation about particular topics and to foster discussion. The first invited guestwas the clinical leader from the ambulatory unit, who discussedthe procedureinvolved in processing patients for the OR. The nurse reviewer, who reviews all patient charts before surgery,was also invited to a meeting to discussthe 48-hour rule. This rule stipulates that a history and physical examination, an ECG for patients older than 50 years,and any laboratory test orderedby the primary care physician or surgeonmust be completed 48 hours before surgery.A completed chart is to be ready 48 to 72 hours preoperatively for patients who are to undergo surgery. Forms providing informed surgical consent and anesthesiaconsent are the only exceptions to this rule. Robinson’ has suggested that changesin patient processing,such as preadmission testing, may reduce the causesof delays. Our institution showed 19% noncompliance with the 48-hour rule 48 hours before surgery, 9% noncompliance 24 hours before surgery, and 2.5% noncompliance on the morning of surgery. The CQI Team recommended that someone speak individually to specific physicians who are noncompliant with the informed consent requirement at the time of surgery. Incomplete patient charts and lack of medical clearance accounted for a number of cancellations that could have been avoided and increased turnover time. The clinical leader of the OR, who formerly had been the clinical leader of the Surgicenter,was invited to a Team meeting l l l l

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and CoveZZ becausethe Surgicenterwas identified as being very efficient with short turnover times. The OR clinical leader explained to the CQI Team the differences between the Surgicenter and the major OR. As someone who had experienced the faster turnover times of the Surgicenter, she gave input on realistic turnover time. The group considered the possibility of attempting to adjust the mindset of the staff toward the practices of an ambulatory setting rather than a major OR. The next guest was the vice president of finance, whose focus was to increasethe Team’s awarenessof cost accounting in our institution. He discussedthe cost of a procedure, illustrated how the overhead is allocated, and provided the CQI Team a clearer picture of how the cost-accounting system works in the hospital. An areaof concern causing delays within the OR itself was instrumentation. The shortage of instruments in the instrument room and the staff’s retention of supplies for their casespresented other problems that causeddelays. Instrument loss and breakagewas also an areaof concern. A new sterilizer was purchased to facilitate instrument availability, and a new instrument repair company was sought to implement faster turnaround time for repairs. The OR/central supply room equipment and instrument room manager was invited to a meeting to discusshis new role as manager of the OR equipment, instruments, and central supply. He reviewed the following changesthat had already been implemented, along with recommended changesfor the future: 1. An instrument technician had been scheduledto work at an earlier time; as a result, instruments in the sterilizers can be processedand made available for staff, who need to procure them for casesin the morning. Staff can procure instruments after ~:~OAM. 2. An instrumenttagsystemwasimplementedfor bettertrackingof broken instruments,more timely repairof instruments,and more accountabilityby instrument techniciansand nursingstaff. 3. Improvement of morale in the instrument room through better management techniques.

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4. Reorganization of the instrument room to provide more spaceand better efficiency. 5. A new software program for instrument tracking. 6. A revised procedure for decontamination of surgical instruments in the instrument room rather than in the OR itself. All instruments will be handled by a certified instrument-room technician. 7. Actual structural changesbetween the central supply room and the instrument room to facilitate better and more expedient handling of instruments. On the basis of an analysis of all of the factors presentedand the Team’s research, a realistic and acceptabletime of 20 minutes between caseswas reconfirmed. It was affirmed that the estimated time needed for room clean-up should be included in the total estimated time for each procedure. Becausethe estimated duration of procedures,including estimated clean-up and set-up times, are used to calculate the start time of the next procedure, this information provides better estimates of case start times.5 Another concern was the delay caused by interviews of pediatric patients by the anesthesia department. Currently these interviews are being held on a floor other than the admitting pediatric unit, which inconveniences the patients and parents and causesadditional delay for the OR. A pilot study of inefficiencies in this process was conducted. The pilot study involved having patients go directly to the OR for assessmentby the anesthesia department rather than requiring the extra step of going first to the ambulatory unit. Major concerns were the lack of privacy and confidentiality during the interview, the need for both parents to be present during the interview, which causesmore congestion in the OR, and the need to administer preoperative medications immediately before surgery.The feasibility of having members of the anesthesia department interview pediatric patients on the 10th floor, where they are admitted, was discussed. The pilot study showed that pediatric

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Kurtz nursesbelieved it was more efficacious to have patients be interviewed by the anesthesia department in the OR on the morning of surgery.With this scenario pediatric patients would not be required to go to the ambulatory unit to be interviewed by the anesthesiadepartment and then return to the 10th floor to wait to be transported to the OR. In the OR, this suggestedchange elicited concerns about congestion, lack of privacy for the patients awaiting assessment, patients who were not premedicated, and noisy and crying children. After much discussion, the Team came to believe that all patients, both adults and pediatric, should be interviewed by the anesthesiadepartment beforethe morning of surgery. If possible, the nursing assessment also would be done at this time. Medical consultations should be done by our medical internist, instead of an outside internist, before the day of surgery. On the basis of an analysis of all gathered data, the team categorizedthe factors that they believed affected the processof turnover times. The following subgroups were identified: 1. Patient preparation a. Possibly schedule the preoperative workup through preoperative testing for 1 week before the OR date. b. Have the anesthesiadepartment assesspediatric patients on the day the child is taken on a tour of the hospital by a child life specialist. 2. Actual turnover time a. Availability of orderlies b. Delays in surgery causedby staff coffee breaks c. Cross-train personnel d. Availability of stretcher beds 3. Equipment/instruments: Initiate accountability for instrument setup 4. Transportation: Have a volunteer operate the elevator at critical times Once presentedwith the factors involved in turnover time, the Team used a multivoting method to break down the more significant factors and make further recommendations. The vote ranked the factors Team members believed were the most important in influencing turnover time. Discussion of the survey identified leading factors for delay between cases. INSIGHT

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and CoveZZ

The factors were then combined, regrouped, and narrowed to the following 4 factors: 1. Anesthesia related Interviewing and testing both adults and pediatric patients on the day of surgery Late arrival of anesthesiologist on the 9th floor Improper sequencing of patients for interviewing on the 9th floor 2. Patient related Late arrival at hospital for a scheduled case Patient medical issuesor problems Lack of designatedauthorized person to decide on arrival time, that is, surgeonor preoperative nurse 3. Instrumentation Unavailability or poor condition of instruments and equipment 4. Cost accounting Need to know both the fixed and variable costs to determine the actual cost of delays, as well as inconvenience of wasted time l

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Recommendations

The CQI Team submitted the following recommendations to improve the quality and accuracyof turnover time: 1. Pediatric patients going to the main OR will report to the ambulatory unit on the 9th floor for their anesthesia interview beforegoing to the 10th floor for nursing assessmentand preparation for the OR. 2. Adult patients who qualify for anesthesia consultations will be seenin afternoon appointments before the day of surgerywhenever possible.The anesthesiadepartment will have an anesthesiologist available daily for consultations and assessments. 3. Healthy, classASA I and II patients having monitored anesthesiacare need not be seenby the anesthesiologist on the 9th floor on the day of surgery.To qualify for this decision,

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and CoveZZ the ECG must have been read, the history and physical completed, and the laboratory work completed, with no problems identified. 4. Nursesmaking preoperative phone calls to patients will inform them of the time they should arrive at the hospital. This would apply to both adult and pediatric patients having surgery in the main OR or Surgicenter. 5. All hospital-based physicians will have their patients assessedby an anesthesiologist as part of the preoperative work-up and evaluation. Nonhospital basedphysicians are encouragedto utilize this service. 6. The 48-hour rule will be strictly enforced. Noncompliance will result in cancellation of the surgical procedure by the anesthesiadepartment. 7. The surgeonwill arrive at the OR room 5 minutes before the scheduled start time to promote an efficient transfer of the patient into the OR. The anesthesiaand nursing staff will move the patient into the OR 5 minutes before the scheduled time. 8. Patients undergoing major head and neck surgery should be in the postanesthetic care unit no later than 6:45 AM to enable the anesthesiastaff to establish the IV lines and hemodynamic monitoring. The CQI Team collaborated further to identify factors regarding turnover time for the recommendations that would be submitted to the Professional Services

1Deadlines

Review Committee (our Quality Council). The team facilitator and the anesthesiologist on the team involved the chief of anesthesiain any recommendations that would affect his department. In addition, the nurse manager of the postanesthetic care unit/Surgicenter was briefed about the potential recommendations for processingpediatric patients. The preoperative evaluation of adults in advance of the day of surgery was discussedfrom many different perspectives.The CQI Team will meet in 6 months to re-evaluaterecommendations and procedures that have been implemented. Overall, this experience demonstrated the strengths and synergy that persons with diversified experience and expertise offer to the process. The CQI process reminds us that continuous improvement offers not only opportunity for growth to all participants but also enhancement of the provision of quality patient care.2 References 1. Robinson J. OR time delays: a time management plan that works. AORN J 1993;58:329-35. 2. Morton P. Synergy at work: using quality improvement to reduce OR delay starts. Today’s OR Nurse 1995;17:5-8. 3. Mazzei WJ. Operating room start times and turnover times in a university hospital. J Clin Anesth 1994;6:405-8. 4. Fogg D. Clinical issues quarantining implants, multipack sutures, glutaraldehyde sterilization, surgical zippers, OR turnover time. AORN J, 1998;67:870, 872-4. 5. Hamilton DM, Breslawski D. Operating room scheduling. AORN J 1994;59:665-80.

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July-SeptemberJournal June 4,1VVV October-DecemberJournal September 3, 1999 Please submit all items to Sarah Smith, RN, MA, CRNO, Editor, Department of Ophthalmology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242-1091.

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Registered Nurses, Inc.