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PPT slides

  1. 1. Improving Hospital Flow to Increase Throughput, Improve Patient Satisfaction July 14 , 2005 Niels K Rathlev MD Vice Chair Department of Emergency Medicine
  2. 2. Maximizing throughput: smoothing the elective surgery schedule <ul><li>James M. Becker, MD </li></ul><ul><li>Keith P. Lewis, MD </li></ul><ul><li>John B. Chessare, MD </li></ul><ul><li>Eugene Litvak, PhD </li></ul><ul><li>Richard Shemin, MD </li></ul><ul><li>Gail Spinale, RN </li></ul><ul><li>Demetra Ouellette </li></ul><ul><li>Abbot Cooper </li></ul>
  3. 3. Boston Medical Center <ul><li>475 bed Level 1 trauma center </li></ul><ul><li>129,000 annual ED visits </li></ul><ul><li>Safety net hospital in Boston’s South End </li></ul><ul><li>ED provides 20% free care, 20% “self pay” </li></ul><ul><li>2 pavilions – East Newton cardiac center </li></ul><ul><ul><ul><ul><ul><li>Menino Trauma Center </li></ul></ul></ul></ul></ul>
  4. 4. Variability <ul><li>“ Natural”: you can’t control it …you just have to manage it. </li></ul><ul><ul><li># of patients coming to the ED </li></ul></ul><ul><ul><li>Types and # of emergency surgeries </li></ul></ul><ul><li>“ Artificial”: you can control it & must eliminate “batching” it to create flow </li></ul><ul><ul><li>When the nuclear med lab reports stress test results </li></ul></ul><ul><ul><li>Types and # of scheduled surgeries </li></ul></ul>
  5. 5. Surgical smoothing <ul><li>Smoothing elective vascular surgery </li></ul><ul><li>Smoothing elective cardiac surgery </li></ul><ul><li>Separating elective from urgent surgery in the Menino Pavilion </li></ul><ul><ul><li>Creating reliable urgency data </li></ul></ul><ul><ul><li>Separating a room for urgent/emergent cases </li></ul></ul><ul><ul><li>Eliminating Block Scheduling </li></ul></ul><ul><li>Smoothing elective cardiac caths (in progress) </li></ul>
  6. 6. Should the ED care? <ul><li>Each additional elective surgical case prolonged the mean LOS per ED patient by 15 seconds. </li></ul><ul><li>The median # of 48 elective surgical cases per weekday add 12.3 mins (5.2%) to the mean LOS per ED pt & 30.6 hrs to total ED dwell time </li></ul><ul><li>No association with diversions </li></ul>
  7. 7. Bed Need by Day of Week for Vascular Surgery (18 mos) Progressive Care Unit
  8. 8. Vascular Elective PCU Cases by Day Random Month July 2002
  9. 12. Mean CT Surgery Unscheduled Cases Weekdays
  10. 13. Average Scheduled CT Surgery Cases by Weekday
  11. 15. 2003 range 10 – 1 = 9 2004 range 7 –2 = 5 55% reduction in variability
  12. 16. Boston Globe, June 2004 “ Anybody who comes to me and says, I can’t do this, I’m going to send them to Boston Medical Center ” Dr. Dennis O’Leary President, JCAHO
  13. 17. Changes to the Menino OR Schedule <ul><li>BMC has 2 OR Suites </li></ul><ul><ul><li>Newton Pavilion </li></ul></ul><ul><ul><li>13 ORs </li></ul></ul><ul><ul><li>Menino Pavilion </li></ul></ul><ul><ul><li>8 ORs </li></ul></ul>
  14. 18. Menino Pavilion compared to Newton Pavilion Pediatrics, Trauma, Gastric Bypass, OB Cardiac, Eye Unique Services 5-20 0-4 #Weekend Cases 5-12 1-2 #Add Ons Per Day 20% 10% Cancellation Rate 6608 8601 # Cases Year 25-32 30-35 # Cases Day 8 13 # Rooms MP NP Variable
  15. 19. Pre-change problems with the schedule – Menino Pavilion <ul><li>Urgent/emergent bump elective cases </li></ul><ul><li>Overall 50% block utilization </li></ul><ul><li>Variable use of block (vacation, meetings) </li></ul><ul><li>Most cases booked 3-4 days out </li></ul><ul><li>33% of daily schedule is “add ons” </li></ul><ul><li>Variable release time between services </li></ul><ul><li>Cases can be lost waiting </li></ul><ul><li>People live in fear of losing their block </li></ul>
  16. 20. Our Goals <ul><li>Reduce bumped Cases </li></ul><ul><ul><li>Reduce waste in rework </li></ul></ul><ul><ul><li>Improve patient satisfaction </li></ul></ul><ul><ul><li>Improve surgeon satisfaction </li></ul></ul><ul><ul><li>Improve scheduling staff satisfaction </li></ul></ul><ul><li>Increase surgical volume </li></ul>
  17. 21. Our Plan <ul><li>Separate urgent/emergent from scheduled surgeries </li></ul>
  18. 22. How many rooms should we set aside for urgent/emergent cases? <ul><li>Created a case classification and prioritization system : </li></ul><ul><ul><ul><li>Emergent 30 minutes </li></ul></ul></ul><ul><ul><ul><li>Urgent 30 minutes – 4 hours </li></ul></ul></ul><ul><ul><ul><li>Semi-urgent 4 – 24 hours </li></ul></ul></ul><ul><ul><ul><li>Non-urgent >24 hours </li></ul></ul></ul><ul><li>Analysis shows that 1 room would be sufficient to have rarely bump an elective case </li></ul>
  19. 23. The Question Whose block time should we take away?
  20. 24. Block scheduling <ul><li>Surgeon or service “owns” blocks of time on the OR schedule </li></ul><ul><li>Allows surgeons to plan their time </li></ul><ul><li>If utilization of the blocks approaches 100%…everyone wins </li></ul><ul><li>Requires redesign of block as surgeons come and go or as demand changes </li></ul>
  21. 25. Advantages of open scheduling model <ul><li>Gives surgeons flexibility in scheduling </li></ul><ul><li>Equal access for all surgeons </li></ul><ul><li>Promotes booking far in advance </li></ul><ul><li>Opens up free time for other surgeons </li></ul><ul><li>Not rigid and gives schedulers flexibility </li></ul><ul><li>No case will be refused </li></ul>
  22. 26. “ Concerns” regarding the open scheduling model <ul><li>“ It’s not what we are used to doing” </li></ul><ul><li>Gaming the system </li></ul><ul><li>Someone may take the time you want </li></ul><ul><li>Late booking may lose out </li></ul><ul><li>Fear of loss of OR access and income </li></ul><ul><li>Cases all over the place </li></ul><ul><li>The winner takes it all! </li></ul>
  23. 27. Menino OR New Design April 26, 2004 Urgent and Elective Flows Separated No-block Scheduling Begins <ul><ul><li>Open Scheduling (Open Scheduled/OS) </li></ul></ul><ul><ul><li>Quantity: 5 Rooms </li></ul></ul><ul><ul><li>Orthopedic Scheduling (Block Scheduled/BS) </li></ul></ul><ul><ul><li>Quantity: 2 Rooms </li></ul></ul><ul><ul><li>Day of Scheduling (Urgent/Emergent Schedule) </li></ul></ul><ul><ul><li>Quantity: 1 Room </li></ul></ul>
  24. 28. Urgent room 5 <ul><li>Monday – Friday 7– 3:30 PM </li></ul><ul><li>Fully staffed and ready to go </li></ul><ul><li>Open to all! </li></ul><ul><li>Case classification and prioritizing </li></ul><ul><li>Emergent 30 minutes </li></ul><ul><li>Urgent 30 minutes – 4 o </li></ul><ul><li>Semi-urgent 4-24 o </li></ul>
  25. 29. OR Executive Committee commitment <ul><li>Want to enhance volume for all </li></ul><ul><li>Want to prioritize and get to all </li></ul><ul><li>emergencies </li></ul><ul><li>Dedicated schedulers </li></ul><ul><li>Tighten final schedule to maximize </li></ul><ul><li>surgeon efficiency </li></ul><ul><li>No case will be denied </li></ul><ul><li>If it fails, we will reassess and change </li></ul>
  26. 30. Separating urgent from elective Before and after <ul><li>Before </li></ul><ul><li>April – Sept 2003 </li></ul><ul><li>157 emergent cases (M – F) 7:00 AM to 3:30 PM </li></ul><ul><li>334 elective patients were delayed or cancelled </li></ul><ul><li>After </li></ul><ul><li>April– Sept 2004 </li></ul><ul><li>159 emergent cases (M – F) 7:00 AM to 3:30 PM </li></ul><ul><li>3 elective patients were delayed or cancelled </li></ul><ul><li>(1 cancelled, 2 delayed) </li></ul>
  27. 31. Summary of open block & separating urgent from scheduled cases <ul><li>Eliminated bumping of elective cases (#3) </li></ul><ul><li>Scheduling cases quicker </li></ul><ul><li>More choice: both day and time </li></ul><ul><li>Book consecutive cases </li></ul><ul><li>More productive use of OR (fewer gaps) </li></ul><ul><li>No need to notify scheduling for time off </li></ul><ul><li>Minimal # of complaints </li></ul>
  28. 32. What’s next?: smoothing elective cardiac caths <ul><li>We have competition for beds between adult cardiac and pulmonary ED patients and patients coming from the cath lab on our 6 North Unit </li></ul><ul><li>Do we have artificial variability in scheduling elective caths and if so, what can we do to smooth this? </li></ul>
  29. 34. Smoothing elective caths <ul><li>We have just implemented a cap of 5 elective cath patients on Mondays and Fridays after studying the variability. </li></ul><ul><li>It is too soon to see the effect of this change. </li></ul>
  30. 35. Summary <ul><li>There is much artificial variability in healthcare. We must do better to design systems to eliminate it. We can no longer afford this waste. </li></ul><ul><li>Separating the flow of urgent surgery from scheduled surgery reduces waste and rework </li></ul><ul><li>No-Block scheduling is a good way to help the surgeons, patients, and staff </li></ul>
  31. 36. References <ul><li>Leading Change; by John P. Kotter </li></ul><ul><li>McManus ML, Long MC; Cooper A, Mandell J, Berwick DM, Pagano M, Litvak E. Impact of Variability in Surgical Caseload on Access to Intensive Care Services, Anesthesiology 2003; 98: 1491-1496. </li></ul><ul><li>http://management.bu.edu/research/hcmrc/mvp/index.asp </li></ul>