A Colorado hospital reduced average turnover time from 26 minutes to 20. How did they do it? The effort began with observation. What was costing turnover teams time? What efforts were being duplicated? What could be done better and faster? The idea, says Treena Dockery, MBA/HCM, CLM, process improvement consultant at University of Colorado Health, was to have a variety of stakeholders step back, observe everything about the process and try to identify waste, using lean techniques and principles. To broaden their perspective, they observed more than 10 cases over multiple shifts and at multiple times throughout the day at Poudre Valley Hospital in Fort Collins, Colo. Here's what they discovered:
1. Little things added up to big things. For example, patients moving from pre-op to the OR, and from the OR to the PACU were having different types and sizes of EKG leads, blood pressure cuffs and pulse oximeters attached and fully removed at every stop along the way. The solution was to create a series of adapters that made it possible to simply disconnect and reconnect patients as they moved from station to station. "Now, the blood pressure cuff stays on and rolls with the patient through the entire process," says Paul Higgins, BSN, RN, CNOR, business manager for perioperative services at Poudre Valley.
2. Duplication of effort is a big time-waster. One of the first things the observers saw was that communication had to improve. There had to be a better understanding of who was doing what. "We would wipe off the back table 3 times, given the opportunity," says Mr. Higgins. "We had to develop that standard work that someone was going to be wiping the horizontal and vertical surfaces, somebody else was going to be mopping the floor, and so on. Everyone had to know what their role was."
3. Turnover kits are true godsends. Cumbersome reusable linens, mop heads and rags are gone, replaced by kits that consolidate all needs in one package and are kept on case carts. "So we're not searching for the parts and pieces to make a bed up, not having to deal with the cost of laundry and we're not having all that laundry that even behind closed doors in an OR has the potential to be contaminated," says Mr. Higgins. The kits turn out to be less expensive than it was to do the laundry needed for each OR.
4. Faster dry and kill times matter. The team switched from a cleaning solution that had a dry time and contact time of 10 minutes to hydrogen peroxide wipes with a kill time of 5 minutes and a dry time of 1 minute. Practically a no-brainer. "So we're not just standing around watching the paint dry," says Mr. Higgins.
SAVING 60 SECONDS
At Arkansas Children's Hospital in Little Rock, the consensus was that tools and tasks had already been optimized, so the goal was to improve turnover time by optimizing human resources. "We felt like our processes and our materials were as efficient as we could make them," says Diana Ramsey, MHSA, the director of surgical services.
Still, with 12 busy ORs, 4 procedure rooms, and a staff that needed to eat lunch and take occasional breaks, some level of unpredictability was inevitable. To tackle the problem, the hospital created revolving daily perioperative utilization teams (PUT teams) and heavily emphasized both teamwork and accountability.
The assigned PUT teams, which change from day to day, can include any staff member able to function as either a nurse or a surgical tech. Each team member is assigned a zone of emphasis (ORs 1 to 5, for example), but is also expected to help out with other rooms, when available.
When the circulator makes the call that a room is ready, everybody in the room is expected to pitch in, says Ms. Ramsey, and any available PUT team member hurries to lend a hand, as well. A checklist for PUT team members helps prevent duplication of efforts.
To pave the way for the PUT approach, the hospital focused on accountability, says Ms. Ramsey. "We spent a month talking about it. We were challenged about 2 years ago by our new CEO for everyone to be accountable to their professions, their jobs and the patients entrusted to our care."
Another month was spent on gratitude making sure staff members made co-workers feel recognized and appreciated when they went out of their way to help.
"When it comes to turnover, you can get a kind of tunnel vision and think only about what happens in the OR," says Ms. Ramsey. "We may not think about what kind of teamwork was needed before that patient even came into the room.
"But you need to be proactive. Maybe we have a case going on and we have a limited number of instrument sets because it's something we don't do that often, but we've got another one to follow. That's when we need to know a PUT team member is going to take the initiative to check with sterile processing and make sure what we need is going to be available."
The initiative has helped trim the hospital's already-tight average turnover time by a minute or 2.
"It doesn't sound like much," says Ms. Ramsey, "but when you do the math, with the number of rooms we're running, it adds 10 hours of additional patient-scheduling time per month. One minute can make a dramatic difference."
5. Use tracker boards to alert the turnover team. When a surgeon's closing, the circulating nurse or anesthesia provider sends an alert via the EMR, and tracker boards throughout the facility let orderlies know the room is about to be turned over. "There are boards in every OR, at the front desk, in PACU, in pre-op, in the doctor's lounge, in the employee lounge every place you might want to be able to see where patients are," says Ms. Dockery. "You can even see where the patients are on the way into the bathroom."
The circulator goes with the patient, but the rest of the staff members stay behind and are quickly bolstered by a couple of orderlies who are ready to go when the doors open. "They hover," says Mr. Higgins. "So there's no waiting. In a lot of hospitals, the norm is, I'll be right there. And each of the players has standard work they're following," adds Ms. Dockery. "So there's no question as to who's doing what."
6. Don't let surgeons dawdle. Of course the impact would have been negligible if surgeons had failed to take advantage of the shortened turnover time. "Our surgeons used to migrate after a case and go sit in the physicians' lounge and watch TV, or go upstairs and do rounds with other patients," says Mr. Higgins. "We had to make them understand that if we were going to work on streamlining our turnover time, we needed them to be invested and back and ready to go, as well."
The selling point was to remind them that the quicker they get through their surgeries for the day, the quicker they could go home to their families or back to the office, or whatever else they needed to do. The result: Surgeon turnover time, measured from the time surgeons leave the OR where PAs or nurse practitioners might finish closing to the time they make their next incision was clipped from 75 minutes to 46.
In addition to slowing patient throughput, the hospital found that redundancies were annoying patients, who felt they weren't being heard because they were being asked the same questions over and over again. Now the admissions clerk asks a series of questions and makes sure the answers are made available to all care team members. When information needs to be confirmed, staff members try to phrase questions in such a way that patients know they're being listened to: I know you've already been asked what procedure you're having, but I need to hear you say it in your own words. And now, says Ms. Dockery, "we have more patients saying they had confidence in their surgical team, 'because the team knew who I was and why I was there.'"
As these 2 hospitals have discovered, world-class OR turnover time emerges from the seamless integration of several key elements the right tools, the right processes, the right people and the right attitudes.