Who is responsible for operating room management and how do we measure how well we do it?

Contribution of Coordination Theories to the Determination of Human Factors Associated With Operating Room Perceived Performance

BACKGROUND

The efficient and fluid organization of surgical interventions in an operating room (OR) and operating suite (OS) is important as these are among the most expensive units to run in medical-surgical facilities. The complexity of OS organization requires careful coordination, defined here as the directing of individuals' efforts toward achieving common and explicitly recognized goals. There is currently sparse literature on OS coordination, especially in the French context. This study aimed to respond to this gap by reporting on the coordination mechanisms associated with the perceived performance of OS across 4 facilities in an urban setting in France.

METHODS

We used a qualitative comparative case study based on ethnographic methodology to explore 4 facilities (2 teaching, 1 general, and 1 private). Several investigation techniques were used for data collection (semistructured interviews, participant and nonparticipant observations, and informal interviews) in the OR, the OS, the regulation council (dedicated to adapting the necessary resources to specific procedures and patients' health status), and the OS council (dedicated to strategic and operational OS transformations and adaptations, and responsible for finding solutions to organizational problems). Analysis was guided by Okhuysen and Bachky's theoretical framework on coordination and multi-team systems theory. Data were compared across the 4 facilities and triangulated using the different techniques to ensure coherence and accuracy.

RESULTS

Overall, 48 interviews with health care providers and hospital managers and 200 hours of direct observations were performed. The OR exhibited a high degree of coordination, whereas improved perception of performance in the OS depended on managerial competency, trust, and authority. Perceived performance in the regulation council and OS council, on the other hand, depended on the identification of formal objectives by all stakeholders and the development of common understanding (developing agreement, direct information sharing, creating common perspective, substitution, bringing groups together, and storing of knowledge).

CONCLUSIONS

Based on existing literature on multi-team systems (as represented in the OS organization), this study identifies success factors influencing OS coordination. These include the OS manager's leadership skills; the identification of formal system objectives; and professional differentiation between stakeholders (absence/decrease of a sense of belonging to a multi-team system). This differentiation was related to the high degree of specialization within OS teams, each bringing different norms, cultures, and contingencies that induce dissonance in organization and task performance. Interventions targeting these success factors might improve coordination, and thus performance, in the OS.

Bibliometric Analysis of Contributions of Anesthesiology Journals and Anesthesiologists to Operating Room Management Science

BACKGROUND

Anesthesiology journals appear to have been progressively publishing a smaller percentage of operating room (OR) management studies. Similarly, non-anesthesiologists have increasingly been authors of these publications. Five hypotheses were formulated to evaluate these impressions based on 2 of the authors' curation of an online, comprehensive bibliography of OR management articles and corresponding referenced course materials.

METHODS

We studied all 2938 publications having Scopus' SciVal topic T.6319 (OR management) more than 28 years from 1996 through May 2023, including 8608 distinct authors.

RESULTS

Half (50%) of the publications were absent from PubMed, and the percentage absent has been increasing progressively (Kendall's τ = 0.71; P < .0001). Fewer than half were published in journals including anesthesiology as the sole classification (20%) or as one of the classifications (27%). The anesthesiology journals have been publishing a progressively decreasing fraction (τ = -0.61; P < .0001). Among the 11 authors each contributing at least 1% of the OR management science publications, 9 were anesthesiologists and the other 2 had anesthesiologists as coauthors on all these publications. Only 3% of authors had at least 10 OR management publications from earlier years. There were 75% of authors with no such earlier publications and 85% with 0 or 1. There was a progressive increase in the number of authors publishing OR management annually and with at most 1 such earlier publication (τ = 0.90; P < .0001). Only 20% of publications had any author with at least 10 earlier OR management publications, 48% had every author with no such earlier publications, and 60% had all authors with 0 or 1.

CONCLUSIONS

Although most of the authors with the greatest production of OR management science were anesthesiologists, the percentage of publications in anesthesiology journals has been decreasing progressively. Anesthesiologists cannot rely solely on anesthesiology journals to keep up with the field. For most publications, every author had few or no earlier publications on the topic. Clinicians and managers relying on OR management science will continue to need to apply more information when judging whether published results can reliably be applied to their facilities.

[Professional teamwork and communication in the operating room-A narrative review]

BACKGROUND

A team in the operating room (OR) is a hierarchically structured, gender-mixed group of people belonging to different professional categories. Disparities in the objectives of the different team members under economic pressure to perform, are sources of potential conflict in the daily work routine. This may have a negative impact on patient safety and commercial efficiency of hospital management.

OBJECTIVE

The aim of this summary is to sensitize the reader to the complex of problems in daily life in the OR and to increase awareness of possible approaches to solve the difficulties in an OR. Problem solutions might be approached by improvement of communication and team building.

METHODS

Narrative review of current literature and expert recommendations by a literature search in PubMed and Medline; keywords included teamwork, communication, operating room, team building.

RESULTS AND CONCLUSION

Communication and teamwork in the OR are of immense importance for patient safety and the economic development of a hospital. Improvements in communication structure, among other things due to the implementation of a team time out and moderation from outside (OR manager) offer solutions to avoid conflicts in everyday clinical practice.

Motivations Influencing the Surgeon's Healthcare Unit Choice to Perform Surgery: A Confirmatory Study in Portugal

Quality surgical practice is a fundamental subject in health institutions, and it is important to understand the structural and organizational conditions of the operating room (OR). The present exploratory study sought to understand the motivations that underlie the choice of surgeons for the best healthcare unit to perform surgery, as well as the characteristics of those professionals regarding age, years of work experience, and sex. A questionnaire survey was administered to a convenience sample of 99 surgeons, 67.3% male and 32.7% female, aged 37 to 66 (M = 23.7; Std = 8.92). The results show that at the top of the surgeons' motivations to perform surgery is the 77.8% attributed to the human resources and equipment available and at the other extreme the 3% to the previous online visit to facilities. This study opens important clues to the development of more in-depth and comparative approaches, necessary for the continuous improvement of the healthcare provided in the context of surgical practice.

Nurses keeping patients safe by managing risk in perioperative settings: A classic grounded theory study

AIM

To develop and expand how nurses promote safety in perioperative settings.

BACKGROUND

This article presents orchestrating a sub-core category from the theory of anticipatory vigilance in promoting safety within preoperative settings (Journal of Clinical Nursing, 27, 2018, 247). Orchestrating explains this and involves effective planning, delegating, co-ordinating and communication.

METHOD

A classic grounded theory methodology was used. Ethical approval was granted. Data comprised of 37 interviews and 33 hr of non-participant observation. Data analysis followed the principals of classic grounded theory.

RESULTS

Orchestrating is fundamental in promoting safety and minimizing risk of errors and adverse events in the perioperative setting. Nurses achieve this through four categories: macro orchestrating, locational orchestrating, situational orchestrating and being in the know.

CONCLUSION(S)

Nurses minimize risk by fostering a culture of safety, risk awareness, effective management and leadership.

IMPLICATIONS

Effective management structures and support systems are essential in promoting a culture of safety in perioperative setting.

The nurse manager's role in perioperative settings: An integrative literature review

AIM

To describe the nurse manager's role in perioperative settings.

BACKGROUND

The nurse manager's role is complex and its content unclear. Research in this area is scarce. We need to better understand what this role is to support the nurse manager's work and decision-making with information systems.

EVALUATION

An integrative literature review was conducted in May 2018. Databases CINAHL, Cochrane, PubMed and Web of Science were used together with a manual search. The review followed a framework especially designed for integrative reviews. Quality of the literature was analysed with an assessment tool. Nine studies published between 2001 and 2016 were included in the final review.

KEY ISSUE

The findings from the review indicate that the nurse manager's role requires education and experience, and manifests in skills and tasks. A bachelor's degree with perioperative specialisation is the minimum educational requirement for a nurse manager.

CONCLUSION

Research lacks a clear description of the nurse manager's role in perioperative settings. However, the role evolves by education. More education provides advanced skills and, thereby, more demanding tasks. Information technology could provide useful support for task management.

IMPLICATIONS FOR NURSING MANAGEMENT

These findings can be used to better answer the current and future demands of the nurse manager's work.

Improving intraoperative handoffs for ambulatory anesthesia: challenges and solutions for the anesthesiologist

Permanent transitions of care from one anesthesia provider to another are associated with adverse events and mortality. There are currently no available data on how to mitigate these poor patient outcomes other than to reduce the occurrence of such handoffs. We used data from an ambulatory surgery center to demonstrate the steps that can be taken to achieve this goal. First, perform statistical forecasting using many months of historical data to create optimal, as opposed to arbitrary shift durations. Second, consider assigning the anesthesia providers designated to work late, if necessary, to the ORs estimated to finish the earliest, rather than latest. We performed multiple analyses showing the quantitative advantage of this strategy for the ambulatory surgery center with multiple brief cases. Third, sequence the cases in the 1 or 2 ORs with the latest scheduled end times so that the briefest cases are finished last. If a supervising anesthesiologist needs to be relieved early for administrative duties (eg, head of the group to meet with administrators or surgeons), assign the anesthesiologist to an OR that finishes with several brief cases. The rationale for these recommendations is that such strategies provide multiple opportunities for a different anesthesia provider to assume responsibility for the patients between cases, thus avoiding a handoff altogether.

The Criterion Validity, Reliability, and Feasibility of an Instrument for Assessing the Nursing Intensity in Perioperative Settings

Patient classification systems generate information for staff allocation based on a patient's care needs. This study aims to test further the instrument for assessing nursing intensity (NI) in perioperative settings. Nine operating departments from five university hospitals were involved. The perioperative nurses gathered data from patients (N = 876) representing different fields of surgery. Reliability was tested by parallel classifications (n = 144). Also, the users' (n = 40) opinions were surveyed. The results support the predictive validity and interrater reliability of the instrument. The nurses considered the instrument feasible to use. The patients' low ASA class did not automatically signify low NI; however, high ASA class was more frequently associated with high intraoperative NI. Intraoperative NI indicated the length of the postanaesthesia care and the type of the follow-up unit. Parallel classifications ensured the homogenous use of the instrument. The use of the instrument is recommended.

Cancellation of operations in Saudi Arabian hospitals: Frequency, reasons and suggestions for improvements

Objective:

To identify the frequency and reasons of operations cancellation in 25 Makkah region hospitals in Saudi Arabia.

Methods:

Retrospective evaluation of the rate of surgery cancellation in 25 hospitals of Makkah region was performed in this study. The data of scheduled surgeries from 15 different surgical specialties was collected from January to December 2013. Frequency and reasons of cancellation of elective surgical cases in different specialty were studied with a view to recommend suggestions for improvement. Data was analyzed on SPSS -16.

Results:

There are 120 operating rooms (OR) in 25 Makkah region hospitals and during the year 2013, a total of 16,211 surgery cases were listed, and 1,238 (7.6%) cases were canceled. Contribution to total cancellation was highest in orthopedic 33.8% followed by general surgery 27.5%, obstetrics 7.7% and ENT 5.2%. According to category, 42.81% rate of cancellation was patient related, 20.03% facility related, 9.45% due to improper work-up, 1.45% associated with anesthesia, 7.19% related to surgeons, and 18.90% other/and not recorded reasons.

Conclusions:

Present study found 7.6% cancelation rate in Makkah region hospitals and three most common causes for cancellations were patients related, facility related and improper work-up.

Operating room data management: improving efficiency and safety in a surgical block

Background

European Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety.

Methods

The developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011.

Results

Raw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011).

Conclusions

The developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.

Assessing the Performance of Operating Rooms: What to Measure and Why?

There are multiple indicators that measure different aspects of operating room (OR) performance such as OR productivity, satisfaction of patients and staff involved. The choice of these indicator(s) used for monitoring the performance of ORs often impacts how the processes of ORs are organised and managed. However, there is still no consensus in literature on which indicator(s) should be used for monitoring OR performance. In an effort to promote consensus within the healthcare community, this paper discusses potential performance metrics which may be employed for evaluation of ORs, their rationale and their limitations, and explains why a multidimensional approach is critical in assessment of OR performance.

Curriculum providing cognitive knowledge and problem-solving skills for anesthesia systems-based practice

BACKGROUND

Residency programs accredited by the ACGME are required to teach core competencies, including systems-based practice (SBP). Projects are important for satisfying this competency, but the level of knowledge and problem-solving skills required presupposes a basic understanding of the field. The responsibilities of anesthesiologists include the coordination of patient flow in the surgical suite. Familiarity with this topic is crucial for many improvement projects.

INTERVENTION

A course in operations research for surgical services was originally developed for hospital administration students. It satisfies 2 of the Institute of Medicine's core competencies for health professionals: evidence-based practice and work in interdisciplinary teams. The course lasts 3.5 days (eg, 2 weekends) and consists of 45 cognitive objectives taught using 7 published articles, 10 lectures, and 156 computer-assisted problem-solving exercises based on 17 case studies. We tested the hypothesis that the cognitive objectives of the curriculum provide the knowledge and problem-solving skills necessary to perform projects that satisfy the SBP competency. Standardized terminology was used to define each component of the SBP competency for the minimum level of knowledge needed. The 8 components of the competency were examined independently.

FINDINGS

Most cognitive objectives contributed to at least 4 of the 8 core components of the SBP competency. Each component of SBP is addressed at the minimum requirement level of exemplify by at least 6 objectives. There is at least 1 cognitive objective at the level of summarize for each SBP component.

CONCLUSIONS

A curriculum in operating room management can provide the knowledge and problem-solving skills anesthesiologists need for participation in projects that satisfy the SBP competency.

Managing quality in an anesthesia department

PURPOSE OF REVIEW

To provide a practical approach to measure and then improve the quality of an academic anesthesia department.

RECENT FINDINGS

The quality of any entity is defined by the user. Anesthesia departments should adopt practices that meet their specific operational needs. The relative importance of each of the user groups will be determined by the purpose of an individual department. Four categories of users will be considered: patients, surgeons (and other proceduralists), the hospital organization and the department itself (i.e. faculty and trainees). Patients value avoiding nausea and vomiting and pain after surgery, surgeons want cases to start on time with low turnover times, and the hospital desires high throughput of surgical cases, all facilitated by department faculty who value professional development. Quality improvement efforts in anesthesia should be aligned with broad healthcare quality improvement initiatives and avoid distortions in perceptions of quality by over-emphasizing what is easily measurable at the expense of what is important.

SUMMARY

Departments of anesthesia should develop performance criteria in multiple domains and recognize the importance of human relationships (between staff and between staff and patients) in quality and safety. To improve the value of anesthesia services, departments should identify their user groups, survey them to determine what attributes are important to the user, then deliver, measure, monitor and improve them on an ongoing basis.

[Importance of material logistics in the interface management of operation departments: is the supply of sterile equipment a new business area of operation room organization?]

The implementation of diagnosis-related groups (DRGs) sharply increased economic pressure on hospitals. Hence, process optimization was focussed on cost-intensive areas, namely the operation room (OR) departments. Work-flow in the OR is characterized by a mandatory interlocking of the job functions of many different occupational groups and the availability of a variety of different materials. Alternatives for staff assignment optimization have been published in numerous publications dealing with the importance of OR management. In this connection the issue of material logistics in the context of OR management has not been frequently addressed. In order to perform a surgical procedure according to plan, one depends on personnel and on timely availability of the materials needed. Supply of sterilized materials is of utmost importance, because in most hospitals sterilized surgical devices constitute a critical resource. In order to coordinate the OR process with the production flow of sterilized materials, an organizational connection to the OR management makes sense. Hence, in a German university hospital the Department of Hospital Sterile Supplies was integrated into the OR management of the Department of Anesthesiology. This led to a close coordination of work-flow processes, and concomitantly a significant reduction of production costs of sterile supplies could be achieved by direct interaction with the OR. Thus, hospital sterile supplies can reasonably be integrated into an OR management representing a new interesting business area for OR organization.

Job satisfaction or production? How staff and leadership understand operating room efficiency: a qualitative study

BACKGROUND

How to increase efficiency in operating departments has been widely studied. However, there is no overall definition of efficiency. Supervisors urging staff to work efficiently may meet strong reactions due to staff believing that demands for efficiency means just stress at work. Differences in how efficiency is understood may constitute an obstacle to supervisors' efforts to promote it. This study aimed to explore how staff and leadership understand operating room efficiency.

METHODS

Twenty-one members of staff and supervisors in an operating department in a Swedish county hospital were interviewed. The analysis was performed with a phenomenographic approach that aims to discover the variations in how a phenomenon is understood by a group of people.

RESULTS

Six categories were found in the understanding of operation room efficiency: (A) having the right qualifications; (B) enjoying work; (C) planning and having good control and overview; (D) each professional performing the correct tasks; (E) completing a work assignment; and (F) producing as much as possible per time unit. The most significant finding was that most of the nurses and assistant nurses understood efficiency as individual knowledge and experience emphasizing the importance of the work process, whereas the supervisors and physicians understood efficiency in terms of production per time unit or completing an assignment.

CONCLUSIONS

The concept 'operating room efficiency' is understood in different ways by leadership and staff members. Supervisors who are aware of this variation will have better prerequisites for defining the concept and for creating a common platform towards becoming efficient.

Operating room management: why, how and by whom?

Operating room (OR) is a cost-intensive environment, and it should be managed efficiently. When improving efficiency, shortening case duration by parallel processing, training of the resident surgeons, the choice of anesthetic methods, effective scheduling, and monitoring of the overall OR performance are important. When redesigning the OR processes, changes should be given a clear target and the achieved results monitored and reported to everyone involved. Advanced, reliable, and easy to use information technology solutions for OR management are under development. Pre-operative clinic and functionally designed facilities support efficiency. OR personnel must be kept motivated by clear management and leadership, supported by superiors.