Hampson Protocol 1: Decreasing OR Turnover Times

Hampson Protocol 1: Decreasing OR Turnover Times

by Lindsay Hampson -

A. What evidence are you proposing to translate into practice?

 

Design an intervention to reduce “turnover time” (time between cases) in the operating room. The first phase of this intervention will evaluate data from the last year to determine current turnover times and a committee of stakeholders will be found to review these data and establish “best practices” time for OR turnover (taking into account the type of case). This committee will then help identify of areas where improvement is possible and ideas for how to make these improvements. The second phase will involve implementation of new guidelines designed to shorten OR times and institute a team environment based on the phase 1 findings. The third phase will involve making monetary payments to members of the OR team who are responsible for room turnover. Throughout all phases of this intervention, turnover times will be monitored and reported back to the OR staff on a weekly basis. In addition, monthly reports will be provided to each surgeon with his/her individualized breakdown of turnover times. Finally, monthly reports will also be provided to each surgical chief, with a breakdown of turnover times by each surgeon within that Department.

 

1. Justify that this evidence is “ready for translation.”

The cost of running an operating room is significant - it is estimated that the cost of the use of a routine operating room at UCSF Health System is $69/minute after a set price for the first 30 minutes. This means that any unused operating room time is a significant loss of money. On any given day, an operating room is used for multiple cases and once one case finishes, a room “turnover” occurs in order to clean the OR after the previous case and set up the room for the next case.

 

Despite the fact that this "turnover" happens multiple times a day in every operating room in the hospital, turnover times vary widely. At times, turnover can happen in 10 minutes, whereas at other times (but under the same circumstances/same cases), those turnover times can exceed an hour. The cost from these lost minutes of OR time is astounding. That extra 50 minutes of unused OR time would cost the hospital $3,450 - and this lost time is occurring in every operating room, multiple times per day. For example, in one random day in the Parnassus OR schedule, the mean turnover time for scheduled cases was 52.2 minutes, with a total of 1776 minutes of turnover time, costing $122,544 (if using the $69/minute cost).

 

This time savings could result not only in benefits to the surgery teams and in cost savings to the institution, but also in enhanced patient and family satisfaction through reduction in unanticipated waiting times due to case delays as well as decreased delays in scheduling surgery.

 

2. Identify a single, key behavior change target for your translational activity.

Reduction of turnover times in the operating room

 

3. Conduct a “gap analysis” of your target behavior.  Look to diverse sources for “best guess” estimates if specific measures are not available.

Most institutions have different levels for goal turnover times based on case complexity. Cases less than 1 hour have expected/goal turnover times of 15 minutes, cases more than 1 hour have expected/goal turnover times of 30 minutes, and cases of high complexity (cardiac cases) have expected/goal turnover times of 45 minutes.

 

B.  What is the quality (performance) gap?

In analyzing one randomly selected day of UCSF turnover time data, the mean turnover time for scheduled cases was 52.2 minutes, with a total of 1776 minutes of turnover time, costing $122,544 (if using the $69/minute cost). If the goal turnover time was set at 30 minutes, this would mean that the preventable turnover time was 754.8 minutes, costing an excess $52,081. If the goal turnover time was set at 15 minutes, this would mean that the preventable turnover time was 1,264.8 minutes, costing an excess $87,271.

 

C.  What is the outcome gap?

Number of cases starting on or before their scheduled time and number of cases per week/month that are able to be performed.

 

D.  Is there evidence that changing performance will improve health (clinical outcomes)? 

At hospitals that have put in place interventions to help reduce turnover time, turnover time has been significantly reduced. One institution used a 6 sigma approach and were able to reduce their turnover times from 27 to 22 minutes. Other examples are institutions who have shown reductions of 16 minutes from pre-intervention, obtained a mean turnover time of 30 minutes, and reduced turnover times by 37% (from 42.8 minutes to 26.4 minutes). Even within our own institution, there are examples of surgeons (Dr. Bozic, orthopaedic surgery) who are able to consistently demonstrate turnover times of 15 minutes or less, showing that with the properly incentivized team, these reduced turnover times are attainable.

Re: Hampson Protocol 1: Decreasing OR Turnover Times

by Ralph Gonzales -

Really nice start with a very tough, but important topic!

A. Evidence readiness:  This is tough.  Is it possible to find a “benchmark” turnover time.  One would then try to define the “positive impact” of meeting the turnover time benchmark (e.g. more cases per day; or shorter OR schedule if same # cases per day).  I also liked your idea that wait-times for surgery could be reduced by being able to fit-in more cases per day.  Both outcomes (OR costs  per case; and wait times for surgery) meet Institute of Medicine quality pillar of “efficient” and “timely” health care.

1. Justify evidence is ready for translation:  need to make a stronger case that the “cost per minute” saved represents recoverable costs.  How much of these costs are a) personnel, b) equipment and c) materials? 

2. Need to get more specific about an individual or organizational behavior change target.  I think turnover time will represent your main impact/process variable. This will become easier if you set-up a conceptual framework for OR turnover time.  Who are the key players involved? What are the key barriers/contributors to faster OR turnover?

3. So will these be your benchmarks?  Is there good evidence for these numbers, or is it convention?  Shouldn’t turnover depend on the pending case complexity as well as the case that was just completed?

 B.  I think it might be good to get you connected with APEX Op-time reports.  Have you worked with these before?  Re: your estimate:  besides the mean turnover time, would be interesting to see the median, and the interquartile ranges (and/or standard deviation).

C.  I like the metric of “cases started on time”.  Not an obvious performance metric for the impact of turnover time, but makes sense and shows the ripple effect on multiple groups of people by running late. 

D.  This is nice… but would like to see the impact of these intervention directly on the “outcomes”—ie, # cases per day, or wait times for surgery.  Would also like to see the financial analysis showing the actual $$ saved.  Where do they come from?

Re: Hampson Protocol 1: Decreasing OR Turnover Times

by Sarah Imershein -

Lindsay, Interestingly, we met with a multi-disciplinary team last week to discuss the re-launch of the post-operative debrief in Neurosurgery and one of the strongest points brought up by surgeons was that in order to obtain buy-in from them, there would need to be process improvement item(s) in the debrief, and a protected system (separate from APEX) developed for documenting discovered inefficiencies, malfunctions, delays, etc.  The primary function of the debrief is to decrease "never" events, reduce mortality and other serious events.  But these are so rare it would take years to accumulate enough cases to show improvement.  Although the surgeons understand this, it is a difficult add processes/time at the end of the case that doesn't show immediate return on investment.  Thus for buy-in, they want the process improvement.  And their suggested outcome was reduction in percentage of delayed surgeries.  I thought of you!

Their feeling is that equipment malfunctions, booking mistakes, and lack of correct equipment readily available (preference cards not accurate) are the main drivers of these delays.

Re: Hampson Protocol 1: Decreasing OR Turnover Times

by JESSICA COHAN -

Hi Lindsay,

Thank you for tackling this very important issue.  I think a strength of this proposal is the fact that you will be feeding back the information so frequently.  This will increase stakeholder engagement and allow small,frequent adjustments that I imagine may be a main method of change to a large and complicated system.  One thing to consider is to create a mechanism to feedback not only the times, but also identified causes for those events with prolonged times.  That will help everyone see where the weaknesses are and work to change them.

In additions to the $$ per minute of OR time, I think another important argument might be decreased costs from prolonged hospitalizations.  Patients admitted through the emergency room who are added on to the OR schedule may have longer LOS because their cases get bumped to the next day due to either a lack of OR space or because the surgeon prefers to do the case during "business hours".  This is huge problem at SFGH, although it seems to be less of an issue at UCSF.

Also, finally, I realize that it is hard to speculate because "phase 1" hasn't been completed yet, but I will be interested to see who will comprise your "stakeholder team".  Do you get a sense that you will get buy-in from other members of the OR team (nurses, techs, anesthesia, materials/processing, transport, cleaning, pre-op/admitting, etc)?  The financial incentive may really help here.  How will that be paid for?  How will payment be determined?

Overall, very important, interesting and challenging - I look forward to seeing your work and helping where I can!

Re: Hampson Protocol 1: Decreasing OR Turnover Times

by Brian -

Lindsay- very interesting project, I enjoyed reading it through as a non-surgeon who had not even thought about this issue. The cost savings potential seems like a clear "win."

I am curious as a non-surgeon who is responsible for OR turnover- is it the surgeon, anesthesia, or OR staff. You mention cases of individual surgeons who have been able to streamline turnover times, as well as lay out incentives for OR team members who turnover rooms (perhaps they are one in the same). This might affect what stakeholders you approach or the make up of that team you propose in phase 1. 

I am also curious about the major drivers for variations in OR turnover times- is it physician preference/timing, case complexity, quality/safety assurance? Sarah mentioned that "never events" are a quality metric in ORs- does reducing OR turnover time have impact on risk of "never events" or risk of decreasing quality through errors in preparation/equipment checks? 

Finally, i'm assuming each institution/hospital has their own OR culture and that will lead to development of 'best practices'- are their published evidence/guidelines on how to make turnover time more efficient that can act as a starting point for UCSFs efforts? you mentioned 6 sigma approach at one institution, and there may be other anecdotal approaches-- i wonder if these cases form your "evidence" base for how UCSF will go about doing its own turnover program.