Cardiac team accomplished its 25% cost reduction goal — and more
Cardiac team accomplished its 25% cost reduction goal — and more
How? By tackling cycle times and re-working equipment, staff needs
When a cardiac team at Morton Plant Mease Health Care in the Tampa Bay area of Florida took a hard look at its surgery program a year and a half ago, it saw some room for improvement.
Through hard teamwork and with the help of the Institute for Healthcare Improvement (IHI) collaborative, the individuals managed to achieve impressive gains. Their costs for open-heart procedures dropped from $8,126 to $6,050, and along the way they standardized practices, re-engineered equipment and staff needs, and reduced cycle times. (See graph on this cost reduction on p. 50.) Accomplishing all of that could not have been easy, and Cost Management in Cardiac Care asked how they managed to do it.
"The best way to make progress like ours is to benchmark and network with people who are facing the same problems you are facing — decreased reimbursement and the need to decrease costs," says Jennifer Lain, BSN, cardiac surgical case manager at Morton Plant Hospital (MP) in Clearwater.
MP enrolled in IHI’s collaborative from the end of 1996 through November 1997 to better position itself in Florida’s competitive cardiac marketplace. It was there the cardiac team formulated its primary goal of reducing operating room (OR) costs by 25% in elective bypass heart surgery (DRG 107). The team has accomplished that goal and more.
"We’re very happy with the outcome of our initiative," says Cheryl Young, RN, director of surgical services at MP. "As well they should be. Key to our success were our physician champions. You have to include in an initiative like this key people within your service lines who have machetes to slash through the forest."
If you don’t have their cooperation, she says — if it is purely a nursing effort — you are limiting yourself. "To do what we’ve done is owing to the MDs that were involved."
In addition to Lain and Young, MP’s core team consisted of two others — the chief cardiac anesthesiologist and the open-heart surgery team leader. The team focused first on improving processes within the OR. They worked to eliminate wastes, enhance workflow, modify the work environment, and reduce cycle time. They looked at utilization and costs of products and services, and these are the changes they effected:
• Eliminated the cell saver and auto transfusion systems and reduced albumin utilization in DRG 107. Contracted perfusionists run the cell saver and the heart-lung machine at MP. (The cell saver filters lost blood and returns it to the patient, eliminating the need for donated units.) The team was able to decrease cost per case by $1,000 by analyzing perfusion supply costs, decreasing them, and cutting the frequency of lab draws.
• Eliminated the use of Swan Ganz catheters in 75% of DRG 107 patients. Specific criteria for their elimination include an ejection fraction of more than or equal to 40%, no infarction within six weeks of admission, creatinine within normal limits, no pulmonary hypertension (pulmonary artery pressure less than 35 mm Hg), and no recent congestive heart failure or valvular disease.
• Revised the custom pack. The team brainstormed to standardize case setups, supplies, and instrumentation so costs could be lowered. They revised instrumentation and looked for ways to eliminate waste by reducing the products in the open-heart custom pack. For instance, they eliminated one Surgiclip and one skin stapler. The team joined Charlotte, NC-based Premier Purchasing Partners, a national consortium of hospital product buyers, and realized an annual savings of 10% by renegotiating supply-buying contracts.
• Decreased mean OR times by 71 minutes. MP’s goal was to reduce total room time by 60 minutes. (See graph on how MP reduced OR times by 28%, above.)
The OR has always generated 40% to 60% of a hospital’s revenue and makes up for departments that don’t generate revenue. But now it’s recognized that 40% of all open-heart costs are generated there — it is the single most expensive portion of open-heart costs.
The OR is now seen as a cost center as well as a revenue center, so the team looked at how to reduce those costs. They looked at tasks that could be performed in parallel instead of in sequence and analyzed intervals within the procedure. Once they had some data, they created a visual display showing the intervals so that the staff could get an overall view of the sequence of events.
• A first objective was to decrease time from "patient in room" to "incision made" by 10 minutes. The anesthesia staff found they could place arterial and IV lines in the pre-op area; once the patient was in the OR, anesthesia and surgery performed their tasks in parallel.
• The time between "surgeon finished" to "patient out of OR" was targeted for a decrease from 30 minutes to four. A nurse anesthetist found that unnecessary delay was the result of IV lines being transferred between two pole systems, so she made changes in one pole to accommodate the other lines. That re-engineering saved valuable minutes.
• Open-heart room setup was standardized as well. The anesthesia team found that if they transported patients to the ICU, the nursing staff could stay behind and prepare the room for the next patient.
The team overshot their 60-minute save per case goal, resulting in an overall cycle savings of $437.40. Since the OR costs $5.76 per minute, those savings were $345.60. The anesthesia cost per minute is $1.53, so savings there were $91.80.
"Our cost per case used to be $570," says Lain. "We’re down now to $460 per case." Multiply that by the approximately 800 heart surgeries performed each year at Morton Plant, and the savings mount.
• Standardized anesthesia medications and developed cost awareness. Prior to this project, the anesthesia team had no formal reporting system so procedure times, drug usage, costs, and case turnaround times were not recorded.
Staff started analyzing, standardizing, and coordinating techniques, and the physicians now use the same narcotics, tranquilizers, muscle relaxants, and inhalation drugs. In the case of anesthesia, Young says, if one technique is proven to be good, why shouldn’t everyone use it? They reduced narcotic use, substituting inhalation agents and shorter-acting muscle relaxants that can be reversed or metabolized before the patient leaves the OR.
The number of anesthesiologists was reduced from 10 to six, and the number of nurse anesthetists from 23 to 10. Before the project, the anesthesia and OR teams worked side by side, with no common goal except to get through the procedure. Today, there are regular meetings where the staffs communicate and see the value of teamwork. They discuss the intricacies of process change, standardization, and ways to save money.
In addition, patients now receive guided imagery tapes pre-op — one talks the patient through to a relaxed state, and the other is music.
"We’ve seen a decrease in patients’ perception of pain and anxiety with the tapes," says Young, "and they may also result in decreased length of stay narcotic use post-op. They love the tapes and want to take them home."
• Decreased and re-figured OR staffing mix. The open-heart team mix has been changed from an all-RN staff to a 70:30 ratio of nurses to scrub technicians. Where two scrub nurses and one circulation nurse used to be assigned to a procedure, now one scrub nurse and one circulation nurse do the job.
Nursing assistants underwent an on-site training program, and their role was expanded to that of patient care technician. With these techs to assist, nurses were given more support during room prep, patient prep, catheterization, and opening of supplies. Techs assumed more functions in the OR with the result that their clinical expertise was enhanced and costs were lowered at the same time.
Throughout the initiative, the core team collected and displayed their data on highly visible bulletin boards in the OR, ICU, and progressive care units.
As instrument trays changed and OR times decreased, costs were attached to each change and displayed. The easily interpreted data were represented as measurements over time, with each change labeled at the time it was accomplished. Cost awareness increased among staff; and ideas for alternative, less costly products and processes have been suggested by members. Some friendly competition developed among OR teams, and became a cohesive, constructive force to bring about improvements.
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