Creating Change That Sticks: Lessons Learned From Years of Improving ORs

The fact that change has become more frequent in healthcare does not mean it's easier.

People are creatures of habit, and professionals in any field know it's extremely challenging to adopt and maintain new ways of working. In a field as regimented as medicine, many healthcare professionals experience discomfort when abandoning the routines, habits or points of view to which they've grown accustomed over time.

Leaders are tasked to not only see their people through unease, but to ensure change is sustained in the long-term. This is not impossible. In fact, most people support change if they believe it makes a real and positive difference to patients.

In the operating room, patients are exposed to several — even hundreds — of decisions, actions and relationships that can immediately help or harm them. The nontechnical skills and behaviors of a care team directly affect patient outcomes, and ORs rife with teamwork, harmonious relationships between management and staff, collegial familiarity, coordination and stress management are safer than their counterparts. These are also the ORs in which surgeons, anesthesiologists and nurses most want to work.

Infusing these skills and behaviors in the OR, however, takes deliberate effort.

Most hospital ORs struggle with problems related to efficiency, behaviors, cost and physician satisfaction. Over time, these problems cascade. They lead to more cancellations, low patient satisfaction, high costs, and ultimately poor financial outcomes since the operating room is one of the most expensive areas in an acute care hospital. Sixty percent of the high-performing hospital's margin derives from perioperative services.

Over the years, Surgical Directions has collaboratively transformed OR cultures for hundreds of clients — from rural to urban facilities, from community-based hospitals to large academic medical centers. The process takes an average of six months, and Surgical Directions is most proud of what occurs after that: Change that sticks.

What does Surgical Directions do to make change stick in the OR?

Tap into team cognition
When working toward lasting change, leaders cannot underestimate the importance of interpersonal relationships and emotion. Oftentimes, change is unleashed upon employees rather than being a goal they work toward together. This puts the horse before the cart. Initiatives that focus first on people — before workflow and processes — are those that gain momentum and ultimately stick.

Oftentimes, the glue holding 'change that sticks' is team cognition. This is a group's collective knowledge about their roles, responsibilities and capabilities. When team members understand how one role affects another, they have greater self-awareness about their own duties and more accurately anticipate their colleagues' needs. To grasp how you fit into the big picture is eye-opening. To grasp how your colleague fits into the big picture is just as important.

Regardless of technical skill, a disjointed team will struggle with any attempt at cultural transformation. When surgeons, anesthesiologists, nurses and other personnel are unfamiliar with one another, their responsibilities and day to day challenges, it is unreasonable to assume they are capable of sustaining meaningful change that will benefit patients.

"A lot of times, members of the same surgical team have different ideas about how to get through their day," says Lee Hedman, senior vice president of Surgical Directions. "It's critical to align motivations and bring people onto the same page to work as a coordinated team toward the same goals."

Surgical Directions addresses team cognition head-on through multidisciplinary performance improvement sessions. Individuals from other areas of the hospital meet with the OR team and participate in roundtable discussions about workflow, efficiency, morale and culture. Sometimes these sessions bring colleagues face-to-face for the very first time, even though their jobs and responsibilities have affected one another for months and years.

Ms. Hedman says the strategic performance improvement sessions are remarkable for many reasons. Aside from team members finally meeting and getting to know one another, the sessions also serve as something similar to a town hall gathering. Each stakeholder has a chance to express his or her dissatisfaction about OR processes or culture, and this peer-to-peer dialogue is precisely what gets things off the ground.

"For many people, learning about a teammate's pain points sparks a total shift in mindset," says Ms. Hedman. "When a member of your organization tells you how your work or attitude affects them, that's a wake-up call. It sparks an internal drive for improvement, and people walk out of the session wanting to do better."

Paint a vivid picture of improvement efforts
While team cognition is a critical piece of the cultural improvement process, individualization is just as key. Once team members understand one another's roles, needs and frustrations — as well as the greater need for cultural change — Surgical Directions digs into data to target improvement efforts. Surgical Directions analyzes numerous metrics and functions, including same-day cancellation rates, direct costs of supplies and labor, case volumes, primetime utilization, block length and scheduling.

One other metric analyzed, which Ms. Hedman uses as an example, is the rate of on-time surgical starts. Delays in first case starts present problems for organizations and contribute to problems further down the line. When the first case does not start on time, the delay cascades throughout the day and can trigger overtime costs and dissatisfaction among patients and staff. What's more, the cause of a delayed first case can change from day to day.

Surgical Directions' performance improvement team benchmarks the OR against the best practice metrics of comparable ORs. In a healthy and efficient OR, 90 percent or more of surgical cases begin within 5 to 7 minutes of the start time. In many hospitals, only 60 to 65 percent of cases start in that timeframe.

Surgical Directions makes these metrics visible so the OR team can see just how far they are from the best practice metric. The disparity is especially powerful given the competitive nature of many physicians and medical professionals, who are wired to outperform and usually despise mediocrity.

But as any medical professional will tell you, numbers without context are meaningless. To craft a comprehensive and meaningful improvement plan, members of the Surgical Directions team sit down with the OR team for a more detailed discussion.

"We say, 'We're going to get that benchmark to 90 percent," says Ms. Hedman. "Then we open it up to the team ask: 'But to do that, what must you change about your work? What will this change look like in your OR?'"

This is where individualization comes in. When it comes to improving first case start times, numerous stakeholders must readjust their workflow. Perhaps the patient's history and physical needs to be completed earlier. Maybe the pre-operative process needs to be standardized, with surgeons arriving and consulting with the patient earlier than 30 minutes before the scheduled start. Perhaps the entire surgical team will huddle post-surgery for a debrief, allowing for an opportunity to address delayed first case starts and further analyze how to prevent them.

Specific conversations force surgeons, anesthesiologists and nurses out of the abstract. Team members must vividly describe their roles in achieving the shared goal, and understand how their behaviors and decisions will help or hinder their team's progress. Such specificity calls for individuals to take responsibility for the outcome and own up to the "small" changes they must make in their daily lives to support the "big" organizational change at hand.

These conversations also strengthen team members' understanding about what the change means for them personally. This is the predominant concern of every member in an organizational transformation. Some roles face a greater intensity of change than others, and people are more empowered when they have an upfront understanding of the degree to which their routines will change.

"It's always easy to go back to the way it was rather than keep it the way it should be," says Ms. Hedman. "Detail is incredibly important when you are trying to distance yourself from the 'old way.' To do that successfully, you need a vivid picture of your new reality."

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