Reports From the Field

Applying a Quality Improvement Framework to Operating Room Efficiency in an Academic-Practice Partnership

Journal of Clinical Outcomes Management. 2016 March;23(3)

References

1. The right strategies can help increase OR utilization. OR Manager 2013;29:21–2.

2. Jackson RL. The business of surgery. Managing the OR as a profit center requires more than just IT. It requires a profit-making mindset, too. Health Manage Technol 2002;23:20–2.

3. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington (DC): National Academy Press; 2001.

4. Hand R, Dolansky MA, Hanahan E, Tinsley N. Quality comes alive: an interdisciplinary student team’s quality improvement experience in learning by doing—health care education case study. Qual Approaches Higher Educ 2014;5:26–32.

5. Scholtes PR, Joiner BL, Streibel BJ. The team handbook. Oriel; 2003.

6. Institute for Healthcare Improvement. Open School. 2015. Accessed 13 Apr 2015 at www.ihi.org/education/ihiopenschool/Pages/default.aspx.

7. Ogrinc GS, Headrick LA, Moore SM, et al. Fundamentals of health care improvement: A guide to improving your patients’ care. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources and the Institute for Healthcare Improvement; 2012.

8. Managing patient flow: Smoothing OR schedule can ease capacity crunches, researchers say. OR Manager 2003;19:1,9–10.

9. Harders M, Malangoni MA, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery 2006;140:509–16.

10. Paynter J, Horne W, Sizemore R. Realizing revenue opportunities in the operating room. 2015. Accessed 13 Apr 2015 at www.ihi.org/resources/Pages/ImprovementStories/RealizingRevenueOpportunitiesintheOperatingRoom.aspx.

11. Cima RR, Brown MJ, Hebl JR, et al. Use of Lean and Six Sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg 2011;213:83–92.

12. Day R, Garfinkel R, Thompson S. Integrated block sharing: a win–win strategy for hospitals and surgeons. Manufact Serv Op Manage 2012;14:567–83.

13. Pardini-Kiely K, Greenlee E, Hopkins J, et al. Improving and Sustaining core measure performance through effective accountability of clinical microsystems in an academic medical center. Jt Comm J Qual Improv Pt Safety 2010;36:387–98.

14. Hall LW, Headrick LA, Cox KR, et al. Linking health professional learners and health care workers on action-based improvement teams. Qual Manag Health Care 2009;18:194–201.

15. Ogrinc GS, Nierenberg DW, Batalden PB. Building experiential learning about quality improvement into a medical school curriculum: The Dartmouth Experience. Health Aff 2011;30:716–22.

16. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice. Washington, DC: Interprofessional Education Collaborative; 2011.

17. World Health Organization. Framework for action on inerprofessional education and collaborative practice. Geneva: World Health Organization; 2010.

Through the creation of the process map, the project team found that there was wide variation in the process and structure for scheduling surgeries. Some departments used one central scheduler while others used individual secretaries for each surgeon. Some surgeons maintained control over changing their schedule, while others did not. Further, the project team learned that the metric of block utilization rate was of varying importance to people working on the ground.

As each department used a unique process to schedule surgeries in their assigned block times, the project team decided to focus on one department. Urology was chosen because they were a smaller department and demonstrated readiness for change. The process map for urology is shown in Figure 1 .

Tool 4: Fishbone Diagram

After understanding the process, the project team considered all of the factors that

could influence block utilization rates using a fishbone diagram ( Figure 2 ). Many people and systems could impact to the global aim of improving block utilization rate and the fishbone diagram served as an organized way to visualize and consider which of the many contributing factors to focus on first.

Tool 5: Specific Aim

Though the global aim was to improve block utilization, the project team needed to chose a specific aim that met S.M.A.R.T criteria: Specific, Measureable, Achievable, Results-focused, and Time-bound [7]. After considering multiple potential areas of initial focus, the OR staff suggested focusing on the issue of case length accuracy. In qualitative interviews, the student team had found that the surgery request forms ask for “case length,” and the schedulers were not sure how the surgeons defined it. When the OR is booked for an operation, the amount of time blocked out is the time from when the patient is brought into the operating room to the time that the patient leaves the room, or WIWO (Wheels In Wheels Out). This WIWO time includes anesthesia induction and preparations for surgery such as positioning. Some surgeons think about case length as only the time that the patient is operated on, or CTC (Cut to Close). Thus, the surgeon may be requesting less time than is really necessary for the case if he or she is only thinking about CTC time. The student team created a survey and found that 2 urology surgeons considered case length to be WIWO, and 4 considered case length to mean CTC.

In order to understand the potential impact of this difference, the project team compared the recorded case length (WIWO time) with the time that had been requested for the urology surgeons in 2014. Surgeons in this department varied from 21%-40% in their case length accuracy ( Table 2 ). Given these discrepancies, the project team established the following specific aim: We will improve the percentage of “accurate” case lengths by 10% in one week (with “accurate” defined as within 15 minutes of the scheduled time).

Tools 6 and 7: PDSA Cycle and Control Charts

The Plan-Do-Study-Act cycle is an iterative plan of action for designing and testing a specific change [7]. This part of the QI cycle involved implementing and testing a change to address our specific aim. As the first cycle of change, the team requested that the scheduler add 15 minutes to the surgeons’ requested case time over 1 week. Of the urologists scheduled that week, one had used CTC and the other had not completed the student team’s survey. In order to study the change, the project team used control charts for the 2 surgeons whose case times were adapted. Prior to the intervention, the surgeons averaged at least 20 minutes over their scheduled time, with wide variation. Surgeons were infrequently completing cases at or below their requested case time. Most of the inaccuracy came from going long. The team used control charts to understand the impact of the change. The control charts showed that after the change in scheduling time, the 2 surgeons still went over their allotted case time, but to a lesser degree.