Actually, Maximilian Mai, CEO of Memmingen Hospital, could look out of the window of his office at the landscape in the foothills of the Alps with satisfaction. Despite the intense competition in the surrounding area, the case volume at his hospital is high. Many patients value the facility highly and prefer it to other care offerings in the surrounding area because they feel they are in good hands, both medically and personally.
Internally, however, the management has repeatedly been confronted with various challenges in the near past, particularly in the operating room area. For example, a significant number of employees in the functional area left their employment within a short period of time. The continuing high numbers of operations threatened to overload the capacities of the hospital and the remaining employees. In the search for the causes underlying this development, the hospital management encountered a diffuse and multi-layered problem situation. Inadequate operating room capacity, poor communication and difficult-to-schedule working hours were frequently cited. Various possible solutions were put forward from all sides. These ranged from building new operating rooms to reorganizing the OR and recruiting new staff.
To avoid getting bogged down in the problems, the hospital decided to call on external support. At the end of 2019, Oberender AG, a management consultancy specializing in healthcare, will be commissioned to identify the underlying causes and find targeted solutions. “The difficulties have grown historically in some cases and require a fresh start. For this, we rely on the combination of on-site know-how via our clinic director and the neutral view from the outside,” says managing director Maximilian Mai.
The Memmingen Clinic
With its 1,800 employees and more than 500 beds, the hospital in Memmingen is of great importance in the region, both for the medical care of the population and as an employer. The 14 main departments of the priority care facility include the Clinic for General, Visceral, Thoracic and Vascular Surgery, Surgical Intensive Care Medicine and Pain Therapy, and the Clinic for Gynecology and Obstetrics. In 2019, the hospital treated 23,900 inpatients and 71,700 outpatients. The teaching hospital of Ludwig Maximilian University in Munich enjoys an excellent reputation beyond the Allgäu region, which is reflected in a clearly supraregional patient catchment area despite intense competition (see Figure 1).
So far, the operating departments have included orthopedics and trauma surgery, general surgery, thoracic surgery, vascular surgery, gynecology, pediatric surgery, neurosurgery, urology and plastic surgery. In total, approximately 11,000 surgeries were performed in eight multidisciplinary ORs in 2019. The surgical wing is located in the old building of the complex, which creates several challenges. For example, separate induction rooms, such as those found in newer surgical buildings, are not available. Also, all of the supplies needed for surgeries must be housed in the OR.
Challenges in the OR area
At the beginning of the mandate, Oberender AG will conduct a quick check in January 2020 to obtain an initial overview of the OR area and the challenges. As part of this, several visits will be made in the first step, during which the consultants will gain first-hand insights into the processes and structures as well as the hierarchies and communication channels. In addition, data is extracted and evaluated from the existing clinical information systems and OR documentation.
The Quick Check makes it clear that a large number of fields of action exist. Of central importance is the optimization of OR planning, since insufficient OR capacity results in various negative effects. The starting point here is the planning of the necessary capacities, which up to now has only been based to a limited extent on reliable key figures and the individual scope of the planned interventions. As a result, there are always peaks in demand, which mean that the emergency operating room has to be used for elective procedures. Excessively long lockout times and changeover times between surgeries, as well as delayed surgery starts in the morning, also mean that elective procedures sometimes have to take place during the period of on-call duty. All of these factors result in high employee stress, which is reflected in a high absenteeism rate due to illness of over 25% and the resignation of 16 of the OR’s total of 40 employees.
In the next step of the Quick Check, employee interviews are conducted. Here it becomes clear that the need for change has been recognized on the part of the employees and that they are ready for it. The employees complain that the current procedure for OR planning and organization is not very transparent and therefore not always comprehensible. On the part of the nursing staff, in addition to a stable OR schedule despite the high staff shortage and the number of emergencies, the desire for more appreciation of the work and for equal rights is expressed. It was repeatedly mentioned that the wishes of the various occupational groups were not taken into account equally in OR planning and that there was a hierarchical gap between the medical and nursing staff. All employees are united by the wish “to be able to work in peace.
Consulting by Oberender AG: Creating transparency through key figures
The results from the Quick Check show that changes need to be made primarily in the area of personnel as well as processes and structural conditions. In the area of personnel, the lack of employees and the hierarchical structures are particularly noticeable. The latter result not least from the fact that, in the absence of clear, data-based mechanisms for allocating the severely limited OR capacity, attempts are often made to resort to the law of the verbally stronger.
In the area of processes and structures, it is evident that almost 600 hours were overrun from core working hours in 2019. Delays in the start of the OR are particularly common. For example, the first surgery in the morning in general surgery starts more than 18 minutes late on average. Since time discrepancies in surgeries are partly due to different circumstances in anesthesia, these peculiarities must be taken into account in the analysis and in the implementation of changes. For example, for individual surgeries, it must be examined whether the anesthesia procedure is adapted to the surgery and whether any deviations can be justified by an increased degree of severity in the patient clientele.
After the problem areas in the OP had been identified, internal discussions began in March (see Appendix 1) about what changes were needed in which areas and by whom in order to address them. Right at the beginning, it became apparent that the debates were emotionally charged, which sometimes led to blockages. The consultants therefore initially initiated an OR working group to bring all the relevant professional groups to the table. It consisted of the chief physicians, the nursing management, the OR coordinator and the management. In this group, a new OR concept was to be developed and implemented together with the consultants. To this end, it was essential that all employees pull together and support the changes. Clear communication rules were established so that the concerns of each professional group would be heard and any hierarchies would have no influence. In addition, the working group always met with the same members in order to establish a personal level between the members and to ensure that information is consistently passed on within the occupational groups.
However, even the newly formed working group alone could not effect change without having detailed information about performance events in the OR. Moreover, it became apparent that without this neutral data, it was also impossible to achieve a structured, targeted dialogue between the specialist and professional groups. Against this background, Oberender AG proposed to the Memmingen Hospital that it introduce a KPI-based OR management system with the aim of making the processes in the OR transparent and creating an objective basis for discussion.
The first step was an in-depth analysis of the data available within the clinic. Based on this, key figures were derived and developed, and it was discussed which of the key figures should be included in the OR management system. At the same time, the results of the quick check already make it clear that although figures, data and facts must form the basis of a factual discussion, it takes many years of expertise to translate the resulting findings into operational recommendations for action and to implement these together with the employees. For this reason, consultants from Oberender AG were used who themselves have many years of experience in the OR, for example as OR ward managers, and can therefore communicate at eye level with the various addressees.
General key figures
First, general key figures were developed that provide an insight into the work in the OR largely independent of the respective specialty groups and personnel types. The key figures are based on the “Glossary of perioperative process times and key figures: A joint recommendation of BDA/DGAI, BDC/DGCH and VOPM” of the relevant medical societies. In order to achieve the highest possible acceptance, care was also taken to use routine data as far as possible, i.e. data originally collected for documentation or billing purposes. In addition to the advantage that this approach significantly reduces the effort required to collect data, the key figures compiled on this basis are particularly reliable and legally secure, as the respective documenters and management are liable for their accuracy
In addition to the key figures in the glossary, further key figures are derived from the routine data:
- Ratio of table occupancy and cut/sew time
- By table occupancy: A room is considered busy if it is operated with 420 minutes of table occupancy time per day, 5 days a week, 50 weeks a year. In addition, there are 30 minutes of room-related preparation and post-processing time.
- According to cutting/sewing time: A room is considered to be fully utilized if it is operated with 300 minutes of cutting/sewing time per day, 5 days a week, 50 weeks a year (differentiation according to Höhn).
- Initial incision times in the operating room (collected as part of the further analyses)
- Occupied operating rooms on weekdays
- Covering time: representation in minutes
Key figures per department
Individual problem areas were already particularly noticeable in the Quick Check, such as the fact that the surgeons in one department frequently overrun the operating time or start late, resulting in disadvantages for the subsequent departments in the operating schedule. However, the extent of such delays may be significantly distorted in the subjective perception of those who suffer. In order to create a transparent basis for argumentation and analysis in these areas as well, various key figures are therefore also derived from the routine data at department level. These include:
- Utilization per department per month in % of available OR capacity according to DKI
- Deviation of first cut in minutes per department
- Overrun time per department in minutes per month
- Overrun time in minutes per department without emergency indication
Introduction of a KPI-based OR management system
The key figures presented in the previous section will be collected monthly and presented once a month in the OR working group, starting in May 2020. The individual departments will be given room to justify negative deviations. For example, a high volume of complex treatment cases in a month may be a reason for longer-than-average operations. The extent to which this justification is valid can be derived directly from the available data on the case severity of a department’s patients.
Following the introduction of KPI-based OR management, a key task was to address the identified problems in the area of personnel. The status quo of the hospital and thus also the problems were to be made transparent for the employees through the preparation and presentation of the key figures. Employees are thus better able to understand the measures and the associated intentions and goals, which increased acceptance of the changes.
In addition, the OR management system was also intended to provide a basis for all clinical staff to make informed decisions. Previously, physicians could not independently access key performance indicators and obtain information about performance. Therefore, in collaboration with internal controlling, the data was prepared and made available to the physicians in the form of a dashboard (see Appendix 2). In this dashboard, physicians can compile the information that is most important to them and also make comparisons with other departments, for example with regard to OR utilization. With the introduction of the dashboard, doctors can now reliably check their own gut feeling – for example, that other departments overrun their operating times more frequently. Accusations are thus averted in advance.
At the same time, the key figures also show transparently in which areas other departments are performing better. After the dashboard has been implemented, it is often the case that doctors in a specialist group initiate changes on their own in the face of unfavorable results for which they are now responsible and which are now transparent – for example, above-average OR turnaround times. External intervention is often no longer necessary. However, in order to be able to realize these positive developments in holdover times and delays in the entire OR area, it was necessary to fix this procedure in the processes and structures. To this end, physicians were held accountable for punctuality, which included adherence to surgery start and duration times, change times, and incision/suture times. As a result, surgeons have moved, for example, to ensure themselves that personnel are on site for the ensuing surgery and that there are no delays.
Results of the OR reorganization
After the introduction of the KPI system, positive developments can be seen in the area of processes. Changeover times can almost always be reduced in the individual halls. Even if it increases slightly in room 2, the decrease is clear on average (see Figure 2). The cutting/sewing time is also reduced almost across the board.
The changed processes and responsibilities additionally contribute to a positive development of the deviations of the first cut and the overdraft time per department over time (see Figures 3 and Appendix 4). The reduction in first cut deviation is particularly evident in OP 1 and OP 5. The outliers in November in OP 4 are due to the fact that an above-average number of emergencies and comparatively complex cases led to delays.
Overall operating room utilization has been optimized by improving processes, making the first cut occur earlier, making utilization more consistent, and making the end of the room more punctual. Thus, the number of concurrently running rooms has compressed in time and increased in utilization (see Figure 4). Significant progress has been made toward the goal of utilizing as many rooms as possible during core working hours (red triangle) so that there are no overruns or vacancies.
At the department level, it can be seen that ORs are increasing in large departments and decreasing in small ones. A closer approximation to the 1.6 factor of anesthesia to incision suture time was achieved in most departments (see Figure 5). This is due to the fact that the anesthesia.
Satisfaction is expressed by the staff after the restructuring. The employees feel comfortable and valued. Interdisciplinary agreements have also increased, for which the OR dashboard provides a factual basis for discussion. The significant reduction in unplanned extensions of the OR day and the resulting decrease in overtime also played a key role in increasing employee satisfaction. It is remarkable that all these improvements were realized despite a slight increase in the number of cases and during the high additional workload caused by the Corona pandemic.tion achieved, such as more punctual start dates and shorter handover times.
The next steps
At the end of 2020, the hospital’s management is very satisfied with the results achieved: The diffuse problem situation at the beginning of the year, for which no direct solution was yet apparent, was not only transparently presented, but also largely resolved. From the point of view of the hospital management, the changed working atmosphere, which is characterized by appreciation and professionalism, shows that the measures and changes have contributed to a sustainable improvement. As a result, not only has the number of resignations fallen, but new specialists have even been recruited. “A start has been made, we have achieved a lot this year, especially in the personnel situation. However, we are not yet at the end of the optimization process, but we want to continue to strongly involve the employees in the further processes in any case,” says Management Board member Maximilian Mai.
The many process optimizations that have been implemented on the basis of transparent data have also resulted in significant efficiency gains. This has led to a reduction in the need for operating theater capacity and nursing staff despite a slight increase in the number of cases. The construction of additional operating rooms, which seemed inevitable before the start of the consultancy mandate, was thus averted. The funds freed up can be used for other important projects, such as the expansion of the digital infrastructure or for the renovation of the OR induction area.