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Process Improvement TeamProcess Improvement Team

Operating RoomOperating RoomSchedulingScheduling

Final Report Respectfully Submitted to the OR Committee Final Report Respectfully Submitted to the OR Committee May 1, 2007May 1, 2007

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Team LeaderStephanie Ramirez

Participating Team MembersDr. Greg Reece Melina ScarboroughDr. V. Gottumukkala Lancelot JonesPatricia Gage Nancy ReinertSusan McConihay Keith ShookAnthony Hoang Irvin SerraCarla Willis Corliss DenmanShirley Morrison Melanie LoprestoStacy Swanson Garry BrydgesMark Winograd

Technical ConsultantJim Vinci, Holland and Davis, LLP

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GOAL:GOAL:

To increase efficiency and accuracy of the Operating Rooms through an

effective and “rules based” scheduling system.

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OR Committee reviews the Team’s recommended solutions and approve with an addendum if necessary.

Forward recommended solutions & final report to OR Executive Team for approval.

Charter the Implementation Planning Team (action for OR Executive Team).

Requests the following:Requests the following:

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Overview

Team representative of all stakeholders Conducted Root Cause Analysis Problems identified:

Communication Staffing Information Technology Cultural/Behavioral

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MAJOR FINDINGS:MAJOR FINDINGS:

1. Failure to take advantage of web-based technology & electronic enhancements.

2. Inadequate structure leading to inefficiency & lack of standardization in scheduling processes.

3. Unpredictability of over & under utilization of OR resources.

4. Inability to track patients thru scheduling process to point of medical clearance.

5. Challenges of complex & multi-team cases.

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MAJOR FINDINGS:MAJOR FINDINGS:

1.1. Failure to take advantage of web-based Failure to take advantage of web-based technology & electronic enhancements.technology & electronic enhancements.

Solution Solution

Implementation of web based & electronic processes are indicated throughout presentation.

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Inefficiencies in inconsistent processes Inefficiencies in inconsistent processes affect everyone.affect everyone.

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MAJOR FINDINGS:MAJOR FINDINGS:

1. Failure to take advantage of web-based technology & electronic enhancements.

2.2. Inadequate structure leading to Inadequate structure leading to inefficiency & lack of standardization in inefficiency & lack of standardization in scheduling processes.scheduling processes.

3. Unpredictability of over & under utilization of OR resources.

4. Inability to track patients thru scheduling process to point of medical clearance.

5. Challenges of complex & multi-team cases.

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MAJOR FINDING:MAJOR FINDING:

2.2. Inadequate structure leading to inefficiency Inadequate structure leading to inefficiency & lack of standardization in scheduling & lack of standardization in scheduling processes. processes.

Short-term Solution (3-6 months)Short-term Solution (3-6 months)

Use this ordered set of priorities to schedule cases:

Patient Safety Maximize OR efficiency Reduce patient waiting time Surgeon preference

Dexter et. al. Making Management Decisions on the Day of Surgery Based on Operating Room Efficiency and Patient Waiting Times, Dexter et. al. Anesthesiology 2004; 101-1444-53

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Short-term Solution (3-6 months)Short-term Solution (3-6 months)

Assign scheduled cases based on principles of efficiency:

Assign by historical case length. Assess OR resources and match

case length. Consider equipment restrictions when

assigning operating rooms. Arrange cases to maximize OR efficiency

(bin stacking) to optimize available resources (minimizing over utilization).

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Short-term Solution (3-6 months)Short-term Solution (3-6 months)

Ensure patient safety through adequate preparation for cases:

Finalize schedule by specific time (to be determined) before day of surgery.

Avoid posting simultaneous case starts in ACB & OR on a single day.

Avoid replacing cancelled cases with new cases in the 24 hrs prior to the day of surgery (excluding urgent/emergent).

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MAJOR FINDINGS:MAJOR FINDINGS:

1. Failure to take advantage of web-based technology & electronic enhancements.

2. Inadequate structure leading to inefficiency & lack of standardization in scheduling processes.

3.3. Unpredictability of over & under utilization Unpredictability of over & under utilization of OR resources.of OR resources.

4. Inability to track patients thru scheduling process to point of medical clearance.

5. Challenges of complex & multi-team cases.

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MAJOR FINDING:MAJOR FINDING:

3.3. Unpredictability of over & under utilization Unpredictability of over & under utilization of OR resources.of OR resources.

Short-term Solution (3-6 months)Short-term Solution (3-6 months)

Assign a scheduler to each Alkek quad & ACB to schedule cases/assign rooms using the nurse manager as a resource.

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Recommended Structure for Surgery Recommended Structure for Surgery SchedulingScheduling17

Scheduler reviews request in surgery scheduling queue

(w)

OR scheduler Nadine

RoboticsGynUrologyThoracicPediatrics

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Surgical Oncology

OR scheduler Michelle2

NeuroOrthoPain

OR scheduler Elena4

H & NOpthalmology / ENTDental OncologyPlastic Surgery

OR scheduler Paula1

ACB OR

OR scheduler Matt5

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Short-term Solutions (3-6 months)Short-term Solutions (3-6 months)

Assess allocation of time by services.

Assess opportunity to post cases with defined allocated time parameters.

Use historical data to: Estimate case duration for scheduling. Validate service allocation utilization &

duration with upper prediction bounds.

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Short-term Solutions (3-6 months)Short-term Solutions (3-6 months)

Identify a representative (Chair or designee) from each Service to assist with resolving conflicts in case scheduling.

Assess opportunity to identify coordinator in each Service to work with surgeon and PA to coordinate scheduling of cases.

Establish oversight process to review service allocation utilization quarterly.

Modify service allocations based on review findings.

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MAJOR FINDINGS:MAJOR FINDINGS:

1. Failure to take advantage of web-based technology & electronic enhancements.

2. Inadequate structure leading to inefficiency & lack of standardization in scheduling processes.

3. Unpredictability of over & under utilization of OR resources.

4.4. Inability to track patients thru scheduling Inability to track patients thru scheduling process to point of medical clearance.process to point of medical clearance.

5. Challenges of complex & multi-team cases.

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MAJOR FINDING:MAJOR FINDING:

4. Inability to track patients thru scheduling process to point of medical clearance.

Intermediate Solution (6-12 months)Intermediate Solution (6-12 months)

Enhance current IT systems to improve patient flow, communication, and patient preparation.

Collaborate with IT & PI to develop electronic and web-based systems (white board subprocess) with business rules for accurate tracking of patients and extraction of data

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MAJOR FINDINGS:MAJOR FINDINGS:

1. Failure to take advantage of web-based technology & electronic enhancements.

2. Inadequate structure leading to inefficiency & lack of standardization in scheduling processes.

3. Unpredictability of over & under utilization of OR resources.

4. Inability to track patients thru scheduling process to point of medical clearance.

5.5. Challenges of complex & multi-team cases.Challenges of complex & multi-team cases.

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MAJOR FINDINGS:MAJOR FINDINGS:

5.5. Challenges of complex & multi-team cases.Challenges of complex & multi-team cases.

Short/Intermediate Solution Short/Intermediate Solution (Timeline as indicated)(Timeline as indicated)

Develop a centralized “time away” calendar to improve process of scheduling multi-team cases. (3-6 months)(3-6 months)

Automate process to notify stakeholders and collect data regarding a change or cancellation of case. (6-12 months)(6-12 months)

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Recommended Implementation TeamRecommended Implementation Team

Greg Reece, MDProcess Improvement

Program Manager

TBDCommunication

Manager

RFO IPT

Project Manager

Stephanie RamirezScheduling IPT

Project Manager

Melina ScarboroughAssistant Program

Manager

TBDImplementation/Change

Agent Advisor

Recorder/Coordinator

Facilitator

Communications Specialist

OR Nursing

Scheduling

Surgeon

PA

PI

IT

Anesthesiologist

Process Improvement Program Task Force4/26/2007

CRNA

Director POE Operations

Surgery Scheduling Implementation Planning Team

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New Surgery ProcessNew Surgery Process

Note:

White Board subprocess is workingin parallel to scheduling process

Scheduling is notified that all is clear on White

board

Scheduling begins to finalize schedule

Are there still OR space available within

24-48 hours?

Review “add-on” queue- RULE

BASED

Go to next patient in queue

Is surgeon still available?

Are all other OR resources available?

Is the patient available?

AConfirm surgery with

all stakeholders

Are there still available slots?

YES

YES

NO

YES

YES

NO

Finalize Schedule

YES

NO

Schedule is closedNO

YES

NO

25

26

27

28

29

NO

35

30

31

32

33

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YES

NO

Patient Requires Surgery

Surgery Done

Nursing and Anesthesia will accommodate the patient at earliest slot

Is it urgent or emergent?

Is it an emergency?

YES

1 2 3

4

5

A

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Is this a Multi-disciplinary case?

Primary surgeon or designee reviews

availability calendar of all surgeons (w)

YES

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BWhite Board Subprocess

NO

B

Primary surgeon requests adjunct

surgeons on the case (w)

Tentatively block adjunct surgeon's

calendar(s)- rule based estimated length of

times (w)

Primary surgeon consult adjunct

surgeons on case (w)

Have consultations been scheduled or

done? NO

YES

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15

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Patient is examined by adjunct surgeon(s)

Adjunct surgeon determines type of procedure and

estimate length of procedure- Enters

information into system re: special needs

Surgeon’s availability adjusted on availability

calendar

15a 15b

Surgeons or designee requests schedule thru web

system (w)

Request goes into surgery scheduling

queue (w)

Surgeon’s review their availability (w)

NO

Schedulers reviews request in surgery

scheduling queue (w)Check OR availability

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9

10

17

18

19

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Is OR available? NO

Tentatively schedule case in OR Manager & notify requester that surgery is

scheduled pending clearances which must be completed 48 hours prior to surgery

Requesting surgeon or designee reviews check off list (Whiteboard) for

completeness of request (w)

Is request and clearance complete?

YES

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DNO

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C

YES

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Emergent/Urgent:•Patient Safety White Board:

Patient SafetySingle & Multidisciplinary Scheduling:

•Patient Safety•Maximize OR EfficiencyOR throughput

Scheduling queue to OR Manager: •Maximize OR efficiencyOR throughputPatient waiting time•Surgeon preference

Final Schedule & Add On Cases: •Patient safety•Maximize OR efficiency•Patient waiting time•Surgeon preference

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Comments, Suggestions, DiscussionComments, Suggestions, Discussion