SIP 1

1. SIP 1 Team Leaders: Judy Canfield Dr. Laurie Amundsen

2. Scope: From patient’s decision of having surgery until 00:01 on the day of surgery. In Scope: Patient scheduling of surgery; Pre-Anesthesia, Lab – including day of surgery; Discharge Planning; Financial Clearance; patient packet; interface to: Med Consult, Radiology, Pathology, Cardiology, Lab appointments; Scheduling Systems: scheduling coordination with PL’s; Communication of special needs – implants, ICU beds, bariatric equipment, etc.; In-patient preparation Out of Scope: Preparing instruments, supplies, and equipments; Charter Outcome Deliverables • Document current state process(es) • Document best industry practices • Value analysis using LEAN methodology • Identification of optimal patient flow (patient experience) • Identification of optimal information flow • Identification of essential variability • Design future state process(es) • Develop project plan and timeline • Identify short and long term projects • Develop metrics and key indicators • Short and long term project completion • Strategy for ongoing Performance Improvement Essential Metrics • Patient ready upon arrival • All resources ready upon arrival • Block time utilization • Planned schedule same as actual schedule Where the team has focused its efforts due to the need for integration of all teams for Patient Preparation and Document Management

3. Condensed Process Map Core process

4. Patient Flow Scheduling Equipment Supplies PAC Key Areas of Improvement • Scheduling Cases • Preparing for Surgical Cases • Accessing Patient Data RPI Recommendation • Case Cart • Patient Preparation • Document Management

5. Condensed Process Map Scheduling Cases Map

6. Patient Flow Scheduling Equipment Supplies PAC Scheduling CasesIssues • Case selection, via PCC, is by procedure name. • Case selection drives the preference list that is chosen for the case. • SCCA patients decide day ahead for surgery and require intense coordination. • Each team member has different definition for surgery time estimate. • Room scheduling is not standardized- Pavilion and Main OR have different rules. • Cases are moved 24 hours ahead after review by charge Anesthesia/Nurse staff for correct room assignment.

7. Condensed Process Map Preparing for Surgical Case Map

8. Preparing for Surgical CaseIssues • All systems are manual, which is resource- and labor-intensive. • Preference lists/ pick tickets are not frequently reviewed the day ahead, resulting in the wrong case cart. • There is no standard for how information is received, reviewed and actions taken. • PCCs are located in multiple sites. • Getting the patient access to essential services in surgical preparation is difficult. • Anesthesia bypass process of the surgical patient is complicated and inconsistent.

9. Condensed Process Map Accessing Patient Data

10. Accessing Patient DataIssues • Information received from outside referral does not always make it to the chart. • All document elements for the pre-surgical patient are not accessible to the requisite and appropriate staff. • Yellow packet travels across sites, and is only accessible to the site where it currently resides. • Records are lost causing case delays and errors. • Document completion is not standardized across surgical clinics.

11. RPI – Case Carts

12. Past and Current Activities • Completed PCC ESI training • Reviewed and evaluated best practice scheduling process from other academic medical centers • Reviewed literature • Created website for open and released block time • Established concepts for a best practice scheduling process • Developed Best Practice scheduling process vision (includes inpatient) • Established shared definitions • Developed standard physician worksheet • Created criteria/guidelines for scheduling TBA cases • Flexible scheduling process for cases that need 24 hour turnaround of schedule (i.e., cancer, orthopedic injuries)

13. Best Practice Scheduling Process Recommendation Process for scheduling is standard for both inpatient and outpatient cases by the PCC Patient and Physician determination of surgical procedure Standard Worksheet completed – essential elements MD determines and is accountable for procedure name, duration and preference list from data sheet with his/her specific cases and PLs Information is entered into ESI and scheduled by PCC Cases are scheduled to accommodate patient preferences and special needs Scheduler acknowledges work submitted PCC places case in block time If no block is open 48 hours before day of surgery – charge personnel checks surgery schedule for fit, moves TBA cases into open block and communicates these to services PCC reviews web site for released time If no released time available PCC places case in TBA schedule

14. Key Reality Checks Next Steps • Develop future metrics • Develop implementation plan for new scheduling process • Develop plan for elements not discussed (due to time constraints) but of importance • Will this make our scheduling process easier?  • Will it flow better and have more accuracy?  • Does our process give feedback to those using it?

15. SIP1 Team

16. Appendix

17. Comments/Questions from OR staff and department road shows • Patients have lots of history but we cannot get/retrieve the record. • PCCs have a lack of training in choosing the right PLs. Do we as the OR need to embrace training and collaborate with the PCCs? • Because of the acuity of our patients, the day before the appointment in the Pre-Anesthesia Clinic is not enough lead time to prepare for the patient. • Inpatients should be seen by the Pre-Anesthesia Clinic also. • We are still getting incomplete instrument sets and wrong items in the case carts. • Continuity of preop evaluation and on-site anesthesia management. • Crisp definitions of time that make sense to the surgeons.

18. Review and Evaluation of Other Scheduling Practices *Please note that this is only a small portion of the informal survey

19. Literature Review Sample • Schedule the Short Procedure First to Improve OR Efficiency – Lebowitz, Phillip, MD, Oct 2003 • What makes a well-oiled scheduling system? – OR Manager • Determining Optimum Operating Room Utilization – Tyler, D et al., 2003 • How to schedule elective surgical cases into specific operating rooms to maximize the efficiency of use of operating room time –Dexter and Traub, 2002 • Optimal Sequencing of Urgent Surgical Cases, Dexter et al., May 1999 • Creating an Optimal Operating Room Schedule, Calichman, Murray, May 2005 • Applications of Queuing Theory, Vanaswala and Desser, Feb 2005 • Improving Operating Room Coordination, Moss and Xiao, 2004