Improving OR EfficiencyImproving OR Efficiency

What are we trying to accomplish?AIM

What are we trying to accomplish?AIM

How will we know that a change is an improvement?Data

(Tools: Surveys, Run Charts)

How will we know that a change is an improvement?Data

(Tools: Surveys, Run Charts)

What changes can we make that will result in an improvement?Process Analysis

(Tools: Flowchart, Cause & Effect Diagram, Pareto Chart, etc.)Decide on changes

What changes can we make that will result in an improvement?Process Analysis

(Tools: Flowchart, Cause & Effect Diagram, Pareto Chart, etc.)Decide on changes

IMPROVEMENT MODEL

Planthe

Improvement

Studythe

Results

Dothe

Improvement

ActAct to keep changeor Abandon and try

another change

PDSA Cycle—Small rapid cycles of changeLangley, Nolan, et al. 1996

P

A D

SWeb Link for Resources: www.ihi.org/ihi/sitemap.aspx

What are we trying to accomplish?

Aim: To reduce Start Time delays in the OR

What are we trying to accomplish?

Aim: To reduce Start Time delays in the OR

How will we know that a change is an improvement?

Measure first case in the morning and record delays in minutes

How will we know that a change is an improvement?

Measure first case in the morning and record delays in minutes

What changes can we make that will result in an improvement?

Process Analysis

What changes can we make that will result in an improvement?

Process Analysis

Run Chart of DelaysOR Delays in Start Time

0

15

30

45

60

75

90

105

120

1 3 5 7 9 11 13 15 17 19 21 23 25

Patients

Tim

e

©VUMC2001

Process Flowchart

Nursing evaluation

done?

Surgery H&P done?

Yes Surgical consent signed?

Yes Anesthesia evaluation

done?

Yes Risk & medicolegal

issues addressed?

YesNeed pre-op lines in holding?

Yes OR ready?

Yes

Perform nursing

evaluation weight

No

Perform H&P

No

Obtain signed consent

NoPerform evaluation:

H&PIndicated tests:

labsECGCXR

No

Cancel Surgery

No

Place indicated lines

No

Wait

No

The flowchart was very large and complicated, but this is how the whole process ended-

having the final inspection just as the patient is ready to go to the OR!

Cause and Effect Diagram

©VUMC2001

OR Start Delays

PEOPLE PROCEDURES

EQUIPMENT POLICY

Surgeon Late

Anesthesia latePatientcomplications

Consultationnot done

Consult notesnot in chart

No pre-opeducation

Meds notgiven

Tests notdone

H&P not done

Nursing evaluation not done

Anesthesia evaluationnot done

Test resultsnot in chart

Doublebooked

Instrumentsnot ready

Not available

Medical record missing

Instruments notavailable

No patientconsent

Noauthorization

Registrationnot complete

No pre-op check list

Data were collected on all these causes to see which contributed most to the delays.

Pareto ChartA tool to prioritize the first

improvement.

42.37

59.32

72.88

83.0589.83

94.92100

A B C D E F G

11.80

0.00

23.60

35.40

47.20

59.00

PARETO CHART

0.00

# of errorsCum Freq

Cum

. Fre

q.

©VUMC2001

Sources of Delays

•A: Tests not ordered or results no posted.

Sources of Delays

• A: Tests not ordered or results no posted were greatest cause of delays.

So let’s study why the tests are not being ordered or posted, right?

But… are all the tests necessary?

What are we trying to accomplish?

New Aim:

To reduce the number of preoperative tests performed so that only those which are important to the medical

mgmt of adult surgical pt during pre-op period are ordered.

What are we trying to accomplish?

New Aim:

To reduce the number of preoperative tests performed so that only those which are important to the medical

mgmt of adult surgical pt during pre-op period are ordered.

How will we know that a change is an improvement?

Percentage Excess Tests Per Specialty Based Upon Agreed Upon

Guidelines

How will we know that a change is an improvement?

Percentage Excess Tests Per Specialty Based Upon Agreed Upon

Guidelines

What changes can we make that will result in an improvement?

Changes Identified

What changes can we make that will result in an improvement?

Changes Identified

• The perception was that anesthesiologists sometimes delay surgical cases in order to conduct further patient testing, with the results that surgeons have learned to order various tests simply as a precaution against such delays. The upshot is unnecessary testing.

Develop disease and surgical procedural

testing guidelines for:

-laboratory testing, -electrocardiography

-chest radiography

in adult surgical patients

Team• Anesthesiology (Chair)• Otolaryngology• OB-GYN• Cardiology• Pathology• Internal Medicine• Pediatrics• Urology• Radiology• Facilitator

PDSA CYCLEPDSA CYCLE

Planthe

Improvement

Studythe

Results

Dothe

Improvement

ActAct to keep changeor Abandon and try

another change

PDSA Cycle—Small rapid cycles of changeLangley, Nolan, et al. 1996

P

A D

S

Cycles of Change• Guidelines developed• Dr. Higgins educated the

surgeons on the guidelines• Test ordering patterns were

monitored• Quarterly reports sent to

surgeons and to the specialty • Results amount to approximately

$200,000 annual cost savings.

Preoperative Testing Variation Rates by Service

25

464

38

310

7 28 53

330

108 94

951 51

157120 12

19

32

3940

54555559616263

6667

86

0

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600

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1000O

ncol

ogy

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o

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ma

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al/T

x

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-Onc Oto

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ro

Gyn

ecol

ogy

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atob

il/Tx

CT

Sur

g

Vas

cula

r

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s

Uro

logy

Surgical Service

Addi

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Rate

(%)

0%

10%

20%

30%

40%

50%

60%

70%

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90%

Num

ber o

f Pat

ient

s

# Patients% Excess Tests

©VUMC2001