S001: MODIFIED TURNAROUND TIME: A SIX SIGMA PROCESS IMPROVEMENT PROJECT
Todd J Smaka, MD; Monique Espinosa, MD; University of Miami
Introduction: Operating room time is a valuable resource. Non-productive operating room time represents a cost to our institution, especially when excessive non-productive time impacts our ability to maximize the performance of cases during normal business hours. In an effort to reduce non-productive time in the operating room, we sought to improve our process for turning over our operating rooms from one patient to the next.
We had already improved our turnaround time, known as TAT, from when the previous patient exited the operating room to when the next patient entered the operating room. We modified this definition by creating a new term, “mTAT” (modified turnaround time), to be equal to the sum of: “procedure end / dressing applied” to “out of room”, TAT, and “in room” to “anesthesia ready”. This time can be thought of as the time the surgeon is not prepping or operating and represents the time the surgeon perceives they are not productive.
Methods: We commissioned a Six Sigma process improvement project to examine mTAT of 839 cases using the DMAIC (Define, Measure, Analyze, Improve, Control) model. After conducting a SIPOC (Suppliers, Inputs, Process, Outputs, Customers) analysis, gathering VoC (Voice of the Customer) data, and creating an Ishikawa diagram, we identified three potential sources of prolonged mTAT. We then measured the contribution of these sources and analyzed their impact on mTAT. Finally, we improved our process by addressing the source of prolonged mTAT.
Results: We identified three potential sources of prolonged mTAT: type of anesthesia (General vs MAC), surgical consents not being completed in a timely manner, and non-contemporaneous charting of when a patient has entered the operating room. General anesthesia cases had an mTAT of 37 minutes versus 49 minutes for MAC cases. This 12-minute difference was mostly during “in room” to “anesthesia ready” and not significantly during the other phases of mTAT. When the surgical consent was completed within 10 minutes after the previous patient exited the operating room, mTAT was 43 minutes compared to 56 minutes for when the consent was completed later. When the circulator alerted the anesthesia attending immediately upon entering the operating room, the difference in mTAT was less than one minute compared to when the circulator did not alert the anesthesia attending until much later.
Discussion: Though type of anesthesia affects mTAT, it does so in a way that is not amenable to improvement. This is because the difference lies in the very nature of the difference between MAC vs General: the time it takes for neuromuscular blockade to take effect and to secure an airway, rather than in wakeup from anesthesia and exiting of the operating room. The anesthesia attending having perfect knowledge of when a patient entered the operating room did not impact the timeliness of turning the patient over to the surgeon. Only timeliness in completing the surgical consent significantly impacted mTAT. When TAT has already been improved, institutions should focus on early surgical consents if they are to reduce the time surgeons are not operating.