OR Manager - February 2020 - 31

AMBULATORY
SURGERY CENTERS
would be all caps and underlined. " It
became very apparent, very fast who the
problem people were, " says Fecteau.
If there was a day when all of the surgeons
arrived on time, a congratulations
or some other icon would be posted.
Fecteau noted that they began to have
" a bit of a revolution " from surgeons who
didn't like that the calendar was calling
them out and from surgeons who weren't
late but who didn't think the calendar created
a good environment.
Some staff were calling the calendar
" The Doghouse, " so it was renamed the
" Wall of Opportunity, " to point out that
this was " our opportunity to get cases
started on time, " she says.
Improvement up and down
FCOTS improved to 76% and 69% in
May and June, 2019, respectively. Improvement
waned over the summer, but
it is now back up above the target of
70% at least 3 days of the week.
Part of the problem in the summer
stemmed from the fact that there are
three anesthesiologists overseeing
the start of cases by certified registered
nurse anesthetists (CRNAs) in
10 rooms. " This made it impossible
for all 10 rooms to start at 7:30 am, "
says Fecteau. " To fix this problem, we
decided to stagger start times to 7:20,
7:30, and 7:40 am, " she says.
The anesthesiologists assign themselves
to rooms based on the type of
patient.
Even with staggered starts, it became
clear that mastectomy patients with reconstruction
had consistently late starts.
" We got a group together who were
responsible for the care of these patients,
including a general surgeon, a
plastic surgeon, an anesthesiologist,
a CRNA, OR staff, and preop staff, to
map out everything that had to be done
for these patients before going to the
OR, " she says. " We were not only doing
blocks on them, but they were highneed
patients who would come in the
day of surgery still with a lot of questions. "
In the end, the group decided to
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change the start times of
these patients to later in
the morning.
Fecteau notes that
this project has been a
huge challenge for them
because of so many professions
involved. " In the
beginning, anesthesia
blamed nursing, nursing
blamed surgeons, and
surgeons blamed anesthesia.
But there is less
finger pointing now, and
it is becoming more of a
blame-free perspective
that looks at the system's
issues, " she says.
For example, there
are situations where surgeons
are late on Thursday
mornings because
Source: Maine Medical Center Scarborough Surgery
Center, Scarborough, Maine. Used with permission.
they are giving a conference at the main
campus and then they have to travel 4
miles to the surgery center. " For these
surgeons, " Fecteau says, " we have had
to adjust their start times because it
doesn't make sense to hold them to a
start time that can't be met. "
Daily feedback
The surgery center receives a graph
every day that shows what percentage
of cases started on time. At 2 pm every
afternoon, charge nurses from the OR
and ambulatory surgical unit, along with
anesthesia representatives, review the
cases that ran late and started late and
the reasons for delays.
Most weeks, FCOTS are 70% or better
3 out of 5 days, and there have
been some weeks with a couple of days
with 100% of first cases starting on
time, she says.
Some of the chronically late surgeons
also have been stepping up or attempting
to step up to be at the surgery center
on time. There are a couple who simply
have no concept of time who have
been moved to later times, she says.
None of this would have been possible
without the fact that OR efficiency
became a divisional priority, says Fecteau.
" That gave us the leverage to really
look at late starts fully because surgeons
will always say they want to start
on time but not enough to do whatever
it takes for them to get there on time. "
At a recent advisory committee meeting,
Fecteau says they talked about the
success of the on-time starts project.
One of the surgeons told the group: " I will
tell you that seeing your name up there
is powerful motivation. I haven't had my
name up there, but that is part of the reason
for the success of the project. "
Besides posting names on the calendar,
Fecteau says she and the surgery
center's chief of surgery send an email to
each late surgeon that says: " You were
late today. That impacts us, our ability
to get your cases started on time, and
patient satisfaction. We really appreciate
you doing whatever you can to fix this. If
we made a mistake, let us know. " ✥
-Judith M. Mathias, MA, RN
Reference
Fecteau D, Reid S, Green S, et al. Project:
Increasing first case on-time starts in
an ambulatory surgery center. Poster.
OR Manager Conference, 2019.
OR Manager | February 2020 31
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OR Manager - February 2020

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