On-time surgical starts increase patient and staff satisfaction, reduce costs

Late starts to the first surgical case of the day can be improved, according to two studies presented at the ANESTHESIOLOGY™ 2013 annual meeting. Improving efficiency potentially reduces costs, increases patient and staff satisfaction, and increases the number of cases that can be performed daily.

"In 2011, fewer than half of the first cases of the day started on time," said Sophia van Hoff, M.D., of Dartmouth Hitchcock Medical Center, Lebanon, N.H. "While this was not unique to our hospital, it led to dissatisfaction for both patients and staff. Correction of these delays was targeted as a high priority improvement project."

To achieve this improvement, Dartmouth Hitchcock chose the Rapid Process Improvement Workshop (RPIW) to address the problem. The RPIW team spent five days assessing barriers to prompt first-case starts and redesigned the workflow of patient preparation.

At Vanderbilt University Medical Center, Nashville, Tenn., an initiative tied to financial incentives for staff jump started their improvement project. The Departments of Anesthesia, Surgery and Perioperative Services shared in the goal to improve first-case on-time starts and the funding went to each of the departments when they reached their goal.

"At the start of the day, operating room (O.R.) managers know at what time and how many surgical cases are expected that day, and how long they should take. Any deviation from the planned schedule disrupts the entire schedule and chances are that administrators will spend the rest of the day playing catch up," said Vikram Tiwari, Ph.D., assistant professor of anesthesiology and director of surgical business analytics at Vanderbilt University Medical Center.

The Dartmouth study improved first-case on-time starts after 16 weeks to 75 percent. Dartmouth then instituted a daily communication to any caregiver associated with a delayed room, and on-time starts rose further, to 82 percent. The average delay decreased from 7.2 minutes to 4 minutes.

This improvement was created by instituting nine key workflow changes. For example, on the day of surgery, certain teams were given authority for specific windows of time in the hour prior to the case starting. O.R. nurse visits were implemented as the first task, rather than occurring just prior to patient transport. Paperwork and testing were completed prior to the day of surgery, and anesthesia teams were no longer required to ask the O.R. for permission to enter the room if it was after 7:20 a.m.

The Vanderbilt study improved first-case on-time starts to more than 70 percent from less than 50 percent. The median delay time was reduced to two minutes from five minutes. The improvements were a result of several factors, including daily meetings or "huddles," increased communications among caregivers and the hiring of a new administrative director. The efficiency improvements initiated during the process redesign have been sustained even after the expiration of the incentives, indicating that the new process is working. This is especially encouraging as it shows a potential way of aligning resources to collaborate on shared goals, said researchers.

The Dartmouth case study estimated that an improvement to greater than 80 percent on-time starts would result in increased patient and staff satisfaction and nearly $2 million a year in combined cost saving in overtime pay, additional cases and increased revenue.