Smart Technology for Operating Rooms Management – STORM
Morgagni-Pierantoni Hospital at Forlì Local Health Authority

The Problem

One of the most important priorities in the public sector agenda is to keep healthcare costs under control. Consequently, healthcare managers need to develop ways to have all available resources better planned in terms of effectiveness and efficiency. In healthcare, the surgical path is one of the most important component of risk for the patient. While the World Health Organization (WHO) calls for a progressive improvement of the surgical path in terms of both quality and safety, it still remains poorly managed in the operating room environment, many different professionals work together, each with his/her own job-specific competencies. This all takes place within an organizational management structure that is extremely complex, making the analysis of effectiveness and efficiency in operating rooms extremely difficult. As a result, it seems clear that there is a need of improved information.
In fact, before the implementation of this project, the situation of Forlì Hospital’s operating room was described by as many points of view as were the number of workers/actors involved in the surgical process (without any possibility to link believes to evidence).The surgical path of each patient starts from the ward when he leaves it, then it goes through the operating room, then back to the ward. Along this process, many workers are involved creating a potential for errors and delays which means not only a waste of time, but a potential for a reduction of value-for-money, and a deterioration of quality and safety for the patient.

Solution and Key Benefits

 What is the initiative about? (the solution)
This project concerns the implementation of an information system supported by a basic Information Technology (IT) tool with the aim to track all the different individuals involved, the micro-activities of the entire process, their start and end times, the locations where these activities are carried out, for each patient’s surgical path. An algorithm based on the medical scientific literature and the project team experience acquired along the start up of the project would have given the possibility to have some key performance indicators (KPIs) computed. The “multidisciplinary” project team was composed by nurses, surgeons, anesthetists, engineers and managers. These KPIs would have been shown in a simple but comprehensive view like a scorecard. The hypothesis of this project was that these real-time data would have made the surgical process a transparent process to all the actors involved, with the final aim to improve the operating room’s efficiency and effectiveness.
More particularly, the objectives were:
[1] To improve the efficiency of the process through the implementation of “flexible management” rules (i.e. the ability of changing what planned according to actual events) to create the better workflow
[2] To identify the critical issues (waste of time, improper procedures, etc.) that emerge during the elaboration of results
[3] To reduce the clinical risk (and thus increase clinical effectiveness) by continuously checking the actual with the planned surgical process for each patient
[4] To translate results into timely organizational reviews

Each worker/actor involved in the surgical process would have been able to see data in terms of efficiency and effectiveness. This would have introduced a new approach to managing the operating room, based on the move toward continuous improvement through the sharing of information amongst managers, physicians and other involved individuals.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The project was developed within the Morgagni-Pierantoni Hospital at Forlì Local Health Authority (AUSL Forlì)’s organization without any external consultancy firm support.
In 2004, the entire Morgagni-Pierantoni Hospital was transferred to a new facility. An important aspect of this change was the centralization of all operating rooms into a single location, the operating rooms block, creating the mandatory collaboration of surgeons with different specialties, obliging them to a share all organizational and managerial arrangements, while at the same time overcoming the somewhat parochial mentality of the previous fragmentation of logistics.
In 2005, AUSL Forlì’s senior managers gave a mandate to a multidisciplinary working group (composed of nurses, surgeons, anesthetists, engineers, and managers) to critically evaluate the system in place and to identify operational mechanisms responding to risk management criteria. It was hoped that this would have improved the level of patient and provider safety, ensuring the efficient and fair distribution of hospital resources to healthcare professionals. The working group was chaired and coordinated by the healthcare directorate and was made up of anesthetists, surgeons, nurses, and engineers.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The strategy used to implement the project rotates around four basic ideas:
[1] Bottom-up approach
[2] Ergonomics
[3] Non-prevalence of a specific point of view
[4] Low-cost.
Bottom-up Approach. The process was born inside the hospital’s organization, following a bottom-up logic. The operating room workers were involved in the development of the process and then each step and information was shared by everybody. The bottom-up process was enhanced with feedback about each component of the system. Team collaboration and the analysis of each process reengineering experiments represented the most important features of the project.
Ergonomics. While the bottom-up approach helped to create an organizational-inclusive approach, IT was introduced to ensure an appropriate and accurate gathering of the large quantity of data needed by the project. The underlying logic used for IT implementation was not to interfere with the daily activities in the operating rooms. Rather, the project team set up a “system ergonomics development” as its primary strategy of implementation of the new information system for the operating room. “Ergonomics” means that methodologies, equipment and devices were designed in a way that fit the human body, its movements, and its cognitive abilities. In essence, the basic thrust of the project was to simplify the procedures of tracking the surgical path in a way that they would be simple and easy to use in other contexts.
Non-prevalence of a specific point of view. The project began with a rough analysis of all the flows of movements of the surgical patient throughout the operating rooms block of the hospital. The aim was to capture all the steps of surgical process and all the times between every step and the next. By a rough analysis it was found that a specific professional profile was free of conflicts of interest, and was available during all the surgical path process. The person who carried out this task was the anesthesia nurse, who was chosen as the one who initiated the first activity in the system.
Low-cost. The PDA (Personal Digital Assistant), an already available device within the wards for drug administration, was used to track all the different elements (individuals involved, micro-activities of the process, their start and end times, the locations where these activities are carried out). No costs were added to the project except the development of the specific software.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The key innovation of the project was data analysis and the implementation of new approaches based on those data. During the development of the system each change into the process was based on an experimentation and the analysis of the related data. We used this way to reengineering the process and we introduced a system to ensure the ergonomic characteristics. In healthcare the most important thing is the patient care.
Bottom up project.
The process was born inside the hospital’s organization, following a bottom-up logic. The Operating room workers were involved in the develop of the process and then each step and information was shared with all. The most important feature has been the team working and the analysis of each experiment/trial.

Know to improve
In every process its possible improves the efficiency but, to do so, one must know each step of the process in order to find room for improvement. In this way we had complete knowledge of the surgical process and we found critical area in terms of costs, clinical risk, and a lack of efficiency.

2006 first experimentation of the IT system
The first experimentation lasted 6 months and was use the PDA and the first generation software.

2007 first time for sharing information and for starting the reengineering of the process

2007 second experimentation
The data were recorded by paper.
The aim was find better time measurements to create a picture of the surgical process in terms of importance of the information and usability of the recording.

2008 third experimentation
The data were recorded by a PDA and new software developed by the project team with new features based on the experimentation analysis. The project team analyzed the recorded data and then discussed the results and looked for solutions for the critical areas found.

2009 born of the new workflow and system
In January 2009 the IT system began recording the data overall the surgical process by the PDA, with a new logistic strategy and an updated version of the software. That system is still use today to track all steps of the surgical process. Every month the project team analyzed the data and shared the results with the Head of the surgical departments and the individuals involved in the process.

2010 development of the algorithm by a data manager
In September 2010 the Data Manager presented an algorithm to manage the information recorded by the system. The algorithm consists in many rules to manage; to clean and to aggregate and a simple excel report is generated. The algorithm‘s first step was to make possible a simple and clear reading of the data for the Hospital’s managers.

2011 creation of a more efficient algorithm by an external company
In 2011 an external company proposed a partnership with the Hospital to develop the system for no fee. The company had developed the algorithm by Business Intelligence support powered by ORACLE in web based technology. Now every manager, surgeon, anesthetist, engineer and nurse involved in the surgical process can view the data of the surgical unit performance.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The main obstacle was the change of the mentality of the people involved in the process. The new system was based on a philosophy of “sharing” in terms of information and outcomes. This approach is not common in operating rooms because the predominant historical model was hierarchical and the surgeon was the main actor. Developing a collaborative approach was the first step toward overcoming this obstacle to overcome our methodological obstacles we developed the system by a bottom up process and we engaged in the reengineering of the process everyone who was involved with the process.
The work began in 2005 and the first opportunity to share the information was in 2007. Than we had made three different experimentation ad after each one the data recorded were analyzed and discussed with all workers involved into the process. The aim of this approach was overcome the cultural gaps in terms of resistance to innovation, difficult to use IT device, difficult to share information and difficult to understand the objective.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The resources used for the project consist of human and technical resources. The human resource is the data manager, who has been hired with a grant. The technical resources consist of hardware and software. The hardware chosen was the PDA system described above, because that device was already in use in the hospital wards. The hospital bought 10 PDAs more to implement the system.
The software has been developed by the data manager upon the information system already use in the Hospital.
The cost of the system consists of start-up and running costs:

Start-up (year 2008)
14,000€ for ten PDAs
7,500€ Data Manager
5,000€ Software development
26,500€ Total

Annual running cost (for each year, from 2009 on):
7,500€ Data Manager
7,200€ Software
14,700€ Total, or about 0.2% of all surgical unit cost (6.800.000€ per year, except drugs and materials)

Sustainability and Transferability

  Is the initiative sustainable and transferable?
This project is consistent with two forms of sustainability:
(a) Financial sustainability
(b) Process sustainability.
The financial sustainability is ensured by the low cost of the project compared to the cost savings that it generates. The total cost of the system consists of start-up costs (26,500€) and the annual running cost (14,700€ per year). According to the accounting system the total cost of the operating rooms block is about 6.800.000€ per year (except drugs and materials). The relationship between the annual cost of the system (14,700€) and the cost of the whole process (6,800,000€) is equal to 0.2% (14,700 ÷ 6,800,000).
The process sustainability is guaranteed by sharing the process and targets with all staff members (surgeons, anesthetists, nurses, data managers, hospital administrators and director). The control of the system is generating a network among all the actors involved; nowadays it is part of the organization’s daily work, since the system is every day automatically checked like other structural parts of the operating room (e.g., ventilator machine or surgical instruments).
This project was awarded as “Best Nominee” at the European Public Sector Award (EPSA) 2011 from European Institute of Public Administration (EIPA) in Maastricht (NL).

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Through the implementation of this project, all stages of the surgical process were made transparent and analyzed in an objective manner, allowing the surgical unit board to implement actions to improve performance based on evidence, instead of "personal beliefs".
The KPIs that have been computed from the dataset available from the tracking system were presented by the surgical unit board to the different department directors, and this facilitated improvements of surgical team performance.
Maintaining the same level of complexity of surgical procedures performed, evidence shows the following performance improvements, in terms of both efficiency and effectiveness (data before 2009, and thus full comparisons between ex-ante and current situations, are not available since this information can only be calculated thanks to the new information system):

[1] Rate of operating room occupancy: from 71% in 2009 to 79% in 2010, i.e. +11% or +401 surgical procedures

[2] Number of unscheduled procedures: from 25% to 16%, i.e. -36% (in operating rooms the clinical risk for the patient is always very high and the first rule to decrease is to increase the level of standardization of the process; when the surgical team works in an unscheduled way there is a lower level of standardization and thus the clinical risk increases)

[3] Over-time working hours expenditure: € 524,000 in 2009 to € 497,000 in 2010, i.e. -21%

[4] Patient’s safety: no wrong surgery or near misses from 2009 so far.

The system also allows to benchmark against other “scientific” indicators. In the scientific literature, there are a few important efficiency indicators to evaluate the operating room performance, which have been computed for the Forlì Hospital:

[5] Turnover-time (delay from the scheduled time to end the surgery of the last procedures of the day and the real time)
- 2009 (mean ± standard deviation): 30 ± 20 min
- 2010: 32 ± 21

[6] Over-time (time for cleaning and setting up of the operating room between two patients – benchmark in literature is 25 min)
- 2009: 80 ± 59 min
- 2010: 77 ± 54

Generally speaking, this project demonstrates that a good idea doesn’t depend on money, it depends on people. A good team is made by different people who are able to share their knowledge for a common goal.
We started from the simple data but as secondary effect we arrived to the culture; this system was able to create a new way of communication among all the people involved and at different levels of management it was able to improve the quality and safety of the operating room activity.
If we think about the operating room block as a car we learnt that it is not important how fast it goes but it is the average speed that makes the difference; Moreover we understood that all the variables involved in the operating room management are well controlled now and the level of risk either for the patient or the team is reduced.

Contact Information

Institution Name:   Morgagni-Pierantoni Hospital at Forlì Local Health Authority
Institution Type:   Government Department  
Contact Person:   Matteo Buccioli
Title:   Data Manager  
Telephone/ Fax:   +39.3934414156-+39.0543738714
Institution's / Project's Website:
Address:   Via Carlo Forlanini, 34
Postal Code:   47121
City:   FORLI'
Country:   Italy

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