Volume 8, No. 3 • Fall 1993

“Production Pressure” Danger Avoided by CQI Effort

Diane Gulczynski, R.N., M.S., C.N.O.R.

Editor’s Note: ‘Production pressure’ is the drive in many operating suites to do as many surgical cases as possible as quickly as possible in a given time period, usually the standard operating day. Hospital administrators want maximum efficiency out of their very expensive physical plant and personnel. Further, surgeons strongly agitate for optimal anesthesia “service,’ particularly an absolutely minimum OR turnover time. These surgeons often threaten the hospital administrator with taking their cases to a competing hospital if they are delayed between cases, which ‘wastes’ their valuable time. The administrator then comes back to the anesthesiologists urging them to hurry. The pressure to cut comers, such as by not taking the time to get thoroughly familiar with a patient immediately preoperatively or to check equipment and supplies, is incredibly strong. The potential threat to patient safety is obvious.

by Diane Gulczynski, R.N., M.S., C.N.O.R.

Programs have been developed to help minimize OR turnover time without compromising anesthesia patient safety. Detailed in this article is one such effort which involved the application of a quality of care initiative.

Quality patient care in the operating room requires consistent and sustained collaboration among several major hospital departments. The traditional focus on the patient as the most important .customer” has often unwittingly prevented operating room personnel from recognizing the need to listen to the staff s perceptions of how other hospital systems can better support the operating room in providing quality patient care. The effective utilization of quality improvement techniques can only take place under strong leadership which is fully committed to the concept, as well as possessed of the discipline and perseverance to see it through.

At the New England Deaconess Hospital in Boston, key concepts of Total Quality Management and Continuous Quality Improvement programs have been integrated into key service quality initiatives. Deaconess Vice President and Chief Operating Officer Al Washko described these initiatives as .a strategically integrated process,” driven by customer needs, which seeks to create a system in which individuals and departments participate in, are held accountable for, and are recognized for, improvements in quality of the provision of services. This process “is part of an overall management strategy,” Washko explained. “It’s not a ‘project.’ If s the way we live.”

Indeed, the success of quality initiatives depends upon establishing a permanent culture of quality. This requires the formulation and articulation of a shared vision for the institution, the definition of basic management and employee expectations, education, and the monitoring of interdepartmental interactions through the collection of data. Also crucial to the creation of a culture of quality is collaboration among departments. Deaconess’s quality initiatives have defined a structure based on “service units” the groups in each department that provide a particular service to other units. Each service unit supplies certain services to other service units, which consume these services. For example, service unit A is an ‘internal supplier’ of certain services and products to service unit B, which acts as an ‘internal customer.’ In turn, service unit B likewise ‘supplies’ other services and/or products to service unit A and/or other service units.

Ideally, the various service units follow mutually agreed-to standards to assure a smooth flow of quality services and products, which ensures both cost effectiveness and patient satisfaction at the same time. In short, interrelated service units should function as a team. At Deaconess, senior management from several departments involved in perioperative care seek to foster team collaboration by example. A surgical working committee, comprised of the Chair and the Associate Chair of the Department of Surgery, the Chair of the Department of Anesthesia, and the Director of Nursing/ Ambulatory and Surgical Services, meets regularly to look at opportunities to improve the efficiency of OR scheduling, to reduce turnover time, and to continuously and critically reassess the roles and responsibilities of personnel and departments involved in perioperative care.

OR Turnover Seen as Key

OR turnover has been a particular concern to the Surgical Working Committee. The reason is simple: any time spent cleaning up after the previous case and preparing for the next one is time that cannot be scheduled for surgery. Deaconess Hospital’s identification of causes of excessive turnover time, and attempts to reduce the duration of this non-productive time, relied on the internal customer and supplier model: The goal of the perioperative nurse is to provide optimum patient care in a highly efficient, cost-effective manner. The perioperative nurse is dependent upon services provided by other departments in order to accomplish this goal. In preparing for the patient s admission to the OR, the perioperative nurse becomes the customer, awaiting the arrival of supplies contained in the case cart which was prepared in Central Processing. Additional items may be requested from other departments such as Medical Equipment and the pharmacy. Services provided intraoperatively by other departments may require preparation time before the patient’s arrival. For example, a radiation therapy physician may come to the OR, activate the Intra-Operative Radiation Unit, and place it in stand-by mode prior to the patient’s admission. All activities required for case preparation occur within the short period known as preoperative set-up time. This, combined with the time allotted for cleanup from the previous case, constitutes room turnover time. Problems with the delivery of supplies or services – including staff and equipment lateness, the malfunction of equipment, a missing or unsterile instrument – may arise, causing delay in completion of these activities, thus increasing room turnover time and, in turn, delaying the start of the next case.

Causes of Slow Turnovers

Over the past three years, the major causes of excessive turnover time and case delays at New England Deaconess Hospital have been identified. Programs were implemented to rectify these problems:

  1. Inconsistent location and par levels of supplies used intraoperatively.
  2. Lack of duplication of specific equipment required for the following procedure that was booked.
  3. Ill-defined expectations of OR attendants, OR technicians, and anesthesia technicians relating to case preparation and room decontamination.
  4. Late arrival of specific and late patient preparation by specific anesthesiologists for booked procedure.
  5. Delays/case cancellation due to presurgical evaluation and detection of medical problems on the day of surgery.
  6. Lack of a defined program of encouragement regarding enhanced work tempo during the nonproductive time between cases.
  7. Consent forms not signed by patient and surgeon prior to procedure.

Continuous quality improvement techniques were applied to these problems to effect change in the OR staffs interactions with other service units.

Suggestions and consultation from operating room attendants, nurses and technicians were all used to make turnover quicker and more efficient. For example, Deaconess messengers were enlisted to transport more patients to and from the OR. This allowed the OR staff to concentrate on replenishing supplies of sutures, linen and other materials. The nursing staff also found other ways to make their use of OR time more efficient and reduce turnover time, including the conversion of a full-time OR technician position to a Biomedical Engineering position to assist the RN circulator with all laser and laparoscopic procedures. This individual is also available to assist the anesthesiologist, the CRNA, and the anesthesia technician in problem identification and resolution, thus saving wasted, nonproductive time. By keeping the experts at the bedside, the hospital can provide a higher level of care delivery to the patients. This is just one example of work restructuring that has benefitted the entire surgical team and has assisted in readdressing performance thresholds. Another example is a formal program of inventory management instituted in a joint venture between Materials Management and the OR. A product manager position evolved and eventually increased the department’s responsibilities by taking on CPD as a prep and sterile department for the OR (instead of a distribution center for all patient care units).

In order to institutionalize quality improvement monitoring into perioperative care, the Deaconess Nursing staff, in collaboration with physicians and other specialty nursing groups, identified four important aspects of care for the intraoperative period and incorporated them into the operative record. The goal is to not only meet standards, but to constantly reevaluate those standards to ensure that the staff is providing the highest quality patient care in the most efficient manner possible. The four important aspects of care (IAOC), along with their respective expected outcomes (EO), are as follows:

1. IAOC: Management of anxiety related to perioperative events.

EO: The patient will demonstrate ability to cope with anxiety.

2. IAOC: Maintenance of skin integrity related to perioperative events.

EO: Skin condition will remain unchanged from preoperative state.

3. IAOC: Prevention of injury related to perioperative events.

EO: Patient will be free from injury upon discharge from operating room.

4. IAOC: Monitoring for fluid volume imbalance related to perioperative events.

EO: Patient’s fluid balance will be monitored and supported.

In addition to these important aspects of care, a separate sheet is used for each procedure to record and track ‘critical indicators’ and occurrences, such as a break in aseptic technique, blood occurrences, complications, intraoperative delay, equipment problems, and incomplete preoperative patient preparation. Both the Important Aspects of Care and the Critical Indicators/Occurrence forms provide constant data to assist in the identification and rectification of chronic or recurring problems during perioperative care.

Another way in which continuous quality improvement was institutionalized was through the establishment of critical indicators for surgical delays, which allowed all forms of delay to be tracked. There are six specific categories of causes of delays: OR suite related, such as case cart problems and unrealistic estimates of procedure length; patient related, e.g. a patient who does not undergo pre-admission testing or a needed cardiac consult; consent-form related; support service related, e.g. delay in messenger services or blood bank services; anesthesia related, such as a difficult line placement or failure to complete pre-op assessment; and physician related, e.g. surgeon late, procedure improperly booked, or resident unavailable, Each delayed case is documented, monitored as part of a larger database, and the appropriate department is notified of the problem. The goal is not to look at personnel (whether it be surgeons, anesthesiologists, etc.) as chronic offenders, but to include those involved in looking at processes that might better improve systems, thus improving compliance.

Major Success

As a result of programs such as these, in 1991 turnover time decreased by more than 1,000 hours from the previous year, and again in 1992, the turnover time was decreased. By freeing up OR nonproductive time and turning it into productive time for more cases, this reduction in turnover time resulted in:

* Hundreds of thousands of dollars in potential revenues through increased time for case scheduling;

* Decrease in staff overtime required to finish each days cases;

* Increased patient satisfaction through more timely, dependable scheduling of surgery;

* Increased physician satisfaction with internal services; and

* Increased teamwork between a wide variety of hospital service units.

The success of Deaconess’s Service Quality Initiatives illustrates the potential in terms of enhancing patient care, employee satisfaction, and the hospital’s bottom line of the proper application of continuous quality improvement principles to perioperative patient care. Critical to the success of Ns endeavor are several components: the commitment and participation of employees at all levels within the organization, especially a unified interdepartmental management team; the institutionalization of quality improvement as an ongoing process through a variety of media, e.g. publicized monitoring reports in bulletin boards, and basic documentation such as the OR record; and imaginative work restructuring experiments which improve service and/or product provision, thereby enhancing the efficiency of the contributions of surgeons, anesthesiologists, nurses, and technicians to perioperative care. With its ameliorative effects on patient care, staff productivity and satisfaction, and the hospitals financial health, continuous quality improvement is not a desirable luxury; it is a critical component of any competitive strategy for all health care institutions seeking to flourish in the 21st century.

Ms. Gulczynski is Vice President for Surgical Services and Quality Initiatives at New England Deaconess Hospital, Boston, MA.