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Four years ago, nearly half of all first cases in the OR at BWH started late. Although all first-cases are typically scheduled for a 7:30 a.m. start, more often than not, the patient would still be in pre-op at that time. Worse still, a significant delay in the first case could start a domino effect of delays for the remainder of the day – a 10 minute delay for the first case could mean the last patient’s procedure was delayed by as much as 40 minutes, sometimes longer.
In December 2007, Michael Zinner, MD, chair of the Department of Surgery, and Sanjay Pathak, vice president of Surgical Services, Imaging and Dermatology, assembled the Perioperative Governance Committee (PGC), an interdisciplinary team of surgeons, nurses, anesthesiologists and administrators that was charged with improving operating room efficiency. They were confident that by improving the predictability of the day, patient care and efficiency would improve as well.
The PGC first turned their focus on the scheduled 7:30 a.m. start time.
“A predictable day depends on getting that first case started on time,” said Pathak. “In order to achieve this, the patient, the surgeon and the entire surgical team need to be in the room and ready to go.”
However, in an environment as fast-paced and complex as the OR, this was easier said than done. Surgeons, anesthesiologists, nurses, technicians and OR assistants perform different tasks in different areas of the OR before each procedure, and it was difficult to get all of these pieces to come together at the right time. In 2008, still only 68 percent of first case patients were in the operating room by their scheduled time.
Investigating the problem, the PGC quickly discovered that delays often occurred because of how the OR team communicated with one another. For example, surgeons and anesthesiologists would wait for the nurse in the OR to signal that the room was ready to go before the patient left the pre-op area. In other cases, a signed consent was not electronically available, forcing a delay until the hard copy was located.
“We determined that all the factors going into getting the case started on time were not consistently occurring,” said Pathak.
It was clear that improving timeliness at the start of the day demanded more effective teamwork across the OR. By 2009, the interdisciplinary team had implemented a simple, yet effective, strategy. Instead of waiting for a “room ready” signal, the OR team worked with the common understanding that the patient would be in the OR by 7:25 a.m.
By establishing this “default” time, the OR team eliminated the extra time needed to confirm that the patient could be brought in, and replaced it with the trust that the OR would be ready to go. By early 2011, nearly 90 percent of first case patients were in the OR by the scheduled time. What’s more, another initiative, aimed at ensuring that surgical consents are electronically available, has led to a dramatic improvement in the last year. In 2010, the consents were electronically available only 50 percent of the time; by the end of FY11, that percentage was up to 85 percent.
“We are very proud of how far we have come in the last three years,” said Zinner. “This has required a concerted effort on the part of everyone in the OR and constant communication, collaboration and teamwork. Predictability has made our jobs easier and has enabled us to provide better care for our patients.”