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