Friday, November 21, 2014

Synchronizing to Start the Day on Time

Imagine if only 30 percent of BWI’s first flights of the day took off on time.  Commercial aviation is a large complex system. If 70% of flights from Baltimore arrived at their destinations late, it wouldn’t be long before the whole country was getting behind. Imagine how many upset travelers there would be. Imagine, also, the pressure on the air traffic controllers as they had to delay other flights to allow late flights to land.

We know that the hospital is also one large, complex system. If the operating room is sending cases out late, the PACU (Post Anesthesia Care Unit) will be delayed and cases will arrive to their inpatient beds (or outpatients to their homes) behind schedule. The downstream staff will be overwhelmed and people will have to stay longer than anticipated. The hospital will have to pay overtime to many or ask more staff to come in to handle the load. Subsequent operating room cases will start and end after their scheduled timeslots and some patients who have been fasting since the previous midnight will need to fast longer. No one is happy. 

It is not easy to make sure that everything is ready to go on time in all operating rooms in a surgical suite. Team members can arrive late, the patients can arrive late, there can be missing lab work that is required to assure that the surgery can be done safely, or the patient may be nervous and want to ask a few more last minute questions. But studying the reasons why cases are late and using problem solving to test changes will result in more on-time first cases. This is just what our Sherwood Outpatient Surgery Center Team has done under the leadership of its medical director, Dr. Aaron Wood, and its Clinical Unit Coordinators,  Holly Clevenger, RN and Kate Devan, RN3 BSN, CAPA.  This team selected first case on-time starts as one of their Least Waste metrics for Lean Daily Management and they have tested many changes and made great progress. You see from the run chart below that in March they had over 70% late first case starts and that number is now down to 34%. They have reduced the defect rate by more than 50% !

Team members understand that cases start late most frequently because of the system for getting ready, so they continue to study their system and ask the “why” questions when one does not start on time. I am so proud of them and I am very grateful for all of their hard work.

Congratulations to our Chairman of Radiation Oncology, Robert K. Brookland, M.D., who earlier this week was honored with the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control by the Maryland State Council on Cancer Control.  For those who don’t know, this award is given annually to a Marylander who has contributed to reducing the incidence, morbidity and mortality of cancer through research focused on cancer control. Dr. Brookland is a great leader at GBMC and we are proud of him for earning this prestigious honor. Please congratulate him the next time you see him!

While on the topic of significant recognitions,
I am so pleased to announce that our hospital was named Top Performer on Key Quality Measures® for 2013 by The Joint Commission, the leading accreditor of health care organizations in America. 

This is a big deal because less than one-third of U.S. hospitals earn this distinction. According to The Joint Commission, we were chosen for “our commitment to assuring that evidence-based intentions are delivered in the right way at the right time – because it’s the right thing to do for your patients.” I want to thank the following individuals and teams for helping us attain this major achievement:  Carolyn Candiello, Vice President of Quality and Patient Safety, the executive sponsor for the Core Measure reporting, Michele Cave, BSN, RN (Director of Clinical Quality Outcomes), Laura Hines, RN, Sara Helman, RN, and Laura Wieber.

The following nurse leaders also contributed: Lindsey Cromwell-Rims, RN (Nurse Manager of IR and the Kroh Center), Stephanie Topscher, RN (Clinical Director ED/UC), Charlene Mahoney, RN (Nurse Manager PACU), along with physician champions: Jeff Sternlicht, MD (Chairman, ED), Reed Riley, MD (Chief of Cardiology), Jack Flowers, MD (Chairman, Surgery), and all of our outstanding physicians, nurses and other clinicians.  Thank you for all you do for our patients.

I am truly proud of this recognition as it clearly demonstrates that we are moving toward our vision of treating everyone the way we want our own loved ones treated.  We are pleased that the Joint Commission has recognized us as one of their “top performers” on key quality measures. 


  1. I work in labor and delivery where we also are monitoring first two OR case start times. If the first cases start late it pushes the schedule back the whole day. However, both in airlines and in the OR if things are rushed peoples lives may be in danger.Something important to remember is patient safety comes first and if the nurse needs 5 or 10 more minutes to better prepare the patient this must be taken no matter how late it is running. Rushing is never appropriate in a scheduled case. Each patient deserves the same care no matter how late they show up, the nurses arrive or the doctors.

    1. Thanks, Anonymous.

      I agree with you, absolutely. This is not about "rushing" to be ready at all. It is about planning to make the routine things ready to go. Patient safety always comes first. We always want a calm review....the pre-op checklist ......done before every case. Any team member should be able to stop the line and not have a case start if there is any concern that the team is not ready. You also realize that not fixing broken systems or allowing team members to always come late is also putting patients at risk. Thanks very much for your comment.

  2. As an Operating Room nurse, I understand the importance of on-time starts. As mentioned, it does impact the entire day and the entire system. However, I think that with our emphasis on the on-time start, we have lost our focus on the patient and on our ability to work as a team. It feels like we must have an on-time start, no matter how we get there. We aren't able to talk to patients and truly individualize their care. Surgeons and anesthesia providers rush in to see the patient, saying "I don't want to be blamed for the late." Pre-op staff rushes to get the patient ready, and are often interrupted by the doctors and other staff members trying to interview the patient. The admission process therefore is disjointed and takes a lot longer. Patients notice, and I have had quite a few patients comment on this lately. One patient the other day actually apologized for having to empty her bladder before her surgery, and asked if we were going to have to rush through her case because we were running a few minutes late. I reassured her, encouraged her to not feel rushed in the restroom, and gave extra special care to making her feel like we were prioritizing her safety and not the on-time start. Starting on time is important, but not as important as patient safety.

    1. Thanks, Anonymous. I wholeheartedly agree. You need to bring your concerns up with your leaders. We are not trying to "rush through broken systems." Using your example of the patient who wants to go to the bathroom one last time as an example, why not build that into the design? If the synchronized time for the patient to be in the OR is 7:30, why not build in that every patient is escorted to the bathroom at 7:20 on the way to the OR? The team needs to be designing this. If it is nothing more than rushing through systems that don't work....someone will get hurt. Being late every day because our systems are not well designed or because we are tolerating systematic lateness is not the answer.


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