sip 1 team leaders: judy canfield dr. laurie amundsen
Post on 21-Dec-2015
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TRANSCRIPT
CharterScope: From patient’s decision of having surgery until 00:01 on the day of surgery.
In Scope: Patient scheduling of surgery; Pre-Anesthesia, Lab – including day of surgery; Discharge Planning; Financial Clearance; patient packet; interface to: Med Consult, Radiology, Pathology, Cardiology, Lab appointments; Scheduling Systems: scheduling coordination with PL’s; Communication of special needs – implants, ICU beds, bariatric equipment, etc.; In-patient preparation
Out of Scope:
Preparing instruments, supplies, and equipments;
Outcome Deliverables1. Document current state process(es)2. Document best industry practices3. Value analysis using LEAN methodology
a. Identification of optimal patient flow (patient experience)b. Identification of optimal information flowc. Identification of essential variability
4. Design future state process(es)5. Develop project plan and timeline
a. Identify short and long term projects6. Develop metrics and key indicators7. Short and long term project completion8. Strategy for ongoing Performance Improvement
Essential Metrics– Patient ready upon arrival– All resources ready upon arrival– Block time utilization– Planned schedule same as actual schedule
Where the team has focused its efforts due to the need for integration of all teams for Patient Preparation and Document Management
Condensed Process Map
Patient Decides to Have Surgery
Physician Initiates
Documentation
PCC Notified by Department
PCC Gathers Patient Data:
DemographicsSpecial NeedsSurgery Date
Availability
Physician IDs Case Type &
Duration
Pt. Calls PCC For
Next Steps
PCC Calls Pt. For Next
Steps
PCC Meets with
Pt. @ Decision
Time
Assists with
PMD if Needed
Refers to MSW
if Needed
Reg Process
?
Insurance Auth?
Pt.
PCC
MD
Yellow Packet
Yellow Packet Started
YP Not Started
Worksheet Possibly Started
Separate Ordersheet
Possibly Started
CPT/ICD9 Case
ID
Case ID By Name
Time Assigned
By Computer Estimate
Case Time Overridden
MM
PCC Enters Phys, Case Type &
Duration into ESI
PCC Gathers Addtn’l Data:Mindscape
Essential Tests
PCC Coordinates Visits
Pre & Post-OP
Phys. Order for Essential Services
Clinic RN/MA
Schedules
Data Available
& Scheduled
RN
Test Results Not Tied to Yellow Packet
Data Not AvailableSearch
Data Available
& Scheduled
Data Not Available Case in
TBA
Case AppropriateDetermined
Accurate Case ID & Appropriate Length
Yes
Consult RN3
Override Computer Estimate
MA
Special Needs in Comment Section
No
Interpreter Scheduled
Yellow Packet Initiated if not
Previously
A 49 Completed
Special Needs ID’d
Med Consult
Arranged
PAC Or Bypass
Determined
Referral Request if Necessary
Orders Started
Consent H&P
Orders Generated-Establish Follow-up
Dictation Completed & Printed?
PCC Returns Info to Referral Source
No Confirm
PSR
OR
Yellow Packet to PAC for Visit/
Bypass
PSR Reviews
YP
YP Checked
in For Visit
Yellow Packet Complete?
Yes
PCC
No
Patient Visits PAC
YP Ready Orders
Complete
RN Assembles
Loose Documents
Pt. Edu
Lab Draw, EKG, RN Assess
Assure Med
Consult if Needed
AncillaryF.U.
Determined
OR Runs ESI Build 2:30 Day
Ahead
Pt. to ED For AM Admit
Consent For Care
YP Prep Day of Surg
Check With OR Sched
For Case Type
OR Reviews Sched For Time Estimates & Site
All Case Items ID’d
Via PL
ESI Pick Ticket Produced
Check Pt On OR Schedule
Call Pt. With
Check-in Time
Patient Has Surg Time &
Instructions
Case Picking/Delivery Prioritized
Carts Picked one at a Time Via Pick
Ticket
Items Not Available
Shortage Documented
Enter Database
PM Crew Rechecks Completes
Carts
Continue?
No
Cancel
PCC Starts PAC Visit or Bypass
Yes
May FAX Info to PAC to
Determine Bypass
FAX H&P’ Health
Assessment Via Request
Form
Sets Up Pre-Surg
Appt.
PAC RN Determines Bypass/Visit
Core process
Key Areas of Improvement
• Scheduling Cases
• Preparing for Surgical Cases
• Accessing Patient Data
RPI Recommendation• Case Cart
• Patient Preparation
• Document Management
Patient Flow
Scheduling
PAC
SuppliesEquipment
Condensed Process Map
Patient Decides to Have Surgery
Physician Initiates
Documentation
PCC Notified by Department
PCC Gathers Patient Data:
DemographicsSpecial NeedsSurgery Date
Availability
Physician IDs Case Type &
Duration
Pt. Calls PCC For
Next Steps
PCC Calls Pt. For Next
Steps
PCC Meets with
Pt. @ Decision
Time
Assists with
PMD if Needed
Refers to MSW
if Needed
Reg Process
?
Insurance Auth?
Pt.
PCC
MD
Yellow Packet
Yellow Packet Started
YP Not Started
Worksheet Possibly Started
Separate Ordersheet
Possibly Started
CPT/ICD9 Case
ID
Case ID By Name
Time Assigned
By Computer Estimate
Case Time Overridden
MM
PCC Enters Phys, Case Type &
Duration into ESI
PCC Gathers Addtn’l Data:Mindscape
Essential Tests
PCC Coordinates Visits
Pre & Post-OP
Phys. Order for Essential Services
Clinic RN/MA
Schedules
Data Available
& Scheduled
RN
Test Results Not Tied to Yellow Packet
Data Not AvailableSearch
Data Available
& Scheduled
Data Not Available Case in
TBA
Case AppropriateDetermined
Accurate Case ID & Appropriate Length
Yes
Consult RN3
Override Computer Estimate
MA
Special Needs in Comment Section
No
Interpreter Scheduled
Yellow Packet Initiated if not
Previously
A 49 Completed
Special Needs ID’d
Med Consult
Arranged
PAC Or Bypass
Determined
Referral Request if Necessary
Orders Started
Consent H&P
Orders Generated-Establish Follow-up
Dictation Completed & Printed?
PCC Returns Info to Referral Source
No Confirm
PSR
OR
Yellow Packet to PAC for Visit/
Bypass
PSR Reviews
YP
YP Checked
in For Visit
Yellow Packet Complete?
Yes
PCC
No
Patient Visits PAC
YP Ready Orders
Complete
RN Assembles
Loose Documents
Pt. Edu
Lab Draw, EKG, RN Assess
Assure Med
Consult if Needed
AncillaryF.U.
Determined
OR Runs ESI Build 2:30 Day
Ahead
Pt. to ED For AM Admit
Consent For Care
YP Prep Day of Surg
Check With OR Sched
For Case Type
OR Reviews Sched For Time Estimates & Site
All Case Items ID’d
Via PL
ESI Pick Ticket Produced
Check Pt On OR Schedule
Call Pt. With
Check-in Time
Patient Has Surg Time &
Instructions
Case Picking/Delivery Prioritized
Carts Picked one at a Time Via Pick
Ticket
Items Not Available
Shortage Documented
Enter Database
PM Crew Rechecks Completes
Carts
Continue?
No
Cancel
PCC Starts PAC Visit or Bypass
Yes
May FAX Info to PAC to
Determine Bypass
FAX H&P’ Health
Assessment Via Request
Form
Sets Up Pre-Surg
Appt.
PAC RN Determines Bypass/Visit
Scheduling Cases Map
Scheduling CasesIssues
• Case selection, via PCC, is by procedure name.• Case selection drives the preference list that is chosen
for the case.• SCCA patients decide day ahead for surgery and
require intense coordination.• Each team member has different definition for surgery
time estimate. • Room scheduling is not standardized- Pavilion and
Main OR have different rules.• Cases are moved 24 hours ahead after review by
charge Anesthesia/Nurse staff for correct room assignment.
Patient Flow
Scheduling
PAC
SuppliesEquipment
Condensed Process Map
Patient Decides to Have Surgery
Physician Initiates
Documentation
PCC Notified by Department
PCC Gathers Patient Data:
DemographicsSpecial NeedsSurgery Date
Availability
Physician IDs Case Type &
Duration
Pt. Calls PCC For
Next Steps
PCC Calls Pt. For Next
Steps
PCC Meets with
Pt. @ Decision
Time
Assists with
PMD if Needed
Refers to MSW
if Needed
Reg Process
?
Insurance Auth?
Pt.
PCC
MD
Yellow Packet
Yellow Packet Started
YP Not Started
Worksheet Possibly Started
Separate Ordersheet
Possibly Started
CPT/ICD9 Case
ID
Case ID By Name
Time Assigned
By Computer Estimate
Case Time Overridden
MM
PCC Enters Phys, Case Type &
Duration into ESI
PCC Gathers Addtn’l Data:Mindscape
Essential Tests
PCC Coordinates Visits
Pre & Post-OP
Phys. Order for Essential Services
Clinic RN/MA
Schedules
Data Available
& Scheduled
RN
Test Results Not Tied to Yellow Packet
Data Not AvailableSearch
Data Available
& Scheduled
Data Not Available Case in
TBA
Case AppropriateDetermined
Accurate Case ID & Appropriate Length
Yes
Consult RN3
Override Computer Estimate
MA
Special Needs in Comment Section
No
Interpreter Scheduled
Yellow Packet Initiated if not
Previously
A 49 Completed
Special Needs ID’d
Med Consult
Arranged
PAC Or Bypass
Determined
Referral Request if Necessary
Orders Started
Consent H&P
Orders Generated-Establish Follow-up
Dictation Completed & Printed?
PCC Returns Info to Referral Source
No Confirm
PSR
OR
Yellow Packet to PAC for Visit/
Bypass
PSR Reviews
YP
YP Checked
in For Visit
Yellow Packet Complete?
Yes
PCC
No
Patient Visits PAC
YP Ready Orders
Complete
RN Assembles
Loose Documents
Pt. Edu
Lab Draw, EKG, RN Assess
Assure Med
Consult if Needed
AncillaryF.U.
Determined
OR Runs ESI Build 2:30 Day
Ahead
Pt. to ED For AM Admit
Consent For Care
YP Prep Day of Surg
Check With OR Sched
For Case Type
OR Reviews Sched For Time Estimates & Site
All Case Items ID’d
Via PL
ESI Pick Ticket Produced
Check Pt On OR Schedule
Call Pt. With
Check-in Time
Patient Has Surg Time &
Instructions
Case Picking/Delivery Prioritized
Carts Picked one at a Time Via Pick
Ticket
Items Not Available
Shortage Documented
Enter Database
PM Crew Rechecks Completes
Carts
Continue?
No
Cancel
PCC Starts PAC Visit or Bypass
Yes
May FAX Info to PAC to
Determine Bypass
FAX H&P’ Health
Assessment Via Request
Form
Sets Up Pre-Surg
Appt.
PAC RN Determines Bypass/Visit
Preparing for Surgical Case Map
Preparing for Surgical Case Issues
• All systems are manual, which is resource- and labor-intensive.
• Preference lists/ pick tickets are not frequently reviewed the day ahead, resulting in the wrong case cart.
• There is no standard for how information is received, reviewed and actions taken.
• PCCs are located in multiple sites.• Getting the patient access to essential services in
surgical preparation is difficult.• Anesthesia bypass process of the surgical patient is
complicated and inconsistent.
Condensed Process Map
Patient Decides to Have Surgery
Physician Initiates
Documentation
PCC Notified by Department
PCC Gathers Patient Data:
DemographicsSpecial NeedsSurgery Date
Availability
Physician IDs Case Type &
Duration
Pt. Calls PCC For
Next Steps
PCC Calls Pt. For Next
Steps
PCC Meets with
Pt. @ Decision
Time
Assists with
PMD if Needed
Refers to MSW
if Needed
Reg Process
?
Insurance Auth?
Pt.
PCC
MD
Yellow Packet
Yellow Packet Started
YP Not Started
Worksheet Possibly Started
Separate Ordersheet
Possibly Started
CPT/ICD9 Case
ID
Case ID By Name
Time Assigned
By Computer Estimate
Case Time Overridden
MM
PCC Enters Phys, Case Type &
Duration into ESI
PCC Gathers Addtn’l Data:Mindscape
Essential Tests
PCC Coordinates Visits
Pre & Post-OP
Phys. Order for Essential Services
Clinic RN/MA
Schedules
Data Available
& Scheduled
RN
Test Results Not Tied to Yellow Packet
Data Not AvailableSearch
Data Available
& Scheduled
Data Not Available Case in
TBA
Case AppropriateDetermined
Accurate Case ID & Appropriate Length
Yes
Consult RN3
Override Computer Estimate
MA
Special Needs in Comment Section
No
Interpreter Scheduled
Yellow Packet Initiated if not
Previously
A 49 Completed
Special Needs ID’d
Med Consult
Arranged
PAC Or Bypass
Determined
Referral Request if Necessary
Orders Started
Consent H&P
Orders Generated-Establish Follow-up
Dictation Completed & Printed?
PCC Returns Info to Referral Source
No Confirm
PSR
OR
Yellow Packet to PAC for Visit/
Bypass
PSR Reviews
YP
YP Checked
in For Visit
Yellow Packet Complete?
Yes
PCC
No
Patient Visits PAC
YP Ready Orders
Complete
RN Assembles
Loose Documents
Pt. Edu
Lab Draw, EKG, RN Assess
Assure Med
Consult if Needed
AncillaryF.U.
Determined
OR Runs ESI Build 2:30 Day
Ahead
Pt. to ED For AM Admit
Consent For Care
YP Prep Day of Surg
Check With OR Sched
For Case Type
OR Reviews Sched For Time Estimates & Site
All Case Items ID’d
Via PL
ESI Pick Ticket Produced
Check Pt On OR Schedule
Call Pt. With
Check-in Time
Patient Has Surg Time &
Instructions
Case Picking/Delivery Prioritized
Carts Picked one at a Time Via Pick
Ticket
Items Not Available
Shortage Documented
Enter Database
PM Crew Rechecks Completes
Carts
Continue?
No
Cancel
PCC Starts PAC Visit or Bypass
Yes
May FAX Info to PAC to
Determine Bypass
FAX H&P’ Health
Assessment Via Request
Form
Sets Up Pre-Surg
Appt.
PAC RN Determines Bypass/Visit
Accessing Patient Data
Accessing Patient DataIssues
• Information received from outside referral does not always make it to the chart.
• All document elements for the pre-surgical patient are not accessible to the requisite and appropriate staff.
• Yellow packet travels across sites, and is only accessible to the site where it currently resides.
• Records are lost causing case delays and errors.• Document completion is not standardized across
surgical clinics.
RPI – Case Carts
Yellow Packet to PAC for Visit/
Bypass
PSR Reviews
YP
YP Checked
in For Visit
Yellow Packet Complete?
Yes
PCC
No
Patient Visits PAC
YP Ready Orders
Complete
RN Assembles
Loose Documents
Pt. Edu
Lab Draw, EKG, RN Assess
Assure Med
Consult if Needed
AncillaryF.U.
Determined
OR Runs ESI Build 2:30 Day
Ahead
Pt. to ED For AM Admit
Consent For Care
YP Prep Day of Surg
Check With OR Sched
For Case Type
OR Reviews Sched For Time Estimates & Site
All Case Items ID’d
Via PL
ESI Pick Ticket Produced
Check Pt On OR Schedule
Call Pt. With
Check-in Time
Patient Has Surg Time &
Instructions
Case Picking/Delivery Prioritized
Carts Picked one at a Time Via Pick
Ticket
Items Not Available
Shortage Documented
Enter Database
PM Crew Rechecks Completes
Carts
Continue?
No
Cancel
PCC Starts PAC Visit or Bypass
Yes
May FAX Info to PAC to
Determine Bypass
FAX H&P’ Health
Assessment Via Request
Form
Sets Up Pre-Surg
Appt.
PAC RN Determines Bypass/Visit
Past and Current Activities
• Completed PCC ESI training• Reviewed and evaluated best practice scheduling
process from other academic medical centers• Reviewed literature• Created website for open and released block time• Established concepts for a best practice scheduling
process• Developed Best Practice scheduling process vision
(includes inpatient)• Established shared definitions• Developed standard physician worksheet• Created criteria/guidelines for scheduling TBA cases• Flexible scheduling process for cases that need 24 hour
turnaround of schedule (i.e., cancer, orthopedic injuries)
Best Practice Scheduling Process Recommendation
Patient and Physician determination of surgical procedure
Standard Worksheet completed – essential elements
MD determines and is accountable for procedure name, duration and preference list from data sheet with his/her specific cases and PLs
Process for scheduling is standard for both inpatient and outpatient cases by the PCC
Scheduler acknowledges work submitted
Information is entered into ESI and scheduled by PCC
Cases are scheduled to accommodate patient preferences and special needs
PCC reviews web site for released time
If no block is openPCC places case in block time
PCC places case in TBA schedule
If no released time available
48 hours before day of surgery – charge personnel checks surgery schedule for fit, moves TBA cases into open block and communicates these to services
Key Reality Checks• Will this make our scheduling process easier? • Will it flow better and have more accuracy? • Does our process give feedback to those using it?
Next Steps
• Develop future metrics• Develop implementation plan for new scheduling
process• Develop plan for elements not discussed (due to
time constraints) but of importance
SIP1 Team
Roles: Active Members: Team Leader Judy CanfieldTeam Leader Laurie AmundsenClinic Manager Nancy EberhardtPre-Surgery Clinic S. Deatrick/S. MossingPCC Manager Kathy HerigstadPCC Colleen MaraOR Scheduler Susan TracyInterpreter Services Linda GolleyCharge RN OR Donna AndersonOR RN3 Jackie WalkerSurgeon Ben GreerSurgeon Brandt OelschlagerSurgeon Ben AndersonSurgeon Neal FutranPL’s & Implants Bill AntonMaterials Management Sal Ramirez
Pharmacy Jim VelezProject Manager Michelle Agnew
Comments/Questions from OR staff and department road shows
• Patients have lots of history but we cannot get/retrieve the record.
• PCCs have a lack of training in choosing the right PLs. Do we as the OR need to embrace training and collaborate with the PCCs?
• Because of the acuity of our patients, the day before the appointment in the Pre-Anesthesia Clinic is not enough lead time to prepare for the patient.
• Inpatients should be seen by the Pre-Anesthesia Clinic also.
• We are still getting incomplete instrument sets and wrong items in the case carts.
• Continuity of preop evaluation and on-site anesthesia management.
• Crisp definitions of time that make sense to the surgeons.
Review and Evaluation of Other Scheduling Practices
UCSF OHSU NYUMC Partners Who Schedules
Phys. Office/standardized form to relay the needed information (ICD code,procedure, implants needed, etc) for emergency/add-on cases either the surgeon or the resident calls to book the case - if the resdient calls we require the attending to call and approve the case before it is add to our "e" board
Phys. Scheduler Physician secretary.
Physician secretary-Schedule beyond block- into 3 virtual OR’s as wait list. 48 hours ahead of surgical day- all unused block time is released and the wait list cases are used to fill in time.
How to estimate times for cases
our surgery scheduling system averages case times (last ten cases by surgeon), for add-on cases we generally ask for a time estimate
Surgeon determines the cut to close case time and schedulers add the average turnover time for each site onto each scheduled case. Alternatively we use average case time aggregated in Ipath Surg. Scheduling system.
Computer system HBOC, ESI averages the time. When the schedule is reviewed the day before , times are reviewed. They are accurate 70% of the time.
Surgeon estimates the time within broad limits.
*Please note that this is only a small portion of the informal survey
Literature Review Sample• Schedule the Short Procedure First to Improve OR
Efficiency – Lebowitz, Phillip, MD, Oct 2003• What makes a well-oiled scheduling system? – OR Manager• Determining Optimum Operating Room Utilization – Tyler, D
et al., 2003• How to schedule elective surgical cases into specific
operating rooms to maximize the efficiency of use of operating room time –Dexter and Traub, 2002
• Optimal Sequencing of Urgent Surgical Cases, Dexter et al., May 1999
• Creating an Optimal Operating Room Schedule, Calichman, Murray, May 2005
• Applications of Queuing Theory, Vanaswala and Desser, Feb 2005
• Improving Operating Room Coordination, Moss and Xiao, 2004