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

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. 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 relationship
in a company providing grant funds and/or a company whose product(s) may be discussed or used
during the educational activity. Financial disclosure will include the name of the company and/or
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indicated according to the following numeric categories:
1. Consultant/Speaker’s Bureau 2. Employee
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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
Center's Commission on Accreditation.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

3. Objectives
1. 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. Polling Question:
Why is Collaboration with Physicians Critical?
A. Drive patient satisfaction
B. Drive improved patient safety
C. Drive improved quality of care
D. Drive reduction in costs
E. Drive improvement in operational efficiency
F. A, B & C
G. All of the above

5. What Has Changed?
 Health Care Reform
 Value Based Purchasing
 Accountable Care Organizations
 Bundled Payments
 Payment Reductions
Sources: Reference Slide #’s 1-3

6. CEO’s Concerns
Source: Reference Slide # 4

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 labor
Source: Reference Slide # 4

8. Surgery's 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 hospitals
Source: Reference Slide #5

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 train
Sources: Reference Slide #6

10. Perioperative Governance
Perioperative Governance
Driving Change

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. Top Ten Questions to Determine if You
Have An Effective Perioperative Governance
1. 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. Top Ten Questions to Determine if You Have
An 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. Efficient Perioperative Governance Structures Should Act
with Confidence, Purpose and a Spirit of Accountability
What 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. 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. 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 change
Objectives 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. 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 flow
Meeting Schedule  Brief huddles each morning to prepare for the day and ad-hoc huddles as needed
Sponsor  Chair of hospital governance

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 Time
Surgical 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 needs
Instrument and instrumentation and supplies
Supply
Management
 Monitor quality and safety metrics at the hospital level and  Enforce quality and safety standards
Quality & 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. Perioperative Metrics

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 cases
Source: Reference Slide # 7

21. Varied View of Ideal Scheduling Needs

22. Ideal Scheduling Program for Surgeons
"Just have my own operating room, staff, equipment, and an
anesthesiologist available 5 days a week whenever I want."
€
Source: Reference Slide # 8

23. Ideal Scheduling Program for Anesthesiologists
 Two or more rooms
 Staggered starts
 Two sets of nursing and anesthesia provider staff
Source: Reference Slide #8

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 end
Source: Reference Slide # 8

25. Ideal Scheduling Program for Administration
Keep all rooms utilized as long as possible
Source: Reference Slide # 8

26. You cannot effectively optimize OR productivity without
addressing OR utilization and accountable surgeon block allocations

27. Rules of Engagement
Key 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. Block Utilization Tools

29. Case Study: Background Summary
St Jude Medical Center, Fullerton CA
We realized throughout the years the tools that we had implemented were not utilized
effectively 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. Case Study: Process Redesign
New methodology focuses on collaboration to drive a new outcome through a
continuous 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. Physician Scorecard
Purpose: 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. Example of Adjusting Blocks with Data

33. Proper Block Utilization

34. Block Utilization Heat Map Overview
Purpose: 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. Questions

36. References
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management-administration/8-key-issues-for-hospitals-and-health-systems-2013.html
5. Voight, Patrick. Presentation: Cutting Cost in the Operating Room. 2008.
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Shoemaker, A. (2007). The High Performance OR – Elevating OR Efficiency Through Strategic
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Cancellation on the Day of Surgery, www.isixsigma.com
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http://www.surgerymanagement.com/presentations/operating-room-scheduling.php#schsurgeon

37. Thank You