APRIL
2005
Volume 29 •
No. 4
N
E W Sx I T E M S
Dean calls for improved bedside teaching
For Whyte, medical direction of the ORs is a balancing act
Match Day brings 151 new house staff to SHC, LPCH
SHC/LPCH house staff arrivals.pdf
Lastword now includes Cath Lab results from Apollo
Joann Rickley, director of operating room services, and Richard I. Whyte, OR medical director, discuss cases at the OR Control Board.
For Whyte, medical direction of the ORs is a balancing act
Richard I. Whyte, chief of the Division of Thoracic Surgery since 1997, said he "raised his hand" when the hospital was looking for its first operating room medical director nearly four years ago. "It was a huge challenge that needed to be done," Whyte said recently. He started the half-time job in November 2001. Despite a demanding administrative schedule, Whyte continues to operate "two to three days a week" and run his three-surgeon subspecialty division. We talked with Whyte about OR issues of interest to the medical staff.
Q: In your OR role you're a member of SHC's senior management. Why would a physician want to enter a world of MBAs and managers? Why did you "raise your hand?"
WHYTE: Put simply, I took the OR medical director job because I think physicians have particular insights into what's needed in an operating room that should be applied to administration. I don't mean that as disrespect for MBAs - and in fact right now I'm working toward one of those. I hope to finish next April [2006] at Wharton [School of Finance's San Francisco professional program]. At age 46, I'm excited about acquiring a new set of skills and new opportunities while I continue to spend a good part of my work life in the OR. A physician - in this case it's me - needs to be at the table when decisions affecting medicine are made. Because of my business studies, I do think I understand things like internal rates of return and investment strategies a lot better than I did before, and I hope that my input is a little more useful at management meetings. But you'd have to ask Mike Peterson [SHC's chief operating officer] if that's true. By the way, in my role I work extremely closely with a great team, including Joann Rickley, director of operating room services; and Ronald Pearl, chair of anesthesia.
Q: After a little more than three years, what are the major challenges facing you?
WHYTE: My job is a very delicate balancing act. Ultimately if we don't do what's right for the patient, everything else will be completely unobtainable. But to serve patients, we have to create conditions that motivate physicians and other staff members to want to work here. To achieve that, patients may sometimes by necessity be inconvenienced - made to wait, told to come in two hours before surgery, asked to fill out a form, whatever. Hence the balancing act.
Q: Can you be specific about what you've had to do to make things work?
WHYTE: Overall we've seen the Stanford OR getting busier and busier. We do about 25,000 cases a year. We have to be more efficient in dealing with the more macroscopic issues, such as allocation of rooms, as well as the more microscopic issues of getting individual cases started on time and shortening turnover time. We also have to match scheduling of staff, particularly OR nurses, to cases.
Q: So where is SHC with each of these issues?
WHYTE: Let's start with scheduling. Things aren't perfect, but the block allocation of rooms has become more predictable and the process has become more equitable. When I started in this job, the process was essentially paralyzed. Room allocations were very difficult to change and there wasn't a very good way to take away underutilized time. Surgeons would fight tooth and nail to keep their unused time block, because they believed that if they got busier later they'd never get the time back. So we've made allocations more fluid. Block allocations are data driven and assigned quarterly. Understandably the people who lose slots are going to be upset about the loss of flexibility. But the reality is that we have a growing surgical volume and we have to be able to provide the resources to expanding services, such as neurosurgery, ENT, or general surgery. We also expect future growth in orthopedics, and pediatric cardiac surgery has added several hundred new cases a year.
Q: What about on-time starts?
WHYTE: Without careful planning, virtually every day would start behind schedule. Think about it. In the ASC we start 12 cases at 7:30 a.m. That's 12 patients who simultaneously go through a preop process. We found that more than half of the patients show up more than 15 minutes late, so we are asking why and whether we can do something. Are patients showing up late because no one stressed the importance of arriving at 5:30? Were patients even told to arrive two hours early? Are they late because they can't find parking? We first need to know these things. In the main ORs, 23 people start at the same time each morning, including 16 adult patients. Nursing is looking into dealing with this issue by reallocating more staff to the early morning hours. Then we can probably live with fewer staff later in the day when patients arrive on a more manageable staggered timetable.
Q: Can surgeons impact the workflow process?
WHYTE: Surgeons can slow things down by not being ready to go, or perhaps more significantly, not having paperwork completed. We've set a noon deadline the day before surgery for completion of patient testing and paperwork. We've had excellent compliance with this standard. The carrot is of course more predictable scheduling for people who work here, but we are prepared and have on rare instances halted early morning start privileges for surgeons who habitually fail to get their paperwork in on time.
Q: What about turnaround between cases?
WHYTE: One of the best things we have done recently is rather simple. We analyzed and can now predict cleanup and room preparation time between cases. Staff members now have some reasonable way to predict when to be ready to go. It also helps staff responsible for the turnaround shoot for reasonable standards
Q: What concerns do surgeons raise with you?
WHYTE: One issue that comes up frequently is that surgeons and anesthesiologists believe working with a core group of nurses will help their cases run more smoothly. But because of the nursing shortage and scheduling realities, this isn't always going to be possible. In fact it may not be the best alternative. Nurse/surgeon team scheduling works fine until a case is scheduled off hours, and the core nurses are not available. Also, nurses who work only in one area may be less professionally challenged than if they had some variation. What I think Joann Rickley is looking at is creating a happy medium - working toward developing staff members experienced in two areas, so that someone with a particular range of skills is available most hours. Nurses, or physicians for that matter, can't be skilled in multiple areas, so again, it's a balancing act.
Q: Are there any initiatives designed to improve safety?
WHYTE: Certainly. A key component of my job is to set up systems to minimize potential errors. In addition to such national trends as electronic medical records and order entry, we have created relatively simple protocols. "Boarding passes," or the preoperative timeout, is second nature here now. Before the first incision everything stops for five or 10 seconds while the team verifies the patient's identity and the procedure to be performed. The team also checks the incision site marked personally by the patient. We felt a lot of resistance to initiating boarding passes. It wasn't part of the culture, but now it is. Wrong side, wrong site surgeries are infrequent, but they are devastating when they occur. We want to make sure they don't happen.
Q: Any other issues?
WHYTE: There are many issues, of course, but surgeons are often perturbed when they can't complete all of their cases in a single room, and surgeons and anesthesiologists naturally find it inconvenient to move between the ASC and the main operating rooms during the course of the day. I sympathize, but the reality is that the ASCs are better equipped for same day surgeries - for example, providing postanesthesia recovery more appropriate to a patient heading home that day. Again, we need to balance physician convenience with operational efficiency - placing patient safety and comfort at the forefront.
Q: Since Stanford is a teaching institution, how do you see the need for ensuring house staff involvement?
WHYTE: Medicare regulations require that surgeons must participate in key parts of the operation and be immediately available for the remainder of the procedure. Within that requirement there is room for variation. Personally, I tend to be in the OR at the beginning because I think it gets the case moving, even though my resident is perfectly capable of getting things started. At the end of the surgery, I often go out and talk with the family while a resident closes the incision. Keep in mind that physicians have an obligation to their patients but they also have an obligation to train their residents. Attending physicians also have other obligations, including research and teaching, and thus must prioritize their time carefully. Also, house staff involvement will vary depending on the residents' experience. For example, a cardiac surgery resident with nine years of experience and board certification in general surgery would clearly be expected to do a lot more than an intern.
Q: What changes are expected in coming months and what benefits will the 12 new suites and three interventional radiology suites in the ambulatory surgery center provide?
WHYTE: For one thing, we'll have more space. The smallest room in the new ASC [on the top floor of the Cancer Center] will be larger than our biggest ASC room now. We need that space for the variety of equipment that made the old rooms outdated, including such innovations as the surgical robot that allows for microsurgery in endoscopic cases. By the way, the old ASC is expected to close when we open the new rooms later this year. Further down the line I might expect that Packard may open its own six ORs in the next 12 to 18 months, and we also will have orthopedic services at the Midpoint Center when that facility opens in about two years.
Q: What is the future for community physicians in the OR?
WHYTE: The reality is that about 80 percent of our cases are done by faculty members who generally don't have options to perform surgery at other hospitals as do most community physicians. It's important to remember, however, that SHC and its board have made a commitment to provide access and service for non-fulltime faculty, and we certainly aim to support that policy in the OR. We serve three anesthesia groups, the large and active Palo Alto Medical Clinic, as well as other individual physicians. We are certainly a unique, dynamic facility. Our commitment is to ensure this vibrant mix of talent, skills and service.
