U.S. hospitals began 2023 with tremendous financial losses and are at the same time struggling with increased expenses, labor shortages and supply disruptions. The operating room (OR) is a main driver of reimbursement/revenue so there is tremendous pressure on perioperative teams to turn over ORs faster to facilitate more cases in a safe and effective manner.
Insights on surgical suite challenges and opportunities for more efficient turnovers from Mandava and others are presented alongside recent peer-reviewed research on proven approaches to improving OR turnover time (TOT).
Set the standard
“Hospitals continue to face compounding obstacles of increased labor costs and staff shortages – factors that can increase the burdens on OR leaders and cause delays in the amount of time it takes to turn over an OR between patients,” said Voss. “This makes it critical for ORs to create efficiencies in terms of both time and resources, regardless of case complexity.”
“Defining the standard turnover time and gaining surgeon buy-in to pinpoint specific areas for improvement is one way OR leaders can identify barriers to OR efficiency,” Voss continued. “With barriers identified, OR leaders can address surgical turnover delays through streamlined supply chain processes, services and technology, creating a more efficient environment for high-quality, cost-effective procedures.”
The impact of effective communication on OR TOTs was demonstrated in a study published in the July 2022 edition of BMJ Open Quality. The researchers stated:
“Operating room (OR) management plays a pivotal role in the healthcare system due to the high cash flow it yields. Enhancing communication in the OR, which is the common root problem for delays, might improve OR efficiency and revenues for healthcare.”
They studied the impact of a “OR relay strategy” on TOT, where a certified registered nurse anesthetist (CRNA) was stationed outside of the OR, coordinating the steps to get the next patient ready. This CRNA communicated with the anesthesia providers within the OR via a Microsoft Team chat. The researchers used the electronic anesthesia record system to record the TOT for the control group.
They found the relay strategy decreased TOT for most ORs, with statistically significant results for three of the ORs and the overall ORs system. They also saw decreased variability between TOTs for the overall OR and the majority of the ORs evaluated individually.
“In talking with hospital executives around the country, the number one challenge for surgical suite turnover continues to be finding and training staff members,” said Mandava. “Hospitals have dealt with the issue of burnout and turnover by continually finding and hiring new people and utilizing traveling clinicians.”
“This means that every step along the way will be slower – how rooms are cleaned and setup, where things are or where to put them away, who should be in the room, etc.,” he added. “On top of this, volumes have returned to, and are often exceeding, their pre-pandemic levels. In every meeting and survey we do with hospital executives, staffing is still the number one issue.”
“Today’s periop leaders have rightly recognized the best way to overcome turnover challenges is to build a process to increase agility,” said Rechin. “One example may be as simple as a process where any staff member who isn’t actively engaged with a patient helps to alleviate suite turnover challenges. On busy days, it helps to have dedicated teams to help increase turnover efficiencies…from housekeeping to room prep. Unfortunately, not every hospital or ambulatory surgical center (ASC) has the luxury of a dedicated team and needs to adopt an “all-hands-on-deck” approach.”
Researchers from Georgetown University School of Medicine and MedStar Georgetown University Hospital in Washington, DC, studied the impact of surgical team consistency on OR TOT, where OR cases were scheduled with the same team and surgeon. They published their findings in the January 2022 issue of the Journal of Medical Systems.
The Georgetown researchers conducted a retrospective analysis of 2,714 cases completed on weekdays between 6:00 a.m. and 11:59 p.m. from July 2017 through March 2018. They found OR cases with the same surgeon and anesthesia team had a significant lower TOT (p < 0.0001). They also discovered OR cases in rooms with the same specialty had significantly less mean TOT compared to rooms switching between different subspecialties.
“Most high performing OR teams have embraced lean principles to help improve OR Suite turnover,” said Rechin. “Consider establishing a project team to evaluate current processes, step-by-step. Measure improvements as well as team member engagement. Strive to develop seamless communication responsibilities. Make sure the SPD is involved in all process decisions to ensure it creates synergies through reprocessing.”
Researchers from Switzerland applied Lean methodology, including Gemba walks, Process Mapping, Root-Cause-Analysis, and the Single Minute Exchange of Dies (SMED) system, to processes in the OR suite and those before and after the patient is in the OR. Their aim was to understand the causes of variability and waste in TOT for gynecological and general surgery cases.
“Lean thinking allowed the team to re-evaluate how the whole operating suite performs as a system, by starting from a sub-process as changeover,” the researchers stated in their findings published in the April 2022 edition of Frontiers in Medicine.
They found “standardized and safer work enabled effective parallel processing” improved patient flow and inter-professional collaboration, enabling the hospital to reduce TOT between operations by 25% on average, without no changes in infrastructure, technology or resources.
One solution for measuring progress toward improved TOT is Stryker’s Dash iQ Surgical Dashboard, noted Tommy Van Galder, Vice President and General Manager of Stryker’s Communications Business Unit. He said OR teams can use the solution to monitor live OR performance and turnover to identify opportunities for improvement through a series of reporting and benchmarking tools.
OR set up and supply management
Supply management in the perioperative space is notoriously complex and challenging because many items fall outside of the hospital’s enterprise resource planning (ERP) system, and therefore beyond the eyes of the supply chain team.
As a result, clinicians often assume the burden of inventory management and tracking. When they are challenged with finding the items they need for a case, it can prolong OR set up time. And when a surgeon finds an item is missing during a procedure, a team member may have to leave the OR and look for that item, causing further delays.
Voss comments on the impact of supply chain challenges on OR efficiency, stating:
“Turning over an OR is a choregraphed affair where every minute matters, but it is just one aspect of improving OR efficiency. Streamlining supply chain activities in the new year can go a long way toward building a smooth transition from one case to another and minimizing the time that clinical staff spend searching for supplies. A strong relationship between perioperative and supply chain teams is crucial to building trust, improving communication, and ultimately optimizing clinical staff’s involvement in supply chain activities.”
According to Van Galder, it is not only supply tracking but also OR set up, including where supplies are stored and how easy it is to clean the room, that impact perioperative workflow efficiency. He stated:
“Customers can set themselves up for success on the front end by ensuring their operating rooms are ergonomically designed and built for room turnover, such as storage for regularly needed suppliers or intentionally selecting easier to clean materials designed to support faster room turnover.”
“The ability to effectively clean and disinfect a room, as well as understanding the availability of materials, supplies and equipment needed in the room, are two of the changes we foresee on the horizon that may impact room turnover,” he added. “In response to these anticipated changes, Stryker’s Connected OR/Hospital Status support interdepartmental communications, especially with respect to patient scheduling, understanding SPD turnaround times, and supply chain management.”
Perioperative workflow automation
“Perioperative executives are seeking automation,” said Mandava. “Even when they hire people, they are often new and require a lot of training. They are looking for systems that automate a lot of the workflows, data entry, and even training of staff. Many of our hospital clients are highly responsive to new features around guiding team members on next steps in their workflows and the real-time location of items throughout the hospital, amongst other benefits.”
“With increased workloads and staffing shortages likely to continue throughout 2023 and beyond, it is critical for perioperative leaders to streamline non-clinical tasks for their team members so they can drive efficient room turnover while maintaining positive patient outcomes in the OR,” said Voss. “Leveraging technology solutions that can manage aspects of OR room turnover that typically require manual processes, thereby freeing up time and space, is a key strategy for achieving these goals.”
Voss pointed to Owen & Minor’s SurgiTrack clinical supply delivery service as a solution, which provides technology and staff to help ensure accurate inventory. She noted how SurgiTrack leverages rigorous analytics of preference cards to help surgical teams standardize product preferences, improve the accuracy of case pick activities, and reduce time spent on removing unused items.
“When the right technology is aligned with the right processes, backed by the right vendor expertise, outcomes like on-time starts and case pick accuracy can be improved, which may in turn help to help alleviate the burden on a perioperative team, and most importantly, drive high-quality patient care,” she added.
“Many technologies are available to automate caregiver workflow,” noted Van Galder. He referenced Stryker’s Connected OR platform, describing how it stores surgeon preferences, enables communication from the operating room, and automates post-operative workflow to securely store and share surgical case data.
Loaner tray readiness
“In spite of the best staff dedication, a key factor in room turnover is case readiness,” said Rechin. “Specific to loaner sets, sterile processing departments are often at the mercy of when inventory gets delivered for a case. If as an example, a vendor delivers 20 trays the evening before a case, that adds enormous pressure and complexity to the sterile processing team, and typically leads to surgical case delays, and poor room turnover.”
“Utilizing a loaner tray solution such as ReadySet Surgical would eliminate that pressure by providing the SPD better visibility into inventory arrival, as well as eliminating all the last-minute run around in trying to see when inventory will arrive,” Rechin continued. “The solution helps increase case readiness; including when inventory will be delivered, what inventory will be delivered, and even providing tracking information to see carrier status. These types of efficiency improvements allow staff to increase productivity and can positively impact staff availability to assist in room turnover.”
A look ahead
“Hospital and health system leaders are preparing to navigate what could be an exceptionally turbulent 2023,” said Tina Wheeler, Health Care sector leader, Deloitte, commenting on the results of Deloitte’s Health Care Industry 2023 Outlook survey. She notes how “many patients continue to put off non-emergency procedures, which continues to squeeze revenue” and how “an increasing number of patients are shifting to ambulatory centers over hospitals for surgical procedures.”
Pressured by staff shortages, inflation, shrinking margins, and increased competition from ambulatory surgery centers (ASC), hospital leaders are looking for ways to get back in the black. Improvements in OR efficiency can help refuel the engine driving hospital revenues, while alleviating perioperative teams of non-value-added tasks.
As Wheeler stated in her blog post on the 2023 Outlook survey findings:
“Hospital and health system leaders might also look for ways digital technology could take over some administrative and menial tasks so that clinical staff can spend more time interacting directly with patients. This could help relieve stress and improve care delivery and staffing models. Many employees are demanding more flexibility in how they work.”
In the conclusion of her post, Wheeler summed up her thoughts on this new year, emphasizing the importance of patient satisfaction:
“I believe 2023 is going to be another challenging year for hospitals and health systems as they work to balance financial pressures with the need to invest in the future while ensuring high-quality care. These organizations will likely need to do all they can to attract and maintain patients. Deloitte’s recent research shows that consumers are less likely to return for care after having a negative experience with a health care provider or staff. Ensuring that patients have a positive experience could help improve trust in hospitals and health systems.”