Section 4 – Nursing | Anesthesia Key

Section 4 Nursing

27 Operating Room Metrics

Todd Brown

The operating room (OR) is a complex and dynamic environment that is difficult to manage and almost impossible to control. Increasing the efficiency and effectiveness of an OR seems to be every hospital’s goals with administration and surgeons supplying ample motivation to be striving for constant improvement. One of the more interesting aspects of measuring OR performance is determining which metrics to use when creating your operational dashboard. When you look at the metrics and dashboards used to measure performance, there is considerable variance in which metrics hospitals use to measure performance. When determining the metrics to include on a dashboard, there seem to be several key assumptions that must be met to make the dashboard meaningful in the decision-making process. These assumptions include that the data should be available in an information system, be meaningful to the key stakeholders, use standard definitions whenever possible, not be qualitative and be detailed enough to be actionable in performance improvement.

The requirement to have the data in an OR information system meets the criteria to have easily extractable data that can be reported on consistently in a timely manner. Manual accumulation of data is useful, but often by the time the data is accumulated and reported, the data is stale and cannot lead to clear meaningful timely action. By using extractable data, the dashboard can be assured to be accurate, reliable and repeatable with limited opportunities for data manipulation.

A dashboard must be meaningful to key stakeholders to be relevant in the decision-making process. Key stakeholders can include surgeons, administration, anesthesia and the management team. For example, the turnover time (TOT) is a key measure of efficiency. The TOT that may be meaningful to the management team may be prior patient out of the room to subsequent patient in the room (wheels in to wheels out) while the surgeon may want to measure TOT from incision closure to ready to be draped. By including the metrics that are meaningful to the key stakeholders the dashboard becomes a way for the OR managers to communicate performance by continually infusing the conversation with accurate data. For example, in an OR committee the TOT was challenged by a surgeon. The surgeon stated his TOT was not anywhere near the presented time. The ability to immediately drill down to the surgeon’s cases and review the TOT defused the situation and validated the data presented. The power of data cannot be understated.

Using standard definitions is critical if the OR chooses to benchmark themselves against an outside organization. Using nonstandard definitions can undermine the credibility of data making external benchmarking less than meaningful. Although benchmarking against external competitors is useful in determining OR performance; best practice is to be using internal benchmarks to strive for continual improvement.

The use of qualitative data can be useful for the internal benchmarking of the customer satisfaction of both the surgeon and patient. These are important measures but should not be confused with more quantitative measures. Because of the wide variation in questions and processes used to collect qualitative data, external benchmarking can be problematic. The recommendation is to stick to quantitative metrics for measuring operational efficiency.

An operational dashboard can be a great opportunity to measure and present the performance of the OR. But without the ability to make decisions and analyze the data in a detailed manner, the management team can measure performance but have a difficult time impacting operations. For instance, if first case on time starts (FCOTS) begin to decrease, the ability to localize the process that is causing the late starts can be difficult to track down. Detailed documentation of the reasons for variances is critical to drive meaningful change in performance improvement. Remember, when you use detailed analysis to drive change it is more often a process problem than a person problem. This should not be a punitive process or the blame game will take over your documentation.

What are some of the top metrics to measure on your operational dashboard? FCOTS, TOT, same day case cancellations, block utilization, prime time room utilization, and case volumes (number of cases over a defined date range, number of case minutes over a defined range and number of procedures performed).

FCOTS is defined as the first scheduled case of the day starting at the scheduled time. This simply means the first scheduled patient of the day is in the room at the scheduled time. The literature suggests most organizations allow a grace period anywhere from zero to fifteen minutes with most suggesting a 6–7-min grace period. FCOTS is one area that a detailed reason for delays can contribute extensively to improving on time performance. One area that has a significant impact on FCOTS is preadmission screenings. Hospitals that offer 100 percent of their patient’s preadmission screenings have 10 percent higher FCOTS than those that do not [1]. Benchmarks suggest the median score is 64.3 percent with the 90th percentile at 88.3 percent [1]. Keep in mind that a first case delay affects every case for the remainder of the day.

Some organizations will also measure second or subsequent cases on-time starts. There are so many variables that can affect second or subsequent on-time starts that I do not find this is an actionable or useful metric to place on the OR dashboard.

TOT is a measure of the time from the prior case patient out of the room to the subsequent patient into the room [2]. Many clinicians will refer to this time as wheels in to wheels out. Most organizations will only measure the TOT for the same surgeon following him- or herself or same surgeon back to back to keep the data set as clean as possible. The literature suggests most organizations will exclude scheduled gaps in the surgery schedule. This is accomplished in several manners including excluding any TOT greater than 60 min. Like FCOTS detailed tracking of the reasons for delays is critical for process improvement. What is a good TOT? There is not a consistent recommendation for TOT. There are so many variables from ambulatory surgery to an academic medical center that it is difficult to set a clear benchmark. I usually strive for a 25-min TOT but strive for an incremental decrease until the goal is attained. The key is to show improvement and set attainable internal benchmarks as the internal benchmark is incrementally decreased. This allows the staff a series of wins as we work together to reach the benchmark. Keep in mind the balance between efficiency and quality when TOT is measured to assure high quality care is not sacrificed to increase efficiency.

Same day case cancellations are a measure of the number of cases cancelled on the same day as scheduled. Unfortunately, this is another case where the literature suggests the definitions “same day” differ from organization to organization. The most common definition of “same day” appears to be from the time the schedule closes the day prior to the cancelled case. The documentation of the reasons for cancellations is critical to process improvement. Same day case cancellations can have a significant impact on OR prime time utilization leading to underutilization of prime OR time. The benchmarks for same day cancellations are as varied as the organizations. For example, hospitals in urban areas experience a much higher same day case cancellation rate than those in more rural areas [1]. Like so many of the OR metrics, the key is to set measurable goals for internal benchmarks with continual performance improvement.

Block time utilization is defined as the actual room time used by the surgeon or group assigned by the actual block time available. Block time usually is assigned to an individual surgeon but can be assigned to a group or service. Block time is neither a good nor a bad thing, but too much allocated block time can decrease flexibility and frustrate the ability to add new surgeons. Managing block utilization can be a significant challenge so a strong policy is a must with clear definitions of the process used for calculating, adding, or subtraction of block time. Recommendations for managing block time can be to include TOT in the actual room time used for calculation, develop a block committee to manage block time with a strong surgeon champion to chair it, only allow blocks of eight hours or more and follow the policy without exception. However, controversial block release should not be an across the board decision because different services typically schedule with different lead times. Automatic block releases should be set to assure there is time to schedule as much as possible in underutilized block times. Benchmarks for block time utilization can vary between 65 to 85 percent with the inclusion or exclusion of TOT having a significant impact on the block utilization goal.

Prime time utilization measures the percentage of total available operating time between 7:00 a.m. and 3:00 p.m. against the total amount of actual case time including TOT. Prime time may vary among organizations depending on the operating start time. Typically, the higher the prime time utilization, the better for the organization but when prime utilization becomes too high it can be a key indicator of the need to expand facilities. Prime time utilization can be measured by day of the week with a target of 75–85 percent utilization.

Case volume is another critical measure of operational efficiency. Of all the other metrics, volume is a key quantitative indicator of surgeon satisfaction. Generally, when surgeon satisfaction is high, volume increases. Case volume can be broken down into three distinct types of volume. Case volume or number of cases completed in the OR, procedures completed (a case can have multiple procedures) and the minutes of surgery completed. Each type of volume should be further analyzed by service and surgeon. Volume can be analyzed by month year over year to account for seasonality and year to date to measure performance. Anytime there is a decrease in volume, it is a perfect time to show your surgeons you appreciate their business. If there is a decrease in volume, it takes only a moment to draft a quick email to the surgeons and let them know you noticed a decrease in volume. This allows you to let them know you appreciate their business and want to follow up and ensure that there are no significant reasons for the decrease. Most of the time there is a vacation, conference or some other reason for the decrease but almost all the time the surgeons appreciate that you noticed. Occasionally you will get feedback for areas of opportunity which gives you the opportunity to respond with a plan for improvement. This opens communication and shows your surgeons you appreciate them and the business they bring to the OR.

There are many more metrics that can and should be monitored in the OR. We have not even begun to touch on the financial cost and reimbursements metrics that can be measured. But from an operational standpoint with these six-metrics, operational efficiency can be measured and more importantly acted upon to drive operational improvement.

References

1.T. Foster (Ed.). (2012). Data for bench marking your OR’s performance. OR Manager, 28(1).

2.S. D. Boggs, M. H. Tsai, R. D. Urman, Association of Anesthesia Clinical Directors. (2018). The Association of Anesthesia Clinical Directors (AACD) glossary of times used for scheduling and monitoring of diagnostic and therapeutic procedures. J Med Syst, Aug 10;42(9):171.

28 Operating Room Staffing Guidelines

Todd Brown

Direct Staffing
Indirect Staffing

The operating room (OR) is a complex and dynamic environment where the only constant seems to be change. Staffing the OR to meet the needs of the environment is a daunting task that is equally complex and dynamic. A difficult task has become even more challenging with the changing generational demographics of the OR, rising labor costs and decreasing reimbursement placing more emphasis on resource utilization including human capital.

As a new manager, I distinctly recall the sense of panic when attempting to develop the first staffing grid or plan to staff the OR while remaining within budget. Over the years the panic has become less although it has never gotten easier. This chapter is not intended to be a how to guide with clear standards and recommendations but rather guidelines that may be useful in trying to meet the staffing needs of a complex and dynamic environment.

The foundation upon which any staffing plan should be built is the core belief that all staff and patients deserve a safe environment. The AORN Position Statement on Perioperative Safe Staffing and On-Call Practices (2014) states “AORN believes that patient and workforce safety must be the foundation for all staffing plans.” Key factors must be considered such as the complexity of cases and staff fatigue. For example, 36 h in a week may not seem excessive but 3 consecutive days in a complex work environment combined with covering call may be cause for concern. Knowing your staff, knowing the specialty they are working in and factoring in the call schedule are important factors to be considered. Recommendations for placing limits on staff work schedules should include scheduling no more than 12 h a day, no more than 3 consecutive days of 12-h shifts or 60 h a week.

When working to determine OR staffing, we will divide the process into direct (core staffing) and indirect staffing. Core staffing or direct staffing will be considered those staff members who are directly staffing the OR suites.

Direct Staffing

Case volume is a key consideration when building a staffing grid. Rooms in progress by hour of the day can be a key indicator for building the core staffing. In many ORs, breaking the cases into rooms in progress by hour of the day by day of the week is necessary because of the differences in block schedules or case volume. See Figure 28.1. In this example based on a 10-bed OR using historical ORs in progress by day and OR scheduling guidelines we will staff the following rooms.

Figure 28.1 Rooms in progress by hour of day.

Monday–Friday

10 rooms: 7:00 a.m.–3:00 p.m.
7 rooms: 3:00 p.m.–5:00 p.m.
5 rooms: 5:00 p.m.–7:00 p.m.
4 rooms: 7:00 p.m.–9:00 p.m.
1 room: 9:00 p.m.–7:00 a.m.

Saturday

2 rooms: 7:00 a.m.–5:00 p.m.
1 room: 5:00 p.m.–7:00 a.m.

Sunday

1 room: 7:00 a.m.–7:00 a.m.

Recommendations for core staffing include one RN for circulating and one scrub person. This equates to 2.5 staff per room per hour. In many nonacademic settings scrub assistants are not supplied, so an additional scrub person is required. This equates to 3.75 staff per room per hour for cases requiring an assistant.

Rooms in progress	RN staff	RN break/lunch	Scrub	Scrub break/lunch	Total personnel
1	1	+.25	1	+ .25	2.5

In the example in Figure 28.1, direct or core staffing would consist of the following.

Monday–Friday	RN	Scrub	Hours × rooms × staff hours
7:00 a.m.–3:00 p.m.	100	100	8 × 10 × 1.25
3:00 p.m.–5:00 p.m.	17.5	17.5	2 × 7 × 1.25
5:00 p.m.–7:00 p.m.	12.5	12.5	2 × 5 × 1.25
7:00 p.m.–9:00 p.m.	10.0	10.0	2 × 4 × 1.25
9:00 p.m.–7:00 a.m.	12.5	12.5	10 × 1 × 1.25
Total worked hours	152.5	152.5