PERFECT MEASUREMENTS What's the one benchmark you religiously track at your surgical facility, the one number that tells you you're on the right path?

Surgery is awash in statistics, perhaps more so than any other branch of medicine. To know how you're doing in the operating room, just compare your performance against surgery's many magic numbers and hallowed yardsticks: turnover times, infection rates, block time utilization, first case on-time starts. But which numbers matter most? Which are the best barometers for how your ORs are doing? We asked a panel of surgical facility leaders for the benchmarks that matter most. Here are their top 10.

1First case on-time starts
"Just like breakfast is the most important meal of the day, on-time starts are the most important benchmark for how your whole day will go," says Faith True, MBA, BSN, RN-NE-BC, CNOR, CGRN, CIC, CHL, director of perioperative services at SoutheastHEALTH in Cape Girardeau, Mo.

SoutheastHEALTH feels so strongly about its on-time starts that it made it a team outcome metric to determine individual merit raises for the entire perioperative area, including anesthesia, says Ms. True. They began last year in the 40% to 50% range of on-time starts, "so we really had nowhere else to go but up," says Ms. True. And up they've gone. The medical director of anesthesia speaks to every late surgeon every day to determine why he was late. If need be, they'll push delinquent surgeons' start times back in 15-minute increments (0815, 0830, 0845 and sometimes even 0900) if they consistently can't get to their first case on time. "Now," says Ms. True, "we're up to 80% and sometimes 90+% on-time first starts."

Many facility managers feel on-time starts are the most important indicator of operating room efficiency. "If cases don't start on time, then there is potential for a cascade effect on the cases that follow," says Michael S. Seator, MBA, BSN, CNOR, administrative director of surgical services and central sterile processing at Detroit Medical Center's Harper University Hospital in Michigan. Late starts mean patients are spending more time than they'd like at your facility, which can drag down your patient satisfaction scores.

Tardy surgeons who are repeat offenders at Harper University Hospital receive a letter warning them that they'll lose the ability to board cases before 0700 for a month, says Mr. Seator. If it continues, it moves to 2 months and then 3. "Usually it only occurs once where the surgeon is not allowed to board first cases before they arrive routinely on time," he says.

It's a good idea to require your surgeon to be ready 10 to 15 minutes before the scheduled start time — a 0720 in-room time for a 0730 case, for example. You'd bring the patient back to the OR at 0715 for induction as the team continues to set up the room.

While surgeons are often to blame for late starts, it's not always their fault. Anesthesia (did you start the block an hour beforehand?), the OR staff (slow turnover time) and central sterile processing (where's that big piece of equipment?) could also cause delays. "Surgeons have reported that the reason they may be late is because the OR is never ready for them," says Mr. Seator. "In a time when surgical volume is king, late-starting cases are a big surgeon dissatisfier. Physicians will see this as a potential reason to move their cases elsewhere."

At Chickasaw Nation Medical Center in Ada, Okla., Surgery Center Manager Ralania Tignor, RN, BSN, is hoping a little friendly competition among her surgeons will lead to improvements. She recently began sending individual surgeons on-time start data for comparison purposes.

2Staff hours per case
If it's true, as Steve Noe, RN, director of surgical services at Huntsville (Ala.) Hospital, says, that "labor is the expense that you can control the most," you'll want to know staff hours per case down to the minute. The industry-wide average for staffing costs as a percentage of collections is 21%. Calculate this figure by totaling up all the hours your clinical staff has worked during a set period of time, then dividing that sum by the number of cases performed during that time. A good benchmark to follow: 6 to 8 staff hours per case.

"It's the benchmark that all levels of management can look at and know, in an instant, whether the staffing for the day was appropriate," says LoAnn Vande Leest, CEO of Northwest Michigan Surgery Center in Traverse City, Mich.

Dan Simonson, CRNA, MHPA, of Spokane, Wash., breaks this benchmark down into 3 categories: licensed clinical (RNs), non-licensed clinical (everyone else who touches patients) and non-clinical (administrative folks). "This is our most effective benchmark," says Mr. Simonson, "because we can now measure against the most important benchmark: our historical selves."

When measuring staff hours per case, be sure you track actual worked hours in the OR. As one manager reminded us, "paid hours" is a much wider net that captures significant unproductive hours and paid time off.

"In surgery, staffing is the biggest cost of doing business, so we want to make sure we keep it under control and reel it back in if it gets out of line," says Emily Duncan, RN, BS, CASC, CNOR, executive director of the Lakeland (Fla.) Surgical & Diagnostic Center. "This is almost impossible to correct if you allow it to get out of your established benchmark."

Martha Bush, RN, director of surgical services at Mat-Su Regional Medical Center in Palmer, Alaska, drills down even further. She wants to know what 1 minute of operating time costs. She tracks cost-per-case minutes broken into expense categories (routine supplies, surgical supplies, staff hours and wages, implants and pharmaceuticals) by service and by surgeon.

3Costs as a percentage of net revenue
"My new favorite benchmark to track is costs as a percentage of net revenue," says Corbett Jackson, CASC, regional administrator of the Sutter Surgery Center Division in Novato, Calif. "Specifically, I watch salaries, supplies and total costs as a percentage of net revenue. I find this indicator to be the best equalizer to compare facilities of different sizes, cases or payor mixes."

4Turnover time
You're all familiar with turnover time. It's the time it takes between the surgeon's first case and the second. "Another way of saying it is wheels-out to wheels-in," says Nancy G. Thompson, RN, BS, director of perioperative services at Upstate University Hospital in Syracuse, N.Y. The lower the turnover time, the better: 7 minutes for short cases and 10 minutes for longer ones. It's long been held that a 10-minute turnover time is a reasonable goal.

5Block time utilization
Surgeons love being able to reserve operating room time, but it's up to you to make sure that they're using that time as efficiently as possible. Whatever your block utilization rate threshold, know how much of their block time doctors must use in order to keep it. Leila Welborn, MD, medical director of the ASC at Children's National Medical Center in Washington, D.C., tracks the number of cases per month, per surgeon, per department. When blocks drop, be swift to act. If a doctor doesn't use at least 75% of the block time, Mike Pankey, RN, MBA, administrator of the ASC of Spartanburg (S.C.), cuts it back. Be judicious with permanent block time slots. Only dole those out to surgeons with heavy caseloads that you reasonably expect will fill their block at least 75% of the time.

6Surgical site infections
The benchmark is to have zero surgical site infections. To that end, you should measure whether you start antibiotics within 60 minutes of the incision. "This is a SCIP initiative that is publically reported," says Denise Yeager, RN, CNOR, nurse manager at the Mount Nittany Medical Center in State College, Pa.

The challenge in benchmarking SSIs is finding out about them. You most likely will have discharged the patient long before a SSI flares up. Jill Andrews, RN, BSN, CNOR, administrator at the Central Utah Surgical Center in Provo, Utah, sends a form to all surgeons with information on all their procedures for the month. If there is a reported infection, she and her infection control specialist retrace the surgical paper trail. They first study the chart to see if there was anything that would have triggered the infection. They look at the patient's history and comorbidities, the timeliness of antibiotic administration, the sterilization logs and the operating room record. "We check to see if there was something in the visit that would have precipitated the infection," says Ms. Andrews, who checks with the surgeon's office to see if any lab work was done or cultures taken, checking to see what organism grew, if any. "We track this data on a spreadsheet and meet quarterly with an infectious disease specialist to report our statistics, along with the number of surgical procedures for that quarter," she says, adding that the specialist tracks quarterly and yearly infection rates.

7Patient satisfaction
Plastic surgeon Evan Sorokin, MD, FACS, of Delaware Valley Plastic Surgery in Cherry Hill, N.J., calls patient satisfaction a very important result. "This endpoint is a totality of the way patients were treated by staff, anesthesia, nurses and the physician," says Dr. Sorokin. "If patients aren't completely satisfied, then their concerns must be carefully considered as potential improbable factors."

At the Chugay Cosmetic Surgery Medical Clinic in Long Beach, Calif., they check patient satisfaction questionnaires "to monitor surgical results of each one of our surgeons." At the Torrance (Calif.) Surgery Center, they call each patient the day after surgery ("even to the point of taking home a work cell phone on Saturdays," says Megan Moore, RN, BSN, CPAN) to let patients know they're checking on them. "The patents tell us they feel appreciated and not just like another surgery. It gives us a quick feedback on how we are doing when they have the experience fresh in their minds," says Ms. Moore.

8Delayed discharge
Whatever the reason for a patient's delayed discharge, Nicomedes W. Pasia, BSN, RN, nurse administrator of the Massachusetts Avenue Surgery Center in Bethesda, Md., wants to know precisely what it is. Did the prior case run over? Was there an equipment delay? Here's something you can easily benchmark, says Mr. Pasia. When patients are in PACU for more than 2 hours, find out why. Was it pain or severe PONV? Were they waiting to void or waiting for a ride?

9Referral sources
Do you know how that patient arrived in your facility? "We track the number of incoming referrals from our various referral sources to identify any trends," says Angela Weeks, vision education specialist at the Advanced Vision Institute in Williamsburg, Va. "This lets us understand where our patients are coming from and any changes in referral patterns."

10Physician case costs
"One of my favorite internal benchmarking reports is when you compare the same procedure within the same specialty between your physicians," says Marcy W. Sasso, CASC, director of compliance and development at Facility Development & Management in Orangeburg, N.Y.

At one of her centers, they looked at an EGD without a biopsy and tracked the length of the procedure and the cost for the procedure for all 6 GI physicians within the center. She plugged the data onto a spreadsheet and shared it with the physicians during the next meeting. The surgeon who had the highest case cost wanted to know how the other physician used $12 less per case, and another wanted to know about shaving off turnover time for the case. "The dialogue that transpired was so beneficial to the center that we now do it for all specialties," says Ms. Sasso.

Worth the time and effort
Benchmarking takes time out of your busy day, but the results could be well worth it in the long run. "Any type of benchmarking that is done with a true purpose for data collection is useful and warranted," says Ms. Sasso. "The data collected and reviewed should be beneficial to the center, either to improve a process or to indicate that the center is on track with all aspects of the performance and goals."