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Credits

Foreword
Table of Contents
Executive Summary
Workshop
Overview
Operational Efficiency & Workflow
Systems Integration & Technical Standards
Telecollaboration
Surgical Robotics
Intraoperative Imaging
Surgical Informatics
Appendix A
Appendix B
Appendix C




CHAPTER 2 AT A GLANCE
OPERATIONAL EFFICIENCY & WORKFLOW

Overview

Improvements in operational efficiency and workflow in today’s operating room (OR) will significantly impact progress in the Operating Room of the Future (ORF). There is a particular need to adapt today’s advanced technologies to meet specific surgical needs. Among these tasks is adapting technologies such as smart tracking for patient records, and radiofrequency identification devices (RFIDs) for locating information about patients and equipment. Doing so successfully is necessary to attain improved efficiency and workflow today and in the ORF.

Clinical Needs
Achieving efficiencies in today’s OR requires identifying mechanisms for:

  • accessing and obtaining correct and current patient-related information.
  • scheduling and accessing use of correct and operable surgical tools.
  • developing consistent OR practices and prescribed workflow routines per procedure/per specialty.

Technical Requirements
Research to address these clinical needs should focus on developing:

  1. Smart cards or nodes that store patients’ complete medical records.
  2. Tracking mechanisms to address OR-wide fragmentation of information about surgical tools (their location,operability, and scheduled use).
  3. A system for creating focused and well-trained work teams to ensure that consistently efficient surgeriesare completed.
  4. Technical standards for the OR that define day-to-day, step-by-step surgical workflows (per procedures and per variable cases).

Research Priorities
This Working Group identified these priorities as the development of:

  • Means for accessing comprehensive and current medical records.
  • Standardized tracking and locating of surgical instruments.
  • Surgical practice standards in the OR that reach across all specialties.

The full report of this Working Group appears below.

CHAPTER 2:
OPERATIONAL EFFICIENCY AND WORKFLOW

…THE REPORT OF WORKING GROUP 1

PARTICIPANTS

Ernest Lockrow, DO, Uniformed Services University of the Health Sciences,
Walter Reed Army Medical Center (Clinical Leader)
Heinz Lemke, PhD, Technical University of Berlin (Technical Leader)
Gary Dorfman, MD, National Cancer Institute
Marie Egan, MS, RN, Massachusetts General Hospital
Tim Ganous, MPA, University of Maryland
Cristian Mihaescu, MS, University of Craiova
Warren Sandberg, MD, Massachusetts General Hospital
Robert Tham, PhD, University of Wisconsin-Madison
Tom Winter, RN, Walter Reed Army Medical Center

2.1 OVERVIEW: COMMON PROCEDURES IN TODAY’S OPERATING ROOM

Standardized and improved workflow processes are central to ensuring the efficient operation of all hospital operating rooms (ORs) today. These processes are of particular importance in response to the continuing workforce shortages that are being experienced throughout the healthcare industry. Optimization of efficiencies in typical workflow processes is of special concern for health care providers, managers, and administrators, given the extent of OR-related costs in this, the most cost intensive sector of today’s hospital. And there is a longer view that needs attention: Improvements in operational efficiency and workflow of today’s OR will impact progress that will be achieved in the Operating Room of the Future (ORF).

Key issues in improving operational efficiencies and workflow in the OR concern implementing better management of a multitude of preparatory information and tasks that are needed before and during actual surgeries. Ready access to patient-related information is a central problem today in OR facilities in every type of hospital (military, academic, and community). Without this access, the workflow is disrupted and surgeons are less productive. Therefore, the need to improve management of information pertaining to patients (their records and histories, their needs, their scheduling, and so on) is key to ensuring efficient OR workflow and patients’ safety. Standardized information technology for scheduling inpatients’ and outpatients’ appointments, tests, and other procedures as well as for scheduling surgeries is critical for achieving improved efficiencies in the OR overall.

This Working Group identified key resources and technologies that could be adapted to improve efficiencies and workflow in the OR. They are “key” in that they address the specific requirements of surgeons and their needs for improved workflow in the OR. Adaptations of, for instance, bar coding systems, radio frequency identification devices (RFIDs), and other tracking technologies were identified specifically as key for addressing chronic delays related to missing information about patients and surgical tools. And finally, a focus on modeling standardized surgical workflow practices for the OR was identified as an essential base from which to develop operational efficiency and workflow practices for the ORF.


2.2 CLINICAL NEEDS: ISSUES IN ACCESS TO INFORMATION AND STANDARDIZED PRACTICE

Probably the most pervasive problem in today’s OR has less to do with surgical technical advances than with the need for mechanisms to access and obtain correct paperwork for patient-related information. Surgeons must divert much of their time and attention beyond the matter of performing surgery adeptly. They must instead deal with a myriad of manually generated paperwork per patient which is sometimes neither all complete nor up-to-date. The potential for inefficiencies and introducing patient safety issues is increased as a result.

This Working Group discussed the very pressing need for a standardized access system from which surgeons and other OR personnel could obtain patient information and histories, patient room scheduling details, and information about location of equipment and the personnel who are trained to use it. Most particularly, there is a need for immediate access to patient information in the OR.

Clinical Areas for Needed Improvements

This Working Group identified and discussed three clinical areas needing improvement:

1. Poor access to patient and surgical information.

  • Absence of a standard, computerized medical record for patients that documents their histories and their needs. These records must be current and complete. All future improvements on which these records are based (e.g., smart scheduling) depend on using a comprehensive electronic record as a template.
  • Disparate patient and medical information and imaging systems that do not “talk” to each other, thus making accessibility issues difficult. An example of a stand-alone anesthesia record keeping system that is separate from the larger hospital information system (HIS) was provided as typical of such disparate islands of information that exist within hospitals.
  • Multiple and disparate systems for tracking related work processes. For example, there are multiple scheduling systems used for tracking surgical in- and outpatients and another system for reserving surgical instruments and ORs.
  • For surgery, in particular, an absence of a surgery-oriented standard for obtaining and viewing multidimensional data about patients during surgery. Improved paper-based records are not the only issue: there is also a critical need for real-time information regarding upstream and downstream processes in the OR. Without this information, the system is slow to respond to variances (and there can be very many variances, this Working Group was quick to note).

All of these access issues affect today’s clinical practice and are detrimental to making optimal use of surgeons’ time and expertise.

2. Lack of consistent OR working practices or prescribed workflow routines.

  • An absence of standardized devices/systems in the OR. Multiple computer operating systems (e.g., Windows-based and DOS systems) are routinely used in the same OR but information cannot be shared between them.
  • Inflexible devices/systems that are currently in place.
  • Slow processes of switching between applications (and so, switching is avoided).
  • Inadequate presentation of data (text, 1D, 2D, 3D, 4D) during the intraoperative and perioperative phases of surgery.
  • Unavailability of a user-configurable information environment. In addition, especially during surgery, there is a need for accessing consistent visual images, preferably with a touchscreen, regardless of the display system that is used.

All told, today’s surgeons who are using new technologies and imaging options appear to be adapting their immediate needs to what has been made available to them by manufacturers. They are devising “work arounds” rather than using advanced technology to improve on their surgical work.

3. OR staff teamwork issues and communication deficiencies.
Fragmented communications and varying levels of competency among OR team members are significant issues affecting efficiencies and improved workflow. These problems impact all aspects of surgery, including ensuring that:

  • patients are appropriately prepared for surgery.
  • patients’ complete and up-to-date records are readily on hand.
  • the correct tools are available and in the OR.
  • a postoperative recovery area has been reserved.
  • appropriate staff have been scheduled.

Informed teamwork is key to improving operational efficiency and workflow. The islands of communications that are typical of today’s OR process simply do not work.


2.3 TECHNICAL REQUIREMENTS: SYSTEMS FOR IMPROVING WORKFLOW

Today, fragmentation of patient information and other needed records impedes optimal operation of the OR. One of the most “wished for” technical advances expressed by this Working Group was a “patient-centric” medical record that would be available to all healthcare providers and so better direct each patient’s care.

Four of the most critical technical needs for improving OR efficiencies and workflow are as follows: 1) creating accessible medical records; 2) developing readable equipment locator/tracking mechanisms; 3) resolving OR teamwork/personnel issues; and 4) developing and following technical standards in the OR. The Working Group addressed these four issues separately as detailed below:

1) Creating accessible medical records

This group suggested that a standardized system for identifying each patient is critical for improving OR efficiencies. These suggestions included:

  1. Creation of a smart card or smart node to be placed on every patient. This mechanism would store a patient’s medical record and could be accessed easily by providers.
  2. Means for assigning a unique identifier to all patients for improving access to their records. Coupled with this suggestion was the requirement for a robust electronic architecture for obtaining this information. The Internet was the suggested means for access, rather than using/depending on a certain computer or operating system that an individual is used to. Security and privacy concerns then became important.


2) Developing readable equipment locator/tracking mechanisms

Information flow is critical to the optimal and efficient use of the OR. However, this flow pertains to information transfer beyond the detail that is included in patient records. Fragmentation of information about patients, tools (location and scheduling of their use), and other critical components of the surgical process is pervasive in today’s OR and must be addressed.

An integrated system for locating information and equipment is a key issue for improving OR efficiencies. This Working Group’s suggested technical improvements for locating and tracking OR equipment included creation of OR-wide systems. Details about these systems are as follows.

  1. Bar coding systems for identifying and tracking instruments and other equipment. These systems can help surgeons and other OR personnel locate equipment prior to the surgical procedure. This tracking can also help prevent the significant costs of unintentionally discarded or lost equipment post-surgery.
  2. Standardized, automated tagging systems of all instruments and patients such as radiofrequency ID (RFID) of patients and equipment. Safety issues play a significant role here as well. There is a need for standardized scanning of patients after surgery and having each instrument tagged with an RFID mechanism to ensure that instruments have not been left inside patients.
  3. Scheduling/tracking systems for specific equipment to have surgeons’ preferred instruments in place.

3) Resolving OR teamwork/personnel issues

Varying levels of competency among OR team members affect efficiency and workflow in the OR. Designing teams that work well together and are well trained from among in-house staff is ideal, but many inconsistencies in scheduling and other issues have been shown to be a problem, this Working Group noted. In addition, cross-training usual OR staff is an inefficient use of resources.

One participant of this Working Group (who drew on his hospital’s own experience) suggested hiring and dedicating a staff of procedure-specific technicians. This process worked particularly well for certain procedures, like laparoscopic surgeries, for which enormous amounts of set-up time and expertise are required on the part of surgical technicians. In this instance, the hospital also contracted with a commercial firm for acquiring all procedure-related instruments, and that firm took responsibility for ordering and maintaining instruments. Doing so ensured that the correct and operable tools and personnel were in place. Increases in efficiencies were realized by working with an informed, regularly scheduled team.

4) Developing and following technical standards in the OR

Standards for creating and integrating information about patients, equipment, and procedures are vitally needed at the outset in planning for an efficient ORF. To determine these standards, research is needed to define day-to-day, step-by-step surgical workflow practices and create surgery workflow models per procedures or per variable cases.


Figure 2: Simulation of surgical workflow
(courtesy of Heinz Lemke, PhD, Technical University of Berlin)


An example that might be used to better understand (and eventually improve on) OR workflows and efficiencies is the recent work by the Improving the Healthcare Enterprise (IHE) initiative and its definitions of workflows and efficiencies in healthcare outside of the surgical room. This body of experts develops recommendations for the healthcare industry on how to implement standards. (Note: IHE’s members do not develop the standards themselves.)

Furthermore, the IHE initiative has developed “integration profiles” that enable consistent access to images and reports for certain medical specialties (such as radiology). Surgical profiles have not been developed yet, but they are needed, as this Working Group noted, as is a “surgical DICOM.” Today’s DICOM standard is not suitable for many imaging types that are needed in the OR (e.g., it does not cover real-time, 2D, and 3D issues, nor does it address interactivity).

2.4 RESEARCH PRIORITIES

The following research needs were identified as priorities by this Working Group.

  • Medical record access improvements. A comprehensive, accessible, and standardized patient medical record must be developed. Ideally, the language and computer system that are used for these records should be universally accessible and should not be machine- or software program-dependent.
  • Equipment tracking improvements. There is a need for equipment tracking mechanisms to address the critical issue of fragmentation of information about the tools that are needed for pre-surgical planning for the actual surgical procedures. New mechanisms must provide means to locate needed detail about the tools, such as information about specific instruments (brands, types, and so on) that are required during a surgery.

Technical means for enabling this tracking should involve standardized use of:

  1. Radio frequency tracking of instruments and lap pads in the OR. Research should be focused on reducing the size of RFID tags and improving their performance in wet or other environments that are typically found in the surgical setting.
  2. A bar coding system for tagging and locating instruments throughout the hospital. System-wide mechanisms for this tracking must be developed so that the correct instruments are in the right place as needed.
  • Practice standardization/improvements. Standardization of surgical practice across many spheres is needed to increase workflow efficiencies in the OR. These areas include standardization in:
    1. Developing technology across the system (for technology used by surgeons, by nurses, and other team members) and across specialties (for technology used in endoscopy, radiology, and so on). Surgical practice itself also needs to be standardized and specific tools/brands decided upon in order for the surgical results to be consistent.
    2. Scheduling of patients and comprehensive preoperative evaluation for their surgical procedures.
    3. Preparing clinical teams who work together in the OR, with each member able to demonstrate skills in a particular technology’s use. Increased education is obviously required to expand and refine team members’ skill sets and enable them to plan ahead for next-day surgeries.
    4. Defining and matching specific jobs/tasks and their roles in OR workflow processes. These roles need to be better defined to address the question: Who are the people that will be needed tomorrow in the OR?
    5. Developing clinical guidelines per surgical specialty. Developing and following practice guidelines will achieve consistency in scheduling and undertaking routine pre-operative screening tasks, and otherwise better ready the patients for surgeries.
    6. Acquiring surgery-oriented presentation of multidimensional data. Images ought to be consistent regardless of the display system that is used.
    7. Developing standard operating procedures (SOPs) for the OR. A goal is to enable surgeries to operate like factories or assembly lines and produce a consistent, measurable product.
    8. Studying individual work roles and activities to understand what people working in the OR do and say they do and why. Obtaining this information requires an ethnographic research study of the OR to be undertaken. From it, workflows can then be better defined from high to micro levels.

As a result of studying the overall workflow practices that characterize today’s OR (including readying patients, preparing tools, performing procedures, and so on), a better understanding can be acquired of how these tasks can be performed efficiently in the future. These findings could lead to development of a needed, standard process model of surgical workflow. As a result, planners would have better information from which to assign and plan for human and non-human involvement in an OR that operates efficiently and productively.