Part of 2 of Access’s Improving the Economy of Surgical Services series
Before you can change a process for the better you have to understand the various elements of the equation. I elaborated on this basic yet core concept in Part 1 of this series, “Improving the Economy of Surgical Services.” In this installment, we’ll focus on what should be the paramount concern of anyone looking to improve their Surgical Services process: the patient and their complete operating room (OR) experience.
Understanding the patient’s OR journey is where any hospital looking to improve Surgical Services efficiency and economies should start. Considering that for many hospitals, the OR accounts for 60% or more of the overall revenue, any improvements made in any phase of the Surgical Services process can literally mean the difference between running in the red or in the black.
If you map out each step of the patient journey within Surgical Services, you’ll soon see many points where improving key process steps can have a major impact on patient experience/satisfaction, as well as cost control.
According to Optimizing your Operating Room: Or, Why Large, Traditional Hospitals Don’t Work (Girotto, Koltz, and Drugas 2010)1 by Dr. John Girotto, Dr. Peter Koltz, and Dr. George Drugas—published in the International Journal of Surgery—the following is a detailed example of a patient’s OR journey. Of course, every hospital has a different process, and you’ll need to map out your own facility’s patient OR journey for a more personalized overview. But this provides a solid blueprint to guide your efforts.
Acknowledge the Process Chain Reaction
The first question one must ask is, “When does the patient’s experience with Surgical Services begin?” I’ve asked this question of many Surgical Services directors, and the most common response I hear is, “When the patient arrives at the hospital for their surgery.” However, if you take a few steps back, you’ll realize the patient’s actual OR journey begins the moment the patient and their doctor agree that surgical intervention is the most appropriate course of action.
At that moment, the first domino falls, and the chain reaction of the Surgical Services process begins. This acknowledgement also marks a transition in the patient’s emotional state. The exact emotions patients feel may vary, of course, but when the decision for surgical intervention occurs, the question of what course of action is settled, but new questions and worries take its place. A key consideration is not just the many internal steps of the Surgical Services process, but how each one could positively or adversely affect the patient’s already heightened emotional state and overall experience.
So let’s have a look at the patient’s Surgical Services journey according to Exhibit 1 provided in the aforementioned research article “Optimizing your operating room…”:
Exhibit 1. Pre-operative Planning: The activities performed during each step and the people/machines/materials utilized are included. The flow diagram documents the process of care for patients including the site of service, resources per service and those “value-added” (blue) steps as perceived from the patient’s perspective. The activities performed during each step were identified and enumerated through interviews conducted with the individuals involved in each of the steps (surgeons, anesthesiologists, office managers, secretaries, and nurses).
Major Milestones along the Journey
Phase 1: Pre-Hospital Phase
Critical steps set the stage before a patient even arrives at the hospital
This phase begins when the surgeon decides upon surgical intervention and the patient consents, to the time the patient arrives at the hospital on the day of surgery. During the pre-hospital phase, the central role of a surgeon’s administrative staff becomes very evident in the process.
As quoted in the study, “These individuals have decentralized, specific knowledge about individual procedure requirements, surgeon availability and preferences, and patient variables (age, geography, insurance and co-morbidities.)” It is clear the surgeon’s administrative team has considerable impact on the Surgical Services workflow, and because of this fact, they should not be measured for performance or incentivized in the same way as other department staff are measured. Rather, it may be more effective to place the surgeon’s administrative staff under the governance of Surgical Services where their job performance may be managed according to its direct impact on the process.
The paper imperative
During this phase, a lot of paperwork is generated at the surgeon’s office, then sent to the hospital, and unfortunately, it’s notorious for being incomplete. The International Journal of Surgery study found that 83% of pre-operative charts were incomplete and 31% of patients had no chart whatsoever on the day of surgery. In another study published in the Journals of American Medical Association titled Missing Consent Forms in the Pre-operative Area, A Single-Center Assessment of the Scope of the Problem and its Downstream Effects (Garonzik-Wang et al. 2013)2, the authors state that 66% of patients were missing consents at the time of surgery, which caused a delay in 14% of operative cases.
If there is no feedback loop to catch such issues before they occur, then incomplete information must be remedied on the day of surgery. An unwelcome roadblock that uniformly results in
1) Delays in the OR
2) Increased stress for the patients.
Furthermore, the informed consent process obtained just prior to surgery is often times rushed. This poses a legal risk for the hospital as the patient may not fully understand the risks and possible outcomes of the surgery. And if a poorly explained potential outcome manifests from the surgery, it may, consequently, manifest a lawsuit.
The International Journal of Surgery article also states that 62% of ICU beds needed on the day of surgery were not scheduled in advance. Surgeries could not occur until the recovery beds were open. Similar statistics can be found published by Duke School of Nursing in, Operating Room Delays – Meaningful Use in Electronic Health Record (Van Winkle et al. 2016)3.
Phase 2: Patient Arrival – From Hospital Check-in to the OR
Economies of time
According to “Optimizing your Operating Room: Or, Why Large, Traditional Hospitals Don’t Work (Girotto, Koltz, and Drugas 2010)1 on the day of surgery, patients are often asked to arrive at the hospital 90 minutes early. Once checked in, the patient is ushered to the surgical center where they begin an average wait time of 67 minutes. From there, the patient is transported to the pre-anesthesia unit where typical wait time averages 48 minutes. Finally, the patient is wheeled into the OR where Phase 3 begins.
The key takeaway here is the carefully choreographed timing for patients upon arrival until surgical procedure gets underway. In this context, time absolutely matters, as does precise, accessible information to keep the process moving at the scheduled pace.
Phase 3: Actions in the OR
Where information and process meet to create greatest impact
The surgical procedures performed in the OR entail a number of orchestrated steps by multiple team members with a single focus on patient safety and surgery success. This is where the rubber meets the road. Success demands precise information and a smooth process flow in order to achieve optimal patient outcomes.
Step 1: The patient enters the room, anesthesia is administered and the patient is ready for the surgical team. Average time elapse: 13 minutes.
Step 2: Patient is positioned for surgery, the procedure occurs, dressings are applied. Patient prep and positioning average time elapse: 13 minutes. Operating average time elapse: 66 minutes. (Note: Operating times vary widely depending upon procedure.)
Step 3: Anesthesia reversal and transfer of patient out of the OR to recovery. Average time elapse: 11 minutes.
Identifying points of risk or potential detours
It should be restated that this is a very high level overview of the Surgical Services process, but it illustrates how extraordinarily complex the process is, prone to error and inefficiency in multiple junctures, and ripe for improvement. Doctors Girotto, Koltz, and Drugas go on to highlight the following critical red flags that can create a chain reaction that can directly impact Surgical Services outcomes and economies:
- Pre-operative charts incomplete
- Operating room scheduling inaccurate
a. Operating room doesn’t start on time
b. Operating room doesn’t start on time
- Anesthesia activity times not incorporated in scheduling
- Patients experience long queue times
- Patient throughput on the operative day is an unstable system
- Data collection inadequate and inaccurate
- No feedback mechanism or pattern of accountability to correct errors
- No incentives or consequences for improved patient care, throughput, cost containment, chart readiness, or adherence to schedule. In fact, the fragmented, “silo” structure of operating room leadership leads to conflicting incentives.
So where can your hospital improve? Not surprisingly, the best place to start is at the beginning. If Pre-Hospital Phase 1 runs smoothly, it enables the anesthesiologists and surgeons, along with their supporting teams, with complete information and timely access to it. Beginning the patient OR journey with the end in mind means less finger pointing, higher staff morale, and ultimately and most importantly, happier, healthier patient outcomes.
Learn about the economic risks on the pre-surgery patient journey in our latest infographic:
2Garonzik-Wang, Jacqueline M., Gabriel Brat, Jose H. Salazar, Andrew Dhanasopon, Anthony Lin, Adesola Akinkuotu, Andres O’Daly, et al. 2013. “Missing Consent Forms in the Preoperative Area.” JAMA Surgery 148 (9): 886.
3Van Winkle, Rachelle A., Mary T. Champagne, Meri Gilman-Mays, and Julia Aucoin. 2016. “Operating Room Delays: Meaningful Use in Electronic Health Record.” Computers, Informatics, Nursing: CIN 34 (6): 247–53.