Wednesday, 8 October 2014

APPLYING SCIENCE AND STRATEGY TO THEATRE MANAGEMENT (PART I)





How well a surgical suite runs depends on whom you ask. Nurses working in the operating theatre may understand efficiency as individual knowledge and experience applicable to the care of the patient as well as preventing problems before they occur, whereas managers understand efficiency in terms of production per unit of time or completing assignments as planned. The hospital administrator may want the highest "throughput" of cases with the least total cost, and the surgeon often wants first-case-of-the-day block time, rapid turnover, a low cancellation rate, and cases that start on time.

Nurse managers, on the other hand, may focus on disposable supply costs per case; the percentage of cases in compliance with flash sterilization policy; the ready availability of instruments; and other resources, such as imaging equipment, maintaining flexibility to move cases around, and having adequate reserve capacity for add-on or emergency cases. In contrast, risk managers want to know the percentage of patients without injury (eg, wrong-sided surgery). Managing a complex environment, such as the theatre suite, is a multidimensional challenge.

Many physicians are now assuming the role of medical director of the theatre as hospitals recognize that further improvements in efficiency and quality require physician leadership.

It is commonly but incorrectly assumed that a clinician who is successful in medical practice can easily transfer those skills to the duties of managing (or leading) a surgical suite. However, leadership and management in fields such as medicine require specific talents, study, and experience.

This article reviews measurements that can be made to assess how well a theatre functions. This issue is increasingly important as hospitals and anesthesia groups negotiate stipends and service contracts, hospitals expand and want to open more theatres (even though gaps in the schedule already exist), and hospitals aim to minimize complaints from the surgeon customer.


Theatre Efficiency

The question "Are your theatre rooms being run efficiently?" could be answered via a qualitative approach by, for example, administering a written survey to theatre personnel (Figure). Getting the perspective from each type of employee can be illuminating. When the lowest-scoring items are identified from a survey, more in-depth analysis may yield opportunities for improvements (Table 1).



Figure. An example of a survey that could be administered to surgeons, registered nurses, anesthesiologists, and other ancillary personnel. 
Getting the perspective from each employee type can be illuminating.



Table 1.


A Scoring System for the Efficiency of the Hospital Theatre

For an initial assessment, it is recommended that hospitals wishing to determine the efficiency of their theatre suite should begin by gathering data already available from the theatre computer information system. A scoring system to asses how well a theatre suite functions from the hospital's perspective is summarized in Table 2. The levels for the thresholds are recommendations on the basis of analyses of multiple hospitals in the United States (Table 2).



Table 2. (PACU = postanesthesia care unit)


The 8 objective criteria listed in Table 2 do not include surgeon satisfaction, which is also an important criterion. However, no valid and reliable instrument to measure surgeon satisfaction has been developed. The 8 metrics could be used by theatre managers for evaluating baseline performance and identifying areas that need improvement. Certainly, safety and patient outcomes can't be compromised when aiming for a more efficient theatre suite.

Some of these 8 metrics are related to one another, and some are more important than others. The first item, "excess staffing costs," is most crucial because nothing is more important in theatre management than to allocate the right amount of theatre time to each service on each day of the week. The matching of workload to staffing has to be precise to promote the efficient use of nurses and anesthesiologists. Neither awakening patients more quickly nor reducing the turnover time will compensate for a manager's poor initial choice of staffing.

Optimal allocation of theatre time should be based on historical use by a particular service, eg, unit of theatre allocation (such as surgeon, group, department, or specialty). Computer software is then used to minimize the amount of underutilized time and the more expensive overutilized time. Theatre suites can reasonably aim to achieve a staffing cost that is within 10% of optimal (eg, workload is perfectly matched to staffing).


On-time starts. Reducing the time that patients have to wait for their surgeries once they arrive at the hospital, especially if the preceding case runs late, is another important goal for the OR manager. If a case is supposed to start at 10:00 AM, but the case starts at 10:30 AM instead, the case is 30 minutes tardy. In computing this metric, no credit is given if the 10:00 AM case starts early, for example, at 9:45 AM. Having patients' medical records ready to go with all needed documents is essential for on-time starts.

Facilities with long workdays will have more tardiness because the longer the day, the more uncertainty there is about case start times. Tardiness does not necessarily depend on the durations of preceding cases or on the relative numbers of long and short cases. Rather, tardiness per case grows larger as the day progresses because the total duration of preceding cases increases.

In well-functioning theatre suites, the cumulative tardiness of the start of scheduled cases should be less than 45 minutes per 8-hour theatre day. To achieve this, the theatre manager should properly determine when patients should be told to arrive (not too early or late), and sequence each surgeon's list of cases in the same theatre on the same day with the most predictable case first and the least predictable (often the longest) case last.

A common practice at many hospitals is to move cases from one theatre to another to reduce tardiness. Although this greatly reduces tardiness for those few cases that are moved, when this reduction in tardiness is spread across all cases, the overall effect is small. To have a significant impact on tardiness for a substantial number of individuals, interventions must involve large numbers of cases. An example of this would be to create a dynamic or auxiliary schedule at the beginning of each day with new start times for each case that are constantly updated after compensating for lateness of first cases and case-duration bias. These revised start times can be used to determine better patient arrival times and to determine the start times of cases for "to follow" surgeons.


Case cancellations. Case cancellation is a vague term that includes a lot of different entities. On any given day, theatre cancellations can occur at several timepoints:

Before the patient even arrives at the facility (patient/guardian refuses, patient non appearance
When the patient is at the hospital (a full intensive care unit, imaging equipment unavailable, case overruns, no theatre staff, or emergency case supersedes the elective schedule); and
When the patient is already in the theatre (sudden drug allergy, can't intubate the patient, complication with line placement, or wound infection discovered after patient is in the room).

Theatre cancellation rates can be monitored statistically. Day-of-surgery cancellation rates vary among facilities and depend partly on the types of patients receiving care. Rates range from 4.6% for outpatient surgery to 13%-18% at Veterans Health Administration (VHA) medical centers.Well-functioning theatre suites should have cancellation rates of less than 5%.

To be continued.

Sources; MedScape Anesthesiology, Alex Macario MD, MBA.



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