OR Pre-Op To Incision

Improvement Project Update By: Jill Treece

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BACKGROUND

The Pre-Op to incision time in the Operating Rooms is beyond the industry standard, causing delayed start times and

prolonged days in the OR. Although physician OR utilization is as low as 41%, surgeons are unable to add cases within

their block. Additional cases frequently run beyond the allotted block time leading to:

• Overtime

• Staffing issues (nursing & anesthesiology)

• Decreased revenue

• Decreased patient, staff, and physician satisfaction

CURRENT CONDITION

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PROBLEM STATEMENT

Time Period: December 2011, n=133 cases

The pre-op to incision time in the Operating Rooms is >60 minutes over the allotted preparation time for surgery. On

average, 45% of the documents and orders required to pre-op a patient are missing the day of surgery. As a result, the

pre-op area is chaotic and surgeries fail to start on time. This has lead to days running longer than scheduled, and

decreased patient, staff, and physician satisfaction.

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Missing information prior to day of surgery:

-Initial H&P

-Surgical Consent

-ATB Order

-Blood Order

-Labs

No one person on the surgical team assigned to complete pre-op tasks:

-H&P update

-Surgical site marking (if applicable)

-Consent (If missing)

Variations in acceptable lab values

-Varied by anesthesia provider

Inability for pre-admission testing information and alerts to flow over to the OR schedule day of surgery

ATBs not readily available in OPR

Inability to easily obtain blood products

-Multiple units ordered at the last minute

-Type and cross re-drawn due to missing blood band

· Patients are not fully optimized prior to day of surgery

· Missing information is know prior to the day of surgery with no follow-up

· Staff & physicians are challenged with navigating the new EMR (Epic)

· Chaotic/ inconsistent communication between team members

· All processes are dependent on the completion of the

surgical team process (e.g. Anesthesia cannot proceed past assessment

w/o consent and site marking)

Deeper

Dive

Analyze

Missing Information – Why?

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Missing HP’s Reasons: 1. EPIC

Input Error – input as progress note versus HP section Cannot be Found – not easy to identify in EPIC

2. Education Standard Process – need to identify best practice for HP input

3. Culture ‘Not My Job’ - task passed on to the resident

Missing Surgical Consents Reasons: 1. EPIC

Cannot be Found – not easy to identify in EPIC – no consent titles Multiple Consents – Periop staff need to open several consents – easier to have a new SC signed Consents Complete but Cannot be Found – Notes and Surgery tabs in EPIC do not always refresh all data which can

appear missing 2. Education

Standard Process – need to identify best practice and that SC’s are scanned to the correct location and uploaded in a timely manner

Consents Expire – a belief that consents may expire 3. Equipment

Scanner Availability – need to ensure all services have the ability to scan vs. fax Forms Not Available – ran out of copies – need to have a template to down load on One Source

4. Culture ‘Not My Job’ - task passed on to the resident Verbal Consent – procedure discussed with patient however no signature obtained Liability Issues – surgeon requests witness from family to be present to understand the procedure

Improve

Multiple examples given to Medical records to illustrate

the issue & research the fax transmission/IHIS interface

Deeper

Dive

Other Improvement Actions

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Improve

Issue Countermeasure Status

Missing Consent Offices to scan directly into IHIS Vs. Faxing

Missing Initial H&P Additional education to providers re: location of H&P in IHIS

Missing ATB Services to assign resident or mid-level provider to place order by 1900 the day prior to surgery

Missing Blood Order Creation of blood algorithm

Lab Delays POC testing for HCG

Type & Cross Not Valid –Blood Band Info Does Not Match ID

Blood band workgroup created between blood bank, periop areas, and L&D to explore alternative methods for blood banding

Blood band red envelope process created for OPAC and Outpatient Labs.

Proposal presented to the Transfusion Committee to obtain barcoding

No Surgical Team Member Specifically Assigned To Pre-Op Tasks

Resident/Mid-Level assigned to complete pre-op duties daily

Standardized arrival time for first case-and dedicated number for subsequent cases

Resident handbook-illustrating pre-op standard work

Variations In Acceptable Lab Values

Standardized lab values for anesthesia

ATB Not Readily Available In OPR

Pharmacy to fill ATB orders after 1900, day prior to surgery

Pre-Admission Testing (OPAC Alerts) Not Available

OPAC alerts will be visible on the status boards and the OR schedule to allow for nursing and anesthesia planning

Visual Management Implementation

Visual management tracking missing information D.O.S. posted in pre-op and at the OR desk

Standard Work Standard work created to follow-up on the missing information data for the manager and the workgroup

Phase II OR Entry To Incision

Begin a deeper dive into bottle neck #2 in the pre-op to incision process

OR Entry To Incision (Phase II)

· Overall Lead Time: 84 Minutes w/ TEE or Bronch 67 Minutes w/o

· Value Added: 73 Minutes w/ TEE or Bonch56 Minutes w/o

· Available Time: 45 Minutes· Demand: 1.6 Patients· Takt Time: 28.15 Minutes

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A B C D E F G H I J K

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Anesthesiologist

OR Entry To Anesthesia Ready

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Takt Time

PROBLEM ANALYSIS

CURRENT CONDITION

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PROBLEM STATEMENT

Surgeon

• Standard arrival time in Pre-Op for surgeon to mark patient (TBD)

• Standard arrival time for the surgeon in the OR:

• 1 Hr OHS, 30 Min PVS, 30 Min T-Surg

Anesthesia

• Standard arrival time in Pre-Op to facilitate line placement

• 30 Min prior to case

• Explore staggered start times to ensure adequate anesthesia coverage

Nursing

& First Assist

• First Assistants to review the chart the day before surgery and notifies nursing of any potential changes (i.e. additional possible procedures, risks, or possible delays)

• Daily huddles to communicate schedule and assignment changes

• Define roles and activities for each role within the OR prep process

The overall pre-op to incision time in the OR is > 60 minutes over the allotted preparation time for surgery. OR entry

to incision time varies greatly, especially by anesthesia provider. The lengthy and unpredictable time has lead to

prolonged days, and decreased capacity on the high demand days in the OR.

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Staff are most excited about two of the initiatives

• Daily Huddles

• First Assistant chart review

Nursing Daily Huddle Communication and

Engagement Survey

• Taken pre-huddle implementation to

measure the impact of huddles on their

daily work

• The staff will be re-surveyed in 3 months,

and again in 6 months

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Improve Status Update

•Policy changes in July and September had a large impact on the

improvements

•Additional countermeasures are being discussed to address

the impact to the process

•Data is shared monthly with the new OR Operations Council

•Council will be responsible for continually monitoring the data

and implementing improvement initiatives

•New ability to drill down to details in previous month’s data

•Requesting ability to create real-time reports in EPIC

•OR staff is currently tracking the items manually and sending

reports weekly

Control

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Block Utilization %

Utilization %

Goal

0102030405060708090

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% O

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% First Cases On-Time

% First Cases On-Time

Goal

Policy

Change