Issue link: https://beckershealthcare.uberflip.com/i/790284
19 Executive Briefing Sponsored by: 7 Actionable Strategies That Helped a Baltimore Hospital Beat OR Stagnation and Increase Case Volume 26 Percent in One Year By Lee A. Hedman A strong operating room is critical to every hospital's bottom line. In top organizations, perioperative ser- vices account for 68 percent of revenue. Not surprising, the reverse is also true. When a hospital is struggling financially, it is nearly always the case that the OR is under-performing. What causes poor OR performance? One issue stands out: low efficiency. Inefficien- cy in the OR leads to low volume and can also contribute to poor quality. It will soon become an even bigger problem, as val- ue-based payment shrinks margins and raises quality expectations. The good news is that efficiency problems are solvable — and effective interventions can quickly produce outstanding results. Recently, my colleagues and I worked with Greater Baltimore Medical Center to turn a stagnating surgery department into a strong revenue driver. Facing Up to Declining Performance GBMC has traditionally operated one of the busiest ORs in Maryland. In recent years, however, the 25-room department has struggled with low efficiency. The numbers paint a challenging picture: More than 8 percent of cases were can- celled on the day of surgery, and only 67 percent of first cases started on time. In addition, downtime between cases was up to 75 percent longer than benchmark. These inefficiencies cut into productive OR time, leading to an overall primetime utilization rate of only 62 percent. Low utilization led to high costs and low margins. It also contributed to physician dis- satisfaction, with many surgeons unable to book OR time despite low overall volumes. Surgeons were also dissatisfied with service levels. These issues led to decreasing case counts, with recent year-over-year volume declines of up to 7 percent. When OR performance hits levels like that, it is very common for clashes to erupt between physicians, nurse manag- ers and administrators. Thankfully, GBMC decided to take positive action. Following are seven strategies that helped GBMC turn around OR performance and achieve strong volume growth. 1. Create a "Board of Directors" for the OR In most hospitals, nursing leaders man- age day-to-day OR operations but have little authority to drive transformative change. At the same time, surgeons and anesthesiologists have very little say in how their work environment is structured. These familiar dynamics were in play at GBMC. Since no one "owned" surgical services, no one could take responsibility for improving department performance. GBMC solved this problem by establishing a Surgical Services Executive Committee to govern the OR. The SSEC brings together all the stakeholder groups that have an in- terest in a successful OR — surgeons, anes- thesiologists, nurse managers and hospital executives. It functions as a hospital-spon- sored "board of directors" for perioper- ative services. With all stakeholders en- gaged and full authority to enact change, the SSEC set about transforming the OR into a high-performing organization. 2. Set Clear OR Policies — and Enforce Them A major symptom of an OR leadership vacuum is a lack of enforced rules. With the SSEC in place, surgical services lead- ers at GBMC were able to develop con- sensus-based policies and standards de- signed to support operational efficiency. The first priority was to create strong poli- cies governing the OR schedule. First, the SSEC replaced inefficient 4- and 6-hour schedule blocks with blocks of 8 hours or longer. Longer blocks reduce turnover waste and allow surgeons to increase overall productivity. Second, the commit- tee allocated all block time to individual surgeons (not groups or specialties). This helped establish personal accountabili- ty for utilization. Third, case cancellation policies were tightened, with the addition of strict lead time expectations. Finally, the SSEC established a policy requiring surgeons to maintain 70 percent utiliza- tion to retain ownership of their block. The committee enforced block time rules through quarterly reviews, probationary periods and other mechanisms. Holding surgeons accountable for block utilization help to reduce wasted time. In addition, policies governing early arrival and pre- op work supported efficiency by ensuring timely starts. 3. Build Efficiency into the Front End In many ORs, patients often arrive for sur- gery with incomplete charts and unman- aged medical conditions. At GBMC, incom- plete prep contributed to high cancellation and delay rates. SSEC leaders realized that the key to solving these problems was to strengthen preoperative processes. Their first step was to redesign the Periop- erative Testing Center. Anesthesia took the lead on developing evidence-based grids and pathways for pre-surgical preparation. These PTC tools spell out required pre-op tests and patient management based on comorbidities, procedures and medica- tions. For example, if a patient has cirrho- sis, PTC staff use the tools to: Order labs: All cirrhotic patients have a complete blood count, a comprehensive metabolic panel and anticoagulant labs. Act on results: If the CMP shows BUN great- er than 45 or creatinine above 1.7, the labs tool directs PTC staff to fax the results to the patient's surgeon and primary physician. Coordinate medications: If the patient is on metformin, for instance, the dose is dis- continued a full 24 hours before surgery. The SSEC also replaced the OR's chaotic scheduling process with a web-based sys- tem that captures accurate case informa- tion up front. Once the changes were in place, OR leaders created an information packet to educate surgeons and primary physicians on new PTC requirements and scheduling processes.