Re-engineering Operating Room Flow to Improve Operational Performance
C. Daniel Smith, MD
Institute for Healthcare OptimizationHospital Efficiency Seminar
July 25, 2013
1
•No financial or other relationship with any product or treatment discussed in this talk
Conflict of Interest / Disclosure
Today’s Goals/Objectives
• Case study on variability management
• Results – objective & subjective
• Personal reflections on do’s and don’ts
• Q&A
3
Case Study Setting
4
Mayo Clinic Culture
• Fully integrated healthcare practice
• Physician lead, consensus based, committee structured
• All physicians salaried*
• No productivity-based financial compensation adjustment*
• Academic practice with expectations of productivity in all “three shields”*
5
Mayo Clinic Florida
• 214 bed hospital (21 ORs, 28 ICUs) and outpatient practice within a single complex/campus – opened in 2008
• 11,900 admissions/ year: 55% surgical
• 12,000 operations/year – complex case mix (e.g., 150 liver transplants, 1,200 NS, 900 GISurg)
• 443,500 outpatient visits annually
6
Mayo Clinic Florida - Demographics
7
Four surrounding counties 47,000
Rest of Florida 23,000
Southeastern USA 11,000
Rest of USA 7,000
International 1,000
Total 89,000
Average age - 59
55% Medicare 2010 OM – 6.7%
Mayo Clinic Florida - Staff
8
Patient Care Research Total
Staff physicians and scientists 307 41 348
Residents, fellows, students 239 85 324
Administrative and allied health 2,918 146 3,064
Total 3,464 272 3,736
CEO Imperatives
• Increase capacity with existing resources
• Leverage organization’s core values (needs of patient come first, teamwork)
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• Aggressive growth and expansion (“30% increase in volume by 2012”)
• Focus on optimization
• “Just do it”
• Rapid cycle change
Healthcare Delivery Goals
10
To provide the right care
To the right patient
At the right time
Healthcare Delivery Goals
11
To provide the right care
To the right patient
At the right time *Outcomes, Safety, Service
Healthcare Delivery Goals
12
To provide the right care
To the right patient
At the right time
VARIABILITY IS THE ENEMY
*Outcomes, Safety, Service
Variability in Healthcare
13
Clinical Variability
Professional Variability
Flow Variability
Variability in Healthcare
14
Clinical Variability
Professional Variability
Flow Variability
Natural Variability – a result of naturally
occurring processes; uncontrollable
Variability in Healthcare
15
Clinical Variability
Professional Variability
Flow Variability
Natural Variability – a result of naturally
occurring processes; uncontrollable
Artificial Variability – a function of man made
decisions; controllable
Variability Management in Our ORs
16
Variability in Operating Rooms
17
Day-to-Day
Within-Day
Variability in Operating Rooms
18
• Peaks and valleys in day-to-day volume of surgical cases
• “No one wants to operate on Monday or Friday”
Day-to-Day
Within-Day
Variability in Operating Rooms
19
• Peaks and valleys in day-to-day volume of surgical cases
• “No one wants to operate on Monday or Friday”
Day-to-Day
• On the day of surgery, changes to the OR schedule and resource allocation
• Emergencies, add-ons, delays, etc.
Within-Day
Day-to-Day Variability
Day-to-Day Variability
StaffingHospital censusSupply chain…..
Within-Day Variability – Light Day
Within-Day Variability – Busy Day
Within-Day Variability
No.
Roo
m C
hang
esElective Rooms on Day of Surgery
2009-2010
8%
Within-Day Variability
No.
Roo
m C
hang
esElective Rooms on Day of Surgery
2009-2010
8%
SafetyPatient satisfactionTeamwork….
• Prime time OR utilization <65%
• 15 FTEs of overtime every pay period
• Low surgeon and staff satisfaction with OR management and efficiencies
• Concern about absence of specialty specific teams
• Frequent disruptions of elective cases by transplants and urgent cases
• “Whatever / Whenever” culture
“Our ORs Are A Mess”
Benefit of Managing Variability
27
Patient – predictability, reliability, safety
Organization – optimize resources & throughput
Departments – collaboration, more resources
Individuals – predictable lives, teams, “flow”
Ben
efits
Operating Room Redesign
Collaboration with IHO
28
OR Variability Management Team
• Chair, Surgical Committee & Chair, Department of Surgery
• Vice Chair, Surgical Committee & Chair, Department of Anesthesiology
• Chair, Department of Ophthalmology
• Administrator, Surgery & Procedural Operations
• Director, Surgical Services
• Director, Systems and Procedures
• Financial Analyst November 2009 meets 2X weekly
Consulting with Institute for Healthcare Optimization (IHO)MVP
Managing Variability Program
MVP – Key Principles
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• Separate and isolate Urgent/Emergent (Natural Variation) from Elective (Artificial Variation) surgical cases
• Effect a predictable and consistent daily elective surgical schedule
• Minimize the number of changes to the elective surgical schedule on the day of surgery
• Optimize the ability for teams to remain intact and surgeons to work with their primary teams
Goals for MVP
• Increase throughput / utilization
• Decrease overtime
• Assure access for urgent/emergent cases
• Assure predictable and reliable elective schedule
• Optimize room flow and efficiencies
• Reduce and limit the number of same-day changes to the elective surgical schedule
31
Case Type Ave Waiting Time
A 11 minutes
B 12 minutes
C 13 minutes
D 15 minutes
E 18 minutes
Urgent/Emergent
Work-Ins ElectiveNo of Rooms: 2
Includes: Unscheduled A-E + H/L Tx Cases + prior night Es
Includes: NS, CTS, GS, Ortho C&A Work-Ins + Abdominal TxAve Room Utilization: 64.9%Ave Room Utilization:
33.5%
No of Rooms: 2
Target Utilization: 80.0%
“Opportunity”: + 1,370 Cases
No of Rooms: 15
Elective Rooms 7:30-5:00
Work-in Rooms 7:30-7:00
Staffing Model Approved
Re-Engineered ORs – Initial Plan
Within 48 hours
Urgent / Emergent (3)
Elective (16)Scheduled
Natural Variability
Artificial Variability
401 402 403 404 102 103 104 105 405 406 407 408 409 410 411 412 414 415
2000
1900
1800
1700
1600
1500
1400
1300
1200
1100
1000
0900
0800
0700
EE
EE
EE
EE
EEEE
EEEE
EE
EE
EE
EE
EE
EE EE
EE
EE
EE
EEEE
EE
EE
EE
EEEE
EEEE
EEEE
EEEE
EEEE
EE
EE
EEEE
EE
EE
EE
401 402 404 102 103 104 105 403 405 406 407 408 409 410 411 412 414 415
34
MVP Results – Time Frame
• Baseline Data
Whatever, Whenever
Nov 1, 2010 – Oct 31, 2011
Nov 1, 2009 – Oct 31, 2010
Nov 1, 2011 – Jul 31,
2012
Aug 1, 2012 – Present
Pre-MVP MVP 1 MVP II MVP III
• Full implementation
Highest compliance
35
Journal of the American College of SurgeonsVolume 216, Issue 4 , Pages 559-568, April 2013
36
Pre- MVP MVP I % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.40 -43%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee Increase adjusted) $93,929,569 $98,686,963 5%
37
Pre- MVP MVP I % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.40 -43%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee Increase adjusted) $93,929,569 $98,686,963 5%
38
Pre- MVP MVP I % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.40 -43%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee Increase adjusted) $93,929,569 $98,686,963 5%
39
Pre- MVP MVP I % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.40 -43%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee Increase adjusted) $93,929,569 $98,686,963 5%
40
Pre- MVP MVP I % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.40 -43%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee Increase adjusted) $93,929,569 $98,686,963 5%
41
Pre- MVP MVP I % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.40 -43%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee Increase adjusted) $93,929,569 $98,686,963 5%
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44239334429524619714899501
11000
10000
9000
8000
7000
6000
5000
4000
3000
2000
Observation
Indiv
idual V
alu
e
_X=6132
_X=6244
UCL=9397UCL=8806
LCL=2866
LCL=3682
Pre-MVP MVP
22
2
22
1
2
11
11
1
22
2
1
Total Patient In Room Minutes per Day (Work-In & Elective)
44239334429524619714899501
70
60
50
40
30
20
10
Observation
Indiv
idual V
alu
e
_X=42.98
_X=43.33
UCL=70.60
UCL=65.36
LCL=15.36
LCL=21.30
Pre-MVP MVP
2
2
2
1
2
1
2
22
Cases per Day by MVP Staging (Work-In & Elective)
↓ 20%
Daily Case Volume Variation
↓ 22%
Daily Surgery Minutes Variation
43
No.
Roo
m C
hang
es
Number of Changed Elective Rooms on Day of Surgery
#3 GOAL: Assure predictable and reliable elective schedule#6 GOAL: Reduce and limit the number of same-day changes to the elective schedule
↓ 69%
44
No.
Roo
m C
hang
es
Number of Changed Elective Rooms on Day of Surgery
#3 GOAL: Assure predictable and reliable elective schedule#6 GOAL: Reduce and limit the number of same-day changes to the elective schedule
↓ 69%
45
↓ 43%
415414412411410409408407406405404403402401106105104103102
1:30
1:24
1:18
1:12
1:06
1:00
0:54
0:48
0:42
0:36
0:30
0:24
0:18
Room
WO
-WI
95% CI for the MeanInterval Plot of WO-WI same specialty -October 2010
415414412411410409408407406405404403402106105104103102
1:40
1:30
1:20
1:10
1:00
0:50
0:40
0:30
0:20
Room
WO
-WI
95% CI for the MeanInterval Plot of WO-WI same specialty-Jan 2011
OR Redesign - Summary
48
• Resulted in more cases and more minutes of surgery
• More of the surgical volume done during prime time
• Added staff without increasing cost/case
• Access to OR for transplants and other urgent/emergent cases not compromised
• The number of same day changes to the elective schedule decreased significantly
• Substantial cost savings without compromise in outcomes
OR Redesign - Concerns/Barriers
49
• Too restrictive
• Hurts the high volume, two-room surgeon
• Decisions not transparent
• Clinic was negatively impacted
• Small groups couldn’t be immediately available for urgent / emergent cases
• Doing cases at the end of clinic and before 7:00 was not very appealing
• Open prime time availability was being wasted
MVP Concerns/Barriers
50
“ I say a prayer everyday that I don’t have to finish my career working under MVP”
Anonymous Surgical Chair
The Divine Barrier
51
MVP Results – Time Frame
Pre-MVP
Nov 1, 2010 – Oct 31, 2011
MVP 1
Nov 1, 2009 – Oct 31, 2010
Nov 1, 2011 – Jul 31,
2012
MVP II
• Baseline Data
Whatever, Whenever
Aug 1, 2012 – Present
MVP III
• Full implementation
Highest compliance
52
MVP Results – Time Frame
Pre-MVP
Nov 1, 2010 – Oct 31, 2011
MVP 1
Nov 1, 2009 – Oct 31, 2010
Nov 1, 2011 – Jul 31,
2012
MVP II
• Baseline Data
Whatever, Whenever
Aug 1, 2012 – Present
MVP III
• Full implementation
Highest compliance
• Opened rooms
• Over allocated Block Time
Minimal compliance
53
MVP Results – Time Frame
Pre-MVP
Nov 1, 2010 – Oct 31, 2011
MVP 1
Nov 1, 2009 – Oct 31, 2010
Nov 1, 2011 – Jul 31,
2012
MVP II
• Baseline Data
Whatever, Whenever
Aug 1, 2012 – Present
MVP III
• Full implementation
Highest compliance
• Opened rooms
• Over allocated Block Time
Minimal compliance
• Lifted overtime pre-approval
• Block sharing
• Block give back
Urgent/emergent
isolation only
4137332925211713951
14
12
10
8
6
4
2
Observation
Indiv
idual V
alu
e
_X=6.43
_X=7.48
_X=8.85 _
X=7.89
UCL=11.11UCL=10.61
UCL=12.67 UCL=12.53
LCL=1.75
LCL=4.35LCL=5.03
LCL=3.24
Pre-MVP MVP I MVP II MVP III
1
Not General Surgery
4137332925211713951
40
30
20
10
0
ObservationIn
div
idual V
alu
e
_X=16.64
_X=10.78
_X=14.13 _
X=11.16
UCL=37.84
UCL=24.31UCL=25.72
UCL=20.50
LCL=-4.56LCL=-2.76
LCL=2.53 LCL=1.81
Pre-MVP MVP I MVP II MVP III
General Surgery
MVP – Engagement &Sustainability
Variability
MVP – Engagement &Sustainability
Not General Surgery
General Surgery (maintained
MVP)
Overtime
OR Redesign – Lessons Learned
56
• Separating surgical patient flows makes sense – decrease cost / increase quality
• Fully understand and appreciate the culture and model of your practice
• Ensure proper resources are in place and functional prior to redesign implementation
• Accurate data collection is vital
• Redesign efforts should become part of your “existence”….not simply a project with a defined beginning and ending
OR Redesign – Lessons Learned
• Establish reporting metrics/tools and management metrics/tools
• Communicate, communicate, communicate – identify the key stakeholders early and at a minimum establish neutrality regarding redesign
• Plan to change the program – be careful to not change too early and don’t be too rigid (yes I mean this)
• You CAN NOT over-estimate the potential disruptive behavior this might stimulate – leaders need to create a safe place and way to support each other
Hazards of Leading of Change
58
“And one should bear in mind that there is nothing more
difficult to execute, nor more dubious of success, nor
more dangerous to administer than to introduce a new
order to things; for he who introduces it has all those
who profit from the old order as his enemies; and he
has only lukewarm allies in all those who might profit
from the new. ”
from Niccolo Machiavelli's "The Prince"
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