Operating Room

OR of the Future: It's Here and Now

By Chris Serb

Even smaller hospitals can adapt this project’s down-to-earth ideas

The “Operating Room of the Future” might be a misnomer. The ORF project, sponsored by the Center for Integration of Medicine and Innovative Technology and launched by Massachusetts General Hospital in 2002, has a name that came out of Buck Rogers. And the focus sounds futuristic, too: The ORF leverages a combination of technology, architecture and staffing to significantly improve OR productivity.

But even though the results have proven groundbreaking, the project’s leaders insist that there’s no big mystery. “There’s nothing experimental or prototype-y being used in the Operating Room of the Future,” says Warren Sandberg, the ORF’s co-program leader and an anesthesiologist at Massachusetts General in Boston. “We’re using equipment that’s readily available, any architect could wrap their mind around the design, any community hospital could make this work.”

The project achieves its gains from synergy between several basic components:

Changing workflow: In traditional ORs, “serial” processes are all done in a row, with nurses, surgeons, anesthetists and even housekeeping waiting idle until the previous task is done. In the ORF, several “parallel” processes save time; for example, anesthesia is administered while the OR is being prepped.

Redesigned architecture: The ORF-Massachusetts General’s pilot room was carved out of an old storeroom, and includes an induction room, operating room, early recovery room and surgeons’ work space, which enables the parallel processes.

Technology improvements: The ORF incorporates a “Wall of Knowledge,” which presents streaming video, important patient data captured from monitoring equipment, even identification of which personnel are in the room at any given time. A much-simpler technology, mobile operating tables, shave time off each case by eliminating the need to physically transfer patients between stretchers and operating tables. They also enhance patient safety by keeping anesthetized patients stable from pre-op to recovery.

Staffing changes: To support the parallel processes, the ORF required a 1:1 anesthetist-to-OR ratio, compared with a 1:2 ratio for the standard operating room. The Operating Room of the Future also added a perioperative nurse to admit patients to the suite and provide early recovery care, freeing up anesthesia personnel to focus on the next case.

After a two-year pilot study, the ORF’s initial results were published in 2005. The results were dramatic: Nonoperative time was cut nearly in half, and the ORF was able to handle an extra case per day compared with the standard OR. The ORF also proved to be budget-neutral; the additional staffing costs were balanced by additional revenue from the extra procedures.

The Power of Parallel Processes

The Operating Room of the Future is just the latest in a long line of attempts to make surgery more efficient and squeeze in additional cases. Many of those other projects have shown initial promise before operating room teams reverted to old practices. The ORF’s productivity gains and budget neutrality, on the other hand, have held up in several follow-up studies.

“The fundamental difference between the Operating Room of the Future and other process improvement projects is that the ORF made the new desired process the most natural way to go about things in that space,” Sandberg says. “The new process is the natural one for that space, so that’s the one you get whether you’re paying attention to it or not.”

One of the project’s key aspects was to look at how operating rooms actually operate. You can only gain so much from telling people to complete their tasks faster; but much bigger gains could be made by reworking what clinicians and ancillary staff did with their time.

“People had thought, ‘Yeah, maybe we can work on turnover time,’ and that meant everybody had to work faster,” says Dan Krupka, a principal with Twin Peaks Group of Sherbourn, Mass., who conducted a study on productivity gains from OR reengineering programs. “With the Operating Room of the Future and with other trials done around the world, people caught on to the fact that you should look not only at turnover time but at nonoperative time, which includes anesthesia induction time and anesthesia emergence time.”

Those studies led to the focus on parallel processing; but Sandberg cautions that parallel processing can’t work in isolation.

“You need a congruence of all those elements,” he says. “It’s not enough to have an induction room if you don’t have the technology to safely anesthetize and move patients; technology alone isn’t enough without the additional space; the space itself is no good without additional personnel.”

A wide range of disciplines can gain “soft” benefits from the ORF’s technologies: the Wall of Knowledge can benefit any surgical team, and improved workflow is always a noble goal. But the program leaders point out that the ORF concepts can only realize financial benefits in ambulatory or other short surgeries.

“If you’re going to reduce nonoperative time, you can only save enough time to add a case routinely in ORs that run short cases,” Krupka says. “This opportunity doesn’t exist in every room. By nature it’s a limited application—unless you’re running an ambulatory surgery center where every case is short.”

So Much Information, So Easy to See

If there’s anything futuristic about the Operating Room of the Future, it’s the Wall of Knowledge, which runs a large flat-panel surgical video screen alongside an integrated patient information display. That display features patient demographics; allergies; case information including diagnosis, procedure and type of anesthesia; current staffing information, transmitted by RFID; and a case progress log, including prompts and checklists.

When it first opened in 2002, the ORF didn’t include the integrated display, just the video screen. “There was nothing else about the patient available—allergies, vital signs, blood pressure, even who the other people in the room were,” Sandberg says. “So we saw an opportunity to have another display next to the surgical display with other important information. We wouldn’t have realized the need for this if the Operating Room of the Future wasn’t there and we weren’t already pushing the envelope.”

That need led the ORF project to partner with LiveData, a Cambridge, Mass., technology vendor. LiveData was working on an integration-and-display prototype for the Department of Defense, and jumped at the chance to go live with a similar project.

“The idea of presenting a crisp synopsis of everything about this patient that matters in real-time, up on a big screen so everyone can see, just seems so obvious,” says Jeffrey Scott, LiveData’s vice president of marketing and business development. “It’s very hard to do; you have to get the information from so many different points. But it’s logical and it’s very visual, and it’s clicked with many people.”

Dubbed the “OR Dashboard,” the LiveData product synchronizes data feeds from several different systems. New York’s Memorial Sloan-Kettering Cancer Center had posted similar information on operating room walls, but in a very low-tech way; a nurse scrawled updates in colored marker on a whiteboard. When Sloan-Kettering executives heard about the OR Dashboard, they signed on to become LiveData’s first widespread rollout.

“It’s in 21 operating rooms, including all of the new ORs on a platform we opened in 2006, and it will be in the next iteration that we do,” says Aileen Killen, Memorial Sloan-Kettering’s director of patient safety. “So it’s not considered ‘research’ at this point, it’s become very much a part of what we do.”

Is Your Budget More Modest?

Not all hospitals have the resources of a Mass General or a Memorial Sloan-Kettering. Still, there are several strategies that smaller, more cash-strapped hospitals can use to achieve some of the productivity, efficiency and safety gains that the ORF embodies.

Some of the technologies that helped the ORF run might have initially been cost-prohibitive, but that’s changing. “Many of the things that we have pioneered are becoming more commonplace,” says Julian Goldman, M.D., a principal anesthesiologist in the Operating Room of the Future project. “It’s not as uncommon to have the monitors, or to have some level of integration with video systems. And as those things become more commonplace, they’re not quite as costly anymore.”

Krupka cites three areas where hospitals can achieve some productivity and efficiency gains without radically increasing spending: to introduce as much parallel processing as possible; to study (and ultimately eliminate) non-OR related delays such as unprepared instruments or staff; and to consider purchasing mobile operating room tables, which typically reduce nonoperative time by about 10 minutes.

“A community hospital in Kansas can look at some initial cheap solutions that will hopefully get a big hit,” Krupka says. “As an example, you might bring housekeeping in as soon as the dressings are removed; they can get going on little things like emptying the trash and be ready to whip through the bigger tasks as soon as the patient leaves the room.”

Even a limited amount of hospital redesign may work in some cases—even when space is at a premium—if it raises productivity more than it raises costs. “Hospitals can use data to look at whether some of those ideas can help with parallel processing,” Goldman says. “They can decide whether their environment might benefit from having a separate induction area, or a local recovery room for a cluster of operating rooms, or a short-stay recovery area to eliminate some of their backup.”

Data modeling can help any hospital figure out where gains can be achieved, and how much extra revenue that can bring in.

“The easy question is, how much extra money will the hospital make from that extra case you can do each day?” Krupka says. “But here’s the big ‘if’: Can this institution generate the additional demand that’s equivalent to an extra case per day? How are we going to find additional patients? This is the issue that needs to be considered before launching a program to reduce nonoperative time.”

The ORF’s findings have been widely published, and more information is available on the Web at www.cimit.org/orfuture.html. The project leaders encourage institutions to borrow whatever they can from the project, even if their versions of the ORF don’t look quite like Massachusetts General’s.

“A lot of institutions have embraced the idea of parallel processing in various forms, but implementing different specific systems from the things we did,” Sandberg says. “And that’s OK. The Operating Room of the Future is a state of mind, not a specific floor plan.”—Chris Serb is a freelance writer in Chicago.

This article 1st appeared in the March 2008 issue of HHN Magazine.

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