Healthcare provider organizations today are looking for opportunities to improve efficiencies across the enterprise. Sometimes, identifying those opportunities happens in surprising ways.
What was intended to be an analysis of OR use in preparation for an expansion project at Indiana University Health Arnett Hospital revealed major opportunities to improve efficiencies in perioperative services. When Daniel Neufelder, FACHE, then president of IUHA and the West Central Region (he retired in September 2021), and his team partnered with BRG to determine how best to handle reduced OR capacity during construction, an entirely different set of issues surfaced.
“BRG told us, ‘Your problem isn’t that you’re not going to have enough operating rooms; your problem is you’re only using half of the block time you set aside for surgery,’” Neufelder says. This was despite the hospital’s internal data systems indicating high OR use.
In addition, some critical inefficiencies were uncovered: chronically late first case on-time starts were creating a ripple effect of late surgeries throughout the day and cancellation of surgeon office appointments, and inaccurate surgical suite turnaround times resulting from incorrect case duration estimates were causing last-minute surgery cancellations.
BRG’s interviews with surgeons, anesthesiologists and other perioperative staff uncovered even more opportunities for improvement. IUHA had been trying to oversee its perioperative operations through a committee of the hospital’s medical staff, but it learned from the surgeons that this committee structure was unsuccessful in driving sustainable performance improvement.
“The interviews also indicated executive and clinical leadership had not consistently held physicians accountable for unprofessional behaviors, which created a toxic environment,” Neufelder says.
Creating a Better Perioperative Services Structure
To address these challenges, IUHA took the following steps, which can serve as key success factors for other organizations seeking to make similar improvements:
Formed a physician-centric governing body. The committee is made up primarily of surgeons and anesthesiologists who were already models of the improvements the organization wished to make. “It’s much easier to tell a surgeon you’re taking away some of their block time because they’re not using it efficiently if that directive is coming from a group of peers,” says Roger Kaiser Jr., MD, managing director, BRG.
Neufelder says it was key to have nondepartment chair clinicians at the table. This helps eliminate the biases that can occur when chairs only represent their own department’s interests, according to Kaiser.
The IUHA perioperative governance committee now comprises the hospital’s president, CMO, director of perioperative services and the carefully selected clinicians, who make up approximately 75% to 80% of the committee’s voting members.
Developed a playbook. Another success factor is the creation of a set of guidelines and rules inspired by leading perioperative practices. At IUHA, these include criteria for surgeons receiving block time, including how it is measured, reported or taken away. The guidelines created a mechanism to be more dynamic in the management of resources.
“Before the perioperative governance committee was formed, it wasn’t clear how decisions were being made,” Neufelder says. “It might have been that years ago a surgeon requested to do surgeries on Tuesday mornings from 7:30 until noon, and that went unchanged for years, even if their use of that time was not high.”
Objective rules help promote fairness and improve relationships among clinicians.
“Historically, the nursing director or manager would hold performance discussions with physicians,” says Noreen Hudson, RN, associate director, BRG. “Now, the governance committee conducts these sensitive discussions with physicians, which eliminates animosity.”
Transparently defined key performance metrics. At IUHA, monthly scorecards for surgeons help show them how they’re performing compared to their peers within the defined metrics. “Now IUHA knows, for example, how a first case on-time start is defined,” Kaiser says. “They have a way to measure physicians who are chronically late, and they know what to do to keep and block OR time.”
Dramatic Improvements
When the new governance committee began its work in February 2020, IUHA’s major OR had a first case on-time start rate of 45%. In June 2021, the rate had improved to 88%. In January 2020, data showed IUHA’s block time utilization rate averaged 53%. In May 2021, that rate for the main OR was 72%. Other benefits include improved collaboration between schedulers and surgeons’ offices and a streamlined pre-surgery process to ensure patients are better prepared for surgery.
“Overall, the changes we’ve implemented have increased satisfaction for patients, clinicians and staff,” Neufelder says.
Says Kaiser, “As we work toward performance improvement, the overriding principles should be, ‘How do you build an operating room and culture where surgeons want to come to practice, where nurses want to come to work and where patients want to come for their care?’”
For more information, please contact Paul Osborne, managing director/Healthcare Performance Improvement Practice co-leader, BRG, at posborne@thinkbrg.com or 305-984-1029.
