Today's SurgiCenter - Clinical Update

OR Turnover: Making the Most of Your Team’s Time

By Kathy Dix

Operating room (OR) turnover time is often a topic of concern for ambulatory surgery centers (ASCs) trying to make the most of time in their facility. The time spent in transition between procedure can be affected by hundreds of factors.

Turnover Defined

“Turnover first involves waking the patient up, or getting the patient from whatever anesthetic state they were in to a stable point for transfer,” says Charles Logan, vice president of management for Surgery Consultants of America, Inc. “Then you have to transport the patient, and that takes your anesthesia person and your circulator at the minimum. The other things are basic cleanup, and that sometimes means cleaning individual equipment that’s used over and over on the same patient. Then you have to change out some of the disposables, and clean parts of it every time. You’ve got replacement of disposables for the new patient. Then you do equipment checks.”

Then there is the matter of removing any unnecessary equipment and bringing in any additional required equipment. All of those tasks requires a team approach, Logan says. “If any part of the team doesn’t function well, then it stops everyone.”

Teamwork goes hand-in-hand with planning, which begins far in advance of the procedure with the physician preference card. “If the preference card isn’t kept current, unless the people working that room are very knowledgeable about the physician and his preferences, they are going to stumble during turnover because they’re not going to have something they need,” Logan observes. “Good preference cards are key to turning cases quickly, and then preparing cases in advance.”

Fortunately, because an ASC is smaller than a hospital, staff members know the entire building and know where all equipment is located. They are also aware of the entire day’s planned activity. “There is a constant awareness of what may or may not go awry,” he says. “They typically will have a plan when the day starts for what makes cases flow, and what they need to do to enhance turnover. For instance, people utilize other rooms; they get out of the mindset that a physician has to follow himself in the same room.”

Because ASCs are smaller and more manageable, staff can plan around expected disruptions, and the entire staff may be involved. “It’s not one person managing the schedule; everybody is looking at it to be sure it’s going well. It’s a team commitment to make the cases turn quickly, since that’s what makes their facility attractive to their customers. Everybody works toward the common goal,” says Logan.

“Turnover is monitored very closely; physicians get involved in surgery centers because they need to manage their time more effectively. If you’re delaying them in case turnover, then your key customer and the person who actually brings you what ultimately results in your income will go away.”

Something as simple as appropriate and adequate instrumentation can affect turnover, and team commitment must include everyone from cleaning staff to the head physician. Even physicians will be held accountable for turnover time, typically by the Performance Improvement committee at the facility.

Meeting Benchmarks

“These are things that can improve OR turnover time: having accurate preference cards; pulling all cases the night before; gathering all of your supplies the night before; custom packs by procedure,” says Caryl Serbin, president of Surgery Consultants of America, Inc. and Surgery Center Billing, LLC.

At one facility, Serbin relates, “They announce, ‘Turnover to Room Four,’ so their perioperative techs can come in and help clean up the room.” That center’s turnover is, on average, 5 to 7 minutes. “Normal turnover time is not more than 15 minutes in an ASC,” Serbin points out. “It’s 30 to 45 minutes in a hospital. Because surgery centers are smaller, people have a tendency to work as a team more; they have less interruptions; they don’t have emergent cases, they have smaller cases, they have better control of their environment. In my opinion, it’s an unfair comparison.”

ASCs also differ in other respects that might improve turnover. “People in surgery centers are motivated, because most of the surgery centers have some sort of profit sharing plan in place, so if they do well, they receive profit. There’s not a real incentive in a hospital to turn a room quickly. Those folks are going to be there all shift. If you get your cases done early in surgery center, you might have an opportunity to leave an hour earlier, and that’s quite attractive to a lot of people. But hospitals don’t seem to do that,” she adds.

The size of a facility can make a difference as well, especially if it’s particularly well planned or poorly planned. “Do you have to walk 60 yards to get something? When they designed the facility, did they think about turnover time?” Serbin asks.

Another factor may include not having enough stretchers, instrumentation or other resources. “If you want to make turnover time awesome, Stryker has a Trio stretcher that serves as an OR table and a recovery bed,” says Serbin. Not having to move the patient from a stretcher to the OR table to another stretcher after the procedure eliminates the necessity of staff to transfer the patient, and it also means that laundry costs can be cut, as only one set of sheets is used instead of three.

The bed is a mobile surgery platform designed for pre-op, procedure and post-op. “Anesthesiologists like it because they can maintain the patient’s temperature more easily when the patient doesn’t have to be transferred to a cold OR table,” says Steve Ueland, a product manager at Stryker Medical. However, because the patient recovers on this product, the surgical staff must do some draping, or add a chuck pad where they anticipate more mess or fluid. Depending on how well the staff implements the bed, “it can save seven to 10 minutes per case,” Ueland says.

“OR turnover time is really a systems issue,” says Terrie Kurrasch, senior consultant for Ratcliff, a design-build firm based in Emeryville, Calif. “There’s not just one single task or action that impacts turnover. It has to do with getting the case started on time so it ends on time. Some of the things we’ve been doing in recent planning include the use of anesthesia induction rooms, so that when the patient gets to the OR, they’re already in a slightly or fully anesthetized state. That allows the surgery to begin as soon as the patient is ready. As the room is getting cleaned after the last case, the patient is getting anesthetized. When the cleaning’s done, the room’s ready, the patient’s ready, and the procedure can start.”

Using a modern suite with all equipment off the floor “means the room can get cleaner faster; the housekeeping staff doesn’t have to move stuff. Just because the room can be cleaned better, I would guess that infection rates would go down, because the room can get cleaned better because everything up off the floor. There’s less chance of staff tripping. When you have electrical cords on the floor, or gas lines going from an anesthesia machine to the patient, it makes it difficult to maneuver equipment and staff.”

When asked how this design might affect the facility financially, Kurrasch answers, “That’s really hard to say. You could argue that the surgery team could work faster because the equipment isn’t on the floor. You could argue that because the room could get turned over more quickly, you could potentially squeeze one or two more surgeries out of each room, during whatever their standard working day was.”

Integrated Suites

When asked if integrated suites improve OR turnover, “That’s absolutely true,” says John D’Anna, MD, senior vice president of strategic planning for the Staten Island University Hospital in New York. “It’s all integrated with video; everything is ceilingmounted so that it’s easy to move out of the way. I think that makes a tremendous difference in turnover time. There’s no question about it; it’s easier to clean the room, to get patients in and out. We’re in the process of studying this so we can quantify it, but everybody’s empirical feeling about this is that it has made dramatic improvements in turnaround time.”

Medical staff members have noticed a difference, too. “Every hospital’s perennial surgical complaint is turnover time,” D’Anna points out. “‘Why is it if I have three cases, I have to sit in the lounge for 25 minutes to start the next case?’ Surgeons complain about that all the time, and many hospitals introduce strategies to try to cut that down. We have struggled with it before we opened the ASC, but the technology of developing these ORs in such a way that we can turn them over quickly, and limiting them to ambulatory cases, which again makes the turnover quicker, has made a tremendous difference.”

Although the surgeons are more satisfied, D’Anna observes that it may not be due solely to improved turnover time. “Before, when we did not separate our inpatient from our ambulatory surgical cases, we had experienced a lot of delays. There were emergency cases that would bump a room that had multiple ambulatory cases, disrupt the surgeons’ schedules and make them very unhappy. By separating ambulatory cases from emergent cases, you start on time, and for the most part, you finish on time. Everybody finishes at a reasonable time and everybody’s happy.”

The Economics of Turnover

For a decade, one researcher and his colleagues have been researching turnover time. “We developed ways to measure benefits for different places; you can divide up potential into either strategic or operational,” says Franklin Dexter,MD, PhD, associate professor and director of the division of management consulting for the department of anesthesia at the University of Iowa.

“The question is, from an operational point of view, if we were to reduce turnover, would it reduce costs in some way?” Dexter asks. “The argument that people make is they may say that, ‘Reducing turnover time can let us do another case that we couldn’t otherwise have done safely.’ The reason why that argument turns out to be wrong — in the research we’ve done, that’s not really the question. You have to fine-tune the question and say, ‘Would reducing turnover time let us do another case in the OR that we couldn’t have done safely, constraining for the fact that we are willing to cancel large numbers of cases?’

“Let’s suppose you have two long surgical cases in a room; there’s always a chance that randomly both cases take less than average, and that if you reduce turnover time, you could get another case on the schedule. But you wouldn’t actually schedule another case, because if the reason you’re trying to reduce the time is because you can’t do another case safely, you’re going to cancel the case so often. Therefore, you have to set additional criteria on how often you’re willing to cancel cases. What determines the uncertainty in the duration is uncertainty in the duration of surgical times. The uncertainty in the duration of surgical times is much larger than the reduction in turnover times. That’s why if you reduce turnover times, you cannot get another case on the schedule, unless you’re willing to have unacceptably large cancellation rates. That’s the reason why reducing turnover times is not a strategy in order to try to get another case on the schedule,” he explains.

However, there is an exception to that finding, Dexter allows. “Typically, the uncertainty in surgical time is proportional to the duration. Let’s suppose you have short cases, such as myringotomy tubes. Let’s say the average is 20 minutes — from the time the patient is ready to go into the OR until the next patient can go into the room — but can be as short as 10 minutes or as long as 30 minutes. Surely in a surgery center, with very short cases such as cataracts, myringotomy tubes, adenoidectomies and so forth, reducing turnover time can let a person get another case on the schedule. But these tend to be very short cases, and they tend to be of predictable duration. A group at Children’s Hospital Philadelphia did an article looking at the benefits and had very similar results; there can be marked advantages for very short cases. But if your cases last more than an hour, it’s very doubtful,” he adds.

“Generally speaking, when you look at organizations that have reduced turnover times, one of the key things is to try to do as many things as possible at the same time. The nurses set up the table with sterile equipment at the same time that anesthesiologists are inducing anesthesia,” says Dexter. “If you have a case cart system, in which all equipment is set up well ahead of time, it’s essentially done in parallel where you’ve got multiple people doing the same task. That’s how you can reduce turnover times.”

Dexter and his colleagues developed a mathematical formula that would allow each individual facility to have its own data analyzed, to determine the balance. If an ASC reduced turnover time by an average of “x” number of minutes, what would be the financial benefit to the facility?

Dexter, with Alex Macario, MD, MBA, published a study on what decrease in case duration was necessary to fit in an extra case. “I expected that (with two ORs) if you reduced turnover times, maybe it would be hard to schedule an additional case. On the other hand, I thought if there were a lot of ORs, if you reduce turnover time, you’d be able to get another case on the schedule, because I wouldn’t know which OR would be done ahead of time, but I could get it into one of the many ORs. As it turns out, that is the opposite — the more ORs you have, the less the benefit of reducing turnover time in order to do another case that could not otherwise have been scheduled,” he says.

“This example is so contradictory to intuition — but in retrospect, it’s very easy. The fallacy to the argument is that it presupposes the additional case could not have been scheduled unless turnover time were reduced.

Suppose you’ve got a short add-on case; usually there’s going to be some OR in which a case can be scheduled at the end of the day even without reduction in turnover time. If you’ve got 20 ORs, the chance that you can find an OR where you can put in a myringotomy tube is very high, whereas it’s only for a long addon case that you could not have already scheduled it if you’ve got many ORs. That’s why reducing turnover time has less of a potential to be able to do an extra case if you’ve got many ORs, because the more ORs you have, the addon case that you couldn’t schedule would have been much longer.

“Suppose you have three ORs, and you’ve filled them. You have six add-on cases, and you want to get as many as you can onto the schedule. It’s like packing the trunk of your car; you start with the biggest suitcase, then go down the line,” he explains. A four and a half hour coronary bypass graft will not fit; nor will a hip replacement (3.7 hours), but a cholecystectomy (3 hours) can be scheduled in one OR. “In the other two ORs, you have 1.6 hours open in one, 1.1 open in the other. The next longest cases are a 2.3-hour orchiopexy, a carpal tunnel release and an adenoidectomy for an hour each; we can do those two. Only three are left over.”

Now, the ASC must assess by how much it needs to reduce turnover to fit the 2.3-hour orchiopexy into the schedule. “Is there likely to be an OR where all the reductions in turnover will give you 2.3 hours? (Doubtful.) That’s the point,” Dexter says. “You reach a point when the add-on case that couldn’t be scheduled is longer than the duration of turnover times.

That’s the reason why the argument — that reducing turnover times will get another case in the schedule — doesn’t hold. In fact, it is less and less likely the more and more operating rooms you have.” He continues, “In a surgery center, as you get to having many shorter cases, and then to the point they’re almost all cases under an hour, with very little uncertainty in duration, then this is much less of an issue. But if you have only three cases per OR per day, the incremental benefit of reducing turnover time in order to get another case in the schedule very rapidly drops off. What people tend to do, when they think about a large benefit, is they add up all the turnover times and say, ‘If we have 20 turnovers in a day and reduce each one by 7 minutes, that’s 140 minutes.’ But you’ve got to think about each individual OR and how many minutes it is,” he says.

“The other potential benefit is increasing surgeon satisfaction; although it’s not been shown that reducing turnover times increases surgeon satisfaction, it makes a lot of sense. If by increasing surgeon satisfaction, you get more work coming to your place, that may then increase revenue,” Dexter concludes.

Dexter references an article by Vitez and Macario on setting performance standards for an anesthesia department; “What they found, when surgeons evaluated the performance of an academic anesthesiology department, was that they rated turnover time as the most important quality attribute with below average performance,” he says. “I would be very surprised if even small reductions in turnover didn’t result in improvements in surgeon satisfaction.

However, I don’t know of a study that has done that to determine whether or not that’s true.”