Operations Management

Operations Management Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics

What is Operations Management?

What is Operations Management? Info Surgery Clinic OPS Online Discharge Surgery Clinic Admission Surgery Clinic ICU Recovery Ward PAT Surgery Clinic Info Additional Testing Surgery Clinic Holding Inpatient Preop No Surgery Regional Urgent Emergent

What is Operations Management? Info Surgery Clinic OPS Online Discharge Surgery Clinic Admission Surgery Clinic ICU Recovery Ward PAT Surgery Clinic Info Additional Testing Surgery Clinic OR1 OR2 OR3 OR4 OR5 Holding OR6 OR7 OR8 OR9 OR10 Inpatient Preop SP MRI Endo Endo Endo No Surgery Regional Urgent Emergent

“It is the responsibility of the OR directors and clinical managers to do any and all cases that can be done safely without compromising quality of care.”

“It is also the responsibility of the OR managers to provide surgeons with open access to OR time, to maximize OR efficiency, and to reduce overall patient waiting.”

Ordered Priorities Safety Open Access Efficiency Patient Waiting Professional Satisfaction

Metrics of Operational Efficiency Safety OR Allocation (Staffing) Turnover Time Open Access Prime Time Utilization Case duration prediction accuracy First-case start percentage Efficiency OR efficiency Clinician efficiency Patient Waiting Tardiness Staff Assignment Staff Scheduling Professional Satisfaction

Operating Room Management Tactical Decisions Operational Decisions • Months to years before DOS • 1st stage of OR allocation • Based on financial data • Allocate OR time to increase Contribution Margin • Involves changes in OR workload over months to years. • Weeks to days before DOS • 2nd stage of OR allocation • Not based on financial data • Allocate OR time to increase OR Utilization • Matches staffing to existing workload

“In order to grow a specialty service, hospital administrators must tactically allocate more OR time by recruiting more surgeons, purchasing more equipment, expanding clinics, or increasing ward and ICU usage.”

Prime Time Utilization

Question 1 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many prime time minutes did CT surgery use on Monday and Tuesday? 240 minute (4 hours) 720 minutes (12 hours) 840 minutes (14 hours) 1080 minutes (18 hours)

Question 1 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many prime time minutes did CT surgery use on Monday and Tuesday? 240 minute (4 hours) 720 minutes (12 hours) 840 minutes (14 hours) 1080 minutes (18 hours) Explanation: On Monday, CT surgery utilized 4 hours of an 8 hour block. On Tuesday, CT surgery utilized all 8 prime time hours, plus 6 additional hours.

Question 2 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What was the prime-time utilization for CT surgery for Monday and Tuesday? 25% 50% 75% 100%

Question 2 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What was the prime-time utilization for CT surgery for Monday and Tuesday? 25% 50% 75% 100% Explanation: Although CT surgery operated for 18 hours, only 12 of those hours were during prime-time. CT surgery was allocated 16 hours. Therefore 12/16 = 0.75 or 75%.

Prime Time Utilization OR Utilization is just one of many factors influencing OR allocation. OR Utilization alone is poorly related to patient waiting time, variable costs, and contribution margin. Many times, increased utilization can decrease the profit margin (over utilization) and decrease surgeon flexibility.

Operating Room Efficiency • Over-utilized time (Over) – time that the OR is used and not staffed (“Overtime” = time and a half) • Under-utilized time (Under) – time that the OR is staffed and not used • Inefficiency of use of OR time (IU_OR)– the sum of the products of cost of under-utilized time multiplied by the number of under-utilized hours and the cost of over-utilized hours multiplied by the number of over-utilized hours. • IU_OR = Under + 1.5(Over) • Heavily dependent on the OR manager’s ability to minimize over-utilized time.

Question 3 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many under-utilized hours did CT surgery have for Monday and Tuesday? 2 hours 4 hours 6 hours 8 hours

Question 3 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many under-utilized hours did CT surgery have for Monday and Tuesday? 2 hours 4 hours 6 hours 8 hours Explanation: 4 hours of under utilized time on Monday and 0 hours of under-utilized time on Tuesday.

Question 4 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many over-utilized hours did CT surgery have for Monday and Tuesday? 2 hours 4 hours 6 hours 8 hours

Question 4 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many over-utilized hours did CT surgery have for Monday and Tuesday? 2 hours 4 hours 6 hours 8 hours Answer: 0 hours of over-utilized time on Monday and 6 hours of over-utilized time on Tuesday.

Question 5 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What is the inefficiency of use of OR time (IU_OR)? 4 hours 8 hours 12 hours 16 hours

Question 5 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What is the inefficiency of use of OR time (IU_OR)? 4 hours 8 hours 12 hours 16 hours Answer: 4 + 1.5(8) = 16. Ideally you would want this number to approach zero.

Tardiness OR 1 20 minutes behind What is the tardiness of OR 1? OR 2 5 x 20 = 100 minutes What is the tardiness of OR 2? 1 x 60 = 60 minutes 60 minutes behind

Two ORs call for their next cases, but only one person is free to prepare the patients. Both ORs are 10 minutes behind schedule. The four remaining cases in OR1 are estimated to end at 2PM. The one remaining case in OR2 is estimated to end at 4PM. Staffing is planned from 7A to 6P. Which patient first? Patient for Room 1 Patient for Room 2

Two ORs call for their next cases, but only one person is free to prepare the patients. Both Ors are 10 minutes behind schedule. The four remaining cases in OR1 are estimated to end at 2PM. The one remaining case in OR2 is estimated to end at 4PM. Staffing is planned from 7A to 6P. Which patient first? Patient Safety – unaffected by decision Open Access – unaffected by decision OR Efficiency – unaffected by decision * OR1 is expected to have 0 over utilized hours. * OR 2 is expected to have 0 over utilized hours. Patient waiting – affected by decision * OR 1 expected total tardiness of 40 minutes * OR 2 expected total tardiness of 10 minutes Patient for Room 1 Patient for Room 2

How do I optimize Prime Time Utilization, OR Efficiency, and Tardiness?

Which of these measures has the greatest impact on OR Efficiency? OR Allocation (Staffing) Turnover time Case Duration prediction accuracy First case start percentage Clinician efficiency Staff assignment Staff scheduling

Which of these measures has the greatest impact on OR Efficiency? OR Allocation (Staffing) Turnover time Case Duration prediction accuracy First case start percentage Clinician efficiency Staff assignment Staff scheduling Explanation: The principal determinant of OR Efficiency is OR Allocation or Staffing. OR Efficiency applies to the existing workload.

Metrics of Operational Efficiency Months before DOS OR Allocation (Staffing) Tactical decisions determine increases in OR time allocation Operational decisions based on OR efficiency fill the OR time once the actual workload is known From an operational perspective, surgeons schedule cases on any future workday, regardless of OR staffing. Dr. Thomas underestimates case durations and operates for 12 hours a day when the OR is only staffed for 8 hours. The OR should be staffed for 12 hours for this surgeon. Over –utilized OR hours are reduced without increasing under-utilized hours. Every case scheduling conflict is a failure of OR allocation until proven otherwise.

Metrics of Operational Efficiency “Working fast and efficiently is always a good characteristic, but if the OR managers do not allocate OR time appropriately, the benefits of working fast may be negated.” Turnover Time Case duration prediction accuracy First-case start percentage Clinician efficiency Case duration prediction accuracy is critical for matching the predicted workload to the actual workload. Hypothetical example: Today, Dr. Lancaster had the best day of his life. He was in the OR at 7:10 for his first case, a massive oncological disaster. Fiberoptic intubation, central line, a-line, and thoracic epidural all done by 7:30. Incision at 7:31. The case is predicted to last 6 hours, followed by a 1 hour port removal (+1 hour turnover time). The first case finishes 2 hours before the predicted case duration, and Dr. Mehl turns over the OR himself in 15 minutes. Because of Dr. Mehl’s awesomeness, the room finishes all of its cases 3 hours earlier than expected. From an operational perspective, did Dr. Mehl improve OR efficiency?

Metrics of Operational Efficiency Wednesday 3/7/12 4 5 6 7 8 9 10 14 17 18 E1 E2 G/S/M 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 10+2 6 4 0 5 under + (1.75) x 11 over = 24.25 inefficiency of use of OR time

Metrics of Operational Efficiency Predicted Scheduled Workload Thursday 3/8/12 4 8 9 10 14 17 18 G1 Sp E2 E1 X X 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 25 under

Metrics of Operational Efficiency Predicted Scheduled Workload Thursday 3/8/12 4 8 9 10 14 17 18 G1 Sp E2 E1 X X 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Metrics of Operational Efficiency OR Allocation (Staffing) Thursday 3/8/12 4 8 9 10 14 17 18 G1 Sp E2 E1 X2 X5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Badon 7A-3P Rosen 7A-3P Mehl Res. Bates Res. St. Joh 7A-3P Weiss Res. Boudr 7A-3P Lanc Res. Palme 7A-3P Rex 7A-3P Murra7A-3P Baker 7A-3P Caloia 7A-7P Call Guilb 7A-3P Train 7A-5P Worle 11-7P Martin 11-7P Guilb 7A-3P Casey 7A-3P Train 7A-5P 25 under + + (1.75) x = Inefficiency of use of OR Time 19 under ? over

Metrics of Operational Efficiency PTU based on Allocated OR Time Thursday 3/8/12 4 8 9 10 14 17 18 G1 Sp E2 E1 2 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 #4 Fried Metz Block 4 of 8 50% PTU #8 FCFS Block 6 of 8 75% PTU #12 FCFS Block 8 of 8 100% PTU #10 ACS McGin Block 8of 8 100% PTU #14 U/E Block #17 Kandil Block 8 of 8 100% PTU #18 Lee FCFS Block 4 of 8 50% PTU #15 CV Releas 0 of 8 0% PTU OSL OSL #5 Hellstr Block 0 of 8 0% PTU #2 Bellow Block 0 of 8 0% PTU

Tulane Statistics

Academic Medical Centers Surgeons are responsible for scheduling cases into block time and accurately estimating case duration. OR Managers are responsible for allocating OR time to match the workload. Departmental Conference Friday Morning Two to One Resident Supervision Resident Didactics on Thursday Afternoon

Operations Management