Optimizing the OR: a bottom-up approach

Why can't we improve turnover time? A systematic review

BACKGROUND

Despite substantial efforts to reduce operating room (OR) turnover time (TOT), delays remain a frustration to physicians, staff, and hospital leadership. These efforts have employed many systems and human factor-based approaches with variable results. A deeper dive into methodologies and their applicability could lead to successful and sustained change. The aim of this study was to conduct a systematic review to evaluate relevant research focused on improving OR TOT and clearly defining measures of successful intervention.

MATERIAL AND METHODS

A systematic review of OR TOT interventions implemented between 1980 through October 2022 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Research databases included: 1) PubMed; 2) Web of Science; and 3) OVID Medline.

RESULTS

A total of 38 articles were appropriate for analysis. Most employed a pre/post intervention approach (29, 76.3%), the remaining utilized a control/intervention approach. Nine intervention methods were identified: the majority included a process redesign bundle (24, 63%), followed by overlapping induction, dedicated unit/team/space feedback, financial incentives, team training, education, practice guidelines, and redefinition of roles/responsibilities. Studies were further categorized into one of two groups: (1) those that utilized predetermined interventions based on anecdotal experience or prior literature (18, 47.4%) and (2) those that conducted a prospective analysis on baseline data to inform intervention development (20, 52.6%).

DISCUSSION

There are significant variability in the methodologies utilized to improve OR TOT; however, the most effective solutions involved process redesign bundles developed from a prospective investigation of the clinical work-system.

First Case On-Time Starts Measured by Incision On-Time and No Grace Period: A Case Study of Operating Room Management

EXECUTIVE SUMMARY

A delay in first case on-time starts (FCOTS) can lead to less operating room (OR) utilization, greater facility costs, and dissatisfaction among staff and patients. FCOTS is usually measured by the patient in-room metric with a small grace period. For this study, the partnering hospital elected to target and improve delays by aggressively defining FCOTS as time of incision with no grace period. Metric standardization, goal setting, and organizational focus contributed to a 9-month implementation plan to improve the newly defined FCOTS metric. The target was achieved during implementation, with 73.6% of first cases starting on time. Annual impact showed 80,587 min, or 1,343 hr, of saved OR time, which led to $771,000 in annual savings for variable OR labor costs. This redefined metric and related interventions contributed to significant reduction in delays and savings to the hospital. Engaged physician leadership played a key role in this improvement initiative, as well. The methods employed here can be used in other hospitals looking to improve FCOTS metrics in their procedural areas.

Improved Operating Room Efficiency via Constraint Management: Experience of a Tertiary-Care Academic Medical Center

BACKGROUND

Suboptimal operating room (OR) efficiency is a universal complaint among surgeons. Nonetheless, maximizing efficiency is critical to institutional success. Here, we report improvement achieved from low-cost, low-technology measures instituted within a tertiary-care academic medical center/Level I trauma center.

STUDY DESIGN

Improvements in preadmission testing and OR scheduling, including appointing a senior nurse anesthetist to help direct OR use, were instituted in March 2012. A retrospective review of prospectively maintained OR case data was performed to evaluate time periods before and after program implementation, as well as to assess trends over time. Operating room performance metrics were compared using Mann-Whitney and chi-squared tests. Changes over time were analyzed using linear regression.

RESULTS

Data including all surgical cases were available for a 36-month period; 10 months (6,581 cases) before program implementation and 26 months afterward (17,574 cases). Dramatic improvement was seen in first-case on-time starts, which increased from 39.3% to 83.8% (p < 0.0001). Additionally, the percent utilization of available OR time demonstrated a steady increase (p < 0.001). After an initial lag, case volume also improved, evident by an increase observed in the 12-month rolling average of cases per month (p < 0.001). The increase in case volume occurred during peak OR time (7 am to 5 pm), and did not result from adding cases after hours (5 pm to 11 pm).

CONCLUSIONS

After many years of what seemed an insoluble problem, simple changes fostering collaboration among services, including active management of the OR schedule and transparent data, have resulted in substantial improvement in OR efficiency and case volume.