PERI-OP GOVERNING COUNCILST. LUKE’S HOSPITAL

CEDAR RAPIDS

IHS Leadership Symposium April 17, 2012

Background• Operating room is a significant driver of net revenue and cost in the hospital

• > 10,000 inpatient and outpatient cases annually• Limitations to hospital resources

• Skilled specialty specific staff• Rooms• Specialty equipment

• Inefficient scheduling system contributes to unintended competition for resources

• Surgeons have limited understanding of the management of those resources beyond their schedule

Peri-Operative Governing Council (POGC) Established 2008

• Aim: To create a shared governance model comprised of hospital administration, peri-operative service mgmt, surgeons, and anesthesiologists

• Purpose: Engage physicians in operational decisions that affect themTo keep physicians abreast of peri-operative initiativesTo identify opportunities to increase physician satisfaction and ease

of practiceTo support initiatives to improve the efficiency and effectiveness of

the OR

POGC StructureOriginal Charter

• Advisory capacity

• Physician membership assigned and approved by St. Luke’s administration

• All physician members had voting privileges in determining recommendations referred to responsible hospital personnel & medical staff committees as appropriate

• Other medical staff attendees invited as topics dictate

2008-2009 POGC Business Identified

and discussed operational issues affecting OR flow • On time starts, first case of the day

• Definition of "start time“

• Scheduled time vs. actual time

• Anesthesia schedule management

• Epidural block placement prior to surgery• Ease of adding on cases

• Turn-over times

• The Flood - our response and what we learned

• ED to OR patient throughput

2010 - Surgical Services Assessment

• Built political capital through engagement and communication

• Took time for due diligence

• Educated physicians

• POGC selected external consultant for surgical services assessment (Sullivan Group)

• Physician participation in assessment interviews

• Communication, Communication, Communication

2010 – Assessment Conclusion and Action plan

• The Peri-Operative Governing Council has worked to establish an organizational foundation that will allow the peri-operative program to function in a high quality, patient-centric, customer-focused, and cost-effective manner

• A primary goal is to get the appropriate resources to the surgeon, including skilled help, the right equipment, and anesthesia services, so that he/she can give the best care to the patient in a timely fashion

• Many surgeons unintentionally compete with other surgeons for the same resources at the same time in the same hospital by way of past scheduling practices

• It is beneficial for everyone to improve scheduling processes and define elective block schedules that are site specific so as to reduce the unintended but frustrating competition for resources

A Platform for Change

Recognize:

• This is a political process

• There are multiple stakeholders

• Foundational changes required to affect real change

• The importance of communication and deliberation

Presentation to St. Luke’s BOD Oct 2010

• History of POGC – Aim and Purpose

• Peri-operative stakeholders

• Proposed improvements in peri-operative services

• Request to advance from an advisory council to a governing council

• Governing Council supported by BOD

2011 –Surgery Executive CommitteeDirector of Surgery, Anesthesia Director, COO, Director Surgical Services

Effective governance structure is essential to a well-run surgery program• Structure: subset of the POGC• Purpose:

Educate, develop, support physician leadersCharged with operational responsibility and authority for all aspects

of the surgical program, including:

• development, implementation, and enforcement of all policies related to surgical services’ operational issues including block scheduling and patient throughput

• responsible for creating the monthly agenda for the POGC

• examine educational opportunities for physician leaders

2011 – POGC Business

• Update charter to evolve from:Advisory capacity to Governing capacityPhysician membership assigned and approved by St. Luke’s administration

to membership selected and approved by POGCAll physician members had voting privileges in determining

recommendations referred to responsible hospital personnel & medical staff committees as appropriate to voting privileges extended to creating policy

Other medical staff attendees invited as topics dictate

• Universal Block Scheduling Policy

• Add-on classification system

• Communicate Council activity to physician colleagues

2011 – POGC and Block Scheduling• POGC oversight of transition from city-wide block

scheduling system to a hospital-based or site- specific system to be completed January 2012

• Collaborative effort between the hospital, anesthesia services and multiple surgeons and offices

• Issue surgeon and specialty-specific blocks

• Define scheduling terms

• Develop and implement Universal Block Scheduling Policy

• Develop and review block utilization reports

Elective vs. Add-On

Principle:

• A well managed elective schedule along with clinically driven prioritization of add-ons can reduce wait times for urgent/emergent volumes.

Elective vs. Add-OnMust be Managed Separately

• Wait times and other delays are key drivers in both patient satisfaction and clinical quality. The most effective organizations will address patient flow issues through “changing the production process” via operational management techniques from private industry.

• Variability in the elective schedule is the main driver in OR delays. The elective schedule is totally schedulable and within our control. Proper management of an elective schedule improves physician/patient access to patient-driven peaks in demand (add-ons). Elective and non-elective volumes are different and must be treated separately.

Results• Operations / Flow:

• Variability – Hours of elective vs. hours or add-ons per day• On-time starts first case of the day• Block utilization

• Matching OR staffing to volumes• OR staff overtime and Extra Hours Incentive• OR rooms open after 1530, 1730 and 1930

Start of Ortho/ENT BlocksQ3 Elective Add-OnAverage 46.34 4.04Median 46.4 4.0Standard Dev. 10.92 2.63

Q4 Elective Add-OnAverage 53.22 7.18Median 54.6 6.4Standard Dev. 12.70 4.56Start of GYN, Gen Surg, & UroJ anuary Elective Add-OnAverage 57.80 10.34Median 60.6 9.6Standard Dev. 8.34 4.14

Start of GYN, Gen Surg, & UroFebruary Elective Add-OnAverage 48.38 9.18Median 47.5 8.7Standard Dev. 9.12 3.83

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St. Luke's Hours of Surgery

Elective Hours of Surgery Add-on Hours of Surgery

Block Start:Neuro Block Start:

Ortho, ENT

Block Start:GYN, Gen. Surg,

Prior to St. Luke's BlocksQ4 2010 Elective Add-OnAverage 47.77 4.79Median 46.25 4.15Standard Dev. 11.50 3.00Start of Neuro BlocksQ1 2011 - Q2 2011 Elective Add-OnAverage 48.60 5.10Median 47.5 4.5Standard Dev. 11.16 2.78

Block Utilization Report SummaryTotal OR Blocked Hours Utilization

QuarterBlock Hours

ScheduledTime

Scheduled Time

Utilization Actual TimeActual Time Utilization

Out of Block Time

Q1 310.50 208.00 67.0% 207.87 66.9% 34.00

Q2 337.50 237.00 70.2% 227.09 67.3% 115.50

Q3 1,002.00 661.00 66.0% 556.01 55.5% 150.63

Q4 1,744.00 1,160.20 66.5% 988.97 56.7% 308.24

Key:Total 2011 3,394.00 2,266.20 66.8% 1,979.94 58.3% 608.37

> 80% Utilization Jan. 1,107.50 728.70 65.8% 550.41 49.7% 103.55

60 - 80% Utilization Feb. 1,158.00 765.06 66.1% 656.19 56.7% 190.00

< 60% Utilization Mar 1,166.00 793.50 68.1% 661.25 56.7% 184.05

On Time Starts – 1st Case of the Day

Overtime and Extra Hours Incentive

Rooms Open after 1530, 1730, 1930

1/2 1/4 1/6 2/1 2/3 2/7 2/9 3/2 3/6 3/80

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101st Qtr 2012 OR Rooms in Use 15:30 - 23:00

15:30 - 17:00 Linear (15:30 - 17:00) 17:01 - 19:00Linear (17:01 - 19:00) 19:01 - 23:00 Linear (19:01 - 23:00)