Reducing Same Day OR Delays and Cancellations Using the Model for Improvement
Martin Koyle, MD, MSc1, Megan Saunders, RN2, Melyssa Stoute, RN2, Walid Farhat, MD3, Darius Baglii, MD4, Armando Lorenzo, MD, MSc3, Vannessa Chin, MD, MSc4.
1The Hospital for Sick Children & IHPME, University of Toronto, Toronto, ON, USA, 2The Hospital for Sick Children, University of Toronto, Toronto, ON, USA, 3The Hospital for Sick Children & IHPME, University of Toronto, Toronto, ON, Canada, 4The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
Background: Delays and cancellations in the operating room (OR) are both costly & inconvenient. In our institution, >20% of first cases do not start on time or are cancelled. We hypothesized that patient-related factors (PF), rather than systems factors (SF) were primarily responsible for OR delays & cancellations. In an effort to reduce them, we employed the "Model for Improvement" (MFI) in an attempt to reduce these occurrences.
Methods: The MFI utilizes Plan-do-study-act (PDSA) cycles in order to promote continuous process improvement (CPI). A series of such cycles were instituted, in particular increasing NPO by an additional hour and having the patient arrive one hour earlier than usual protocol to assess their impact on cancellations and on time first case starts.
Results: Delays prior to this initiative were found to be primarily related to SFs while cancellations were almost always PF in etiology (illness>NPO). After changing NPO and arrival instructions, 13/14 (92%) consecutive days started at or before scheduled starting time , while the last one started within 15 minutes of schedule. 100% of 67 consecutive patients were NPO compliant. Of these patients, 3 cancelled same day due to a change in their decision, not other factors. Importantly all 67 families surveyed were satisfied with revised NPO and arrival instructions and nursing touchback identified that they were well understood. Stakeholder engagement however, was complex and demonstrated polarity within different components of the care team.
Conclusions: With healthcare costs and value being increasingly scrutinized, Lean/Six sigma and the MFI have been increasingly used to promote CPI. Although CPI in OR start times occurred in our study, this may be due to "Hawthorne effect", as this series involved a single surgeon. As a result PDSAs are ongoing with expansion of this methodology to all surgeons. In addition, studying changes in OR booking and scheduling, enhancing patient and family education and buy in, are ongoing in order to further improve OR efficiency and maximize utilization, and assess as ti whether our interventions are sustainable. Silos and inherent institutional culture, represent formidable obstacles.
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