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Improving Ambulatory Surgery Wait Times to Enhance Patient Satisfaction
1. Increasing Patient Satisfaction by
Improving Wait Times in Ambulatory
Surgery
Robin Blackwell MSN, BSN, RN
Nursing 6600: Capstone Synthesis Practicum
Walden University
November 1, 2014
2. The Importance of Patient Satisfaction in
the Ambulatory Surgery Setting
• Research has shown that the assessment of patient
satisfaction is a more sensitive indicator than
traditional morbidity and mortality patterns
(Trurairatmun et al, 2014).
• Reimbursement by CMS is dependent upon patient
satisfaction as measured by HCAHPS scores.
• Patient satisfaction with the ambulatory surgery
center affects surgeon and patient preference.
3. Press Ganey Scores
June 2014 July 2014 August 2014
Waiting time
before procedure
81.9 88.0 82.5
Information about
delays
86.2 89.0 85.5
4. Goal Statement
The goal of this project is to improve the HCAHPS
scores on the measure of “patient wait times” for the
ambulatory surgery center.
6. Rationale for the Project
• Patients have expectations of quality of care, and patient
satisfaction is seen as an indicator of quality of care (Farber, 2010;
Harnett, Hurwitz, Bader & Hepner, 2010).
• The length of waiting time for ambulatory surgery patients is a
primary complaint and is linked to patient satisfaction (Freeman
& Denham, 2008; Lemos, Pinto, Morais, Pereira, Loureiro, Teixeira & Nunes, 2009).
• Patients are more anxious and less satisfied with their surgical
experience when they perceive a “loss of control”. Prolonged
waiting times may influence the patient’s sense of control
(Freeman & Denham, 2008; Rhodes et al., 2006), thereby decreasing
satisfaction scores.
7. Factors Affecting Wait Times in Ambulatory
Surgery
• The number of “on-time” surgery starts (Cima, Brown,
Hebl et al., 2011; Scheriff, Gunderson & Intelisano, 2011).
• Process and patient flow (Nicloay, Purkayastha, Greenhalgh et
al., 2011; Mottram, 2011).
• Methods of case scheduling (Heiser, 2013; Cima et al., 2011).
8. Methodology for Objective One: Analysis
1. Process map of preoperative phase of surgery.
2. SWOT analysis.
3. Retrospective time study of case starts using ORMIS
O.R. Scheduler.
4. Time study for registration wait times and
preoperative times.
11. Time Study: Average Time between
Scheduled Start Time and Patient to OR
0:00 0:07 0:14 0:21 0:28 0:36 0:43 0:50 0:57
1
Average Wait Times
Surgeon five Surgeon four Surgeon three Surgeon two Surgeon one
12. Time Study: Average Scheduled vs. Actual
Start Times
0:00 0:14 0:28 0:43 0:57 1:12 1:26
1
Scheduled vs. Actual Start Time
Surgeon five
Surgeon four
Surgeon three
Surgeon two
Surgeon one
13. Surgeon 2 Data: In Hours and Minutes
Scheduled Start Time: Surgeon Two Time in OR Room Start Time Patient wait times Scheduled start time vs actual start time
7:30 7:17 7:37 0:00 0:07
7:30 7:16 7:42 0:00 0:12
8:20 7:45 8:02 0:00 0:00
8:30 8:24 8:42 0:00 0:12
9:35 9:55 10:15 0:20 0:40
9:40 9:33 9:57 0:00 0:17
10:35 11:26 11:55 0:51 1:20
11:00 12:09 12:25 1:09 1:25
12:05 13:15 13:40 1:10 1:35
12:30 13:16 13:45 0:46 1:15
13:00 14:55 15:24 1:55 2:24
13:40 14:44 15:03 1:04 1:23
14:30 16:09 16:29 1:39 1:59
14:40 15:49 16:16 1:09 1:36
15:40 17:15 17:33 1:35 1:53
Average: 0:46 1:05
14. Surgeon 4 Data: In Hours and Minutes
Scheduled Start Time: Surgeon
4 Time in OR Room Start Time Patient wait times Scheduled start time vs actual start time
7:30 7:18 7:40 0:00 0:10
7:30 7:14 7:32 0:00 0:02
8:00 7:49 8:23 0:00 0:23
8:50 9:18 9:39 0:28 0:49
9:30 9:12 9:39 0:00 0:09
10:00 11:21 11:40 1:21 1:40
10:50 11:11 11:34 0:21 0:44
11:15 12:39 13:10 1:24 1:55
12:00 13:57 14:25 1:57 2:25
12:00 14:15 14:50 2:15 2:50
13:30 15:30 16:08 2:00 2:38
14:00 14:23 15:04 0:23 1:04
14:00 14:49 15:05 0:49 1:05
15:30 16:15 16:49 0:45 1:19
Average: 0:50 1:13
15. Time Study: Registration Times and “Nurse
Ready” Times in Minutes
Registration times Nurse times
0:12 0:30
0:30 0:30
0:10 0:35
0:08 0:30
0:10 0:55
0:10 0:35
0:18 0:17
0:05 0:35
0:11 0:30
0:10 0:05
0:25 0:50
0:20 0:40
0:11 0:40
0:13 0:30
0:28 0:55
0:15 0:45
0:22 0:30
0:45 0:25
0:25 0:25
Average 0:17 0:33
16. Methodology for Objective Two: Focus
Group
• Members of Focus Group.
• The focus group met weekly for four weeks.
17. Methodology for Objective Three:
Communication Method
In collaboration with the focus group, a communication
method was formed to enhance communication
regarding delays between staff members and patients.
Patients are verbally updated every 15 minutes once
the scheduled surgery time has passed.
18. Methodology for Objective Four
Recommend five measures to decrease patient
wait times to the Executive Committee.
These recommendations will be given to the
committee in Week 6 of the Project.
19. Recommendations to the Executive
Committee
Post cases according to ORMIS.
Post additional cases in open block time.
Initiate a set schedule for releasing block time.
Continue the new process for updating patients.
Give patients the option to re-schedule.
20. Methodology for Objective Five:
Educational Materials
• A Power Point Presentation will be created and be
shared during a staff meeting to educate staff
members.
• A survey will be given to assess additional learning
needs of staff members regarding the new process.
21. Survey for Educational Needs
• 1) Why are wait times for patients important?
– Less than desirable Press Ganey scores
– Patient complaints about wait times
– Improvement of customer service
– All of the above
• 2) Who is responsible for keeping patients informed about delays?
– Nurse Manager
– Charge nurses of each unit
– The patient’s primary nurse
– The physician
• 3) When does the primary nurse need to begin updating the patient?
– 5 minutes after the scheduled surgery time
– 30 minutes after the scheduled surgery time
– When the charge nurse provides the primary nurse with an update
– When the patient asks for an update.
– B and D
• 4) How often should the patient be updated?
– Every hour
– Every 30 minutes
– When the charge nurse provides the primary nurse with an update.
– Every 15 minutes.
• 5) If I am assuming care for a patient that is delayed, how will I know he/she has been updated?
– A note will be in the patient’s chart
– I will ask the surgery schedulers
– I will ask the patient
– I will assume that the previous nurse updated the patient
• 6) What do I do if the patient becomes very upset about the delay?
– Affirm the patient’s concerns
– Suggest alternatives for distraction
– Call the supervisor to speak with the patient
– Ask the surgeon to speak with the patient
– All of the above
– None of the above
• What suggestions do you have about informing patients about delays?
• How do you think we can improve customer satisfaction regarding wait times in the unit?
22. Summary of Project Findings
1. Actual case start times vs. scheduled start times range between six
minutes late to two hours and 50 minutes late. Two of the five surgeons
studied started over 50% of cases over one hour late.
2. The average wait in the registration area was 17 minutes. The average
time for the preoperative nurse to “ready” the patient for the OR was 33
minutes.
3. Cases are posted according to the requested time amount from the
surgeon’s office instead of from the surgeon’s average time per case.
4. Patient wait times are increased by the lag in surgeons’ start times as the
day progresses.
5. Additional studies may be completed using all patient populations in the
ambulatory surgery center. Studies may be performed using times from
similar ambulatory surgery centers within the regional health system.
23. Conclusions and Recommendations for
Practice
1. Follow recommendations given to Executive
Committee if financially feasible.
2. Counsel individual surgeons.
3. Provide additional education in Pre-assessment.
4. Post dedicated registration person.
5. Evaluate Press Ganey scores.
24. Summary
• Patient “wait times” for the orthopedic population of
surgery patients are prolonged because of surgeon
patterns.
• Changing scheduling practices may assist in decreasing
patient “wait times”.
• Keeping patients informed about delays is an important
aspect of the patient’s emotional well-being before
surgery.
• These measures are important to implement in order to
increase HCAHPS scores on “waiting time before
procedure” and “information about delays”, as well as to
remain the surgery center of choice for the region.
25. References
Cima, R., Brown, M., Hebl, J., Moore, R., Rogers, J., Kollengode, A., Amstrutz, G.,
Wesbrod, C., Narr, B., & Deschamps, C. (2011). Use of lean and six sigma
methodology to improve operating room efficiency in a high-volume
tertiary-care academic medical center. Journal of American College of
Surgeons, 213 (1), 83-94.
Farber, J. (2010). Measuring and improving ambulatory surgery patients’ satisfaction.
AORN Journal, 92 (3), 313-321.
Freeman, K. & Denham, S. (2008). Improving patient satisfaction by addressing same
day surgery wait times. Journal of PeriAnesthesia Nursing, 23(6), 387-393.
Harnett, M., Correll, D., Hurwitz, S., Bader, A. & Hepner, D. (2009). Improving efficiency
and patient satisfaction in a tertiary teaching hospital preoperative clinic.
Anesthesiology, 112(1), 66-72.
Lemos, P., Pinto, A., Morais, G., Pereira, J., Loureiro, R., Teixeira, S. & Nunes, C. (2008).
Patient satisfaction following day surgery. Journal of Clinical Anesthesia,
21(1), 200-205.
26. References
Rhodes, L., Miles, G. & Pearson, A. (2006). Patient subjective experience and
satisfaction during the perioperative period in the day surgery setting: A
systematic review. International Journal of Nursing Practice, 12(1), 178-192
Thurairatman, R., Mathew, G., Montgomery, J. & Stocker. (2014). The role of patient
satisfaction surveys to improve patient care in day surgery. Ambulatory
Surgery, 20(1), 16-18.
Editor's Notes
Why should the ambulatory surgery center be concerned about patient satisfaction? Traditionally, the success (or failure) of care in health care settings has been measured by the improvement in a patient’s illness and those patients that die as a result of care. However, recent research has shown that patient satisfaction is a more sensitive indicator to measure when determining the success or failure of care. A second reason that patient satisfaction is important is that reimbursement from CMS is dependent upon patient satisfaction. A third reason that patient satisfaction is important is it affects whether or not the surgeon (or the patient) chooses the center for care. If the ambulatory surgery center is known for poor customer service, neither surgeons nor patients will utilize it for care.
At the surgery center, patient satisfaction is measured by HCAHPS scores. A Press Ganey Survey is mailed to a randomized sample of patients within two weeks after surgery. For the last quarter, the surgery center has received less than targeted responses on these questions. The target for these questions is set at 93%.
The goal of this project is to improve patient satisfaction and subsequently improve Press Ganey scores for “patient wait times”.
To complete a process analysis for orthopedic cases in order to identify case scheduling issues, patterns of orthopedic surgeons, and workflow issues that may affect “patient wait times”.
To create a focus group to make suggestions for process improvement.
In collaboration with the focus group, to develop a communication method to inform patients about delays in the preoperative period.
To recommend five measures to decrease “wait times” to the Executive Committee.
To create teaching materials necessary to facilitate deficits in the current process.
A review of the literature concerning “wait times” in surgery centers reveals that the length of waiting time affects the patient’s perception of the quality of care as well as the patient’s perception of “control”.
According to the literature, several factors affect wait times in ambulatory surgery. These include “on-time” surgery starts, process and patient flow, and methods of case scheduling. An “on-time” surgery start is defined as the surgeon makes the incision at the precise moment that the case is scheduled to start. Elements which affect wait times for process and patient flow include the steps that the patient must complete before going to the OR: Registration and preoperative activities. Methods of case scheduling include the use of block time, how the length of the case is chosen, and “flipping rooms”. OR room “flipping” is the practice of scheduling patients in two different OR rooms at staggered times. For example, surgeons that work with “fellows in training” and/or surgery residents may perform surgery in OR 1 while the subsequent patient is being prepped (positioned, surgically cleaned) in OR 2. The attending surgeon finishes the surgery in OR 1 and allows the fellow or resident to close the skin while the attending begins the surgery on the already prepped patient in OR 2. The practice of OR room “flipping” allows the surgeon to perform more cases per day than if he is scheduled in one OR only. The down-side to this practice is if the surgeon in OR 1 is “tied up” for a long period because of unanticipated complications. If this occurs, the patient in OR 2 is under anesthesia for much longer than would be required if the case started as scheduled.
A process analysis was performed for the ambulatory surgery center in order to identify the potential etiology of increased wait times. This process analysis includes a process map, a SWOT analysis, and time studies.
After mapping the pre-operative workflow, it can be seen that the process is streamlined. Gaps in this process may occur if the patient cannot find the surgery center desk after registration (since he is not escorted to the surgery center), the receptionist forgets to call and inform the pre-operative nurse of the patient’s arrival, or the anesthesiologist is delayed in assessing the patient.
This is a SWOT analysis of the problem. Strengths of the current system are 1) a streamlined process, 2) efficient OR turnover, 3) pre-assessment does a good job notifying the patient of time changes before day of surgery, 4) surgeons “flip” rooms. Weaknesses include 1) surgeon does not stay “on-schedule” as the day progresses, 2) the patient may get “bogged down” in registration because the registration office is responsible for registering all patients for the outpatient center, not just surgery patients, 3) surgeon delays are not communicated to patients on the day of surgery. Opportunities include 1) most surgeons WANT to start on time, 2) patient satisfaction increases if informed about delays, and 3) staff members care about their patients and want to improve their experience. Threats include 1) the schedulers for the surgeons post too many cases in one day for the block time allotted in order to get more cases on the schedule, 2) the surgery center schedulers are not allowed to use the physician’s average case time when scheduling cases. They are authorized to remind the surgeon’s scheduler that “last time, it took the surgeon 2 hours to complete a similar case, are you sure you only want one hour for this case?”, however, they are not allowed to override the given time frame.
This time study was completed using retrospective data from the ORMIS OR scheduling system. Five orthopedic surgeon’s times were assessed over a one month period. Case times were taken from the “Data from Logged or Charted Cases” report. This report logs “patient in room/out of room” times, actual case start and finish times (start times are from when incision is made), and scheduled case start/stop times. The actual start time is compared with the time in the OR room. Surgeon one (dark blue) had no delays in the time patient was taken to the OR. Surgeon two (red) had an average delay of 46 minutes, with a range between 0 minutes and one hour and 55 minutes. Surgeon three (green) had an average delay of nine minutes. Surgeon four (purple) had an average delay of 50 minutes, with a range between 0 minutes and 2 hours 15 minutes. Surgeon five (light blue) had an average delay of 22 minutes. As shown above, surgeon two and surgeon four had the longest wait times of the five surgeons studied.
Utilizing times generated in the “Data from Logged or Charted Cases” report, scheduled times are compared with actual start times (incision times). Surgeon one (dark blue) has an average time of six minutes for scheduled vs. actual surgery start time. Surgeon two (red) has an average time of one hour and 5 minutes, with a range between seven minutes and two hours and 24 minutes. Surgeon three (green) has an average time of 35 minutes. Surgeon four (purple) has an average time of one hour 13 minutes, with a range between 10 minutes and two hours 50 minutes. Surgeon five (light blue) has an average time of 51 minutes. In this study, none of the surgeons started at the scheduled time.
This chart shows specific data about surgeon two. Note that the cases done later in the day tend to have longer wait times.
This chart shows specific data about surgeon four. As seen with surgeon two, cases that are later in the day have longer wait times. This suggests that the surgeon lags behind as the day progresses.
This time study was performed in the ambulatory surgery unit. The average registration time (patient arrival at registration desk until patient was brought back to the unit by the preoperative nurse) was 17 minutes. The average time it took the preoperative nurse to prepare the patient for surgery was 33 minutes. The longest registration time of 45 minutes may have been due to a “bog” in the registration office.
A focus group was formed which consists of the OR supervisor, the nurse manager, the preoperative and PACU charge nurses, the scheduling office manager, and two unit council members. The focus group met weekly for four weeks.
Week one: Discussed the purpose of the project, reviewed current Press Ganey scores.
Week two: Reviewed results of process analysis. Discussed communication method for updating patients.
Week three: Formulated communication method and began to synthesize recommendations for Executive Committee.
Week four: Finalized recommendations for presentation to the Executive Committee.
A new process was initiated in which patients are verbally updated by the primary nurse every 15 minutes after the scheduled surgery time has passed. Each time the patient is updated, the primary nurse will note this in the patient’s chart. The OR charge nurse will be responsible for notifying the charge nurse of Preop and PACU when a delay occurs and the extent of the delay. This information will be passed to the patient’s primary nurse. The charge nurses will maintain communication with the OR charge nurse to insure that timely information is passed to the patient.
The recommendations for the Executive Committee will be given during week 6 of the project. The slide that follows outlines these recommendations. A meeting with the committee has been scheduled for week 6.
These are the recommendations that the focus group pinpointed as issues to be addressed. Financial aspects will need to be considered by the Executive Committee.
The surgery schedulers for the ambulatory surgery center will post cases according to the physician’s average time per case (using ORMIS) instead of per physician’s office request.
Physicians will be given an option of posting additional cases on another day that has open block time.
Physician’s block time will be released if no cases are posted for the time period three business days before unless the scheduling office is notified by the physician. The scheduling office will send an email to the physician two days before the block time is released.
A new process for updating patients regarding delays on the day of surgery has been initiated and should continue.
Patients that have waited over one hour past the scheduled surgery start time will have the option of rescheduling their surgery for another day at no charge.
This power point presentation will be used to educate staff members during a staff meeting. A copy of the survey follows.
This is the survey that will be given to staff members after the educational power point is presented.
In summary, patients experience long waits for orthopedic cases on the day of surgery. In particular, there are two surgeons that become behind as the day progresses. These surgeons should be counseled by members of the Executive Committee about “start times” and the importance of OR efficiency. The average wait times for the registration and preoperative phases are acceptable. Additional studies may be performed using all of the patient populations served at the center (ENT, breast surgery, pediatric urology, plastic surgery). Also, studies may be performed using times from similar ambulatory surgery centers within the regional health system.
These are the recommendations for practice for the surgery center. Evaluation will be accomplished through Press Ganey surveys (to assess patient satisfaction with wait times) and chart audits (to assess the effectiveness of the new update process). If these recommendations are adopted by the Executive Committee, it would be helpful to complete another time study several weeks after the scheduling changes have been in place. The Ambulatory Surgery Center should follow recommendations given to Executive Committee if financially feasible.
Individual surgeons should be counselled regarding “on-time” starts.
Additional education should be done in the pre-assessment period to inform patients that delays in surgery may occur.
Posting a dedicated registration person at the ambulatory surgery desk may decrease the wait time for registration.
Press Ganey scores should be evaluated (including comments) as soon as they are available.
Thank you for your attention. What questions may I answer for you?
