Joanne M. Bonnot, MSN, RN, NE-BC

Debbie L. Hoffman, EMBA, BA, RN

Jane A. Kusler-Jensen, MBA, BSN, RN, CNOR

Jamie L. Sanchez-Anderson, MSN, MBA, BS, RN

� Collaborating with Physicians:Engaging for Results

Faculty Disclosure

AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity.  Disclosures for this activity are indicated according to the following numeric categories:

1. Consultant/Speaker’s Bureau 2. Employee

3. Stockholder 4. Product Designer

5. Grant/Research Support 6. Other relationship (specify)

7. No conflict.

Jane Kusler-Jensen, Jamie Sanchez-Anderson, and Debbie Hoffman:2. Deloitte & Touche, LLP

Joanne Bonnot: 7. No conflict.

Accreditation StatementAORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

Objectives

1. Discuss key metrics within perioperative services, including first-case on-time starts, block utilization, and turnover time.

2. Discuss criteria for successful perioperative governance, including physician role and engagement.

3. Explore the necessity of cutting cost and improving perioperative efficiencies.

Polling Question:Why is Collaboration with Physicians Critical?A. Drive patient satisfactionB. Drive improved patient safetyC. Drive improved quality of careD. Drive reduction in costsE. Drive improvement in operational efficiencyF. A, B & CG. All of the above

What Has Changed? Health Care Reform Value Based Purchasing Accountable Care Organizations Bundled Payments Payment Reductions

Sources: Reference Slide #’s 1-3

CEO’s Concerns

Source: Reference Slide # 4

Surgical Services Drive Hospital Performance Major driver of revenues and costs Major driver of patient safety and quality Close multi-disciplinary functioning Major driver of patient satisfaction Major driver of advanced technology use/capital

purchasing Critical need for specialty nursing labor

Source: Reference Slide # 4

Surgery's Cost and Complexity

240 million surgeries are performed worldwide each year

50 million surgeries are performed annually in the US – 9 per person in a lifetime

7 million patients in the world a year suffer complications following surgery, and half of them are likely preventable

Cost of Surgical Errors in US: nearly $1.5 billion annually in the US

65% Hospitals Profit Margin in US: Perioperative Services is a multimillion dollar business, the OR is the revenue engine for most hospitals

Source: Reference Slide #5

Surgical Services: Engine of the Hospital

Sources: Reference Slide #6

If surgical services is the engine of the hospital it must run efficiently like a bullet train

Past Future

Perioperative Governance Perioperative GovernanceDriving Change

Polling Question: Perioperative Governance

How many people have a perioperative governance structure?(Raise your hands)

How many people think their perioperative governance structure is effective in driving change and holding surgeons and staff accountable?(Raise you hands)

Top Ten Questions to Determine if You Have An Effective Perioperative Governance

Answering “No” to any of the above indicates your Perioperative Governance is in need of an

overhaul

1. Does your governance meet regularly (monthly)?

2. Do you have high and consistent attendance?

3. Are there more surgeons on the Perioperative Governance than hospital administrators?

4. Are Perioperative Governance members respected and seen as champions across the disciplines?

5. Do members of the Perioperative Governance cycle through periodically to allow new individuals to participate?

Top Ten Questions to Determine if You HaveAn Effective Perioperative Governance (cont.)

Answering “No” to any of the above indicates your Perioperative Governance is in need of an

overhaul

6. Are governance representatives appointed based on leadership qualities rather than their organizational position?

7. Is the Perioperative Governance a productive working session?

8. Are members’ self-interest aligned with organizational and departmental mission, vision, and goals?

9. Does your Perioperative Governance make data-drive decisions?

10. Do surgeons on your Perioperative Governance understand the long-term impact of low OR utilization?

Efficient Perioperative Governance Structures Should Act with Confidence, Purpose and a Spirit of Accountability

A multi-million dollar surgical enterprise must have cohesive leadership

through an active group known as the Perioperative Governance

What does a Perioperative Governance Do?

Act as a governing body for improvement opportunities relating to Perioperative resources including:

– OR and PACU utilization– OR scheduling, block qualification, and allocation– Processes fundamental to optimal patient care and safety

Achieve the Perioperative vision through data-driven decisions

Monitor Key Performance indicators (KPI):

– Ensure KPIs have met target– Develop an action plan for variances– Champion results

Use a broad perspective to evaluate long-term strategy and sustainability of the organization

How Can Perioperative Governance Be Successful? Support from Senior Management

­ Validate the authority of the Perioperative Governance by championing its decisions and messaging its role to the organization

Clear Responsibilities

­ Have clearly defined roles designating the Perioperative Governance’s sphere of influence to manage accountability

The “Right Team”

­ Highly credible surgeons, representation from throughout the hospital, and member align their priorities with the mission, vision and goals of the organization

Characteristics of the “Right” Team Members

- Puts self interest second to organizational

- Ground in Financial Reality- Understand Quality/Safety- Politically Astute and Pragmatic

- Active Listener- Optimistic - Honorable, effective

negotiator - Skilled technician

- Champion - Accepts and values

accountability - Stays the course- Embraces change

Hospital Governance CharterName Perioperative Governance

Objectives and Goals

Set strategic direction for perioperative services at the hospital level aligned with the region / system’s strategic mission, values, and goals

Act as decision making body with authority to make operational decisions for perioperative services within the hospital

Work with patient, surgeon, anesthesia and staff to ensure high levels of satisfaction

Lead and sustain culture of change

Delegate authority to daily managers and be accessible for consult / problem solving

Monitor dashboard to triage and respond to operational issues

Own fiduciary impacts and risks

Manage internal and external communication strategies

Manage and direct perioperative operations and subcommittees at the hospital level

Participants

Meeting Schedule Monthly meeting for 1.5 hours

Sponsor Hospital CEO

Director of Operations

NursingSurgery

(Approx. 4-5)

QualityAnesthesia Finance Administration

(8­–­12­members)

• Representation­from­Supply­Chain­will­be­included­as­needed­­­­­Appointments­will­be­evaluated­annually

Day to Day Governance Charter Name Day to Day Leadership Team

Objectives and Goals

Make operational decisions for nursing, anesthesia and surgery

Execute performance improvement initiatives

Act as a role model and change agent to achieve cultural change

Match resources (staffing) between nursing and anesthesia to meet surgical demand

Manage room process in real time and coordinate patient flow

Ensure quality and regulatory measures are followed

Manage expected behaviors

Own add on accuracy, reason for cancellation and time allowable for cases

Serve as primary contact to resolve real time operational issues and make operational decisions

Participants

Triad Leadership – Supports and gives authority to Daily Operations Coordinator / Manager or Charge Designee responsible for daily operations

Director of Perioperative Nursing

Chief of Anesthesia

Chief of Surgery

Daily Operations Coordinator – Responsible for making real time decisions to manage the OR Schedule and patient flow

Meeting Schedule Brief huddles each morning to prepare for the day and ad-hoc huddles as needed

Sponsor Chair of hospital governance

Triad Leadership

Surgeons

Daily Operations Coordinator

NursingAnesthesia

Functional Responsibilities of Governance

Function Hospital Day to Day

Surgical Services Initiatives

Set strategic direction for perioperative services department Own accountability for achieving initiatives metrics Make implementation decisions for initiatives initiatives Enhance system policies / guidelines to meet hospital specific

needs; enforce policies / guidelines within the hospital Identify operational issues and variances to target metrics lign physicians and staff to Value Imperative

Serve as a change agent and execute initiatives: FCOTS Turnover Time OR Schedule Management PACU LOS

Deliver communications to frontline staff Enforce and manage policies on a daily basis

Performance Management

(Executive Dashboard)

Monitor and address variances on the Executive Dashboard Ensure KPI meet targets Develop plan of action to manage variances Champion results

Ensure accurate collection of data per established processes and guidelines

Capital, Instrument and

Supply Management

Manage and prioritize department needs for necessary capital, instrumentation and supplies

Identify on-going capital,, instrument and supply needs

Quality & Safety Monitor quality and safety metrics at the hospital level and

address any gaps in established standards Implement quality and safety initiatives

Enforce quality and safety standards Assure compliance with regulatory standards in the clinic setting

Satisfaction (Patient, Staff,

Surgeon)

Monitor satisfaction and implement initiatives at the hospital level

Manage and address areas of low satisfaction

Provide feedback to the hospital governance Manage satisfaction concerns on a real time basis

Perioperative Metrics

Perioperative Metrics

Source: Reference Slide # 7

Metric Purpose Methodology Target

Prime Time UtilizationProvides the current and historical trend of utilization of the OR during prime time hours of operation

Prime Time “Patient in Room” minutes divided by Prime Time Resource Minutes

75%(exclude TOT)

Block Utilization Provides trend of utilization of assigned blocked OR

Total Patient In-Room Minutes per block over designated block time

75% (exclude TOT)

Block Allocation Provides trend of blocked OR to increase OR efficiency

Number of operating rooms designated as block over total available operating rooms

80%(Inpatient Facility)

% FCOTS

Provides the percentage of cases that start on time, which would affect both patient and surgeon satisfaction and OR utilization

FCOTS defined as the first case of the day that starts no later than 5 minutes past the Scheduled Start Time (adjust for late start days)

Excludes any first case gaps outside of 90 minutes

95%

Turnover Time(TOT)

Provides the average length of time to turn from one surgical case to the next case

Measures the time from prior Patient Out of Room to succeeding Patient In Room Time for consecutive patients

Excludes gaps ≥ 90 minutes

IP: 20-25 minOP:15-20 min

% of Add-On Cases Provides the percentage of cases which are added to the surgical schedule after schedule close

Cases that are added to the surgical schedule after close of schedule divided by total case Volume

<10%

% of Case Cancellation

Provides percentage of cases canceled after close of schedule

Shown as a percentage of Total cases completed plus number of canceled cases < 4%

Varied View of Ideal Scheduling Needs

Ideal Scheduling Program for Surgeons

"Just have my own operating room, staff, equipment, and an anesthesiologist available 5 days a week whenever I want."

Source: Reference Slide # 8

Ideal Scheduling Program for Anesthesiologists

Source: Reference Slide #8

Two or more rooms Staggered starts Two sets of nursing and anesthesia provider staff

Ideal Scheduling Program for Nursing

Source: Reference Slide # 8

One team per room Scheduled lunch and breaks Surgeon and anesthesiologist waiting in lounge for

case starts All cases finish in time to leave by shift’s end

Ideal Scheduling Program for Administration

Source: Reference Slide # 8

Keep all rooms utilized as long as possible

You cannot effectively optimize OR productivity without addressing OR utilization and accountable surgeon block allocations

Rules of Engagement

Key questions:

Who are your stakeholders?

Who are the formal and informal leaders?

Do you have a clear understand of your data and metrics?

o Block Utilization, First Case On-Time Starts, Turnover Time

Do you have leadership support and clear team approach?

Things to consider:

Collaboration vs. Disciplinary Actions

Operational Governance vs Medical staff oversight

Office Scheduling vs Surgeon Scheduling

Future Time Management vs Daily Schedule

Block Utilization Tools

Case Study: Background SummarySt Jude Medical Center, Fullerton CA

Old Methodology Block Utilization Reports sent

to surgeons monthly Monitored TOT and FCOTS Surgeons dreaded block

utilization discussions

Reasons for Change After new EMR implementation

data became difficult to obtain Volume had Dropped Lack of diligence to adjust

Block times

We realized throughout the years the tools that we had implemented were not utilized effectively and allowed us to slip back into old practices

New Methodology Current health care reform

changes, required our organization focus on improving surgical services efficiencies

Ensuring surgeons understand getting the right size block and the right amount of time

Went from what felt like a bad report card, to being collaborative, engaging surgeons in the decision making process

For Example: seeing where physicians are utilizing time

Case Study: Process Redesign

Successful Elements to Drive Collaboration for Results 1 on 1 meetings with physicians and surgical schedulers to prioritize

opportunities for block schedule Follow up summary with administration Partnering with Anesthesia Circle of trust - patient readiness Redesign Blocks Low Lying Fruit

Started meetings to adjust blocks with surgeons who were under 50% utilization Challenging Events

Being persistent to get an appointment Gaining agreement with surgeons Flexibility, willingness to get back and review as necessary Constant Tweaks

New methodology focuses on collaboration to drive a new outcome through a continuous improvement process that will be sustainable

Physician ScorecardPurpose: present a comprehensive picture of how blocks are utilized

Block utilization trends over time Overall block utilization and total utilization by day of week

and at half an hour increment FCOTS and add-on trends

Example of Adjusting Blocks with Data

Proper Block Utilization

Block Utilization Heat Map OverviewPurpose: present a detailed block utilization at the facility level

Overview of block utilization at half an hour increment for each OR and each day of the week

Questions

References 1. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/racs-/-

icd-9-/-icd-10/defining-the-episode-of-care-average-bundled-payments-for-16-ms-drgs.html

2. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/5-points-hospital-cfos-need-to-know-about-the-bundled-payment-business-model.html

3. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/8-tips-for-hospitals-considering-bundled-payments-for-orthopedics.htm

4. Becker Hospital Review. Retrieved online from, http://www.beckershospitalreview.com/hospital-management-administration/8-key-issues-for-hospitals-and-health-systems-2013.html

5. Voight, Patrick. Presentation: Cutting Cost in the Operating Room. 2008.

6. All Free Download. Retrieved online from, http://all-free-download.com/free-photos/the_high_speed_train_picture_168538.html; http://www.freepik.com/free-photos-vectors/train

7. Milewski, F. Operating Room Utilization and Perioperative Process Flow. Premier, Inc. 2. Shoemaker, A. (2007). The High Performance OR – Elevating OR Efficiency Through Strategic OR Management. Clinical Advisory Board 3. Dempsey, C. (2009) Managing Variability in Perioperative Services, AORN,, Inc. Nov 2009, Vol 90, NO 5; 4. Reducing Avoidable Cancellation on the Day of Surgery, www.isixsigma.com

8. Surgery Management. Retrieved online from http://www.surgerymanagement.com/presentations/operating-room-scheduling.php#schsurgeon

Thank You