A schedule change brings peace to rural Montana OR

It took selling, but block usage improves efficiency

For four years, Mary C. Seitz, RN, worked as an operating room (OR) nurse at the 45-bed Northern Montana Hospital in Havre. And for four years, there was a lot of down time, she says. "Staff were scheduled from 6:30 a.m. to 3:30 p.m., and after that, there was a call crew on." But physicians didn’t schedule their cases to fill all the slots for the three operating rooms during the scheduled OR time. Instead, there were a lot of after-hours operations. "They were working until all hours of the night because the physicians wanted to stay in their offices."

For the four years she worked as an OR nurse, physicians used the operating rooms on a first-come, first-served basis. "Whatever doc called first got the perfect time for him," Seitz explains. "They would schedule times before they had cleared it with the patients. We had a lot of rooms supposedly tied up, only to have the slots canceled later."

The haphazard scheduling even caused problems for staff who had to clean and restock the ORs for the next procedure, says Seitz. "They had to make sure that the equipment was right for the next surgeon coming in." It was, Seitz concluded, an extremely inefficient way to operate operating rooms.

After four years, Seitz was made operating supervisor and was delighted when the two top producing surgeons approached her and asked her to take a crack at creating a block schedule for the rooms. "I’d never even heard of block scheduling," she says. "But I had thought that using the room in solid chunks of time would be a good thing." She called friends at other hospitals and asked what they did. She researched the idea on the Internet, making particular use of the Association of perioperative Registered Nurses web site (www.aorn.org).

"I created a mock schedule on paper over the course of a couple weeks," Seitz says. "I figured out how much operating time each physician had each year and averaged out their weekly working minutes in the OR. The biggest producers got the best time slots."

There were three operating rooms in the hospital that were open full time five days a week. "But from my calculations, I knew we could really do what we were doing in two rooms," she says. That would leave the third room open for emergent cases. "There were times when physicians would get bumped out of their time because we had an emergency coming in. But with the new schedule, we could leave a room open just for those cases."

Such a change also could help the anesthesia team. "We have three nurse anesthetists on full time, and this would let the third person be available for the emergency room, X-ray, or obstetric sedations. They all would never be tied up at once based on the OR schedule."

Physicians were given days — or partial days — when they were in surgery. Rather than running from office to hospital and back again, they had complete blocks of time when they used the ORs. "It was a hard idea for the office staff at first," Seitz says. "They were used to scheduling the docs on a piecemeal basis. Now they had to have surgery days or surgery afternoons. It was a harder idea for them to grasp than I thought it would be."

Nice idea, but . . .

While on paper the ideas looked grand, Seitz still had to sell the new scheduling system to the physicians, OR staff, and office staff. "I had no idea what a ruckus this would raise," she says. "Two physicians wanted it and seven others weren’t happy at all."

At the first meeting to float the idea, Seitz presented all the statistics she had gathered. "They questioned every bit about their time," she recalls. Seitz asked all who came to that initial meeting to provide feedback. If a physician didn’t call, write, or e-mail her, Seitz made it a point to contact him or her. "The only ones who didn’t show up were low producers, and even though I tried repeatedly to get their input, they never communicated with me about it," she notes.

After letting the physicians mull over the statistics and offer criticism, Seitz created a sample block schedule, got more comments, and provided training for the OR and office staff.

"One of the benefits we were looking for was a reduction in turnover time," she says. "I wanted it done in less than 30 minutes." In a big city, that might seem a long time, but the nurses have to do the turnover themselves at Northern Montana Hospital. There are no specific turnover teams. By creating blocks of time that were all orthopedic or all laparoscopic, some efficiency immediately was achieved. "It really minimized equipment issues for us. There was no moving beds or equipment every time a surgery ended."

When, during training, the OR staff said they couldn’t meet the 30-minute goal, Seitz showed them how. "It really helped that I was a working manager," she notes.

She then introduced a three-month trial of the schedule, holding monthly meetings so that rules could be tweaked and concerns aired. For instance, Seitz learned that there had to be open times specifically inserted into the OR schedule. "You can’t just create a complete schedule months in advance. You have to have some blank spots in case something comes up."

If physicians were out of town on their scheduled day, rather than waste the eight hours by leaving the OR empty, that block opened up for general use by all the doctors on a first-come, first-serve basis. Open days were freed for that purpose three days in advance of a day when nothing was scheduled. "That solved the problem of nonemergent, but urgent cases," says Seitz.

One problem that arose during the three-month trial was physicians stacking their schedules to inflate their average weekly OR minutes. "Every single procedure they could schedule and do was scheduled and done," she says. But, Seitz notes, inflation of estimated surgery times stopped. "The physicians follow themselves in a block schedule," she says, explaining that there is no point in saying a 60-minute procedure is going to take 90 minutes because the only people the physicians would shortchange would be themselves.

After the initial trial period, the statistics were reviewed, and they continue to be evaluated periodically. "The funny thing was that the physicians who had the most problems with the idea in the first meeting never told me they were wrong or that it was a great idea. But they certainly got really quiet."

Seitz now works in the office of one of the surgeons, but the hospital has kept intact the block scheduling that she implemented more than two years ago. The whole idea was something of a fluke, but once it got rolling, Seitz says, it seemed to solve a whole host of problems. For instance, in the recovery room, there was no one scheduled for after hours. If a surgery came in and the call team was requested, a nurse had to be pulled from somewhere else in the hospital to be in recovery.

Overtime was cut. An overstaffing issue was addressed. Salary figures declined. Utilization was more efficient. "But that wasn’t the goal at all," Seitz says. "I thought morale was low and that doing something at 7 p.m. when we had sat for hours drinking coffee earlier was silly."

Still, the numbers speak for themselves: productivity has increased 15%, and two ORs are used at 57% for an 80-hour week, compared to 28% when all three were in use for 120 hours per week. Overnight stays by patients are less frequent, with many often released the evening after surgery.

The success, Seitz says, is credited in part to having senior administrative staff such as the nurse director and CEO backing her, and doing it verbally in front of the physicians. Having two of the nine physicians on her side also helped. "You can’t do this if no doctor wants it," she says.

Physicians are scientists, and Seitz said having the data available to determine which doctors did what in the operating rooms helped convince some of the skeptics. "They had to really think about how much time they needed in the OR," she says. "And I also think it made them reevaluate what they wanted their practice to be."

Lastly, she says that being a working manager was important. "I think a lot of managers will hate me for saying that. But I worked every day in the OR. I got in there and did it with the staff. I think that helped them learn and understand that I wasn’t doing something that would make their lives more difficult." (See Chart 1 and Chart 2)

[For more information, contact:

  • Mary C. Seitz, RN, CNOR, 20 13th St. W., Havre, MT 59501. Telephone: (406) 262-1763.]