Process Improvement Team

1. Process Improvement Team Operating Room Scheduling Final Report Respectfully Submitted to the OR Committee May 1, 2007

2. Team Leader Stephanie Ramirez Participating Team Members Dr. Greg Reece Melina Scarborough Dr. V. Gottumukkala Lancelot Jones Patricia Gage Nancy Reinert Susan McConihay Keith Shook Anthony Hoang Irvin Serra Carla Willis Corliss Denman Shirley Morrison Melanie Lopresto Stacy Swanson Garry Brydges Mark Winograd Technical Consultant Jim Vinci, Holland and Davis, LLP

3. GOAL: To increase efficiency and accuracy of the Operating Rooms through an effective and “rules based” scheduling system.

4. Requests the following: • OR Committee reviews the Team’s recommended solutions and approve with an addendum if necessary. • Forward recommended solutions & final report to OR Executive Team for approval. • Charter the Implementation Planning Team (action for OR Executive Team).

5. Overview • Team representative of all stakeholders • Conducted Root Cause Analysis • Problems identified: • Communication • Staffing • Information Technology • Cultural/Behavioral

6. MAJOR FINDINGS: • Failure to take advantage of web-based technology & electronic enhancements. • Inadequate structure leading to inefficiency & lack of standardization in scheduling processes. • Unpredictability of over & under utilization of OR resources. • Inability to track patients thru scheduling process to point of medical clearance. • Challenges of complex & multi-team cases.

7. Solution • Implementation of web based & electronic processes are indicated throughout presentation. MAJOR FINDINGS: Failure to take advantage of web-based technology & electronic enhancements.

8. Inefficiencies in inconsistent processes affect everyone.

9. MAJOR FINDINGS: • Failure to take advantage of web-based technology & electronic enhancements. • Inadequate structure leading to inefficiency & lack of standardization in scheduling processes. • Unpredictability of over & under utilization of OR resources. • Inability to track patients thru scheduling process to point of medical clearance. • Challenges of complex & multi-team cases.

10. MAJOR FINDING: Inadequate structure leading to inefficiency & lack of standardization in scheduling processes. • Short-term Solution (3-6 months) • Use this ordered set of priorities to schedule cases: • Patient Safety • Maximize OR efficiency • Reduce patient waiting time • Surgeon preference Dexter et. al. Making Management Decisions on the Day of Surgery Based on Operating Room Efficiency and Patient Waiting Times, Dexter et. al. Anesthesiology 2004; 101-1444-53

11. Short-term Solution (3-6 months) • Assign scheduled cases based on principles of efficiency: • Assign by historical case length. • Assess OR resources and match case length. • Consider equipment restrictions when assigning operating rooms. • Arrange cases to maximize OR efficiency (bin stacking) to optimize available resources (minimizing over utilization).

12. Short-term Solution (3-6 months) • Ensure patient safety through adequate preparation for cases: • Finalize schedule by specific time (to be determined) before day of surgery. • Avoid posting simultaneous case starts in ACB & OR on a single day. • Avoid replacing cancelled cases with new cases in the 24 hrs prior to the day of surgery (excluding urgent/emergent).

13. MAJOR FINDINGS: • Failure to take advantage of web-based technology & electronic enhancements. • Inadequate structure leading to inefficiency & lack of standardization in scheduling processes. • Unpredictability of over & under utilization of OR resources. • Inability to track patients thru scheduling process to point of medical clearance. • Challenges of complex & multi-team cases.

14. MAJOR FINDING: Unpredictability of over & under utilization of OR resources. • Short-term Solution (3-6 months) • Assign a scheduler to each Alkek quad & ACB to schedule cases/assign rooms using the nurse manager as a resource.

15. 17 Robotics Gyn Urology Thoracic Pediatrics H & N Opthalmology / ENT Dental Oncology Plastic Surgery OR scheduler OR scheduler Nadine 1 Paula 3 Neuro Ortho Pain Surgical Oncology OR scheduler OR scheduler Michelle 2 4 Elena ACB OR OR scheduler 5 Matt Recommended Structure for Surgery Scheduling Scheduler reviews request in surgery scheduling queue (w)

16. Short-term Solutions (3-6 months) • Assess allocation of time by services. • Assess opportunity to post cases with defined allocated time parameters. • Use historical data to: • Estimate case duration for scheduling. • Validate service allocation utilization & duration with upper prediction bounds.

17. Short-term Solutions (3-6 months) • Identify a representative (Chair or designee) from each Service to assist with resolving conflicts in case scheduling. • Assess opportunity to identify coordinator in each Service to work with surgeon and PA to coordinate scheduling of cases. • Establish oversight process to review service allocation utilization quarterly. • Modify service allocations based on review findings.

18. MAJOR FINDINGS: • Failure to take advantage of web-based technology & electronic enhancements. • Inadequate structure leading to inefficiency & lack of standardization in scheduling processes. • Unpredictability of over & under utilization of OR resources. • Inability to track patients thru scheduling process to point of medical clearance. • Challenges of complex & multi-team cases.

19. MAJOR FINDING: Inability to track patients thru scheduling process to point of medical clearance. • Intermediate Solution (6-12 months) • Enhance current IT systems to improve patient flow, communication, and patient preparation. • Collaborate with IT & PI to develop electronic and web-based systems (white board subprocess) with business rules for accurate tracking of patients and extraction of data

20. MAJOR FINDINGS: • Failure to take advantage of web-based technology & electronic enhancements. • Inadequate structure leading to inefficiency & lack of standardization in scheduling processes. • Unpredictability of over & under utilization of OR resources. • Inability to track patients thru scheduling process to point of medical clearance. • Challenges of complex & multi-team cases.

21. MAJOR FINDINGS: Challenges of complex & multi-team cases. • Short/Intermediate Solution (Timeline as indicated) • Develop a centralized “time away” calendar to improve process of scheduling multi-team cases. (3-6 months) • Automate process to notify stakeholders and collect data regarding a change or cancellation of case. (6-12 months)

22. Recommended Implementation Team

23. Final Schedule & Add On Cases: • Patient safety • Maximize OR efficiency • Patient waiting time • Surgeon preference • Scheduling queue to OR Manager: • Maximize OR efficiency • OR throughput • Patient waiting time • Surgeon preference • Emergent/Urgent: • Patient Safety • Single & Multidisciplinary Scheduling: • Patient Safety • Maximize OR Efficiency • OR throughput White Board:Patient Safety New Surgery Process

24. Comments, Suggestions, Discussion