Charlotte Damato, Lean-Six Sigma Quality Coach for Sarasota Memorial Health Care System [SMH] in Sarasota, Florida joins us for this episode of the Patient Flow Podcast. Damato discusses how increased demand impacted SMH and led to the decision to improve the efficiency of their existing 34 operating room suites. Through a combination of TeleTracking’s Clinical Workflow™ Suite, Lean techniques and process redesign, and staff development, SMH increased on-time surgery starts, decreased OR turnover time and increased utilization.
Charlotte Damato | Sarasota Memorial Hospital
Lean Six Sigma Coach
Charlotte Damato is a Lean/Six Sigma Quality Consultant. In 2006 Charlotte joined Sarasota Memorial Health Care System (SMHCS) in Sarasota, Florida as their Quality Coach. Prior to joining SMHCS she was an independent Quality Consultant. She works with the staff at Sarasota Memorial to reduce process waste, streamline patient flow, improve patient satisfaction and facilitates strategic initiatives. She is a Certified Lean/Six Sigma Black Belt and Certified Manager of Quality/Organizational Excellence.
In the past 25 years, she has facilitated quality workshops and coached thousands of Directors and Managers in healthcare and other industries across the United States to manage and improve their work processes. She has trained and mentored others to eliminate finger pointing and conjecture by using the power and value of data in meetings, conversations and in day to day operations.
A few noteworthy accomplishments:
Charlotte has a Bachelors degree in Speech Communications and a Masters in Counseling from Appalachian State University in Boone, North Carolina.
Speaker 1: Welcome to the Patient Flow Podcast powered by TeleTracking. On today's episode of the Patient Flow Podcast, we welcome Charlotte Damato, QI Coach at Sarasota Memorial Health Care System, one of the largest public hospitals in the country, boasting a Level II trauma center with 829 beds, more than 24,000 surgeries per month, and 34 operating rooms. Listen as Charlotte walks us through their goals of increasing OR utilization and reducing turnover time.
Charlotte, with the challenges that you were facing, how did you utilize Clinical Workflow Suite and the data generated by those reports to improve utilization and maximize your existing resources?
Charlotte D.: I was asked about three years ago to go in and watch some surgeries. So, I watched about 80 different surgeries, every single service line that you can think of--large surgeries and small from ENT's to hearts and all kinds of things. And what they really wanted me to look at was in-to-incision time. Without having a Clinical Workflow Suite, I was in the OR with my little laptop, and putting every timestamp in myself. Everything from when the patient rolled in the room to prep time to time out to when the surgeon walked in the door, when the anesthesiologist arrived, I put in every single one of those timestamps. And also every delay that occurred during the time I was standing in there. So, it was quite a cumbersome process, and I kept thinking there has to be an easier way. And that was about three years ago.
What I learned from it, though, there were two huge problems that we had to overcome to improve in-to-incision time, and that was--the first was getting all the right equipment and instrumentation in the room in a timely manner and make sure it wasn't broken, make sure it was all working properly and that you had the right equipment in the right room at the right time.
And the second big problem we had to overcome--and I'm sure most people find this--and those are communication issues. So, the communication that took place in the OR had to do with telephones, hard-wired phones, pagers, overhead pages and also just intuition. I think my patient's probably ready in pre-op. I think I'll go back and go get my patient.
I also knew there had to be a better way for the people in the back in the OR suite to understand what was happening in pre-op. And then this huge miracle happened. I went and visited this hospital that had the Clinical Workflow Suite, and my eyes popped. And I said, "We have to have this." So, we put it into a package with a large capacity project that we were doing and it was absolutely a need that all the members of the C-suite agreed 100%, not one naysayer. They all said, "We have to have this."
And so we started our journey to implement the Clinical Workflow Suite. Almost immediately we were able to see huge changes in the number of telephone calls made from the OR suite to the peri-operative area. I had been standing there again--this was another one of my wonderful times when I'm standing behind in the control room listening to the number of calls that the nurses were having to answer and what kinds of calls they were. So the next time I went there, there were no phone calls.
When I was in the pre-op area, I asked the nurses, "So, how are you doing on phone calls?"
"It's so quiet around here." That's the answer I got. And it was fabulous because they could look on a board in the pre-op area and see every patient who was either in registration, or maybe they were in surgery check-in. They knew they were coming upstairs to their pre-op area. They had already assigned a nurse; they were ready to go. And in the back, in the OR, they could then look and, by looking at a number of icons that are provided on the Clinical Workflow Suite, they could tell whether the anesthesiologist had been to pre-op, whether the surgeon had been to pre-op, if the nurse was completed, had completed everything they needed to do with the patient, so it was true transparency, and it was quiet. And it was a beautiful thing to watch.
Speaker 1: And just such a better use of their time and letting them do the nursing that they trained to do.
Charlotte D.: And that's another excellent point because I was recently standing and watching surgeries again, and it's really nice to see the circulator actually standing at the bed of the patient taking care of the patient and not having to run over to a hard-wired phone and call and page the surgeon or call and page the anesthesiologist. Everybody knows the patient has rolled into the room. And so, the circulator can actually stand there and take care of the patient, and that's what a circulator does best.
Some of the immediate data that we used, because to me, data is a miracle.
Charlotte D.: It tells the story. It helps me build a case for what I need, and I was able to use the data to build the case for getting the Clinical Workflow Suite. So now I had to build the case for, "Hey, it's actually doing what it's supposed to be doing." So a couple of things we use our data for--every morning at around 8:30 after our first cases have been into the OR, we get a flash report from the OR. It goes out to the C-suite, it goes out to everybody on the capacity team, it goes out to everybody who needs to know anything about how our OR is functioning. And on that flash report is: here's the percent of patients that were on time for the first case of the day.
And so first thing in the morning I see the percentage of on-time cases. But that's not all. Here's the really exciting part--the nurses are so accustomed to putting the delay reasons at now, because the Clinical Workflow Suite gives us that opportunity, if there's a delay, enter a delay code. So now we can actually look at those delay codes and say, "Okay. Why did we have these delays?" And so they'll say, "Which surgeons were late? Was there an anesthesia delay? Was there a medication delay, a pre-op delay, an equipment delay?" So that's all specifically laid out for us and it doesn't just say how many surgeons were delayed, it tells you which surgeons. And it doesn't just tell you which surgeons, it tells you how long they were delayed.
So we get a lot of information, and I just have to explain that we didn't go right there immediately. We wanted to make sure we fixed the in-house processes within the OR before we started looking at anesthesia, or surgeons, or anybody else. So let's fix our problem, and then no one can really point a finger at the OR because they're going to be working better.
So that's what they did. When we finally felt like everything was working like, just spinning really well, that's when we started actually talking to the surgeons, "Okay, now it's your turn. We want you to push the "S" in pre-op; we want you to push the "S" in the OR suite, so we know you've arrived. More and more surgeons are doing that because they get a report card at the end of every month that shows how compliant they were with hitting the "S". They also get a report card that says, "Here's how many first cases you had, and here's your percent delays." It gives a lot of information, and our surgical governance committee really wants to post all the names, but right now we're still doing it individually and we do it in an envelope so that only that surgeon knows where they are.
But, it's really great because the surgeons are on board with it. Those surgeons that are always on time--they are so happy that the surgeons who aren't always on time are finally--there's data to prove that they're late and how often they're late.
So, for an example, we started out at 39% patients on time before we had the Clinical Workflow Suite. Imagine, 39% of our patients on time. That can only mean that you have a lot of unhappy surgery patients sitting there knowing that, "I was supposed to go in at eight or 7:30, and I'm still sitting here." Now, we're up to 61% of our patients on time. It's still not where we want to be, but we implemented it in October, but we didn't really get fully engaged until December, and then everybody was fully-trained by April, so we're talking April to September 2017. That's a short amount of time to go from 39% to 61%.
Charlotte D.: One of the very first things that happened, we brought in a new director of the OR and they made him the Associate Chief Nursing Officer, so that raised his level to a stature that he was able to go into the OR and he had the authority to make the changes and do the things that he needed to do within that suite.
And then we were very short on surgical techs, very difficult to find good surgical techs. So what he inspired was, let's groom our own. He's done a great job of bringing people in from the Community College and actually teaching them the culture of SMH, so now you don't have to retrain people on why things are different at Sarasota Memorial. You train them on the way we do things and what's expected, and it's a much better way to groom our surgical techs. And they love it and they're doing a great job.
And, they came in learning Clinical Workflow Suite, so it wasn't like we had to find people who didn't know it, bring them in and say, "Okay, here's how we do business at SMH." These are new people, this is just the way they know how to do things.
We also brought on ... we used to have two educators. We now have six, and our Associate Chief Nursing Officer believes that education is really key to building a strong organization within the OR, so he's brought on these educators who are divided up into specialty areas and can really get in there and teach and train and bring people up to the level that we want them all to be, so we were very excited about that educational component.
The other thing, we had always tried to have specialty areas. So you'd have certain teams that would work with certain specialties, but we never had enough people, and a lot of it had to do with not having enough surgical techs. We also had problems getting in enough circulators, because there's demand throughout the nation for nurses and we're living through some of that same pain, but through some of the things that our new Associate Chief Nursing Officer did, he's been able to really attract some great circulators.
So we've been able to fill all the positions that were open and he's brought about surgical teams, the physicians are much happier 'cause now they know who they're going to be working with on a day-to-day basis, and those people know how these surgeons act, what their needs are, what equipment they want, what special instruments they might want to have, so having these specialty teams has really been a huge boost within the OR.
All of those types of things have really brought about a massive change within the culture of our OR as well. It's not even the same OR anymore, it's a totally different place. Just to quote one of the surgeons, he said, "Our turnaround times have gotten so good, I feel like I have a flip room now," and years ago when I was in there doing in to incision metrics, all the surgeons wanted to do was tell me what they wanted changed: "Can you help us with this and can you help us with that?" And now it's nice to be able to go into an OR and hear the accolades from the surgeons, or at least you're getting maybe not an accolade, but you can tell that there's a difference in the room. You can tell that the atmosphere is a much more positive place, so it's great.
I keep talking about the Associate Chief Nursing Officer, but I can't say enough about him. The other day we were in the C-Suite, because we have weekly meetings with our Chief Nursing Officer, our COO, our CIO, and we go over all the data from the Clinical Workflow Suite, we go over the utilization, we go over our turnaround times and we go over our first case late starts every week. He was sitting here in the meeting, and he said, "I just want you to know, we would not be this successful without the Clinical Workflow Suite."
Interviewer: With the success of Clinical Workflow Suite, what role did transport play in keeping things on track?
Charlotte D.: Well, it's interesting because we have our own transporters in our PACU and our pre-op area. We actually try to bring the handheld devices to the pre-op areas, and I believe some of them are using the handhelds, but the thing that was even more helpful was how our Manager of Transport wanted to work with us to get our first cases in on a timely manner. So we had meetings with the Transport Manager to try to figure out what were the delays in the past and how could we remove those delays so transport could bring those patients down to the pre-op area and we could make the metrics.
And again, it's not about the metrics, it's about the patient. It's about getting the patient to the OR in a timely manner, because that patient's scared and you don't want them to wait. So whether they're an outpatient or an inpatient you still want that surgery to go on time. So that was our goal. When we discussed it with the Transport Manager, what we found was some of the issues occurred on the units themselves, so for our inpatients there were some delays. So when the transporter would go upstairs to actually take the patient to the OR, what they would find is the patient wasn't ready. And why wasn't the patient ready? Well, I could give you a litany of reasons.
Charlotte D.: But the bottom line was we had to put in a pre-check system. So what we did, we added a liaison from the OR who goes up the day before and checks on every inpatient who's supposed to come to surgery the next day, and actually goes through the checklist with the nurse to find out what's still needs to be done. Do we need a cardiac clearance? Do we need some special medications? Do we need an MRI or a CT? What do we need to get this patient so that when the transporter comes, they're going to be ready the next day. And sometimes it's even, do I need a different IV?
So we have somebody that goes around every day and checks those patients to make sure that they're going to be ready, and that the nurses know what time we're going to be picking those patients up, and how important it is to deliver that patient on time to the OR.
Interviewer: And, Charlotte, I imagine that these changes from transport and the surgical side, your patients' satisfaction grows, must've been impacted positively.
Charlotte D.: Well, patients aren't really thinking about satisfaction scores at the beginning of their journey. It's usually the end of their journey when they're healthy enough to think about what's going on in the inpatient unit, so sometimes we really don't know if we've had an impact on patients' sat scores as far as the surgical areas is ... But I know what we're doing and we know we're still not there; we still have work to do. I still need to fix in to incision time.
As a matter of fact, I was in a heart surgery last week and the doctor said, "You know, I don't care if the patient comes into the room on time, I want to make sure my incision time is good." And I said, "You know what? I'm working on that right now. But for you to have a quick incision time, we've got to get the patient in on time." And he said, "You know, you've got a point there." I said, "So give me a little time and we'll fix that next."
Interviewer: My next question is, what is next? So you said fixing incision time. What else?
Charlotte D.: We have a very exciting rollout ahead of us. For 2018, we're going to be rolling the Clinical Workflow Suite out, actually in December of 2017, into our radiology area, and so we have been working with TeleTracking and the consultants from TeleTracking to design what that's going to look like, 'cause it's very different from what you see in the OR.
It's going to be in our ER area when we do portable X-rays, it'll be in our interventional radiology, it'll be for all MRIs. Every patient, outpatient, inpatient, ER patient, who comes through and needs a radiology test of any kind, the Clinical Workflow Suite will be working with them to get them in and out in a timely manner. So that's just one thing.
Then, in 2018, we're delivering the Clinical Workflow Suite to cath lab.
Interviewer: That was my next question, is it going to extend to other departments?
Charlotte D.: Yes it is, and also to endo. And that's going to be very neat for our anesthesiologists, because the same anesthesiologists who work in the OR and work in interventional radiology also work in the cath lab and endoscopy areas, so they're very excited to have the Clinical Workflow Suite in all of the areas where they are doing anesthesiology work.
We also have a six bay OR suite across the street for outpatients, so Clinical Workflow Suite's already in there and we're monitoring their metrics as well.