Greenville Hospital System Medical Center (GHS) is a five-hospital, 1,268-bed hospital system based in Greenville, South Carolina. Altogether, over 40,000 surgical procedures are performed annually in the health system, with about half of those procedures being performed at Greenville Memorial Hospital, the system’s flagship facility (which also has 30 of the system’s 54 operating rooms).

Last year, in an effort to improve the effectiveness of the organization’s OR operations, leaders at GHS began an initiative to install patient tracking systems in the health system’s perioperative areas, beginning with Greenville Memorial Hospital. Work has proceeded apace, and results from the 2011 go-live at Greenville Memorial have been encouraging. Erwin Stainback, senior administrator for perioperative and GI services, and Gilbert Ritchie, Ph.D., director of anesthesia services, spoke recently with HCI Editor-in-Chief Mark Hagland regarding GHS’s initiative. Below are excerpts from that interview.

Tell me a bit about your initiative and how it came about?

Gilbert Ritchie, Ph.D.: A few years ago, we were interested in evaluating patient tracking systems for perioperative services. And in response to our RFP, we were a bit taken aback at the cost of those systems. We were already in the process of installing an asset tracking system, and (the Columbia, S.C..-based) IBSS Corp. was the vendor. And IBSS presented a proposal, and the cost was very reasonable, because they proposed that we partner with them in their development [of a patient tracking system]. And so we agreed, and that partnership began about two years ago. And as we got into this, we determined early on that what we wanted was not just patient tracking, but a surgery schedule management system that included patient tracking. So one of the basic problems for a large OR suite is the day-of-surgery schedule management. That can be a very dynamic entity; and it’s hard to keep track of all the variables, and that’s what we needed the most help with. And by tracking with IBSS, we were better able to address our needs.

Gilbert Ritchie, Ph.D.

When did you go live?

The first version went live about a year and a half ago.

Erwin Stainback: We went live with sort of a base system that we’ve continued to added functionality. It was the spring of 2011. Since we were partnering with them to develop it, the functionality that we started with versus the functionality we have today—it just continues to grow today. The solution is called ORMax.

Erwin Stainback

What was included in the functionality of the first iteration of the system?

Ritchie: The first functionality was RFID tags, to track patients through the portals we had installed in our operating suites. We could determine when a patient entered pre-op holding, and then the surgical suite, and then post-operative recovery. Another element was an electronic scheduling board that showed what the current schedule was, and what surgeries remained to be scheduled. A major project milestone occurred in the summer of 2011, when we removed our erase-board and shifted to using our electronic scheduling board exclusively.

And we have some additional status boards that take the same information, but tailor it to the needs of a particular area; for instance, in our family waiting area, we have a status board that shows a color-coded icon and a case number that only the family members know, so that they can track their family member or loved one, as they progress through the perioperative process.

Stainback: And that allows them to track the patient from pre-op through inter-op, and while in inter-op it’s progressively changing color, and changing color again in post-op.

How are the colors changed?

Ritchie: It’s automatic; as the patient passes from pre-op to the surgical suites, the patient passes under a portal, which senses that the patient is entering the OR, and the movement is automatically tracked through the RFID tag associated with that patient.  And once the patient is in the operating room, as the patient care is documented in the anesthesia information system, the intra-operative case progression is registered, automatically triggering color changes. And the family tracking was actually an afterthought. The key purpose was to help the staff track the status of cases and patients.

How has it changed things?

We can’t really quantify this, but before ORMax, the staff would have to make phone calls to determine whether the patient was ready to come to surgery. Specifically, before we transfer patients from pre-op holding to the OR, certain steps have to be taken, including the fact that the patient’s surgical site has to be marked, and the patient’s history and physical has to be checked off by the surgeon or resident. And the staff can now look at that in ORMax. And that enables the staff to see more of the perioperative process and be clued into it, whereas before, the only way to do that was through a phone call.

Stainback: And there are about eight or 10 checklist items involved, and any outstanding items that needed to be completed in order to not impeded the progress of the patient through surgery, the system can alert us to that. For example, if the surgeon has not done an H&P update or a surgical site marking, the system will send them alerts, in the form of an e-mail or text message, or in whatever form they choose to be communicated with.

Ritchie: We’re currently using text messaging to notify anesthesiologists when the patient enters the OR suite and goes underneath that portal; the anesthesiologist can plan their next five to 10 minutes, to make sure they’re present in the operating room, for the induction of anesthesia, to prevent delays, since anesthesiologists typically manage the anesthesia for about four surgeries at once.

Have you been able to document any measures of improvement of time-efficiency in the OR?

Stainback: As you know, healthcare is very complex; and the perioperative environment, I would say, is one of the most complex; there are a lot of moving pieces. And to say that one project single-handedly made an improvement or detracted from it, is not easily done. But we certainly know that this particular tool has enhanced our performance in various ways. And we have various principles that we call pillars—a quality pillar, growth pillar, financial pillar, people pillar, etc.—and in terms of the people pillar, we know that there’s been enhanced staff satisfaction, because they now have an easier means of communication, and a fuller picture of what’s going on with the perioperative process. And some of the metrics they like to focus on are on-time case starts. We just had a consulting firm in, and they were giving us accolades for our performance in that area.

You know that you’ve had improvement in on-time case starts?

Yes.

And this was part of that change?

Stainback: Absolutely. And as we’ve been able to trend our patient satisfaction, it’s not that this product has single-handedly improved our patient satisfaction, but this product has obviously been a contributor. And we know that part of that is that we’ve acquired much fewer overhead pagers. And we do patient routing post-op with patients and families; and we’ve actually been pretty amazed at the feedback we’ve received from patients and families. And we have, for wont of a better term, “frequent flyers.” And even with the limited information we’ve been able to give them through this tracking tool, they’ve been very pleased. They can see on a continuous basis where their patient is, and they view that as a real enhancement.

On the quality side, by having information in a more granular fashion, one of the things we’ve been able to do—the perioperative environment is very emotionally charged, and there’s generally a steady stream of surgeons coming in to complain about something, and oftentimes, it’s not very factually based. The thing about ORMax is that it allows you to very factually sort through things. And the capture of that data not only helps dispel rumors and myths in their mind; it also gives us very granular data that we can use to make improvements in our perioperative processes. One of the areas related to quality is that there’s a Joint Commission focus, and actually a standard out there to implement better process flows.

We also think that this is a tool to help us with patient logjams; we don’t have logjams in periop as many hospitals do.

What core lessons have you learned that you’d like to share with CIOs and CMIOs?

Ritchie: I think what ORMax has been able to do has been to reduce the communication overhead between caregivers on status updates, and through automation, better connect the staff members to the full perioperative process, rather than just their own little work area, such as preop holding or PACU. Nurses can see how what they do can affect downstream or upstream processes.

Stainback: I would agree, and I think the ability to really proactively resolve issues, has been a real outcome of this. We tend to be very reactionary in healthcare, and not very proactive in solving problems. This allows you to create greater efficiency in perioperative flow. So we’ve continued to grow as an organization, and this tool has been one element in that growth. We have been able to grow concurrently with decreasing capacity. And it’s not ORMax that’s the only thing to contribute to this. But it has helped facilitate that, as a result of having a better system in place to monitor flow, per capacity.