The document outlines a process improvement initiative at Tawam Hospital, a tertiary facility in Al Ain, aimed at enhancing the surgical admission process through a series of defined steps, such as project selection, analysis, and solution development. Utilizing quality management tools and a multidisciplinary team, the project identified key issues impacting surgical cancellations and patient flow, ultimately implementing a surgical admission unit to streamline operations. Results included increased patient and staff satisfaction, improved hospital reputation, and recognition at national levels.

1. The Surgical Admission Process
A Cultural Shift Paradigm
Breakthrough Process Improvement
Case

2. About Tawam Hospital
• 477-bed tertiary hospital in Al Ain
• Highly specialized and well trained doctors and
nurses.
• In affiliation with Johns Hopkins Medicine from 2006
• JCI accredited since 2006 and reaccredited in 2009.
• Recognized as Baby Friendly Hospital.
• An educational hospital and training center for
faculty of medicine and health sciences- UAE
University

3. 1.Project
Selection
2.Current
4.Implem
Situation
entation
Analysis
3.
Solution
Develop
ment

4. PROJECT SELECTION & PURPOSE

5. T Data And Quality Tools Used To Select The
Project
Define Measure Analyze Improve Control
Data Reason for use
Operational reports, KPI To take evidence based decisions considering a balanced view
indicators (as LOS, Delays in OR of the process at hand.
start time, # of surgeries, # of
admissions ), patients feedback,
Tools Reason for Use
Multidisciplinary team Pool of subject matter expertise to ensure comprehensive
understanding of the problem, broad generation of innovative
ideas and easy buy in during implementation
Brainstorming & Group discussion Proven effective tool to generate big number of ideas from all
stakeholders
Prioritization matrix To select important projects based on objective and
comprehensive criteria to consider projects impact from all
aspects
Project Charter To clearly communicate, define goals, targets, scopes, and
expectations. To identify project responsibility and
accountability
SIPOC To identify the scope, inputs, outputs internal and external
customers, and main process steps.
Subject Matter Expert (SME) To consider the project form all aspects, with a professional
view

6. Involvement of potential stakeholders
in project selection
Define Measure Analyze Improve Control
Surgery Quality Committee including:
• Division chiefs
• Nursing representatives
• Administration representatives
• Pharmacist
identified “Bed management” and OR booking”
as two of the top five priority projects for the
Surgery

7. Why The Project Was Selected
Define Measure Analyze Improve Control
• To select the priority projects a group consensus using
a prioritization matrix consisting of 10 criteria was
applied:
– Patients needs & expectations
– Outcome
– Mission /Vision/Strategic Plan
– Regulatory compliance
– High Risk / Volume
– Problem prone
– Cost
– Impact
– Ease of implementation

8. Why The Project Was Selected – 2
Define Measure Analyze Improve Control
Score of > 18 = Top Priority Score of 15-18 = Moderate Priority Score of 10-14= Low Priority Score of < 10 = Not a Priority

9. ALIGNMENT WITH THE ORGANIZATION'S GOALS,
PERFORMANCE MEASURES, AND/OR STRATEGIES

10. Affected Organizational Goals
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11. IDENTIFICATION OF POTENTIAL STAKEHOLDERS

12. Potential Internal & External Stakeholders
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Team analyzed: How
•Patients flow •Brain storming
•Areas affected by the project •SMEs
•+/- impact •SIPOC
•Inputs /outputs/process steps •Process Flow Chart
SIPOC

13. Types Of Potential Impact On
Stakeholders & Potential
Define Measure Analyze Improve Control

14. 1.Project
Selection
2.Current
4.Implem
Situation
entation
Analysis
3.
Solution
Develop
ment

15. THE APPROACH/PROCESS THE TEAM
USED TO IDENTIFY THE POTENTIAL ROOT
CAUSES/IMPROVEMENT OPPORTUNITY

16. Innovative Methods And Tools Used To
Identify Possible Root Causes 1/2
Define Measure Analyze Improve Control
Process walk through Cause & Effect Diagram
• Patients view • Possible causes of the
problem
Pareto Structured Data
• Prioritize possible Analysis
contributing factors • Evidence based
Staff Shadowing
• In-depth understanding-
provider view

17. Innovative methods and tools used to
identify possible root causes2/2
Define Measure Analyze Improve Control

18. Describe The Team’s Innovative Analysis
Of Data To Identify Possible Root
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Data analysis included an extensive assessment of:
• KPI results (including OR Cancellation Rate & number
of elective surgical admissions).
• Reasons of surgical cancellations on day of surgery.
• Reasons for “patients no show”(by calling the
patients).
• Available vs. needed” Surgical education materials”.

19. THE TEAM ANALYSIS OF INFORMATION TO IDENTIFY
THE FINAL ROOT CAUSES

20. Tools Used To Identify The Final Root Cause(s)
Define Measure Analyze Improve Control

21. Team’s Analysis Of Data To Select The Final Root
Cause(s)
Define Measure Analyze Improve Control
• The old process was inefficient
– No proper communication between various
stakeholders (patient, or scheduling office,
anesthesia clinic and financial clearance office).
• The OR elective cancellation rate (on day of
surgery) was 20%.
– System errors accounted for a significant
percentage of cancellations.

22. How The Team Validated Final Root Cause(s)
Define Measure Analyze Improve Control
Relationships Score
Strong Impact 9
Moderate 3
Low 1

23. 1.Project
Selection
2.Current
4.Implem
Situation
entation
Analysis
3.
Solution
Develop
ment

24. METHODS USED TO IDENTIFY THE POSSIBLE
SOLUTIONS/IMPROVEMENT ACTIONS.

25. Methods And Tools Used To Develop Possible
Solutions /Improvement Actions
Define Measure Analyze Improve Control
• Run comprehensive literature review to identify other
healthcare (HC) systems approach to similar problems.
• Used the PICO Model (Population Intervention Comparability
Outcome) to validate our comparison with HC systems similar
to our environment.
• Held one to one discussions with the process owners.
• Generated and captured possible solutions during brain
storming sessions & 5 Whys Exercise

26. Team’s Analysis Of Data To
Develop Possible Solutions
Define Measure Analyze Improve Control
• Improvement actions were based upon
extensive review of:
– Base line KPIs and process related data
– Results of the studies done by the various team
members about the reasons for the delay,
cancellation rate and source by wards, etc.
– Possible impact on the results
– Easiness of implementation
– Impact on patients safety and satisfaction
– (as mentioned in 2A b & 3Ac).

27. Criteria The Team Decided To Use In
Selecting The Final Solution(s)
Define Measure Analyze Improve Control
• Criteria for selection were chosen in a balanced
approach considering:
– Financial
– Operational
– Customer
– Quality perspectives

28. Criteria The Team Decided To Use In Selecting
Final Solution(s) 2/3
Define Measure Analyze Improve Control

29. HOW THE FINAL SOLUTIONS
IMPROVEMENT ACTIONS WERE DETERMINED

30. Tools Used By The
Team To Select The Final Solutions
Define Measure Analyze Improve Control
Tools Rational for use
Fish Bone Provided a holistic qualitative approach for identifying the possible solutions considering the 5
Diagram Ms and E and in relation to the Identified causes under the same categories. It also helped in
generating ideas for improvement.
During discussion on the possible root causes, all ideas generated were listed then they were
prioritized by the team using the Prioritization Matrix.
Prioritizati This useful technique used to rank the solutions based on important criteria to identify the most
on Matrix important solutions to work on first: (kindly refer to the scoring in 3Ac)

31. Team’s Analysis Of Data To Select The Final Replicable
Solution(s)/Improvement Actions 1/2
Define Measure Analyze Improve Control
Benchmarking with evidence based proven practices
For example, Ortigo et al , found in a study including 6053 patients that the
implementation of a Surgery Admission Unit for patients undergoing major elective
surgery has proved to be an effective strategy for improving bed management,
improving the proportion of patients admitted on same day as surgery and a shorter
length of stay

32. Team’s Analysis Of Data To Select The Final Replicable
Solution(s)/Improvement Actions 2/2
Define Measure Analyze Improve Control

33. FINAL SOLUTIONS VALIDATION

34. 1.Project
Selection
2.Current
Implemen
Situation
tation
Analysis
3.
Solution
Develop
ment

35. Types Of Resistance Identified And Addressed
Define Measure Analyze Improve Control
• Resistance from various stakeholders was both expected and
encountered:
– Multiple meetings were held
– The SAU team identified physicians who presented a
challenge. This was addressed to the Director of Peri-
Operative Services.
– Protocol was strictly enforced such that surgeons who
followed the protocol were able to get more cases on the
schedule while those who were resistant lost operative
time.
– Surgeons and staff were encouraged to counsel patients
on the benefits of this process.

36. Improvements Implemented
Define Measure Analyze Improve Control
The final solutions, validated through literature review
and impact analysis included:
• Enriching the current function of the Day Case Unit by adding
the function of a Surgical Admission Unit.
• Remodeling of the elective surgical admission process. All
elective surgical admissions unless otherwise medically
indicated will be admitted on the day of surgery.
• Developing a Surgical Admission Office
• Improving surgical educational materials

37. Improvements Implemented
Define Measure Analyze Improve Control
• Centralize
– Surgical Scheduler (medical background)
– Admissions/Bed Board Officer
– Insurance Specialist
– Patient Advocates

38. Improvements Implemented
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 Surgery scheduled and communicated electronically
to the office by surgeon
 Patient seen in office, oriented, assigned patient
advocate
 Patient flow through system virtually shadowed by
office
 Patients called 1wk, 48, and 24hrs prior to surgery

39. Improvements Implemented
Define Measure Analyze Improve Control
 Patients called to arrive 2 hours prior to surgery
based on schedule
 Goal set for patient arrival to being ready for
transport to OR: 20 min
 Ambulatory patients discharged efficiently based on
nursing care pathways

40. Improvements Implemented
Define Measure Analyze Improve Control
 Patient removed from schedule if not cleared and
empty space communicated to surgeons
 Surgical Schedule communicated electronically to
entire organization at 48 and 24 hours
 Charts available night before scheduled surgery and
reviewed by nurse-Problems Identified
 Beds allocated night before based on expected
admissions

41. RESULTS ACHIEVED

42. Tangible Results
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43. Other Results
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• Increased patients satisfaction
• Increased staff satisfaction
• Better hospital reputation and word of the mouth
• Increased efficiency

44. Creation And Installation Of A System For
Sustaining Results
Define Measure Analyze Improve Control
Results of the following KPS were reviewed weekly by a
core team :
• OR utilization
• OR start times
• Patient arrival times
• Patient transport times
• Reasons for cancellations

45. Project Closure
Define Measure Analyze Improve Control
• Sharing of successes and recognition at Tawam and
national levels
• At SEHA level  won the Golden Medal
• Transparency
• Learning form challenges
• Next step: move the Pre-anesthesia clinic closer to
the surgical admission office.

46. Lessons Learnt
• Chronic problems are always associated with high
resistance to change
• When incremental improvements are not effective, a
process reengineering should be considered
• Team work is the fuel for success

47. The Project Team
Team Leader : Dr. Waleed Hassen, Chairman of Urology
Team Members:
• Alexander Jankuloski RN, Associate Director of Nursing
• Alec Napier, Operations Officer
• Aysha Al Ameri, Administrative clerk, Surgical Admissions Office
• Susie Delgado, Nurse Manager, Surgical Admissions Unit
• Urszula Allen, Nurse Manager, Operating Room
• Mervat Mansour, Section Head, Quality Improvement &
Innovation ,DPI.

48. Any Questions?
Thank you