University of Virginia School of Nursing
With more than 30K surgeries each year, room turnover teams – like this one, made up of Irving Miller, Donna Fewell, Sharon Jacobs, and Major Jackson – have recently overhauled their protocols.

An icon of an open book to signify scholarship in teaching and learning. What happens in UVA Medical Center’s 29 busy general operating rooms (OR) is profoundly critical in the fight to save, improve, and prolong patients’ lives.

But what happens in the OR between patients, as teams of specialists clean up and prepare the space for who and what’s to come next, is just as important, if less heralded.

While some come and go, like patient transporters who wheel patients into recovery areas, and sterile processing technicians who remove used surgical instruments for sterilization, others work on the room itself: emptying accumulated trash, stripping soiled bed linens, sweeping and mopping floors, and painstakingly wiping every single surface – lights, shelves, walls – to ensure sterility.

It was 2016 when the OR team determined to overhaul these processes. Jobs were consistently getting done, and well, but the timeliness of room turnover was occasionally spotty and needed improving.

Enter Be Safe coach Crockett Stanley, OR nurse manager Donna Fewell, and Center for ASPIRE associate director and School of Nursing professor John Owen , who assembled a team of stakeholders, conducted data analysis, and plotted a path forward. The idea, the trio asserted, was not to issue mandates to change, but to work interprofessionally across disciplines to improve systems through collaboration.

First, they assessed room turnover metrics. Between January and June 2016, it took an average of 61 minutes for scrub and anesthesia techs, patient care technicians and circulating nurses to clean up from one surgery and prepare for the next.

"We were surprised," said nurse manager Donna Fewell, a veteran OR nurse. "That seemed like a long time. We realized that everybody did something different, and did it as a team, but room-to-room, there was little consistency. I'd certainly known there was variation, but not to the degree it was happening."

Led by Stanley, Fewell, and Owen, the review team, comprised of a phalanx of nurses, administrators, physicians, anesthesiologists and patient care techs, all of whom had a hand in room turnover, discussed what they did well, and areas they perceived were ripe for improvement -- what Stanley calls "capturing current conditions." The group’s stated goal? Reduce turnover time, “wheels out to wheels in,” by 15 percent.

"We're not robots, yet processes needed to be more predictable," explains Stanley. "There is definitely standard work and roles in a room turn, and we wanted to take the variation out of it. What we did was work through those processes like we were doing an experiment, testing as we went."

After a literature review of room turn procedures and a list of suggested procedural improvements in place, Owen established a simulation process for the team to practice their new roles, and how they did them. He filmed the staff executing their new roles, led subsequent debriefing, and assisted the team in ironing out improvements and unforeseen issues. Through these dress rehearsals, a new and better, more streamlined room turn protocol emerged.

"Simulation is an effective assessment tool," explains Owen. "It allows you to test proposed changes and make improvements prior to actual implementation."

Some of the biggest changes involved which staff did what jobs. The circulating nurse, for instance, initially had the most responsibility in a room turn, but the group determined that it was more prudent for patient care techs to assume more responsibility so that the nurse could focus purely on the patient. Other issues, like floor dry times -- which require 10 full minutes to dry so that the full effect of the antibacterial solution could activate -- had to be worked around.

After a six-month process of review, rehearsal and refinement, the team kept data on their new between-surgery moves. Today, their average room turn rate is 34 minutes, a near 50 percent reduction in time.

But improvements go a step beyond efficiency, says Stanley. While the changes yield predictability and punctuality for patients and surgeons, the process will likely also improve staff morale and reduce attrition. If you turn a room efficiently, explains Fewell, you have a more predictable day as well as the specific knowledge of exactly what’s expected of you in your work.

"People know more clearly what their job duties and expectations are," says Fewell. "Keeping the day predictable and orderly means that you've got a good likelihood of getting off at your scheduled time, and that's a satisfier. It's one less variable that's going to impact your personal and family time."

The overhaul has also provided a road map for others. The General OR's new room turn procedures are now being moved to other specialty service lines, including pediatrics, orthopedics and heart and vascular operating rooms. Stanley and others say the task now, in addition to spreading their gospel of efficiency, is to keep the improvements sustained.

"It's hard work, but it's not as hard as keeping the momentum sustained," says Stanley, "but the key is having end users involved. It was the people who do the work who were most intimately involved, and that their ideas and recommendations were taken to heart, that's a satisfier, too."


While the Nov. 2017 Center for ASPIRE's upcoming Train-the-Trainer Faculty Development Program is full, spots in the spring, 2018 program are still available. Please visit the CIPC web site for more information, or query staff members about interprofessional consulting.