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Where Was The Detour? Turning ORs in 7 to 10 Minutes

November 12, 2012 Leave a comment

An article was recently published regarding the possibility of turning operating rooms in ambulatory surgery centers in 7-10 minutes.  In this article the author talked about the fact that turning the rooms inside this time frame is still a possibility.

I was left struck with, yet again, that we in the ambulatory surgery business took another detour somewhere.  I recently responded to a previous article calling for surgery centers to consider moving toward a patient-centered environment.

As someone who has been involved in the development of ambulatory surgery centers since 1979, I simply had to respond because back in the ‘old days’ this was what ASCs were all about.  In reviewing the article about room turnover times, I was, once again, stuck with the fact that back in the early days of ambulatory surgery, we pledged to turn all our operating rooms over in 7-10 minutes—-patient to patient.  Should the turnover time exceed 10 minutes, a QI study was immediately conducted to identify the problem/area for improvement.  And yet, over the last twenty years, I have begun observing that these times are being extended.

Some of the reasons put forth by ASC leaders for this extended time include the fact that more complex surgeries are being performed in the ASCs.  Another issue presented during QA/PI studies is that our patients are more challenging.  More and more centers are admitting ASA class III and more patients who require a great deal more attention.  Care of the morbidly obese has become a big issue.

The question arises, however, if these are valid reasons for longer turnover times, or is it just that we need to better plan for those challenges?  The second question that arises is that if the condition of those patients validate the longer room turnover times, then what is going on that room turnover times, in general, are increasing?  One could make an assertion that the industry, in its proliferation, has lost track of its roots—its initial commitments.  Is it that more and more centers popping up means more and more hospital trained nurses being put in leadership roles with no distinctions from the freestanding ambulatory surgery center culture.

As long ago as the early 1990s a study was done documenting room turnover times in hospitals.  Understanding that the turnover times were being measured from patient out to next patient in, these times ranged from 45 minutes to 1 ½ hours.  During this same study, it was observed that the average freestanding ASC was able to turn their rooms within the 7-10 minute time frame.  Outlier times were identified for procedures where there were excessive irrigation fluids used, or in shoulder joint replacement surgeries.  It was further documented that turnover times in hospital owned ASCs were primarily in line with hospital turnover times.

In reviewing practices within 36 different ASCs, it has been noted that turnover times have been increasing exponentially with the exception of, universally, cataract surgery.  However, even in this surgery, in multi-specialty centers, turnover times of 15 minutes has become acceptable.  It was cataract surgery centers that perfected the ability to turn rooms in seven minutes with patients commenting that they knew they were on a conveyor belt kind of schedule, but that the personalization of their care was such that had they not observed this, they would not have known.  It was further observed that turnover times for GU and GI procedures generally were far shorter than in other specialties, but still exceeded the 10 minute goal.

So, what happened? 

We have to first look at the commitments of the staff and physicians.  Are they aware that with the turnover times being inside the declared goal of 7-10 minutes,  more procedures/cases could be performed and that this results in happier surgeons who are more likely to utilize their center more and more?   Are they aware that greater utilization increases profitability and, thus, increases their chances of getting a raise or a bonus at year’s end?  Are they aware that faster turnover times, means that patients get out of the center faster and aren’t left with long waiting room times?  This makes for happier patients reporting back to their physicians.  It is a ‘win-win’ all the way around.  The staff has to be gotten on board with the possibility of faster room turnover times.  You need to enroll them 100%! And this includes those physicians who like to hit the staff lounge to gossip, make calls, etc. Or who like to go to their office next door between patients.  Educate them into what is possible in coming right back to the OR after they have seen their patient in recovery and the care person in attendance.

It is impossible to experience rapid room turnovers without assessing the layout of your ORs and procedure rooms.  Hospital operating rooms are typically equipped with large banks of storage cupboards which are usually stuffed full of supplies.  In the ambulatory surgery industry it was quickly recognized that if the procedures were to be reimbursed on a ‘flat fee’ basis, rather than for every widget used, then it was imperative that supplies be strongly controlled.  The basis materials management premise that supplies sitting on shelves have a powerful intrinsic cost become paramount in cost containment practices.  Supplies were moved out of the ORs and were centrally located such that turning them and reducing PAR levels could be easily controlled.  All supplies for the center were treated in this manner with the exception of those supplies only used in certain areas such as peel packs for the sterile processing area.  Thus, all inventories were conducted out of the bulk and sterile storage areas excepting those specialized items stored in those specialized areas.  This kept supply costs down significantly and reduced manpower hours in conducting weekly inventory and re-ordering of supplies.

Operating rooms were equipped with one supply cupboard and one “case cupboard.”  The inventory for the supply cupboards was limited to only those items that were essential as back up for items already pulled for the cases to be conducted in that room.  These included two each of the various sized, most commonly used gloves, one package of sterile 2x2s, 4x4s, etc.  Again, thought was put into what kind of cases were being performed in the center, what would be pulled from the two different storerooms to perform the procedure and what else might be needed because a glove was punctured or ripped, a gown sleeve contaminated, or additional sponges might be needed.

However, staff considered what eventualities would drive them to tap into the back-up supplies.  They considered the most common eventualities, rather than those that might be rare.  Consideration was given that emergency supplies would most likely be found in anesthesia carts, but also considered what surgical supplies like drains, hemmorrhagic sponges, etc. should be stored in limited numbers in the room. The supply cupboard was never considered to provide everything needed to perform a case.  Limits to the number of items stored there relied heavily on the concept that these were only ‘back-up’ supplies.  The inventory stored in this cupboard was listed on an inventory sheet kept in the cupboard.  The cupboard was restocked at the end of each operating day from the bulk or sterile storage areas.  The restocking of this cupboard was identified on the duty list for each or staff to complete each day.  This list required a date, a ‘completion’ check mark and the initials of the staff.

A second cupboard was dedicated as a case cupboard.  In cataract surgery, GI and GU rooms, two case cupboards were installed to allow for the increased volume.  Each cupboard contained 6-7 shelves representing one shelf for each case scheduled for that room for that day.

In looking at what it would take to get turnover times to that magical 7-10 minutes, staff met in one of the ORs and looked at every task performed in turning a room from the circulating nurse going with the anesthesia provider to take the patient to PACU, to delivering the soiled instruments to the soiled receiving area for processing, to mopping the room, cleaning the or bed…the whole gamut.

AORN recommended practices and the center’s policies were reviewed and implemented for housekeeping and cleaning between cases.

Job functions were reviewed and assigned.  Who was to do what to turn the rooms was not only identified but embraced.  Who was to grab the mop?  Thrown out the window was any conversation about ‘not my job’.  The OR Supervisor and the Executive Director both pitched in with the mop when needed, as did the physician.  All kept the agreed upon goal clearly in mind.  Mopping was not done during non-invasive procedures.  Surgical team areas were identified for mopping between invasive procedures.

It was agreed upon that at the end of the case the RN would take the patient to the PACU with anesthesia, give the hand off communication, visit the next patient scheduled for that room then return to the or to assist in the turnover.

The organization employed a sterile processing technician to wash and process instruments.  Any surgical technician not working a room was assigned to assist in the sterile processing and soiled receiving areas.

At the end of the procedure the surgical technician removed the soiled instrumentation from the room to the soiled receiving area for processing and returned to the room to begin the turnover process.

When the page for turnover was heard, any available staff reported to that room.  The staff lounge was reserved for assigned breaks and lunches.  The organization also employed an orderly, receiving, housekeeping, maintenance person who helped as available turn rooms in this seven-OR facility.  However, whoever was available either grabbed a mop or begin wiping off the flat surfaces and or bed with the germicidal solution.

The OR was equipped with a soiled linen hamper, a biohazardous waste hamper, a general waste hamper and two kick buckets—one for anesthesia and one for sponges.  At the end of the case, these were emptied and disposed according to recommended practices and standards.

In identifying all the elements involved in turning a room the staff noted the hamper liners, kick bucket liners and the linen needed for the or bed as routine.

Physician procedure cards were scrutinized and updated as necessary. Staff met and agreed to follow these rigorously in pulling cases.

It was decided that all cases would be pulled the afternoon prior to the procedure.  All supplies would be put on the shelves in the close cupboard designated as the case cupboard.  Each shelf would be labeled; e.g., #1, #2, etc.  The cupboard shelves were equipped with a lip around the entire shelf and pulled out of the cupboard allowing it to be used as a transporting tray.

The organization approached the local grocery store and were able to get, free of charge, grocery carts with those irritating wobbly wheels.  These carts were cleaned up and the wheels were changed out transfiguring them from grocery carts to supply carts.  Staff used these to transport supplies from the bulk and sterile storage areas and to pick their cases.

Staff, following their procedure cards, pulled every item needed for each case and placed those on the assigned shelf in the case cupboard.

As part of the process for rapid room turnovers, the staff developed a system for “room turnover packs.”  These consisted of the OR table/bed sheet, the draw sheet, the kick bucket liners, and the various hamper liners.  Staff were assigned daily to make these packs by gathering all the items and making rolls that were held in place with a strip of masking tape.  These were kept at the OR control desk.  When pulling cases the staff person would pull however many of these rolls needed based on the number of cases scheduled for that room for the next day.  One of the rolls was placed on each shelf with the supplies for the case.

Once the room was cleaned, the RN or other staff person, as agreed in their assignment meeting, would pull the roll, make the table/bed and place the liners in the appropriate spot.  The surgical technician would pull the pack and place it on the back table and begin draping the instrument table and mayo stand . The RN Circulator began assisting in the opening of sterile supplies and dropping them onto the sterile field while the surgical technician scrubbed.  The RN then would set up the prep table, then leave the room to collect the patient with the anesthesia, provider.  Upon re-entering the room, the RN finishes gowning the tech and physician and turns to assist anesthesia in sedating the patient as needed.

Many larger organizations are turning to developing and/or hiring an anesthesia technician.  Certification for this person is available on the internet, but in-house training on the part of the anesthesia providers is acceptable.  This person can be quite valuable in assisting in room turnovers, too.  In the absence of an anesthesia technician the anesthesia providers have to assume an “assistive” position in turning rooms.  Include them in your training.  In the absence of an AT, the medication management nurse should be assigned the job of keeping the anesthesia carts fully stocked.

The system/process described above will absolutely allow you to turn rooms within the identified national standard of 7-10 minutes.  However, it is crucial to this process, that each staff person remember that every time someone leaves a room to go fetch something, it is manpower hours that translate to increased room turnover times.  Plan to review your turnover times at least twice a year.  Develop an electronic log and assign a data entry person the task of documenting times patients enter and leave rooms to facilitate your study.

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Housekeeping…The Backbone Of The ASC

November 7, 2012 Leave a comment

The patient’s car pulls into the parking lot of the ASC.  He is here for his pre-anesthesia/surgery assessment and education visit.  He can’t help but notice that there is trash here and there around the lot.  A nagging little thought enters his mind about the apparent disregard for tidiness.  He approaches the front door of the Center and, again, notices some pieces of napkins and a styrofoam coffee cup lodge in the corner by the entrance.  There is a sand-filled ashtray near a bench, but the ashtray is overflowing.  That nagging little thought is getting bigger.  When he enters the reception area he notices the wilting—almost dead—plant on the corner of the reception desk.  The carpet shows a clearly defined dark/dirty traffic path.  The upholstery on one of the chairs is badly stained while another is clearly frayed along the front seam.

Does the above scenario sound implausible?  It shouldn’t, for it is a scene CMS surveyors are reporting across the country.  That patient’s nagging thought becomes a roaring symphony to CMS surveyors entering a Center.

Infection Control Surveys

When CMS began the unannounced infection control surveys in the summer of 2009, it became evident that housekeeping practices in ASCs were an urgent issue in the rising rates of infections being reported in the ambulatory surgery Centers.  Surveyors came out of these surveys certain that housekeeping, the training of housekeepers, and the follow-up of the housekeeping practices was not a high priority among the leaders in the ASCs.  Indeed, some surveyors were heard making statements like “it is clear that the leaders of this organization hire incompetent, unskilled and unqualified persons to perform housekeeping (and sterilization) services in this organization.”

In assessing the housekeeping practices in some 36 surgery Centers across the US what was discovered was that the ASC leaders largely hired housekeeping contractors who had “experience” cleaning healthcare facilities.  However, some of this experience was in cleaning doctor’s offices.  Some did list other ASCs.  On occasion, some owners of the housekeeping service had worked, themselves, in the housekeeping department of the hospital.  Several Centers interviewed performed all the housekeeping inservices internally using their RN staff.  In none of the Centers did the organization meet with the housekeeping staff themselves to perform training or to observe their cleaning practices.  And yet, virtually all of the Centers had quite a litany of complaints regarding the services that were being delivered.

In performing inspections of the various ASCs, CMS has reported;

  • Water stained ceiling tiles throughout many Centers.  These stains harbor bacteria.
  • Rust on stretchers, or tables, IV poles, the legs of instrument tables, anesthesia and emergency carts, endoscopic cleaners, in and on sterilizers, medical gas connectors, oxygen tanks and connectors…the list becomes extensive.  Rust harbors bacteria.
  • Dust—everywhere!  Windowsills, blinds, tops of suction canisters, the top of emergency and anesthesia carts, microscope arms, behind equipment on counters, inside drawers in medication rooms and in the OR and sterile processing.  Dust is a large contributor to post-op infections!
  • Chipped and peeling formica throughout the Center on doors, counters, cupboards.  This leaves a surface that is far from ‘seam-free’ and harbors bacteria.
  • Peeling and torn wallpaper—again, not smooth and seam free for washing w/o harboring bacteria.
  • Chipped paint on walls and door frames—same story as above as far as preventing adequate cleaning.
  • Nasty, dirty areas behind sterilizers and open drains that are full of what looks like mold.
  • Mold in air vents—dirty and dusty air vents.
  • Blackened separated floor seams.
  • Separated coving on floors in sensitive areas like the OR
  • Separated back splashes leaving gaping spaces between the back splash and the wall in sterilization and soiled cleaning rooms.
  • Housekeeping closets that either have no or too long black hoses that are touching the bottom of the sink pan.
  • Housekeeping closets that are dirty, cluttered and un-kept.
  • Corners of floors, especially behind doors, that are dirty and appear to have been ‘waxed over’.

In one Center, CMS instructed the ORs/Administrator to demand the housekeepers come in during the day shift in order for CMS to observe their cleaning the ORs.  It was disastrous!  The cleaning crew mopped the OR walls with dripping mops starting at the bottom and working their way up.  In addition, the same mop head was taken into the second OR to use, but, then, so was the same bucket of water!

While observing housekeepers in another Center, the observation was made that the housekeeper pushed the bucket full of solution out of the one OR, mopped the OR corridor and proceeded into the Pre-op/Recovery area.  When the observer questioned the housekeeper as to when she would change the water/solution in the bucket, the housekeeper replied that she changed it when it got dirty!

In another Center where the RN staff performed all housekeeping duties, it was discovered that counters were never being cleaned, nor was deep cleaning behind equipment, or corners being done.  It appeared that the old ‘a lick and a promise’ was the rule of thumb, as this service was being done at the end of the day’s schedule, and staff were eager to ‘get out of here’.

One cannot assume that these are isolated occurrences.   In the face of increasing numbers of infections in ASCs, we in this industry must cast a disparaging eye toward housekeeping practices in our own ASCs.  ]

We have to carve out the time to address this very serious issue.

  1. Comprehensive Housekeeping Policies.  Surgery Centers should have comprehensive housekeeping policies.  Housekeeping guidelines for hospitals and healthcare facilities can provide the stepping stone for your policies and protocols.  Look at every area beginning with the entry into your Center.  What does it tell the patient about what he can expect from a safety/infection-free environment for him?  What does it tell him about your commitment to cleanliness?  Patients know about sterility.  They strongly suspect that the place where they are having their surgery should be above and beyond clean, if their outcome is to be good.  They all have friends or family, or they know someone who got a post-operative infection.  The condition of your Center also has a huge impact on your marketing.  What does it say to your patient community if you have not maintained your Center either physically or through housekeeping?
  2. Orientation.  Develop a housekeeping orientation program and tools.  Include all areas and essential tasks.  Look at your own expectations in each area.  Meet with your key staff members to discuss and explore their expectations, issues and complaints.  Incorporate clear instructions based upon this analysis as part of the housekeeping orientation.
  3. Tools and Recommended Practices. Develop housekeeping checklists for each area.  Look at recommended practices from the AORN.  These checklists should include terminal cleaning of the ORs, the expected schedules for the cleaning of all areas and the contents of all the different rooms.  What pieces of equipment are they to clean, if any.  Also, develop checklists to document what the nurses are expected to clean and how often.
  4. In developing checklists identify those things that are outside of the daily or weekly routine; e.g., carpets, tile, windows, upholstered furniture, stripping and waxing floors, woodwork, doors, inside cupboards, etc.
  5. Housekeeper’s checklists should hang in their closet.  Get in the habit of checking these several times a month.
  6. Put together a housekeeping training packet and meet, not only with the supervisor, but with the housekeepers who are going to be cleaning your Center.
  7. Determine whether or not the housekeepers have had training in both blood-borne pathogens and toxic/hazardous substances, but also HIPAA.  If not, provide them with those policies and demand that the contractor provide further, documented training.
  8. Provide the housekeepers copies of your housekeeping policies and complete the orientation tool.  Observe their cleaning practices.
  9. During the orientation and training period there should be a conversation regarding the ability of the housekeeping staff to read and speak English.  If the staff is unable to do so, you are expected to provide instructions, checksheets, MSDS in their language!  There are sources for this available on the internet, or contract with an interpreter to make these changes.  You can also have the interpreter provide all the instructions verbally.  Document this in the contract workbook with their contract.
  10. Orient the ASC staff to housekeeping practices.  This should include not only what can be expected from the housekeepers, but what is expected of them.  It is unfortunate that we still see RNs who drop some piece of paper on the floor and leave it stating that it is not in their job description to clean, or they call the MA to pick it up.  The RN’s job is to provide a safe environment for their patient.  This includes a clean environment.  During a recent survey, the surveyor did the white glove test on the bottom of a drawer in the medication room.  She held up a finger laden with dust and showed the RN who was the medication management nurse.  The RN said, ‘housekeeping doesn’t clean inside drawers.’  The surveyor remarked, ‘and clearly, neither do you, nurse!”…..not a good impression…and this is a room where medications are prepared!
  11. CMS expects that the leaders are periodically observing the housekeeping staff at work.  Schedule a midnight visit at least several times a year to ensure that best practices are being followed.
  12. Lastly, CMS also expects that the leaders of the organization are conducting housekeeping inspection tours.  It makes sense that the infection control coordinator be responsible for monitoring the housekeeping practices in the Center.  However, the leaders should hold this person accountable by reviewing the logs on a regular basis and demanding that the housekeeping practices and results of the weekly housekeeping inspection tours be included in her quarterly infection control report to the QA/PI meeting.

In closing, housekeeping practices are the backbone of the Surgery Center.  Without good, sound and solid housekeeping services, low infection rates are in jeopardy, and, eventually, word is going to get out that your Center is less than an ideal place for patients to have their surgery.  Remember, they do have a choice.

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