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Theme: Inclusion and Collaboration Theme: Inclusion and Collaboration

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System Analysis Identifies Preparatory Time as a Substantial Source of Hand Surgery Operating Room Inefficiency
Michael Milone, MD; Orthopaedics, New York University Hospital for Joint Diseases, New York, NY; Louis W Catalano, MD; New York University Hospital for Joint Diseasses, New York, NY; Mark Saraceni, MBA; New York University Hospital for Joint Diseases, New York, NY; Heero Hacquebord, MBA; APT Leadership LLC, West Cape, South Africa; Jacques Henri Hacquebord, MD; Department of Orthopaedic Surgery, University of California Irvine, Orange, CA


Maximizing operating room efficiency is important.  However, little attention is paid to the role of preparatory time (time from when patient enters the operating room to incision).  We hypothesize that preparatory time is an important contributor to hand surgery operating room inefficiency. 


189 consecutive hand surgery cases from an outpatient surgical center were reviewed.  Wide awake local only cases were excluded. Prep time was defined as the time from the patient entering the operating room to skin incision.  We assessed mean and variations in prep time for all cases and analyzed relationships with surgeon, anesthesia, and start time.  We employed ANOVA and t-tests to assess the statistical significance of these variables and control charts (ProAptive 2.0) to determine process variation and outliers. 


14 hand surgeons were included with a.mean prep time of 25.5 minutes but range from 7-61 minutes (Figure 1).  On average, prep time was 82% of total surgical time.  In 37% of cases, prep time exceeded that of surgical time.  ANOVA revealed a significant difference amongst prep times by surgeon (p<0.0001).  3 surgeons had mean prep time > 30 minutes, 6 between 25 and 30 minutes, 3 between 20 and 25 minutes, and 1 less than 20 minutes.  T-testing revealed that prep time was only 7 minutes longer in cases that received an anesthetic block preoperatively (29 minutes, N=92) compared to those that did not (22 minutes, N=92).  There were no differences in prep time for ASA 1 versus ASA 2 (p=0.97), first start cases (p=0.13), of for cases after 2 pm (p=0.82).  Individual values control chart revealed that process variation ranged from 8 to 51 minutes. The three prep times that fell outside the control limits are outliers by definition.  Figure 1 also identifies Surgeon Y as consistently under the mean in prep time.



Preparatory time is highly variable and contributes to a substantial portion of surgical time. This variability is much greater than expected, highly undesirable and detrimental to plan an elective outpatient OR schedule.  Any effort to decrease the variability and mean prep time must focus on improving the process.  Analysis also revealed that surgeon had greatest effect on prep time. The next step will be to analyze best practices and implement process changes.

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