Efficiency by Design: Clinical Process Redesign

Delays are inefficiencies that can have negative impacts on patients, physicians and staff. Frustrations and anxiety associated with delays are unnecessary stressors for those in the peri-operative arena. A first case delay has an exponential trickle-down effect on all cases in a particular OR suite for the day, which also impacts a surgeon’s time and their ability for rounding or seeing patients in the office prior to arriving in the OR.

To help address the delays, actions included observations in pre-op and timing in- to-incision times and analyzing all components within those processes to identify bottlenecks to flow. However, the challenges of communication and lack of transparency that emerged posed particular difficulties. A new, cross-functional approach that integrated technology and process redesign was needed.

Recognizing that change was necessary, members of the OR team took another deep dive and reviewed every step of the OR process to determine where positive changes could be implemented. The team looked at everything from when the patient rolled in the operating room, the prep time, and the time out of the operating room, to the time the surgeon walked in the operating room, to the time the anesthesiologist arrived. In the end, four key areas for improvement emerged—ones that could be changed without an expensive and time-consuming capital investment:

OR Process Redesign

• Redesigning OR processes for the patient and the staff—from patient registration to the OR to the PACU, as well as the processes that staff follow to prep the OR for surgery.

Equipment

• Ensuring availability of all equipment and instrumentation that surgeons need to start on time.

Communication

• Improving communication between pre-op and OR suites to know what the real-time status of patients is.

Automation

• Eliminating manual processes and educating staff on the new automated approaches.

Drilling down even further, the team determined a critical step in the OR process that needed to be improved was the in-to-incision time—a step that has a significant impact on subsequent activities. Being able to improve this metric depended on two key processes:

• Transporting the right equipment and instrumentation to the room in a timely manner, along with making sure it was working properly, and;
• Improving communication in the OR and between staff in all areas of the surgical suite. Staff members were using hardwired phones, pagers, overhead pages, etc.

The decision to move forward became one component of a wide-reaching project that was also supported with operational, process and staffing changes. From the process perspective, lean techniques were used to redesign workflows, including:

• Factoring in the time necessary for sterile processing of equipment.
• Working closely with the transport manager to determine the causes of delays and removing them in order to get patients to the pre-op area in a timely manner.
• Creating a surgery pre-check process—including having a liaison from the OR review the checklist with the unit nurse the day before a procedure to discuss the tasks/procedures that need to be completed before a surgery can proceed. For instance, a cardiac clearance, MRI, CT, special medications, etc.
• Educating surgeons on the updated pre-op to wheels-in process, which involved checking in electronically when they were in pre-op and again when they entered the OR. This helps ensure that all the staff members who need to be in the OR for a surgery to proceed are there at the designated time.
• Eliminating the manual processes that lead to delays and making Clinical Workflow Suite [CWS] the single, comprehensive source for patient flow information.
• Using the data generated by the technology to further refine underperforming processes.

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