TeleTracking Workflow Consultant Brandi Hollins, RN, BSN, MBOE shares her in-depth knowledge of perioperative solutions and how TeleTracking’s Clinical Workflow™ Suite module provides real-time information and enhanced transparency.
Using perioperative best practices
Best practices are an important part of helping organizations achieve performance goals. Before an organization can implement a best practices strategy, it is important to first perform a self-assessment, measure baseline data, and benchmark against like facilities. The next step is to look at current processes and align them with best practices to achieve better outcomes.
Key operational outcomes and indicators
TeleTracking’s perioperative best practices are divided into two categories—organizational transformation and procedural area practices.
For example, organizational transformation focuses on strategies and tools that provide enterprise visibility, cross-functional accountability, and continuous improvement across a health system. Whereas the procedural area practices focus on addressing common OR challenges that result in delays, inefficiencies, poor utilization, and a less-than-optimal patient and family experience. These practices include strategies to:
Case studies indicate that when these best practices are followed, surgical volumes increase, unnecessary staff overtime is reduced, patient flow is improved throughout the surgical continuum of care—to name a few benefits.
Because it’s difficult to improve what you don’t or can’t measure, TeleTracking’s perioperative best practices include leading indicator targets such as patient wait times, first case on time starts, overall on time starts, OR primetime utilization, average room turnover time, average PACU length of stay, and the time from when a patient is clinically ready to move in the PACU to the time they have a clean, ready bed.
A patient flow governance council plays an important role in driving operational decision making based on data and ensuring that best practices are being followed. For example, this includes the creation of effective and efficient scheduling guidelines to optimize patient flow and improve access and volume growth. The council also has responsibility for developing strategic plans, which include patient flow and capacity management, as well as a mission, vision, values, and accountability structure.
If the guidelines are not enforced, and/or not followed, having reporting in place to verify and confirm that schedules are accurate (actual scheduled time versus schedule duration time) is important. It’s also important to ensure that key stakeholders have access to metrics daily, weekly, monthly, or as needed to track trends. And if improvements need to be implemented, an executive sponsor, such as the chief nursing officer, should be identified.
First case, on-time start delays
There are always first case, on-time start delays. However, one way to improve this metric is to have patient’s complete preadmission testing prior to surgery because if medical records are incomplete on the day of surgery, the case may be delayed.
TeleTracking’s perioperative solutions can help ensure that incomplete medical records are identified, and solutions expedited—including a patient’s history and physical exam, consent forms, pending labs or x-rays, etc. Capturing the patient's real-time information, so nursing, physicians and volunteers are aware of the status is critically important—because if there is a delay that will impact the scheduled procedure, the delay can be viewed in real-time by the receiving department.
Improving provider coordination
This is another common challenge that every facility faces. It is important to include providers early on and encourage them to become champions when implementing perioperative technology, processes, and practices. Surgeons arriving on time to the OR is often a challenge. Some hospitals have implemented a process where the provider is contacted 15 minutes prior to the scheduled start time. If delays do occur, those cases can be referred to the surgical services committee, along with evidence to drive improvements.
Improving family satisfaction through better communication
Patient and family satisfaction is very important to every organization, and with TeleTracking’s perioperative solutions, it’s possible to show the entire perioperative. For example, families can view screens in waiting areas that provide real-time updates of their loved one moving through the process. This decreases the number of phone calls and streamlines communications. For example, a ‘family’ icon signals that the patient is ready to receive visitors.
Working together to ensure efficiency across the continuum
When a patient receives care, they should see no boundaries or separation, and their care should be efficient and consistent. For example, staff in the perioperative area can utilize the ready to move indicator in TeleTracking to notify patient placement that a bed assignment is needed; they can also request patient transport through TeleTracking, helping to avoid delays, reduce phone calls, and automatically track the process.
On the flip side, inpatient units that utilize TeleTracking can see that the patient is in the perioperative process, and the milestones indicate when the patient is out of surgery, going into recovery, or if there has been a delay. This real-time visibility helps predict when to expect the patient on the unit.
Executive champions driving accountability
A key part of a successful implementation is engaged leadership to encourage others to adopt new standards and integrate them into their daily workflows. It’s so important for the executive champion to be present, to be a project champion, to listen to leaders and staff, and to understand what end-users face on a daily basis. This is critical to driving better outcomes for the facility and delivering a higher quality of care.
Workflow Consultant - TeleTracking Technologies, Inc.
Brandi is a Workflow Consultant with TeleTracking Technologies’ Clinical Workflow Suite Team, assisting surgical services by exploring a facility’s current processes and providing recommendations to improve efficiencies and increase productivity based on industry experience, best practices and successful implementations.
Brandi joined TeleTracking after more than 17 years’ experience in the healthcare industry. Her expertise spans Operational Excellence, Lean Leadership, Strategy Development, Surgical Services, Pre-Admission Testing, Endoscopy Services, Infusion Services, Neurology, ICU, and Heart & Vascular care.
In addition to her work at TeleTracking, Brandi is also currently serving as the Chair of Nursing Informatics for the AORN and she was recognized as an ASC Leader to Know in 2017.
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Brandi Hollins: So, I have been a registered nurse for the past 17 years. I first started out in ICU nursing. I did branch over to the surgical services division and slowly worked my way up — it was not a plan of mine, but I became a leader. I was, actually, a Director of Nursing and I had the pre-admission testing. So, patients who, as soon as they walked in the building or they would need some testing, I had that part of the group, and then I also had the pre-op and the PACU. I also dove a little bit deeper into the actual intra part, so patients who were going into the OR setting. I'm kind of like a hybrid, I've been a little bit everywhere.
Susan McLaughlin: Brandi, TeleTracking we know has just released the best practices for the peri-operative settings. Can you share your perspective on how these best practices should be used and when health systems who use TeleTracking in their perioperative settings receive the best practices, what steps should they take to start to put those into practice as soon as they can?
Brandi Hollins: Best practices, are really big right now in the industry. So, just to explain what a best practice is and the how and the why, they're really used for organizations to increase the quality of care. And then they're frequently referred to, to maintain that quality of care. Organizations, they may need to perform a self-assessment and see where they currently are measuring with benchmarking with like facilities in the industry. So, it's really important for them to look at their processes and tie them up with these best practices for everything to work correctly. So simply put, they're just the best way to do things.
They really should be utilized, to one, their leadership teams should strive to improve outcomes, increase operational efficiency, achieve performance improvement on their key measures in their perioperative departments. So the best practices really are a set of guidelines or ideas that represent the most efficient course of action, are the end desire in the organization we need to accept the best practices as their alternatives because it produces results, and it will become the standard way of doing things for their organization and in the perioperative setting.
Susan McLaughlin: Brandi, does perioperative best practices focus on the number of leading indicators and overall outcomes? Could you briefly summarize what some of those key operational outcomes and indicators are?
Brandi Hollins: The way that our TeleTracking best practices are divided up, they're between two areas. So we have, one is the organizational transformation and two, the procedural areas. So this is what I love about being able to provide clients these best practices, because one is from a high level — senior leadership, executives, administrators — and then the other one is for the actual to dive deeper in the procedural area locations.
So as far as the first one, the organizational transformation, so this would be for executives. There are three different items for them to focus on. So, one is improving visibility, and so this can be a team through dashboards with real-time information, that could possibly be displayed in their executive level admin areas or even to the command center teams. So everybody can see what's going on inside the ORs in a live-time feed. The second is driving accountability to ensure that the organization is aligned everywhere, and the third is to monitor progress. So making sure that they have the patient flow discussions and they're reviewing metrics and following through with process improvement.
The second is, key operational outcomes for the procedural area. This is diving deeper and there are so many ways to tackle this, honestly, and we must know that having that real-time visibility for the staff in the periop setting is important and remarkable. This also is a plus, and it is just as important for the family members to be able to see that as a patient is flowing through the surgical continuum of here, it is displayed in real-time on the family views. So these are views that are shown in the waiting room locations. So they are real-time locating views, and they can see their loved one at all times, meaning their location.
The second is to increase surgical volume. This can be achieved through an accurate scheduling, creating effective and efficient scheduling guidelines to optimize the patient flow that will improve access and volume growth for the organization. So this can be done by the room utilization. I'm making sure that, that is maximized through increased visibility, making sure that they have those real-time alerts and those triggers, and to proactively position the hospital for growth. The third is to decrease staff overtime. This can be accomplished through efficient scheduling, making sure they're streamlining the perioperative flow and the on-time starts through efficient patient preparation and supply preparation as well, and to ensure the right patient is going to the right bed the first time for the inpatients. So meaning if I come in as an outpatient and I'm going to the inpatient world and have to spend the night, we want to make sure that patient is going to the right bed the first time.
Last but not least, to increase the contribution margin. Contribution margin is measured per hour, and like I said before, it's variable between hospitals, but we do know that the OR contributes approximately 65% of the total revenue for hospitals. So this is why it's important to streamline, make sure that we're standardizing processes, we're creating real-time visualization that will ultimately lead to creating efficiencies and increase the OR utilization rate.
Now, this is just part of the best practices. These are just the key operational outcomes for these two types, so we have the organizational and then we have the procedural. However, we also provide in the best practices, leading indicators. Leading indicators always assist with measuring change. It doesn't matter what industry you're in, that's what it will do, it will assist with measuring any change. Currently, they're dealing with immediate progress and can assist with the likelihood that an organization will achieve their goals. The leading indicators that we are including in the TeleTracking BP's are patient wait times, the second is first case on time starts, then we have the overall on time starts, the OR primetime utilization, the average room turnover time, average PACU length of stay, and then the occupied timer. So this is the one everybody always says, "what's the occupied timer?". So, it's basically moving out from one location into the next location. So, that is the occupied timer.
Susan McLaughlin: Brandi, one recommendation is about creating scheduling guidelines, could you share some examples of how the scheduling guidelines help, and on the flip side, what happens when you don't have them?
Brandi Hollins: Well, it's always a wish to have a smooth and efficient scheduling system and having those guidelines, and it's a must for any operating room environment, honestly. If there is not a system in place, the entire perioperative department, the patient and family experience will be affected. The supplies may be lost the utilization of time, rooms, and staffing, are all jeopardized when there's not a scheduling guideline in place.
Susan McLaughlin: Can you provide a brief overview of how workflow tools help optimize the OR utilization?
Brandi Hollins: As the patient, or schedule information is changed in the EMR, it will automatically update in real-time within Clinical Workflow Suite on the large monitors that will be displayed throughout the perioperative setting. So as the information is updated, there will be notifications that can also be sent to staff on devices. So, surgeons, anesthesiologists, administrators, leaders, managers, they can all have access to the schedule via any iOS device. So by providing that increased visibility of the schedule, this will ensure that the staff are aware of their assignments to facilitate a more efficient room utilization, such as shifting of pieces or reassigning of staff.
Susan McLaughlin: Brandi, if you'd like to talk about how to approach developing guidelines if your system doesn't have them, and then how do you enforce them if they're not being followed?
Brandi Hollins: We must ensure a patient flow governance council is in place that drives operational decision making based on data and the best practices that are brought forth. We also could develop a strategic plan or roadmap, which includes patient flow and capacity management, which would include their mission, vision, and values, and an accountability structure. We can also create effective and efficient scheduling guidelines to optimize patient flow, to improve access and volume growth.
If they're not enforcing them, or they're just not being followed, we first must have the reporting to verify and confirm that the schedule is accurate and actual versus the actual scheduled time versus the schedule duration time. We must be able to have that data as evidence, so we can track and trend that information to report any kind of deviations to providers. We must ensure that those key stakeholders have access to the metrics daily, weekly, monthly, or as needed, so they can track those trends and if the improvement is not being met, then a provider would be a good candidate to possibly have a strategic plan, or that roadmap be developed for them with the assistance of an executive sponsor like your Chief Nursing Officer.
Susan McLaughlin: Delays often begin with a lack of coordination around patient preparation. Can you share some common challenges that cause first case, on time start delays and how TeleTracking clients have successfully addressed these?
Brandi Hollins: It's never going to be perfect and there will be some first case, on time start delays. However, what we can do with our clients is by providing these best practices on how they can ensure that they do start to facilitate on time start. One of the ways is by their Pre-Admission Testing. Pre-Admission Testing is where the patient typically always starts for the surgical cases, meaning that the patient will be ordered Pre-Admission Testing prior to surgery, and that it will have all the patient's information, they will have testing, and the testing results will be uploaded to the system. So, if any event that the medical records are incomplete on day of surgery, the case may be delayed.
So, our system can actually ensure that these incomplete medical records are identified timely and expedited, including the history and physical exam, the consents, if there’s pending labs or x-rays, to ensure that they're facilitating those on-time starts. Making sure that the patient has clear preop instructions, patients are educated prior to coming in, and so we always want to make sure that the facilities are not the cause of the delay. If we're making sure that we have that patient information uploaded in the system, we can increase our first case on time starts.
Now, once the patient is in house, so they're in the facility, then we can start to move to capturing of the patient's real-time information. So, the patient arrival, the movement, so nursing, physicians, techs, volunteers, everybody is aware that the patient's status is immediately available via the real-time electronic screens. So, or even like the device alerts. So if there is a patient delay that will impact the schedule procedure, the delay will be viewed in real-time by the receiving department. So this is allowing for in the moment of rescheduling of resources, staff, or even the room utilization.
Susan McLaughlin: Brandi, we know another challenge is sort of choreographing the providers, so maybe the surgeons, the anesthesiologist, and the nursing staff. Could you share some common challenges related to this issue, and again, how can TeleTracking clients improve their provider coordination?
Brandi Hollins: We always include the providers and really drive them to become champions when implementing Clinical Workflow Suite. We always include them in the project as stakeholders due to the impact of the provider challenges they present and the impacts that they ultimately can create for the OR setting, whether be positive or negative. So one of the biggest impacts is the barrier of the surgeons getting to the OR on time. We must enhance the provider and the anesthesia on time arrivals, through effective and real-time communication. Some clients have implemented bylaws, some will contact the provider 15 minutes prior to the scheduled start time if they're not physically in the OR setting. They also have notified the providers of any scheduled time changes and are reporting all case delays to the surgical services committee. So they have that evidence base to be able to take back and create changes.
Susan McLaughlin: Could you share some examples of how clients have improved patient, family satisfaction of course, just solely by providing better communication?
Brandi Hollins: I mean, this is their whole purpose of implementing the system, is to really leverage the real-time communication, and be able to provide those status updates to the patient's family members. Family satisfaction is very important to every organization. Right now, what we can do with the system is having that capability to show the entire perioperative journey from beginning of entering the building, to going home, or to the inpatient world. So, being able to show on the family view screens in all the waiting areas, to allow for real-time updates of the patient actually moving throughout the perioperative suite, this actually decreases phone calls, and anxiety for the patients and their loved ones. So it improves communication across the board with the family, the visitors, and actually the staff.
The staff can also utilize. There's a family icon that they can utilize to signal that the patient is ready to receive visitors. So they can do this without having to leave the patient's bedside and actually make a phone call to a waiting room volunteer, or to a clerk, or to the family. They can click on an icon and it would actually show that they are ready for the family to come back. We also can see that the length of stay in all the areas for these patients. On the timers that are displayed, we can see if they are in an area for a prolonged amount of time. So this can also trigger service recovery for the staff. So if a patient has been waiting too long (example: in a waiting room location), we can see that we need to activate service recovery, so now they can see them in live time, actual times, the patients have physically been in a location.
Susan McLaughlin: Can you share some examples of how the perioperative inpatient leaders can work together to ensure, again, getting that level of efficiency across the continuum and at all levels of the hospital.
Brandi Hollins: I have to be honest, I love this question, and I've been on both sides – I've been in the inpatient world, I've been in a perioperative world, so I absolutely love this. You know, we have to break down silos of the procedural areas and the inpatient areas of the organizations. When a patient looks at the facility, they see them as one team, and they shouldn't be able to recognize any boundaries or separation of departments.
The inpatient units that utilize our BedTracking Portal, they actually will have a live-time feed of the current step that the patient is in and the periop process, and they have that in a live-time feed. So that helps them with better predictability of when the patient may be coming out of surgery and going into recovery or where they're at in the recovery process. You know, in Clinical Workflow Suite, we can utilize the patient and bed attributes, and the isolations to increase accuracy of patient placements. So once we put that information in a system, now the Bed Board can see it, and also the inpatient world can see it.
Staff in the periop, they can actually utilize the ready to move indicator, and that sends an indication that the patient is now recovered, which will state that the patient is prepared for a bed assignment, and that will ensure that a ready bed is for a ready patient. We can also utilize the transport in Clinical Workflow Suite. So as soon as an assigned bed is clean, and the patient is ready to move, this will help with avoiding any kind of delay once they click on the "ready to move" and they call for a transporter inside Clinical Workflow Suite.
Susan McLaughlin: Can you share some ways you've seen perioperative leaders really work closely with their c-suite and really turn a full focus on optimizing OR utilization and efficiency?
Brandi Hollins: This really goes back to the organizational transformation and once Tele becomes a partner with the organization, it truly is a journey of change management and being able to adopt systemic performance improvement to enhance operational efficiency. So, the operational efficiency truly is key at every organization, especially for the perioperative departments. Having that leadership support and communicating a sense of urgency and understanding of why the operational change is necessary and why it's critical. To be able to implement a project, there must be buy in and inclusion from the executive level folks. There is pushback and challenges, and that's everywhere. So once everybody is educated and sustaining the mission, the vision, values and how the teams will be held accountable, then everybody can start to grasp the outcomes that can be obtained, and the quality of care that will be accomplished.
Susan McLaughlin: Can you share a few specific examples of how strong executive champions have driven that kind of accountability?
Brandi Hollins: I've been in these positions before and now working here as a consultant, I can truly say just by being present, just recognizing the importance of being part of the team and becoming a project champion, being able to sit down and listen to the leaders and the staff, do a grassroots effort, understand what the end users are facing on a daily basis, and being able to provide that support to drive that change for the organization is huge. Once you obtain that, you will be able to see better outcomes for the facility and higher quality of care.
Every organization looks for best practices and a lot of our clients have reached out and said, "what can we do?" or, "how do we get started?", because it is overwhelming. You have electronic medical record and then now we're having a communication tool and taking care of patients. It's just knowing where to get started, making sure you have that support to get started, and then tearing down those silos, breaking those barriers and becoming one team, and making sure that you all are actually focused on the project and process improvement, and you're all in this together. You will have the outcomes, ultimately in the end. It's tough to get started, however, the reward at the end is grand, for everybody.
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