Organic growth of total joint replacement volume is growing at 3-4% per year as the number of physicians entering orthopedic residency programs is in decline. Cuts in Medicare reimbursement for total joints is forecast every year producing stressors for the surgeon to perform more surgery just to tread water financially. Increasing surgical volume without increasing time in the day requires a team approach to process improvements. By taking a fresh look at operating room processes, it’s possible to accomplish this goal. Discussion points include: • Pre-op patient preparedness • Resolving inherent conflicts • Surgical case order • Tracking case efficiency • Surgical tray streamlining About the Speaker: Sandy Nettrour has specialized in orthopedics for 30 years. She is the Neurosurgery and Orthopedic Service Line Coordinator for Butler Health System, providing oversight of the business aspects of Neurosurgery and Orthopedics, while continuing to first assist in the operating room and provide patient care at the bedside. Sandy graduated from Alderson Broaddus College in 1980 with a Physician Assistant degree. She has been awarded the Distinguished Fellow Recognition by the American Academy of Physician Assistants, the Hu C. Myers Award for lifetime professional achievement and community service, and the Pennsylvania Society of Physician Assistants Humanitarian of the Year 2013. She was a Round Table Participant in Orthopedics Today June 2012′s “Effective and Efficient Joint Replacement Programs Need Constant Review and Renewal of Processes.”

1. ThePatientJourney
A Guided CarePath helps automate patient preparation and follow-up
activities through the entire journey of a total joint replacement.

3. Total Joint Replacement
Improving Day of Surgery Efficiency and Throughput
Sandy Nettrour, PA-C

4. Let’s get acquainted

5. Did you know?
On average, hospital surgical suites waste over 30% of their capacity due to
inefficient processes.
The average costs in the peri-operative services are 20% higher than they
should be due to poor utilization of staff, equipment and supplies
CMS has reduced total joint surgeon’s professional fees by 36% since 1991
Total knee replacement surgery is projected to triple over the next 15 years,
while the number of total joint surgeons is in decline

6. Why is the surgeon grumpy?
The average surgeon only spends
60% of their time performing
surgery while in the OR
On average, only 70% of first
surgical cases start on time
#1 surgeon complaint:
Lack of a collaborative surgical
environment

7. Universal Issues
Inherent Conflicts
Patient Preparedness
Surgical Start Time
Case Efficiency
Turn Over Time
One Room or Two Rooms?

8.  Inherent Conflicts- The Hospital Salute
• Pre-op Staff
• OR Team
• Anesthesia Team
• Surgeon
• Central Sterile
• Housekeeping
• Post-op Staff
• Product Rep
• Administration
Each person has the power to de-rail the day

9. Resolving Conflicts-Create an Operations Team
• All team members sit at the same table
• Each team member’s opinion is valuable
• Goals must be defined and understood
• Champions are empowered to institute
changes
• Accountability is clear

10.  Patient Preparedness
• Patients with many questions slow the
process.
• Assure that the patient is well
informed and knows what to expect
• Everybody sings the same song
• Don’t do anything on the day of
surgery that you can do ahead of time.

11.  Surgical Start Time
• You will NEVER make up lost time
• How is surgical start time defined?
• Does everyone agree?
• Paralysis by analysis
• Capitalize on your data
On time start decreases end of day
overtime costs, case length, and need
to use staff with a different skill set

12. Surgical Start Time
Pre-Op and Anesthesia drive the day’s success
Anesthesia needs to contribute to case order

13. Case Order can make or break the day

14.  Case Efficiency
Teams should know their numbers
Track case efficiency:
• On time start accuracy
• In room to incision
• Turn over times
• Average case times
• Case volumes
• Block utilization
Hard data tells the story:
• Finger pointing doesn’t work
• Each OR team member must
own their contribution
• Where are the roadblocks?
• Who needs help?

15. Turn Over Time
Don’t make a mess
Start clean up during closure
Key team members take
breaks during closure
Enlist help
Allow tandem work

16. Streamline your trays
Before SPD collaboration After SPD collaboration

17. SPD cost savings= $105,000 annually
• Average cost to process a tray: $35.00
• 60% of the costs are related to labor
• Sample model
• 500 total joint replacement cases per year
• Reduction from 10 trays to 4 trays
Time and Efficiency = More cases

18. Post-op and Floor Staff-
play a part in OR efficiency
• Use only one order set
• Consistent block duration to
decrease stay in PACU
• Beds sent from the floor
• Ice packs sent to the floor
• Consistent floor discharge time
(11:00am) to prevent backups
in PACU

19.  To Swing or Not to Swing?
Established criteria for swing rooms:
Surgeon has to increase 10% within
first year
75% utilization of their current block
Partner or first assist available to
close case
Patient safety not compromised
Top 50% of their service line
(volume)

20. Typical OR Day- One Surgeon, One Room
Start time Case Turn Over time
0724 Knee Arthroscopy 14 min
0805 Knee Arthroscopy 11 min
0906 Total Hip 24 min
1100 Total Knee 21 min
1305 Total Knee Day end: 14:45

21. Typical O.R. Day- One Surgeon, Two Rooms
Room 1
• 7:30: Knee scope
• 8:50: TKA
• 11:00: TKA
• 1:15: TKA
Room 2
• 7:45: TKA
• 9:55: TKA
• 12:10: TKA
• 2:20: Hip fracture
Done at 2:50
Total Count for Day: 1 Knee scope, 6 Primaries, 1 Hip fracture

22. Swing Room Model
TIME 6:00 6:30 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00
PRE-OP Prep/Block 1 Prep/Block 2 Prep/Block 3 Prep/Block 4 Prep/Block 5 Prep/Block 6 Prep/Block 7
ANESTHESIA Anesthesia 1 Anesthesia 2 Anesthesia 3 Anesthesia 4 Anesthesia 5 Anesthesia 6 Anesthesia 7
SURGEON
Marks, Completes
Rounds Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7
family
1
family
2
family
3
family
4
family
5
family
6 Postops
OR STAFF Open Case 1 Open Case 2 Open 3 Open 4 Open 5 Open 6 Open 7
Every team member knows their role and proceeds without prompting

23. Team Building
• Each person can be the problem or
part of the solution
• Every person has a contribution
• Each contribution has value
• Use a carrot instead of a stick-
Incentivize your staff
Delayed surgeon

24. Team Building-What works?
Are you kidding?!?
• Milkshake races
• Song games
• Pizza for Central Sterile, O.R.
• Mop stealing
• Floor Staff (every shift)
• Muzzy Monday- Cookies
• Tropical Tuesday- Fresh fruit
• Wacky Wednesday- Candy
• Thirsty Thursday- Soft drinks
• Souper Friday- Soup/rolls

25. In Conclusion
• O.R. efficiency is a collaboration
• Empower team members to find
solutions- recognize their efforts
• Break down barriers by leveling the
playing field
• Find a way to work smarter not
harder
• Everyone wants to do a good job
and be appreciated

26. THANK YOU
Chautauqua Lake, New York