The Sibley Ambulatory Surgery Center (SASC) Peri-Operative Management Program (POMP) team had a challenge.
They needed to ensure that the first surgery of the day began on-time more often. To those who don’t work in health care, this probably seems like a simple problem to solve, but we know that there are many different factors that influence the time a surgery begins. Everything from what time the surgeon arrives to a last-minute restroom request from the patient can affect an on-time start. Even for those of us who think about these factors, we don’t always consider the downstream impact of a delayed start time. Consider this—when the first surgery of the day begins behind schedule, it affects not only our surgery schedule, but also the office schedule of every surgeon who practices here. It was clear to the team that making progress toward improving first surgery start-time would have a major impact!
To identify process improvements that would help them meet their goal, the team developed and executed a Lean project. They began by assessing the current process to identify areas for improvement and analyzed data on delayed start times. The team also had an outside observer (Angela Stoehr, M.H.A.), map the process from patient arrival to operating room entry to identify potential areas of delay. Based on this information, Genevieve Cirineo, M.S.N., R.N., the SASC unit R.N. manager, decided to eliminate the staggered arrival of pre-operative R.N.s and instead instructed all three R.N.s to arrive at 6 a.m. Next, the team examined workflow and implemented two key changes:
- Day Prior to Surgery Reviews: Pre-op R.N.s were instructed to review the first four cases the day before surgery to identify any missing consent forms or history and physical (H&P) information. This allowed for any issues to be resolved before the morning of surgery.
- Morning Task Teamwork: All three R.N.s worked together as a team to prepare for morning tasks, including point of care testing, IV preparation, chart review and safety checklist.
In addition to implementing these changes, the team continued use of its “Ticket to Ride,” a pre-surgery and post-surgery checklist. The Ticket to Ride is a concise, one-sheet checklist that improves efficiencies and staff communication, while decreasing delays without sacrificing quality. Nurses use Ticket to Ride to record the reason for delays in Epic, allowing for identification of improvements to reduce late start times. Additionally, the team worked to improve patient communication. A critical factor involved identifying precision timing for patient arrival, which impacts not only on-time start, but also patient satisfaction, efficiency, and management of patient and staff stress. And, always important, the team worked to identify the ideal time to offer the patient an opportunity to visit the restroom before surgery. Perhaps unsurprisingly, last-minute toilet requests actually do contribute to delayed on-time start.
The team monitored the impact of their changes over a five-month period, from September 2016 to February 2017, and have already seen success with the first surgery of the day more consistently beginning on time. In addition to this improvement, the team also significantly reduced the length of on-time start delays, with average delays now at only a few minutes. All of this means that the team is seeing increased efficiencies and creating a positive ripple effect for everyone involved–both here at Sibley and throughout the D.C. region. Congratulations to each team member (see the sidebar for the full team listing) for the excellent work!