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

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

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    1. 1 Improving Hospital Flow to Increase Throughput, Improve Patient Satisfaction July 14, 2005 Niels K Rathlev MD Vice Chair Department of Emergency Medicine

    2. 2 Maximizing throughput: smoothing the elective surgery schedule James M. Becker, MD Keith P. Lewis, MD John B. Chessare, MD Eugene Litvak, PhD Richard Shemin, MD Gail Spinale, RN Demetra Ouellette Abbot Cooper

    3. 3 Boston Medical Center 475 bed Level 1 trauma center 129,000 annual ED visits Safety net hospital in Boston’s South End ED provides 20% free care, 20% “self pay” 2 pavilions – East Newton cardiac center Menino Trauma Center

    4. 4 Variability “Natural”: you can’t 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

    5. 5 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)

    6. 6 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

    16. 16 Boston Globe, June 2004

    17. 17 Changes to the Menino OR Schedule BMC has 2 OR Suites

    18. 18 Menino Pavilion compared to Newton Pavilion

    19. 19 Pre-change problems with the schedule – Menino Pavilion

    20. 20 Our Goals Reduce bumped Cases Reduce waste in rework Improve patient satisfaction Improve surgeon satisfaction Improve scheduling staff satisfaction Increase surgical volume

    21. 21 Our Plan Separate urgent/emergent from scheduled surgeries

    22. 22 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 >24 hours Analysis shows that 1 room would be sufficient to have rarely bump an elective case

    23. 23 The Question

    24. 24 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 100%…everyone wins Requires redesign of block as surgeons come and go or as demand changes

    25. 25 Advantages of open scheduling model

    26. 26 “Concerns” regarding the open scheduling model

    27. Menino OR New Design April 26, 2004 Urgent and Elective Flows Separated No-block Scheduling Begins

    28. 28 Urgent room 5

    29. 29 OR Executive Committee commitment

    30. 30 Separating urgent from elective Before and after Before April – Sept 2003 157 emergent cases (M – F) 7:00 AM to 3:30 PM 334 elective patients were delayed or cancelled After April– Sept 2004 159 emergent cases (M – F) 7:00 AM to 3:30 PM 3 elective patients were delayed or cancelled (1 cancelled, 2 delayed)

    31. 31 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

    32. 32 What’s 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?

    34. 34 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.

    35. 35 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

    36. 36 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

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