David Kashmer, MD MBA MBB (@DavidKashmer)
OR turnaround time is a classic opportunity for quality improvement in hospitals. The surgeons typically say it takes way too long to clean and prepare the ORs. The materials management and housekeeping staff often add that they’re doing everything they can to go as quickly as possible–without sacrificing their safety or doing a bad job for the patient. Anesthesia colleagues may add that they too are going as fast as possible while completely preparing the rooms and maintaining patient safety. However, the rest of administration will remind the team of an estimated cost of OR time so as to put a face on the costs associated with that downtime when no one is operating in the ORs. I’ve seen these range from as low as $50/minute to as high as $100/min!
Here’s a classic quality improvement project
Here, then, is a classic project that involves many stakeholders, shared OR governance, and an obvious opportunity to decrease what many hospitals consider non-value added time (VAT). I bet it’s a project that your healthcare system has performed before, will perform soon, or is eyeing as a potential for significant quality improvement.
And you know what? Even if you’ve gotten this challenging project done in your healthcare system, the issue may not be behind you my friend. Let me tell you why…
Once upon a time, at one hospital, the goal of an important quality improvement project was to reduce that turnaround time in the operating rooms. And wow had it ever worked!
The team had adopted a clear definition of turnaround time, and had used a DMAIC project to significantly decrease that time–it was almost like a NASCAR pit crew in there. It was safe, orchestrated, complete, and really helped the rest of the staff improve OR flow. The time required to turnover a room had also become much more predictable, and this decreased variation in turnover times was also a big help to patient flow and scheduling.
The team used several classic tools, including a spaghetti diagram to decrease wasted motion by the “pit crew” team, a kanban inventory system, and a visual control board to notify all of the players in the process (Anesthesia, Surgery, Pre-op Nursing, & the holding room) when the operating room was ready to go. They saved days worth of wasted motion (time spent walking) for the OR prep crew when projected out over a year’s worth of turnovers. The OR staff could complete about one extra case per room per day. Truly amazing.
…but only three months later, the turnaround time had crept back up again to where it had been before the changes–a median of 25 minutes per case.
Good quality projects never die. And if you plan them right, they don’t even fade away. –Anonymous
Nobody noticed, at first, that the turnaround times were slowing down from great to just pretty good again, until one day the OR got very backed up because a couple of turnarounds took 40 minutes. The Chief Surgeon wasn’t happy and didn’t hesitate to tell anyone she could how she felt.
What had kept the gains from being sustained? (You’ve probably seen these culprits before.) It was a combination of factors. Two new people started in the OR; one longtime employee in the facilities-services department had retired. The new people weren’t educated all that well about the turnaround system, and they also didn’t know exactly where everything was yet. But that wasn’t the real problem.
Failure is much more likely when there’s no control plan
In fact, the quality-improvement team hadn’t built a control plan into the system. The first sign they may have had a problem was when the Chief Surgeon fired off an angry e-mail to the rest administration and most of the staff. The signal should’ve come much earlier, when the variation in turnover times increased unexpectedly. That signal could’ve been noticed weeks before.
How? The team could’ve used an ImR control chart (more on that here) to notice that the range of times for room turnover had gone out of control. The team could’ve had someone, a process owner like the OR administration, positioned to sound the alarm that the process needed to be solidified when, weeks earlier, several other turnovers took an unexpectedly long time.
Fortunately, in this case, the project team recovered. They quickly deployed an ImR chart and also reviewed their data. The Chief Surgeon had been correct: yes, those cases did take an unexpectedly long time when viewed in the context of the OR’s data. A root cause analysis was performed and the quality team quickly realized that several issues lined up to make those times take so much longer.
After addressing the issues, the team was back in full swing only a week or two later. The pit crew was back at it, and the NASCAR-like precision had returned.
The lesson: creation of a control phase plan to maintain the good work you & the team have done is an essential part of quality improvement projects. Without an excellent control plan, it is very difficult to maintain the improvements you’ve made as a foundation for future improvements. Failure to plan a control phase is, unfortunately, planning to fail.
Excerpt originally published as part of Volume to Value: Proven Methods for Achieving High Quality in Healthcare