#62

Purpose/Aim:

The number of first surgical cases of the day not started on time has a direct impact on the overall operating room (OR) efficiency. UTMB recently implemented a real-time location system (RTLS) to track patient progress through the perioperative cycle. This technology (OR Controls) was used to support improvement efforts to increase the daily on-time start percentage. On-time starts were measured two ways: by the actual wheels in (patient in room) time, as well as the briefing (timeout) time. On-time start based on “wheels-in” is defined as patient in the room within 5 minutes from scheduled start time. On-Time start based on “briefing” is defined as briefing no later than 7:30 am with the exception of 9:15 am on Wednesdays.

Our project Aim was to “increase the percentage of first-start cases that occur by target from 41% to 60% by June 7, 2013.”

Tools and Measurement: A detailed cause and effect diagram (Exhibit 1) and a cross-functional process flow map

(Exhibit 2) were developed to understand where the delays can occur. OR Controls functionalities were used to record patient-in time. Epic was utilized to track briefing time. Both variables were measure and analyzed over a ten-month timeframe. In addition, OR Controls text notification functionality was implemented. OR Controls was the primary tool utilized for our project. Some main points pertaining to OR Controls and its functionality are:

ORControls™ (ORC) is a patent-pending, real-time, workflow solution designed to automate and coordinate all day-of-surgery activities

Enhanced operational efficiency through consistent automated communication Puts physicians, OR staff, and other groups and departments across a facility on the

same page at the same time Automatically alerts to situations that may cause delays in the immediate future Sends text notifications for surgeons and anesthesiologists to improve time management

and OR throughput See Exhibit 3 for OR Controls screenshots

PROJECT NAME: Operating Room First Case On-Time Starts

Institution: University of Texas Medical Branch (UTMB) Health System

Primary Author: Sean FunstonSecondary Author: Bernard (Bud), Cherry, Monica Clark, Ri Dorado, Judy Ramirez, Susan Seidensticker, Wayne Fischer

Project Category: General Efficiency

Intervention and Improvement: There were numerous opportunities identified around communication, and interventions

were developed that allowed the automated functionality of the RTLS to close those communication gaps. Four main interventions were implemented:

1. Familiarized and educated the Perioperative staff with the ORC system functionalities and reinforced the importance of wheels-in by 7:20 am/9:05 am.

2. Provided same-day feedback with daily “on-time” start reports posted in each OR and throughout the department.

3. Presented the ORC system to all surgical service lines and the anesthesia department.4. Activated text “alerts” feature for all surgeons and anesthesia providers.

Intervention Results: The on-time data were tracked daily and plotted on SPC charts (Exhibit 4). The results

from our interventions can be summarized as follows:

• Real-time tracking provides more accurate data, eliminates human error.• Wheels-In on-time improved from 33% to 37% (12% relative increase).• Briefing on-time improved from 71% to 78% (10% relative increase).• Decrease in variability for on-time start.• April 2013 was the highest recorded on-time start at 82%.• OR Controls features provide real-time status updates, which increase patient, staff and

physician satisfaction.• OR Control text alerts had the greatest impact. This last intervention increased the

briefing on-time starts from 71% to 78% (as shown on Exhibit 4).

Revenue Enhancement /Cost Avoidance / Generalizability: We identified a 27% decrease in overtime expenditures when comparing pre- and post-

OR Controls (Exhibit 5). Between June 2012 and October 2012 the average monthly overtime expense was $19,479 (pre-OR Controls), and between November 2012 and May 2013 average monthly overtime expense was $14,203 (post-OR Controls). This represents an average monthly overtime expense reduction of $5,276, with an annualized value of $63,307.

In addition, we identified an increase in case volume (completed cases) while we decreased total case hours (patient room time for all completed cases; Exhibit 5). We identified that, when comparing pre- and post-OR Controls case volumes, on average we were able to perform one more surgical procedure per business day. The Average surgical procedure contribution margin is $7,745. If we sustain this improvement, we will see an annualized increase in contribution margin of $1,943,995.

  Therefore, we can conclude that OR Controls and the interventions implemented during this project have helped to improve the OR operations by making us more efficient. We expect other areas to capitalize in the benefits of RTLS. Our Correctional Facility( TDC), Sterile Processing(SPD), and Blood Bank will soon be  implementing OR Controls that will result in enhanced communication with the OR and its operations. In addition, other areas within UTMB Galveston that will be implementing  RTLS include Interventional Radiology and L&D.

Exhibit 1 - Cause and Effect Diagram

Exhibit 2 - First Case Workflow Process

Exhibit 3 – OR Controls

Exhibit 4 – SPC Charts

On-Time Start - Wheels-In, P-Chart 8/1/12-5/31/13

Phase LCL Avg UCL Epic 0.013599 0.407583 0.801567 ORC started 0 0.333333 0.804738 Staff 0 0.268182 0.600441 New ORC features 0 0.323944 0.713326 Surgeons' meetings 0 0.352679 0.750235 Surgeons' text 0 0.374126 0.74895

On-Time Start - Wheels-In, Xbar Chart 8/1/12-5/31/13 (minutes)

Monitors/Kiosk Text alerts Transceiver

Phase LCL Avg UCL Epic -3.27562 5.436671 14.14896 ORC started -4.41484 6.075688 16.56622 Staff -0.63143 7.708372 16.04817 New ORC features -2.93058 8.016828 18.96424 Surgeons' meetings -2.97779 6.246667 15.47113 Surgeons' text -2.54403 5.074582 12.6932

On-Time Start – Briefing, P-Chart 8/1/12-5/31/13

Phase LCL Avg UCL Epic 0.32811 0.696682 1 ORC started 0.262229 0.71408 1 Staff 0.350294 0.695455 1 New ORC features 0.364037 0.732394 1 Surgeons' meetings 0.338404 0.714286 1 Surgeons' text 0.4587 0.77972 1

On-Time Start – Briefing, Xbar Chart 8/1/12-5/31/13 (minutes)

Phase LCL Avg UCL Epic -9.84398 -0.48072 8.882538 ORC started -12.3331 -0.70726 10.91856 Staff -8.70048 0.888527 10.47753 New ORC features -11.6178 -0.21588 11.186 Surgeons' meetings -11.2016 -1.62222 7.95711 Surgeons' text -10.9255 -3.05938 4.806722

Exhibit 5 – JS OR Overtime Expenses (June 2012 – May 2013)

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-135,000

10,000

15,000

20,000

25,000

30,000

35,000

Overtime ($) Linear (Overtime ($))

Exhibit 6 – JS OR Case Volume and Hours (June 2012 – May 2013)

-27%

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13500

1,000

1,500

2,000

2,500

3,000

Case Volume Linear (Case Volume)Case Hours Linear (Case Hours)

8%

-0.2%