Follow the evidence to improve satisfaction and efficiency.
- Using operating room first case on-time start data can help drive satisfaction and efficiency .
- Transparency and communication of process outcome data promotes positive empirical outcomes.
Data speak louder than words. Empirical outcomes, grounded in scientific findings and derived from validated evidence, demonstrate real change has occurred because of a particular action or intervention. They can be used to measure a hospital’s performance compared to its own baseline and national benchmarks. Organizations with Magnet® designation, for example, have demonstrated a history of excellence in nursing sensitive indicators, patient experiences, and nurse satisfaction outcomes over a minimum of 2 years.
The Magnet model empirical outcomes component incorporates expectations for accountability and evidence related to quality care. Organizations have several options for evaluating and measuring healthcare performance improvement (PI) initiatives. Bayhealth, a Magnet-designated organization, used the Donabedian framework (structure–process–outcomes) in its perioperative services PI project aimed at increasing patient and staff satisfaction and cost efficiency. Each component of the framework directly influences the next.
Bayhealth predicted that moving to streamlined interprofessional staff communication (structure) to enable increased awareness of operating room first case on-time starts (process) could ultimately improve staff satisfaction, patient satisfaction, and cost efficiency (outcomes). It used interprofessional communication and real-time monitoring of empirical data to improve performance that exceeds national benchmarks.
Background and significance
Satisfaction and cost efficiency are essential not only to Magnet designation, but also to the business of healthcare. They affect knowledgeable and competent staff retention, patient satisfaction, and continued hospital operation.
Sound structures and processes help generate continuous empirical data (which describe the steps taken, how they were implemented, and the differences they made) for ongoing analysis and continuous PI planning. Sharing these data provides transparency and communicates the value and impact of team structures and processes on overall outcomes.
Patient care demands, time constraints, availability of staff resources, and technology limitations can make developing an infrastructure conducive to reliable measuring, real-time monitoring, and improving outcomes challenging for healthcare organizations. However, organizations must take steps to overcome these challenges so they can develop strategies to improve outcomes.
Perioperative PI project
The Bayhealth OR and PI teams collaborated to identify the need for the perioperative services PI project. They assessed the overall OR and support team care delivery processes, staff and patient satisfaction data, and cost efficiency. According to research by Chua and colleagues, improving first case on-time starts can help enhance each of these components.
Understanding the problem
In November 2016, Bayhealth OR data demonstrated that only 37% of the Kent campus first cases and 66% of the Sussex campus first cases started on time. The national mean was about 70%.
In addition, Bayhealth OR nurse satisfaction NDNQI RN survey scores deviated from desirable results.
- “Unit RNs reporting more than 12 hours worked last shift” was well above the national benchmark, which negatively affected budgets (increased overtime pay) and staff satisfaction (burnout), compared to hospitals of similar size.
- OR and perioperative nurses reported low probability of their “plan to remain in direct patient care on the same unit.”
- Unit-specific collegial nurse–physician relationship scores were lower than the national mean and Magnet benchmarks, indicating a low level of trust between care providers.
- Lower-than-benchmark results were reflected in the staffing resource and adequacy category when compared to other Magnet organizations. (Meeting or exceeding Magnet benchmark is the Bayhealth target.)
Unit nurse leaders sparked PI project initiation by being transparent with the first case on-time start data and nurse and patient satisfaction results. Research by Foglia and colleagues on the effects of starting first OR cases were shared with the team. Lower first case on-time start percentages are associated with decreased OR efficiency, increased staff overtime, increased preventable errors, and decreased staff, surgeon, patient, and family/support person satisfaction.
OR and support team brainstorming identified several barriers to first case on-time starts, which the NDNQI RN survey results reinforced. The barriers included
- incomplete preoperative documentation and pre-admission testing from surgeons’ offices
- disconnects between surgeons and the OR team related to perceived lack of trust
- needed relationship repair between the sterile processing and OR teams
- lack of a defined preoperative process
- first case set-up inefficiencies
- inefficient instrument packaging.
Through open face-to-face communication, the team quickly realized that improved overall efficiency and satisfaction required collaboration among all perioperative areas in addition to sterile processing, central supply, and surgeons. In addition, changes in practice and routine were needed. For example, environmental services was included in team meetings and huddles, and packaging of equipment and supplies was revised for easier room set-up.
Nursing leadership engaged the OR team to establish a goal for process improvement and encouraging staff buy-in. The team set an initial 4-month goal of improving first case on-time starts at both campuses to at least 75%. This goal exceeded the 70% national benchmark. Vassell notes that increasing case turnover rates also correlates with improved cost efficacy and staff satisfaction.
Implementing the process
During PI meetings, the team used the 5 Whys method to perform root-cause analysis of late starts. For example, the team might ask the following:
- Why was the surgeon late?
- Why was preoperative paperwork incomplete?
- Why were patient care needs not met?
- Why was staff unaware?
- Why was the environment (room temperature, humidity, setup, and correct equipment) inadequate?
Using the PDCA (plan–do–check–act) cycle helped us organize operations. (See Improvement strategies.)
To achieve its goal of improving operating room first case on-time starts and ultimately improving patient and staff satisfaction and efficiency, Bayhealth:
- broke down silos between stakeholder teams
- discouraged the “but we’ve always done it this way” attitude
- created plan transparency
- designed a timeline for first-case start times
- developed a plan to improve sterile processing
- regularly shared relevant data (overtime, RN satisfaction survey results, patient satisfaction survey feedback, instrument packing changes, variance report reviews, and percentage of daily first case on-time starts)
- empowered team members to speak up using high-reliability concepts
- focused on and highlighted gains
- initiated a daily interprofessional team huddle.
Stakeholders represented in the daily huddle included surgeons; anesthesiologists; and those who worked in pre-admission testing, day surgery, sterile processing, environmental services, materials distribution, the postanesthesia care unit, and offices that routinely send patients to the OR. A call-in line increased huddle accessibility and participation by physician offices and other teams. In addition, a standardized agenda streamlined meaningful information exchange during huddles.
Evaluating and recognizing results
Evaluating and monitoring cycles of improvement and continuously sharing performance data with staff enhanced motivation and trust. Private and public recognition provided positive personal reinforcement on the journey to the team’s goal.
Reasons for delays were reviewed for improvement opportunities during each interprofessional team huddle, and communication boards provided daily data tracking. For example, daily efficiency tracking and a living Pareto chart (process improvement model) were hung in the unit. Our living Pareto chart, a daily updated graphic, displayed data for everyone to review and acted as a continuous visual progress reminder. It provided clear focus on real-time deficiencies or mistakes that required prioritization but never placed blame. When an incident occurred that potentially hindered goals, we performed an immediate root-cause analysis to elicit improvement strategies for preventing a recurrence. In addition, weekly electronic huddle notes were sent to the interprofessional team members.
Early empirical outcomes
In October 2018, the Kent campus average first case on-time starts was 80% and for the Sussex campus it was 84%. At the time, the national benchmark was close to 80%. However, Bayhealth was driven to continue to improve. Staff overtime drastically decreased, improving cost efficiency, but according to the 2018 NDNQI RN survey results, room for improvement existed in the amount of time staff worked more than a 12-hour shift compared to other Magnet organizations.
Bayhealth initiated another cycle of process improvement with expectations redefined for surgical documents. In an attempt to retrieve missing preoperative information, reports were sent to physician offices 72 and 24 hours before surgery. Regular town hall meetings and daily huddles reviewed first case on-time start percentages as well as other data to aid improved communication, transparency, and trust among interprofessional team members. In addition, the sterile processing team began packing surgical supplies to remove unneeded instrument sets, simplify tray handling, and decrease waste.
In September 2021, Bayhealth’s first case on-time starts surpassed national benchmarks (70% to 75%) with the Kent campus at 84% and the Sussex campus at 91%. Compared to 2016 and 2018, Bayhealth’s 2020 NDNQI RN Survey results significantly improved in three areas: unit-specific collegial nurse–physician relationship, staffing resource and adequacy, and the likelihood to remain in a position on the unit. Bayhealth Press-Ganey HCAHPS scores measuring OR patient satisfaction also demonstrated improvement.
Bayhealth continues to consistently have 85% to 100% first case on-time starts each month, exceeding current national benchmarks.
Using accurate, transparent data can drive an organization’s positive empirical outcomes. Sharing the data reveals the effects of PI initiatives on patients, staff, the work environment, and the organization. Dated, trended data help document sustained change over time, motivate stakeholders, and demonstrate solid empirical outcomes. (See Key takeaways.)
- These actions can influence important change outcomes.
- Provide opportunities for open interprofessional communication (via meetings and daily huddles) to improve trust among teams.
- Empower staff autonomy in creating goals.
- Use defined streamlined processes whenever possible.
- Use a process improvement model.
- Provide a clear, consistent understanding of change initiatives.
- Make process outcomes and satisfaction data accessible and transparent using visual aids (place posters and charts in public spaces and share information in meetings).
- Motivate staff with recognition and positive reinforcement.
To keep staff informed and motivated to drive improvements, Bayhealth communicated its first case on-time starts and associated them with important empirical outcomes such as nurse satisfaction, patient satisfaction, overtime use, and turnover between cases. Four years of data transparency and improved communication have led to long-standing improvements in patient and staff outcomes. Your organization can do the same.
Christie Tomaseski is the Magnet Program® Manager at Bayhealth in Dover, Delaware.
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