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8 Steps to Achieve 7-10 Minute Turnover Times in an ASC

The following article is written by Anne Dean, RN, BSN, LRM, CEO and co-founder of The ADA Group.

An article was recently published regarding the possibility of turning operating rooms in ambulatory surgery centers in seven to 10 minutes. In this article, the author talked about the fact that turning the rooms inside this time frame is still a possibility. I was left struck with the idea that, yet again, we in the ambulatory surgery business somewhere took another detour.

I recently responded to a previous article, calling for surgery centers to consider moving toward a patient-centered environment. As someone who has been involved in the development of ambulatory surgery centers since 1979, I simply had to respond, because back in the "old days," this is what ASCs were all about. In reviewing the article about room turnover times, I was once again struck with the fact that back in the early days of ambulatory surgery, we pledged to turn all our operating rooms over in seven to 10 minutes — patient to patient.

What has happened to turnover times?
When the turnaround time historically exceeded 10 minutes, a QI study was immediately conducted to identify the problem and area for improvement. And yet, over the last 20 years, I have begun observing that these times are being extended. Some of the reasons put forth by ASC leaders for this extended time include the fact that more complex surgeries are being performed in the ASC setting. Another issue presented during a QA/PI studies is that our patients are more challenging. More and more centers are admitting ASA class III and more patients, who require a great deal more attention. Care of the morbidly obese has also become a big issue.

The question, arises, however, whether these are valid reasons for longer turnover times. Is it just that we need to better plan for these challenges? The second question that arises is that if the condition of those patients validate the longer room turnover times, then what is going on that causes room turnover times to increase? One could make an assertion that the industry, in its proliferation, has lost track of its roots — its initial commitments. Is it that more and more centers popping up means more and more hospital-trained nurses being put in leadership roles, with no distinction from the freestanding ambulatory surgery center culture?

As long ago as the early 90s, a study was done documenting room turnover times in hospitals. The turnover times were being measured from patient out to next patient in, and these times ranged from 41 minutes to 1.5 hours.

During this same study, it was observed that the average freestanding ASC was able to turn their rooms within the seven to 10 minute time frame. Outlier times were identified for procedures where excessive irrigation fluids were used, or in shoulder joint replacement surgeries. It was further documented that turnover times in hospital-owned ASCs were primarily in line with hospital turnover times.

In reviewing practices in 36 different ASCs, it has been noted that turnover times have been increasing exponentially with the exception of, universally, cataract surgery. However, even in multi-specialty centers, turnover times of 15 minutes have become acceptable. It was cataract surgery centers that perfected the ability to turn rooms in seven minutes, with patients commenting that they knew they were on a conveyor belt kind of schedule, but that the personalization of their care was such that had they not observed this, they would not have known.

It was further observed that turnover times in gastroenterological procedures were generally far better than in other specialties, but still exceeded the 10 minute goal.

1. Involve staff in the effort to reduce turnover times. So what happened? We have to first look at the commitments of the staff and physicians. Are they aware that with the turnover times being inside the declared goal of seven to 10 minutes, more procedures/cases could be performed and result in happier surgeons who will utilize the center more? Are they aware that greater utilization increases profitability and thus increases their chances of getting a raise or bonus at year's end? Are they aware that faster turnover times mean that patients get out of the center faster and aren't left with long waiting room times?

This makes for happier patients reporting back to their physicians. It is a "win-win" all the way around. The staff has to be on board with the possibility of faster room turnover times. You need to enroll them 100 percent! And this includes those physicians who like to hit the staff lounge to gossip or make calls, or who like to go to their office next door between patients. Educate them about coming back to the OR after they have visited the patient in recovery and seen the care person in attendance.

2. Assess the physical layout of the facility. It is impossible to experience rapid room turnovers without assessing the layout of your ORs and procedure rooms. Hospital operating rooms are typically equipped with large banks of storage cupboards, which are usually stuffed full of supplies. In the ambulatory surgery industry, it was quickly recognized that if the procedures were to be reimbursed on a 'flat fee' basis, rather than for every widget used, then it was imperative that supplies be strongly controlled. The basic materials management premise that supplies sitting on shelves have a powerful intrinsic cost becomes paramount in cost-containment practices.

3. Centralize supplies and limit inventory in ORs. Supplies were moved out of the ORs and were centrally located, such that turning them and reducing par levels could be easily controlled. All supplies for the center were treated in this manner, with the exception of those supplies only used in certain areas, such as peel packs for the sterile processing area. Thus, all inventories were conducted out of the bulk and sterile storage areas, excepting those specialized items stored in those specialized areas. This kept supply costs down significantly and reduced manpower hours in conducting weekly inventory and re-ordering of supplies.

Operating rooms were equipped with one supply cupboard and one case cupboard. The inventory for the supply cupboards was limited to only those items that were essential as back-up for items already pulled for that rooms' cases. These included two each of the various-sized, most commonly used gloves; one packages of sterile 2x2s, 4x4s, etc. Again, thought was put into what kind of cases were being performed in the center, what would be pulled from the two different store rooms to perform the procedure; and what else might be needed because a glove was punctured or ripped, a gown sleeve contaminated or additional sponge needed.

However, staff considered which eventualities would drive them to tap into the back-up supplies. They considered the most common eventualities, rather than those that would happen rarely. Staff thought about the emergency supplies that would most likely be found in anesthesia carts, as well as which surgical supplies — such as drains, hemorrhagic sponges, etc. — should be stored in limited numbers in the room. The supply cupboard was never supposed to provide everything needed to perform a case. Limits to the number of items stored there relied heavily on the concept that these were only "back-up" supplies. The inventory stored in this cupboard was listed on an inventory sheet kept in the cupboard.

The cupboard was restocked at the end of each operating day from the bulk or sterile storage areas. The restocking of the cupboard was identified on the duty list for each OR staff to complete each day. This list required a date, a "completion" checkmark and the initials of the staff member.

A second cupboard was dedicated as the case cupboard. In cataract surgery, GI and GU rooms, two case cupboards were installed to allow for the increased volume. Each cupboard contained six to seven shelves representing one shelf for each case scheduled for that room for that day.

4. Analyze every task performed in the room turnover process. In looking at what it would take to get turnover times to that magical seven to 10 minutes, staff members met in one of the ORs and looked at every task performed in turning a room. This included every task performed, including the anesthesia provider taking the patient to the PACU, delivering the soiled instruments to the soiled receiving area for processing, mopping the room and cleaning the OR bed.

AORN-recommended practices and the center's policies were reviewed and implemented for housekeeping and cleaning before cases.

5. Assign tasks to everyone — and don't make exceptions for leadership. Job functions were reviewed and assigned. Staff members identified and embraced which staff members were responsible for which tasks. Who was to grab the mop? The conversation eliminated any complaining about a task being "not my job." The OR supervisor and the executive director both pitched in with cleaning when needed, as did the physician. All kept the agreed-upon goal clearly in mind. Mopping was not done during non-invasive procedures. Surgical team areas were identified for mopping between invasive procedures.

It was agreed upon that at the end of the case, the RN would take the patient to the PACU with anesthesia, give the hand-off communication, visit the next patient scheduled for that room, then return to the OR to assist in the turnover. The organization employed a sterile processing technician to wash and process instruments. Any surgical technician not working a room was assigned to assist in the sterile processing and soiled receiving areas.

At the end of the procedure, the surgical technician removed the soiled instrumentation from the room to the soiled receiving area for processing, and returned to the room to begin the turnover process. When the page for turnover was heard, any available staff reported to that room. The staff lounge was reserved for assigned breaks and lunches. The organization also employed an orderly, receiving, housekeeping, maintenance person who helped turn rooms in this seven-OR facility. However, whoever was available either grabbed a mop or began wiping off flat surfaces and OR bed with the germicidal solution.

The OR was equipped with a soiled linen hamper, a biohazardous waste hamper, a general waste hamper and two kickbuckets — one for anesthesia and one for sponges. At the end of the case, these were emptied and disposed according to recommended practices and standards.

In identifying all the elements in turning a room, the staff noted the hamper liners, kick bucket liners and the linen needed for the OR bed, as routine.

6. Scrutinize physician preference cards. Physician procedure cards were scrutinized and updated as necessary. Staff met and agreed to follow these rigorously in pulling cases. It was decided all cases would be pulled the afternoon prior to the procedure. All supplies would be put on the shelves in the close cupboard designated as the case cupboard. Each shelf would be labeled (e.g. #1, #2, etc.). The cupboard shelves were equipped with a lip around the entire shelf and pulled out of the cupboard, allowing them to be used as a transporting tray.

The organization approached the local grocery store and was able to get — free of charge — grocery carts with those irritating wobbly wheels. These carts were cleaned up and the wheels were changed out, transfiguring them from grocery carts to supply carts. Staff used these to transport supplies from the bulk and sterile storage areas and to pick their cases.

Staff, following their procedure cards, pulled every item needed for each case, and placed those on the assigned shelf in the case cupboard.

7. Develop "room turnover packs." As part of the process for rapid room turnovers, the staff developed a system for "room turnover packs." These consisted of the OR table/bedsheet, the draw sheet, the kickbucket liners, and the various hamper liners. Staff were assigned daily to make these packs by gathering all the items and making rolls that were held in place with a strip of masking tape.

These were kept at the OR control desk. When pulling cases, the staff person would pull however many rolls were needed, based on the number of cases scheduled for that room the next day. One of the rolls was placed on each shelf with the supplies for the case.

Once the room was cleaned, the RN or other staff person — as agreed upon in their assignment meeting — would pull the roll, make the table/bed and place the liner in the appropriate spot. The surgical technician would pull the pack and place it on the back table and begin draping the instrument table and mayo stand. The RN circulator would begin assisting in the opening of sterile supplies and drop them onto the sterile field while the surgical technician scrubbed. The RN would then set up the prep table and leave the room to collect the patient with the anesthesia provider. Upon re-entering the room, the RN would finish gowning the tech and physician and turn to assist anesthesia in sedating the patient, as needed.

8. Hire an anesthesia technician. Many labor organizations are turning to developing and/or hiring an anesthesia technician. Certification for this person is available on the internet, but in-house training on the part of the anesthesia providers is acceptable. This person can be quite valuable in assisting in room turnovers, too. In the absence of an anesthesia technician, the anesthesia providers have to assume an assistive position in turning rooms. Include them in your training. In the absence of an AT, the medication management nurse should be assigned the job of keeping the anesthesia carts fully stocked.

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The system/process described above will absolutely allow you to turn rooms within the identified national standard of seven to 10 minutes. However, it is crucial to the process that each staff person remember that every time someone leaves a room to go and fetch something, manpower hours are used that translated to increased turnover times. Plan to review your turnover times at least twice a year, and develop an electronic log and assign a data entry person the task of documenting times to facilitate your study.

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