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Improving Hospital Flow Improving Hospital Flow to Increase Throughput, to Increase Throughput,

Improve Patient Improve Patient SatisfactionSatisfaction

July 14July 14, , 20052005

Niels K Rathlev MDVice Chair

Department of Emergency Medicine

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Maximizing throughput:smoothing

the elective surgery schedule

James M. Becker, MDKeith P. Lewis, MDJohn B. Chessare, MDEugene Litvak, PhD

Richard Shemin, MD

Gail Spinale, RNDemetra OuelletteAbbot Cooper

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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

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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

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Surgical smoothing

Smoothing elective vascular surgerySmoothing elective cardiac surgerySeparating 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)

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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

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0.2

0.4

0.6

0.8

1

1.2

Abramson

Restucci

Madison

Sampson

Wong

Bed Need by Day of Week for Vascular Surgery (18 mos)

Progressive Care Unit

Volume

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0.5

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1.5

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Volume

Vascular Elective PCU Cases by DayRandom Month July 2002

Vascular Scheduled PCU Cases - Weekdays Only (October 2003)

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2

3

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5

10/0

1/03

10/0

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10/0

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10/0

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0/03

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1/03

# o

f S

ch

ed

ule

d C

as

es

E6W Direct Nursing Hours per Patient Day

8.66

8.16

7.90

8.00

8.10

8.20

8.30

8.40

8.50

8.60

8.70

Prior to Vascular Smoothing

After Vascular Smoothing

Average Nursing Care Hours per Patient per Day By Week

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6.5

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7.5

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8.5

9

9.5

10

9/29

10/610

/1310

/2010

/2711/311

/1011

/1711

/2412/112

/812

/1512

/2212

/29 1/51/

121/

191/

26 2/2

2/92/

162/

23 3/2

3/93/

163/

233/

30 4/64/

134/

204/

27 5/45/

115/

185/

25 6/1

6/86/

156/

226/

29 7/67/

137/

207/

27 8/38/

108/

178/

248/

31 9/79/

149/

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FY2003

FY2004

Mean CT Surgery Unscheduled Cases Weekdays

Average Scheduled CT Surgery Cases by Weekday

Cardiac Scheduled Cases Histogram January & February Non-holiday Weekdays Only

0%

5%

10%

15%

20%

25%

30%

35%

Monday Tuesday Wednesday Thursday Friday

2004

2003

March Daily PCU Census - 2003 vs. 2004

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2

4

6

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12

1-Mar

2-Mar

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ar

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2003

2004

2003 range 10 – 1 = 9

2004 range 7 –2 = 555% reduction in variability

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Boston Globe, June 2004

“Anybody who comes to me and says, I can’t do this, I’m going to send them to Boston Medical Center ”

Dr. Dennis O’Leary President, JCAHO

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Changes to the Menino OR Schedule

BMC has 2 OR Suites

Newton Pavilion

13 ORs

Menino Pavilion

8 ORs

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Menino Pavilion compared to

Newton Pavilion

Variable NP MP

# Rooms 13 8

# Cases Day 30-35 25-32

# Cases Year 8601 6608

Cancellation Rate 10% 20%

#Add Ons Per Day 1-2 5-12

#Weekend Cases 0-4 5-20

Unique Services Cardiac, Eye Pediatrics, Trauma, Gastric Bypass, OB

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Pre-change problems with the schedule –

Menino Pavilion

•Urgent/emergent bump elective cases•Overall 50% block utilization•Variable use of block (vacation, meetings)•Most cases booked 3-4 days out•33% of daily schedule is “add ons” •Variable release time between services•Cases can be lost waiting•People live in fear of losing their block

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Our Goals

Reduce bumped Cases– Reduce waste in rework– Improve patient satisfaction– Improve surgeon satisfaction– Improve scheduling staff

satisfaction Increase surgical volume

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Our Plan

Separate urgent/emergent from scheduled surgeries

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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

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The Question

Whose block time should we take away?

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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

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Advantages of open scheduling model

•Gives surgeons flexibility in scheduling•Equal access for all surgeons•Promotes booking far in advance•Opens up free time for other surgeons•Not rigid and gives schedulers flexibility•No case will be refused

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“Concerns” regarding the open scheduling

model

•“It’s not what we are used to doing”•Gaming the system •Someone may take the time you want•Late booking may lose out•Fear of loss of OR access and income•Cases all over the place •The winner takes it all!

Menino OR New DesignApril 26, 2004 Urgent and Elective Flows

SeparatedNo-block Scheduling Begins

1. Open Scheduling (Open Scheduled/OS)Quantity: 5 Rooms

2. Orthopedic Scheduling (Block Scheduled/BS)Quantity: 2 Rooms

3. Day of Scheduling (Urgent/Emergent Schedule)Quantity: 1 Room

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Urgent room 5

•Monday – Friday 7– 3:30 PM•Fully staffed and ready to go•Open to all!•Case classification and prioritizing

Emergent 30 minutesUrgent 30 minutes – 4o

Semi-urgent 4-24o

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OR Executive Committee commitment

•Want to enhance volume for all•Want to prioritize and get to all emergencies•Dedicated schedulers•Tighten final schedule to maximize surgeon efficiency•No case will be denied•If it fails, we will reassess and change

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Separating urgent from elective

Before and after

BeforeApril – Sept 2003 157 emergent cases (M

– F) 7:00 AM to 3:30 PM

334 elective patients were delayed or cancelled

AfterApril– 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)

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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

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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?

E6N Tuesday Noon Census

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Week of...

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sus

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Total

Interventional

Other

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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.

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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

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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