  PROPOSAL TITLE: 

            Improving Operating Room Efficiency

  PROJECT LEAD(S):

            MB Triad, Nathan Schwab, Joyce Chang, Jina Sinskey

  EXECUTIVE SPONSOR(S):

            Amy Lu

  ABSTRACT:

Operating room (OR) delays result in wasted resources by increasing unused OR time, which can potentially decrease OR utilization. This can lead to increased staffing costs (e.g. pay for traveling nurses, after hours coverage), which is especially challenging in the setting of national healthcare staffing shortages. Improving OR efficiency can provide an opportunity for us to optimize such wasted resources and improve morale by increasing professional satisfaction for all perioperative team members. Separate highly reliable teams work together to take care of our patients and while improving efficiency is important, we do not want to compromise patient safety and quality of care. Thus, we plan to address OR efficiency in a systematic, coordinated fashion across our multidisciplinary perioperative teams. We propose three areas of focus to improve perioperative efficiency: (1) Improving first case on time starts (FCOTS), (2) Improving OR turnover times (TOT) and (3) Minimizing non-operative OR time. Our project will identify and map the causes of delays and identify strategies to maximize efficiency and safety by targeting these causes. Our hope is that this will help address UCSF Health’s current financial challenges by (1) improving operating room utilization and (2) reducing the use of agency and contract staff and resources. This will also allow UCSF to increase patient access to surgeries and enable patients to receive more timely care.  Teamwork and communication will be critical to the success of this project.

  TEAM – 

Joyce Chang – Anesthesia MBE1am

Lee-lynn Chen – Anesthesia Triad Lead

Sharon Gleeson – Nursing Triad Lead

Arturo Luna – MB Hospitality Services

Nathan Schwab – Preop/PACU Nursing Manager

Jina Sinskey – Associate Chair of Well-being

Mika Varma – Surgeon Triad Lead

  PROBLEM –

• OR delays result in wasted resources in the form of OR time and staffing costs for the nursing and anesthesia teams.
• OR inefficiencies are a driver of burnout as evidenced by a recent faculty well-being survey of anesthesia and surgical faculty. Quicker OR turnovers while prioritizing patient care has emerged as a priority for perioperative faculty morale.
• Currently at Mission Bay, an average of 41% of first cases start at the scheduled time with an average delay time of 10 minutes. Mean OR turnover times (i.e., time between surgeries) are 41 minutes with a median of 42 minutes.
• Although overall OR utilization from July 2022 to January 2023 is 73%, utilization decreases after 3 pm to 52%, since time at the end of the block grid tends to be less utilized because it is difficult to fit an extra case in if it runs past the grid. This represents an opportunity to increase OR utilization after 3 pm by being able to schedule additional cases in the grid.
• Overtime labor costs for 2022 were unavailable at the time of this submission.

  TARGET -  

Our goal is to (1) increase the number of FCOTS to > 80% and decrease average first case delay time to 5 minutes and (2) decrease mean OR turnover times (TOT) to 30 minutes. This would result in a total annual time savings of 14,326 minutes due to FCOTS improvements and 16,428 minutes due to TOT improvements. By addressing OR delays, we will also be addressing a documented barrier to anesthesia and surgery faculty satisfaction, which will hopefully mitigate burnout due to OR inefficiency. We will also increase access to surgical care for our patients.

  GAPS – 

We have begun to document and collect delay reasons for FCOTS, with the most common reasons thus far in being lack of surgical consent (8.9%), lack of surgical history and physical note (4.4%), and surgeon unavailability (3.7%). However, objective data and presentation of this data is lacking. While the nursing team documents the delay reason, but it is not discussed with the rest of team, which is a missed opportunity for improvement. In addition, there is no current data on TOT delay reasons. Delays cause frustration and erode the morale of the perioperative team members. In the past, previous efforts to endorse a workflow have met resistance and have not been coordinated across perioperative stakeholders.

  INTERVENTION – 

We would like to further characterize the delay reasons for FCOTS and TOT and modify existing workflows to reduce inefficiently utilized time. We have met with multiple stakeholders in the perioperative area to see how we can best coordinate our efforts. For example, we have met with stakeholders from the environmental services and anesthesia tech support teams, who have suggested ways to improve advanced communication when OR turnovers are needed to help reduce TOT. We plan to provide individual feedback on personal performance (automated reporting, weekly/monthly). We are also planning to provide team-level incentives for reaching our FCOTS and TOT goals (e.g., acknowledgement, gift cards, food). Our target population are the surgery teams, anesthesia teams, nursing teams, and support staff. To ensure adequate patient safety, we will monitor the incident reporting system for possible adverse safety outcomes.

  PROPOSED EHR MODIFICATIONS:

• HAIKU (Apex mobile app) can notify the surgery team and anesthesia team when patients arrive in the preoperative area.
• We will utilize a communication platform (i.e. Voalte) to provide real-time communication and notification of barriers to proceeding with the surgical case.
• We will improve ICANDOS notification visibility to all team members, including a notification when all criteria are met for the patient to enter the operating room.

  COST – 

Based on the minutes saved from addressing FCOTS (14,326) and TOT (16,428) delays, we could potentially add an extra 172 cases per year based on an average case time of 196 minutes. The average revenue per case is $42K with a contribution margin of $14K. We realize that we cannot directly translate the saved minutes into additional cases and revenue. However, overlaying the saved minutes with the decreased OR utilization after 3 pm suggests that the opportunity exists. By improving FCOTS and TOT, we could potentially then fit one additional case at the end of the day. We estimate one additional case per day would lead to an additional 200 cases per year (40 weeks x 5 days), or $2.8M in revenue. Decreased overtime costs for nursing (intraoperative and postoperative care) and anesthesiologists represent another opportunity for cost savings.

  SUSTAINABILITY –

Perioperative triad leads at each campus will provide day-to-day leadership and help implementing interventions to address FCOTS and TOT delays at all UCSF sites.

  BUDGET

$50,000 will be split between:

• IT support (i.e. Voalte or other communication technologies)
• Reporting efforts to create automated reports
• Incentives to team members for reaching target goals
• Project management support

APPENDIX--

First Case On-time Starts

41% of first cases start on time.  Of the 59% that start late, they are delayed an average of 10 minutes.  There are 12 ORs, 5 start on-time. If the 7 late rooms start 10 minutes earlier for each business day in FY24, that would create 288 hours (17,280 minutes) of additional OR time.  The average case at MB-A is 196 minutes.  If every minute could be utilized, there would be room for 88 more cases.  However, we know that you can’t fit a case into every available minute across multiple ORs.  Somehow, these minutes would need to be aggregated into a block of time that could accommodate a case. 

If the target is 80% of rooms start on time and the average delay is 50% of baseline (5 minutes), the incremental time generated would be 14,326 minutes

[9.6 rooms on time, 4.6 more than now, saving 10 minutes each (4.6*10*247= 11,362).  2.4 rooms start 5 minutes late, saving 5 minutes each (2.4*5*247= 2,964). 14,326]

Turnover Time

Average is 42 minutes across 1,369 cases (36% of total).  If you assume the same % of cases have turnover and save 12 minutes, you would free up 16,428 minutes, enough for 84 more cases if every minute could be utilized.

However, as with the FCOTS, you cannot fit a case into small increments of time.  These increments would need to be aggregated somehow to make a large enough block to accommodate another case.

The chart below is from the Periop KPI dashboard and shows the average TOT minutes at Mission Bay adult by service.  As you know, this metric only measures surgeons who follow themselves and there is a 60 minute cap.