New Ways for Anesthesiologists to Add Value to the Management of their O.R.s

Several recent publications have described strategies for hospitals and ambulatory surgical centers to improve their operational health—their profitability, to be blunt.  Anesthesiologists are well aware of the role that they can play in O.R. management and of the need to assume O.R. leadership responsibilities in order to remain competitive.  There are some valuable ideas to be gleaned from articles and presentations directed to O.R. managers.  Anesthesiologists can take charge of most, if not all, of the processes described below.

Many ways to improve O.R. efficiency are already familiar.  The value of on-time starts, fast turnover times and block scheduling, to name but a few such ways, is a given.   Jeffry Peters’s February 28, 2013 webinar hosted by Becker’s Healthcare and entitled Managing Surgical Services Lines under Accountable Care and Value-Based Purchasing identified some additional operational changes that would help hospitals obtain a “sustainable competitive advantage.”  Peters is the president and CEO of Surgical Directions, LLC, a consulting firm with a long history of turning around underperforming O.R.s.

One of the interesting suggestions is to hold a “huddle” daily to plan for cases three days ahead.  The participants in the huddle are the O.R. director and representatives of anesthesia, pre-admission testing (PAT), central sterile supply and scheduling.  These individuals review the schedule for the next 72 hours and consider patient risk factors, equipment needs, sequence of patients and assignment of O.R. staff.  The desired outcomes are reduced cancellations, more on-time starts and improved clinical outcomes.

Planning and preparation before the day of surgery are proving their value elsewhere in reducing wasted time and other inefficiencies.  At the multispecialty ASC that is the focus of the article 10 Tips to Make Efficient ASCs Even Better in the March 4, 2013 issue of Becker’s ASC Review, team leaders gather their team every night to make sure surgical equipment and trays are ready for the next day.

The ASC also coordinates O.R.s so that similar cases follow each other.  “The goal is to minimize the movement of equipment.”  Various ways to accomplish the goal include scheduling all left side surgeries followed by all right side surgeries, or all the knee procedures and all the shoulder procedures in two dedicated rooms in an orthopedic ASC or specialty hospital, or putting all the general surgeries in one room and the hand surgery cases in another.

In another ASC, the circulators review their patients' charts the day before surgery.  They take the necessary time, making note of pertinent health information, and consequently they do not feel rushed when it is time for the patient interview. 

PAT and patient optimization similarly are conducted prior to the day of surgery in order to minimize case delays and cancellations.  To maximize efficiency, hospital or ASC personnel should perform a risk assessment using a telephone questionnaire to identify the patients who need to be seen by a physician and/or who need an intervention before surgery.  The process involves testing protocols and protocols to manage co-morbidities.

Physicians with Allied Anesthesia in Orange, CA, including one of the founders of ePreop™ (the software that integrates various electronic health records and uses that information to deliver evidence-based preoperative recommendations), have developed a pre-operative "Patient Ready Protocol" to improve pre-surgical coordination, eliminate unnecessary tests and reduce the number of surgical delays and cancellations. In 3-Step Preoperative System Promotes Positive Outcomes, Paul Yost, MD writes:

Under the protocol, a nurse reviews each patient's chart two business days before surgery to make sure there are no discrepancies between the consent to read orders and the OR schedule and that all the required tests have been performed. If there is a problem, the nurse follows up with the physician or consults with an anesthesiologist to resolve the issue before the day of surgery.

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[The clinical coordinator] conducts a monthly audit to determine the reasons for incomplete charts and reports her findings to the medical executive and operating room committees.

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The protocol has generated a lot more education and communication between the hospital and the surgeons' offices. [The clinical coordinator] provides updates on their performance and assistance in increasing compliance to the PReP protocol.

According to Dr. Yost, the pilot version of the protocol caused the percentage of complete patient charts to increase from 22 percent to 51 percent in the first month, February 2012.  By December, the percentage was up to 71 percent.

Mr Peters recommends creating a perioperative governing body to align incentives among the various individuals and departments working in the O.R.—a “Surgical Services Executive Committee” (SSEC) composed of anesthesia leadership, surgical leadership, O.R. nursing leadership and senior hospital leadership.  Transforming governance in this manner would position surgical services for the new paradigm of value-based purchasing and accountable care—by such means as collaboratively addressing the surgeons' block schedule, improving case efficiency and minimizing turnover time in order to make the O.R more efficient.  Clearly, by driving a transformation of governing structures so as to prepare the O.R. to thrive in value-based purchasing and in accountable care/shared savings ventures, anesthesiologists would provide a great service to the hospital or ASC.

We are always interested in hearing from our readers, and we particularly welcome your success stories.  In the area of anesthesia’s O.R. leadership, we are sure there are many success stories—and many to come.