University of Michigan Health System

Program and Operations Analysis

Analysis of Inpatient Flow to Operating Rooms at the

University of Michigan Hospital

Final Report

To: Shawn Murphy

Associate Hospital Administrator and Director of Nursing

UMH Operating Rooms

Sally Webb

Clinical Manager

UMH Operating Rooms

Mark Williams, Project Coordinator

ME Fellow

Program & Operations Analysis

Mary Duck, Project Coordinator

Industrial Engineer Expert & Lean Coach

Program & Operations Analysis

Mark Van Oyen, Professor

Industrial and Operations Engineering 481

College of Engineering

From: IOE 481 Student Team #11, Program and Operations Analysis

Paige Erspamer

Ahmer Javed

Danielle Paniccia

Date: December 14, 2010

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EXECUTIVE SUMMARY

Inpatients at the University of Michigan Hospital (UH) scheduled for surgery must be treated in

the preoperative area (pre-op) before their procedures. Patients are put “on call” for surgery

while they are in their rooms; the floor nurses assist patients with preliminary tasks before the

patients can be taken down to pre-op. Nursing assistants arrive on the floors to transport patients

down to pre-op. Operating room (OR) staff at UH would like to improve this process of

inpatient flow from the floor units to the preoperative area before surgery. The OR clinical

manager stated that the ideal time for inpatients to arrive in pre-op is approximately 20 minutes

after the OR puts the patient on call, however the actual time it takes is over 50 minutes. A

physician at UH also brought this issue to attention; therefore, the team was asked to study and

analyze the tasks and entities involved in transporting patients from their floor down to the pre-

op area.

Methodology

To analyze the current inpatient flow process the team collected various types of data collection

to define problems or causes of delay in the current process. These methods included:

Interviews with hospital staff (sample size: 16)

Two questionnaires (total sample size: 59)

Job shadowing of hospital staff

Time studies (sample size: 20)

Historical data (sample size: 157)

Using the collected data, team members documented the current process, gained perspective

from the staff’s opinions, and determined areas of improvement.

Findings

Based on time study data, the team concluded that the average time it takes for patients to arrive

in pre-op after being put on call is 45 minutes; the team also found that 61% of patients were not

ready to leave their room when pre-op nursing assistants (NAs) arrived to take them to pre-op.

Recurring reasons for which inpatients were not ready include:

NAs arrive quicker than the unit nurse expected

NAs take longer than expected to arrive at room to retrieve the patient

Patient has not had preoperative shower or bath

Patient is not properly dressed in a hospital gown

Patient has to use the restroom or have catheter removed

Family requests more time with the patients, or has not yet arrived and would like to see

patient before procedure

Patient is waiting for medications or IVs from the pharmacy

Patient is not NPO

Unit nurse has not filled out the transport sheet.

Another common problem is that patients do not know the details of their procedures, or even

what time their procedures are scheduled for. If a patient has been put on call for a surgery he or

she is uncertain of, the patient will likely request to speak to a doctor, which results in a delay in

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getting the patient to pre-op. Along with these reasons, the project team has also deemed there is

a lack of communication between staff in the preoperative area and that on the floor units,

frequently leaving room for error. This claim has been supported by several staff members,

whom also believe effective communication is necessary. For example, if a surgery is added or

moved on the daily schedule, OR staff may not update the change in CareLink, the hospital’s

charting system, leaving floor nurses unaware of the change.

Recommendations

Based on data analysis and observations, the team has developed the following list of

recommendations that could collectively aid in creating a more efficient process.

Preoperative visitation program – The team recommends that an RN consults the

inpatient the night before the patient’s scheduled procedure. This program will eliminate

uncertainties regarding procedure information, as well as those regarding the time and

length of the procedure, and the operating physician. At these visits, nurses will also

discuss what needs to be done before going down to pre-op, and the time for last solid

food to assure the patient is NPO. A preoperative visit will reduce delays caused by

patient uncertainties.

Specified on call times - A second recommendation is to put patients on call at a specific

time, regardless of the availability of the operating rooms. This time will be noted on the

daily surgery schedule for all staff members to see. As a result, the nursing assistant will

arrive at the units at predetermined times to retrieve the patients, so all staff members can

prepare and properly plan their daily schedules to assure patients are ready. A nurse will

know when to order their patient’s medications, or when to give the patient a bath and

have him or her in proper attire.

Effective communication - The final recommendation enforces that operating room

staff, preoperative staff, and floor unit staff members are all communicating effectively.

This might include ensuring that, if a surgery is cancelled or added on to the daily

schedule, OR staff quickly documents the change in CareLink. Given the size of UMHS,

communication is imperative for any operation to run smoothly.

The team believes that by implementing all of these recommendations, on-call inpatient flow

from the floor units to the preoperative area will be more efficient.

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TABLE OF CONTENTS

INTRODUCTION .......................................................................................................................... 6

BACKGROUND ............................................................................................................................ 6

Key Issues ................................................................................................................................... 7

Goals and Objectives .................................................................................................................. 7

Project Scope .............................................................................................................................. 8

PROJECT METHODOLOGY........................................................................................................ 8

Data Collection ........................................................................................................................... 8

Interviews ................................................................................................................................ 8

Job Shadowing ........................................................................................................................ 9

Time Studies ............................................................................................................................ 9

Historical Data ....................................................................................................................... 9

Data Analysis ............................................................................................................................ 10

FINDINGS AND CONCLUSIONS ............................................................................................. 10

Process Flow ............................................................................................................................. 10

Floor Process ........................................................................................................................ 11

Process Time ............................................................................................................................. 12

Process Delays .......................................................................................................................... 15

Misinterpretations within the Hospital...................................................................................... 17

Comparable Processes within the Health System ..................................................................... 18

Cardiovascular Center.......................................................................................................... 18

C.S. Mott Children’s Hospital .............................................................................................. 18

Process Comparison ............................................................................................................. 19

RECOMMENDATIONS .............................................................................................................. 20

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Standardized On-Call Times ..................................................................................................... 21

Pre-operative Reviews .............................................................................................................. 21

Effective Communication ......................................................................................................... 22

Future Analysis ......................................................................................................................... 22

Expected Impact........................................................................................................................ 23

SUPPORT RECEIVED ................................................................................................................ 23

APPENDIX A - RN QUESTIONNAIRE 1 AND RESPONSES ................................................ 24

APPENDIX B - RN QUESTIONNAIRE 2 AND RESPONSES ................................................. 28

APPENDIX C – DATA COLLECTION FORM.......................................................................... 30

APPENDIX D – HISTORICAL DATA ....................................................................................... 31

APPENDIX E – MOTT INPATIENT FLOW PROJECT PROPOSAL ...................................... 34

APPENDIX F – HISTORICAL DATA ANALYSIS BASED ON TIME OF DAY ................... 36

APPENDIX G – PREOPERATIVE REVIEW SAMPLE FORM ................................................ 37

APPENDIX H – COLLECTED DATA FROM TEAM TIME STUDIES .................................. 38

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LIST OF TABLES

Table 1: Survey results of time before RN attends to different tasks after inpt. is put on call ..... 12

Table 2: Summary of historical data and collected data ............................................................... 13

Table 3: Comparison of departmental processes for inpatient flow from floor to pre-op ............ 19

LIST OF FIGURES

Figure 1: Flow chart of process flow from time OR puts inpatient on call to time inpatient arrives

in pre-op ........................................................................................................................................ 11

Figure 2: Frequency of process times from historical data, September 1, 2010 - November 1,

2010, n = 157 ................................................................................................................................ 13

Figure 3: Comparison of historical data and collected data .......................................................... 14

Figure 4: Value stream map of inpatient flow process, October - November, 2010. ................... 14

Figure 5: Percentage of observed cases .............................................................................. 15

Figure 6: Comparison of time the NAs spend .............................................................................. 15

Figure 7: Tasks that are not completed when NAs arrive, November 2010, n=52 ....................... 16

Figure 8: Time needed to prepare inpatient, according to RN, November 2010, n=51................ 17

Figure 9: Ishiwaka (Fishbone) diagram showing causes of long process times ........................... 20

Figure 10: Distribution of historical based on the time of day an inpatient was put on call by OR,

September 1 – November 2010, n = 154 ...................................................................................... 36

Figure 11: Average process time of historical data separated by the time of day the inpatient was

put on call by OR, September 1 – November 1, 2010, n =154 ..................................................... 36

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INTRODUCTION

The time taken for an inpatient to arrive at the pre-operative area (pre-op) at the University of

Michigan Hospital (UH) operating rooms (OR) is perceived to be too long by staff. A physician

at the hospital reported that transporting inpatients to pre-op from the floor where they are

staying takes over an hour. In one case, the time elapsed for an inpatient to be brought to the OR

was so long, the resident went directly to the floor to retrieve the patient. Therefore, UH would

like to improve the efficiency of inpatient flow from the floor units to the preoperative area

before surgery. To address this issue, an IOE 481 student team was asked to study the tasks

involved in transporting patients from their floor to pre-op. A value stream map of the

transportation process on the day of surgery was created to facilitate moving the inpatients to

pre-op, and determine why current inpatient flow is poor. From the conclusions, the team has

recommended changes to determine the most effective process for transporting inpatients, as

well as to improve the flow of inpatients to the UH-OR. The purpose of this report is to present

the project team’s findings, conclusions, and recommendations.

BACKGROUND

According to the clinical manager at the UH preoperative area, the 27 operating rooms in the

hospital utilize most of their patient capacity per day; staying on schedule is important for the

OR. When interviewed, 6 out of 9 floor unit nurses and the entirety of pre-op staff agreed that

the process of transporting inpatients to pre-op on the day of surgery takes too long and is

inefficient. After speaking with OR and pre-op staff, the basic process involved in retrieving and

transporting an inpatient to pre-op are:

1. OR puts the inpatient on call.

2. Pre-op notifies the inpatient’s registered nurse (RN) that the inpatient is on call.

3. Pre-op nursing assistants (NAs) are notified the inpatient is on call.

4. On the floor, the inpatient’s nurse prepares the patient to be transported to pre-op .

5. NAs go to the floor to retrieve the patient.

6. The floor nurse transfers care of the patient to the NAs.

7. The NAs transport the patient to pre-op.

The pre-op NAs are assigned to a given number of the sixteen slots in pre-op. If no one in pre-op

is available, a nursing assistant from the post anesthetic care unit (PACU) is called. Two NAs go

to retrieve a patient because patients are all brought down on beds; the transport of such requires

two people.

Before an inpatient is transported to pre-op, various tasks are completed by the patient’s RN.

The tasks include:

Fill out Intrahospital Transfer summary

Assist patient with antibacterial shower or bath; assure patient is in proper attire

Secure patient valuables in safe or with family

Take patient’s vitals and administer medications

Empty Foley or colostomy, remove catheter, and/or have patient use bathroom

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Remove IVs

Unhook oxygen from room supply, and attach to transportable oxygen tank

Double-check that patient has been NPO for appropriate length of time

Answer family questions

The process of retrieving an inpatient after the patient is put on call for surgery is supposed to

take approximately 20 minutes as stated by the OR clinical manager, but is reported to take up to

an hour by hospital staff. According to the pre-op charge nurse, the NAs almost always receive

the transport log slip within 15 minutes. Also, the Intrahospital Transfer summary is reportedly

not always completed by the time the NAs go to get the patient; therefore the NAs have to wait

in the patient’s room until it is filled out. A nurse at the Post-Anesthetic Care Unit (PACU), who

previously worked at the University of Michigan Cardiovascular Center (CVC), stated that when

she worked on the floor, getting an inpatient ready in time was difficult because she was unsure

exactly when the NAs from pre-op or PACU were expected to arrive. She did not want to take a

patient off the monitor or the oxygen supply, in the event that patient was not picked up soon.

Aside from this, she also had additional patients to tend to. Another factor causing bottlenecks in

the process, according to staff, consisted of patients who were delayed while saying goodbye to

their families.

The UH clinical manager told the project team that while 20 minutes is an ideal process time, the

OR staff are primarily concerned with process times that exceed 45 minutes. This project

focused on determining the root cause of the long process times at UH and providing

recommendations to improve the efficiency of inpatient flow to OR on the day of surgery.

Key Issues

The key issues affecting the project included:

OR and pre-op staff dissatisfaction with the length of time required for an inpatient to be

transported to pre-op

Inpatients meeting certain criteria to be transported to the OR; various forms and

information must be prepared

Inpatients not always ready to be taken to the OR when the pre-op NAs arrive

Goals and Objectives

The primary goal of this project was to increase the efficiency of inpatient flow to operating

rooms on the day of surgery. To achieve this goal, the team analyzed the current inpatient flow

process including quantifying the length of time needed for inpatients to be brought to the OR,

and identifying common delays and problems in the process. The team compared the current

state of the UH-OR to similar processes within the University of Michigan Health System

(UMHS), including C.S. Mott Children’s Hospital and the UMHS Cardiovascular Center. With

this information, the team developed recommendations to:

Reduce time taken for inpatients to be retrieved from their floor and brought to the OR

Improve consistency and quality of all steps completed in process

Increase staff confidence and satisfaction in process of inpatient flow

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Project Scope

The project scope included:

Analysis of inpatient flow at the UH-OR, beginning when an inpatient is put on-call for

surgery, and ending when the inpatient arrives at pre-op.

Observation of floor procedures for preparing an inpatient on units 4A/4D (NICU), 4B

(Surgery), 5A (Ortho/Trauma), 5C (Surgery), and 5D (SICU); these five units have the

highest volume of inpatients requiring surgery

Observation of weekday processes

Comparison of inpatient flow at C.S. Mott Children’s Hospital (Mott) and the UMHS

Cardiovascular Center (CVC)

The project scope excluded:

Analysis of inpatient flow at UMHS departments other than Mott and CVC

Observation of weekend processes, as they primarily consist of emergency operations

Analysis of outpatient procedures

PROJECT METHODOLOGY

The project team analyzed the current inpatient flow to the OR preoperative area in UH. The

project involves UH-OR, pre-op and PACU staff, and nursing staff on inpatient floors. The

project approach consisted of three primary phases: data collection, data analysis, and

recommendations.

Data Collection

Data collection for this project included interviews and surveys, job shadowing, time studies, and

use of historical data.

Interviews

The team interviewed hospital employees to identify problems in the process and opportunities

for improvement. The project team interviewed the following staff members:

Pre-op charge nurse

Four pre-op nursing assistants

Two pre-op clerks

Six floor unit nurses

Three floor unit charge nurses

Additionally, the team met with the nurse manager at Mott and the clinical manager at the CVC

to understand and compare those departments’ processes for bringing inpatients to pre-op. The

clinical nurse manager at UH informed the project team that Mott and the CVC have similar

processes to that at UH, but with shorter process times. The team felt studying the processes at

Mott and CVC would provide insight into process improvements at UH.

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The team also developed two questionnaires for the floor nursing staff regarding the current

process of inpatient flow, and collected responses from nursing staff in NICU, Ortho/Trauma,

SICU, and 4B and 5B Surgery. Fifty-one responses were obtained from the first survey, and

eight from the second survey. The questionnaires can be found in Appendix A and Appendix B.

Job Shadowing

The team shadowed staff to fully understand the flow and steps necessary to complete the

process of an inpatient arriving in pre-op. The team shadowed and observed pre-op clerks, NAs,

and floor nurses. Shadowing pre-op staff included following the process of inpatient flow,

beginning with the OR placing a patient on-call to the inpatient arriving in pre-op. The team

identified all steps in the portion of the process that takes place in pre-op and noted potential

problems and delays. In addition to shadowing pre-op staff, the team observed floor unit nurses

from the time their patient is put on-call, to the time their patient is retrieved by pre-op NAs.

Time Studies

Time studies were used to detail the time taken for each step of the inpatient flow process. The

project team conducted approximately 25 hours of time studies, which included quantifying the

time required to complete each step of the process identified through job shadowing. Time study

data was collected by the team in pre-op and on the unit floor (20 cases). The data collection

form created and used by the team is included in Appendix C. The time studies of the process

identified bottlenecks and helped the team develop final recommendations. The time study

results also provided a quantifiable measure of the current state to compare to the team’s

recommended improvements. Also, for some cases observed by the team, not each step of the

process was recorded, resulting in incomplete total process times. All recorded times were

included in the data analysis; for this reason some time study data will have varying sample sizes

lower than the total of 20 observed cases.

Historical Data

The project team requested historical data from the Applications Systems Analysis project

supervisor in the Anesthesiology Department. The data received by the team consisted of the

time an inpatient was put on-call by the OR, and the time that the patient arrived in pre-op.

However, this data included all patient cases - whether inpatient (IP), outpatient (OP) or admitted

patient (AP) - across all the facilities of the University of Michigan Health System. As a result,

the data was first filtered to include only the cases from UH and then sorted to include just the

inpatient cases. The filtered data consisted of 157 cases that occurred from September 1, 2010 to

November 1, 2010. This data also included cases from Mott and the CVC, which were sorted

and compared to times at UH. The historical data received by the team is included in Appendix

D.

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Data Analysis

The team observed the process over several weeks and analyzed the collected data to develop a

flow chart of the current state of inpatient flow. Using this flow chart, time study data, historical

data, and interview responses, the team identified aspects of the process that could be shortened,

eliminated, or improved upon. Furthermore, the team developed recommendations to ensure a

more efficient process for patient transport to the preoperative holding area.

FINDINGS AND CONCLUSIONS

After analyzing data collected through interviews, job shadowing, times studies, and historical

resources, the project team has come to the following conclusions.

Process Flow

Through observations and job shadowing, the team identified the steps of the inpatient flow

process, from the time OR places an inpatient on call to the time the inpatient arrives in pre-op,

and created a flow chart of the process. The process steps are:

1. The OR puts the inpatient on call; the name of the patient is highlighted in red on the

central pre-op monitor

2. The charge nurse at pre-op is paged and notifies the pre-op clerk that the inpatient has

been put on call

3. The pre-op clerk calls the floor to alert the inpatient’s nurse that the patient is on call and

will be picked up in 20 minutes. Additional information about the patient is also

requested consisting of special needs for transport. (If the patient’s nurse is not available,

the unit charge nurse on that floor is paged.)

4. The pre-op clerk fills out an inpatient transport information slip and posts the slip for the

pre-op NAs

5. On the floor, the inpatient’s nurse prepares the patient and fills out the Intrahospital

Transport Summary report. Inpatient preparations include dressing, notifying family,

taking vitals, and assisting with the bathroom.

6. The NAs read posted inpatient slip and go to the floor to retrieve the patient.

7. The floor nurse transfers the patient to the care of pre-op nurse, which includes handing

off intrahospital transfer form and flow chart. (If the patient is not ready, the NAs wait; if

the patient will not be ready soon the NAs call the pre-op charge nurse and ask if they

should wait or go back to pre-op).

8. The NAs transports patient to pre-op.

A flow chart of the inpatient flow process is shown in Figure 1.

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Figure 1: Flow chart of process flow from time OR puts inpatient on call to time inpatient

arrives in pre-op

The flow chart in Figure 1 shows that the process takes place in two primary locations: pre-op

and the inpatient’s floor. The process is often dependent on the preparation status of the

inpatient when the NAs reach the floor. If the patient is not ready to be transported to pre-op, the

NAs must wait until all necessary tasks are completed. There are cases during which the patient

will not be ready in a short amount of time, causing the NAs to return to pre-op and come back

later to pick up the patient; through a survey, 12.5% of floor RNs reported such cases. One nurse

commented that this happens with one in ten patients due to last minute requests made by the

patients.

Floor Process

The team observed the process that occurs on the floor to prepare an inpatient, and interviewed

RNs regarding the process. Through a questionnaire distributed by the team, eight out of eight

RNs responded that there is no standard process on their unit for preparing an inpatient for pre-

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op. The order of tasks completed depends on the RNs preferences. In the same questionnaire,

seven RNs responded with the times taken to complete the necessary steps to prepare an on-call

inpatient; Table 1 shows the results. As seen by Table 1, properly dressing the patient in a gown

and storing personal belongings take the least time. Alternatively, saying goodbye to family and

using the bathroom are attended to last.

Table 1: Survey results of time taken for RN to complete tasks. November 2010, n=8

Time before task completed

from time pt. put on call

Percentage of RNs with same

response

Put on Gown 0-2 minutes 71%

Personal Belongings 0-2 minutes 86%

Medications/IV 3-5 minutes 67%

Paperwork 3-5 minutes 67%

Family 9-11 minutes 67%

Restroom/Catheter 9-11 minutes 100%

Certain steps are required before an inpatient can be transported to pre-op; the RN can complete

these steps at various times in the day. Five RNs interviewed by the team expressed that most

tasks could be tended to before the patient is put on call. However, this is dependent on whether

the RNs know their patient is scheduled for surgery a sufficient amount of time before the patient

is put on call. Exceptions to this include removing catheters and having the patient use the

bathroom, or unhooking the patient from monitors, IVs, and the oxygen supply; which all have to

be done shortly before the patient is transported.

Through interviews and observations by the team, it is apparent that there is no standardized

process on the floor units for preparing an inpatient for surgery. The process order of completing

preoperative tasks is up to the discretion of the floor nurses. The lack of standardization may be

problematic due to the infrequency of inpatients scheduled for surgery in some of the units. In

the team’s questionnaire, 67% of RNs stated they have less than 1 patient per day with a

scheduled procedure, and another 27% stated they have approximately 1 patient go to pre-op

daily (51 RNs were surveyed).

Process Time

The project team analyzed the process times from both the historical data and the time studies

collected by the team. Figure 2 shows the frequency of cases with varying process times of the

historical data received by the team. The histogram in Figure 2 indicates that 2% of the cases (3

out of 157) had process times over two hours. The team discounted these three outlying data

points in their analysis. As reported by the pre-op charge nurse, cases with such long process

times are exceptional instances and rarely occur. In all subsequent analyses of the historical

data, the team used only the 154 samples with times under two hours.

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Figure 2: Frequency of process times from historical data, September 1, 2010 - November 1,

2010, n = 157

The historical data was analyzed and used to verify the time studies collected by the project

team. The summary of the historical data versus the data collected by the project team is shown

in Table 2 below, and is represented graphically in Figure 3.

Table 2: Summary of historical data and collected data

Historical Data

September - October 2010

Collected Data

October - November 2010

Average Process Time 51 min 45 min

Maximum 1 hr 51 min 1 hour 13 min

Minimum 18 min 30 min

Stadard Deviation 17 min 17 min

Sample Size 154 15

As seen in Table 2, the historical data yielded an average process time of 51 minutes, which is 6

minutes greater than the total mean time from the team’s collected data. The discrepancy

between times can be attributed to the inaccuracies of the data entry in pre-op. Preoperative

clerks mentioned the possibility of a delay between the actual time an inpatient reaches pre-op

and the time the pre-op charge nurse enters the information into the database.

14

0

20

40

60

80

100

120

Minimum Average Maximum

Min

ute

s

Historical Data, September - October 2010, n = 154

Collected Data, October - November 2010, n = 15

Figure 3: Comparison of historical data and collected data

The time study data revealed the average process time is 45 minutes (sample size of 15). As

previously noted, the ideal time given by the pre-op clinical manager is 20 minutes. The team

created a value stream map showing the average times for the major steps in the process, shown

in Figure 4.

Figure 4: Value stream map of inpatient flow process, October - November 2010.

As exhibited above, actual process times are two and a half times greater than the ideal process

time of 20 minutes, as well as being greater than the observed process times found in the time

studies.

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Furthermore, the CVC had eight inpatient cases throughout September and October; the

historical data showed that patients arrived in pre-op approximately 36 minutes after being put

on call. Similarly, Mott had four inpatient cases in this time frame, which took an average of 38

minutes per case. Since process times at Mott and the CVC are substantially lower than at UH,

the team met with staff members from each to discuss their respective processes to better that at

UH.

Process Delays

Through interviews, time studies, and job shadowing performed by the project team the

following issues regarding the inpatient flow process were identified:

In 61% of cases observed by the team, inpatients are unprepared to go to pre-op due to

unfinished tasks at the time the NAs arrive on the floors, as displayed in Figure 5.

Common tasks still required completion in order for inpatients to be ready, which can be

seen in Figure 7.

A lack of communication exists between the preoperative area and the inpatient units

regarding the time that NAs will arrive.

Similarly there is little communication between the OR and the inpatient units. When a

patient is added on to the surgery schedule or the surgery time changes, the floor nurses

may not be notified until the pre-op clerk calls to inform them the patient has been put on

call.

As previously mentioned, Figure 5 shows the proportion of cases observed by the team in which

the inpatient was ready, compared to times the inpatient was not ready when the NAs arrived

from pre-op. Additionally, Figure 6 exhibits how the preparedness of the patient affects the

process time. When the RN still needs to complete tasks after the NAs reach on the floor, the

NAs must wait until the tasks are completed. If the additional length of time necessary to finish

preparing the patient is substantial, the NAs return to pre-op until the patient is ready. NAs

reported to the team that if they have been waiting on the floor for longer than 10 minutes, they

call pre-op for direction on whether to stay or return later.

Figure 5: Percentage of observed cases Figure 6: Comparison of time the NAs spend

where the inpt. was or was not ready to be on floor when a patient is ready, compared

transported to pre-op, to when patient is not ready,

October-November 2010, n = 18. October-November 2010, n =17.

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Figure 6 compares the time duration spent on the floor by NAs in cases where the patient is

ready versus cases where the patient is not ready; the times are 4 minutes and 10 minutes,

respectively. Though the difference in times is not substantial, the cases with unprepared

patients have a standard deviation of 5 minutes. This variation, coupled with the small sample

size collected by team, indicates that a patient who is not ready may have a significant effect on

the total process time.

The team surveyed 51 unit nurses regarding reasons inpatients were not ready when the NAs

came to retrieve them. Figure 7 shows the most common responses regarding what tasks are

often not completed when NAs arrive on the floor.

0%10%20%30%40%50%60%70%80%

Bathroom Proper Dress

Family Vitals Labs Test Results

Pe

rce

nta

ge o

f R

N r

esp

on

ses

Uncompleted Task

Figure 7: Tasks that are not completed when NAs arrive, November 2010, n=51

In this survey conducted by the team, RNs were also asked how much time was necessary for

them to prepare an inpatient for pre-op. The results are displayed in Figure 8; the figure

indicates that 90% of the nurses responded that inpatient preparation could be completed within

20 minutes. With the majority of surveyed nurses in agreement, the team concluded that 20

minutes is indeed an adequate time buffer to use when putting an inpatient on call from pre-op.

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5 min29%

10 min34%

15 min27%

20 min6%

> 20 min4%

Time needed by RNs to prepare an inpatient for pre-op

Figure 8: Time needed to prepare inpatient, according to RN, November 2010, n=51

Misinterpretations within the Hospital

Specific instances have been observed where a lack of communication has led to oversights in

the current process. Additionally, approximately 83% of surveyed nurses expressed that

communication methods need improvement. Every so often, an inpatient needs to be added to

the surgery schedule after that day’s schedule has already been made and released; this patient is

referred to as an “add-on.” The OR does not always document this addition in CareLink, the

hospital’s online charting system. Thirty-seven percent of nurses surveyed stated that they are

rarely informed of OR schedule changes (greater than 70% of the time); another twelve percent

stated they are only notified about half of the time. Due to this, unit nurses are unaware when

one of their patients is scheduled for surgery that same day; nurses likely only find out when the

pre-op clerk calls to say that patient has been put on call which does not give nurses adequate

time to get the patient ready. Therefore, delays occur in getting the patient down to pre-op, as

the nurse might have more pressing issues to attend to.

Similar miscommunications occur quite often; pre-op could be waiting for a patient who has

actually been discharged, but the discharge had not been documented online. It was also

observed on two separate instances where a patient had already arrived in pre-op, but pre-op

nurses were unaware of this because the patient arrivals had not been documented on the central

pre-op data screen.

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Comparable Processes within the Health System

Upon interviewing the Mott Nurse Manager and the CVC Clinical Manager, the team found that

both hospital departments have similar, though not identical, processes as UH. Staff at both Mott

and CVC expressed that they have inpatient throughput times quicker than those at UH, possibly

due to small changes each has made.

Cardiovascular Center

The main differences between the process for CVC and UH are summarized as follows:

The preoperative technicians (PT) in the CVC leave the CVC preoperative area 15

minutes after the patient has been put on call to retrieve the patient.

It was discovered that patients frequently did not know the details of the procedure they’d

soon be receiving. Therefore, the CVC has a nurse visit their patient the night before that

patient’s procedure. The nurse describes the procedure and gives details such as

approximate time of surgery, length of time until completion, and name of the surgeon.

Multiple benefits arose from such a change; patients who are aware of their surgeries can

have any questions answered. Likewise, nurses are aware of their patient’s procedure,

and the time at which that patient is expected to leave for to pre-op. This change reduced

delays resulting from patients requesting to speak with their doctors after they’ve been

put on call for surgery.

The CVC Clinical Manager expressed that the process time for getting inpatients to pre-op is

approximately 35 minutes. Delays in the CVC process are similar to those at UH; inpatients may

not be brought to pre-op on time because they haven’t showered yet, or are improperly dressed,

or because the nurse is unaware that the patient was scheduled for surgery.

C.S. Mott Children’s Hospital

Mott recently made changes to its process for retrieving inpatients for pre-op. Before the

changes, Mott had a similar process to UH, in which a patient was put on call by the OR clerk

one hour before being transported to pre-op. The nurse manager at Mott expressed that this

process led to long and undesirable lead times. After analyzing the current process, Mott made

various to changes, which included:

The “on-call” period for patients was eliminated; RNs are notified that PTs will be up

immediately to get patient.

Patients are sent despite completion of consent forms, documentation, or labs. The floor

nurse only completes vitals, confirms NPO, and documents weight and allergies before

sending patient.

The OR sends for patients 45 minutes before estimated arrival time at pre-op.

All PTs carry walkie-talkies; they are notified via walkie-talkie by the OR clerk to

retrieve patient.

19

The implemented changes have decreased the process time to approximately 16 minutes, as

stated by the nurse manager. Though Mott has experienced a decrease in lead time for getting

inpatients to pre-op, delays in the process still occur. The nurse manager at Mott explained that

the longest delays involve parents; these delays include saying good-bye and waiting until

parents arrive to inpatient units before sending patient. The Mott project proposal for these

changes is included in Appendix E.

Process Comparison

Table 3 summarizes the main differences between the inpatient flow processes for UH, Mott, and

CVC.

Table 3: Comparison of departmental processes for inpatient flow from floor to pre-op

UH CVC Mott

Process time

(From OR on call to arrival

in pre-op)

45 min 35 min (estimated by

CVC clinical

manager)

16 min (reported by

nurse manager)

On call time length 20 min 15 min 0 min

Patient transporter NA PT PT

How patient transporters

are notified

Posted slip Schedule Walkie-Talkie

Main delays, issues ● Inpatient not ready

on floor - bathroom,

forms, correct attire

● Inpatient not ready

on floor - bathroom,

forms, correct attire

● Family issues,

mostly parents

● RN unaware of

inpt. surgery, and/or

surgery time

● RN unaware of

inpt. surgery, and/or

surgery time

● Family issues

Additional communication

elements

Pre-op reviews PTs always carry

Walkie-Talkies

The team used the comparisons described above to develop recommendations for process

improvements for UH.

20

Figure 9: Ishiwaka (Fishbone) diagram outlining primary causes of long process times

The Ishiwaka diagram in Figure 9, above, displays the causes that result in delayed inpatient

flow times at UH, and the effect that the delays have on the system. The four factors listed all

contribute to delays in the system. Measurement and materials consists of reasons such as late

CareLink updates and inconsistencies in patient transport times; personnel includes gaps in

communications across departments and the notion that unit nurses do not prioritize surgical

patients; environmental factors include that UH is a large institution, making communication

across departments more difficult; and methods and machines include a lack of standardization

of processes on the unit floors.

RECOMMENDATIONS

The UH nursing director, OR clinical manager, and select UH physicians are unsatisfied with the

current process flow of inpatients to pre-op. Additionally, the pre-op charge nurse and 87% of

floor unit nurses surveyed reported being unsatisfied with the current process, and feel it needs

improvement. The team used the analysis of data collected from interviews, job shadowing, and

time studies to develop a list of recommendations to achieve a more efficient process.

21

Standardized On-Call Times

First, the team suggests a system where the time patients are put on call is predetermined, even if

their assigned operating room is not yet available. Currently, the OR puts a patient on call when

that patient’s scheduled based on the availability of the assigned operating room. It is possible

that a patient might be put on call hours after the initially scheduled surgery time. Due to this,

nurses on the patient floors have no way of knowing when to expect their patients to be put on

call. The project team recommends a revised system where all patients are put on call at

standard, predetermined times. For example, the hospital might choose to put all patients on call

two hours before their scheduled surgery times. If a patient is scheduled for surgery at 11:30am,

the OR will put this person on call at 9:30am. The “on call times” will be specifically

documented on the surgery scheduled received by all patient units each morning. At the

beginning of their shift, unit nurses can see when to expect their patient to be put on call, and

hence, will know when to have patients ready. In the second questionnaire administered by the

team, 7 out of 8 RNs replied that it would easier to have the patient ready in time if there was a

designated on call time (the remaining 1/8 replied “maybe”).

Such a system will allow for a predetermined time of arrival of NAs to the units to retrieve the

patient. Given the documentation of the on call times, nurses will know when to expect their

patient to leave for surgery, and can properly schedule their day to allocate time to have this

patient ready to leave for the OR. Many unit nurses mentioned that NAs frequently arrive

around 7 a.m. during the shift change which presents issues; it is difficult for the nurses to have

patients ready to leave for pre-op when they also need to be reporting to the incoming shift.

Predetermined on-call times will take factors such as this into consideration. For example, the

revised system could account for shift changes and not have any on-call times between 6:45 and

7:15. Nurses will be able to outline when to administer medicine and take vitals, which will aid

in minimizing delays when the patient needs to be prepared for pre-op. Similarly, nurses will

know when to contact the pharmacy so that the patients are not waiting on medicine or IVs after

they are on-call for surgery. The patient will also be informed exactly when they will be leaving

for pre-op so they have time to speak with their family, change into proper attire, or take care of

any other personal needs. The team found that eighty percent of unit nurses felt that such a

system would allow for patients to be ready on a consistent basis.

Pre-operative Reviews

During interviews, various staff members mentioned that one recurring delay results when

patients are not aware of the details of their procedures, or still have questions for the physicians.

In either case, patients require answers before they can leave their rooms for pre-op. The next

recommendation is to have a preoperative review the day before a patient’s surgery. The

evening before a patient’s scheduled procedure a nurse would speak with the patient about the

procedure and anything related. The nurse would carry a form to fill out and leave with the

patient or the patient’s family, as proof that the patient has been informed basic details of the

surgery. This form would include information such as the following:

Details of procedure, including name of operating surgeon

Estimated time and length of procedure

Time for last solid food, and for last sip of water

Details of pre-op preparation (time of shower, personal needs, etc.)

22

This form would only be applicable to patients with scheduled surgeries (not add-ons). The team

believes it will reduce delays caused by uncertainties regarding the procedure. The patient, and

even their family, will be informed, and can plan the next day accordingly. A sampled form can

be found in Appendix G; this form was created by team based on a similar form utilized at the

CVC.

Effective Communication

The final recommendation suggests that certain means of communication are strictly enforced. It

was observed by the team, and mentioned by several staff members that OR staff, pre-op staff,

and unit staff do not communicate effectively, and that this frequently causes issues. For

example, if a patient surgery is added to the OR schedule on the day of the surgery, the change

might not be documented in CareLink, leaving no way for unit nurses to be aware of the surgery

before the time when the pre-op clerk calls to say that patient has been put on call. This gives

unit nurses inadequate time to properly prepare the patient to leave for the OR. Similarly, if a

surgery is cancelled, the message is not conveyed across all involved departments within the

hospital.

The previously mentioned gaps in communication have been observed by the project team, and

have also been voiced by hospital staff as problematic and recurring. The project team witnessed

various other miscommunications as well. Three separate instances were observed where the OR

put a patient on call, and the pre-op nurses waited so long for this person that they called the unit

nurses, who told pre-op that the patient had actually been discharged. Two cases were witnessed

where the pre-op nurse called the floors looking for a patient, only to realize that the patient was

already in pre-op.

Furthermore, the team recommends that NAs carry beepers or phones in the event changes are

made. Beepers can also be used as a method of alerting NAs when a patient has been put on call

(or, if the first recommendation is implemented, reminding them that a patient’s scheduled on

call time is approaching).

Oversights such as these can easily be avoided if hospital staff members take active

measurements to ensure more effective communication. The team believes that if these

recommendations are utilized, surgical patients will become more of a priority, and patient flow

from the units to pre-op can be much more efficient.

Future Analysis

Due to the nature of the project, the team recommends future analysis of the process; it would be

beneficial to make observations and perform time studies over a greater period of time. Data

collection of this kind requires a longer time frame due to the infrequency of scheduled inpatient

surgeries. In a survey, 67% of unit nurses stated that, on average, they have less than one

surgical patient each day; another 27% had only one scheduled surgery per day. The team also

recommends further research into a standardized process for all floor units regarding preparing

an inpatient for pre-op.

23

Expected Impact

The recommendations of the project team aim to improve the efficiency of inpatient flow to the

OR. The implementation of the team’s recommendations will result in:

Reduced time for inpatients to arrive at the OR from their respective floor

Increased efficiency of process needed to prepare an inpatient for transport to pre-op

SUPPORT RECEIVED

The project team would like to acknowledge the project coordinators, for providing guidance

throughout this project. The project clients also provided great support and assistance.

Additionally, hospital staff from the pre-op, PACU, and the floor units played pivotal roles in

assisting the team with interviews and data collection. The team also appreciates the staff

members from Mott and the CVC for their time and cooperation.

24

APPENDIX A - NURSE QUESTIONNAIRE 1 AND RESPONSES

Note: this survey was created so that questions could be left unanswered, and some could have

multiple answers. Therefore, the responses for each question may not be equal to the sample

size.

Opinions on UH-OR-IP Flow: Survey 1 Summary

November – December 2010

Sample Size: 51 Registered Nurses

1. The clerk notifies you the OR has put your patient on call. Do you tend to this patient

immediately to prepare them to go down to pre-op? Why or why not?

Summary: Most nurses say they will tend to the patient if there isn’t an emergent situation or

higher priority going on. High priorities include getting all patients their correct medications on

time, etc. They can’t always drop what they are doing to get the patient ready immediately.

“Make sure clerk tells them na3 will be up in 15-20 minutes; some nurses were under the

impression they’d be up within an hour”

2. The clerk says an NAIII will be up in 15-20 minutes to retrieve the patient. On average,

how long before you tend to the patient?

Immediately 27.5% (14)

5 min 52.9% (27)

10 min 17.6% (9)

15 min 5.9% (3)

20 min 2.0% (1)

other 3.9% (2)

3. What actions need to be performed before the patient is ready to leave for pre-op? (i.e.

take vitals, check H&P, change dressing, fill out paperwork, ..)

Summary: Transport hand-off form, Patient valuables to security or family at bedside, Vitals,

empty Foley or colostomy or have patient use bathroom, double-check that they have been NPO

for appropriate length of time, answer family questions

“the pt needs to have ID checked, have current vitals, i & O recorded and totaled, the pt needs to

be aware and the family notified if the pt desires the pt needs iv access, the or checklist/transfer

sheet filled out, the consent needs to be in the chart or MD made aware it is not there, if pt is

uncomfortable try to make them comfortable answer questions and educate pt of procedure to be

performed and check that the pt is going for correct procedure, if a dressing needs changed it

should be done, pt should have hibiclens shower when ordered and iv fluids, running if ordered

and pre op meds obtained to send with pt to or if thymo is ordered it should be ordered up from

pharmacy, advance directive and h& p should be present and completed if possible pts

belongings should be gathered and labeled if pt isn't coming back to room post op, items should

be sent to security if needed, jewelry should be removed any specimens and labs should be

25

obtained as well as any other pre op work up procedures such as chest X-rays and EKGs when

applicable, another id check when pt is taken to or”

4. On average, how long do these actions take to complete?

5 min 30.6% (15)

10 min 36.7% (18)

15 min 28.6% (14)

20 min 6.1% (3)

Longer 4% (2)

5. What are common reasons the patient is not ready to leave for pre-op?

Na3 arrives too fast 63.3% (31)

Need vitals 14.3% (7)

Need labs 10.2% (5)

Need test results 4.1% (2)

Pt not npo 6.1% (3)

Bathroom 77.6% (38)

Not in right attire 28.6% (14)

Family 28.6% (14)

Other (eg don’t know about procedure) 28.6% (14)

6. The clerk states an NAIII will be up in 15-20 minutes to retrieve the patient. Would you

operate differently if they were to come up immediately after you have been notified the

patient has been put on call?

Summary: Majority of people said no. Some said they’d like a more accurate time frame as to

when exactly na3’s will be there so they can juggle tasks accordingly.

7. On average, how many of your patients go down for surgery each day?

<1 67.3% (33)

1 26.5% (13)

2 4.1% (2)

3 4.1% (2)

8. How frequently are your patients not ready to leave the room immediately when the

NAIII arrives?

7/31 said frequently – like 75% of the time or more

16/31 said rarely

3/31 said about half the time

The rest left comments on things that might occur

26

9. Do you receive a copy of the OR schedule every morning? Is there ever a case where you

are unaware your patient has a scheduled surgery? Why is this?

Summary: Charge nurse receives a copy of the schedule; every nurse doesn’t get their own

individual copy. For the most part every nurse knows what to expect but the schedule comes out

the night before. Sometimes they don’t know about emergencies, add-ons, or scheduled

changes.

“Make sure that time changes in the schedule or significant holdups are communicated between

OR and unit floors.”

10. Do you have any final thoughts or comments? Your answers will be kept confidential so

please offer honest feedback. Your responses are very important to this project, and we

appreciate your time.

“It is always so crazy when transport comes at 7am because that is right during report and so the

new nurse coming on to shift doesn't always know what is happening and if everything has been

completed.”

“If the clerk says the transporter will be here if 15-20 min, I can have the pt ready. But when the

transporter comes up right away after the call and I still think I have 20 mins, that's a problem”

“It seems as if the expectation is that the nurse drops everything to accommodate the OR. We

have multiple things pressing on us too, it isn't always so easy to drop everything I am doing to

tend to my one going to OR”

“change of shift presents issues”

“At times it is frustrating because the OR or those who come up think I can just wait for them to

come and get the patient. Just because they call me 15 or 20 minutes early it does not mean I can

get into that patient in a timely fashion due to that patient needs or other patient needs at that

time. I figure I do have a few minutes to finish what I am doing.”

“PACU should fill out CareLink - If doctor reschedules/cancels, as a nurse, it would be great to

know and not look dumb and uncommunicative to your patient. Annoyed when you put them on

call, and then never get them because they have been bumped, but nobody called. If a doctor

reschedules/cancels, as a nurse, it would be great to know and not look dumb and

uncommunicative to your patient. Annoyed when you put them on call, and then never get them

because they have been bumped, but nobody called.”

“Instead of telling RN or unit pt is being placed on call when OR (NAIII) is on the way, just tell

the unit they are on their way.”

“Clerks need more training on their role with patient handoffs and that they can answer questions

regarding the pt once they have the patient hand off sheet in front of them. RN should be getting

the pt. ready and can freq get pulled out to answer questions of the OR. The time that the NA

comes up to get a patient for a scheduled surgery (obviously emergency surgeries are different)

27

should be much more consistent. If RN's know what the time will be and it is consistently

followed then it will be easier to hold each accountable to the protocol.”

“Good communication is the key to success. This is a large institution, and communication is

poor.”

“Specify strict NPO, NPO x meds, 1/2 dose long acting insulin. Have physician team share

info/plans with patient so they are prepared too! Encourage pt readiness to get toileting tasks

done before time to go.”

28

APPENDIX B - NURSE QUESTIONNAIRE 2 AND RESPONSES

Opinions on UH-OR IP Flow: Survey 2 Summary

December 2010

Sample Size: 8 Registered Nurses

1. After a patient has been put on call, how long does it take to help the patient with

the following:

-Medications/IV: 66.7% said 3-5 minutes

-Restroom/Catheter: 100% said 9-11 minutes

-Gown: 71.4% said 0-2 minutes

-Personal Belongings: 85.7% said 0-2 minutes

-Family: 66.7% said 9-11 minutes

-Paperwork 66.7% said 3-5 minutes

2. A patient has been put on call for surgery by the OR. Is there a standard process

throughout your unit for getting this patient ready? Is there a particular order you

follow?

No standard process; order depends on nurse’s personal preferences

3. Has it ever occurred where the NAIII arrives and the patient will not be ready for a

significant length of time (i.e. too long for the NAIII to wait, so they return to pre-op

without the patient)?

87.5% said no, 12.5% said yes

4. If you answered yes to the previous question, please provide detail. How frequently

does this happen? What were the circumstances?

“About 1 in 10 patients going to the OR does this happen. Usually the pt. decides last

minute that they have a lot of things that need to be done (restroom, pain meds, etc.)”

5. If a patient's surgery gets rescheduled or canceled, or there is a case that is added on

to the daily schedule, how are you notified of this? How much time are you given

notice?

“Primary service or SCC usually informs us of this...in my experience, OR rarely does. It

seems the RN is the "last to know".”

“through the charge nurse, the notification depends on the rescheduling reason”

“We are not, usually have to call and ask why a patient hasn't been picked up”

“by calling down to OR”

6. What percent of the time are you not notified of cancellations, add-ons, or

rescheduled surgeries?

50% said they are always notified

12.5% said 4/10 times they are NOT notified

12.5% said 7/10 times they are NOT notified

12.5% said 8/10 times they are NOT notified

12.5% said 9/10 times they are NOT notified

29

7. Would it be easier for you if, at the beginning of your shift, you knew exactly what

time a patient would be put on call for surgery, and what time the NAIII would

arrive to pick up the patient?

87.5% said yes

12.5% said maybe

8. What changes do you feel could be made to the current process to minimize the

amount of time it takes for patients to get down to pre-op after being put on call?

What recommendations would you make?

“They should have a notification system that pops up just like when new labs have been

read for the patient.”

“Communication”

“Have plenty of notice of what time the surgery will be and what time they will be put on

call.”

9. How satisfied are you with the current process for getting patients down to pre-op

after they are put on call by the OR?

12.5% are satisfied

37.5% are somewhat satisfied

37.5% said it needs improvement

12.5% said very dissatisfied

30

APPENDIX C – DATA COLLECTION FORM

31

APPENDIX D – HISTORICAL DATA

Dept On Call Preop Time Elapsed Time Dept On Call Preop Time Elapsed Time

CVC 9/10/10 10:56 AM 9/10/10 11:37 AM 0:41:10 UH 9/14/10 12:09 PM 9/14/10 1:32 PM 1:23:17

CVC 9/16/10 8:53 AM 9/16/10 10:07 AM 1:14:09 UH 9/14/10 2:01 PM 9/14/10 2:39 PM 0:38:31

CVC 9/24/10 8:30 AM 9/24/10 9:24 AM 0:54:21 UH 9/15/10 5:15 PM 9/15/10 7:05 PM 1:50:39

CVC 10/1/10 10:04 AM 10/1/10 10:29 AM 0:25:19 UH 9/15/10 9:22 AM 9/15/10 10:16 AM 0:54:05

CVC 10/5/10 3:12 PM 10/5/10 3:42 PM 0:30:42 UH 9/15/10 2:54 PM 9/15/10 3:48 PM 0:54:51

CVC 10/14/10 8:46 AM 10/14/10 8:54 AM 0:08:11 UH 9/16/10 1:58 PM 9/16/10 2:56 PM 0:58:57

CVC 10/21/10 6:10 AM 10/21/10 6:20 AM 0:10:56 UH 9/16/10 2:18 PM 9/16/10 3:23 PM 1:05:02

CVC 10/28/10 2:19 PM 10/28/10 3:03 PM 0:44:04 UH 9/17/10 8:55 AM 9/17/10 10:08 AM 1:13:51

IR 10/25/10 10:10 AM 10/29/10 6:24 AM 20:14:20 UH 9/20/10 8:01 AM 9/20/10 8:25 AM 0:24:26

MOTT 9/8/10 6:16 PM 9/8/10 6:42 PM 0:26:31 UH 9/20/10 9:58 AM 9/20/10 10:30 AM 0:32:54

MOTT 10/5/10 10:56 AM 10/5/10 11:23 AM 0:27:15 UH 9/20/10 8:45 AM 9/20/10 9:43 AM 0:58:00

MOTT 10/6/10 12:51 PM 10/6/10 1:59 PM 1:08:27 UH 9/20/10 9:56 AM 9/20/10 10:47 AM 0:51:27

MOTT 10/7/10 12:24 PM 10/7/10 12:56 PM 0:32:02 UH 9/20/10 3:22 PM 9/20/10 3:54 PM 0:32:05

UH 9/1/10 10:07 AM 9/1/10 10:52 AM 0:45:09 UH 9/21/10 9:18 AM 9/21/10 10:16 AM 0:58:46

UH 9/1/10 9:39 AM 9/1/10 10:16 AM 0:37:15 UH 9/21/10 8:39 AM 9/21/10 9:22 AM 0:43:55

UH 9/1/10 11:05 AM 9/1/10 11:47 AM 0:42:59 UH 9/21/10 8:59 AM 9/21/10 9:53 AM 0:54:39

UH 9/1/10 1:46 PM 9/1/10 2:25 PM 0:39:16 UH 9/21/10 9:39 AM 9/21/10 10:13 AM 0:34:21

UH 9/1/10 3:14 PM 9/1/10 3:43 PM 0:29:44 UH 9/21/10 12:07 PM 9/21/10 12:54 PM 0:47:00

UH 9/1/10 3:49 PM 9/1/10 4:43 PM 0:54:54 UH 9/24/10 7:42 AM 9/24/10 8:17 AM 0:35:03

UH 9/2/10 8:14 AM 9/2/10 9:08 AM 0:54:26 UH 9/24/10 9:38 AM 9/24/10 10:20 AM 0:42:51

UH 9/2/10 8:45 AM 9/2/10 9:44 AM 0:59:35 UH 9/27/10 7:50 AM 9/27/10 8:33 AM 0:43:21

UH 9/2/10 8:09 AM 9/2/10 8:55 AM 0:46:16 UH 9/27/10 12:42 PM 9/27/10 1:37 PM 0:55:01

UH 9/2/10 8:31 AM 9/2/10 9:37 AM 1:06:33 UH 9/27/10 10:59 AM 9/27/10 11:42 AM 0:43:35

UH 9/2/10 12:30 PM 9/2/10 1:10 PM 0:40:33 UH 9/28/10 7:42 AM 9/28/10 8:03 AM 0:21:43

UH 9/2/10 12:50 PM 9/2/10 1:31 PM 0:41:19 UH 9/28/10 7:56 AM 9/28/10 8:35 AM 0:39:58

UH 9/2/10 1:37 PM 9/2/10 2:20 PM 0:43:27 UH 9/28/10 8:44 AM 9/28/10 9:20 AM 0:36:21

UH 9/3/10 9:17 AM 9/3/10 10:03 AM 0:46:08 UH 9/28/10 10:44 AM 9/28/10 11:21 AM 0:37:37

UH 9/3/10 7:14 AM 9/3/10 7:55 AM 0:41:07 UH 9/28/10 2:30 PM 9/28/10 3:27 PM 0:57:19

UH 9/3/10 12:40 PM 9/3/10 1:15 PM 0:35:53 UH 9/30/10 9:26 AM 9/30/10 10:11 AM 0:45:50

UH 9/3/10 2:10 PM 9/3/10 3:20 PM 1:10:50 UH 10/1/10 10:23 AM 10/1/10 11:02 AM 0:39:38

UH 9/3/10 10:23 AM 9/3/10 11:16 AM 0:53:34 UH 10/1/10 10:08 AM 10/1/10 10:38 AM 0:30:08

UH 9/7/10 12:28 PM 9/7/10 1:09 PM 0:41:56 UH 10/1/10 10:46 AM 10/1/10 11:58 AM 1:12:48

UH 9/7/10 12:47 PM 9/7/10 1:41 PM 0:54:09 UH 10/1/10 1:00 PM 10/1/10 1:50 PM 0:50:54

UH 9/7/10 11:53 AM 9/7/10 12:50 PM 0:57:37 UH 10/4/10 8:22 AM 10/4/10 9:16 AM 0:54:44

UH 9/7/10 11:44 AM 9/7/10 12:18 PM 0:34:02 UH 10/4/10 11:16 AM 10/4/10 12:20 PM 1:04:18

UH 9/8/10 11:14 AM 9/8/10 11:49 AM 0:35:58 UH 10/4/10 2:06 PM 10/4/10 2:29 PM 0:23:28

UH 9/8/10 12:33 PM 9/8/10 1:15 PM 0:42:25 UH 10/5/10 10:38 AM 10/5/10 11:39 AM 1:01:20

UH 9/8/10 10:08 AM 9/8/10 10:37 AM 0:29:43 UH 10/5/10 10:56 AM 10/5/10 11:52 AM 0:56:01

32

Dept On Call Preop Time Elapsed Time Dept On Call Preop Time Elapsed Time

UH 9/10/10 8:58 AM 9/10/10 9:37 AM 0:39:26 UH 10/5/10 2:14 PM 10/5/10 2:45 PM 0:31:35

UH 9/10/10 1:19 PM 9/10/10 2:28 PM 1:09:10 UH 10/6/10 8:25 AM 10/6/10 9:10 AM 0:45:27

UH 9/10/10 8:08 AM 9/10/10 8:52 AM 0:44:34 UH 10/6/10 9:17 AM 10/6/10 9:58 AM 0:41:40

UH 9/13/10 11:20 AM 9/13/10 12:03 PM 0:43:55 UH 10/6/10 1:04 PM 10/6/10 2:01 PM 0:57:48

UH 9/13/10 1:03 PM 9/13/10 2:03 PM 1:00:10 UH 10/6/10 11:31 AM 10/6/10 12:07 PM 0:36:19

UH 9/14/10 7:21 AM 9/14/10 8:37 AM 1:16:54 UH 10/7/10 11:39 AM 10/7/10 12:57 PM 1:18:07

UH 9/14/10 8:29 AM 9/14/10 9:18 AM 0:49:11 UH 10/7/10 10:01 AM 10/7/10 10:51 AM 0:50:33

UH 9/14/10 12:06 PM 9/14/10 1:07 PM 1:01:22 UH 10/7/10 10:00 AM 10/7/10 10:33 AM 0:33:24

UH 10/7/10 10:32 AM 10/7/10 11:46 AM 1:14:55 UH 10/22/10 12:16 PM 10/22/10 1:00 PM 0:44:29

UH 10/7/10 1:54 PM 10/7/10 3:35 PM 1:41:51 UH 10/22/10 1:47 PM 10/22/10 2:34 PM 0:47:14

UH 10/8/10 8:02 AM 10/8/10 9:07 AM 1:05:37 UH 10/22/10 1:45 PM 10/22/10 2:56 PM 1:11:24

UH 10/8/10 8:07 AM 10/8/10 9:17 AM 1:10:52 UH 10/22/10 11:55 AM 10/22/10 1:18 PM 1:23:39

UH 10/8/10 8:00 AM 10/8/10 8:31 AM 0:31:28 UH 10/22/10 3:52 PM 10/22/10 4:38 PM 0:46:51

UH 10/8/10 7:23 AM 10/8/10 7:52 AM 0:29:44 UH 10/25/10 10:51 AM 10/25/10 11:40 AM 0:49:42

UH 10/11/10 12:19 PM 10/11/10 1:17 PM 0:58:04 UH 10/26/10 8:28 AM 10/26/10 9:03 AM 0:35:26

UH 10/12/10 8:06 AM 10/12/10 8:52 AM 0:46:55 UH 10/26/10 9:55 AM 10/26/10 10:42 AM 0:47:44

UH 10/12/10 12:36 PM 10/12/10 1:28 PM 0:52:09 UH 10/26/10 8:31 AM 10/26/10 9:20 AM 0:49:55

UH 10/12/10 11:06 AM 10/12/10 12:15 PM 1:09:20 UH 10/26/10 7:28 AM 10/26/10 8:00 AM 0:32:23

UH 10/12/10 9:15 AM 10/12/10 9:54 AM 0:39:49 UH 10/26/10 10:15 AM 10/26/10 11:08 AM 0:53:09

UH 10/12/10 11:05 AM 10/12/10 12:03 PM 0:58:50 UH 10/26/10 9:12 AM 10/26/10 10:02 AM 0:50:15

UH 10/12/10 12:41 PM 10/12/10 1:36 PM 0:55:29 UH 10/26/10 11:41 AM 10/26/10 12:30 PM 0:49:05

UH 10/12/10 4:18 PM 10/12/10 5:33 PM 1:15:07 UH 10/26/10 12:50 PM 10/26/10 1:53 PM 1:03:47

UH 10/12/10 4:37 PM 10/12/10 5:20 PM 0:43:03 UH 10/27/10 8:54 AM 10/27/10 9:33 AM 0:39:36

UH 10/13/10 7:44 AM 10/13/10 8:24 AM 0:40:08 UH 10/27/10 1:14 PM 10/27/10 2:23 PM 1:09:23

UH 10/13/10 10:29 AM 10/13/10 11:34 AM 1:05:07 UH 10/27/10 1:18 PM 10/27/10 1:56 PM 0:38:46

UH 10/13/10 8:57 AM 10/13/10 9:39 AM 0:42:06 UH 10/27/10 1:39 PM 10/27/10 2:38 PM 0:59:36

UH 10/13/10 11:07 AM 10/13/10 12:04 PM 0:57:13 UH 10/27/10 3:22 PM 10/27/10 4:09 PM 0:47:37

UH 10/13/10 12:21 PM 10/13/10 1:17 PM 0:56:39 UH 10/28/10 8:41 AM 10/28/10 9:31 AM 0:50:33

UH 10/13/10 3:36 PM 10/13/10 4:54 PM 1:18:23 UH 10/28/10 8:40 AM 10/28/10 10:00 AM 1:20:14

UH 10/13/10 10:53 AM 10/13/10 11:38 AM 0:45:51 UH 10/28/10 8:52 AM 10/28/10 9:56 AM 1:04:52

UH 10/14/10 10:28 AM 10/14/10 11:06 AM 0:38:17 UH 10/28/10 11:22 AM 10/28/10 12:35 PM 1:13:01

UH 10/14/10 11:30 AM 10/14/10 12:04 PM 0:34:41 UH 10/28/10 10:43 AM 10/28/10 12:02 PM 1:19:40

UH 10/14/10 3:54 PM 10/14/10 4:13 PM 0:19:47 UH 10/29/10 7:16 AM 10/29/10 8:13 AM 0:57:15

UH 10/14/10 5:15 PM 10/14/10 5:44 PM 0:29:33 UH 10/29/10 9:41 AM 10/29/10 10:22 AM 0:41:24

UH 10/14/10 1:57 PM 10/14/10 2:47 PM 0:50:52 UH 10/29/10 7:57 AM 10/29/10 8:49 AM 0:52:15

UH 10/15/10 7:53 AM 10/15/10 8:28 AM 0:35:29 UH 10/29/10 7:52 AM 10/29/10 8:41 AM 0:49:51

UH 10/15/10 9:17 AM 10/15/10 9:56 AM 0:39:07 UH 10/29/10 11:22 AM 10/29/10 11:59 AM 0:37:46

UH 10/15/10 1:32 PM 10/15/10 2:50 PM 1:18:39

UH 10/18/10 10:21 AM 10/18/10 11:24 AM 1:03:54

UH 10/19/10 10:34 AM 10/19/10 11:17 AM 0:43:23

33

Dept On Call Preop Time Elapsed Time

UH 10/19/10 12:51 PM 10/19/10 2:03 PM 1:12:44

UH 10/19/10 11:12 AM 10/19/10 12:43 PM 1:31:00

UH 10/20/10 10:14 AM 10/20/10 10:43 AM 0:29:33

UH 10/20/10 9:01 AM 10/20/10 9:18 AM 0:17:48

UH 10/20/10 10:53 AM 10/20/10 11:20 AM 0:27:43

UH 10/20/10 10:58 AM 10/20/10 11:45 AM 0:47:26

UH 10/20/10 2:07 PM 10/20/10 2:45 PM 0:38:41

UH 10/21/10 9:20 AM 10/21/10 9:59 AM 0:39:53

UH 10/21/10 8:48 AM 10/21/10 9:39 AM 0:51:46

UH 10/21/10 10:17 AM 10/21/10 11:15 AM 0:58:44

UH 10/21/10 11:06 AM 10/21/10 12:51 PM 1:45:20

UH 10/22/10 8:29 AM 10/22/10 9:06 AM 0:37:29

UH 10/22/10 9:38 AM 10/22/10 10:26 AM 0:48:49

UH 10/22/10 10:37 AM 10/22/10 11:01 AM 0:24:18

Note: The unique case number was also provided to the team, but has been removed due to

protected health information polices.

34

APPENDIX E – MOTT INPATIENT FLOW PROJECT PROPOSAL

The report was received on November 1, 2010 by the team from the Nurse Manager at Mott.

35

36

APPENDIX F – HISTORICAL DATA ANALYSIS BASED ON TIME OF DAY

Figure 10: Distribution of historical based on the time of day an inpatient was put on call

by OR, September 1 – November 2010, n = 154

Figure 11: Average process time of historical data separated by the time of day the

inpatient was put on call by OR, September 1 – November 1, 2010, n =154

0

5

10

15

20

25

30

35

6AM-8AM 8AM-10AM 10AM-12PM 12PM-2PM 2PM-4PM 4PM-6PM

Pe

rce

nta

ge o

f to

tal c

ase

s (%

)

Time

37

APPENDIX G – PREOPERATIVE REVIEW SAMPLE FORM

UH Preoperative Teaching Review Pt. Name______________________________________ Unit/Bed#_________________________________ Date___________________ Scheduled Procedure ________________________________________________________________________________ Service_______________________ Surgeon_______________________________________________________ Date of Procedure_______________ Scheduled Time___________ Est. Length_____________________ Approximate time you will be taken to the pre-op holding area_________________________________ Time for last solid food____________________ Time for last sip of water___________________________ Solid food includes gum, candy, mints Diabetic? Yes No If yes, diabetes is treated with _____________________________________________________________ Instructions for morning____________________________________________________________________ Pre-op Preparation Shower in: AM PM Shower with hibiclens sponge, antibacterial soap completed by________________________ Remove: Dentures Eyeglasses/Contacts Jewelry MAR Review

____Patient is not on any aspirin or aspirin products, Ibuprofen products, or any other blood thinners (Coumadin, Heparin, Plavix, etc). ____Preoperative orders are on chart. Specific meds patient will be taking:_______________________________________________________ ________________________________________________________________________________________________

Information reviewed with: Patient Family Other:_________________________ Reviewed with patient by:___________________________________________________________________________

38

APPENDIX H – COLLECTED DATA FROM TEAM TIME STUDIES

Case

# Date

Floor

Unit

OR

puts

inpt on

call

Pre-Op

clerk

calls

floor

Clerk

places

slip on

lamp

NAIII

sees

slip

NAIIIs

leave Pre-

Op for

floor

NAIIIs

arrive at

inpt

room

NAIIIs

leave

with

inpt

NAIII

arrive

at Pre-

Op

1 11/2/2010 5B 10:53 11:01 11:08 11:20 11:23 11:25 11:31 11:36

2 11/5/2010 TBICU 10:27 10:29 10:29 10:36 10:56 10:57 11:06 11:08

3 11/2/2010 5B 11:02 11:07 11:09 11:24 11:25 11:28 11:31 11:34

4 11/5/2010 8C 10:24 10:30 10:30 10:37 10:39 10:45 10:50 10:54

5 11/5/2010 5A 3:39 3:39 3:43 3:48 3:59 4:02 4:08 4:12

6 10/28/2010 8A 12:02 12:12 12:23 12:23 12:44 12:47 13:11 13:15

7 10/28/2010 7D 11:22 12:15 12:19 12:19 12:24 12:27 12:31 12:35

8 10/14/2010 8B 10:53 11:01 11:05 - 11:20 11:22 11:29 11:33

9 11/10/2010 5B - 1:47 1:52 1:59 2:11 2:14 2:19 2:25

10 11/12/2010 5A - 10:39 10:43 10:46 11:06 11:09 11:20 11:23

11 11/3/2010 7A - 1:52 2:00 2:41 2:43 2:45 2:54 2:57

12 11/3/2010 8A - 2:12 2:17 2:21 2:22 2:25 2:31 2:37

13 11/12/2010 8C - 11:07 11:10 11:25 11:37 11:41 11:50 11:53

14 11/2/2010 5A - 11:36 11:39 11:46 11:54 11:57 12:00 12:08

15 11/3/2010 5A 10:57 11:02 11:14 11:18 11:20 11:24 - -

16 11/12/2010 8A - - - - 10:30 10:34 10:47 10:50

17 11/3/2010 BICU 11:32 11:34 11:36 11:38 11:45 11:47 - -

18 11/3/2010 - 12:16 12:17 12:22 - - - - -

19 11/5/2010 4A - - - 9:34 9:36 9:38 9:42 9:49

20 11/5/2010 7B - - 11:11 11:13 11:25 11:30 11:34 11:36