Protocol Assignment Forum: Organizational Culture, Behavior

(earlier portions below in other colors in case you want to reference)

Assignment 4: Organizational System

1. Describe the organizational and/or delivery system environment in which your intervention will take place.

The OR turnover time reduction intervention will take place in the operating rooms at UCSF Medical Center. The ultimate goal will be to include operating rooms at both Mount Zion and Parnassus campuses. There are a few different approaches in terms of inclusivity – one is to start with an OR pod (a cluster of operating rooms assigned to the same department) while another option is to be all-inclusive. The benefit of using a pod is the ability to make more targeted changes that may be specific to that pod and may be easier to implement and get people on board. On the other hand, implementing this OR-wide may be more effective in terms of thinking about how to standardize procedures in a more general way. In addition, there would be more ORs that may come up with methods for change that could then be applied to other ORs. This would also promote data-sharing and comparison of data.

The other question for implementation is the possibility of different implementation at the two sites. Mount Zion will be transitioning to Mission Bay, and this may pose a difficulty in terms of new challenges/barriers that may arise with the move to Mission Bay. One option would be to institute this intervention at the Parnassus campus only in the beginning, and once we have learned from this intervention, start the second iteration of the intervention in Mission Bay – in this way the implementation could be “the way it works” at Mission Bay with more acceptance of changed/modified procedures or standardization.

Any thoughts/suggestions on these questions appreciated!

2. Based on Shortell’s 4 domains of organizational change, identify organizational barriers that could potentially impede successful implementation of your proposed intervention.

3. Using the same 4 domain model, describe how your intervention plan can take advantage of organizational strengths OR propose practical methods for addressing these barriers within your program.

** Numbers provide methods for addressing barriers – numbers correspond to above table.

Assignment 1: Evidence and Gap

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.

Assignment 2: Community Engagement

1. Define the communit(ies) for your project and explain why each is a stakeholder for your study. 

There are many groups that come together to form a community around the issue of OR turnover time, which is one of the reason that it makes this such a difficult challenge to tackle.

-Surgeon team: surgical attending and residents

The surgeon team wheels the patient out of the OR and must prepare the next patient for the OR. This involves talking with the patient to answer questions, get an updated interim history, consenting the patient, and documenting this in the electronic medical record.

-Anesthesia team: anesthesia attending, resident, CRNA, tech

The anesthesia team takes the patient out of the OR to the PACU and then must prepare for the next patient. The anesthesia tech needs to check supply levels and obtain any necessary instruments, devices, etc. The anesthesia attending/resident needs to see the next patient, place an IV if it has not been placed by the nurse, and talk with the patient to get an interim history and consent for anesthesia.

-Nursing team:

            a) OR team: circulating nurse, surgery scrub tech

The circulating nurse and scrub tech are responsible for ensuring that all of the supplies and medications are in the room for the next case. This means that the nurse and scrub tech must open the instruments and perform a count of all the supplies. The circulating nurse also needs to interview the patient and confirm that all of the necessary preop items have been completed. During the case, the circulating nurse will also try to update preop/PACU as to the timing of the case, as they are responsible for notifying preop about when to send for the next case, and notifying PACU of when a space in PACU needs to be prepared for the patient.

            b) Pre/Post-OR team: Preop nurse, PACU nurse

The preop nurse calls admitting for the next patient when s/he receives word from the circulating nurse. The preop nurse must then check the patient in, get the patient changed and take care of their belongings. The PACU nurse receives the patient from the OR. S/he must get signout from anesthesia and the room nurse.

-Housekeeping staff

Housekeeping staff come to clean the OR, including disposing of all waste and mopping the OR floor, after the patient has left the room. The room must be fully cleaned before the scrub tech can start to open the instruments for the next case.

-Radiology tech for certain cases

Some cases involve use of fluoroscopic radiology, and in some cases the radiology tech must be called to position the fluoroscopy machine before the case starts.

-Patients/families

Patients and families wait in admitting until they are called into preop and prepare for surgery. If the case is running late, this may involve long wait times in admitting and/or in the preop area.

-Hospital administration

Hospital/medical center administrators want to reduce turnover time in order to decrease unused OR time in order to save costs by using the ORs more efficiently.

-Surgery schedulers

Surgeon schedulers slot patients into time slots for the OR, making use of the surgeon’s block time. In concert with the surgeons, they have the ability to choose which cases get scheduled at what time. They can also only schedule within a surgeon’s block time, and thus are limited in the number of cases they can schedule on a given day by the time available.

2. Describe your plan for approaching potential community partners to ask for their involvement.

This intervention should be carried out in a transparent manner, where all members of the OR team are aware of the common goal towards reducing OR turnover time. To bring awareness of the goal to the OR community, a presentation can be given at the OR committee about the goals of the intervention; this can also serve as an invitation for any individuals who are interested in helping to address this issue to become involved.

The first phase of this project will involve creation of a committee comprised of stakeholders in order to evaluate the existing practices and identify areas for improvement. This will involve soliciting involvement from all members of the stakeholder group in order to ensure we have members that represent these various groups and their interests. Stakeholders from each group will be identified by medical center staff and team members for their involvement and approached for their interest in participating.

Part of this initial information-gathering process will also require involving OR nurses in recording information about the current practices – together with the entire OR staff, nurses will fill out a survey about what barriers existed in prolonging the turnover time of their last case, what could have been improved, and any ideas for improvement. To get the nurses buy-in, a presentation can be made at their morning huddle to inform them of the project and solicit their participation.

In addition, there will be an idea box at the OR front desk that any members of the OR team can leave anonymous suggestions for improvement or areas of concern that need to be addressed. These measures will help to gather concerns and ideas from all members of the OR team.

3. Identify which stages of your project you'll incorporate community input, and describe what types of input you'll solicit.
This stakeholder committee will help to evaluate the areas of concern and ideas for improvement in phase 1 to come up with the educational intervention that is to be instituted and in evaluating which changes should be made at a systems level. The committee will help to review data in order to determine “goal” turnover times.

They will also be vital in evaluating the data as interventions are instituted and will serve as a body to review presented data at regular time-points. Their suggestions for implementation will be important in ensuring the intervention is implemented in an effective manner that is well received.

In the final phase of this project, this committee will help to advise the Project Team about the type and amount of financial payments that will be instituted and who should receive them, in order to ensure that these payments are carried out in an effective and fair manner. 

4. Name three ways you plan to share your results, beyond writing an academic article or presenting at an academic conference.

A weekly report will be made to all OR staff regarding the daily and weekly turnover time of each OR. In addition, a monthly report will be given to each attending surgeon and attending anesthesiologist with his/her individualized breakdown of turnover times for the month. Monthly reports will also be provided to the OR committee and the surgical chief, which a breakdown by each surgeon, anesthesiologist, and OR room number. 

Assignment 3: Theories of Behavior Change

1. 1.    Identify a patient or community group that contributes to or is involved in the principal behavior you are attempting to improve with your intervention.

The main community group that will need to undergo behavioral change is the intraoperative staff that are responsible for OR turnover time. This includes the surgeon team, the anesthesia team, the nursing team, and the housekeeping staff.

1. 2.    Using any of the individual explanatory theories in “Theory at a Glance”, develop an explanatory model for the target behavior (above) that you will be attempting to influence with your intervention.  This can be an extension/based on expected findings (or previously published literature) from your answers to Homework #3.  Figures are always very useful... keep it simple.

This intervention will be most effective at an interpersonal level, in understanding the context and environment through which these different groups of individuals interact to make a process happen (and to improve and change this process). Therefore I think theory that may be most applicable is the Social Cognitive Theory, which emphasizes how personal and environmental behaviors as well as human behavior influence each other.

(1)  self-efficacy: this will be potentially the most important aspect of this intervention, as this is currently the area in which these groups struggle the most. Because there are so many components of OR turnover time that must occur simultaneously and in tandem, no one individual realizes their ability to achieve change or success.

(2)  Goals: it will be important not only to set goals for the community, but also for the community to be involved in setting these goals. The goals must be achievable but also capable of resulting in a meaningful difference.

(3)  Outcome expectancies: individuals must be held to expectations regarding outcomes of the group. Giving feedback on outcomes will also be a central component to not only setting the expectations, but then reinforcing them.

1. 3.    Identify how one or more of your specific interventions will target one or more of these key factors contributing to the behavior of interest.

The table below reflects the Social Cognitive Theory concepts, definitions, and potential strategies for change for this particular project:

1. 4.    Create a framework that draws upon a socio-ecological framework to orient your target behavior within a larger context.  ie, what are some of broader, external forces that influence the individual behavior of interest...see Figure 2 of “Theory at a Glance.”

Ultimately there are many intersecting, interacting, and overlapping external forces that place this problem into a larger context. While everything is grounded in the first priority of patient health, there are also other rules, regulations, and codes of behavior that are important. For example, nurses and physicians are trained to carry out tasks while keeping in mind standards and expected behaviors, the institution sets out rules about how tasks can and cannot be performed, the institution makes requirements based on their own health as an institution, and hospitals are also regulated by outside agencies that impose requirements as well. All of these combine to exert many external forces on all of the individuals that are involved in this process.