Going By the Book: OR Governance with Chris Hunt
Nurse executive Chris Hunt describes a typical conflict that may come up in an OR department: Surgeon Smith is having a tough day and wants to do his case without waiting for Doctor Jones. With a solid governance structure, the rules state that Smith must wait. The burden is off the charge nurse because their only job is to enforce the rule, not convince Smith that he has to wait for Jones. However, the process also outlines what happens if your patient is ill and needs their case done immediately. But in both scenarios, it’s not an individual’s personal decision or preference; these are the rules created by consensus.
This, in a nutshell, describes OR governance.
In this month’s BtRL, Hunt breaks down how to approach creating an OR governance committee, how to keep its goals focused, and where a Director of Surgical Services can start when they come to a new facility.
Where does OR governance begin?
It starts with executive support—the CEO, CMO, the entire C-Suite need to support this. The C-Suite should select the governance group, but the participants run and own the committee. That committee serves as the Board of Directors for the operating room.
Ideally, the governance group sets up all the rules and regulations for the OR. How many rooms will we run and during what parts of the day? What time are we going to start? How do we set up block time, and who gets it? What are the rules for that? All your basic OR rules and regulations. There are some excellent best practices, but there is nothing innovative or earth-shattering in those. However, it’s the area where every OR stumbles.
“You want your governance group to stay big picture, just like a Board of Directors would.”
You want your governance group to stay big picture, just like a Board of Directors would. Once that group begins to mature, they can start looking at what kinds of subcommittees or operations councils will focus on the frontline work. Subcommittees and operations councils focus on tactics because they are the ones that know how to get the work done and are aware of the potential challenges. They should be empowered to find solutions. But they also need backing from the OR governance group when they need to make a change.
What departments/areas are represented in a governance committee?
Every department that works in the OR should be represented on this committee. Your nursing directors, sterile processing, key surgeons, and some C-Suite involvement (either on the committee or at least supporting the committee) so that as any issues arise, you have all the right people at the table to make decisions. But the basic triad, or three-legged stool, are surgeons, anesthesia, and nursing. At a minimum, you have representation for those three areas and add other key stakeholders as needed.
What is an example of a situation that OR governance can address?
Say we’re going to start cases at 7:30. The CEO can’t come in and say, “I want you guys to start cases at 7:00.” This governance group empowered us. We’re the decision-makers. We’re going to start our cases at 7:30.
The governance group also sets targets that we want to achieve. For instance, 100% on-time starts. You start tracking scorecard metrics and asking questions like, “Why are we at 40% on-time starts?” And maybe the nurses say it’s because the surgeons don’t know when to arrive and show up half an hour late. Or the patients show up on time, but we don’t have the H&Ps. So we would need a rule that says all your H&P documentation must be in place. Otherwise, your case will potentially get rescheduled or canceled.
“Review the existing governance structure to determine its effectiveness. Are there some gaps or opportunities? Do you have the three-legged stool?”
As a new Director coming into a new facility, how do you introduce OR governance?
Review the existing governance structure to determine its effectiveness. Are there some gaps or opportunities? Do you have the three-legged stool? Is there a committee charter? Is the purpose of the group clearly defined? Are there one or two individuals dominating the meeting?
See where you are, and then figure out the next steps depending on the size of the facility. No matter what you want to do, you can’t do anything without good executive buy-in and partnership. Get your executives on board, so they understand that surgery is the financial engine of the hospital, that it has to run efficiently, and that surgeons are one of your most precious resources. The surgical team needs to be cared for and grown.
How does an OR governance committee stay focused?
Sometimes the governance group gets very ambitious and puts rules into place that are not enforced. Then, the group has no credibility. People stop coming to meetings because they see that there is not going to be action. They don’t want to waste their time. Don’t make a decision that you are not willing to enforce. But also, make sure you have enough buy-in. You might want to wait a little bit before making a change. Make sure people are engaged and supported.
“Use the consensus-based decision-making process, and say, ‘I know we’re not in full agreement here, but are we able to move forward?’”
The governance group will sometimes get stuck where they are looking for 100% agreement on everything. Use the consensus-based decision-making process, and say, “I know we’re not in full agreement here, but are we able to move forward?” I use the zero and minus scale: +1 is a huge supporter; 0 is neutral; -1 is not my favorite, but I’m okay moving forward; -2 is no, I’m not game moving forward. Sometimes you need to bring that consensus model into play so that people understand that you’re not always going to get things exactly the way you want.
Do you have knowledge on a specific topic you want to share? Contact Carisa Brewster, Writer and Media Relations at Whitman Partners.
Carisa Brewster
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