Maximizing Throughput:Smoothing the Elective Surgery Schedule to Improve Patient Flow

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Maximizing ThroughputSmoothing 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

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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.

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Urgent Matters Starts
Diversion Goal
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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

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Variability

• Natural you cant 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

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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)

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Bed Need by Day of Week for Vascular Surgery (18
months of data)
Progressive Care Unit
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Vascular Elective PCU Cases by Day Random Month
July 2002
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Results of Suggested Physician Schedule Change
Scenarios and the Status Quo
30.0
25.0
20.0
Mon
Tue
15.0
Wed
Thu
Fri
10.0
5.0
0.0
Scenario 5
Scenario 7
Scenario 8
Status Quo
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Average CT Surgery Unscheduled Cases Weekdays
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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
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Changes to the Menino OR Schedule

• Boston Medical Center has 2 Operating Suites
• Newton Pavilion OR
• Menino Pavilion OR

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Menino Pavilion compared to Newton Pavilion
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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
  100everyone wins
• Requires redesign of block as surgeons come and
  go or as demand changes

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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

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Our Goals

• Reduce Bumped Cases
• Reduce waste in rework
• Improve patient satisfaction
• Improve surgeon satisfaction
• Improve scheduling staff satisfaction
• Increase Surgical Volume

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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 gt24 hours
• Analysis shows that one room would be sufficient
  to have only a rare bump of an elective case

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But the Surgery Leadership Wanted to do More!
They said Lets get rid of block
schedulingADVANTAGES 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

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Menino OR New DesignApril 26, 2004 Urgent and
Elective Flows SeparatedNo-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

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Separating Urgent from ElectiveBefore and After

• Before
• April Sept 2003
• 157 emergent cases (M F) 700 AM to 330 PM
• 334 elective patients were delayed or cancelled

• After
• April Sept 2004
• 159 emergent cases (M F) 700 AM to 330 PM
• 3 elective patients were delayed or cancelled
• (1 cancelled, 2 delayed)

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Change Here
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Menino Volume Comparison Before Separating and
After
Total 03 3,560 Total 04 3,574
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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

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Whats 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

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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