A recent Office of Inspector General (OIG) report on Veterans Health Administration (VA) ORs paints a clear picture of what makes an OR run efficiently, and what makes it more chaotic.1
“The overall message of the report is that you have to collect information to make an organization operate efficiently,” says Leigh Ann Searight, deputy assistant inspector general for audits and evaluations, VA OIG. “If you have measures, use those measures to help influence decisions.”
The OIG report is the result of an audit by the VA OIG conducted to determine if the VA effectively used National Surgery Office (NSO) data to identify and address OR efficiency problems. The audit team focused on four measures:
- Surgical case cancelations. The number of surgeries canceled within 48 hours of the scheduled start time and measured as a percentage of the total scheduled surgeries.
- OR first-time starts. The number of first operations of the day that start on time or earlier than the scheduled start time, also measured as a percentage of total first starts.
- OR use rate. The total run hours of the active ORs as a percentage of the total number of assigned OR nurse hours.
- Lag times. The elapsed time needed to clean, reconfigure, or prepare the OR between surgeries, expressed as the percentage of total surgeries meeting the threshold.
The study authors found OR efficiency data was not used consistently by facilities to help inform decisions, Searight reports. The VA medical facilities with less efficient ORs experienced more problems, including OR closures and canceled surgeries. Their inefficiency was caused by not following up on using data to identify problems and initiate corrective actions. These facilities started programs, but did not monitor them to ensure staff continued to follow best practices and maintain their compliance and efficiency.
“There is inconsistency between facilities and how they use that data,” Searight notes. “The VA collects a lot of information to inform decisions, and there is such inconsistency in how that data is used.”
That inconsistency is expressed in the striking difference between how the most efficient and least efficient facilities use the data. “It came down to communication and collaboration within services,” Searight says. “You have sterile processing service [SPS], environmental and resource management, and surgeons and nurses who all have different chains of command. If those four groups didn’t collaborate and work together, we saw a lot of breakdowns in the process.”
For instance, a chief of surgery might say a problem is SPS’ responsibility, and hand off the issue, instead of finding ways to collaborate and work together to solve the problem, Searight offers. When facilities ignored opportunities for collaboration and communication, their efficiency suffered. “Those were the ones that weren’t able to solve the problems because they required collaboration,” Searight says.
One example is the surgical kit. Sites that did not communicate clearly with SPS about which tools a particular surgeon needed would end up with kits that either contained unnecessary items or were lacking the items the surgeon wanted.
Another problem observed among the inefficient sites was surgical kits sometimes showed up with the sterile wrap damaged. The wrapping might have been cut, rendering it no longer sterile.
“[Investigators] walked through the process and discovered that when the kits were being delivered to the OR, they were jarred. This resulted in cuts that made it less sterile,” Searight says. “They might deliver multiple kits, sitting on a cart, and somehow they’re getting damaged in that transport.”
In less efficient ORs, leaders would receive quality assurance reports or inspections that consistently highlighted issues that needed to be addressed. But when these less efficient sites made changes to correct the problems, they did not follow-up on the changes. “They didn’t make sure those changes took hold, and then they’d go back to their old ways,” Searight explains. “They never followed through with their action plans. They started them, but didn’t follow through, and a month later they were back to the old ways.”
There also was no accountability for the people who did not maintain best practices. “It’s a leadership problem,” Searight adds.
In the VA system, there is a Veterans Integrated Service Network (VISN) that oversees multiple VA Medical Centers (VAMCs). They conduct quality assurance reviews to monitor how facilities are performing. “If [investigators] don’t hold [sites] accountable for those inspections and make sure [leaders] follow through with action plans, then nothing changes,” Searight says.
Inefficient ORs fell through the cracks because their leadership did not hold employees accountable to make sure the action plan was foolproof. Sometimes, facilities neglected monitoring and follow-up practices because of staffing issues.
The most efficient facilities engaged in various practices that helped them become more efficient. For instance, some would presoak instruments after surgery in anticipation of SPS taking them. The less efficient facilities did nothing to prepare the instruments for cleaning and sterilization.
The more efficient ORs also handled cancelations and late starts better than the less efficient ones. More efficient facilities held surgeons and others responsible if they caused a late start. If the surgeon, anesthesiologist, or chief nurse is late, the more efficient facilities would hold keep them off rotation or not give them first-start surgeries.
“At the more efficient facilities, you found that the [patient] was assigned one person or a group within a service to be responsible for ensuring all preop [actions] were done,” Searight says. “They made sure all tests were done and the veteran was ready for surgery and had done everything needed in preparation.”
- Department of Veterans Affairs, Office of Inspector General, Office of Audits and Evaluations. Improved Oversight of Surgical Support Elements Would Enhance Operating Room Efficiency and Care. Sept. 17, 2020.