In our last post, we discussed the issues that cause operating room turnovers to be delayed and how those slow turnovers can wreak havoc on OR operations throughout the day and across the team. By comparing turnovers between cases in the OR to turnovers between scenes in a play, we started to close the gap between what could possibly go wrong and what’s actually causing real pain to the perioperative staff as they try to keep on schedule and serve as many patients as they can.
To review, we focused on three teams in the OR during turnovers: environmental services, circulating nurses, and surgical techs. And we emphasized the three coordination problems that are the biggest sources of delays in OR turnovers:
- Insufficient correspondence between hospital staff and environmental services when they get blocked or need direction or decisions
- Parallel processing of post-case and pre-case turnover tasks, which keeps staff away from the OR and can introduce its own choreography challenges
- Logistical dependencies that prevent surgical techs from delivering materials to and setting up equipment in the OR in a timely manner
Here, we’ll be looking at what surgical teams have done to address these challenges. Historically, OR managers have prescribed three strategies to improve and speed up turnovers: the extra bodies solution, the pit crew solution, and the vertical integration solution. At least one (if not all three) of these approaches has been put into effect at pretty much every hospital at some point over the past couple decades. That’s evidence enough of how hard it is to improve the efficiency of turnovers. And, as we’ll explore, the solution sometimes exacerbates the problem.
The Extra Bodies Solution
Talk to any OR manager or director of perioperative services, and they’ll certainly let you know how frustrating turnovers lengths can be. Most have a turnover duration goal. Yet few have any tools or real metrics to break down the problem so that the root cause can be isolated and addressed. That said, if they had their druthers, most would start with the most obvious approach: throw more personnel at the problem.
The thinking goes that more sets of hands in the OR during turnovers would speed things up. By distributing tasks across a larger team — whether cleaning crew, technicians, or nurses — the time per task should decrease and more tasks could be handled in parallel.
However, as we highlighted in “How Slow Turnovers Wreak Havoc in the Surgical Theater and Stage,” the most common sources of inefficiency are the difficulty of coordination and poor communication, especially when everyone is already busy. In addition to driving up the cost of staffing (a problem hospitals are trying to avoid in the first place), we often see too many cooks in the kitchen, both complicating the alignment between the various teams and people, as well as encouraging repeated steps. So, ultimately, the extra body solution is a bit of an extra body problem.
Similarly, adding more bodies to handle turnovers often leads to a "fizzle effect." First, the short-term improvements regress to the mean — slowing over time to fill the previous average turnover time. Moreover, as more people crowd the workspace, additional bodies actually increase scale and likelihood of coordination and communication issues. Space and time limitations typically cause new problems as team members trip over one another, both literally and figuratively.
The Pit Crew Solution
Specialization is by far the most common solution to operational challenges, not only in the operating room, but also across industries. If a technical process can be broken down into a workflow, then assigning distinct jobs to specific owners can optimize efficiency. In many contexts, mastery and control of a single part of the value chain are the keys to efficiency. The most well-known examples of this are the assembly line in the factory model and the pit crew in auto racing.
In the pit crew solution, each member of the turnover team has a discreet and specific role for which they are uniquely responsible. While specialization does require some additional training and accountability, the expected outcome is that coordination challenges decrease as dependencies and communications improve. Each task has a single owner so, ideally, handoffs are much easier to manage, and troubleshooting any issue is more straightforward. Subsequently, the efficiency of each task is expected to improve as the specialists get more practice and experience with their particular tasks.
Almost as important, the pit crew solution is also an effort to return control, both in and out of the operating room. Outside the OR, the needed levels of control are returned to the charge nurse who oversees the steady flow of work. Inside the OR, the control is returned to the surgeon who needs everything to run to expectation and according to schedule once the case starts. In this scenario, control is largely related to having one point of failure should anything go wrong.
But while the pit crew, for example, has few distinct roles and a relatively small number of races, each operating room in a hospital has many tasks repeated across several turnovers per day, tens per week, and thousands per year. So, while control and coordination are important benefits of specialization, it also creates significant new risks and issues. Specifically, rather than having one point of failure, any unexpected delay can fail the entire process. The nature of all roles in the OR is multitasking and parallel processing, so there will always be events that keep turnover specialists from being able to show up, a massive dependency to overcome.
With the pit crew solution, there may be too little redundancy — backup people with the training and awareness, not to mention experience and expertise — to fill the gap. And with so much specialization and so little cross-training, an otherwise innocuous occurrence like a sick day or bathroom break can set back turnovers to previously unknown lengths on any given day.
The Vertical Integration Solution
The third way that hospitals have tried to improve their efficiency is to bring more support into the OR during turnovers. For example, instead of having surgical techs take used equipment to sterile processing, sterile processing comes to the OR to gather and transport the used equipment out of the OR. The float nurse takes the last patient to post-op and brings the next patient from pre-op instead of the circulating nurse leaving the room. Surgeons get implicated into turnovers so that they’re present in the OR to answer questions and give direction for the next case.
Although this vertical integration does keep the core turnover teams in the room and avoids their parallel processing problem, it also steals productivity away from other tasks. Sterile processing may have to wait to deal with used equipment and setting up the next day’s materials and tools until after hours. Float nurses are often an understaffed resource to begin with, so the math for having them attend to multiple turnover needs just doesn’t work out. And, fundamentally, surgeons need to be out of the OR during turnovers to prep for their next case.
Additionally, the vertical integration solution can look a lot like the extra bodies solution and can cause the same kinds of problems: more coordination issues, more trip-ups, more fizzle. In the end, the vertical integration approach to turnovers has been shown to not only exacerbate known efficiency issues but create new issues, as well.
New Solutions are Needed
Because of the poor outcomes and, often, worse problems that result from some of the legacy approaches to improving OR turnover time, there’s still a need for new solutions. In addition to there typically being too little budget and too little time to address turnover inefficiencies, there has historically also been way too few metrics to develop meaningful guidance on what to improve and how. In our next post, we’ll discuss new, data-driven solutions for improving turnovers and where emphasis may need to be placed in the future.