MEASURED STEPS The dance of the turnover team should be closely choreographed.

In the quest to run an efficient surgical facility, you're always looking to shave seconds off your turnover times so you can start the next case sooner and squeeze another case onto the schedule, all in the hopes of keeping your ORs hopping and your surgeons happy. Last month we went searching for the secrets to rapid turnover times.

Before we get to the how, however, let's first address the who. As in, who should be on your turnover team? Should it be an all-hands-on-deck mad dash to ready the room for the next case, or is it better to form a dedicated platoon of turnover specialists who are on cleanup duty all shift long? Everyone's job, or the job of a few good men and women? Let the debate begin.

Turnover is everyone's job
"Everyone is the turnover team," says Jenna Pon, ADN, BSN, administrator of the Outpatient Surgery Center of La Jolla (Calif.).

"No one is above helping with turnover," adds Kelly Wilson, RN, administrator of the Ponte Vedra (Fla.) Plastic Surgery Center. "Nurses, scrubs and techs all participate in turnovers. No one is too good to mop or wipe down equipment. Turnover is everyone's job."

Some facilities literally sound the alarm when a room's ready to be turned over, relaying via walkie-talkies that the procedure is finished, the patient is ready to be transferred and the room is ready to be turned over, or announcing on an overhead page that "Room 2 needs turnover help."

"No prima donnas. The entire room staff participates in the turnover and setup of the next case — even anesthesia," says Denise Wooten, ASN, RNFA, nurse manager of the Renue Surgery Center in Waycross, Ga.

"Even the doctors are involved and will walk or wheel the patients in and out of the OR while the rest of the team is turning over," says Mary Radke, RN, BSN, manager of the Dakota Surgery and Laser Center in Bismarck, N.D.

CHOREOGRAPHED CHAOS The moment a case ends, the OR should be cleared of trash and dirty linens, and wiped down.

Send in the turnover team
But you'll also hear from surgical facilities who favor a more specialized turnover concept, a dedicated team of quicker-picker-uppers who do nothing but take out the trash, make up the tables and wipe down the equipment. They'll argue that less can be more with room turnover. And by less, they mean fewer people with clearly defined roles.

"Approach room turnover like a NASCAR pit crew where everyone has a specific job and knows their role," says Tina Piotrowski, RN, BSN, the clinical director of the Northwest Michigan Surgery Center in Traverse City, Mich. "Having more people involved in turnovers isn't necessarily as important as having the right amount of staff all knowing what their job in the turnover is. Sometimes if you have too many people, nothing really gets done because everybody assumes that someone else took the trash out, wiped down the bed or changed the breathing circuit. Fewer people with more defined roles is the better way to go."

This is not to say that Ms. Piotrowski won't plug in staff to lend a hand on the turnover team. When you host 19,000 cases a year, as Northwest Michigan does in its 6 main ORs, 3 GI suites and 1 minor procedure room, there are plenty of opportunities for team members to pitch in. If the radiology tech isn't taking X-rays, she's expected to help the OR aides ready the room. There's also the case mix to consider. The staff at Northwest Michigan huddles at the start of each day to identify the potential bottlenecks in the schedule. "We identify those rooms that need the most focused attention," says Ms. Piotrowski, explaining that turning over a room after an orthopedics case is much more involved and labor-intensive than cleaning up after a cataract case.

"It's important to allocate your resources properly," she says, "and to have a game plan so that everyone knows what the plan is at the start of the day."

You'll also find a dedicated turnover team at Harper University Hospital in Detroit, Mich. The team checks each case cart before the start of each case to ensure all supplies and equipment are present, says Michael Seator, MBA, BSN, Harper's administrative director of surgical services. The team also removes the used case cart from the room, cleans the room and begins opening essential supplies while the surgical tech scrubs and the circulating RN check the next patient.

TARGET PRACTICE
Preset Your Turnover Times by Procedure

TIME BANDITS The Mercy Medical Center in Canton, Ohio, writes the target turnover time on a white eraser board.

The Mercy Medical Center in Canton, Ohio, has assigned a target turnover time for every procedure it hosts, from a low of 10 minutes for basic cataract cases to a high of 45 minutes for a craniotomy (see table below). They use wheels-out to wheels-in to measure.

"At the end of the case, the RN says, 'The time for this turnover is X. Do we all feel we can meet that time?' If anyone knows of a problem, they state it. Otherwise, we write that time on the whiteboard and everyone strives to meet that time," says Vicki Merrick, RN, BSN, CASC, Mercy Medical's administrative director of surgical services.

Target Turnover Times GEN, GYN, GU, Vascular, Robot
General Major	20 minutes
General Minor	15 minutes
GYN Major	20 minutes
GYN Minor	15 minutes
GU Major	20 minutes
GU Minor	15 minutes
Vascular/Endovascular	20 minutes
Robotics	30 minutes
Ortho/Neuro
Ortho Major	30 minutes
Ortho Minor	15 minutes
Ortho Spine	30 minutes
Arthroscopic	20 minutes
Neuro/Crani	45 minutes
ENT, Eyes, Plastics, Dental, OM
Phaco	10 minutes
Retina	15 minutes
ENT Minor	10 minutes (peds <10: 15 min)
ENT Major	20 minutes
Plastics Major	20 minutes
Plastics Minor	15 minutes
Oral Rehab	15 minutes
Oral-Maxillofacial	20 minutes

After consulting with her staff, Ms. Merrick laid out her turnover targets like this. You can turn over a room between ear tubes and tonsils in 10 minutes. Then you've got such middle-of-the-road cases as abdominal and minor orthopedic surgeries that might take 15 to 18 minutes to turn over. Then you've got your major bone cases (total hip and knee replacements) that can take 30 to 40 minutes to turn over because you've got lots of equipment and instrumentation being moved in and out of the room.

"It's not reasonable to say every room turnover is 20 minutes or 45 minutes," says Ms. Merrick. "You can do a string of small ENT cases or 4 or 5 total joints. Each one of those has a different expected turnover time."

Ms. Merrick has assigned each team member a specific role so "you don't have people falling all over themselves and repeating what someone else is doing."

he benefit of writing the target turnover time in each OR for all to see? "The written time is a visual goal," says Ms. Merrick. "This is the number you're trying to get the patient back in the room by. Right now, everyone is competing for surgical volume. To a surgeon, efficiency and time are money. The quicker and the more efficiently that we can get that surgeon's cases processed through surgery safely, the faster that we can get him back into this office to see more patients, the happier he is and the more likely that he is to send us more business."

— Dan O'Connor

SPIC 'N' SPAN The turnover team at Northwest Michigan Surgery Center in Traverse City, Mich., takes out the trash and linen, transports the dirty instruments, mops the room and resets for the next case.

Choreographed steps
Teamwork is essential to fast turnover, but choreography runs a close second. In room turnover, choreography — which literally means "dance-writing" — means many moving parts moving with purpose, precision and urgency. Check out some of your colleagues' fancy footwork:

• Parallel Processing. "Once the patient is wheeled out of the OR, the RNs and techs break down the room simultaneously while housekeeping begins the cleaning. Housekeeping used to wait until the nurses were done, which bloated turnover times to more than 40 minutes. Now, turnover is 15 to 20 minutes," says Lorraine Ensminger, MSN, perioperative educator at Jersey City (N.J.) Medical Center.
• Facilitator Nurse. "The facilitator nurse evaluates each patient in pre-op and transports the patient to the OR, then hands off the patient to the circulator. The facilitator assists the anesthesia provider with intubation and induction so the circulator can continue setting up the case. At the end of the case, the circulator hands off the patient to the facilitator, providing detailed information regarding the procedure and patient plan. The facilitator transports the patient to the PACU with the anesthesiologist and hands off the patient to the PACU RN staff. The circulator doesn't need to leave the OR at the end of the case, thus allowing for swift cleanup and setup for the next procedure. The facilitator goes immediately to the holding area to interview, check-in and transport the next patient to the OR," says Sandi Witcher, RN, BSN, MPA, director of the Plaza Surgery Center in Santa Maria, Calif.
• Next Case, Please! "Our team starts wiping down non-used items as the patient leaves the room. The scrub leaves with the instruments and we attack the room. One person wipes all equipment while one wet-mops the floor. While they are cleaning, the tech comes back with new linen and makes the OR table. Bring in the next case," says Steve Harp, materials manager at Cedar Park (Texas) Surgery Center.
• Hand Me a Mop! "The circulators gather the trash, linen and suctions, and have them bagged when the OR assistants enter the room. Once the patient is out of the room, the surgical techs and the ORAs wipe down the tables and equipment. All that's left to do is mop," says Myron E. Lawson, lead operating room assistant at Carolinas Medical Center-NorthEast in Concord, N.C.
• Two-Tech Two-Step. "We have 2 techs on our busy cataract days. At the end of the case, tech No. 2 cleans up, gets the next case's supplies and opens them while tech No. 1 takes the used trays to sterile processing, then scrubs and goes back into the OR to start setting up. We literally have a 5-minute turnaround time, which includes the CaviWipe contact time of 3 minutes. We have 6 trays, so we have time to reprocess trays using 2 autoclaves," says Emily Duncan, RN, BS, CASC, CNOR, executive director of the Griffin Road Campus of Lakeland (Fla.) Surgical & Diagnostic Center. A note on kill times: You might consider switching to a disinfectant with a 1-minute kill time. "This saves at least 2 minutes of waiting for it to dry," says Mike Pankey, ADN, BA, MBA, administrator of the ASC of Spartanburg (S.C.).

Let staff know you're watching
Know the old saying, what gets measured gets done? Let your staff and surgeons know that you're tracking turnover times and case delays, says Deborah Niccolini, BSN, director of surgery at Memorial Hospital of Union County in Marysville, Ohio. "Collect and analyze this data to identify causes and bottlenecks, and discuss the results at meetings to keep the process on everyone's mind."

Pay for performance, says Paul Rein, DO, medical director of the Port Warwick Ambulatory Surgery Center in Newport News, Va. Dr. Rein incentivizes the nursing staff with bonus money. He sets standard turnover times. Staff know they'll be rewarded with a bonus if they meet or exceed the case-dependent times. "Amazing what a little money will do to make the process more efficient," he says.

Your scheduler can assist with room turnover by ensuring that like cases and the same laterality of surgical site follow one another. "Group your arthroscopic cases with same procedure and same side to reduce furniture and cart rearranging," says Lizbeth Bozeman, RN, CNOR, OR director of the Virginia Beach (Va.) ASC.

Your surgeons can help, too. Ask them to mark patients when they're done with the previous procedure, but before they dictate. "Oftentimes our physicians disappear into dictation and then get sucked in to other phone calls and we're waiting on them to take the patient back to the OR," says Stacy Meadows, RN, pre/post team leader at Court Street Surgery Center in Redding, Calif.

OR turnaround kits are a great idea. These pre-packaged kits contain all the materials that are necessary to turn the room around quickly: all disposable table pads, arm covers, laundry bags, biohazardous bags, mops and whatever other products that your facility uses to turn around the room.

"The secret sauce to our rapid turnover is that we all share the responsibility of the tasks involved: the nurses, the scrubs, CRNAs, everyone," says Karen Brown, RN, BSN, team leader of the Meridian (Miss.) Surgery Center. "Anything that needs doing gets done in a timely manner. Because we are a small facility, we are the housekeeping staff until after hours when the cleaning service arrives. Turnover times that are too long can add hours to your day and subtract dollars from your bottom line over the course of a year. It is a total team effort, and we take great pleasure in providing our doctors with a rapid turnover."