June 18, 2012

On-time case starts can make the difference between profitable and unprofitable operating rooms.  There are multiple causes for late starts, among them clinical complications, unavailable instruments or supplies, unavailable laboratory reports or other paperwork, delays in room turnover and late arrivals on the part of surgeons, patients, and yes, anesthesiologists and nurse anesthetists.

Almost all of the problems listed above are within the control of the anesthesiology group in charge of managing the OR.  A June 14th Outpatient Surgery Tip of the Day (www.outpatientsurgery.net) republished four tips to incentivize surgeons and anesthesiologists to arrive on time for scheduled cases.  These tips originally appeared in the November 2010 issue of Outpatient Surgery.   The article by Dan O’Connor was directed to readers who manage both types of physician, but the strategies can be implemented (or at least proposed) by a practice that provides an anesthesiologist-medical director. 

Tip No. 1:  Make wake-up calls.  An anesthesiologist in Maryland was quoted as saying, “If the telephone goes unanswered, use the cell phone.  Call repeatedly.  Call their answering service.  Our physicians now arrive on time and all is well.”  Another method is to page surgeons who are not in the preoperative area ready to mark the patient within five minutes of the scheduled start time. 

Tip No. 2:  Discipline repeat offenders.  Some facilities levy fines on surgeons who are chronically late for the first case of the day.  Others fine the surgeons for every minute that they are late.  One Pennsylvania ambulatory surgical center (ASC) sends surgeons a warning letter after six offenses, and introduced a policy of requiring physicians to buy lunch for the entire staff, instead of paying a $100 fine, after the 12th offense.  The buy-lunch policy was adopted by the medical review board committee because it “thought being forced to buy lunch for the staff had a little more teeth as a punishment and deterrent," according to the medical director.

Tip No. 3:  Post offenders’ names.  Surgeons who are regularly or periodically late may be inspired to arrive on time by the embarrassment of seeing their names posted on a “list of shame,” according to the practice of one Illinois hospital that has a zero-tolerance policy for tardiness and posts the list in the surgeons’ lounge.  More effective penalties would include the loss of access to 7:00 am start times or the loss of block time for surgeons who are late a set number of times, e.g. twice in a calendar quarter.  As a commenter on the Outpatient Surgery web page points out, however, “If you take some surgeon's block time away, especially if he is one of your high volume producers, you may lose volume. Also, what if there is nobody waiting in line to take that block?”

Tip No. 4:  Document first-case arrival.  Unless there are data to prove tardiness, some physicians will challenge the perception that they are frequently late.  An electronic sign-in or a swipe card system can provide the data to support a penalty, if there is one.  The existence of technology that documents compliance with a requirement to sign in, e.g. by 15 minutes before the first scheduled case of the day, may in itself improve behavior.   It is also possible, frankly, that the surgeons will object to such technology and find ways to circumvent the system.

After the First Case of the Day

The four tips above address late arrivals for the first case.  Tardiness may occur throughout the surgical day, though. An article entitled “Real-Time Surgery Tracking Leads to Better Operating Room Utilization and Turnover, and Earlier Surgery Starts” appears on the federal Agency for Healthcare Quality and Research (AHRQ) Health Care Innovations Exchange’s website, which AHRQ maintains in order “to promote diffusion and uptake of innovations and tools that have met specific inclusion criteria” without endorsing the innovations.  In this study, the Vineland, New Jersey Regional Medical Center methodically implemented and evaluated a computerized real-time system for updating OR physicians and staff on the current status of cases.  The system provided immediate identification and notice of delays as they developed so that the clinicians could respond appropriately.  Among the observed results were the following:

• Increased utilization of OR capacity: Utilization of ORs (10 main ORs, 1 smaller OR and 3 endoscopy rooms) increased from 70 to 82 percent of capacity, as more surgical cases can now be handled in a given day. The surgical caseload increased by 16 percent from 2007 to 2008.
• Fewer cases started at the end of the day: Because of the greater efficiency facilitated by the OR tracking system, the number of “late” cases (cases performed after 3 p.m., which is the end of the surgical day) decreased from 10 to 3 per day after introduction of the system.
• Faster room turnover: Before the development of the OR tracking system, approximately 10 percent of cases were not turned over within the target of 20 minutes; currently, that percentage has declined to nearly zero. In addition, the caseload turnover has increased without extending daily work hours.
• Faster pharmaceutical restocking: Pharmacy personnel can now complete the restocking process for all suites in 2 hours; before using this system, restocking required 2.5 to 3 hours.
• Improved surgeon satisfaction: Before the implementation of the OR tracking system, surgeon satisfaction ratings were "average"; since implementation, surgeon satisfaction ratings are consistently "above average." (Some of this increase may have been due to a concurrent improvement—24-hour access to a surgical scheduler.)

The OR tracking system reduced surgeons’ late arrivals through the following mechanisms:

• Monitoring from the surgeon’s office: Surgeons with access to the hospital computer network were able to view the electronic status board from their offices, allowing them to monitor the status of their schedule/room and determine whether their cases would be starting on time or be delayed (and if so, by how long).
• Alerts based on operative time: Each time a surgery was scheduled, the OR scheduling system used historical data to calculate estimated procedure duration based on the average duration for that procedure by that surgeon over the last year. This average expected duration was transmitted to the OR tracking system; if a case extended beyond the expected end time, the status board flashed an alert for that room. This alerted the surgeon and staff that the surgical suite would be occupied longer than anticipated.

There are other measures besides electronic tracking that will decrease late starts and turnover times throughout the day.  If the surgeons’ own time isn’t spent waiting for their patients and rooms, they may make a greater effort to keep from wasting others’ time.

We would be very interested in learning of methods that you, our readers, are using.  If you send us descriptions of strategies and tactics that can be generalized to other facilities, we will gratefully use them to update this Alert.

With best wishes,

Tony Mira
President and CEO