0
Re-engineering the Operating Room
Using Variability Methodology to Improve
Healthcare Value

C. Daniel Smith, MD
1
Healthcare Delivery Goals

To provide the right care
To the right patient
At the right time

Quality *
Value =
Cost
*Outco...
Variability in Operating Rooms
Day-to-Day

• Peaks and valleys in day-to-day volume
of surgical cases

• “No one wants to ...
Day-to-Day Variability

Staffing
Hospital census
Supply chain
…..
Within-Day Variability
U

U

E

2000
1900
1800
1700
1600
1500
1400
1300

E
E

E
E

E E

E

1000
0900
0800
0700

E E
E
E

E...
X

Within-Day Variability

E

E

E

2000
1900

E

1800
1700
1600
1500
1400
1300

E

E

E

1000
0900
0800
0700

E

E E

E E...
Within-Day Variability

No. Room Changes

Elective Rooms on Day of Surgery
2009-2010

Safety
Patient satisfaction
Teamwork...
Variability Theory in Surgery
Natural Variability

Artificial Variability

•a result of naturally
occurring processes
•unc...
Elective (16)

Urgent / Emergent (3)

Scheduled

Within 48 hours

2000
1900
1800

Artificial
Variability

Natural
Variabil...
Case Study Setting

10
Mayo Clinic Florida

• 214 bed hospital (21 ORs, 28 ICUs)

and outpatient practice within a single
complex/campus – opened...
Baseline Data 2009
• Prime time OR utilization <65%
• 15 FTEs of overtime every pay period
• Low surgeon and staff satisfa...
Proposal / Hypothesis

Applying variability theory and methodology, we could
expand the capacity of our hospital’s operati...
Goals for Variability Management Program
Primary Goals (Endpoints)
Increased Surgical Volume (No. cases and minutes of sur...
Elective (16)

Urgent / Emergent (3)

Scheduled

Within 48 hours

• 3 month prospective data collection
2000
1900
1800
170...
Operating Room Redesign
Results

16
Surgical Cases
Surgical Minutes
OR Utilization (19 Room Model)
Number of Overtime FTE's (average)
Staff Turnover (highest ...
Surgical Cases
Surgical Minutes
OR Utilization (19 Room Model)
Number of Overtime FTE's (average)
Staff Turnover (highest ...
Surgical Cases
Surgical Minutes
OR Utilization (19 Room Model)
Number of Overtime FTE's (average)
Staff Turnover (highest ...
Surgical Cases
Surgical Minutes
OR Utilization (19 Room Model)
Number of Overtime FTE's (average)
Staff Turnover (highest ...
Surgical Cases
Surgical Minutes
OR Utilization (19 Room Model)
Number of Overtime FTE's (average)
Staff Turnover (highest ...
OR Redesign - Summary
• Increased volume of surgery
• Added 15 FTEs without significant increase in cost/case
• Prime-time...
OR Redesign - Conclusion

• Major cultural and operational change to operating
room management

• Re-design around managin...
Re-engineering the Operating Room
Using Variability Methodology to Improve
Healthcare Value
Southern Surgical Association
...
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Re-engineering the Operating Room Using Variability Methodology to Improve Healthcare Value

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Hospitals across the country are aggressively pursuing cost-cutting strategies, and the high-value, high-cost environment of the operating room is a prime target for cost reduction.

Applying variability methodology swings the pendulum for access to the hospital’s operating rooms from “whatever and whenever” the surgeon wants, to what is best for the hospital. Put more directly, in this model, the surgeon is asked to compromise to meet the hospital’s financial needs. The resultant tension between a surgeon and hospital administration can become intense and was certainly present during the redesign and implementation detailed in this case study.

Software and information technology tools to help schedule surgical cases within the redesign goals, and reporting tools within a quantitative dashboard are essential to facilitate adoption of this program. Transparency regarding leadership decisions and frequent feedback to all providers about performance improvements should be emphasized. Change management and analytics support should be identified either internally or pursued externally before starting such a program.

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  • Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
  • With this understanding, there have been several key principles that have guided our efforts. These include isolating the unpredicatble variation of the urgent/emergent practice, Natural Variation, from the manageable and modifiably variation of the elective practice, Artificial Variation. Design a process to create a predictable and more consistent surgical schedule, Limit the number of changes we make to the elective schedule on the day of surgery, and maintain the integrtity of our surgical teams so that patients can benefit fomr the expertise and quaity we deliver through our team-based care.
  • Specific to our surgical practice we identified two drivers of significant variability. First, day-today variability. AS you can see here, our surgical volumes can vary from 35 cases on one day, to over 60 cases a few days later. This degree of day-to-day variability has a significant negative impact on staffing, planning for hospital placement and flow, supply chain and many other aspects of running a safe, efficient and value driven operating room.
  • Another type of variability is within day variability. This is the changes that we make in the elective schedule on the day of surgery. These changes most often are the result of a poorly crafted schedule for the day that needs to then be remedied on the day of surgery. This graph represents the number of changes to the elective schedule that were made on the day of surgery. Almost 10% of our elective cases are moved on the day of surgery, or around 5 cases each day. Remember, these are cases that are scheduled into a particular room with a particular team to support that case. You can see that these cahnges have a significant impact on safety, teamwork, patient satisfaction, to name a few.
  • While we are all familiar with variability in clinical care (every case is unique and requires a tailored solution), professional variability (each clinician approaches things differently), and flow variability (we can’t control when the patients need care), applying variability theory provides us with a different way to look at and manage variability in healthcare. Natural…….and Artificial. We embarked on our MVP intiative to apply variability theory and operations management to our surgical practice in an attempt to improve the value of our surgical care.
  • This represent the OR allocation to support these principles and design. Notice the explicitly defined and isolated resource for the urgent emergent cases.
  • With this understanding, there have been several key principles that have guided our efforts. These include isolating the unpredicatble variation of the urgent/emergent practice, Natural Variation, from the manageable and modifiably variation of the elective practice, Artificial Variation. Design a process to create a predictable and more consistent surgical schedule, Limit the number of changes we make to the elective schedule on the day of surgery, and maintain the integrtity of our surgical teams so that patients can benefit fomr the expertise and quaity we deliver through our team-based care.
  • This represent the OR allocation to support these principles and design. Notice the explicitly defined and isolated resource for the urgent emergent cases.
  • Overall Summary
  • Overall Summary
  • Overall Summary
  • Transcript of "Re-engineering the Operating Room Using Variability Methodology to Improve Healthcare Value"

    1. 1. Re-engineering the Operating Room Using Variability Methodology to Improve Healthcare Value C. Daniel Smith, MD 1
    2. 2. Healthcare Delivery Goals To provide the right care To the right patient At the right time Quality * Value = Cost *Outcomes, Safety, Service In the right place VARIABILITY IS THE ENEMY 2
    3. 3. Variability in Operating Rooms Day-to-Day • Peaks and valleys in day-to-day volume of surgical cases • “No one wants to operate on Monday or Friday” Within-Day • On the day of surgery, changes to the OR schedule and resource allocation • Emergencies, add-ons, delays, etc. 3
    4. 4. Day-to-Day Variability Staffing Hospital census Supply chain …..
    5. 5. Within-Day Variability U U E 2000 1900 1800 1700 1600 1500 1400 1300 E E E E E E E 1000 0900 0800 0700 E E E E E E E E E 1200 1100 E E E E E E E E E E E 101 102 103 104 105 401 402 403 404 405 406 407 408 409 410 411 412 414 415 E E E E E E X E E E E
    6. 6. X Within-Day Variability E E E 2000 1900 E 1800 1700 1600 1500 1400 1300 E E E 1000 0900 0800 0700 E E E E E E E E E E E E E E E E E E E E X E E E E E E E E 101 102 103 104 105 401 402 403 404 405 406 407 408 409 410 411 412 414 415 E E E E E E E E E E E 1200 1100 E U E E E E E E E E E X E E E
    7. 7. Within-Day Variability No. Room Changes Elective Rooms on Day of Surgery 2009-2010 Safety Patient satisfaction Teamwork ….
    8. 8. Variability Theory in Surgery Natural Variability Artificial Variability •a result of naturally occurring processes •uncontrollable •a function of man made decisions •controllable • Emergency or unscheduled Operations • Uneven scheduling of elective cases 8
    9. 9. Elective (16) Urgent / Emergent (3) Scheduled Within 48 hours 2000 1900 1800 Artificial Variability Natural Variability 1700 E 1600 E E E E 1200 E 1000 0900 0800 0700 E E E 1300 1100 E E 1500 1400 U E E E E E E E E E E E E E E 401 402 403 404 102 103 104 105 405 406 407 408 409 410 411 412 414 415 404 102 103 104 105 403 405 406 407 408 409 410 411 412 414 415 E E E E E E E E E E E E E E E
    10. 10. Case Study Setting 10
    11. 11. Mayo Clinic Florida • 214 bed hospital (21 ORs, 28 ICUs) and outpatient practice within a single complex/campus – opened in 2008 • 11,900 admissions/ year: 55% surgical • 12,000 operations/year – complex case mix (e.g., 150 liver transplants, 1,200 NS, 900 GISurg) • 443,500 outpatient visits annually 11
    12. 12. Baseline Data 2009 • Prime time OR utilization <65% • 15 FTEs of overtime every pay period • Low surgeon and staff satisfaction with OR management and efficiencies • Concern about absence of specialty specific teams • Frequent disruptions of elective cases by transplants and urgent cases
    13. 13. Proposal / Hypothesis Applying variability theory and methodology, we could expand the capacity of our hospital’s operating rooms and increase surgical throughput without adding infrastructure or expense. 13
    14. 14. Goals for Variability Management Program Primary Goals (Endpoints) Increased Surgical Volume (No. cases and minutes of surgery) Decreased Overtime (non-prime time minutes of surgery) Maintain Access for Emergency Surgery (classification compliance) Secondary Endpoints Predictable Elective OR Schedule (no. of same day changes to elective case schedule) Assure Surgeons Work with Their Primary Team (Block Utilization) Staff Satisfaction (Staff Turnover Rate) Financial Impact (NOI) 14
    15. 15. Elective (16) Urgent / Emergent (3) Scheduled Within 48 hours • 3 month prospective data collection 2000 1900 1800 1700 1600 1500 1400 1300 1200 1100 1000 0900 0800 0700 Artificial • Rooms reallocated based Natural Variability Variability volumes/utilization E on real E E E • Staff allocated to services (added E E 15 FTEs)E E E E E E E E • Implemented November 1, 2010 E E E E E E • ImpactE assessed at one year E E 401 402 403 404 102 103 104 105 405 406 407 408 409 410 411 412 414 415 404 102 103 104 105 403 405 406 407 408 409 410 411 412 414 415 E E E E E E E E E E E E E E E E E
    16. 16. Operating Room Redesign Results 16
    17. 17. Surgical Cases Surgical Minutes OR Utilization (19 Room Model) Number of Overtime FTE's (average) Staff Turnover (highest to most recent) Daily Case Volume Variation Daily Surgery Minutes Variation Elective Room Changes (Average/Mon) Elective Room Changes (%) Pre- MVP 11,874 1,757,008 61% 7.4 20.3% 55.24 6,531 80 8% Post-MVP % Change 12,367 4% 1,844,479 5% 64% 5% 5.4 -27% 11.5% -43% 44.06 -20% 5,124 -22% 25 -69% 2% -70% Salary Dollars (Adjusted for Salary Increases) Total Monthly $12,607,061 $1,045,942 $13,395,997 $1,115,646 6% 7% $1,062 $7.18 $1,070 $7.26 0% 1% $2.47 $1.47 $111,488 -41% $93,929,569 $98,686,693 5% Cost/Case Cost/Minute of Surgery Staff Turnover Cost (millions) Overtime Cost Savings Total OR Net Revenue (Fee increase adjusted) 17
    18. 18. Surgical Cases Surgical Minutes OR Utilization (19 Room Model) Number of Overtime FTE's (average) Staff Turnover (highest to most recent) Daily Case Volume Variation Daily Surgery Minutes Variation Elective Room Changes (Average/Mon) Elective Room Changes (%) Pre- MVP 11,874 1,757,008 61% 7.4 20.3% 55.24 6,531 80 8% Post-MVP % Change 12,367 4% 1,844,479 5% 64% 5% 5.4 -27% 11.5% -43% 44.06 -20% 5,124 -22% 25 -69% 2% -70% Salary Dollars (Adjusted for Salary Increases) Total Monthly $12,607,061 $1,045,942 $13,395,997 $1,115,646 6% 7% $1,062 $7.18 $1,070 $7.26 0% 1% $2.47 $1.47 $111,488 -41% $93,929,569 $98,686,693 5% Cost/Case Cost/Minute of Surgery Staff Turnover Cost (millions) Overtime Cost Savings Total OR Net Revenue (Fee increase adjusted) 18
    19. 19. Surgical Cases Surgical Minutes OR Utilization (19 Room Model) Number of Overtime FTE's (average) Staff Turnover (highest to most recent) Daily Case Volume Variation Daily Surgery Minutes Variation Elective Room Changes (Average/Mon) Elective Room Changes (%) Pre- MVP 11,874 1,757,008 61% 7.4 20.3% 55.24 6,531 80 8% Post-MVP % Change 12,367 4% 1,844,479 5% 64% 5% 5.4 -27% 11.5% -43% 44.06 -20% 5,124 -22% 25 -69% 2% -70% Salary Dollars (Adjusted for Salary Increases) Total Monthly $12,607,061 $1,045,942 $13,395,997 $1,115,646 6% 7% $1,062 $7.18 $1,070 $7.26 0% 1% $2.47 $1.47 $111,488 -41% $93,929,569 $98,686,693 5% Cost/Case Cost/Minute of Surgery Staff Turnover Cost (millions) Overtime Cost Savings Total OR Net Revenue (Fee increase adjusted) 19
    20. 20. Surgical Cases Surgical Minutes OR Utilization (19 Room Model) Number of Overtime FTE's (average) Staff Turnover (highest to most recent) Daily Case Volume Variation Daily Surgery Minutes Variation Elective Room Changes (Average/Mon) Elective Room Changes (%) Pre- MVP 11,874 1,757,008 61% 7.4 20.3% 55.24 6,531 80 8% Post-MVP % Change 12,367 4% 1,844,479 5% 64% 5% 5.4 -27% 11.5% -43% 44.06 -20% 5,124 -22% 25 -69% 2% -70% Salary Dollars (Adjusted for Salary Increases) Total Monthly $12,607,061 $1,045,942 $13,395,997 $1,115,646 6% 7% $1,062 $7.18 $1,070 $7.26 0% 1% $2.47 $1.47 $111,488 -41% $93,929,569 $98,686,693 5% Cost/Case Cost/Minute of Surgery Staff Turnover Cost (millions) Overtime Cost Savings Total OR Net Revenue (Fee increase adjusted) 20
    21. 21. Surgical Cases Surgical Minutes OR Utilization (19 Room Model) Number of Overtime FTE's (average) Staff Turnover (highest to most recent) Daily Case Volume Variation Daily Surgery Minutes Variation Elective Room Changes (Average/Mon) Elective Room Changes (%) Pre- MVP 11,874 1,757,008 61% 7.4 20.3% 55.24 6,531 80 8% Post-MVP % Change 12,367 4% 1,844,479 5% 64% 5% 5.4 -27% 11.5% -43% 44.06 -20% 5,124 -22% 25 -69% 2% -70% Salary Dollars (Adjusted for Salary Increases) Total Monthly $12,607,061 $1,045,942 $13,395,997 $1,115,646 6% 7% $1,062 $7.18 $1,070 $7.26 0% 1% $2.47 $1.47 $111,488 -41% $93,929,569 $98,686,693 5% Cost/Case Cost/Minute of Surgery Staff Turnover Cost (millions) Overtime Cost Savings Total OR Net Revenue (Fee increase adjusted) 21
    22. 22. OR Redesign - Summary • Increased volume of surgery • Added 15 FTEs without significant increase in cost/case • Prime-time utilization increased and overtime decreased • The overall surgical schedule became more predictable and reliable • Staff satisfaction improved as evidenced by decreased staff turnover • Increased volume without added cost & cost avoidance resulted in improved financial performance 22
    23. 23. OR Redesign - Conclusion • Major cultural and operational change to operating room management • Re-design around managing variability worth pursuing • The increased capacity without increased operational costs may be important adjunct to tactics to deal with expected payment reductions accompanying healthcare reform 23
    24. 24. Re-engineering the Operating Room Using Variability Methodology to Improve Healthcare Value Southern Surgical Association 124th Annual Session December 3, 2012 The Breakers Palm Beach, Florida C. Daniel Smith, MD 24
    25. 25. 25
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