7 common traits of a successful OR and how to achieve them

In the era of falling payments and rising quality expectations, perioperative services are absolutely critical to a hospital's success. In fact, perioperative services account for more than 68 percent of better performing hospitals' revenue, according to Jeff Peters, MBA, president and CEO of Surgical Directions, a perioperative consulting firm.

Mr. Peters and Alecia Torrance, MBA, BS, RN, CNOR, senior vice president of clinical operations at Surgical Directions, shared the common characteristics of successful perioperative service lines, as well as tools to optimize them, in a recent webinar hosted by Becker's Hospital Review.

"As we move toward a value-based system, it's really important we understand what's driving perioperative services, how we can go about growing them and how we can really structure them to ensure we have the best clinical outcomes," said Mr. Peters.

After examining more than 550 healthcare systems across the country, the systems with the highest level of surgeon satisfaction, patient satisfaction, financial performance and top clinical outcomes have several characteristics in common, according to Mr. Peters and Ms. Torrance. They highlighted the following seven traits as key drivers of perioperative success.

1. Collaborative governance structure. To drive change in the OR, Mr. Peters and Ms. Torrance recommended installing a Surgical Services Executive Committee. This committee should bring together clinically active surgeons, nurses, anesthesia leadership and hospital administration, so no one person is in charge of developing the vision for perioperative services in the hospital or health system. The SSEC controls the access and operations of the OR and sponsors and directs perioperative team activity.

A surgeon typically chairs the SSEC, but it may also be led by an anesthesiologist. An anesthesiologist should serve as a co-medical director to participate in the daily huddle and drive daily performance. By including leadership from across the organization, a multidisciplinary huddle can really permeate the whole department and drive cultural change, according to Mr. Peters.

"We want to make sure that anesthesiology leadership is engaged, that they actually designate a person and take time out to participate in the daily huddle, that they participate in safety and that they honor the protocol of the department," said Mr. Peters.

2. Transparent, comprehensive information. Second to leadership in driving change is providing staff, especially surgeons, with accurate and up-to-date information. "Fifty percent of all problems in most ORs can be solved by just giving surgeons or key individuals information, both on clinical performance, on how their cost compares and particularly on surgical case time for surgeons," said Mr. Peters.

One large East Coast academic teaching facility with extraordinarily long and variable case times implemented a SSEC and several task forces and began to provide physician performance data, which helped drive dramatic improvements, according to Ms. Torrance. The data was provided on physician-specific report cards, which included financial, operation and clinical information.

All the information was drilled down and synthesized into a dashboard specific to each surgeon, where the physician could compare their surgical minutes, the number and type of procedures performed, block utilization and the type of cases compared to prior month and year-to-date data. Surgeons were also able to pinpoint their performance and compare it to other physicians doing the same type of procedure.

3. Engaged physicians, nursing and administrative leadership. It is important to enable all staff to have an impact. One way to do this is to identify what Ms. Torrance calls 'physician champions' who help their colleagues perform better and demonstrate commitment on a daily basis. For some physician champions, this may mean they review case time data with surgeons on a daily basis and discuss opportunities to be more efficient.

Another opportunity to engage staff is to use turnover teams to ensure every staff member is able to work at the top of their license. Reducing support personnel can actually backfire on some hospitals as technicians and RNs will have to spend more time preparing the room between cases. Using a turnover team will help reduce turnover time and leave experienced staff free to engage and drive performance improvement.

4. New care delivery models. Focusing on innovative care models, such as bundled payments or surgical homes, will help ensure the hospital can provide higher quality care to the patient at a better cost, according to Mr. Peters.

"The surgical home is really designed to manage the entire patient's experience from scheduling, to pre-surgical optimization, to talking about what goes on during surgery and recovery," said Mr. Peters. "Increasingly our job in looking at care is to realize our responsibility to the patient does not end when that patient is discharged from the hospital, but increasingly what goes on in the first 30 days after they leave the hospital."

This means a home health team may visit a patient's home before surgery to ensure it is set up and accessible to the patient post-surgery. A ramp may be installed at the front door, for example, or toilet assistance may be deemed necessary. The team will also talk to the family to prepare them to support the patient post-discharge.

Another feature of the surgical home includes having a clinician sit down with the patient prior to surgery to talk about pain management and what to expect in terms of pain post-surgery, Mr. Peters said. This can help reduce the amount of narcotics needed to manage the pain post-surgery and helps patients give patients strategies to prepare for recovery.

It also includes coordination with the patient's primary care physician. "Helping coordinate a visit or discussion with the primary care physician within 24 hours of surgery helps improve outcomes," said Mr. Peters.

5. Focused processes to enhance OR efficiency. In addition to new innovative care models, surgeons in successful ORs should always be focused on turnover times, on-time starts and case times, according to Mr. Peters.

Case-time data will drive organizational change. Organizations should always measure turnover time and share it with surgeons as mentioned above. The SSEC can establish a case-time task force to help address issues and develop innovations to improve efficiency.

Pre-anesthesia testing can also truly drive clinical performance. Anesthesiologists need to make sure patients are optimized before surgery and help manage co-morbid diseases. Guidelines and testing protocols for pre-anesthesia are the responsibility of the anesthesiology team. Most of these evaluations can be done over the phone, but some complex cases may require patients to come in and meet with the hospitalists.

6. Lower costs. Any organization with successful perioperative services constantly works to lower costs through multiple channels.

One thing the SSEC can begin with is deciding how to block in the OR. Full blocks increase hospital revenue, according to Mr. Peters. He recommends an 8-hour block with 75 or 80 percent utilization to maintain blocks. Even a small change like this can increase growth in volume and profitability by 2 to 5 percent annually.

"A real opportunity in most organizations to improve profitability is really focusing on nonlabor costs," said Mr. Peters. "It's one of those things you can improve without getting into a lot of political battles." Plus, nonlabor costs account for about 60 percent of the OR budget.

Some of the better performing systems turn their inventory over 10 to 12 times per year by focusing on par levels and centralizing the ordering process so it is led by a single person or small team. The number of supplies that go into a case cart based on the surgeon's preference cards should be returned at a rate of less than 10 percent, he says. Another opportunity to lower costs is in implants, especially high-cost implants such as knees. Strategies that optimize GPO contracts, create capitated rates and leverage consignment will all help reduce costs. Some disposable supplies can also be reprocessed, and better performing systems will reprocess them at a rate of 30 percent, according to Mr. Peters.

7. Clinical excellence as the top priority. Above all, organizations should create a culture, vision and team that prioritizes clinical excellence and does not resist change.

"Organizations that are successful are never satisfied with how they are and in a constructive, collaborative way, go about pushing each other to get to the highest form of clinical and operational excellence," said Mr. Peters.

 

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