#62

Purpose/Aim:

The number of first surgical cases of the day not started on time has a direct impact on the overall operating room (OR) efficiency. UTMB recently implemented a real-time location system (RTLS) to track patient progress through the perioperative cycle. This technology (OR Controls) was used to support improvement efforts toincrease the daily on-time start percentage. On-time starts were measured two ways: by the actual wheels in (patient in room) time, as well as the briefing (timeout) time.On-time start based on “wheels-in” is defined as patient in the room within 5 minutes from scheduled start time. On-Time start based on “briefing” is defined as briefing no later than 7:30 am with the exception of 9:15 am on Wednesdays.

Our project Aim was to “increase the percentage of first-start cases that occur by target from 41% to 60% by June 7, 2013.”

Tools and Measurement:

A detailed cause and effect diagram (Exhibit 1) and a cross-functional process flow map (Exhibit 2) were developed to understand where the delays can occur. OR Controls functionalities were used to record patient-in time. Epic was utilized to track briefing time. Both variables were measure and analyzed over a ten-month timeframe. In addition, OR Controls text notification functionality was implemented. OR Controls was the primary tool utilized for our project. Some main points pertaining to OR Controls and its functionality are:

  • ORControls™ (ORC) is a patent-pending, real-time, workflow solution designed to automate and coordinate all day-of-surgery activities
  • Enhanced operational efficiency through consistent automated communication
  • Puts physicians, OR staff, and other groups and departments across a facility on the same page at the same time
  • Automatically alerts to situations that may cause delays in the immediate future
  • Sends text notifications for surgeons and anesthesiologists to improve time management and OR throughput
  • See Exhibit 3 for OR Controls screenshots

Intervention and Improvement:

There were numerous opportunities identified around communication, and interventions were developed that allowed the automated functionality of the RTLS to close those communication gaps. Four main interventions were implemented:

  1. Familiarized and educated the Perioperative staff with the ORC system functionalities and reinforced the importance of wheels-in by 7:20 am/9:05 am.
  2. Provided same-day feedback with daily “on-time” start reports posted in each OR and throughout the department.
  3. Presented the ORC system to all surgical service lines and the anesthesia department.
  4. Activated text “alerts” feature for all surgeons and anesthesia providers.

Intervention Results:

The on-time data were tracked daily and plotted on SPC charts (Exhibit 4).The results from our interventions can be summarized as follows:

•Real-time tracking provides more accurate data, eliminates human error.

•Wheels-In on-time improvedfrom 33% to 37% (12%relative increase).

•Briefing on-time improved from 71% to 78% (10%relative increase).

•Decrease in variability for on-time start.

•April 2013 was the highest recorded on-time start at 82%.

•OR Controls features provide real-time status updates, which increase patient, staff and physician satisfaction.

•OR Control text alerts had the greatest impact. This last intervention increased the briefing on-time starts from 71% to 78% (as shown on Exhibit 4).

Revenue Enhancement /Cost Avoidance / Generalizability:

We identified a 27% decrease in overtime expenditures when comparing pre- and post-OR Controls (Exhibit 5). Between June 2012 and October 2012 the average monthly overtime expense was $19,479 (pre-OR Controls), and between November 2012 and May 2013 average monthly overtime expense was $14,203 (post-OR Controls). This represents an average monthly overtime expense reduction of $5,276, with an annualized value of $63,307.

In addition, we identified an increase in case volume (completed cases) while we decreased total case hours (patient room time for all completed cases; Exhibit 5). We identified that, when comparing pre- and post-OR Controls case volumes, on average we were able to perform one more surgical procedure per business day. The Average surgical procedure contribution margin is $7,745. If we sustain this improvement, we will see an annualized increase in contribution margin of $1,943,995.

Therefore, we can conclude that OR Controls and the interventions implemented during this project have helped to improve the OR operations by making us more efficient. We expect other areas to capitalize in the benefits of RTLS. Our Correctional Facility( TDC), Sterile Processing(SPD), and Blood Bank will soon be implementing OR Controls that will result in enhanced communication with the OR and its operations. In addition, other areas within UTMB Galveston that will be implementing RTLS include Interventional Radiology and L&D.

Exhibit1 - Cause and Effect Diagram

Exhibit 2 - First Case Workflow Process

Exhibit 3 – OR Controls

Exhibit 4–SPC Charts

On-Time Start - Wheels-In, P-Chart 8/1/12-5/31/13

Phase / LCL / Avg / UCL
Epic / 0.013599 / 0.407583 / 0.801567
ORC started / 0 / 0.333333 / 0.804738
Staff / 0 / 0.268182 / 0.600441
New ORC features / 0 / 0.323944 / 0.713326
Surgeons' meetings / 0 / 0.352679 / 0.750235
Surgeons' text / 0 / 0.374126 / 0.74895

On-Time Start - Wheels-In, Xbar Chart 8/1/12-5/31/13 (minutes)

Phase / LCL / Avg / UCL
Epic / -3.27562 / 5.436671 / 14.14896
ORC started / -4.41484 / 6.075688 / 16.56622
Staff / -0.63143 / 7.708372 / 16.04817
New ORC features / -2.93058 / 8.016828 / 18.96424
Surgeons' meetings / -2.97779 / 6.246667 / 15.47113
Surgeons' text / -2.54403 / 5.074582 / 12.6932

On-Time Start – Briefing, P-Chart 8/1/12-5/31/13

Phase / LCL / Avg / UCL
Epic / 0.32811 / 0.696682 / 1
ORC started / 0.262229 / 0.71408 / 1
Staff / 0.350294 / 0.695455 / 1
New ORC features / 0.364037 / 0.732394 / 1
Surgeons' meetings / 0.338404 / 0.714286 / 1
Surgeons' text / 0.4587 / 0.77972 / 1

On-Time Start – Briefing, Xbar Chart 8/1/12-5/31/13 (minutes)

Phase / LCL / Avg / UCL
Epic / -9.84398 / -0.48072 / 8.882538
ORC started / -12.3331 / -0.70726 / 10.91856
Staff / -8.70048 / 0.888527 / 10.47753
New ORC features / -11.6178 / -0.21588 / 11.186
Surgeons' meetings / -11.2016 / -1.62222 / 7.95711
Surgeons' text / -10.9255 / -3.05938 / 4.806722

Exhibit5–JS OR Overtime Expenses (June 2012 – May 2013)

Exhibit6–JS OR Case Volume and Hours (June 2012 – May 2013)