How to cure a dysfunctional operating room

Karen Cheung

 Karen M. Cheung

The University of North Carolina (UNC) Hospitals did what seems like the impossible--transform a dysfunctional operating room by turning around its culture. But it didn't happen without a lot of hard work, and it certainly didn't happen overnight.

UNC had faced the massive problem of anesthesiology going bankrupt, which triggered reductions of working ORs. Staff blamed each other. OR morale was at an all-time low, while case volume continued to rise, mounting on the pressure cooker that was the OR.

"We all went down, under together," Susan Phillips, vice president of surgical services at University of North Carolina Hospitals, said about the chain of events at last week's American College of Healthcare Executives' annual congress in Chicago.

The hospital administration was anxious and called for immediate resolution. In fact, the OR at UNC affected 14 percent of the net operating budget.

"The OR is the economic engine of making up revenue," Kenneth Cohn, a general surgeon, CEO of and frequent Hospital Impact  blogger, said at the conference. A well-functioning OR system was in everyone's self-interest, according to Cohn.

With tensions mounting, the OR called for a change in culture.

"One way [to change the] environment is having a place where they like coming to work," Cohn said. It seems like such a simple idea but one with merit. All parties must view the OR as a complex system where each role is unique and critical to its success. "We're all part of the same ecosystem in curing and caring," he added.

To signal commitment to change, UNC staff even started to wear home-made buttons with slogans, including "I'm on the bus" and "The beatings will continue until morale improves."

"The message was clear; we would maintain our sense of humor, but we were serious about the culture," Stanley Mandel, director of the operating room at University of North Carolina Surgical Services, said.

The surgeons, anesthesiologists and surgical services staff also developed their own core values that they all signed as a commitment to the professional code of conduct:

  • I will value creative collaboration, not drama, and ask for honesty.
  • I will never raise my voice, use profanity or have a heated conversation in front of staff or patients.
  • My actions and the delivery of my opinions, at all times and under all circumstances, will be professional. I will reflect positively on UNC Health Care since I am [its] representative
  • By signature, I agree to abide by the above criteria of excellence, which will provide caring, teaching and innovation.

Any breach in the code of conduct was addressed directly and immediately, Cohn said.

And all the agenda meetings at UNC Hospitals state the organization's core values of services, quality, people, finance, growth and innovation, just as an added reminder, Phillips noted.

Phillips also said the staff engaged in TeamSTEPPS, an evidence-based teamwork system from the Agency for Healthcare Research and Quality used to improve healthcare quality, safety and efficiency.

In addition, the hospital created a governance structure to support decision-making. Like an executive committee, the group meets weekly and includes permanent members of the medical director, the anesthesiology chair and the vice president of surgical services, as well as two rotating members of surgical chairs from the largest departments.

The hospital developed another group called the surgical operations governance group that meets monthly to expand on the input in decision making with elected members from all surgical departments, anesthesiology and surgical services.

What was the result of all the new initiatives?

First-case on-time starts jumped from 50 percent to 87 percent, according to Phillips. Room turnover decreased from a high 55 minutes in fiscal year 2009 to 38 minutes in 2011. Patient throughput became smoother, as the number of patients transferred off the specialty floor decreased from 50 percent to 10 percent, and patient satisfaction scores at Carolina Care increased from 88 percent to 92 percent.

The hospital system also noticed that people were focused more on measures and programs. It introduced Surgical Care Improvement Project (SCIP) and met an overall score of 98, Phillips said. And as for the employees, the overall satisfaction scores moved from a very low score to a mid-point score, and overall employee retention increased from 80 percent to 91 percent, Phillips noted.

"It's a humbling thought that people from all different backgrounds have to come together in the OR at the same time," Cohn said. "The OR puts my life in perspective."

- Karen (@FierceHealth)