At Flagler Hospital in St. Augustine, a Decisive Push on OR Operational Efficiency

At Flagler Hospital, a 315-bed community hospital in St. Augustine, Florida, clinician and operational leaders have prioritized the use of analytics in order to improve operating room and perioperative services operational performance. As a result of their strategic planning, Flagler leaders have implemented an IT solution from the Alpharetta, Ga.-based Surgical Information Systems (SIS) that is helping them in their efforts to strongly improve performance on all levels. According to Pam Barberi, R.N., director of surgical services, a range of improvements have been made in this work, among them:

• Block utilization—the effective utilization of blocks of surgical time in the OR on the part of surgeons—has increased by more than 8 percent in less than one year
• First-case late starts—the incidence of late-starting surgeries on the part of surgeons and surgery teams—decreased by more than 10 percent over the past year-plus
• Room turnaround—the ability to effectively prepare an operating room for a new case after the conclusion of the previous case—has decreased by 8 minutes over the course of a year
• Time management and patient throughput have improved over the course of the past year

The implications of these kinds of improvements are numerous, for perioperative services at other hospitals. Recently, Barberi spoke with HCI Editor-in-Chief Mark Hagland about her and her colleagues’ efforts in these areas. Below are excerpts from that interview.

What kinds of things were you trying to accomplish, as you and your colleagues moved forward in the perioperative and OR operations area?

There are performance goals that I’ve been endeavoring for us to meet, so I’ve been using SIS Analytics to help us meet those goals. I have an analyst from SIS who will get the data together for me, and we want to look at block utilization among surgeons.  Block utilization gives me an idea of what I can count on. There are elective surgeries I know will occur on a particular day. A block would be a period of time—say, a doctor will block 7:30 AM to 1 PM—and a doctor can book their cases during that time, and no one else can book into that time. So I’m looking at non-emergency cases, not emergency or add-on cases.

Pam Barberi, R.N.

So you’re looking at how efficiently surgeons use their blocked time, essentially?

That’s correct.

How did you improve utilization?

In their quarter [of a year], the surgeons have to have at least 50 percent of their daily block utilized. If they ask for an all-day block and only use half, we’ll cut their time in half. The national average is about 65 percent; we had been at 62 percent. We’ve now reached 69 percent in the last quarter.

How achieved?

When we first started the analytics, we were in the 40s. And we were contacting the surgeons who were at 50 percent or below, they were going to have to change their block. So those below 50 percent of their time, I would cut it by about 50 percent.

What was the process of dialogue around this like?

We have an OR Advisory Committee and meet every other month, and then quarterly, we make decisions as a committee as to who is going to lose their block time or have their block time cut. On the committee, we have surgeons, the chief of surgery, the chief of anesthesiology, and some administrators. Usually, myself, the chief of surgery, and chief of anesthesia, are the key decision-makers. And we have the analytics to show them. And also, I have printed-out report cards for each of the surgeons who have blocks, so they’ll have a monthly report card, so they know what’s going on.

One of the things we found out is that if surgeons go on vacation, we give them credit, but if they don’t inform us, they get penalized. They let us know now, two weeks in advance. And that comes out in the report card. One surgeon went for a month to Africa without letting us know; but once she let us know she would be out, her report card improved. They do not like to see their names in red; they want to be in the green. I also have a big board at the end of the hallway that we use as well. And I want to put the names of the surgeons consistently late and who aren’t optimally using their blocks, up there. They don’t want to be on that list; they’re very competitive.

Tell me about how you improved your metrics on first-case late starts?

We have a big, laminated dry-erase boards, and we have goals, and we have an arrow that shows where we are, and they can see how they’re doing. I eventually want to put each surgeon’s name on there.

What was your rate when you started?

Around 75 percent of surgical cases were late when we started; we’re at 50 percent this month. I’ve been working on this for six months now. I show the surgeons where we are. I have conversations with them. I also show them why they were late—the circulating nurses keep track of why the case started late into the room, and they don’t like to see that it was the surgeon’s lateness. I bring it up at the OR advisory committee and to the chief of surgery. And we have an election for a new chief of surgery set for next month, and the lead candidate is very much a proponent of on-time starts. And I’m waiting for the right time to start posting names. And a few are consistently late. But we do counsel them about this.

Tell me about your efforts around room turnaround?

Yes, we are below the national average in that area. The physicians will say we take forever to get rooms turned around, but I’m looking at wheels in to wheels out. The national average is about 30 minutes, the benchmark we’re using. We’re between 25 and 30 minutes; we were between 38 and 40 minutes prior to this. What improved it was showing the staff where we were. And the bariatric surgeon, when we showed the statistics, said, you know, I’m the only bariatric surgeon, and I don’t want to be at the bottom of the list, so let’s get going. And the staff started to look at processes they could change to improve that time. In conjunction with using analytics, I am Lean-certified, so we did a Lean project with the orderly staff to bring the equipment to right outside the room on one cart so they weren’t running back and forth to get items like mops, etc. So that was a staff-driven project to improve efficiency. That probably only took about three months to show that improvement. And on a monthly basis, I’m posting data in all three of those areas, so staff can see the data.

What have been your biggest learnings so far in all this?

I guess the biggest learning has been how to use the analytics tool to our advantage, and that data really does provide the proof you need. Because we can document who was late in the room and why, I can show surgeons that their room turnaround was different from what they thought; I’ve got proof now, and

What advice would you give to peers who might wish to pursue leverage data and analytics, as you and your colleagues have, to improve operational efficiency and performance in the OR and the perioperative areas?

We very much appreciate the vendor solution we’ve been using; it’s a very easy tool to use. Beyond that, what really helps me is that I have an analyst who can go in and help me drill down deeper. He’ll prepare reports for me that are extremely easy to read and that can be customized to individual physician performance; and it’s important to share the data with everyone. That’s a big motivator. Also, we use something called the SIS Com board, a digital board that shows what we have on the schedule every day. And other departments can be more efficient such as central services. And we also have it in our logistics department to see what kinds of meds we need. We also use it for patient and family members, for locationing.