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Can you improve your facility's performance through benchmarking? Without question. When we started benchmarking at our hospital, OR utilization percentage was in the mid-50s. It now runs between 80 percent and 84 percent. In fact, utilization is so high that we're faced with a new challenge: finding open time for add-on procedures.

Benchmarking is a valuable quality-improvement tool that you can use to improve practices and performances when instituted properly. We chose to benchmark internally. Many others prefer to compare their facilities' practices and processes to others' by using external benchmarking (see "Your Benchmarking Options").

Starting out
In March of 2002, we embarked on our benchmarking initiatives. The first step was figuring out what to do with the 25 data reports coming out of our OR information system, including turnover, utilization, actual case start, case end and delay reports.

As we reviewed the reports, we found they were built on unrealistic comparatives and that the data sets were highly inaccurate. As a result, our physicians saw little of this information and how it actually affected them.

An overall assessment of our systems identified the areas we needed to improve. Out of that, we created four very specific reports to reflect measurements for our targets: overall utilization, individual block-time utilization, start times/ turnover times and delays.

Overcoming hurdles
We didn't see dramatic improvements overnight, and there were many stumbling blocks that cropped up that we dealt with before we were able to realize success with our benchmarking.

• Physicians didn't believe in the data. While there was a forum, it didn't have reporting accountabilities. So we instituted a formal work plan that empowered the physicians to get, use and suggest changes based on the data.
• There were no identified processes to measure efficiency. Nurses, anesthesiologists and surgeons had their own agendas, but we had to find way to bring it together to achieve maximum efficiency. Now, for example, in ambulatory services we have defined a set of people for ENT, and the surgeons will see those nurses and those techs for each case. That way, everyone becomes extremely familiar with each other's practices and habits.
• The surgeons had limited understanding about how an ill-prepared patient directly affected our getting the first procedures of the day started and, therefore, procedures throughout the day. Physicians expected the hospital staff to assure patient readiness, obtaining reports from clinics and other facilities, and assuring that diagnostics and X-rays were accounted for.
• Anesthesia, surgeons and OR staff had different definitions of what "getting the procedure started" actually meant, from entering the O.R. to the actual incision time. We standardized this definition - incision time equals start time - to get everyone on the same page.
• The relationship between surgery and data management was not clearly established; there was no understanding of the ultimate goal. We now use data - instead of anecdotal perceptions - to drive surgery decision-making. The surgical services committee, co-chaired by an anesthesiologist and a surgeon, is empowered to make operational decisions, with the support of administration. Administration members accountable for surgical services also attend the committee's meetings.
• We have centralized scheduling, but the process hurt daily-schedule management and caused mid-day slow downs. The result: The inability to develop a day-end closure plan. For example, between 11 and 13 ORs would still be running at 3:30. We now assign block time based on measured utilization data that the surgical services committee reviews quarterly. New block allocations are based on actual performance; surgeons are not automatically given time to operate. We allocated time to new surgeons based on practice history.

Reaping the rewards
Before benchmarking, our overall average turnover was 52 minutes; however, we did not historically look at specialty-specific turnover times. Now we look at turnover times by specialty and evaluate the data to understand surgeon, staff and anesthesia practices and how they affect overall turnover efficiencies. We have also re-aligned individual strategies for simple and complex cases because they require different resources and time considerations. For cataract surgeries, for example, turnover time is about five or six minutes - we wouldn't have been able to tell you that before.

Our overall OR utilization percentage was in the mid-50s when we started; it now runs between 80 and 84 percent. In fact, our utilization is now so high that obtaining open time for add-on procedures has become a challenge.

We've seen improvements outside the performance indicators, too. Striving to maintain a day-end closure plan has improved staff satisfaction, increasing retention and enhancing recruitment. Clarifying the roles and responsibilities of our centralized scheduling department has improved relationships and efficiency. How we work together as a team has also improved - our pre-admissions staff, pre-op staff, office staff, surgeons, anesthesia providers, OR teams, PACU staff and administration all better understand the role accountability plays in success.

Looking ahead
We've made changes, yes, but we're now targeting other areas for improvement.

For example, when it comes to patient preparedness, we still struggle with last-minute morning tests and report tracking; the goal now is to establish a turn-key operation for the day of surgery in which all paperwork is ready when a patient walks through our doors.

We'd like to improve our information systems so that we can benchmark against other facilities. We're working with our software vendor to integrate recognized, standard benchmarking indices and reporting systems, not only for efficiency, such as OR utilization, but also for productivity, such as personnel/staffing satisfaction. In addition, we'd like to help establish nationally recognized benchmarks that we can use to compare to other facilities in our healthcare system. When we participate in teleconferences, we often find that within our chain, facilities vary considerably in how they measure processes and time indices.

We have made improvements in several specialties, some greater than others, with some setbacks. The difference now is that we can always go back and review data to understand what is actually occurring - then refocus and devise changes that may be necessary to keep the process moving forward.