The challenge

With a regional mandate to increase efficiency in the operating room, one of the most expensive of all areas in a hospital, Southern California’s Irvine service area looked at streamlining the costliest and most time-intensive of surgeries—the total hip- and knee-joint replacements.

I think the idea of triggers was a big thing that stood out in this process. How do you know when a certain task should be done at a certain time? If you hear a certain word or a certain task, that will be your trigger.

Karen Perlas, RN, UNAC 

Before the Sand Canyon Surgery Center at Irvine Medical Center opened in May 2008, a team was created to evaluate the current orthopedic surgery process and create something more efficient to establish at the new center’s opening.

“Physicians who worked at outside facilities had concerns about coming back to Kaiser and what turnaround would be like,” said Jennifer Cody, director of perioperative services at Irvine Medical Center. “We assured them that we would have the best turnaround time.”

The outcome

And they did. Irvine trimmed turnaround time for total joint replacements from an average of 45 minutes to 20 minutes. Staff now does four and sometimes five total joint replacements every day—up from an average of one or two procedures a day.

By streamlining the process and increasing the number of surgeries that can be done in a day, the team has reduced their backlog of patients waiting for total joint replacements. Patients are happier with the faster surgery and workers are more satisfied with their jobs.

“We couldn’t have done this at (a non-KP) hospital,” said Tadashi Funahashi, MD, the chief of Orthopedics. “You have multiple surgeons from multiple different practices, each wanting to do it their own way….It’s like night and day. It’s the difference between a well-organized, choreographed team and things happening in a default chaotic state.”

How’d they do it?

Working in partnership with consultants from DePuy, Irvine put together a team of OR nurses, surgical technicians, EVS workers, orthopedic surgeons, sterilizing technicians and any others whose job touched the surgery process.

Together the group of union staff, management and physicians walked through every step of the total joint replacement surgery—from early pre-op through preparing the OR to the actual surgery to clean-up to instrument sterilization. Step by step, action by action, the team stopped to examine every point in the process to find out why and when people did their tasks and to ask if there might be a more efficient and coordinated way to do it.

“Usually when we’re in the room, we wish it would be done different,” said OR nurse Karen Perlas, RN, a UNAC/UHCP member and part of the efficiency team. “But this time we actually got a voice in how it’s done differently. And we were able to try it out when it wasn’t a rush situation.”

Successful practice spreads

The new protocol, dubbed the “Total Joint Dance,” showed such dramatic results that the practices have been adopted by general surgery, head and neck, urology, vascular and other surgery procedures at Sand Canyon. Additionally, ORs at Riverside and Bellflower have also undergone the total joint replacement analysis and brought their turnaround times down as well.

“It’s now a norm, not just an exception in one room,” Perlas said. “Now in the room, every action is done with purposeful movement.”

Effect on morale

Dr. Funahashi and others say the new protocols have also improved morale. Surveys of Riverside’s OR staff before and after the new protocol model was adopted showed an 85% increase in job satisfaction.

By squeezing the waste out we’re able to use the OR for more urgent things.

Tadashi Funahashi, MD, chief of Irvine Orthopedics 

“Everyone’s morale went up despite that fact that they’re doing more work,” Dr. Funahashi said. “Because they know what their roles are. The lead for Riverside was an EVS worker, who said, ‘Hey, we’ve seen this as a problem for a long time, but didn’t want to say anything.’ That’s the power of a team approach.”

Perlas added: “It’s also repeatable. Other people can repeat it. I think it’s more satisfying to come to work to think you’re not picking up the slack for others.”