OR Efficiency is a Team Sport: Using Daily Huddles to Improve Quality
David Young, MD, managing partner of Surgical Directions and medical director of pre-surgical testing at Advocate Lutheran General Hospital in Chicago, Nell Panten, DNP(c), MSN, RN, CNOR, NEA-BC, chief nurse executive of Surgical Directions and Cindy Mahal-van Brenk, RN, MS, CNOR, director of operations of surgical and GI services at Advocate Lutheran General Hospital, explain the inner workings of a successful daily huddle.
What are daily huddles?At Advocate Lutheran General Hospital, a "HUDDLE" stands for Healthcare United for Daily Decisions through Leadership Enthusiasm. The huddle includes a group of OR stakeholders who meet every day at 2 p.m. for about 35 minutes to discuss 40 to 60 cases scheduled for the following day. The goal is to review any problems from the current day and prevent them from occurring in the future and to actively manage the surgical schedule for the next day. "We're trying to use collective intelligence to plan the next day and prevent any delays, cancellations or problems in a proactive way," Dr. Young says.
What is the agenda?The huddle starts by recapping the day's problems, determining their root causes and planning to prevent the problems from recurring. Then, the team reviews all of the next day's cases. At Advocate Lutheran General, this is done by projecting the schedule for everyone to see and going through each case separately. Usually the scheduler calls out the case, after which the preanesthesia testing nurse provides the patient's clinical history. The team discusses patients who will need a pain block and those who may need special management, such as patients who have had previous pain issues and diabetic patients.
The team also identifies inefficiencies in the schedule, such as a case that is scheduled for too much or not enough time, and rearranges the schedule to avoid delays and cancellations. In addition, the huddle discusses patients who may have antibiotic problems due to multiple allergies.
Who participates?The huddle should include a multi-disciplinary team of representatives from different stages of the surgical process — from schedulers to materials management to anesthesiologists. Including people from each area of the OR drives accountability, as each person plays an important role in creating an efficient process. For the huddle to be successful everyone needs to be committed to the group; they need to arrive on time each day and understand the expectations. "You have to identify people who believe in proactive management of problems and are willing to put in the time to make it right," Dr. Young says. In addition, the huddle should consist of the same people to create consistency and allow the group members to form a cohesive unit, according to Ms. Panten.
A critical aspect of the huddle is that decisions are made collaboratively. "Everyone is working in a cohesive manner to do what's best for the patient," Ms. Panten says. While nursing management and the anesthesiologist typically lead the group, everyone is expected to contribute. "We believe in a just culture where everybody has a voice. That's why we involve all the different areas and feel that's really key. Everybody has an opportunity to speak," Ms. Mahal-van Brenk says.
The following areas should be represented in the huddle:
1. Nurse liaison navigator. The liaison reviews problems that occurred that day to determine the root causes and prevent them from recurring.
2. Scheduling. This person is responsible for knowing the next day's schedule. The scheduling representative will also need to contact surgeons to change the schedule when needed. At Advocate Lutheran General, the scheduling representative calls out each case of the next day to start the patient verification process as the huddle reviews each one.
This allows the huddle to change the schedule the day before the surgery to improve efficiency. Calling the patient the evening before surgery also enables the scheduler to confirm the patient will arrive.
3. Preanesthesia testing. This person should know all the patients scheduled for the next day, as he or she provides the patients' clinical history and notes any potential problems from a clinical standpoint. At Advocate Lutheran General, the PAT nurse provides the history after the scheduler announces the case and also confirms the correct procedure is scheduled.
4. Anesthesia. The anesthesiologist is responsible for identifying patients with histories of adverse reactions and developing plans to manage these patients. The anesthesia representative should also help arrange the schedule to best manage patients with co-morbid diseases.
5. Presurgery. This person is responsible for communicating with staff to alert them of anticipated problems related to the following day's cases. For example, Advocate Lutheran General Hospital identifies all diabetic patients scheduled for the next day. The presurgery representative needs to ensure these patients have their weight, vital signs, and blood sugar tested when they come in so the team can begin managing their blood sugar as soon as possible.
6. Materials management/sterile processing. This person is responsible for contacting the appropriate vendors when a device is needed for the next day's case and for ensuring the correct trays of materials are in sterile processing to be prepared for the next day. For example, if a total hip case is scheduled for the next day, the materials management representative would verify the implant trays have arrived.
Dr. Young says, "It is essential to include materials management and sterile processing in the huddle to communicate the importance of this role in the surgical process. If the correct materials are not prepared for each case, there can be delays, which decrease surgeon and patient satisfaction and create inefficiencies."
7. Surgical leadership. The surgeon, who may participate by phone, is alerted to changes in the next day's schedule. Surgeons need to be aware of any schedule changes so they arrive on time for each case. The process is also audited by the executive director on a weekly basis to make sure that they have the tools they need to be successful and to remove recurring barriers.
How can daily huddles drive efficiency?Dr. Young provides several examples of ways daily huddles can prevent delays and streamline processes.
A patient scheduled for the next day has been on chronic pain medication and may have issues related to post-operative pain management. The presurgery representative in the daily huddle would notify the anesthesiologist caring for that patient. The anesthesiologist would then develop a pain plan that may include a regional block, according to Dr. Young. The huddle participants would also notify the advanced practice nurse in pain about the patient so he or she could plan to visit the patient in recovery and ensure the patient has an appropriate pain management plan. The huddle thus avoids a delay that may occur if the anesthesiologist does not find out about the patient's pain history until the day of surgery. In addition, the huddle puts in motion processes to ensure the patient's safety.
A patient scheduled for the first case the next day has been on Coumadin and may need an international normalized ratio test the morning of surgery. The huddle may re- shuffle the schedule so this patient's procedure is performed later in the day — the third case, for example, to avoid a first-case delay if the INR is abnormal.
A patient scheduled for the first case the next day is identified as having unreliable transportation to the OR. The huddle may move this case later in the day to prevent a first-case delay or cancellation.
A patient scheduled for the afternoon the next day is diabetic. The huddle may want to move this patient earlier in the day to reduce the time clinicians need to manage the patient's blood sugar. Scheduling a diabetic patient for the morning reduces the chance of changes in blood sugar before surgery, which improves patient safety.
Conducting daily huddles in the OR creates a collaborative working relationship between OR team members so they can effectively prepare for the next day's surgical cases. Taking the time beforehand to identify potential delays and patient safety issues can decrease costs and improve efficiency, safety and satisfaction.
The huddle "smoothes" the daily operating schedule to decrease first-case start delays and decreases cancellations on the morning of surgery. This in turn leads to increased profitability for the institution by not having an OR sit empty for greater than 30 minutes or having a three to four hour case that has been cancelled with no case to shift into that OR.
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