OR Manager - August 2020 - 13

Performance improvement
work they did and the recommendations
they made.
The Model for Relationship-based
Care, a framework for team feedback,
was used to create a caring and healing
environment. " A lot of what we needed
to do was rebuild relationships, re-engage
staff, and develop a level of trust
with staff so that when their shift was
over, they knew they would be able to
leave on time, " Strauss says.
The leadership team presented three
options to the advisory council for OR
staffing and scheduling:
* Seniority: The pros of the seniority
option were that it was an equalizer,
and it was easily defendable. " When
all else fails, you can fall back on
seniority, " says Strauss. The cons
were that it was a much longer process,
it might not meet the goals
and expertise of the staff, and it
might not achieve the equity they
were looking at for all staff.
* Staff survey: The pros of this option
were that it was a faster process,
and it asked staff their preferences
while ensuring broader options.
" They could have 8-, 10-, and 12hour
shifts, and it factored in the
experience level of staff for all shifts
and reflected Magnet standards for
shared governance, " she says. There
weren't any cons for this option.
* Random selection: This option had
only one pro-it would be a faster
process than options one or two.
The cons included staff not getting
a choice and not having the expertise
they were looking for throughout
the day and into the evening, and it
didn't reflect a culture that values
the voice of the staff.
Leadership structure
Strauss says staff told her they rarely
saw their charge nurses or clinical coordinators,
and they wanted them to be
more available in the OR.
The new model provided an opportunity
to create a patient-centered leaderwww.ormanager.com
ship
structure that could support what
staff needed.
This included:
* fostering a culture of professional
development in leaders
* ensuring leaders were able to have
the autonomy to make decisions
* inspiring gratitude and recognition
in leaders that would transcend to
the staff.
Strauss says they set an objective,
which was to clarify performance expectations
of service line coordinators throughout
perioperative services to shift their
focus toward patient progression and minimize
focus on tasks. This allowed them to
work more closely with their staff, troubleshoot,
and ensure that staff had what they
needed throughout the day.
They also standardized the role of the
clinical service line coordinators by eliminating
the charge nurse role and aligning
their title and structure with existing
nursing leadership structures (eg, time
card approval, performance appraisals).
Finally, they discussed with the Penn
Medicine Academy (corporate education
support and development) how to
enhance the role of the coordinators
to be leaders for the staff. " We wanted
to build and strengthen them, develop
a robust plan for change, establish a
change agent competency model, and
provide change management tools and
resources for them, " says Strauss.
Financial implications
The two orthopedic surgeons who left
took about 10% of the volume from the
main hospital OR. " Knowing that our
volume was decreasing and our labor
costs were rising, we knew we had to
do something, " says Megan E. Sanders,
BS, business manager, perioperative
services, Penn Medicine-Pennsylvania
Hospital. She says they came
up with several strategies to attack the
labor spend year-over-year increases.
One strategy was to look at the RN
to ST ratio, knowing that in the systemwide
rate variation, RNs compared at
a 2:1 ratio against STs. Though AORN
suggests a 70:30 ratio, it was important
to take patient safety and case
complexity into account.
Staffing ratios were adjusted as follows:
* FY 2018: 77% RNs and 23% STs
* FY 2019: 74% RNs and 26% STs
* FY 2020: 70% RNs and 30% STs.
" Compared to when we started this
plan in FY 2018, we are on track to
save more than half a million dollars, "
says Sanders. The next goal is to have
68% RNs and 32% STs because the
case mix justifies it, she says.
The second strategy was to develop
a productivity tool that compares in percent
an ideal OR day with the reality of
an actual day. The tool is loosely built
on the nursing hours-per-patient-day
(HPPD) model.
To build the model, a broad range
of subject matter experts were brought
together, including Sanders, Strauss,
nurse managers, clinical coordinators,
medical secretaries, and the advisory
council.
The two main constants in building
the model were the number of hours
the OR needed to staff and the number
of staff needed per room, per hour,
and per day. AORN's generic staffing
number is 2.5 people per room per hour
per day. However, Sanders says they
wanted to see if they could get a more
accurate number and increase buy-in
by getting to a Pennsylvania Hospitalspecific
complexity number.
" We wanted to get down to what
our number was every day of the week,
and we wanted to make sure our homegrown
metric was simple to understand
and use, " says Sanders. " We used
100% as our perfect OR day, which
means we had the exact staff hours to
cover the case durations we had that
day. "
The complexity factors are filled in
for each day (sidebar, p 12).
Sanders says they start with the
Continued on page 14
OR Manager | August 2020 13
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