Six Sigma Trims Turnover Time for Orthopedic Surgeries

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y Heather Anderson, Marilyn Brazda, Stephanie Struble and Carolyn Pexton

Orthopedic and neurological spine surgery represents a competitive and profitable business for many healthcare organizations. Expanding this particular service line and ensuring efficiency in the operating room (OR) are among the strategic initiatives at Memorial Hermann Southwest Hospital in Houston, Texas, U.S.A., one of 16 hospitals in the Memorial Hermann system.

Surgeons at the hospital had begun to express dissatisfaction with the length of time required to prepare the operating room between cases. To identify issues and opportunities related to OR turnover time for orthopedic and neurosurgical spine cases, a multi-disciplinary Six Sigma project team was assembled.

The core team included the director of pharmacy, the OR manager, a project manager in administration and a Six Sigma Black Belt. The service line manager played a key role in the success of the project, and the central processing department technician over orthopedics also was involved.

Collecting and Verifying Data

The team began by establishing clear objectives. It anticipated that being able to shorten turnover time would raise physician and staff satisfaction. The primary goal was to eliminate process variability and reduce average orthopedic OR turnover time. Based on interviews conducted with both neurosurgeons and orthopedic surgeons, the operational definition of turnover time was defined as patient out to next patient in. Using feedback from the interviews, the upper specification limit for turnover was set at 25 minutes and anything in excess was defined as a defect.

A key step in Six Sigma is to verify the accuracy of the method used to collect data. Unfortunately, measurement system analysis indicated the initial data was invalid due to the manner in which time was being recorded.

The team determined that half the nurses were recording the patient out as the time after they left the patient in post-anesthesia care unit, which artificially shortened turnover times. This meant the process could actually take an additional 5 to 15 minutes, which would significantly impact the overall turnover target of 25 minutes. The team made the necessary process and education adjustments, and then gathered new measurements.

The team found the mean turnover time to be 24 minutes, which does not appear very far from physician's expectations. However, when applying the Six Sigma methodology, it found the defect rate to be at 40 percent. The 40 percent defect rate is what the physicians were feeling and validated their concerns.

Identifying the Turnover Time Issues

Hundreds of variables may impact turnover, so the team used a fishbone diagram to prioritize and target the most critical factors. Two of the biggest contributors were equipment and instrumentation availability, and attendant availability to help set up equipment and position patients.

Not having attendants on hand to clean the room in a timely manner causes delays, but moving or positioning patients is an even larger issue in orthopedics. A wide variety of tables are used and requires knowledgeable attendants for proper set up. The attendants rotated through the orthopedic suites and would rotate assignments between pods every two days to non-orthopedic cases. In addition, the attendants were often not available to assist with moving or positioning patients. This was a source of frustration for the staff.

With equipment and instrumentation, many issues can impact lack of availability. Not having automated conflict management as part of the scheduling system allows for similar cases to be scheduled at the same time. For instance, there may be only two pieces of equipment, but three patients scheduled for use. The service line manager was performing manual reviews, but was unable to catch all conflicts ahead of time.

A related issue involved the central processing department (CPD) preparation of case carts, which were often incomplete due to procedural difficulties in the central sterilizing process. There were delays in turnover because the staff was trying to locate essential instruments prior to bringing the patient into the OR suite. Using the surgery schedule, CPD would prepare the first two carts the day before. However, there was not a continuous systematic review to add the missing items on the incomplete carts through the second and third shifts, which left many case carts incomplete for the next day of surgery. 

Making the Positive Changes

During the DMAIC Improve phase, OR equipment and instrument sets with limited quantities were loaded into a conflict management system. This allowed for electronic flagging when too many cases requiring the same equipment or sets were scheduled.

To further improve instrument availability, a review sheet was developed as a pilot to bring more oversight, accountability and communication to the case cart process. CPD began to prioritize cart preparation according to the schedule and, using a review sheet, checked off carts once complete. This review sheet was worked by all shifts and the team leads focused on any missing items that were noted on the review sheet. By 6:30 a.m. the review sheet was sent to the OR and to the CPD technician over the service line. This final review sheet allowed the OR team to know if any item was missing from the case cart along with the item's location. The technician would serve as the point person to retrieve the item once available and prior to the case.

Project Team's Strategies for Improvement
Improvement Strategy	Risk Abatement/Monitoring Plan
Case Cart Completion (Dashboard)	1. Daily completion lists are loaded into database and CPD sends compliance report monthly. 2. Monthly review of missing instruments with service team.
Attendant Availability (Dashboard)	1. Delay codes pulled monthly in surgery department, monitor three codes: a) room clean-up delay, b) positioning delay, c) moving help delay.
Preference Card Maintenance	1. Preference cards updated for high-volume procedures every January and February.

In the past, there was no data to indicate what was missing on a regular basis, so it was difficult to determine what instrument shortages existed. The daily review sheets were saved into a tracking tool which allowed OR management to easily identify what was missing, how many times and why. A monthly review process was established to monitor progress, with a report posted in the OR and sent to management staff.

This improvement was rolled out beyond these services, so that all service areas could benefit. Being able to track where items are, whether they are in short supply and which supplies are being used most frequently, greatly improved resource management and communication among staff. It also provided justification for purchasing specific instruments used in surgery cases. New measurements were taken two months post-improvement and instrumentation availability had already improved by 39 percent.

Work-Out Session and More Changes

To address attendant availability, the team conducted a Work-Out with two attendants, two surgical technicians, two circulating nurses, and one CPD technician. Several recommendations came from this session. One of the main solutions was to have a core group of attendants that know the physician preferences and equipment, instead of rotating with a different group every two days. The unique positioning and equipment that must be learned in orthopedics and neurosurgery requires some level of specialization and staff must be able to act quickly.

During the course of the project, the team established a core group of four attendants and a fifth that rotates through the surgery suites. This allowed ownership of the area, while still providing others with exposure to the equipment. By all accounts, this change has made a tremendous difference and increased staff satisfaction.

Initially, the team found that attendants were where they needed to be and easily accessible 71 percent of the time, and this metric has since increased to approximately 98 percent. Several recommendations made during the Work-Out session were put in place, resulting in a patient care environment that could operate "like clockwork."

Sharing Insights and Results

The OR has experienced continuous improvements in turnover time. The baseline turnover of 24 minutes is now running at 20 to 21 minutes. More importantly the number of defects (turnovers exceeding 25 minutes) has dropped from 40 percent to 21 percent. As of January 2006, 11 months post-improvement, the CPD department had sustained their 40 percent improvement in instrumentation availability. The orthopedic team in the OR and CPD were integral in implementing and sustaining these improvements. Below is the graph of the progress made in OR turnover defects.

Operating Room Turnover Defects

The level of satisfaction among surgeons is much higher as a result of the project. They appreciate both the specific changes that were made, and the overall involvement and communication from the executive team taking place on a consistent basis.

Through Six Sigma training and project completion, one of the most important lessons the team at Memorial Hermann Southwest Hospital learned was the value of looking at data in a different way. Instead of concentrating on averages, which can be misleading, they are now able to view processes in terms of defects and variation. Lessons learned during the first wave of projects are being applied to other clinical and operational initiatives throughout the system.

About the Authors: Heather Anderson is the director of Medicare profitability for the Memorial Hermann Healthcare System. Previously she was the director of operational improvement for Memorial Hermann Southwest Hospital, where she oversaw the Six Sigma program and became a Six Sigma Black Belt. She can be reached at heather.anderson@memorialhermann.org. Marilyn Brazda is a registered nurse, CNOR (certified nurse operating room), with 22 years experience in the peri-operative area. She is a clinical manager in the operating room and is a Six Sigma Green Belt at Memorial Hermann Southwest Hospital. She also serves as the laser safety officer and works with customer service, infection control, risk management and process improvement in the operating room. Ms Brazda can be reached at marilyn.brazda@memorialhermann.org. Stephanie Struble is the director of research analysis for Memorial Hermann Southwest Hospital and is a Six Sigma Green Belt. She oversees administration projects from strategic planning to program development. Ms. Struble has a bachelor's degree in biology pre-healthcare, a master's in clinical gerontology and is currently a doctoral candidate in health management. She can be reached at stephanie.struble@memorialhermann.org. Carolyn Pexton has more than 20 years of experience in communications and healthcare and is the director of communications for Performance Solutions at GE Healthcare. She is a certified Green Belt and has presented and published on topics including Lean Six Sigma and change management within the healthcare industry. She can be reached at carolyn.pexton@med.ge.com.

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