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Collaborating with Physicians:Engaging for Results                             €   Joanne M. Bonnot, MSN, RN, NE-BC       ...
Faculty Disclosure Jane Kusler-Jensen, Jamie Sanchez-Anderson, and Debbie Hoffman: 2. Deloitte & Touche, LLP Joanne Bonnot...
Objectives1.   Discuss key metrics within perioperative services,     including first-case on-time starts, block utilizati...
Polling Question:Why is Collaboration with Physicians Critical?A. Drive patient satisfactionB. Drive improved patient safe...
What Has Changed?     Health Care Reform     Value Based Purchasing     Accountable Care Organizations     Bundled Pay...
CEO’s ConcernsSource: Reference Slide # 4
Surgical Services Drive Hospital Performance      Major driver of revenues and costs      Major driver of patient safety...
Surgerys Cost and Complexity 240 million surgeries are performed worldwide each year 50 million surgeries are performed ...
Surgical Services: Engine of the Hospital                              Past                                            Fut...
Perioperative GovernancePerioperative Governance     Driving Change
Polling Question: Perioperative Governance How many people have a perioperative governance structure? (Raise your hands) H...
Top Ten Questions to Determine if YouHave An Effective Perioperative Governance1. Does your governance meet regularly (mon...
Top Ten Questions to Determine if You HaveAn Effective Perioperative Governance (cont.)6. Are governance representatives a...
Efficient Perioperative Governance Structures Should Actwith Confidence, Purpose and a Spirit of AccountabilityWhat does a...
How Can Perioperative Governance Be Successful?   Support from Senior Management         -     Validate the authority of ...
Hospital Governance Charter    Name             Perioperative Governance                     Set strategic direction for...
Day to Day Governance Charter     Name           Day to Day Leadership Team                    Make operational decision...
Functional Responsibilities of Governance    Function                                      Hospital                       ...
Perioperative Metrics
Perioperative Metrics      Metric                             Purpose                                        Methodology  ...
Varied View of Ideal Scheduling Needs
Ideal Scheduling Program for Surgeons"Just have my own operating room, staff, equipment, and ananesthesiologist available ...
Ideal Scheduling Program for Anesthesiologists  Two or more rooms  Staggered starts  Two sets of nursing and anesthesia...
Ideal Scheduling Program for Nursing   One team per room   Scheduled lunch and breaks   Surgeon and anesthesiologist wa...
Ideal Scheduling Program for Administration Keep all rooms utilized as long as possibleSource: Reference Slide # 8
You cannot effectively optimize OR productivity withoutaddressing OR utilization and accountable surgeon block allocations
Rules of EngagementKey questions:   Who are your stakeholders?   Who are the formal and informal leaders?   Do you have...
Block Utilization Tools
Case Study: Background SummarySt Jude Medical Center, Fullerton CAWe realized throughout the years the tools that we had i...
Case Study: Process RedesignNew methodology focuses on collaboration to drive a new outcome through acontinuous improvemen...
Physician ScorecardPurpose: present a comprehensive picture of how blocks are utilized   Block utilization trends over ti...
Example of Adjusting Blocks with Data
Proper Block Utilization
Block Utilization Heat Map OverviewPurpose: present a detailed block utilization at the facility level  Overview of block...
Questions
References1.   Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/racs-/-icd-     9-/-icd...
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9021 session collaborating with physicians engaging for results_aorn 2013_congress_spkr final

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A close look into sucessful Block Scheduling redesign and Surgeon Score cards

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  • http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/defining-the-episode-of-care-average-bundled-payments-for-16-ms-drgs.htmlhttp://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/5-points-hospital-cfos-need-to-know-about-the-bundled-payment-business-model.htmlhttp://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/8-tips-for-hospitals-considering-bundled-payments-for-orthopedics.html
  • http://www.beckershospitalreview.com/hospital-management-administration/8-key-issues-for-hospitals-and-health-systems-2013.htmlhttp://www.beckershospitalreview.com/hospital-management-administration/8-key-issues-for-hospitals-and-health-systems-2013.html
  • http://www.beckershospitalreview.com/hospital-management-administration/8-key-issues-for-hospitals-and-health-systems-2013.htmlhttp://www.beckershospitalreview.com/hospital-management-administration/8-key-issues-for-hospitals-and-health-systems-2013.html
  • http://all-free-download.com/free-photos/the_high_speed_train_picture_168538.htmlhttp://www.freepik.com/free-photos-vectors/train
  • Use a broad perspective to evaluate long-term strategy and sustainability of the organization
  • NursingSurgeryAnesthesia Finance Quality AdministrationDay to Day will have
  • Old MethodologyMonthly block utilization Reported sent out monthly with little action to follow Monitored TOT and FCOTS Over the course of this past year in working with block schedules Due to a period with no data to make informed decisions and a drop in volume a change had to be made Over the course of this past year working with block schedules going from being punitive to become collaboratively engage the surgeons in the decision making process Ensuring surgeons understand getting the right size block and the right amount of time For example: seeing where physicians are utilizing time allowed us to make the best decisions in redesigning their block to meet their needs.
  • Over the course of this past year in working with block schedules Punitive to become collaborative and drive change Developed physician scorecards and physician schedule – prioritized below 50% first and re-designed met with surgical schedulers and physicians 1:1
  • Helps to level load (take something away that is beneficial to the overall picture)
  • Transcript of "9021 session collaborating with physicians engaging for results_aorn 2013_congress_spkr final"

    1. 1. Collaborating with Physicians:Engaging for Results € Joanne M. Bonnot, MSN, RN, NE-BC € Debbie L. Hoffman, EMBA, BA, RN € Jane A. Kusler-Jensen, MBA, BSN, RN, CNOR € Jamie L. Sanchez-Anderson, MSN, MBA, BS, RN
    2. 2. Faculty Disclosure Jane Kusler-Jensen, Jamie Sanchez-Anderson, and Debbie Hoffman: 2. Deloitte & Touche, LLP Joanne Bonnot: 7. No conflict.AORN’s policy is that the subject matter experts for this product must disclose any financial relationshipin a company providing grant funds and/or a company whose product(s) may be discussed or usedduring the educational activity. Financial disclosure will include the name of the company and/orproduct and the type of financial relationship, and includes relationships that are in place at the time ofthe activity or were in place in the 12 months preceding the activity. Disclosures for this activity areindicated according to the following numeric categories: 1. Consultant/Speaker’s Bureau 2. Employee 3. Stockholder 4. Product Designer 5. Grant/Research Support 6. Other relationship (specify) 7. No conflict. Accreditation Statement AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.
    3. 3. Objectives1. Discuss key metrics within perioperative services, including first-case on-time starts, block utilization, and turnover time.2. Discuss criteria for successful perioperative governance, including physician role and engagement.3. Explore the necessity of cutting cost and improving perioperative efficiencies.
    4. 4. Polling Question:Why is Collaboration with Physicians Critical?A. Drive patient satisfactionB. Drive improved patient safetyC. Drive improved quality of careD. Drive reduction in costsE. Drive improvement in operational efficiencyF. A, B & CG. All of the above
    5. 5. What Has Changed?  Health Care Reform  Value Based Purchasing  Accountable Care Organizations  Bundled Payments  Payment ReductionsSources: Reference Slide #’s 1-3
    6. 6. CEO’s ConcernsSource: Reference Slide # 4
    7. 7. Surgical Services Drive Hospital Performance  Major driver of revenues and costs  Major driver of patient safety and quality  Close multi-disciplinary functioning  Major driver of patient satisfaction  Major driver of advanced technology use/capital purchasing  Critical need for specialty nursing laborSource: Reference Slide # 4
    8. 8. Surgerys Cost and Complexity 240 million surgeries are performed worldwide each year 50 million surgeries are performed annually in the US – 9 per person in a lifetime 7 million patients in the world a year suffer complications following surgery, and half of them are likely preventable Cost of Surgical Errors in US: nearly $1.5 billion annually in the US 65% Hospitals Profit Margin in US: Perioperative Services is a multimillion dollar business, the OR is the revenue engine for most hospitalsSource: Reference Slide #5
    9. 9. Surgical Services: Engine of the Hospital Past Future If surgical services is the engine of the hospital it must run efficiently like a bullet trainSources: Reference Slide #6
    10. 10. Perioperative GovernancePerioperative Governance Driving Change
    11. 11. Polling Question: Perioperative Governance How many people have a perioperative governance structure? (Raise your hands) How many people think their perioperative governance structure is effective in driving change and holding surgeons and staff accountable? (Raise you hands)
    12. 12. Top Ten Questions to Determine if YouHave An Effective Perioperative Governance1. Does your governance meet regularly (monthly)?2. Do you have high and consistent attendance?3. Are there more surgeons on the Perioperative Governance than hospital administrators?4. Are Perioperative Governance members respected and seen as champions across the disciplines?5. Do members of the Perioperative Governance cycle through periodically to allow new individuals to participate? Answering “No” to any of the above indicates your Perioperative Governance is in need of an overhaul
    13. 13. Top Ten Questions to Determine if You HaveAn Effective Perioperative Governance (cont.)6. Are governance representatives appointed based on leadership qualities rather than their organizational position?7. Is the Perioperative Governance a productive working session?8. Are members’ self-interest aligned with organizational and departmental mission, vision, and goals?9. Does your Perioperative Governance make data-drive decisions?10. Do surgeons on your Perioperative Governance understand the long-term impact of low OR utilization? Answering “No” to any of the above indicates your Perioperative Governance is in need of an overhaul
    14. 14. Efficient Perioperative Governance Structures Should Actwith Confidence, Purpose and a Spirit of AccountabilityWhat does a Perioperative Governance Do? Act as a governing body for improvement opportunities relating to Perioperative resources including: – OR and PACU utilization – OR scheduling, block qualification, and allocation – Processes fundamental to optimal patient care and safety Achieve the Perioperative vision through data-driven decisions Monitor Key Performance indicators (KPI): – Ensure KPIs have met target – Develop an action plan for variances – Champion results Use a broad perspective to evaluate long-term strategy and sustainability of the organization A multi-million dollar surgical enterprise must have cohesive leadership through an active group known as the Perioperative Governance
    15. 15. How Can Perioperative Governance Be Successful? Support from Senior Management - Validate the authority of the Perioperative Governance by championing its decisions and messaging its role to the organization Clear Responsibilities - Have clearly defined roles designating the Perioperative Governance’s sphere of influence to manage accountability The “Right Team” - Highly credible surgeons, representation from throughout the hospital, and member align their priorities with the mission, vision and goals of the organization Characteristics of the “Right” Team Members - Puts self interest second to - Active Listener - Champion organizational - Optimistic - Accepts and values - Ground in Financial Reality - Honorable, effective accountability - Understand Quality/Safety negotiator - Stays the course - Politically Astute and Pragmatic - Skilled technician - Embraces change
    16. 16. Hospital Governance Charter Name  Perioperative Governance  Set strategic direction for perioperative services at the hospital level aligned with the region / system’s strategic mission, values, and goals  Act as decision making body with authority to make operational decisions for perioperative services within the hospital  Work with patient, surgeon, anesthesia and staff to ensure high levels of satisfaction  Lead and sustain culture of changeObjectives and  Delegate authority to daily managers and be accessible for consult / problem solving Goals  Monitor dashboard to triage and respond to operational issues  Own fiduciary impacts and risks  Manage internal and external communication strategies  Manage and direct perioperative operations and subcommittees at the hospital level Director of Operations (8 – 12 members) Participants Surgery Nursing Anesthesia Finance Quality Administration (Approx. 4-5) Meeting  Monthly meeting for 1.5 hours Schedule Sponsor  Hospital CEO •Representation from Supply Chain will be included as needed Appointments will be evaluated annually
    17. 17. Day to Day Governance Charter Name  Day to Day Leadership Team  Make operational decisions for nursing, anesthesia and surgery  Execute performance improvement initiatives  Act as a role model and change agent to achieve cultural change  Match resources (staffing) between nursing and anesthesia to meet surgical demand Objectives and  Manage room process in real time and coordinate patient flow Goals  Ensure quality and regulatory measures are followed  Manage expected behaviors  Own add on accuracy, reason for cancellation and time allowable for cases  Serve as primary contact to resolve real time operational issues and make operational decisions  Triad Leadership – Supports and gives authority to Daily Operations Coordinator / Manager or Charge Designee responsible for daily operations Daily Operations Coordinator  Director of Perioperative Nursing Triad Leadership  Chief of Anesthesia Participants  Chief of Surgery Anesthesia Nursing Surgeons  Daily Operations Coordinator – Responsible for making real time decisions to manage the OR Schedule and patient flowMeeting Schedule  Brief huddles each morning to prepare for the day and ad-hoc huddles as needed Sponsor  Chair of hospital governance
    18. 18. Functional Responsibilities of Governance Function Hospital Day to Day  Set strategic direction for perioperative services department  Serve as a change agent and execute initiatives:  Own accountability for achieving initiatives metrics  FCOTS  Make implementation decisions for initiatives initiatives  Turnover TimeSurgical Services  Enhance system policies / guidelines to meet hospital specific  OR Schedule Management Initiatives needs; enforce policies / guidelines within the hospital  PACU LOS  Identify operational issues and variances to target metrics  Deliver communications to frontline staff  lign physicians and staff to Value Imperative  Enforce and manage policies on a daily basis Performance  Monitor and address variances on the Executive Dashboard  Ensure accurate collection of data per established processes and  Ensure KPI meet targets guidelines Management (Executive  Develop plan of action to manage variances Dashboard)  Champion results Capital,  Manage and prioritize department needs for necessary capital,  Identify on-going capital,, instrument and supply needsInstrument and instrumentation and supplies Supply Management  Monitor quality and safety metrics at the hospital level and  Enforce quality and safety standardsQuality & Safety address any gaps in established standards  Assure compliance with regulatory standards in the clinic setting  Implement quality and safety initiatives Satisfaction  Monitor satisfaction and implement initiatives at the hospital  Provide feedback to the hospital governance (Patient, Staff, level  Manage satisfaction concerns on a real time basis Surgeon)  Manage and address areas of low satisfaction
    19. 19. Perioperative Metrics
    20. 20. Perioperative Metrics Metric Purpose Methodology Target Provides the current and historical trend of  Prime Time “Patient in Room” minutes 75%Prime Time Utilization utilization of the OR during prime time divided by Prime Time Resource Minutes (exclude TOT) hours of operation Provides trend of utilization of assigned  Total Patient In-Room Minutes per block 75% Block Utilization blocked OR over designated block time (exclude TOT) 80% Provides trend of blocked OR to increase OR  Number of operating rooms designated as Block Allocation (Inpatient efficiency block over total available operating rooms Facility)  FCOTS defined as the first case of the Provides the percentage of cases that start day that starts no later than 5 minutes on time, which would affect both patient past the Scheduled Start Time (adjust for % FCOTS 95% and surgeon satisfaction and OR utilization late start days)  Excludes any first case gaps outside of 90 minutes  Measures the time from prior Patient Turnover Time Provides the average length of time to Out of Room to succeeding Patient In IP: 20-25 min (TOT) turn from one surgical case to the next Room Time for consecutive patients OP:15-20 min case  Excludes gaps ≥ 90 minutes Provides the percentage of cases which are  Cases that are added to the surgical % of Add-On Cases added to the surgical schedule after schedule after close of schedule divided <10% schedule close by total case Volume % of Case Provides percentage of cases canceled after  Shown as a percentage of Total cases < 4% Cancellation close of schedule completed plus number of canceled casesSource: Reference Slide # 7
    21. 21. Varied View of Ideal Scheduling Needs
    22. 22. Ideal Scheduling Program for Surgeons"Just have my own operating room, staff, equipment, and ananesthesiologist available 5 days a week whenever I want."€Source: Reference Slide # 8
    23. 23. Ideal Scheduling Program for Anesthesiologists  Two or more rooms  Staggered starts  Two sets of nursing and anesthesia provider staffSource: Reference Slide #8
    24. 24. Ideal Scheduling Program for Nursing  One team per room  Scheduled lunch and breaks  Surgeon and anesthesiologist waiting in lounge for case starts  All cases finish in time to leave by shift’s endSource: Reference Slide # 8
    25. 25. Ideal Scheduling Program for Administration Keep all rooms utilized as long as possibleSource: Reference Slide # 8
    26. 26. You cannot effectively optimize OR productivity withoutaddressing OR utilization and accountable surgeon block allocations
    27. 27. Rules of EngagementKey questions:  Who are your stakeholders?  Who are the formal and informal leaders?  Do you have a clear understand of your data and metrics? o Block Utilization, First Case On-Time Starts, Turnover Time  Do you have leadership support and clear team approach?Things to consider:  Collaboration vs. Disciplinary Actions  Operational Governance vs Medical staff oversight  Office Scheduling vs Surgeon Scheduling  Future Time Management vs Daily Schedule
    28. 28. Block Utilization Tools
    29. 29. Case Study: Background SummarySt Jude Medical Center, Fullerton CAWe realized throughout the years the tools that we had implemented were not utilizedeffectively and allowed us to slip back into old practices Old Methodology New Methodology  Block Utilization Reports sent to  Current health care reform surgeons monthly changes, required our organization  Monitored TOT and FCOTS focus on improving surgical  Surgeons dreaded block utilization services efficiencies discussions  Ensuring surgeons understand getting the right size block and the right amount of time Reasons for Change  Went from what felt like a bad  After new EMR implementation report card, to being collaborative, data became difficult to obtain engaging surgeons in the decision  Volume had Dropped making process  Lack of diligence to adjust Block  For Example: seeing where times physicians are utilizing time
    30. 30. Case Study: Process RedesignNew methodology focuses on collaboration to drive a new outcome through acontinuous improvement process that will be sustainable Successful Elements to Drive Collaboration for Results  1 on 1 meetings with physicians and surgical schedulers to prioritize opportunities for block schedule  Follow up summary with administration  Partnering with Anesthesia  Circle of trust - patient readiness  Redesign Blocks  Low Lying Fruit  Started meetings to adjust blocks with surgeons who were under 50% utilization  Challenging Events  Being persistent to get an appointment  Gaining agreement with surgeons  Flexibility, willingness to get back and review as necessary  Constant Tweaks
    31. 31. Physician ScorecardPurpose: present a comprehensive picture of how blocks are utilized  Block utilization trends over time  Overall block utilization and total utilization by day of week and at half an hour increment  FCOTS and add-on trends
    32. 32. Example of Adjusting Blocks with Data
    33. 33. Proper Block Utilization
    34. 34. Block Utilization Heat Map OverviewPurpose: present a detailed block utilization at the facility level  Overview of block utilization at half an hour increment for each OR and each day of the week
    35. 35. Questions
    36. 36. References1. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/racs-/-icd- 9-/-icd-10/defining-the-episode-of-care-average-bundled-payments-for-16-ms-drgs.html2. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/racs-/-icd- 9-/-icd-10/5-points-hospital-cfos-need-to-know-about-the-bundled-payment-business-model.html3. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/racs-/-icd- 9-/-icd-10/8-tips-for-hospitals-considering-bundled-payments-for-orthopedics.htm4. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/hospital- management-administration/8-key-issues-for-hospitals-and-health-systems-2013.html5. Voight, Patrick. Presentation: Cutting Cost in the Operating Room. 2008.6. All Free Download. Retrieved online from, http://all-free-download.com/free- photos/the_high_speed_train_picture_168538.html; http://www.freepik.com/free-photos- vectors/train7. Milewski, F. Operating Room Utilization and Perioperative Process Flow. Premier, Inc. 2. Shoemaker, A. (2007). The High Performance OR – Elevating OR Efficiency Through Strategic OR Management. Clinical Advisory Board 3. Dempsey, C. (2009) Managing Variability in Perioperative Services, AORN,, Inc. Nov 2009, Vol 90, NO 5; 4. Reducing Avoidable Cancellation on the Day of Surgery, www.isixsigma.com8. Surgery Management. Retrieved online from http://www.surgerymanagement.com/presentations/operating-room-scheduling.php#schsurgeon
    37. 37. Thank You
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