The operating room (OR) is the economic hub of most healthcare systems in the United States today, generating up to 70% of hospital revenue. Ensuring these financial powerhouses run efficiently is a major priority for healthcare providers. But there’s a challenge. Turnovers—cleaning, preparing, and setting up the OR between surgeries—are necessary and unavoidable processes. OR turnovers can incur significant costs in staff time and resources, but at the same time, do not generate revenue. For surgeons, the lag between wheels out and wheels in is idle time. For incoming patients, who may have spent hours fasting in preparation for a procedure, it is also a potential source of frustration and anxiety.
Reducing OR turnover time is a priority for many US healthcare providers, but it’s far from simple. For one thing, cutting corners in pursuit of efficiency risks patient safety. Then there’s the makeup of OR teams themselves. As a rule, well-established or stable teams work fastest and best, their efficiency fueled by familiarity and well-oiled interpersonal dynamics. But in hospital settings, staff work in shifts and according to different schedules, which creates a certain fluidity in the way turnover teams amalgamate. These team members may not know each other or have any prior experience working together.
For hospital administrators this represents a quandary. How do you cut OR turnover time without compromising patient care or hiring in more staff to build more stable teams? To put that another way: how do you motivate OR workers to maintain standards and drive efficiency—irrespective of the team they work with at any given time?
One novel approach instituted by Georgia’s Phoebe Putney Health System is the focus of new research by Asa Griggs Candler Professor of Accounting, Karen Sedatole PhD. Under the stewardship of perioperative medical director and anesthesiologist, Jason Williams MD 02MR 20MBA, and with support from Sedatole and co-authors, Ewelina Forker 23PhD of the University of Wisconsin and Harvard Business School’s Susanna Gallini PhD, staff at Phoebe ran a field experiment incentivizing individual OR workers to ramp up their own performance in turnover processes.
What they have found is a simple and cost-effective intervention that reduces the lag between procedures by an average of 6.4 percent.
Homing in on the Individual
Williams and his team at Phoebe kicked off efforts to reduce OR turnover times by first establishing a benchmark to calculate how long it should take to prepare for different types of procedure or surgery. This can vary significantly, says Williams: while a gallbladder removal should take less than 30 minutes, open-heart surgery might take an hour or longer to prepare.
“There’s a lot of variation in predicting how long it should take to get things set up for different procedures. We got there by analyzing three years of data to create a baseline, and from there, having really homed in on that data, we were able to create a set of predictions and then compare those with what we were seeing in our operating rooms—and track discrepancies, over-, and underachievement.”
Williams, a Goizueta MBA graduate who also completed his anesthesiology residency at Emory University’s School of Medicine, then enlisted the support of Sedatole and her colleagues to put together a data analysis system that would capture the impact of two distinct mechanisms, both designed to incentivize individual staff members to work faster during turnovers. The first was a set of electronic dashboards programmed to record and display the average OR turnover performance for teams on a weekly basis, and segment these into averages unique to individuals working in each of the core roles within any given OR turnover team. The dashboard displayed weekly scores and ranked them from best to worst on large TV monitors with interactive capabilities—users could filter the data for types of surgery and other dimensions.
Broadcasting metrics this way afforded Williams and his team a means of identifying and then publicly recognizing top-performing staff, but that’s not all. The dashboards also provided a mechanism with which to filter out team dynamics, and home in on individual efforts.
“If you are put in a room with one team, and they are slower than others, then you are going to be penalized. Your efforts will not shine. Now, say you are put in with a bigger or faster team, your day’s numbers are going to be much higher. So, we had to find a way to accommodate and allow for the team effect, to observe individual effort. The dashboards meant we could do this. Over the period of a week or a month, the effect of other people in the team is washed out. You begin to see the key individuals pop up again and again over time, and you can see those who are far above their peers versus those who, for whatever reason, are not so efficient.” Sharing “relative performance” information has been shown to be highly motivating in many settings. The hope was that it would here, too.
Three core roles: Who’s who in the Operating Room turnover team?
OR turnover teams consist of three roles: circulating nurse, scrub tech, and anesthetist. While other surgery staff might be present during a turnover, depending on the needs of consecutive procedures, these are the three core roles in the team, and they are not interchangeable in any way: each individual assumes the same responsibilities in every team they join. Typically, turnover tasks will include removing instruments and equipment from the previous surgery and setting up for the next: restocking supplies and restoring the sterile environment. Turnover tasks and activities will vary according to the type of procedure coming next, but these tasks are always performed by the same three roles: nurse, scrub tech, and anesthetist, working within their own area of expertise and specialty. OR turnover teams are assembled based on staff schedules and availability, making them highly fluid. Different nurses will work with different scrub techs and different anesthetists depending on who is free and available at any given time.
With dashboards on display across the hospital’s surgery department, Williams decided to trial a second motivational mechanism; this time something more tangible.
“We decided to offer a simple $40 Dollar Store gift card to each week’s top performing anesthetist, nurse, or scrub technician to see if it would incentivize people even more. And to keep things interesting, and sustain motivation, we made sure that anyone who’d won the contest two weeks in a row would be ineligible to win the gift card the following week,” says Williams. “It was a bit of a shot in the dark, and we didn’t know if it would work.”
Altogether, the dashboards remained in situ over a period of about 33 months while the gift card promotion ran for 73 weeks.
It was important to stress the foundational importance of safety and then allow individuals to come up with their own ways to tighten procedures. This was a bottom-up, grassroots experience where the people doing the work came up with their own ways to make their times better, without cutting corners, without cutting quality, and without cutting any safety measures.
Jason Williams MD 02MR 20MBA
Incentives: Make it Something Special and Unique
Crunching all of this data, Sedatole and her colleagues could isolate the effect of each mechanism on performance and turnover times at Phoebe. While the dashboards had “negligible” effect on productivity, the addition of the store gift cards had immediate, significant, and sustained impact on individuals’ efforts. Differences in the effectiveness of the two incentives—the relative performance dashboard and the gift cards—are attributable to team fluidity, says Sedatole.
“It’s all down to familiarity. Dashboards are effective if you care about your reputation and your standing with peers. And in fluid team settings, where people don’t really know each other, reputation seems to matter less because these individuals may never work together again. They simply care less about rankings because they are effectively strangers.”
Tangible rewards, on the other hand, have what Sedatole calls a “hedonic” value: they can feel more special and unique to the recipient, even if they carry relatively little monetary value.
Something like a $40 gift card to Target can be more motivating to individuals even than the same amount in cash. There’s something hedonic about a prize that differentiates it from cash—after all, you will just end up spending that $40 on the electricity bill.
Asa Griggs Candler Professor of Accounting, Karen Sedatole
“A tangible reward is something special because of its hedonic nature and the way that human beings do mental accounting,” says Sedatole. “It occupies a different place in the brain, so we treat it differently.”
In fact, analyzing the results, Sedatole and her colleagues find that the introduction of gift cards at Phoebe equates to an average incremental improvement of 6.4% in OR turnover performance; a finding that does not vary over the 73-week timeframe, she adds. To get the same result by employing more staff to build more stable teams, Sedatole calculates that the hospital would have to increase peer familiarity to the 98th percentile: a very significant financial outlay and a lot of excess capacity if those additional team members are not working 100% of the time.
These are key findings for healthcare systems and for administrators and decision-makers in any setting or sector where fluid teams are the norm, says Sedatole: from consultancy to software development to airline ground crews. Wherever diverse professionals come together briefly or sporadically to perform tasks and then disperse, individual motivation can be optimized by simple mechanisms—cost-effective tangible rewards—that give team members a fresh opportunity to earn the incentive in different settings on different occasions—a recurring chance to succeed that keeps the incentive systems engaging and effective over time.
For healthcare in particular, this is a win-win-win, says Williams.
“In the United States we are faced with lower reimbursements and higher costs, so we have to look for areas where we can gain efficiencies and minimize costs. In the healthcare value model, time and costs are denominators, and quality and service are numerators. Any way we can save on costs and improve efficiencies allows us to take care of more patients, and to be able to do that effectively.
“We made some incredible improvements here. We went from just average to best in class, right to the frontier of operative efficiency. And there is so much more opportunity out there to pull more levers and reach new levels, which is truly encouraging.”
Looking to know more or connect with Asa Griggs Candler Professor of Accounting, Karen Sedatole? Simply click on her icon now to arrange an interview or time to talk today.
