Clinics can reap benefits from forming high-performance operating room teams

Keeping a team’s processes consistent, efficient can lead to better surgical outcomes.

As a long-time fan of the Indianapolis 500, I recently had the opportunity to watch Helio Castroneves and the Penske team capture yet another victory.

While the secret to their success is likely multifactorial, I was struck by how well they work together as a team. They have an obsession with error reduction, and the smallest details of their pit stops are compulsively rehearsed. The team members, their roles and the processes are all standardized.

In contrast, many operations performed at hospitals are characterized by variable people performing variable roles in variable procedures. It is not surprising that this model results in poor productivity and more errors.

For many years, we have had a collaborative program with our hospital that is designed to reduce the variability of total hip and knee replacement, improve the efficiency of the procedures and improve the quality of the outcomes. It has been highly successful.

The concept of reducing variability of processes as a strategy to improve quality and productivity is not new. In fact, most high-volume manufacturing processes utilize elements of these concepts, and many have proven to be enormously successful. Nonetheless, few clinics have adopted these concepts into patient care and hospital processes.

Anthony M. DiGioia

High-volume surgical procedures such as total hip and knee replacement are particularly well-suited to standardization. One critical aspect of standardizing the processes is to develop teams with expertise in these procedures.

A common mistake at many hospitals is to use “pools” of employees, such as surgical technicians, who rotate among procedures and surgeons. We believe that this is a flawed concept for high-volume procedures and results in reduced efficiency, high error rates, increased waste, and stress among surgeons and the staff.

The Penske team would never consider having a pit crew member change the right front tire on one pit stop and pump the gas on the next. They know this reduces the skill set of the crew member and makes errors more likely. Yet, this staffing model is extremely common in hospitals.

Steady as she goes

We work with operating room teams that are highly skilled experts in the procedure. Typically, the assistants perform the same role on every case and the procedures are done in a standardized manner. As a result, the error rate is extremely low, the cases are performed quickly and the productivity of our rooms is very high.

Jeff Pierson

It is important to point out that the emphasis in these rooms is not on speed. We find a frenetic operating room to be stressful and undesirable. Speed in the operating room is a byproduct of standardization of the procedure, team skill development and anticipation of the next steps in the procedure. This model virtually eliminates the time in between the steps of the procedure, which results in brief procedures with high precision.

There are many barriers to developing high-performance operating room teams. There must be sufficient volume to justify developing these highly specialized teams. The surgeon must be willing to standardize the procedure, and anesthesia must be a cooperative partner in the process.

In our experience, when these elements are met, the outcome is one of the least stressful operating room environments that can be created, even though the amount of work performed is high. A stressful operating room is more often created when staff assist on cases in which they either have limited experience with the procedure, limited experience with the surgeon, or both.

At the surgeon level

Surgeons are frequently the source of inefficiency in the operating room. While we are all fascinated by new technology, procedures, instruments and surgical approaches, this often results in highly variable procedures with higher error rates and lower productivity.

It is unreasonable for a surgeon to expect the staff to anticipate his/her next step if he/she is “unanticipatable.” Surgeons should consider the benefits of standardization before deciding to make frequent changes in their selection of prostheses, surgical approaches and instruments. While there is considerable pressure for change from direct-to-consumer marketing, sales representatives and other sources, these changes can paradoxically reduce the quality of the procedure and outcome for the patient.

A superbly done total hip or knee replacement can be achieved using variable people and variable processes. However, to do this consistently requires a different approach – a highly standardized procedure with consistent and talented team members. In the words of Aristotle, “We are what we repeatedly do. Excellence then, is not a single act, but a habit.”

For more information:

• Jeff Pierson, MD, is an orthopedic surgeon with Joint Replacement Surgeons of Indiana and is the medical director at St. Vincent Orthopedic Center in Indianapolis. He can be reached at Joint Replacement Surgeons of Indiana, 8402 Harcourt Road, Suite 128, Indianapolis, IN 46260; e-mail: jpierson@JRSI.org.