Perioperative workflow: barriers to efficiency, risks, and satisfaction

AORN Journal,  Jan, 2008  by Patricia H. Fowler,  Janet Craig,  Lawrence D. Fredendall,  Uzay Damali

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On March 6, 2007, the United States Pharmacopeia, the official public standards-setting authority for all prescription and over-the-counter medicines, released the seventh annual National MEDMARX Data Report. (1) Created in partnership with AORN; the American Society of Perianesthesia Nurses; and the Uniformed Services University of the Health Sciences, Bethesda, Maryland, the report included an examination of more than 11,000 medication errors that had occurred in various health care departments through which patients move in the perioperative process. The report indicated that 5% of the errors resulted in patient harm. (1) There is further evidence suggesting that most errors are hidden and are not identified or reported by established routine procedures at the time they occur. (2-4) Little is known of the process factors that underlie these errors.

The pressure on perioperative services to improve safety and quality while reducing costs creates both challenges and opportunities. Service efficiency and effectiveness is an important concern for many hospitals today. This is true particularly in the OR, which typically is a hospital's largest revenue and cost center, contributing an estimated 40% of the hospital's revenue. (5,6) Purchasers and payers alike are taking a greater interest in the quality of surgical care, including process and patient outcome measures as well as complications. (7-9) The Centers for Medicare and Medicaid Services (CMS), the largest insurance payer in the United States with $330 billion in annual hospital expenditures, is developing information transparency initiatives to improve the information available to the public for making informed health care decisions.

In August 2006, President George W. Bush signed an executive order requiring four federal agencies to compile information regarding the price and quality of care and to make that information available to the public. To date, 32 states have passed laws requiring hospitals to report their charges for various procedures. (8) When this presidential order is fully implemented, potential surgical patients will have access not only to pricing information but also to data regarding hospital volumes by procedure; patient satisfaction; and outcomes (eg, infection rates, complication rates). (8)

Many factors affecting quality, safety, productivity, and cost are embedded in the perioperative process, and yet many process improvement initiatives have bypassed the OR. Reasons for this may include that surgical workflow is considered too complex to track, various stakeholders are too diverse in their agendas to reach a consensus on what to improve, and deficient information technology (IT) systems lack the capacity to provide managers with real-time information and analysis. (10,11)

Wide variations in OR efficiencies have been documented on selected measures such as on-time starts, turnaround times, missed or lost charges, capacity utilization, pieces of paper involved in intraoperative RN documentation, and physician preference items as a percentage of supply expenditures. (10,12-17) Likewise, wide variations in clinical process outcomes and complication rates have been demonstrated. (9,18) Operational definitions and the type of data that were measured lack standardization, creating barriers to accurate comparisons and benchmarking. (10)

The National Academy of Engineering and the Institute of Medicine have suggested that what is needed to understand and improve processes in health care is a new partnership between systems engineering and health care providers, as well as a general systems view of operations. (19) Knowledge, tools, and research from the engineering disciplines that are associated with the analysis, design, and control of complex systems still are largely unknown in the clinical operations of health care delivery. (19) Instead, in the health care industry, there has been a dependence on hard work and personal vigilance, a focus on mediocre benchmark outcomes rather than processes, more standards and procedures imposed on staff members without analysis and design of new systems, and a wide tolerance of provider autonomy. (20) As a consequence, results on CMS quality indicators for the surgical infection prevention pay-for-performance and indicators reported in HealthGrades' Hospital Quality and Clinical Excellence Study (18) fluctuate from period to period without consistently reliable results. These indicators measure outcomes by procedure, complications, and infections, as well as results of patient, staff-member, and physician satisfaction surveys.

STUDY GOALS

The goal of this in-depth, interdisciplinary case study was to map and describe information, material, and functional processes and the interdependencies common to high-volume surgical specialty procedures, beginning with patient scheduling and ending with the patient's discharge to the postanesthesia care unit (PACU). Of special interest were

* the identification of perioperative processes (ie, a series of simple or complex linked activities or procedures designed to achieve an objective, such as scheduling of operative procedures, preoperative preparation of patients, and case cart preparation);