Increasing the percentage of first case on-time starts in the labour and delivery operating room

Problem description

Operating room (OR) efficiency is a cornerstone of healthcare delivery, affecting patient care, resource utilisation and healthcare costs. Delays in first case on-time starts (FCOTS) lead to interruptions in patient care, dissatisfaction among patients and staff, and increased facility costs.1 2 Operating an OR incurs an average cost of 62 dollars per hour, which can result in significant healthcare expenses if the OR is not used efficiently.3 Furthermore, each delay has a downstream effect on subsequent procedures for the remainder of the day. Patient safety is jeopardised by surgical start delays, which may lead to an increased risk of surgical site infections due to extended preoperative waiting times, longer fasting periods that impact patient comfort and recovery, and the possibility of rushed procedures later in the day.3 4 FCOTS, therefore, not only serves as a key measure of OR efficiency but also as an important quality metric tracked in most hospital systems.

Available knowledge

There have been studies addressing OR efficiency in general adult and paediatric ORs that have led to significant improvements.5–8 Factors that contribute to on-time case starts include preoperative preparedness, standardised workflows and protocols, effective communication, real-time monitoring and ongoing quality improvement initiatives. In a community-based hospital, surgeon practices and preoperative processes were found to be the main factors contributing to OR inefficiency.9 To date, there have been no studies focusing specifically on improving on-time case starts in labour and delivery (L&D) units. L&D poses additional challenges to on-time starts due to its unpredictable nature. In addition to add-on emergent caesarean deliveries, patients can arrive at any time with limited or no prenatal care and with a wide range of medical issues. More research needs to be conducted on improving the efficiency of L&D units. Given its unique characteristics, studying OR efficiency specifically in L&D becomes essential.

Rationale

The model for improvement suggests that the insights and ideas of staff members involved in the process can foster shared learning within the team and system, leading to innovative solutions. To support this concept within the framework, a survey was created to assess team member satisfaction, along with barriers to timely case starts and failure modes and effects analysis (FMEA). Brainstorming sessions were conducted with stakeholders from quality, obstetrics, anaesthesiology, nursing, OR techs, scheduling and housekeeping to cultivate a shared understanding of the current state process. The root causes of gaps that contribute to OR case delays were identified and used to develop tests of change (figure 1).

Specific aims

This quality improvement project aims to identify the barriers to timely case starts in L&D ORs and develop interventions to minimise case delays. Our primary outcome measure is the percentage of first cases that begin at the scheduled start time. We aim to increase the rate of FCOTS from 12% to 75% by November 2023 and reduce the average number of case delays per month by 50% from a baseline of 178 min (about 3 hours).

Context

Jackson Memorial Hospital is a non-profit organisation, the only public tertiary hospital in Miami-Dade County and the largest teaching hospital in the nation, catering to a high-risk obstetrical population in downtown Miami. The hospital manages an average of 4600 deliveries each year, along with over 1500 surgical procedures performed in the L&D unit. This unit includes 20 rooms designated for labour, delivery and recovery (LDR). An obstetric team, consisting of an attending physician and two resident physicians, is always assigned to staff the OR for scheduled cases, accompanied by a dedicated anaesthesiology team made up of attending and resident physicians; additional obstetricians and anaesthesiologists are also assigned to L&D and remain available for unscheduled surgical cases. This study was conducted as a Quality Improvement Initiative, and the following report was developed in line with the Standards for Quality Improvement Reporting Excellence 2.0 Guidelines10 .

Project team

In November 2022, a quality improvement project aimed at enhancing FCOTS in the L&D OR was initiated by a multidisciplinary team made up of representatives from obstetrics, anaesthesiology, nursing, hospital leadership and quality improvement. The team used the Institute for Healthcare Improvement (IHI) model to establish initial consensus on the project’s objectives, methods for determining whether a change constitutes an improvement and the tests of change we would carry out to enhance our outcome measures.

Patient involvement

The project’s inception was based on patient feedback about case delays. This was obtained from patient discharge surveys and patient experience rounds. Though patients and families were not involved in setting the research, outcome measures, or designing and implementing the interventions, their feedback throughout the study was incorporated into our interventions. Given the nature of quality improvement, real-time Plan-Do-Study-Act (PDSA) cycles rely on the success of tests of change. Therefore, any patient feedback regarding case delays from patient experience rounds and team members during post-case debriefs was relayed back to the project team and discussed at weekly meetings.

Measures

Our primary aim was to increase our percentage of on-time first cases in the L&D ORs from 12% to 75% within 1 year of project initiation. The operational definition of an on-time first case start was any situation where the patient was in the OR at or before the scheduled time. Our process measures included the percentage of first cases that began within fifteen minutes of the scheduled start time and the average delay in minutes. Our population encompassed all maternal patients scheduled for an operative procedure in the L&D OR, including caesarean deliveries, cerclage placements and postpartum tubal ligations. We did not include emergency or unplanned procedures, as they are inherently not scheduled cases. The primary outcome measure consisted of all scheduled L&D procedures from Monday to Friday at either 08:00 or 08:45. The FCOTS rate and average delay in minutes were calculated each month during the study period. Ongoing meetings were held with the project team, and interventions were implemented throughout the study based on the results of previous interventions.

Preintervention state

A thorough analysis of the preoperative process revealed significant variability. Before the procedure, patients were scheduled, preoperative labs were drawn and instructions were provided. On the day of the procedure, patients would arrive at the hospital and get registered. They were then taken to the preoperative area, where the nursing staff prepared them for the OR. Appropriate team members completed preoperative documentation and consent. The nursing staff followed a pre-procedure checklist. Once completed, OR staff were notified via an overhead speaker system, and nursing and anaesthesia staff wheeled the patient into the OR.

The patient scheduling prioritisation process required more formalisation; reliance on a single individual led to same-day changes in the order of scheduled cases. Additionally, there needed to be a better shared understanding between the healthcare team and patients regarding the meaning of nothing by mouth or nil per os (NPO), which resulted in patients arriving without being properly fasted.

Preoperative laboratory orders depended on real-time obstetric (OB) physician approval, which delayed completion during high patient volumes. The team routinely awaited each patient’s type and screen (T&S) results, although most were identified as low-haemorrhage risk and did not require a blood transfusion within 60 min of the case start. Despite OR availability, optimal staffing and staffing structure needed to be more consistent, creating a barrier to having two ORs open simultaneously.

We also found a significant communication breakdown between team members.

Based on the contributors to delays, five key drivers were identified (figure 2):

1. Standardised case scheduling and preoperative practices.

2. Inter- and intra-disciplinary shared mental model on case prioritisation.

3. Timely, efficient and appropriate use of diagnostic and blood orders.

4. Patient and family engagement in pre-op preparation.

5. Closed-loop communication with OR team on performance metrics.

Interventions

Based on the key drivers, we implemented the following interventions and tested them using the IHI Model for Improvement’s rapid PDSA cycles.

1. Communication: after the initial project team meetings in October 2022, results from the staff survey, outcome and process measures, and patient experience scores were communicated at OB safety huddles, staff meetings, and to executive sponsors to secure buy-in for the proposed interventions. In May 2023, initial results, planned interventions and findings from the team’s FMEA were presented at the health system’s Performance Improvement Continuous Improvement meeting and OB-GYN Grand Rounds. Feedback from team members informed modifications to the scheduling form and the process measures, which prompted discussions on current blood ordering practices and suggested changes. For example, while achieving 75% of FCOTS was challenging, one obstetrician proposed adding process measures to monitor decreases in case delays or the percentage of cases arriving within 15 min during the project period as secondary improvement measures.

2. Scheduling prioritisation guidelines (online supplemental materials): in February 2023, a working group of schedulers, obstetricians and anaesthesiologists redesigned the OR and L&D induction scheduling form, incorporating new criteria based on diagnoses and gestational age for patient prioritisation as a scheduled first case in line with clinical practice guidelines. In April 2023, the updated scheduling form was launched and distributed to both internal and external obstetrics stakeholders. The scheduling form had not been revised in years and was redesigned for electronic submission instead of fax. However, following the rollout of the new version, initial feedback revealed challenges users encountered when attempting to complete specific sections of the form.

3. Modified T&S process for low-haemorrhage risk patients: in May 2023, the team modified the guidance and practice of waiting to wheel patients into the OR until T&S results were available. This modification allowed patients with a low haemorrhage risk score to proceed to the OR for their scheduled case without having the results first.

4. Preoperative patient preparation:

   1. Evidence-based NPO pre-op instructions: in December 2022, the project team, in collaboration with the health system’s marketing department, developed an evidence-based infographic providing preoperative instructions (online supplemental material). This infographic was designed to be shared with team members and patients visiting the clinic, serving as a guide for communicating preoperatively. Obstetricians presented the infographic to patients during their OB visits to ensure patient comprehension, and it was available in English, Spanish and Haitian Kreyol. The project team reviewed several iterations of the infographic for flow, readability and fluency in Spanish and Kreyol, considering the high percentage of patients who predominantly speak these languages. The infographic received positive feedback from staff and members across the health system and was adapted for use in community hospitals within the system.

   2. Preoperative preparation calls: in December 2023, L&D staff were tasked with completing preoperative preparation calls the day before the patient’s procedure to confirm their arrival time. Collaborating with a student nurse anaesthetist, the preoperative instructions were shared via email and text prior to the patient’s scheduled procedure day. This intervention aimed to decrease the frequency of delays caused by insufficient patient preoperative preparation. Although the team tested automated text messaging to notify scheduled patients using the text from the infographic, the decline in the rate of FCOTS immediately following this test led the team to discontinue it, as it confused the arrival time for patients who were not scheduled as the first cases.

5. Optimise OR staffing and structure: the most effective intervention tested was implemented in August 2023, during which the OR staffing was adjusted to enhance patient flow between the LDRs and the OR, while ensuring adequate OR staffing and alleviating team members as needed. An associate nurse manager was designated to oversee this patient flow, lead debriefs after each first case and resolve any barriers preventing patients from being transferred to the OR, such as missing preoperative labs, absent documentation signatures, OR case staffing and others. A one-page preoperative preparation standard with space for documenting findings from the postoperative debrief tool was created and used to gather information during the PDSAs (online supplemental material).

Analysis

By using the hospital system’s operational definition for FCOTS, we established a common understanding between the project team and stakeholders within the obstetrics team regarding which cases were deemed on time. We monitored this rate on a statistical process control chart that calculates the percentage of on-time first cases out of the total first cases each month. Applying Montgomery control chart rules, the team observed the number of points that met the criteria for process instability, defined as either 1 point above the upper control limit, 8 points above the centreline or multiple points exceeding 1 or 2 SD above the centreline11. The team concurred that trends in outcome measures aligning with these rules after testing iterative PDSA cycles would suggest that the intervention contributed to system and process improvement and could be implemented for sustained use12 .

Interventions for testing via rapid PDSA cycles, as designed in the IHI framework, were identified based on root causes identified in the FMEA brainstorming sessions and survey suggestions. The team used the 5-whys methodology to drill down to the root causes. It consolidated similar root causes across common key drivers of change, such as standardisations in scheduling, case prioritisation, timeliness and appropriate resource use, communication, information transparency, and patient and family engagement in preoperative preparation (figure 2).

Outcome measure

Our team reached the target of 75% on-time starts by the projected goal date (November 2023). Since the project’s inception, there have not been any months with a 0% first-case on-time start rate. A 41% increase in the average percentage of on-time first cases from baseline (12%) to postintervention (53%) was observed and sustained for 4 months (figure 3).

Process measures

A 69% decrease in the average case delay (from 178 min to 55 min) was observed 6 months after the project began (figure 4). Additionally, the percentage of cases that commenced within 15 min of the scheduled start time increased by 47%, rising from a baseline rate of 20% to a post-intervention rate of 67% (figure 5).

Patient, provider and systems-level contributors to the delays were identified. Patient-level factors included the necessity for patients to arrive on time, complete the appropriate bloodwork before surgery and be adequately fasted for surgery. Provider-level factors involved the need for more staff due to caring for another patient and changes in the order of scheduled cases on the day of surgery. Systems-level factors included a lack of a clean, available OR and issues with the laboratory order set. Interventions related to structure, process, team member involvement and patient engagement were identified. Changes implemented throughout the study period included standardising patient scheduling, patient instructions, the order process for pre-op testing and improving access to a backup OR for unscheduled ‘crash’ caesarean deliveries. Given the improvements in operational efficiency, the backup OR was not used during the study period. Regarding pre-op testing, the original plan was to develop an order set that the pre-op clinic could use without OB physician sign-off. Sponsorship from the pre-op clinic leadership was secured; however, on reviewing the current process, a simple modification that the OB physician could make in their workflow led to this intervention being abandoned.

Summary and interpretation

A multidisciplinary team identified several barriers to on-time case starts within L&D ORs. By applying quality improvement methodology, we exceeded our goal of achieving 75% of first cases starting on time at our safety net hospital. This is the first report on a successful quality improvement initiative aimed at enhancing FCOTS, specifically within L&D. Similar to previous studies, various barriers to on-time case starts were identified. Interventions at the patient, provider and systems levels were recognised and implemented, leading to improvements in FCOTS. The most impactful change was assigning a nurse manager to oversee OR scheduling optimisation and guide staffing. This key process change significantly improved our primary outcome.

The strengths of this study were the significant improvements observed during a 1-year evaluation in a busy tertiary care centre serving a high-risk obstetrical population. This can be attributed to the formation of a multidisciplinary team that included representatives from obstetrics, anaesthesia, nursing, quality improvement and the OR staff. Our ongoing commitment to reassessing delays through standardised work and a debriefing tool enabled us to respond swiftly to system deficiencies and identify immediate tests for change. Involving a diverse range of staff in the planning process and communicating progress has promoted a commitment to continually implement changes aimed at the initiative’s success. Most importantly, the project team and other stakeholders recognised the importance of continuous improvement and post-event debriefing, as well as the value of standardising OR throughput for this population and setting, which led to system-level alterations in staffing assignments and structure.

Limitations

This study has inherent limitations. Our patient population comprises many individuals with publicly funded insurance and limited resources, which impact patient-related factors that contribute to timely case starts, such as lack of access to private transportation and challenges with childcare arrangements. At the beginning of this project, we faced difficulties in securing executive sponsorship for additional financial resources, therefore, our key drivers and initiatives had to be developed without access to additional capital. Furthermore, a significant number of the surgeons operate as hospitalists, juggling multiple responsibilities while covering the OB service, with very few private physicians available, which may influence physician-related contributions to FCOTS.

We acknowledge the significant decline in FCOTS, despite achieving the goal of 75% during our study period in December. As previous studies have shown, debriefing tools enhance team communication and efficiency13 . We applied this approach in our study by implementing a post-case debriefing tool, which OR members completed and the project team used during weekly discussions about areas of the process that were functioning well or improving, as well as identifying gaps that continued to create bottlenecks in patient flow. This tool enabled the project team to recognise changes in staffing over the holiday period that likely contributed to the shift in rates. Engagement with OR staff and ongoing development of a shared understanding of the process and the value of optimised patient throughput are critical factors in maintaining optimal FCOTS.