Process improvement can result in a better bottom line for you—and your hospital
Orthopaedic surgeons frequently complain about operating room (OR) inefficiencies, specifically the turnover time between consecutive total joint arthroplasties. At a recent meeting I attended, this was the most common concern, and many audience members provided testimonials on the strategies they had used to improve turnover time in their individual hospitals.

Although orthopaedic specialty hospitals generally have better efficiency and surgical throughput, they require a large initial capital outlay and may have to meet state Certificate of Need laws. In some facilities, high-volume orthopaedic surgeons have a second ‘flip room,’ with a second surgical team. Staffing these rooms with ancillary personnel and anesthesia, however, is often problematic.

Our hospital successfully reduced turnover time using a process improvement approach. In 2004, the orthopaedic surgeons at Mercy Medical Center in Des Moines, Iowa, identified a problem with OR efficiency—specifically with turnover time, which we defined as the time between when a patient left the OR until the next patient was wheeled into the same room. A sampling of the turnover times in our main operating room found that only 55 percent of total joint cases were turning over in 30 minutes or less. The mean turnover time was 36 minutes. More troubling, however, was a standard deviation of 24 minutes per case. As surgeons, we felt that we could not plan our days appropriately, given the wide variability in the amount of time between cases.

Using the Six Sigma method
We began with open discussions with the hospital administrators about our concerns and about how we could address this lack of efficiency. Six Sigma had recently been integrated into the organization and we decided to apply this methodology to improve turnover within the OR.

Six Sigma was first championed by Bill Smith, a senior engineer and scientist at Motorola, as a way to measure defects and improve quality by reducing defects to a minimum level. It has been successfully used by such companies as Bank of America, Caterpillar, and General Electric. The success of Six Sigma focuses on the DMAIC methodology:

• Define the customers and their demands or requirements
• Measure current processes and collect relevant data
• Analyze relationships and causality of factors
• Improve processes, based on the analysis
• Control the process through continuous monitoring

Our initial goal for the project was to have 85 percent of joint replacement surgeries turn over in 30 minutes or less, while reducing the variability of time between cases.

In defining this project, we were able to identify actual phases in the turnover process. This enabled us to more easily recognize the problems that could occur during each distinct segment. Ultimately, turnover time was split into the following three separate categories:

• Patient out to room clean
• Room clean to room ready
• Room ready to next patient in

Picking the fishbone
We then developed a fishbone diagram, which classified the various explanations for delays in turnover. This allowed the team to focus on specific sources for delays in the process, such as patient, equipment, supply, anesthesia, and OR staff issues. We found that the most common delays involved lunch scheduling, nursing /staffing issues, equipment problems, and delays in the presurgical evaluation area.

The team made several recommendations to both the department of surgery and the orthopaedic group. Adopting these recommendations meant changing some well-established standards that the hospital had been following for quite some time. But as the process improvement program clearly defined staff roles, individual staff accountability improved. Other areas of delay could be individually addressed.

Once straightforward processes—such as paperwork flow through the presurgical evaluation area—were actually acknowledged as contributing to the overall delay, they could be easily addressed. Ultimately, we experienced some fairly dramatic improvements. By August 2006, we had cut our average mean turnover nearly in half, to just 19 minutes. Even more significant, our standard deviation was reduced by more than 65 percent, to approximately 8 minutes.

The results matter
On a very real level, process improvement resulted in increased productivity in our ORs. Prior to the Six Sigma project, we were performing three total joint replacements (TJRs) a day in one OR. Now, we can schedule and perform four TJRs a day per room. We’ve increased the volume of joint replacements in our hospital by 13 percent, without adding any more OR staff or increasing the number of ORs available. We hope that sustained sampling will demonstrate continued improvement in turnover times, not only for joint replacement procedures, but for all general orthopaedic cases.

By working together, both the hospital and the orthopaedic group were able to improve efficiencies that benefited both systems greatly. As long as the per-case net operating margin for orthopaedic cases remains positive, increasing OR effi ciency will improve the hospital’s financial situation. From an individual surgeon’s standpoint, the more cases I do in a day, the better my personal and my group business situation is.

Given the continued decreases in reimbursement facing both hospitals and orthopaedic groups, encouraging process improvement in our offices and in our hospital systems becomes vitally important. Simply put, inefficient systems will not endure; the only way to survive in this environment will be to provide efficacious and safe care in the most efficient manner possible.

If turnover time between cases is a problem for you or your hospital, I encourage you to consider process improvement programs, such Six Sigma, as potential avenues to improve efficiencies. Our situation is not perfect, but the improvements we have made have helped both the hospital and our surgeons. NOW

Craig R. Mahoney, MD, is chairman of the orthopaedic department at Mercy Hospital in Des Moines, Iowa. He can be reached at iowamahoneymd@aol.com. Laurie Dickinson, Certified Six Sigma Black Belt at Mercy Hospital, contributed to this article.

Resources
The Inventors of Six Sigma: www.motorola.com/=3079

De Feo JA, Barnard WW: JURAN Institute’s Six Sigma Breakthrough and Beyond: Quality Performance Breakthrough Methods, New York, NY, Tata McGraw-Hill Publishing Company Limited, 2005.