Maximizing Throughput:Smoothing the Elective Surgery Schedule to Improve Patient Flow <ul><li>John B. Chessare, MD, MPH </...
Objectives <ul><li>The participant will contrast artificial and natural variability and will relate this distinction to th...
Diversion Goal Urgent Matters Starts
 
 
Our Improvement Principles <ul><li>focus on the patient or family member </li></ul><ul><li>knowledge of process (Design!) ...
Variability <ul><li>“ Natural”: you can’t control it …you just have to manage it.  </li></ul><ul><ul><li>Numbers of patien...
Surgical Smoothing to Date <ul><li>Smoothing Elective Vascular Surgery </li></ul><ul><li>Smoothing Elective Cardiac Surger...
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 Suggest...
 
 
 
 
Average CT Surgery Unscheduled Cases Weekdays
Average Scheduled CT Surgery Cases by Weekday
 
2003 range  10 – 1 = 9 2004 range  7 –2 = 5 55% reduction in variability
Changes to the Menino OR Schedule <ul><li>Boston Medical Center has 2 Operating Suites </li></ul><ul><ul><li>Newton Pavili...
Menino Pavilion compared to Newton Pavilion Pediatrics,  Trauma , Gastric Bypass, OB Cardiac, Opth Unique Services 2-20 0-...
Block Scheduling <ul><li>Surgeon or service “owns” blocks of time on the OR schedule </li></ul><ul><li>Allows surgeons to ...
Pre-change Problems with the Daily Schedule – Menino Pavilion <ul><li>Overall 50% block utilization </li></ul><ul><li>15-2...
Our Goals <ul><li>Reduce Bumped Cases </li></ul><ul><ul><li>Reduce waste in rework </li></ul></ul><ul><ul><li>Improve pati...
How Many Rooms Should We Set Aside for Urgent/Emergent Cases? <ul><li>Created a Case classification and prioritization sys...
But the Surgery Leadership Wanted to do More! They said: “Lets get rid of block scheduling” ADVANTAGES of Open Scheduling ...
Menino OR New Design April 26, 2004 Urgent and Elective Flows Separated No-block Scheduling Begins <ul><ul><li>Open Schedu...
Separating Urgent from Elective Before and After <ul><li>Before </li></ul><ul><li>April – Sept 2003 </li></ul><ul><li>157 ...
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 <ul><li>Eliminated bumping of elective cases (#3...
What’s next?: Smoothing Elective Cardiac Catheterizations <ul><li>We have competition for beds between adult cardiac and p...
 
 
 
 
Summary <ul><li>There is much artificial variability in healthcare. We must do better to design systems to eliminate it. W...
References <ul><li>Leading Change; by John P. Kotter </li></ul><ul><li>Michael L. McManus, M.D., M.P.H.; Michael C. Long, ...
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Maximizing Throughput:Smoothing the Elective Surgery Schedule ...

  1. 1. Maximizing Throughput:Smoothing the Elective Surgery Schedule to Improve Patient Flow <ul><li>John B. Chessare, MD, MPH </li></ul><ul><li>Eugene Litvak, PhD </li></ul><ul><li>James M. Becker, MD </li></ul><ul><li>Keith P. Lewis, MD </li></ul><ul><li>Richard J. Shemin, MD </li></ul><ul><li>Gail Spinale, RN </li></ul><ul><li>Demetra Ouellette </li></ul><ul><li>Abbot Cooper </li></ul>
  2. 2. Objectives <ul><li>The participant will contrast artificial and natural variability and will relate this distinction to the act of surgical scheduling. </li></ul><ul><li>The participant will compare block and non-block scheduling methodologies. </li></ul><ul><li>The participant will appraise the value of separating urgent from scheduled surgical flow. </li></ul>
  3. 3. Diversion Goal Urgent Matters Starts
  4. 6. Our Improvement Principles <ul><li>focus on the patient or family member </li></ul><ul><li>knowledge of process (Design!) </li></ul><ul><li>decisions driven by data </li></ul><ul><li>empowerment of those who know the process to make change </li></ul><ul><li>teamwork </li></ul>
  5. 7. Variability <ul><li>“ Natural”: you can’t control it …you just have to manage it. </li></ul><ul><ul><li>Numbers of patients coming to the ED </li></ul></ul><ul><ul><li>Types and numbers of emergency surgeries </li></ul></ul><ul><li>“ Artificial”: you can control it….you must eliminate it to create flow. (batching) </li></ul><ul><ul><li>When the nuclear med lab reports stress test results </li></ul></ul><ul><ul><li>Types and numbers of scheduled surgeries </li></ul></ul>
  6. 8. Surgical Smoothing to Date <ul><li>Smoothing Elective Vascular Surgery </li></ul><ul><li>Smoothing Elective Cardiac Surgery </li></ul><ul><li>Separating Elective From Urgent Surgery in the Menino Pavilion </li></ul><ul><ul><li>Creating reliable urgency data </li></ul></ul><ul><ul><li>Separating a room for urgent/emergent cases </li></ul></ul><ul><ul><li>Eliminating Block Scheduling </li></ul></ul><ul><li>Smoothing Elective Cardiac Caths (in progress) </li></ul>
  7. 9. Bed Need by Day of Week for Vascular Surgery (18 months of data) Progressive Care Unit
  8. 10. Vascular Elective PCU Cases by Day Random Month July 2002
  9. 11. 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
  10. 16. Average CT Surgery Unscheduled Cases Weekdays
  11. 17. Average Scheduled CT Surgery Cases by Weekday
  12. 19. 2003 range 10 – 1 = 9 2004 range 7 –2 = 5 55% reduction in variability
  13. 20. Changes to the Menino OR Schedule <ul><li>Boston Medical Center has 2 Operating Suites </li></ul><ul><ul><li>Newton Pavilion OR </li></ul></ul><ul><ul><li>Menino Pavilion OR </li></ul></ul>
  14. 21. 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
  15. 22. Block Scheduling <ul><li>Surgeon or service “owns” blocks of time on the OR schedule </li></ul><ul><li>Allows surgeons to plan their time </li></ul><ul><li>If utilization of the blocks approaches 100%…everyone wins </li></ul><ul><li>Requires redesign of block as surgeons come and go or as demand changes </li></ul>
  16. 23. Pre-change Problems with the Daily Schedule – Menino Pavilion <ul><li>Overall 50% block utilization </li></ul><ul><li>15-20% cancellation rate </li></ul><ul><li>33% of daily schedule is “add ons” and may be 50% </li></ul><ul><li>Prevents other surgeons from getting time </li></ul><ul><li>Cases can be lost waiting 4-6 weeks (dental, gyn) </li></ul><ul><li>Urgent/emergent bump elective cases </li></ul>
  17. 24. Our Goals <ul><li>Reduce Bumped Cases </li></ul><ul><ul><li>Reduce waste in rework </li></ul></ul><ul><ul><li>Improve patient satisfaction </li></ul></ul><ul><ul><li>Improve surgeon satisfaction </li></ul></ul><ul><ul><li>Improve scheduling staff satisfaction </li></ul></ul><ul><li>Increase Surgical Volume </li></ul>
  18. 25. How Many Rooms Should We Set Aside for Urgent/Emergent Cases? <ul><li>Created a Case classification and prioritization system : </li></ul><ul><ul><ul><li>Emergent 30 minutes </li></ul></ul></ul><ul><ul><ul><li>Urgent 30 minutes – 4 hours </li></ul></ul></ul><ul><ul><ul><li>Semi-urgent 4 – 24 hours </li></ul></ul></ul><ul><ul><ul><li>Non-urgent >24 hours </li></ul></ul></ul><ul><li>Analysis shows that one room would be sufficient to have only a rare bump of an elective case </li></ul>
  19. 26. But the Surgery Leadership Wanted to do More! They said: “Lets get rid of block scheduling” ADVANTAGES of Open Scheduling Model <ul><li>Gives surgeons flexibility in scheduling </li></ul><ul><li>Equal access for all surgeons </li></ul><ul><li>Promotes booking far in advance </li></ul><ul><li>Opens up free time for other surgeons </li></ul><ul><li>Not rigid and gives schedulers flexibility </li></ul><ul><li>Keeps red (urgent/emergent) cases to 1 room </li></ul><ul><li>No case will be refused </li></ul>
  20. 27. Menino OR New Design April 26, 2004 Urgent and Elective Flows Separated No-block Scheduling Begins <ul><ul><li>Open Scheduling (Open Scheduled/OS) </li></ul></ul><ul><ul><li>Quantity: 5 Rooms </li></ul></ul><ul><ul><li>Orthopedic Scheduling (Block Scheduled/BS) </li></ul></ul><ul><ul><li>Quantity: 2 Rooms </li></ul></ul><ul><ul><li>Day of Scheduling (Urgent Schedule) </li></ul></ul><ul><ul><li>Quantity: 1 Room </li></ul></ul>
  21. 28. Separating Urgent from Elective Before and After <ul><li>Before </li></ul><ul><li>April – Sept 2003 </li></ul><ul><li>157 emergent cases (M – F) 7:00 AM to 3:30 PM </li></ul><ul><li>334 elective patients were delayed or cancelled </li></ul><ul><li>After </li></ul><ul><li>April– Sept 2004 </li></ul><ul><li>159 emergent cases (M – F) 7:00 AM to 3:30 PM </li></ul><ul><li>3 elective patients were delayed or cancelled </li></ul><ul><li>(1 cancelled, 2 delayed) </li></ul>
  22. 29. Change Here
  23. 30. Menino Volume Comparison Before Separating and After Total ‘03 = 3,560 Total ’04 = 3,574 +14
  24. 31. Overall Summary of Menino Open Block and Separating Urgent from Scheduled <ul><li>Eliminated bumping of elective cases (#3) </li></ul><ul><li>Scheduling cases quicker </li></ul><ul><li>More choice: both day and time </li></ul><ul><li>Book consecutive cases </li></ul><ul><li>More productive use of OR (fewer gaps) </li></ul><ul><li>No need to notify scheduling for time off </li></ul><ul><li>Minimal complaints </li></ul>
  25. 32. What’s next?: Smoothing Elective Cardiac Catheterizations <ul><li>We have competition for beds between adult cardiac and pulmonary ED patients and patients coming from the cath lab on our 6North Unit </li></ul><ul><li>Do we have artificial variability in scheduling elective caths and if so, what can we do to smooth this? </li></ul>
  26. 37. Summary <ul><li>There is much artificial variability in healthcare. We must do better to design systems to eliminate it. We can no longer afford this waste. </li></ul><ul><li>Separating the flow of urgent surgery from scheduled surgery reduces waste and rework </li></ul><ul><li>No-Block scheduling is a good way to help the surgeons, patients, and staff </li></ul>
  27. 38. References <ul><li>Leading Change; by John P. Kotter </li></ul><ul><li>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. </li></ul><ul><li>http://management.bu.edu/research/hcmrc/mvp/index.asp </li></ul>

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