Maintaining high efficiency and productivity is critical for hospitals and ASCs, which operate on increasingly thinner margins due to changes in reimbursement policies and other factors.
During Becker's ASC Review and Becker's Spine Review 19th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference, in a workshop sponsored by Mizuho OSI®, a leading manufacturer of specialty surgical tables and other positioning solutions, two orthopedic surgeons from Arthritis & Total Joint Specialists in Georgia — Charles A. DeCook, MD, and Jeremy Statton, MD — discussed root causes of inefficiency and strategies to achieve operational excellence.
Four key insights were:
1. Operating room inefficiency has multiple drivers. One driver is the amount of time a surgeon spends not operating despite an OR being available, which limits surgical case volume. Another driver, specifically for knee and hip arthroplasty, is operative time that exceeds 80 to 90 minutes. Studies have shown that surpassing that threshold increases the risk of adverse outcomes such as surgical site infections. So, in addition to crowding out other surgeries, excessive operative time has a negative impact on value-based care.
Other drivers of inefficiency include the multitude of steps a joint replacement patient's journey involves from the moment they arrive at a site until discharge. Those steps include registration, preoperative assessment, spinal injection, positioning, prep and drape, exposure, trial, final implants, closure, transfer, recovery, physical therapy and discharge. When a care site is managing flows of multiple patients through those steps, the challenge to maintaining efficiency is significant.
2. Radical time transparency can boost OR efficiency. The concept, pioneered by Dr. DeCook and Dr. Stanton, encompasses six aspects about time:
- Measured – Need to break each case down into smaller pieces to capture and track metrics for each step including first case time start, in room to draped/anesthesia/cut, each step of the procedure, cut to closing, breakdown and cleaning time
- Visible – make operative times visible by displaying on monitors how long it takes to perform each step of the patient's journey
- Live – make times visible in real time
- Valued – create a culture where staff members value time and do not fill operative segments with personal distractions (e.g., checking their phones)
- Personal – personalize times shown to each surgeon so they can know and track their own performance
- Radical – once we know our times, we are honest and transparent, and this leads to fundamental change
"This is not about speed; we're not trying to see how quickly we can go — it's about efficiency," Dr. Statton said. "We want to take a task we're already doing and do it in a better, easier way. Ultimately that may result in [improved] speed, but speed itself is not the goal."
3. Improving OR utilization leads to operational excellence. One indicator for operational excellence is nonoperative time (NOT). To nudge surgical teams to reduce NOT, organizations need to scrutinize how they define first case on time start (FCOTS). For example, the definition may need to be changed from starting within 15 minutes of scheduled time to starting within one minute of scheduled time. Dr. Statton highlighted a study looking at how an institution was able to apply operating room efficiency to decrease personnel, turnover and overtime costs even as they hired more staff and increased the number of cases and revenue. Other approaches to increasing OR efficiency include:
- Using Lean and Six Sigma methodologies to map out surgical flows.
- Working in parallel versus in series to reduce the impact of delays.
- Improving anesthesia efficiency by using a "swing room" model.
- Ensuring consistent teams with well-defined workflows and routines.
- Encouraging surgeon leadership.
- Considering an ASC model with smaller footprint, consistent anesthesia and experienced staff.
- Using enabling technology such as the Hana® table, which is designed to optimize hip arthroplasty. Any technology that helps the surgery go easier, better and faster is worth investing in.
4. Achieve true efficiency through aggregation of marginal gains. Because hospitals and ASCs balance many issues simultaneously, trying to define a single problem as a target for optimizing efficiency is not the best approach.
"If you think big about this, you stay fixated on the obvious problems, things like turnover time, which are never actionable. By thinking small, you have consistent ways of measuring and evaluating small things that are always overlooked [but can be improved on]," Dr. DeCook said. He added that focusing on individual processes in the OR (e.g., breaking down trays), evaluating each step in those processes and optimizing for those actions is the fastest way to improve efficiency that eventually channels tiny gains into big wins.