William Beaumont Hospital in Royal Oak, Mich., is immense, but large doesn't necessarily equate to efficient. It's one thing to have the capacity to churn out a huge number of surgical cases; it's quite another to actually do it. Beaumont, Royal Oak is a perfect example of a big hospital that does, to the tune of 52,239 total surgeries, including 19,451 outpatient surgery cases in 2003.

But active ORs didn't always define Beaumont. In 1998, the surgical services team was plagued with many inefficiencies, low morale and high staff attrition stemming from an overall lack of being able to handle high caseloads. New leadership was brought in to improve the team's efficiency and over the last five years, the staff has evolved into a well-oiled machine. Here are some ways Beaumont developed into one of the busiest hospital surgical centers in the country.

Improved staff education
A large part of Beaumont's success lies in the education standards set for its staff. From the most experienced surgeon to the newest RN, Beaumont demands excellence. As a result, the hospital boasts a top-notch collection of healthcare professionals.

All of Beaumont's surgeons, in fact, are required to complete a fellowship in an interest of their choice or in a specialty that meets the needs of the hospital before even being considered for a staff position. That high - and unusual - standard has been in place since the 1970s, enabling Beaumont to build an impressive lineup of surgical talent.

The nursing staff is no less qualified. A major focus of the surgical department overhaul in 1998 involved a renewed dedication to staff education. To help with that cause, a surgical services education department was created. Today, that team is responsible for keeping a steady stream of newly trained and newly educated RNs filtering through the operating rooms of Royal Oak.

"The work of the surgical education department helps keep us on top," says Denise Lewis, CRNA, the nurse manager at Beaumont. "While other hospitals might be struggling with staff shortages, we're able to maintain consistent and quality healthcare."

Following are a few of the initiatives started by the surgical services education department.

• OR Registered Nurse internship program. This 24-week program prepares nurses without surgical experience for work as circulating OR staffers. The interns hired into the program receive full-time employee benefits, are promised a position within Beaumont and are required to work for two years in the OR upon completion of the program.
• Competency-based orientation. New hires with OR experience are entered in a 12-week to 15-week orientation program based on individual skills and competency.
• Certification review courses. Beaumont nurses are encouraged to become certified in their area of specialty. Classes are offered at no cost and are scheduled at times deemed convenient by the participants.
• Continuing education classes. Beaumont helps its nurses obtain continuing education credits by providing state-approved classes.
• Staff meetings. Surgical cases start an hour late one day a week to allow for staff education and business meetings. "Every Tuesday, from 7 to 8 in the morning, we hold information meetings about updated policies, new equipment or whatever may be relevant to our staff at the time," says Alice Speers MEd, BScN, BA, RN, BC, education specialist, surgical services. "We consider it essential to allocate time to teach new skills."

It is this incredible prioritizing of staff education that has helped increase employee satisfaction across the board. Beaumont faced a 40-percent staff turnover rate in 1998; today the figure has dropped to 5 percent. That turnaround is evidenced by a rise in staff morale and recruitment capabilities.

"We've seen an increased interest in our education problems over the past five years," says Karen Zaglaniczny, PhD, CRNA, FAAN, director, surgical services education and graduate program in nurse anesthesia. "Staff members are now asking us about what we have planned for them, and that's great to see."

Minding your pod
Beaumont's success in rapid case turnover is aided by the division of the main OR into four areas of specialties. Each area - or pod - consists of six rooms to eight rooms and is run like a separate unit with the assigned staff committed to the location for at least a year.

Nurses and administrators are not asked to cross into other specialty pods; each core's staff can therefore mature into a cohesive unit. The thinking is that a skilled OR team can form an instinctive working relationship if allowed to gel. A consistent staff also improves efficiency by their ability to learn the expectations and particulars of the surgeons and equipment they work with on a daily basis.

The pod setup of the OR also enables one surgeon to take ownership of a single room for an entire day. "By eliminating turnover delays that are inevitable when changing room setups for different specialties, the intervals between cases are minimized and the overall efficiency of the facility is increased," says James Catto, MD, vice chief of surgical services and medical director of operative services at Beaumont.

Beaumont also took advantage of its size and resources to develop a six-room outpatient facility for cataract and plastic surgery cases. The lesson involved is not the addition of more square footage; it is Beaumont's creative and insightful use of the annexed rooms. Administrators purposely paired cataract and plastics in the same facility because the two complement each other perfectly. During the summer months, likely candidates for cataract surgery live in the Michigan area; the opposite is true during the winter, as most of the area's elderly head south.

Most plastic surgery patients don't want to be operated on during the summer; they'd rather have procedures done when winter clothes can cover scars as they heal. "That set-up has provided a high degree of efficiencies because when cataract cases are down, the vacant ORs can be filled with plastic surgery cases, and vice versa," says Dr. Catto.

Numbers don't lie
Jeff Burmeister, director of business operations and information systems for surgical services at Beaumont, is a numbers man. He tracks everything from total cases performed to surgeon block utilization before detailing the numeric truths in colorful graphs and charts.

"I'm a means to an end," says Mr. Burmeister. "I provide data to people who hold people accountable. What they choose to do with that information is up to them. I'm not a decision maker."

Mr. Burmeister is, however, a self-proclaimed "black-and-white guy" whose sole concern is to improve Beaumont's efficiency, and ultimately, its bottom line.

"Jeff's stats provide invaluable feedback," says Ms. Lewis. "Numbers help more than a perception of what you think might need improving. With actual data you can recognize what the actual problem is and go after it."

But not everyone is a fan of Mr. Burmeister's charts and graphs. "Sometimes I'm the enemy," he says. "When data comes out, a common reaction is 'the data's wrong,' and I say 'fine, but you have to show me why it's wrong.' Most of the time they can't."

One of the biggest sources of contention surrounding Mr. Burmeister's figures is that of physician utilization. Is a doc using his block time? Is he performing out of his block time? Can rooms be better utilized? The guy with access to the numbers knows all - and he's not afraid to tell it like it is.

"Some docs keep a block because they've had it for 30 years. Is that right?" asks Mr. Burmeister, almost rhetorically. "I don't know. I say you've got to move this guy from strictly a numbers point of view."

After all, the numbers don't lie. "Information is the biggest key to making proper decisions," concludes Mr. Burmeister.

Outgrowing themselves
In response to unprecedented demands for surgical services, Beaumont's facility is adding 16 operating rooms to its existing 36 as part of a 656,000-square-foot, eight-level tower expansion scheduled to open this month. The surgical team is humming along at efficiency levels reminiscent of a Ford assembly line in nearby Detroit.

But there is no one deciding factor in making Beaumont successful; instead, the physical layout of the ORs, the highly trained staff and a detailed analysis of surgical data all play key roles. "If a staff is trained properly and placed in the right setting, they are more skilled and better prepared to do procedures," says Ms. Speers. "That it turn increases efficiency and ultimately improves patient care."