Regardless of size or specialty, every OR faces the same obstacles to efficient room turnovers — inflexible thinking, institutional dogma and long-held beliefs about how rooms should be reset between cases. Thankfully, there are several practical ways to give your staff the tools and support they need to wipe down surfaces, mop floors, position equipment and gather needed supplies faster than ever.
1. Trace the turnover team’s steps. Observe your turnover team in action to identify areas for improvement. How many people enter the room to clean and what role(s) does each play? How many times do they leave to grab missing supplies? How often are they called away to another assignment? What excess movements can you streamline? Begin this process with an open mind.
“When we started out, we didn’t know what we were looking for,” says Alicia Rock, BSN, RN, CNOR, interim assistant nurse manager at University of Iowa Hospitals and Clinics in Iowa City. “But after watching, the issues became obvious. We were able to narrow them down to things that we’d be able to influence.”
Spaghetti diagrams that trace each member of the turnover team’s path will help you identify wasted movements that you as the conductor of this OR orchestra can eliminate. Alternatively, you could ask all those involved in turning over rooms — surgeons, anesthesia providers, nurses and techs — to map out their roles in the process.
“Determine which steps are ‘valued’ — those that generate a positive return on investment in terms of the resources or staffing involved, or cannot be eliminated without having a negative impact,” says Robert Cerfolio, MD, MBA, chief of clinical thoracic surgery at NYU Langone Health in New York City. He helped lead efforts to cut average turnover times in the hospital from 37 minutes to 14 minutes, well under the 20-minute goal his team set out to achieve.
Then, says Dr. Cerfolio, do whatever is necessary to eliminate unnecessary or non-valued steps in the turnover process. For example, circulating nurses at NYU Langone no longer walk to the supply room to retrieve needed supplies between cases. Instead, techs gather supplies the night before surgery and store them in case carts, which are wheeled into the OR as needed.
2. Assign roles. Just as having not enough staff show up to turn a room over is a problem, so is having too many. Yes, many hands usually make light work, but Ms. Rock noticed that too many team members mopping the floor or spraying a surface actually slowed the team down and resulted in duplication of efforts at University of Iowa Hospitals.
“I was shocked to observe that the more people who were in the room, the less effective they were because no one had any idea what the others had already cleaned,” she says.
Now, 6 team members — an anesthesia tech, circulating nurse, scrub tech and 3 members of the hospital’s housekeeping team — descend on rooms with assigned cleaning roles. Ms. Rock says appointing position-specific cleaning roles makes it clear who will clean what during turnovers. If a member of the turnover team is called away or the task is taking longer than expected, colleagues know where their help is needed.
3. Create cleaning carts. The team at University of Iowa Hospitals developed cleaning supply carts — 9 to cover the facility’s 32 ORs — that wheel gloves, surface disinfectants, garbage and linen bags, mops and buckets to the point of use. “We included everything our turnover teams would need — including items they often had to leave the room to grab,” says Ms. Rock.
4. Switch to a surface disinfectant with a shorter dwell time. The turnover team at Iowa further reduced turnover times by switching surface disinfection products from a quaternary ammonium product with a dwell time of 10 minutes to an accelerated hydrogen peroxide disinfectant with a dwell time of 1 minute.
5. Track your progress. Post weekly room turnover data — average turnover time, the week’s best turnover time — so staff can track their progress and aim to better their times. “Change is difficult when surgical teams are used to the routine of room turnovers,” says Dr. Cerfolio. “Once they see the value in efficient room turnovers, you’ll be able to sustain and scale process improvement.”
Before implementing widespread changes, test the effectiveness of the new turnover approach in several ORs involving a variety of cases. Over a 3-month span in 2018, Dr. Cerfolio and his team tested process improvements over 7 days in 35 ORs involving 42 cases. The process improvement team met weekly to review the data and identify barriers to greater efficiency. At the end of the trial period, they compared the results to historic data that involved the same surgeons performing the same cases, and found they cut turnover times by more than half. Anecdotally, the process improvement team noticed turnover times were shorter when surgeons were present in the room between cases, perhaps because staff saw they were ready to get started on the next case as soon as the patient arrived.