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Surgeon late arrival is the major cause of delays in first case starts. The estimated cost of these delays can reach $800,000 a year. The purpose of this integrative review and proposed quality improvement (QI) project plan was to increase the first case on-time starts through surgeon behavior modification.
Design
An integrative literature review and creation of a QI project plan.
Methods
The literature review included an independent electronic literature search between the years of 2011 and 2020 through CINAHL PLUS, PubMed, and Medline OVID databases. The search was limited to scholarly peer-reviewed journal articles in the English language, and search terms included: “operating rooms,” “delay first cases start,” “first case tardiness,” and “operating room efficiency.” The QI project plan was a three-phase process based on surgeon behavioral modification using educational material, visual reminders, and individualized e-mail notifications of habitually late surgeons.
Findings
A synthesis of articles reported proper site marking and surgical consent 15 to 30 minutes before surgery increased first case on-time starts from 55.90% to 66.60% and a mean delay decrease of 9.67 minutes to 7.17 minutes. Visual cues significantly enhanced memory, 64% versus 50%, and e-mail reminders increased compliance, 77% to 86.1%.
Conclusion
As the need for hospital revenue dependency grows, so will the need for more efficient operating rooms. The evidence shows a positive correlation between early arrival by surgeons to the preoperative area and increased on-time first case starts.
What is your in-room time? This question is asked every day for every case done in an operating room (OR), but most importantly, the first case start of the day. Benchmarking OR performance is measured using several key performance indicators, including first case on-time starts to rate operating room efficiency among hospitals nationwide.
A comparative analysis of 134 U S. facilities by OR Benchmark Collaborative (ORBC), which included short-term acute care hospitals, ambulatory surgery centers, and specialty hospitals, reported a first case on-time start median of 64.3%, compared to 88.3% at the 90th percentile.
Although starting an OR case on time is multifactorial, involving many disciplines and departments to collaborate systematically and efficiently to get a patient from approval to surgery, evidence shows a need for improvement.
Inefficient ORs can lead to case cancellations averaging 19 hours of lost surgery time per month, thousands of dollars in lost hospital revenue, slow turnovers averaging 28.5 minutes, and long patient wait times.
Maximal utilization of OR time, specifically improving on-time first case starts, is paramount to increasing efficiency.
Background
The Agency for Healthcare Research and Quality reported an estimated 17.2 million hospital visits for therapeutic and invasive surgeries in the United States in 2014, contributing to hospital workload and generating revenue.
To decrease preventable delays in the OR, the 2018 Crossing the Quality Chasm report by the Institute of Medicine (IOM) identified efficiency as an area of improvement for U.S. hospitals.
In the current state of rising healthcare costs, increasing first case on-time start is essential in maintaining OR efficiency and providing quality surgical care. The efficiency of the OR is dictated by how resources are used for a given task based on a predictable measure, like the first case starts of the day.
In the fiscal year 2019 quarter 3 (FY19Q3), a 273-bed teaching hospital in South Florida with medical, psychiatric, ambulatory care, and surgical services with six operating rooms had an average on-time start of 72% of the first cases in the OR. The surgical services offered include, but were not limited to general and vascular surgery, thoracic surgery, ophthalmology, orthopedics, urology, and plastic surgery. It costs a hospital an average of $105 every minute a case is delayed, so if the OR has a five-minute delay for 4 cases daily, the average revenue loss is $546,000 a year.
This article presents a review of literature and an evidence-based quality improvement (QI) project proposal to increase the current first case on-time start for the surgical patient population through surgeon behavior modification.
Literature Review
Methods
An independent electronic literature search was performed through the Cumulative Index to Nursing and Allied Health Literature (CINAHL) PLUS, PubMed, and Medline OVID databases. The search criteria were limited to full text, peer-reviewed scholarly journal articles in the English language dating 2011 to 2020 using the advance search in each database. The complete list of search terms included: “operating rooms,” “delay first cases start,” “first case tardiness,” “operating room efficiency,” “electronic reminders,” and “visual cues for memory.” Articles with abstracts published before 2010, not related to increasing operating room efficiency, electronic reminders, and use of visual cues were eliminated. Criteria for the search included controlled studies, statistical reports, studies conducted in large hospitals, tertiary care centers, and international hospitals. Exclusion criteria included studies with children or pediatric hospitals. The search yielded 30 articles, a total of 24 articles were selected based on proper title, and the final 16 articles were selected after abstract review. The articles were given a level of evidence rating based on the John Hopkins Nursing Evidence-Based Practice Evidence Rating scale.
The majority of the articles were level 1 (RCT) and level 2 (quasi-experimental) studies, and a few level 5 (QI) studies were included.
Defining On-Time Start
The definition of on-time start in the operating room may vary within each hospital system. The University of Pittsburgh Medical Center Health System defines on-time start as the “time the patient is able to be positioned and prepped without interference from anesthesia-related activities.”
The New York University Langone Medical Center defines on-time start as the “patient entering the OR at or before 7:35 a.m. for a scheduled 7:30 a.m. start.”
defined an on-time start as “in-room time equal to or before scheduled surgical time.” A large teaching hospital in South Florida defined on-time start as the exact time the patient enters the operating room with an anesthesiologist or nurse anesthetist, so 1 minute past the scheduled time is considered late. This project defined an on-time start based on the large teaching Hospital in South Florida and Bauer et al's description.
studied a resident-lead program to guarantee on-time documentation of surgical consent and surgical site marking in the Department of Neurological Surgery. The surgical resident and attending physician were responsible for signing appropriate surgical consents and accurate site marking 30 minutes before the scheduled start time. This level 5 QI study found a significant mean delay decrease for the first case starts in all neurosurgery cases from 9.67 minutes to 7.17 minutes.
focused not only on timely completion of surgical consent, but also required the anesthesia, surgical, and nursing team to be in the preoperative holding area with the patient at a specific time based on the scheduled case start time. The surgical consent and surgical team sign-in were established for 15 minutes before the schedule case time or 45 minutes when a patient required a preinduction procedure to be done in preoperative holdings, like regional anesthesia. The results of this level 2A quasi experimental study showed a statistically significant improvement for surgical consent completion and compliance, with an average increase of 35% from preintervention to 84% postintervention.
The first case on-time start also had a statistically significant increase from 55.90% preintervention to 66.60% postintervention. The sustainability of this implementation was recognized with a documented average result of 67.6% for the first case on-time start several years after implementation.
conducted a level 5 QI study in New York University Langone Medical Center to increase physician accountability. The On-Time Start committee, in collaboration with the surgeon-in-chief, developed a plan to modify surgeon behavior through daily e-mail notifications instructing all surgeons to arrive in the OR 20 minutes before their patient's scheduled surgery start time. This allowed for informal briefing between the surgeon, anesthesia staff, and circulator nurse to resolve any potential patient care issues before causing a delay. There was an initial increase in first case on-time start from 31% to 43%, and 10 months later, as a permanent policy, the on-time starts increased to 80%.
Also, daily surgeon attendance was recorded and sent to the chiefs of surgery and anesthesia. The daily data were used to identify and individually address habitually late surgeons.
In the current age of electronics, e-mail reminders are being used more readily in work environments to disseminate important information. Several studies have supported the success of e-mail reminders to increase compliance for important tasks.
Weekly e-mail reminders influence emergency physician behavior: A case study using the joint commission and centers for Medicare and Medicaid services pneumonia guidelines.
Weekly e-mail reminders influence emergency physician behavior: A case study using the joint commission and centers for Medicare and Medicaid services pneumonia guidelines.
found a significant association between weekly e-mail reminders and increased compliance. This level 2 quasi-experimental study sent e-mail reminders to all emergency department (ED) staff to increase Joint Commission compliance regarding the administration of antibiotics within 4 hours of arrival for patients diagnosed with community-acquired pneumonia.
Weekly e-mail reminders influence emergency physician behavior: A case study using the joint commission and centers for Medicare and Medicaid services pneumonia guidelines.
Eleven months postintervention, the overall median time from ED arrival to antibiotic administration decreased from 162 to 146 minutes (P = .018), and antibiotic administration within 4 hours increased from 77.5% to 86.1% (P = .009).
Weekly e-mail reminders influence emergency physician behavior: A case study using the joint commission and centers for Medicare and Medicaid services pneumonia guidelines.
found a positive correlation between electronic physician notification and automated customized patient reminders promoting medication adherence post-kidney transplantation. The combination of patient reminders coupled with physician notification showed a consistently high medication adherence rate of 88% versus the control group at 55%.
Both studies demonstrate the powerful link that exists between e-mail reminders and increased compliance.
Visual Cues
Visual cues have a long history in education and a strong presence in healthcare. Visual cues, including posters with illustrations and handouts with graphics, are used to trigger memory recall and execute intentions at precise moments.
confirmed that distinctive cue-based reminders are associated with increased success on intentional follow-through. Specifically study one showed that the participants in the reminder-through-association intervention group performed the expected actions at a significantly higher rate, 74%, than did those in the control group, 42% (P = .004).
in a tertiary metropolitan ICU investigated a person's ability to remember to execute future tasks using cues through a simulation-based scenario. This simulation-based study found that not only do visual cues significantly enhance memory performance for a given task, 64% versus 50% but increasing the chances of encountering the cues can continue to improve performance.
By using a visual cue presented on a poster in high traffic areas, like the preoperative holding area, staff lounge, and physician dictation room, the surgeon can accurately recover content related to the visual posted. Undoubtedly, increasing physician compliance with evidence-based recommendations can be challenging. But using e-mail notifications for habitually late surgeons and visual cues to promote early arrival time in preoperative holding is a simple solution to a long-standing problem of surgeon tardiness.
Synthesis of Literature Findings
Multiple research articles have attributed increasing first case start times with having the surgeon at the bedside 20-30 minutes before the scheduled surgical procedure.
A synthesis of articles reported proper site marking and surgical consent 15 to 30 minutes before surgery increased first case on-time starts from 55.90% to 66.60% with a mean delay decrease of 9.67 minutes to 7.17 minutes. Everyday memory benefits from supportive environmental items like visual cues.
Visual cues significantly enhance memory, 64% versus 50%, and e-mail reminders increase compliance, 77% to 86.1%. The combination of patient reminders paired with physician notification resulted in a consistently high adherence rate of 88% versus the control group of 55%.
The evidence demonstrates that enforcing surgeon accountability with early consent and site marking, visual and e-mail reminders has resulted in positive outcomes. The data, as well as the evidence in the integrative review, supported the proposed QI project. The strengths of the literature review are the majority of articles are level 1 (RCT) and level 2 (quasi-experimental) studies. The primary weakness interwoven through the synthesis of findings is the lack of any definitive reason why surgeons arrive late to the operating room.
Project Purpose
The purpose of the proposed PI plan was to increase first case on-time starts in the OR at a large teaching hospital in South Florida from 72% to the national target of 83.3% . We planned to accomplish this through surgeon behavior modification using education, visual reminders, and e-mail notifications focused on habitually late surgeons.
Goal and Objectives
The overarching goal was to improve the on-time first case start in the perioperative setting.
The first objective was to increase the first case start times. To meet the first objective, the aim was to increase start times by 10%. The interventions used to meet the first objective were observation and documentation of surgical first case start times preimplementation during month 1 and postimplementation on month 3. The second objective was to increase surgeon adherence to arriving 20 minutes before the scheduled surgery time. To meet the second objective, the aim was to increase surgeon adherence by 50%. The intervention used to facilitate the second objective was a PowerPoint presentation and visual reminders during the first 2 weeks of month 2. The third objective was to decrease late arrivals of habitually late surgeons. To meet the third objective, the aim was to decrease late arrivals by 20%. The intervention to meet the third objective was to use individual based e-mail notifications by month three.
Methods
Proposed Project
This project sought to improve the on-time first case starts through education, visual reminders, and individual e-mail notifications to habitually late surgeons. To facilitate project implementation, the Revised Ottawa Model of Research Use (OMRU) framework was used to guide the process. The Revised OMRU framework views research as an interactive process of interconnected decisions that take place over time. The actions of individuals are associated with each of the model's three phases: phase 1 assesses barriers and support; phase 2 monitors interventions; and phase 3 evaluates the outcomes to continuously improve the process.
The project was presented to the Chief of Surgery and Anesthesia for support, and an assessment of barriers were discussed 3 months before preimplementation (see Figure 1). Also, the Non-Human Subject Research application was filed 2 months before preimplementation, and after approval, the implementation process can begin.
Figure 1Project implementation timeline. This figure illustrates the project timeline for the implementation of the proposed project. This figure is available in color online at www.jopan.org.
After assessing project barriers and support from the surgical department leaders and acquiring final approval, phase 1 began. Phase 1 consisted of observation and data collection using two data collection tools to record daily first case start times, minute delays, the reason for the delay—such as late surgeon arrival due to personal issues, and surgeon arrival time (see Table 1 and Table 2). A nonidentifiable code was given to each surgeon, and individual surgeon minute delay was documented. Then during the first 2 weeks of June, a brief PowerPoint presentation was presented for all surgeons regarding the current data on the effects of delayed first case start times. The surgeons were educated on the importance of starting surgical cases on-time and arriving 20 minutes before scheduled cases. The presentation included the negative financial impact of delays to the hospital system, the potential for adding more cases leading to increased hospital revenue, and the prospect of increasing end of year bonuses related to the increased institutional compliance with a national benchmark. The surgeon's attendance at the presentation was documented and coded appropriately. The assigned unidentifiable codes of each surgeon followed them through the data collection and analysis process.
Table 1Data Collection Tool 1
FIRST Case Start Times in the OR Weekly Report
Dates
OR 1
OR 2
OR 3
OR 4
OR 5
OR 6
MON
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
TUES
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
WED
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
Yes
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
THURS
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
FRI
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
•
On time
•
NO--delay code & min:
Delay Codes: PT= Patient; SS= Short Stay; POH= Pre-Op Holding; SXL= Surgeon Late; SXNC= Surgeon NO Consent; SXNM= Surgeon NO site Marking; Lab = Laboratory; AS = Anesthesia Staff; ORS= OR Staff; SR= Sales Representative; XRS = X-ray Staff; TS = Transport Staff; Delay Min = delay minutes.
This data collection tool served as a place to document daily data on first case start times and reason for the delay for each operating room.
Project Improvement: “Improve On-Time First Case Starts in the Perioperative Setting” Data Collection Sheet (Please fill out for first case of the day)
Scheduled surgery date & time ______
Patient arrival time in preop holding ______
Surgeon arrival time to preop holding ______
Surgeon performed:
Patient identification ______
Procedure and procedure site identified ______
Site marked ______
Consent(s) signed ______
This data collection tool served as a place to document surgeon adherence through daily data gathering of the first case starts of the day.
Phase 2 consisted of project implementation in months two and three and monitoring interventions. A cue-based reminder for surgeons in the form of a visually appealing poster was placed in areas of high traffic for surgeons, like the pre-op holding area, the operating room staff lounge, and the physician dictation room (see Figure 2). Also, during implementation, data collection of daily first case start times, minute delays, the reason for delay, and surgeon arrival time continued. Any surgeon that was late to the pre-operative holding area, causing a first case start delay, was identified and sent an individual e-mail the same day or day after the incident. The Surgical Nurse Administrator from the surgery office was designated to send the surgeon an e-mail stating the date he or she was late, the requirement to be on-time for surgery, and a reminder that tardiness will affect his or her end of year bonus.
Figure 2First case start reminder poster. Example poster display for surgeons in the surgical unit. This figure is available in color online at www.jopan.org.
Phase 3 involved the evaluation of outcomes during month 3 and the continued improvement process. A statistical analysis using JASP (version 0.14.1, 2020, JASP Team, University of Amsterdam, Amsterdam, The Netherlands) was conducted on all the data collected preimplementation, during implementation, and postimplementation. The evaluation of surgeon education, visual reminders, and individualized e-mail notification targeting the habitually late surgeons was reflected in the percent of the first case start times, percent of surgeon adherence, and individual surgeon delay minutes. These outcomes either reflected the success of the established project and its continued utilization or guided the team toward other evidence-based practice strategies to improve on-time first case starts. See Figure 1 for a summary of the sample project timeline.
Financial Analysis and Budget
At our hospital, the cost of 1 hour in the OR is $105, so a five-minute delay for 4 cases daily can average $546,000 a year of lost revenue. Consider a 7-year study by Veen-Berkx et al,
which found that 7,094 hours of delays were lost each year in first cases start delays. The cost of 7,094 hours at $105 results in a loss in revenue for the hospital of $744,870 a year.
This may not only result in a profit loss, but inadvertently impacts patient care through a redirection of funds away from direct patient care equipment or programs. A major tertiary children's hospital in Connecticut significantly improved first case start times from 62% to 77%, which amounted to a cost savings of $4,023 a week.
A cost has been presented for a QI project to increase the percent of on-time first case starts, which will avoid unnecessary expenses created by surgical delays. The operational cost of this project incurred labor costs of staff needed to execute specific plan parts and office supplies cost. Refer to Table 3 for an itemized report of all the labor and supply costs required to implement the proposed project. The total cost of implementation is $12,822.09, and this total includes labor and supply costs for 3 months (see Table 3).
To evaluate the overall success of this 3-month project implementation and the predicted increase of surgical on-time first case start, a dependent sample t-test was employed. This dependent sample t-test analyzed the difference between the overall preimplementation with the postimplementation minute delay. After presenting the educational material to the surgeons, comprehension and acknowledgment of new protocol was measured through observation based on the frequency of surgeons arriving 20 minutes before the scheduled surgery time. A dependent sample t-test compared the frequency of surgeons arriving early pre-education and posteducational presentation. After identifying the habitually late surgeons, the use of e-mail notification was evaluated using a dependent sample t-test, comparing the individual surgeon minute delay difference before implementation and after the e-mail notification.
The outcome of this proposed 3-month implementation was to increase on-time first cast starts by 10%. Ultimately, the goal was to reach the national benchmark of 83.3%, by focusing on surgeon behavior modification through education, a visual reminder, and e-mail notifications. This project should inadvertently increase operating room efficiency, increase hospital revenue, and decrease unplanned surgical delay costs.
Discussion
Healthcare is driven by cost containment, patient experience, and physician-focused reimbursement.
During the review of literature, a synthesis of the evidence reported surgeons as the leading cause of the first case start delays, which was also confirmed by the FY19Q3 results of an in-house daily data collection.
There is a critical need to increase OR efficiency as the demand for elective surgeries grows. The evidence supports that early surgeon arrival to the perioperative unit, visual reminders, and email notifications of habitually late surgeons can help increase on-time first case starts. The proposed QI project resulted in a cost-savings intervention directed toward modifying surgeon behavior, and although the reason for tardiness was not crystal clear, these strategies served as a stride toward a more efficient OR and increased hospital revenue.
Ethical Implications
The process of data collection and analysis of preimplementation and postimplementation information becomes sensitive when some of the data acquired are based on individual statistics. During the data collection of this project, close attention was given to protect the surgeon's right to privacy. The QI project goal, objectives, and plan was discussed with all the participating surgeons. A system of coded numbers was given to each surgeon during the collection and statistical analysis, so each surgeon's result were not directly connected by his or her name. Although the project results of this implementation were coded, the charge nurse and surgical nurse administrator had the names of the habitually late surgeons because of the direct data collection and mandatory e-mail notification. Although every project presents a different set of ethical implications, respecting the privacy and confidentiality of the surgeons was paramount for the success of this project implementation.
Sustainability
The sustainability of this QI project will be based on implementing a permanent policy, like in the study by Fezza and Palmero,
which had an 80% increase in on-time starts 10 months after instituting a permanent policy. To evaluate this project, the utilization of a Shewhart chart helped assure improvement over time and ensured long-term success; furthermore, looking at statistical methods specific to QI projects also helped meet the targeted outcomes for sustainability.
The expectation was to mirror these results by incorporating a PowerPoint presentation for new surgeons during orientation regarding expectations of arriving early for scheduled surgery and the consequences of noncompliance. The circulating nurse will enter the daily data collection of all first case starts into the computer, and a report will be generated daily to identify late surgeons. The e-mail notifications will continue to be sent to late surgeons, and visual reminders will remain posted in the surgical unit. These actions will further enable us to measure long-term outcomes to improve on-time first case starts. These small changes in policy have the potential to increase OR efficiency and minimize unnecessary revenue loss.
Conclusions and Recommendations
Owing to the high cost and source of revenue of operating rooms, there is an interest in QI projects, specifically for on-time first case starts.
the examination of first cases start delays over 7 years found that 7,094 hours of delays were lost each year. The hours lost to delays has a significant economic impact that must be addressed by every healthcare system providing surgical services.
Recommendations based on the literature search suggest a lack of information regarding reasons surgeons arrive late to the perioperative unit and whether punitive versus incentive solutions are better received by surgeons. Future studies should be conducted about the causes of surgeon tardiness to better understand why surgeons are the major cause of first case start delays. Future research is also needed to compare punitive versus incentive solutions for surgeon tardiness. Exploring the reasons for surgeon tardiness and punitive versus incentive solutions through sound research can shed light on other ways of improving OR efficiency. Interventions should be based on evidence and comprised of a multidisciplinary team, a transparent process from initiation and evaluation with appropriate actionable metrics.
The current on-time start at a large teaching hospital in South Florida was 72% compared to the national target of 83.3% for the surgical patient population. The 2018 IOM report
identifies efficiency as an area of improvement and this integrative review focused on surgeon behavior modification to increase OR efficiency. This QI project used educational PowerPoint presentations, visual reminders, and e-mail notifications targeting habitually late surgeons to increase on-time first case starts. This project has the potential for a positive financial impact on any hospital system through increase revenue and redirection of monetary funds toward areas of need. The future direction of this QI project manuscript is for hospital systems to implement these simple cost-saving strategies in their operating rooms and validate the positive impact surgeon accountability has on OR efficiency.
Acknowledgments
The author would like to express gratitude toward the following educators from the University of Miami School of Nursing and Health Studies: Nicole A. Gonzaga Gomez, DNP, CRNA, CHSE, and Mary Hooshmand. PhD, MS, RN. The author would also like to recognize Howard Maisel, MD, Associate Chief of Surgery for Anesthesia and Peri-operative Care.
References
Foster T.
Data For Benchmarking Your OR's Performance. 1st ed.
Weekly e-mail reminders influence emergency physician behavior: A case study using the joint commission and centers for Medicare and Medicaid services pneumonia guidelines.
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