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4. Sandbaek BE, Helgheim BI, Larsen OI, Fasting S. Impact of changed management policies on operating room efficiency. BMC Health Serv Res 2014;14:224. 5. Friedman DM, Sokal SM, Chang Y, Berger DL. Increasing operating room efficiency through parallel processing. Ann Surg 2006;243:10e14. 6. Dexter F, Epstein RH. Operating room efficiency and scheduling. Curr Opin Anaesthesiol 2005;18:195e198. 7. Harders M, Malangoni MA, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery 2006;140:509e514; discussion 514e516. 8. Panni MK, Shah SJ, Chavarro C, et al. Improving operating room first start efficiencydvalue of both checklist and a preoperative facilitator. Acta Anaesthesiol Scand 2013;57: 1118e1123. 9. Wright JG, Roche A, Khoury AE. Improving on-time surgical starts in an operating room. Can J Surg 2010;53:167e170. 10. Kodali BS, Kim D, Bleday R, et al. Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center. J Surg Res 2014;187:403e411. 11. Seim AR, Sandberg WS. Shaping the operating room and perioperative systems of the future: innovating for improved competitiveness. Curr Opin Anaesthesiol 2010;23:765e771. 12. De Deyne C, Heylen R. Introduction of an operating room information management system improved overall operating room efficiency. Stud Health Technol Inform 2004;110:61e67. 13. de Mast J, Kemper B, Does RJMM, et al. Process improvement in healthcare: overall resource efficiency. Qual Reliabil Engineer Int 2011;27:1095e1106. 14. Cima RR, Brown MJ, Hebl JR, et al. Use of lean and six sigma methodology to improve operating room efficiency in a highvolume tertiary-care academic medical center. J Am Coll Surg 2011;213:83e92; discussion 83e84. 15. Poksinska B. The current state of Lean implementation in health care: literature review. Qual Manag Health Care 2010;19:319e329. 16. DelliFraine JL, Langabeer JR 2nd, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Qual Manag Health Care 2010;19:211e225. 17. Nicolay CR, Purkayastha S, Greenhalgh A, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg 2012;99:324e335. 18. Breen AM, Burton-Houle T, Aron DC. Applying the Theory of Constraints in health care: part 1dthe philosophy. Qual Manage Healthc 2002;10:40e46. 19. Rahman Su. Theory of constraints. Int J Oper Prod Manage 1998;18:336e355. 20. Saver C. Efficiency soars in wake of strategic OR cultural changes. OR Manager 2013;29:17e19. 21. Heslin MJ, Doster BE, Daily SL, et al. Durable improvements in efficiency, safety, and satisfaction in the operating room. J Am Coll Surg 2008;206:1083e1089; discussion 1089e1090. 22. Sohrakoff K, Westlake C, Key E, et al. Optimizing the OR: a bottom-up approach. Hosp Top 2014;92:21e27. 23. Niemeijer GC, Does RJ, de Mast J, et al. Generic project definitions for improvement of health care delivery: a case-based approach. Qual Manag Health Care 2011;20:152e164. 24. Motwani J, Klein D, Harowitz R. The theory of constraints in services: part 2dexamples from health care. Manag Serv Qual 1996;6:30e34.
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25. Fezza M, Palermo GB. Simple solutions for reducing firstprocedure delays. AORN J 2011;93:450e454. 26. Dexter F, Willemsen-Dunlap A, Lee JD. Operating room managerial decision-making on the day of surgery with and without computer recommendations and status displays. Anesth Analg 2007;105:419e429. 27. Scalea TM, Carco D, Reece M, et al. Effect of a novel financial incentive program on operating room efficiency. JAMA Surg 2014;149:920e924. 28. Krupka DC, Sandberg WS. Operating room design and its impact on operating room economics. Curr Opin Anaesthesiol 2006;19:185e191. 29. Seagull FJ, Plasters C, Xiao Y, Mackenzie CF. Collaborative management of complex coordination systems: operating room schedule coordination. Proc Hum Factors Ergonom Soc Annu Meet 2003;47:1521e1525. 30. Wright IH, Kooperberg C, Bonar BA, Bashein G. Statistical modeling to predict elective surgery time. Comparison with a computer scheduling system and surgeon-provided estimates. Anesthesiology 1996;85:1235e1245. 31. Stepaniak PS, Mannaerts GH, de Quelerij M, de Vries G. The effect of the operating room coordinator’s risk appreciation on operating room efficiency. Anesth Analg 2009;108: 1249e1256.
Discussion DR RIFAT LATIFI (Tucson, Arizona): The authors report the results of what they call “straightforward” and “common sense approaches,” supported by low-cost, low-technology solutions to improve operating room (OR) performance and efficiency in a tertiary care academic medical center with a level I trauma center. Its importance is obvious to all of us who struggle to start the case on time, to make sure that preoperative testing and documentation are done properly and the patient is moving effortlessly to the operating room, that the anesthesiologist has seen the patient and has asked the right questions, that the Coumadin and aspirin and other anticoagulants were stopped on time, and that there will be no surprises in the minutes before cutting time. The authors have accomplished a considerable feat. They report on the process of reengineering of the OR governance at their institution by establishing accountability, the metrics of transparency, and creating a culture of data-driven efficiency. In other words, they took full responsibility for the grave situation at their institution and changed it. In the business world, this is commonplace. But, for some reason, we in health care tolerate significant delays for starting the first case, tolerate long delays between cases, and tolerate if the patients are not ready for the operating room, even when we have already scheduled the operation. Can you imagine a shop or factorydor any other business office for that matterd that opens on time only 39% of the time? Surely if they did, they would not remain in business for very long. I congratulate the authors for taking the required steps to change the status quo of their OR patient flow. In fact, what they did is simple. They took the steps that we surgeons should take to change and innovate the process if it does not work or
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when it needs improvement. This is surgical leadership driven process 101. When the entire process is analyzed, problems are identified, and measures are taken to solve them for the entire complex continuum of perioperative care, from perioperative orders to postanesthesia care. But instead of having a surgeon lead this process, often a retired surgeon, they chose to hire an aggressive certified registered nurse anesthetist (CRNA) who manages the entire process. Personally, nothing makes me happier than starting the case on time. Have you studied the surgeons and surgical team satisfaction, including residents and nurses, with this new governance? You report only results of Monday through Friday. Did you notice a more efficient OR during the weekends? It is important to run the operating room more efficiently, but it is also important to know whether patients are benefiting from these practices. Have you studied or do you plan to study the patients’ outcomes in these 2 periods and see if there is a difference in their length of stay, and, most importantly, patient and patient family satisfaction? Did you decrease anesthesia time? Finally, can you tell us more about these text messages? What is the message: “get your a. to the OR or what?” Can this be automated perhaps? When you and I were residents, we saw the patient the night before, reviewed the documentation beforehand, planned the operation, read about the operation, and were ready for the operation. Do you think we can upgrade this “simple technology” to send a reminder via some sort of Health Insurance Portability and Accountability Act compliance technology that includes health professional and laboratory imaging studies to our residents in charge of the patients (although this will be a difficult concept nowadays to understand) in order to further improve what seems like a great process already? DR CHARLES SCOGGINS (Louisville, KY): At our university hospital, it has always been a culture of: “the cases will get started sometime,” which is very typical of university settings. There has been a huge improvement in surgeon morale. You are right. It is very satisfying to have a 7:30 case that is actually going at 7:30. We have not really looked at the weekends for a couple of reasons. The weekends are run by a skeleton crew. They do mostly things that are left over from the week, some orthopaedic trauma cases and things like that, and frankly, Dr Farah does not work on Saturdays, so we have not studied the weekends. We have not looked at patient outcomes as far as reduced anesthesia time or improved outcomes, but we certainly have been interested in both patient and family perspectives on their experience. I can tell you that they are at an all-time high. The families are approached and asked to give feedback on their experiences with university operating room and faculty and staff, and they are at an all-time high because of being more efficient, getting the cases done, fewer cases being bumped, and things like that. With regard to texts, there are some that are as you described. Ian Farah is a taskmaster. And he stands up there with the cell phone, and if your folks are not around and you cannot be found, your case will get bumped and somebody else will get slotted in. It is very common for me to get a text or a call from Ian Farah on Tuesday evening asking if I want to move my Wednesday case up. That was unprecedented before. He calls, and no one is afraid to call the department chair or an attending senior to discuss
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a case. He will walk over to the preoperative area and start an IV if there seems to be a holdup. He will help wheel a patient back to the operating room. It is unbelievable and highly collaborative. His enthusiasm is infectious. For a lot of the nurses, if he is there and active and moving, so are they. If he is off that day, things slide back a little bit, so we do not give him any vacations. DR STEVEN DeJONG (Maywood, IL): These metrics in the operating room are both interesting and frustrating at the same time. We would like to think that we as surgeons can run the operating room. But, in fact, most of the operating rooms are run by anesthesiologists, and they may have unique and different priorities and interests. Have you or one of your surgeons, ever shadowed that process or actually run the operating room as clinical director and learned about issues that surgeons are often unaware of? What lessons have you learned from that? Second, how much of this is the result of a Hawthorne effect, that people are watching more and paying attention knowing that the data are being collected? How then can or do you assess the true effect of the processes that you have put in place? Third, could you expand a bit about the type of cases, because I would question the validity of comparing the 2 if you are comparing your morning elective schedule to a more urgent or emergent schedule in the afternoon or evening. DR CHARLES SCOGGINS (Louisville, KY): We have not tried to run the OR ourselves. Ian Farah, the CRNA, really runs the show. We work closely with him, but he is a chess master. He sits there at the OR board. He is moving those magnetic strips around and firing out texts and calling people all the time. I do not think I could do it. These are elective cases being done. At our center, we have a dedicated operating room that is sitting ready, waiting for the gunshot wounds and the trauma cases coming up, so I think that has minimal effect on these results. There is no question there has got to be some Hawthorne effect. There are graphs and charts of performance all around the OR for everyone to see. If they are going to perform better because they are being measured, then let us measure them and publish those data. I can assure you, however, that in the 25 years before this we did not see improvement in the OR no matter how closely people were being observed. DR JOHN RUSSELL (Albuquerque, NM): I cannot imagine that there is any academic medical center that does not struggle with these kinds of daily operational issues. I do note that over the course of your study, with the increased case numbers and the improved use, your turnaround time was remarkably stable. Now, is that because you have maxed out the possibilities there, or that you hit roadblocks in improving that metric? What do you think the opportunities are to improve that, because I can tell you, at our institution that remains the most difficult operational problem in the OR to fix. Starting the first case is great. If you do not start the first case on time, you have no chance for the rest of the day. But getting the second or third case in a room started is something we struggle with. I would like to know what you have done to fix that problem. DR CHARLES SCOGGINS (Louisville, KY): That is project number 2. You are absolutely right, the easy one to fix, the low-hanging
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fruit, was the first starts. Turnover time is going to be a harder nut to crack. At our place, we still have a lot of the same culture, in which it seems like everybody goes to lunch at a restaurant off campus between cases. So it is difficult to get things moving. But turnover time is project number 2, and I hope that we can generate some meaningful data and bring that back to this meeting. DR WILLIAM C CHAPMAN (St Louis, MO): Your turnover time was very low. Forty-one minutes, I think, is what was quoted, and it was low even before you started this project. That is a killer at our place. It is sometimes an hour and a half, and it has been 2 hours for the reasons you point out. What do you do to keep that turnover time so low? I assume that is out-of-the-room to in-the-room time. DR CHARLES SCOGGINS (Louisville, KY): The turnover time is “wheels out to wheels in.” Turnover time is a very contentious issue. These cases run the gamut from laparoscopic cholecystectomies to major orthopaedic cases, Whipples, and liver resections, so it is a big mix of things. It is not all simple needle localization partial mastectomies that do not need a lot of instruments. There is a concerted effort by many of the nurses and clean-up crew to work hard and get cases turned around. Then you have got the crew in the preoperative area working hard to get the next patient ready so that when the room is ready, the patient is ready, as opposed to: the room is ready but we still have to start some IVs and, oh, we did not get consent. All of that takes a lot of effort. Our next efforts are looking for ways to improve in that process and reduce variability. DR KELLY McMASTERS (Louisville, KY): When they see the Surgery Department chair mopping the floor, that tends to get them moving along pretty well too. DR PETER RHEE (Tucson, AZ): In operating room efficiency and use there are 3 categories of time. There is private practice; we know they are better than we are in all institutions. And there is academia, where there are residents. And then there is the Veteran’s Affairs time. The number of cases you can get done is very different in each of those settings. I think this paper is great because getting this out in print is nice. I have been going to our OR meetings for 7 or 8 years now, and I have not seen our start time change by more than 2%. We are getting hounded to get that up to a certain number. I do not know where that number should be and whether it is really that important or if it is just an artificial goal that we are trying to go for. If you can
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get that pushed up to maybe 75% or so for a while, you relax a little bit, it bounces right back to 70%. So I am wondering whether that should be a real laudable goal or not. DR CHARLES SCOGGINS (Louisville, KY): I recommend you find an Ian Farah; do not take ours. He has real street credibility. He worked in our hospital as a CRNA for years and knows everybody. He knows what happens. He is not just some figurehead that walks in wearing a suit and tie. He is there actually working. DR MARK TALAMONTI (Evanston, IL): I agree with everything you said, especially about having a coordinated person who oversees the process who is not an anesthesiologist or a nurse. Which brings me back to Dr Dejong’s question about anesthesia. In your institution, how are they compensated? Because we have found that financial incentives are the only thing that seem to work in many cases. If anesthesiologists are compensated for the number of inductions and intubations they do, then they would much rather do 6 laparoscopic cholecystectomies in 6 hours than 2 Whipples in 10 hours. And trying to lower that turnover time between the bigger cases and not have the 90-minute turnover is almost impossible unless they are incentivized for all the same things that we are incentivized for when we manage the OR: turnover times, utilization times, first start times, etc. If anesthesia is only incentivized financially for the number of intubations they do in a given day, I do not see you making any more progress. Can you give me more information about how you have worked with anesthesia to share motivations and to share the same destiny in terms of the metrics that you are responsible for? DR CHARLES SCOGGINS (Louisville, KY): Our anesthesia department is on straight salary, so they get paid the same salary whether they do 1 case or 10 cases. It really comes down to a sense of pride and wanting to get the cases done and take care of patients. You know, the sense that somebody’s mom is on that stretcher. So getting cases through and taking care of people is what drives it. DR KELLY McMASTERS (Louisville, KY): I just wanted to stress that this is our university hospital, which is a trauma and indigent care hospital traditionallydthis is not the Mayo Clinic. Operating room efficiency has been an unsolvable problem for 25 years. The fact that such progress has been made using a CRNA with a magnetic strip board and a cell phone was so remarkable to us that we thought it would be a lesson worth sharing with all of you.