Improving Hospital Flow to Increase Throughput, Improve Patient Satisfaction July 14, 2005

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Improving Hospital Flow to Increase Throughput,
Improve Patient SatisfactionJuly 14, 2005

• Niels K Rathlev MD
• Vice Chair
• Department of Emergency Medicine

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Maximizing throughputsmoothing the elective
surgery schedule

• Richard Shemin, MD
• Gail Spinale, RN
• Demetra Ouellette
• Abbot Cooper

• James M. Becker, MD
• Keith P. Lewis, MD
• John B. Chessare, MD
• Eugene Litvak, PhD

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Boston Medical Center

• 475 bed Level 1 trauma center
• 129,000 annual ED visits
• Safety net hospital in Bostons South End
• ED provides 20 free care, 20 self pay
• 2 pavilions East Newton cardiac center
• Menino Trauma Center

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Variability

• Natural you cant control it you just have
  to manage it.
• of patients coming to the ED
• Types and of emergency surgeries
• Artificial you can control it must
  eliminate batching it to create flow
• When the nuclear med lab reports stress test
  results
• Types and of scheduled surgeries

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Surgical smoothing

• 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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Should the ED care?

• Each additional elective surgical case prolonged
  the mean LOS per ED patient by 15 seconds.
• The median of 48 elective surgical cases per
  weekday add 12.3 mins (5.2) to the mean LOS per
  ED pt 30.6 hrs to total ED dwell time
• No association with diversions

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Bed Need by Day of Week for Vascular Surgery (18
mos)
Progressive Care Unit
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Vascular Elective PCU Cases by Day Random Month
July 2002
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Mean 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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Boston Globe, June 2004
Anybody who comes to me and says, I cant do
this, Im going to send them to Boston Medical
Center Dr.
Dennis OLeary
President, JCAHO
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Changes to the Menino OR Schedule

• BMC has 2 OR Suites

• Menino Pavilion
• 8 ORs

• Newton Pavilion
• 13 ORs

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Menino Pavilion compared to Newton Pavilion
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Pre-change problems with the schedule Menino
Pavilion

• Urgent/emergent bump elective cases
• Overall 50 block utilization
• Variable use of block (vacation, meetings)
• Most cases booked 3-4 days out
• 33 of daily schedule is add ons
• Variable release time between services
• Cases can be lost waiting
• People live in fear of losing their block

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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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Our Plan

• Separate urgent/emergent from scheduled surgeries

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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 1 room would be sufficient to
  have rarely bump an elective case

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The Question
Whose block time should we take away?
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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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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
• No case will be refused

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Concerns regarding the open scheduling model

• Its not what we are used to doing
• Gaming the system
• Someone may take the time you want
• Late booking may lose out
• Fear of loss of OR access and income
• Cases all over the place
• The winner takes it all!

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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/Emergent Schedule)
• Quantity 1 Room

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Urgent room 5

• Monday Friday 7 330 PM
• Fully staffed and ready to go
• Open to all!
• Case classification and prioritizing
• Emergent 30 minutes
• Urgent 30 minutes 4o
• Semi-urgent 4-24o

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OR Executive Committee commitment

• Want to enhance volume for all
• Want to prioritize and get to all
• emergencies
• Dedicated schedulers
• Tighten final schedule to maximize
• surgeon efficiency
• No case will be denied
• If it fails, we will reassess and change

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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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Summary of open block separating urgent from
scheduled cases

• 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 of complaints

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Whats next?smoothing elective cardiac caths

• We have competition for beds between adult
  cardiac and pulmonary ED patients and patients
  coming from the cath lab on our 6 North Unit
• Do we have artificial variability in scheduling
  elective caths and if so, what can we do to
  smooth this?

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Smoothing elective caths

• We have just implemented a cap of 5 elective cath
  patients on Mondays and Fridays after studying
  the variability.
• It is too soon to see the effect of this change.

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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
• McManus ML, Long MC Cooper A, Mandell J, Berwick
  DM, Pagano M, Litvak E. 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