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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
100
200
300
400
500
600
700
800
900
1000O
ncol
ogy
Orth
o
Ora
l/Max
il
Gen
eral
Trau
ma
Ren
al/T
x
Gyn
-Onc Oto
Neu
ro
Gyn
ecol
ogy
Hep
atob
il/Tx
CT
Sur
g
Vas
cula
r
Pla
stic
s
Uro
logy
Surgical Service
Addi
tiona
l Tes
ting
Rate
(%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Num
ber o
f Pat
ient
s
# Patients% Excess Tests
©VUMC2001