maximizing throughput:smoothing the elective surgery schedule to improve patient flow

1. Maximizing Throughput:Smoothing 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

6. 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

7. Variability �Natural�: you can�t 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

8. 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)

20. Changes to the Menino OR Schedule Boston Medical Center has 2 Operating Suites Newton Pavilion OR Menino Pavilion OR

21. Menino Pavilion compared to Newton Pavilion

22. 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

23. Pre-change Problems with the Daily Schedule � Menino Pavilion

24. Our Goals Reduce Bumped Cases Reduce waste in rework Improve patient satisfaction Improve surgeon satisfaction Improve scheduling staff satisfaction Increase Surgical Volume

25. 25 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 one room would be sufficient to have only a rare bump of an elective case

26. But the Surgery Leadership Wanted to do More! They said: �Lets get rid of block scheduling�ADVANTAGES of Open Scheduling Model

27. Menino OR New DesignApril 26, 2004 Urgent and Elective Flows SeparatedNo-block Scheduling Begins

28. 28 Separating Urgent from ElectiveBefore 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)

30. 30 Menino Volume Comparison Before Separating and After

31. 31 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

32. What�s 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?

37. 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

38. 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