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    Maximizing Throughput:Smoothing the Elective Surgery Schedule ... Maximizing Throughput:Smoothing the Elective Surgery Schedule ... Presentation Transcript

    • Maximizing Throughput:Smoothing the Elective Surgery Schedule to Improve Patient Flow
      • John B. Chessare, MD, MPH
      • Eugene Litvak, PhD
      • James M. Becker, MD
      • Keith P. Lewis, MD
      • Richard J. Shemin, MD
      • Gail Spinale, RN
      • Demetra Ouellette
      • Abbot Cooper
    • Objectives
      • The participant will contrast artificial and natural variability and will relate this distinction to the act of surgical scheduling.
      • The participant will compare block and non-block scheduling methodologies.
      • The participant will appraise the value of separating urgent from scheduled surgical flow.
    • Diversion Goal Urgent Matters Starts
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    • Our Improvement Principles
      • focus on the patient or family member
      • knowledge of process (Design!)
      • decisions driven by data
      • empowerment of those who know the process to make change
      • teamwork
    • Variability
      • “ Natural”: you can’t control it …you just have to manage it.
        • Numbers of patients coming to the ED
        • Types and numbers of emergency surgeries
      • “ Artificial”: you can control it….you must eliminate it to create flow. (batching)
        • When the nuclear med lab reports stress test results
        • Types and numbers of scheduled surgeries
    • Surgical Smoothing to Date
      • 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)
    • Bed Need by Day of Week for Vascular Surgery (18 months of data) Progressive Care Unit
    • Vascular Elective PCU Cases by Day Random Month July 2002
    • 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Scenario 5 Scenario 7 Scenario 8 Status Quo Mon Tue Wed Thu Fri Results of Suggested Physician Schedule Change Scenarios and the Status Quo
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    • Average CT Surgery Unscheduled Cases Weekdays
    • Average Scheduled CT Surgery Cases by Weekday
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    • 2003 range 10 – 1 = 9 2004 range 7 –2 = 5 55% reduction in variability
    • Changes to the Menino OR Schedule
      • Boston Medical Center has 2 Operating Suites
        • Newton Pavilion OR
        • Menino Pavilion OR
    • Menino Pavilion compared to Newton Pavilion Pediatrics, Trauma , Gastric Bypass, OB Cardiac, Opth Unique Services 2-20 0-4 #Weekend Cases 5-10 1-2 #Add Ons Per Day 20% 10% Cancellation Rate 6608 8601 # Cases Year 25-32 30-35 # Cases Day 8 12 # Rooms MP NP Variable
    • 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
    • Pre-change Problems with the Daily Schedule – Menino Pavilion
      • Overall 50% block utilization
      • 15-20% cancellation rate
      • 33% of daily schedule is “add ons” and may be 50%
      • Prevents other surgeons from getting time
      • Cases can be lost waiting 4-6 weeks (dental, gyn)
      • Urgent/emergent bump elective cases
    • Our Goals
      • Reduce Bumped Cases
        • Reduce waste in rework
        • Improve patient satisfaction
        • Improve surgeon satisfaction
        • Improve scheduling staff satisfaction
      • Increase Surgical Volume
    • 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 one room would be sufficient to have only a rare bump of an elective case
    • But the Surgery Leadership Wanted to do More! They said: “Lets get rid of block scheduling” 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
      • Keeps red (urgent/emergent) cases to 1 room
      • No case will be refused
    • 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 Schedule)
        • Quantity: 1 Room
    • 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)
    • Change Here
    • Menino Volume Comparison Before Separating and After Total ‘03 = 3,560 Total ’04 = 3,574 +14
    • Overall Summary of Menino Open Block and Separating Urgent from Scheduled
      • 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 complaints
    • What’s next?: Smoothing Elective Cardiac Catheterizations
      • We have competition for beds between adult cardiac and pulmonary ED patients and patients coming from the cath lab on our 6North Unit
      • Do we have artificial variability in scheduling elective caths and if so, what can we do to smooth this?
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    • 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
    • References
      • Leading Change; by John P. Kotter
      • Michael L. McManus, M.D., M.P.H.; Michael C. Long, M.D.; Abbot Cooper; James Mandell, M.D.; Donald M. Berwick, MD; Marcello Pagano, Ph.D.; Eugene Litvak, Ph.D. 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