Medical center slashes late starts, long turnovers
In 2008, Heartland Regional Medical Center in St. Joseph, MO, was struggling with late start times, long turnovers, and elective cases that sometimes stretched to 4 a.m. The patients, surgeons, and staff were unhappy, so the administrators determined the root causes of the problems with the help of a surgical oversight committee composed of surgeons, anesthesiologists, and managers.
The successes have been dramatic, according to Press Ganey Associates, which featured the hospital in a recent publication.1
"We are starting on time," says Connie M. Stanton, RN, team leader of post-anesthesia care and same-day-care units. "Our a.m. starts have been at 80% since July 1, 2009." The hospital's wait time before procedure is at the 84th percentile, she reports.
Additionally, the hospital has reduced its turnover time by 11 minutes, says Tony Claycomb, RN, team leader of surgery/sterile processing.
Additionally, the hospital has decreased overtime in the same-day care unit (SDCU), surgery, and the postoperative care unit (PACU), Stanton says. "We're getting our work done by 5:30 p.m., which decreases call time," she says.
Members appointed to surgical committee
Step One was revamping the surgical oversight committee, which previously had been made up of voluntary members who were spotty in their attendance.1 The new committee has appointed members from all surgical specialties, anesthesia, and managers from the OR, PACU, SDCU, and the hospital. They meet twice a month on Tuesdays from 6:30 to 8 a.m.
Now, "we have a surgical oversight committee that is run by physicians who are involved and make crucial decisions for our areas," Stanton reports. "They are assigned physicians that they are to communicate with to keep information flowing."
The committee even included representatives of the surgeons' practices. "We have staff from all the areas involved and staff from areas that support our areas," Stanton says.
To ensure that decisions are made and implemented quickly, the committee developed a "request sheet" for physicians.1 [The request sheet is available. For assistance, contact customer service at (800) 688-2421 or firstname.lastname@example.org.] Any physician who has a request or complaint for the committee uses the sheet to explain the issue and present data or additional information to back up their argument. That physician meets with a "pre-meeting" committee that makes a recommendation to the oversight committee. This decision is documented on the original request sheet with an implementation date, and it is returned to the surgeon.
Such actions were critical to the hospital's efforts, Stanton says. "Make changes quickly and monitor success," she advises.
- Press Ganey Associates. A sense of urgency in the heartland a hospital rapidly smooths out patient flow, spurring cultural change. Partners 2010; 9:22-29.
Hospital targets blocks, staffing
In August 2008, Heartland Regional Medical Center in St. Joseph, MO, began work on its patient flow through the OR with PatientFlow Technology, now called PatientFlow Optimization, and since January 2008, a part of Press Ganey Associates.
A surgical oversight committee looked at the total hours of elective surgery by surgeon, according to Press Ganey Associates, which featured the hospital in a recent publication.1
The committee members compared this number to the block schedule to adjust the block times for surgeons who consistently were underusing their blocks and those who needed more time. Also, case duration times were analyzed to make the scheduling more accurate. The committee developed guidelines for the block schedule that included an 80% utilization rate for maintaining the blocks. They also reviewed and adjusted the blocks quarterly.
Next, a staffing workgroup had surgeons review staffing and develop competency skills for each specialty. The workgroup identified the number and types of staffs needed to cover the OR.1
Specialties were examined to determine which ones were understaffed and which ones were over-staffed. The OR is training staff to have the correct skills and expertise in the blocks. For example, some RNs are training to become scrub nurses.
"With regard to staffing, we staff in accordance with our block," says Tony Claycomb, RN, team leader of surgery/sterile processing. "We had to change a few shifts to accomplish this, but it turned out well for all as staff are productive while they are here and not idle before and after the day's blocks."
The specialty teams have developed an internal peer review process specific to the teams as well as required competencies for each team member to complete to remain on the team, Claycomb says.
Heartland Memorial addresses start times
Data were the focus when Heartland Regional Medical Center in St. Joseph, MO, decided to address late start times.
Connie Stanton, RN, team leader of Heartland Memorial's post-anesthesia care and same-day-care units, was a leader for the workgroup assigned to improve each day's opening surgery starts. Stanton reviewed data on first starts daily, according to Press Ganey Associates, which featured the hospital in a recent publication.1 She identified problems and communicated with her team by e-mail.
Keys to improving the start times included identifying all the steps necessary to start on time. (See steps, p. 43.) The steps also include penalties for noncompliance, such as the physician losing the 7:30 or 8 a.m. start times for a month after being the cause of 20% of their cases being late starts.
Members of the team also agreed on definitions and responsibilities, and they staggered nursing shifts to handle the morning rush. The guidelines were amended and then implemented by a surgical oversight committee that included surgeons and anesthesiologists.
|Guidelines for the New Work Flow
| 0730 Case|
|Patient arrival 0500-0530|
|Same-Day Surgery Unit (SDCU) completed prep of patient 0630|
|Family to waiting room 0645|
|Anesthesia evaluation completed 0650-0655|
|Circulator in SDCU 0650|
|Surgeon in SDCU 0650 (as needed)|
|Patient in OR 0700
| 0800 Case|
|Patient arrival 0530-0600|
|SDCU nurse completed prep of pt 0700|
|Family to waiting room 0715|
|Anesthesia evaluation completed 0720-0725|
|Circulator in SDCU 0720|
|Surgeon in SDCU 0720 (as needed)|
|Patient in OR 0730
|Source: Heartland Regional Medical Center, St. Joseph, MO.|