Pediatric facility links teamwork, OR productivity

Outperforms adult hospitals in benchmarking

If you ask the director of perioperative care at Valley Children’s Hospital in Fresno, CA, how the 201-bed facility consistently outperforms its benchmarking peers in operating room/post-anesthesia care unit (OR/PACU) productivity, Paula Richards, RN, MHA, has a one-word answer: teamwork.

"It’s not just one thing one person is doing — or even one change we’ve made in the department," stresses Richards, who leads a staff of 48 perioperative nurses.

"It’s working together as a team to question each and every step of the process. We continually ask ourselves not just, ‘Are we doing X in the most cost-effective manner?’ but, ‘Do we need to be doing X at all?’"

For six quarters, with an indicator of 3.36 worked hours per OR/PACU hour, this pediatric surgery department has outperformed the adult benchmark hospitals," says Sharon Lau, senior consultant for the BENCHmarking Effort for Networking Children’s Hospitals, a program of Medical Management Planning, a consulting firm in Bainbridge Island, WA. (For more information, see chart, p. 33.)

Best practices lay groundwork

The department, which consists of five surgical units, a cardiac catheterization lab, endoscopy, sedation, day surgery, and PACU, averages about 500 surgeries per month, says Richards. About 68% are outpatient, 33% are add-ons, and the rest are inpatients. (Add-ons are patients who are not on the published scheduled but are added because of urgent need or available space.)

Richards shared the following best practices that she and the team say they believe affect productivity:

1. Reorganize work hours and areas.

"We changed shift hours to accommodate the surgery admission in the morning and to ensure late coverage in the evening," she says.

Instead of assigning multiple nurses at once, she has staggered the morning shifts as well as arranged to have one nurse whose primary responsibility is to get large cases started.

"It’s labor intensive until the surgery is under way. Then he or she can leave that room and move to another to assist in its beginning," Richards says.

Some nurses also were assigned to work primarily in a specific area. "This reassignment has helped tremendously with the efficient flow of admissions, turnover in the OR, and the post-operative care and education of patients and families," she says.

2. Cross-train nurses.

Yet it’s important to cross-train nurses so downtime is minimized. "Our staff is capable of working in all areas. One day a nurse may work in general surgery; another day he or she may work in cardiac cath unit," she explains.

This system helps Richards accommodate the add-on cases. "This way, I can schedule a surgery in any open spot available," she says, adding that she estimates the OR utilization rate is approaching 80%.

PACU nurses also were cross-trained to administer respiratory treatments as soon as the orders are received. "This has provided quicker response to patient needs," she says.

3. Facilitate transfer of post-op patients.

A team with representatives from PACU and surgical floor met to coordinate transfers more efficiently.

"Not only did this create open communication between departments, but it also helps to decrease families’ waiting times and overcrowding in the PACU and facilitates a faster turnaround in OR," she says.

4. Shorten pre-op admitting time.

In the hospital’s short-stay unit, a parent can register his or her child, while a registered nurse assesses and admits the patient — all in the same room.

5. Increase efficiency of pre-op lab work.

Health unit coordinators, aides, and nurses have been trained to perform blood draws, enabling pre-op lab work to be completed within 15 minutes.

"This decreases down-time waiting for the phlebotomist, increases patient satisfaction, and allows for a prompt scheduled surgery," Richards explains.

6. Use unlicensed assistive personnel.

For example, housekeepers were cross-trained as anesthesiology technicians. "They can set up equipment, turn on the washer sterilizer, help out in work room, and transport specimens to laboratory," she explains.

7. Take team members’ suggestions seriously.

To develop best practices, Richards says it’s important to remain flexible and open to suggestions in order to reap the most from members’ creativity.

"In the beginning, we listen to all suggestions. No idea is too outlandish to start with. Without this guideline, we wouldn’t catch the ideas of those members who think outside the box," she says.

8. Don’t expect change to be easy.

As you strive to implement best practices, Richards recommends that you be prepared for resistance and counteract it with pertinent information.

"You can’t close your eyes to the fact that change will be difficult. If you do, you set yourself and your department up for failure."

Benchmarks reduce resistance

Providing benchmarking information to the team can help that resistance crumble — or even prevent it from occurring in the first place. "I believe that staff can never have too much benchmarking information. If I go to a class or read an article, I pass it on to them," Richards says.

For example, once a month she circulates a packet of information to help nurses understand the precepts behind change. "It’s imperative you let them know why it’s important to measure these indicators," she explains.

By measuring progress and updating best practices regularly, Valley Children’s Hospital has maintained its superior performance in OR/ PACU and continues to improve it, she says.

For more information on Valley Hospital’s benchmarking successes, contact: Paula Richards, Director Perioperative Care, Valley Children’s Hospital, 3151 N. Millbrook Ave., Fresno, CA 93703. Telephone: (209) 243-5356. Fax: (209) 243-5390.