What Hospital Executives Need to Know to Achieve Top OR Performance
Top OR performers provide oversight to perioperative services with an empowered interdisciplinary leadership group consisting of key stakeholders including surgeons, anesthesiologists, nursing executives and certain hospital administrators. The membership of this "OR Board" is not representational — instead, it's comprised of stakeholders who are willing to assume fiduciary responsibility for the health of perioperative services in general, according to Dr. Firestone. Other qualifications include well-developed negotiating and listening skills and the ability to see the "big picture."
The governance team's responsibilities include acting as a unified group; establishing and enforcing policies; developing an OR dashboard with key performance indicators; establishing and monitoring the OR's capacity; keeping the focus on OR process improvement; and communicating. Its authorities include creating clinical and scheduling policy, protocols, standards and routine procedures for the OR; allocating and monitoring surgeon block utilization; and sometimes, participating in recruitment and performance evaluation of OR management.
The OR dashboard is an important tool in driving continuous improvement and is fundamental to operations in top performing ORs, according to Dr. Firestone. The dashboard should be posted and available to the entire OR workforce so they understand their organization's current performance and goals for operational, safety and service metrics. Setting goals based on benchmarks can be helpful in determining how an OR compares to other facilities, and results should be continuously trended month-to-month.
For example, regarding the operational metrics, Dr. Firestone says top performers should have at least a 75 percent OR utilization rate; a 24-hour case cancellation rate no greater than 2 percent; and a first-case on-time start rate of 95 percent, even in complex institutions. Safety and service metrics are often institution-specific. For these KPIs to be useful, they must remain constant for at least six to 12 months to track improvements over time. "Constantly changing the KPIs on a dashboard is the enemy of operational success and meeting the targets," Dr. Firestone said.
Dr. Firestone described two types of OR management: a daily OR charge team, which manages short-term issues, and OR department managers, who make longer-term decisions. The OR charge team should include the charge nurse and charge anesthesiologist. In many top performing ORs, the charge team includes a charge surgeon — a new concept Health Inventures has been recommending. The charge team's goal is to optimize utilization of staffed hours and promote reliability; this happens through morning, mid-day and afternoon huddles and proactive adjustment of the next day's OR schedule. Including charge surgeons' input is useful because of their knowledge of the habits and capabilities of fellow surgeons and their unique negotiating and "monitoring" position, Dr. Firestone said.
The second management type, performed by the OR director and clinical and department managers, focuses on clinical management, including staffing and education. The OR director needs to understand the skill mix of staff and the competencies required to meet patients' and surgeons' needs. The director should supervise OR staff recruitment, retention, training and skill maintenance.
Cross-training is often helpful in establishing a balance between sub-specialization and the need to function as a "utility player," according to Dr. Firestone. For example, he's observed that top performing ORs typically ask the OR staff to pick a "major" and "minor" specialty — "majors" set the performance bar in that service area, while OR staff are expected to only "meet the bar" in their minor specialty. Recently, top performing ORs have identified the need to separate management responsibilities for staffing from those of core process oversight. The OR director typically oversees the former, while a business director oversees the latter.
Core processes in an OR include OR scheduling, preoperative preparation, materials management and sterile processing. The OR scheduling office is responsible for a complex array of functions including telecommunications, customer service, education of surgeons' offices, case length estimates, coordination of case scheduling with preoperative clinic appointments, bed management and materials management for particular OR cases. In contrast, OR scheduling policy and block time allocations are governance committee functions in top performing ORs, rather than functions of the OR scheduling office, Dr. Firestone said.
The preoperative preparation process makes patients ready for surgery and avoids same-day case cancellations through an equally complex array of duties (i.e., prepare medical records, gather and file documents, screen patients either in-person or by phone, conduct nursing assessments, perform medication reconciliation, conduct insurance precertification, collect co-pays, correct abnormal tests and implement consultant recommendations). There is substantial controversy about who "owns" responsibility to respond to abnormal laboratory tests or consultant recommendations, and top performing ORs have resolved the ambiguity for their own institutions.
Materials management is in large part inventory management, as this core process involves tracking inventory, par levels, storage locations, charge capture, preference cards and sometimes, case carts and OR equipment. The principal challenge in this area is determining the relative roles of the OR materials management team and the hospital materials management team. These two groups need to communicate and establish who has the authority to make purchases, create policies, change processes and introduce new preference items.
Sterile processing refers to instrument processing — decontamination, assembly, sterilization and distribution. The goal of instrument processing is to complete this cycle in a time frame that allows an instrument to be used more than once a day while also avoiding immediate-use ("flash") sterilization. Efficient sterile processing is highly dependent on a staffing plan that supports the instrument processing cycle. Dr. Firestone has learned that top performing ORs right-size their instrument inventories by identifying high- and low-utilization instruments and managing them accordingly. For example, ORs should purchase relatively more high-utilization instruments to avoid shortages and eliminate low-utilization instruments on trays to lighten their weight. These low-use tools can be stored in "peel-packs" and used on an as-needed basis.
The value of top performance can be recognized in expense savings (supply and instrument costs; OR staffing and overtime costs), revenue enhancement (improved charge capture; increased capacity for growth) and "brand building" through greater customer satisfaction (more rapid throughput of add-on cases; greater reliability noticed by medical staff, employees and families).
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