As often happens with efficiency initiatives and quality improvement projects, the first big effort to make process changes — the low-hanging fruit — can result in swift and significant improvement. The second round of changes often is more challenging as an organization attempts additional improvements.

For the Surgery Center Fremont in Fremont, CA, the challenge was to accelerate and make more efficient the turnover process to use resources more effectively and increase staff, provider, and patient satisfaction.

The first step to reduce its lengthy OR turnover rate was to measure it and record delay reasons for each turnover. The ASC’s patient traffic controller used a data collection tool that included a record of delays and the stated reasons for the delays for each turnover. OR members discussed ways to continuously improve the process during brainstorming sessions. Frontline staff, including employees from the OR, sterile processing, admissions, and leadership, identified causes and potential solutions to reduce lengthy turnover times.

The group also built itself into a team that the ASC called the NASCAR Pit Crew Model team. The NASCAR team-building approach improved communication and built trust. This went a long way toward improving turnover efficiency within the first 30 days after beginning the process improvement project. But it took additional data, brainstorming, and effort to further reduce turnover rates and improve efficiency. The following is how the ASC continued to improve its processes:

• Reinforce “wins” — efficiency and improvements. When people are engaged and having fun, it’s much easier to sell any improvement ideas. One way to make the workplace and its faster pace fun was to recognize staff for their successes, says Robin Menefee, RN, BSN, MBA, nursing director at Surgery Center Fremont.

For instance, ASC leaders recognize individuals for their work and compliment the team on its wins. They also hold listening sessions to hear employees’ complaints and frustration. Positive reinforcement helped mitigate staff frustration with the faster pace.

• Boost morale. Another change was the creation of a good humor committee, Menefee says.

“The short version is that good humor is all about employee engagement,” she says. “It’s a way for people to be acknowledged and staff-driven.”

The committee acknowledges employees’ birthdays with signs. There also is a wall of inspiration that features a different message each quarter.

“This quarter, it’s ‘focus,’ so we have signs and memos and everything that has to do with focusing,” Menefee says.

Other inspirational words have included “humor,” “strength,” and “courage.” Group team-building events have included barbecues and fundraising “cupcake war” challenges.

“The lab department challenged us in the cupcake war, and we thought we had the best idea, but the lab won,” Menefee says. “We had blind judging, and after they voted, we sold the cupcakes and took the proceeds to donate to a family resource center in the area.”

• Hold debriefing huddles each day. The ASC holds daily staff huddles, says Nathalie Waite, RN, MSN, CNL, registered nurse at Surgery Center Fremont.

“The huddles became a sort of debriefer at the end of every day,” Waite says. “It was a chance for people to adjust to the change.”

The end-of-day huddles were created to provide employees with the opportunity to discuss what worked well that day, what they learned, and where they saw opportunities to improve their turnovers, Menefee says.

“Recently, it has transformed into a venue to allow team members to voice frustrations within the group, which has increased the trust level within the team,” she adds.

Waite suggested team members focus on the process and team, and not think about the time.

“In theory, if you follow the process, the time will follow,” she says. “The most common frustration I heard was, ‘You’re pushing me, rushing me.’ But it wasn’t about the time; it was about the process we were trying to implement.”

When an employee complained about feeling rushed, the underlying problem usually was that the worker had resorted to old habits and was repeating work that had already been done, or that the person had not followed the process, Menefee notes.

“That’s where the pressure and stress were coming from, and some of it we’re still working on,” she says.

Also, the listening sessions were instructive. For instance, surgical scrub techs talked about feeling that a lot of the work fell on them as nurses pushed to bring in the next patient, Menefee says.

“They would say, respectfully, to that nurse, ‘You really made me feel like all I do is turn over rooms,’” she recalls. “And the nurse would say, ‘I didn’t realize I did that. I’m sorry.’”

The main point was to get everyone to work as a team. Menefee wanted employees to trust that their concerns about feeling rushed, pressured, and pushed would be heard.

• Tackle each step that slows the turnover rate. One issue that affected turnover time was anesthesia regional blocks, Menefee says.

“The issue with regional blocks was related to our not knowing when blocks would happen,” she explains. “Sometimes, anesthesia would do a regional block on a joint case, which works great for the patient.”

But the problem, initially, was the regional blocks were not added to the schedule. The anesthesiologist would walk in, speak to the patient, and then go through the process of getting an ultrasound, which would delay turnovers, Menefee says.

“So, we spoke with anesthesiologists, asking them to let our in-house scheduler know of the regional block, so she could have it added to the schedule,” Menefee says. “People then could prepare for the block, and we’d see it on the OR schedule.”

Anesthesiologists made the change, and that helped improve turnover times.

Another problem that slowed the process involved instruments and trays. When there were back-to-back cases, someone had to prioritize the instrument tray for a turnover for the next case. But sometimes, when the tech or nurse in the room would go on a break, there would be no communication about using the tray again; the instrument tray would not be ready for the next case, Menefee explains.

“The tray would be sitting in decontamination,” she says. “The sterile processing team came up with an idea to use a pink card system.”

Laminated pink cards, which are placed on the OR’s white board, indicate which instruments are required for the next patient. This ensures the instruments are ready faster.

“The pink card gives notice it needs to be prioritized,” Waite says. “As a nurse, I was never involved in understanding which instruments I needed to have turned over. On a white board, the card is a big flag for me, and I can bring the tray to sterile processing way in advance so it’s ready well ahead of time.”

Prior to using the pink card system, OR staff relied on word-of-mouth communication, which fell through the cracks as people took their breaks, Waite adds. Plans are underway to purchase additional instruments.

• Keep quality improvements continuous. The program has succeeded in bringing turnover times to the goal range. The next step is to tweak it for further improvements, Waite says.

“There are some hiccups in the sense staff still feel rushed and pressured,” she says. “I completed a staff survey several months ago, and 100% of staff felt rushed at turnover, and 58% felt unprepared for the start of the case.”

When employees feel unprepared, that affects the efficiency process.

“This new project that I’m helping to start, along with the medical director, is where we expand on the staging process,” Waite says. “Staging is part of the pit crew model; it’s how we get prepared for an OR case.”

The ASC’s staging includes supplies and implementation. Eventually, staff members hope to expand it to include medication, positioning devices, equipment, and prep solutions, she adds.

“The goal is to take as much work out of the operating room as possible and get it done in advance,” Waite says. “When the turnover occurs, what the nurse and tech need is all over the staging table.”

There would be no last-minute search for a chest roll or hip wedge. Rather than pulling only medication vials, they’d pull everything they need to use that medication, including syringes, needles, and alcohol swabs. “Everything would be pulled and placed with meds, so the nurse doesn’t have to walk to the cabinet and pull those items,” she explains.

All items for all cards are pulled, and preference cards have an area for the hold items. Those items are pulled and placed in a separate basket so employees understand that they’ll be held until requested for the case. Items that are unused are restocked at the end of the day.