Factors contributing to the productivity of an operating theatre department in a hospital

It clocks 7.30 in the morning, the time exactly the first surgery must start for the day in an “XYZ” hospital. The situation is a bit flex and there are just 3 to 4 most common questions going around, is the OT ready? Has the surgeon arrived? Where is the anaesthetist? What about the patient? Sounds familiar? Welcome to a usual day in surgical services.

The operation theatre suit in any hospital is a complex environment and is the most important facility of the surgical department. “Operating Theatres are an expensive resource with an expensive production capacity”. As more productive OR can result in a significant amount of savings to the hospital, it is often the most sought-after department in terms of efficiency, resource utilization and clinical outcomes. In short, everyone in the management is looking at you:)

ORs’ contributes to almost two-thirds of a hospital’s total revenue and accounts for 40 % of the resource costs, hence improving cost effectiveness, while maintaining a quality of care, is a universal agenda.

Delays in the perioperative processes have a major effect on patient flow, resource utilization and at worst could lead to human errors too. Delays negatively affect both patients and the healthcare professionals. Not necessarily all the delays have direct clinical implications for the patients, but for sure they increase the worry for them and their families and are a constant source of irritation for the surgeons, the anaesthetists, the nursing team and all the other staffs involved.

Sadly, even in the best of the hospitals, despite of excellent planning and outstanding processes, avoidance of delay is not always achieved, credit goes to the built-in polymorphic variables in the perioperative processes and highly unpredictable nature of the surgeries.

Often the OT managers, the doctors and the nursing teams do not have all the necessary deets required to manage the OT efficiently. Lack of real time information’s often prevents the whole team to develop better efficiency measures, or to better understand the OT capacity along with the cost factors.

Then the most important questions that pops here for the higher management are:

• Are the data and the information available to the team?
• Is that relevant?
• Are the informations actionable?
• Is my team motivated?

Precisely, Operating theatre management is complicated & it’s a farrago of time management, team work, workflow management, right communication, data management, inventory management, patient safety, leadership, policies, practices….

Operating theatre management requires harmonisation of humans, numbers, materials & machines with input of multi-disciplinary stakeholders across the hospital with good intentions, collaboration and commitment for continuous improvement.

Well, let’s try to figure out the operationally meaningful parameters in the perioperative processes, the important KPIs, OR complexity, the role of an OR Leader, importance of motivation, teamwork and open communication, patient centricity and how all these factors make or break the image of an ideal and efficient OT department.

Let’s crack on the complexity of OR

Precisely, there are 10–15 departments which are involved in the execution of a surgery in OR. For the successful accomplishment of every surgery, multi-disciplinary teams are involved throughout the hospital, coordinating with each other and working on many interfaces to finish the surgery on time, just like a domino and this is where the complication starts. So, if there is a delay in starting a surgery on time, it’s possible that its coming from some distant department.

So how to get out of this catch-22? To clear this jam, some of the most potential questions the decision makers must ask themselves are:

• How to attain a system-wide perioperative process sync?
• How to bring down the departmental & functional silos?
• How to tackle the conflicting interests?
• How to handle the challenging information, material & patient flow?
• Is my service consistent?
• Are my patients and their families satisfied?
• Is my OR team motivated and involved in the decision making?
• Are the blocks optimally utilised?

There are multiple parameters that contributes to the efficiency of OR, some tangible and some not so tangible but both equally critical. The quantitative ones are, surgery cancellations rates, OT utilization, case-overruns, under-utilization, case changeover time, delayed start etc. and the qualitative ones being patient satisfaction, staff satisfaction, teamwork and communication. It’s extremely critical for all the stakeholders to have a clear definition of targets for each of the operative disciplines concerned.

It’s vital to monitor target times, achievements and failures in order to continuously improve. And to initiate any continuous program in your hospital, you need the motivation of all the participants with a culture of open communication.

The three phases of Perioperative process

Pre-Operative phase and the KPIs’

A very important part of the patient’s surgical pathway is the pre-operative assessment which ensures the patient’s fitness for the surgery. It’s the first phase and begins with the decision to have surgery and ends when the patient is wheeled into the OR. During the assessment, patient is fully informed about the surgery and consent is taken. Enabling patients to take informed decisions improves the patient experience of the surgery as well as it cuts on the anxiety part for both the patient and their families.

Pre-operative patient assessment and informed consent are pivotal to safe care as it contributes to flawless intra-operative processes.

Patchy documentations and missing consent forms can disrupt any surgical day. Thus, hospital and OT management should ensure robust preparatory procedures to identify individual risks as any frailty at this phase can cancel the surgery at the last moment.

The major focus of Pre-operative phase is on:

• Patient history and physical examination
• Patient and family education
• Guidelines to follow
• Pre-op checklist
• Legal & ethical issues related to the surgery
• Consent

Let’s look into the Pre-operative phase from the operational point of view. Various studies show that surgeries cancelled on the day, or the day before is potentially avoidable by following a more personalised and patient centric approaches. The nearer these cancellations are to the day of surgery, the greater the impact is on scheduling and theatre utilization. Case cancellation adds to the resource waste as well as gives extra administrative burden to the staffs. Cancellation on the day of surgery is the worst scenario, as the slots cannot be utilised by another patient. Right Pre-ops planning & assessment could improve hospital’s efficiency by:

• Reducing the Length of stay
• Minimising the risk of last-minute surgery cancellations

Few Pre-Operative KPIs’:

• Patient arrival to admission
• PRE-OP delays by reason
• PRE-OP Length of stay
• Same day case cancellations by reason

Note: Tracking the reasons of case cancellation could lead you to the operational bottlenecks in the system from non-availability of beds, to equipment unavailability to case overruns to poor case booking and scheduling practices to the reason as weird as billing delays and non-clearance.

Intra-Operative phase & the KPIs’

The Intra-operative phase extends from the time a patient arrives in an OR suite, to the time anaesthesia administered and the surgery completed, until the patient is wheeled out to the recovery room or the post anaesthesia care unit (PACU). This is a complicated phase, both clinically and operationally, usually the conventional operational KPIs tracked by the hospitals are, theatre utilisation, case delays, case changeovers, overruns, under runs, first case start and so on.

Theatre utilisation is a broad & a useful measure of this phase, as it enables the hospital management to determine whether optimum usage is done for the available theatre capacity or not? And if it is not, then what are the reasons?

Low theatre utilisation rates must be investigated to determine why the optimum usage is not being achieved? As mentioned earlier the constraints in theatre utilization can possibly come from the factors outside the surgery department, such as non-availability of beds, too busy ward nurses, miscommunication in the transport department, CSSD delays, the reasons could be umpteen.

It’s vital to track these constraints, and note how frequently these constrains from outside the OR department are hampering the overall theatre performance.

Services to patients cannot be improved if operating theatre departments are designed and overhauled in isolation. Any improvement initiative in the operating theatre efficiency must be seen in the context of a bigger system of the hospital management, including preoperative assessment, elective and emergency admissions, bed management, discharge planning etc.

Management must take a system-wide improvement approach with the involvement of all the stakeholders from multiple departments in order to increase the accountability of each and every individual involved. Theatre managers or floor managers could play a key role in managing system wide patient flow by collaborating and communicating with ally’s in other departments, though it’s not as simple as it sounds!

The key day-to-day operational questions to be asked are:

• Are the delays between cases, large?
• Are theatres the main constraint in the patient’s journey or the constraint is coming from elsewhere?
• Does the demand and capacity synchronise?
• Is the flow of the patients optimally managed with minimum delays between cases?
• What’s the pattern of my theatre lists? Does it consistently start late and/or finish early?
• What are the major reasons for the late start and delays between cases? (Do a Root Cause Analysis).
• Does the team plan the case mix that takes account of constraints and availability of essential resources, e.g. consultants, anaesthetists, expensive equipment, SICU/HDU beds?
• How dynamic & intuitive is the scheduling and case booking process?

Few common Intra-operative KPIs:

• On time case start
• Day of surgery cancellation rate
• Theatre utilization
• Early finishes/late finishes
• Booked vs actual time/ prediction bias
• OR turnaround time
• Average case changeover time
• Average late start minutes
• In room to cut time
• Closure to out of room time
• % of case with delay
• Total minutes lost in delays
• Average minutes/delay
• Emergency cases

Note: Delays may be caused due to a variety of reasons, such as poor management, delays for equipment, delayed discharge, poor communication between theatres and wards, shortage of key staffs etc.

Post-Operative phase & the KPIs’

Finally, we have the Post-Operative phase, this is the period that immediately follows the surgery. Once the patient becomes stable and free of any symptoms of complications, the post-anaesthesia nurse will typically transfer the responsibility of the care back to the appropriate nursing unit.

Until then:

• PACU nurse continue acute care as per surgeon’s orders until the patient becomes stable.
• The PACU nurse must understand the patient’s risk for post-surgery complications
• Monitoring vitals, pain management and other clinical interventions
• Prepare a thorough report of patient’s status for handover to the receiving nurse and for the family
• Communicate and coordinate the post discharge plans

Few common Post-operative KPIs:

• Bed-Assigned to Ready-to-Move
• Ready-to-Move to Occupy-Bed
• Ready-to-Sign-Out to Sign-Out
• Number of Patient Holds in PACU
• PACU Length of Stay (LOS)
• Complications post-surgery
• Unplanned return to OT

Smarter case scheduling

One which makes the economic sense

With the amount of dubiety attached, the scheduling of the operating theatre on a daily basis is a complicated task. One really has to juggle around multiple things, be it expedient block allocation to the surgeons or prudent OT utilization or just making sure that everything is in the right place at the right time, often the experience of the human planner plays an epic role.

An Efficient case scheduling can boost hospital’s profitability, keep the staff’s motivated and patients satisfied concurrently. But over and again, in order to attain that, the entire facility must be in sync with the consistent policies & every stakeholder’s unfeigned involvement.

Usually different hospitals follow different scheduling systems, but the ideal goal of every hospital is to have neither under-utilised nor over-utilised OT time. Irrespective of what system one follows, scheduling always remains a classic optimization problem for them.

Accurate scheduling requires knowledge of both surgeon and anaesthetist that includes the precision in estimating average operative times for each surgical procedure. Also other parameters like uncertainty in the arrival of the emergency cases, the capacity of the pre-op and post-op facilities, the conflicting priorities and preferences, the scarcity of costly resources and many more operational fickle alter the scheduling process immensely.

Whenever OT efficiency is in question, all the eyes are on the First case delays and turnover/changeover delays. We are more worried about how long it will take until the next surgery can start? We often think that improving turnover time and starting the first case on time can solve all the problems, it can maximize the clinician’s time and can have a direct impact on the bottom line, not saying that these two are non-significant KPIs but there is something else which need to be addressed, which specifically impacts the scheduling process and that is “Case length overestimation”.

Think over it, watch for the pattern, analyse your historical data & figure out what percentage of total unused time is contributed by “Case length overestimation” in your hospital?

With technology we have more smart solutions for case scheduling, with the real time block request and release. Many solutions send message when block time is released and becomes available for other surgeons to use, reminders to release blocks which doctors are unlikely to use. Such a dynamic & real time updates enables the OR planner to quickly reallocate blocks and improve overall utilization.

For any hospital block time is an extremely valuable asset and efficient scheduling is directly proportional to the cost. The focus should be to make the scheduling process as intuitive and as seamless as possible.

The KPIs to look for:

• Suite Utilization
• Scheduling Accuracy
• Average Inaccurate Minutes per Case
• Unused Minutes
• Delay Minutes
• Add-on vs Scheduled cases

Teamwork, Motivation & Open Communication

How often does it happens that a surgery is delayed because the lab reports did not reach the doctor on time or the housekeeping didn’t get alarmed about the OR cleaning or a transport boy missed the lift or the ward nurses are really busy with other critical patients and not releasing the patient who is scheduled for the surgery?

Success in any OR department depends on the cordial collaboration of multiple people, processes and material in the entire hospital. Though traditionally, we consider surgeons, anaesthetist and nurses the part of the OR team and make them accountable for the overall performance of the department, but the chain doesn’t stop there, any employee who is a part of OR process belongs to the OR team, be it transport or housekeeping or a phlebotomist sitting in a lab.

To improve patient safety, quality of care and satisfaction levels of all the stakeholders, it’s imperative that this team has clear communication, accountability, respect and comfortability to work for a common goal. The culture needs to be such that each and every voice is heard and everyone’s opinion matters and respected irrespective of the hierarchy.

A well-staffed OR can be felt in all the metrics below:

• Defined hours of operation
• Staffing pattern aligned with the case demand pattern
• Appropriate skill mix
• Adequate room coverage
• Compressed daily schedule to eliminate gaps
• Surgeon or service-specific teams
• Prudent use of call teams

OR Leadership

An efficient OR leadership should set a direction for change & develop a vision to solve the challenges by creating a participative culture in which all the stakeholders are able to communicate freely with each other. Staffs should not feel threatened to speak up or put their voices on the problems they face while handling the process or while suggesting any improvement initiative ideas. Leaders must be willing to try new and innovative approaches to improve patient and staff satisfaction, achieve clinical & operational efficiencies and make use of the best KPIs.

Few recommendations for efficient operating theatre leadership:

• In OR the concept of collaborative leadership is a great idea, as it encourages the culture of shared responsibility across the hospital.
• Interdisciplinary team collaboration can lead to meaningful improvement projects with a common goal to achieve patient centric care.
• Burnouts and stressed work environments are very common for the OR employees, the leadership team must ensure that staff is adequately supported and heard.

Pay attention to the minutest of the details, even the proper arrangement of departmental facilities like changing rooms and resting lounges adds hugely towards employee satisfaction.

• Encourage process ownership & decisions making, ensure transparency, build trust, respect and mutual understanding among the team members as well as the management and the staffs.

A lot of time staffs feel left out and not included in the decisions and feel a compulsion to follow the high command decision even if they are not really happy to do so. Being a people’s person, prevent that to happen!

What’s being Patient Centric in perioperative care?

From a patient’s perspective, surgery is always scary and unknown. As a healthcare provider it’s pre-eminent to involve Patients and their families in the care continuum and give them an extremely clear documentation & understanding of what, when and how of their care.

So, how do you differentiate between a perioperative process that is patient-centered and one that isn’t?

As the Institute of Medicine defines it, patient-centered care is establishing a partnership between the providers and the patients and giving them the support they need to make decisions and participate in their care. The core concepts of any patient and family engagement include: dignity and respect, information sharing, participation, and collaboration. But again, that’s easier said than done as there are multiple reasons why patient-centered care is often a struggle for the hospitals.

So, how do we get an engaged, highly informed patient?

To simplify it, start seeing things from the patient’s point of view, involve patients and their families in the surgical care cycle. You can use patient process mapping as your diagnostic tool. This will enable all the stakeholders to see the perioperative services from the patient’s perspective and can give the team spot on ideas and opportunities for improvement. Patients or their representatives can also be present during the exercise to provide a patient-centred view of the process.

Some key elements to consider in patient centric perioperative care:

• Efficient patient reception
• Patient flow and its coordination
• Timely patient preparation
• Measuring patient waiting time
• OT safety
• Safe handling & monitoring the safety of the environment
• Safe handovers
• Timely information & clear updates to the NOK

Regular evaluation of the ‘patient experience’ can be performed to ensure that patient needs are being met and delays through confusion are minimised. Smart way is to include, patient-centric metrics which are based on the experience of patients who have undergone surgeries. Such metrics and parameters will have a direct impact on both patient satisfaction and safety.

To end with…

Tackling an important area as the operating theatre is always a challenging job, since becoming efficient or staying inefficient directly hits the patient satisfaction, staff motivation & the bottom lines of any hospital. Healthcare providers always aspires to improve the quality of care by raising the bar for better practices, improved communications, controlled expenses and following the perfect KPIs’. As healthcare professionals we must always explore the interrelated functions and examine things at both macro and micro levels, which can expand our own abilities for conflict resolution, problem solving, and timely decision making.

Unless we are willing to collaboratively contribute to the substantial changes, this goal of achieving a patient centric perioperative ecosystem will remain elusive.

Please share your experiences of OT department, there would be many ultra modern set-ups as well as the one which lacks even the basic infrastructures. Scenarios might differ with the payment modes and insurance coverage, would love to hear:)