How One Hospital Increased First Case On-Time Starts From 4% to 72%

Starting the first case on time is crucial for maintaining an operating room's schedule. For a variety of reasons, however, first cases can be delayed, causing subsequent cases to be delayed and patient satisfaction to decrease. Yolanda G. Smith, RN, MSN, CCRN, president of YGS Medical-Legal Consulting, describes a process for improving first case on-time starts. As a continuous quality improvement/performance improvement administrative consultant for perioperative services at a hospital, she helped increase the percent of first case on-time starts from 4 to 72 percent.

Process
Ms. Smith began monitoring the hospital's operating room in Feb. 2010. She found that the hospital did not have a clear policy for the anesthesiologists' and surgeons' arrival times. Secondly, nurses were required to arrive only 15 minutes before the first case, which was not enough time to prepare and set-up the room. Compounding this problem was surgeons' assumption that the nurses would not be ready on time, causing them to arrive late. The number one reason the first cases started late was surgeons' late arrival, according to Ms. Smith. Overall, 4 percent of first cases started on time.

To improve this rate, in May 2010 Ms. Smith participated in a rapid improvement event in which she measured how long it took for anesthesiologists, nurses and surgeons to complete their tasks. In June 2010, she monitored a new policy requiring surgeons to arrive half an hour before the start time of the first case and anesthesiologists to arrive 45 minutes before the start time of the first case. In Aug. 2010, the nurses' arrival time was moved from 7:30 a.m. to 7 a.m., when anesthesiologists also had to arrive. Ms. Smith monitored each OR team member's arrival time, when the room was ready and any delay reasons that prevented the cases from starting on time. Ms. Smith then submitted a daily report to the chief of perioperative services and administrator. By December, Ms. Smith already noticed a spike in percentage of on-time starts for first cases, and by March the team was starting on time for the first case 72 percent of the time.

Buy-in
The most challenging part of the process was gaining buy-in from surgeons, Ms. Smith says. She first gained the support of leadership by monetizing the delay of first case start times. She calculated the amount of money the hospital was losing based on how long nurses were waiting before the case started, the frequency of the delays and the nurses' salaries. "The monetary effect is a major incentive for people to want to change," Ms. Smith says. The support of leadership helped her get surgeons' buy-in, she says. Another factor that helped motivate the OR team to change was the fact that she was not affiliated with the hospital, she was an independent, objective observer. "You cannot have an employee [monitor the OR] because people have difficulty being objective with their peers," she says.

The OR team also became more invested and committed to the process when they began seeing its benefits. By increasing first case on-time starts, surgeons were able to schedule an additional case at the end of the day and the team finished earlier. "They had better buy-in because it was impacting them positively," Ms. Smith says. Although some surgeons remained resistant to the change, the support garnered from the majority of the team helped boost on-time first case starts, which saves the hospital money and improved employee satisfaction.

Related Articles on OR Efficiency:

The One Change ORs Should Make to Improve Efficiency: 9 Responses
NAPA Releases White Paper on Improving OR Efficiencies Through Perioperative Leadership

American College of Surgeons, 20 Others Offer Guide on Operations Requiring Physicians as Assistants




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