optimizing operating room utilization and improving ... · some improvements began prior to aeh,...

The Academy for Excellence in Healthcare The Ohio State University

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Optimizing Operating Room Utilization and Improving Discharge Times at Instituto Modelo De Cardiologia Privado SRL, Cordoba, Argentina Academy for Excellence in Healthcare IAP C-09 IMDCP Feb. 7, 2017


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Optimizing Operating Room Utilization and Improving Discharge Times

Two improvement projects help advance pioneering organization in Argentina Instituto Modelo De Cardiología Privado SRL is a private-patient institution in Cordoba, Argentina, with a strong history of cardiovascular care. From its beginning 40 years ago, when it was solely a cardiovascular center, the institution sought to offer the best comprehensive medical care by focusing on patients, incorporating the most advanced technology, and promoting the training of professionals and the development of research. The institution — owned and managed by its physicians — began adding other specialties about 20 years ago. The institution’s physician leadership wants to see the organization become the benchmark healthcare provider in Argentina against which others can measure and improve. It is seeking international accreditations and to further develop a healthcare model of value inclusive of quality and cost. To achieve those objectives, leadership has looked to implement lean practices across the care continuum. The institution began pursuing a lean transformation and process improvements approximately four years ago, at a time when, to leadership’s knowledge, there were no lean benchmark healthcare organizations in Argentina and only a handful in South America. As with many healthcare providers, initial application of lean began with processes such as pharmacy, labs, and facilities maintenance. The institution now is applying lean in patient-facing processes and engaging physicians in those implementations. “The next step in the future of medicine is process improvement, and it is going to be one of the most important things for our physicians to learn,” says Javier A. Sala-Mercado, MD, PhD, and Adjunct CMO and COO. The institution sought the support of the Academy for Excellence in Healthcare at The Ohio State University to support physicians with two major projects:

• Optimization of operating room (OR) utilization

• Improving the patient discharge process and the times to discharge.1

1 Cindy L. Grines MD, et al, “A Comparison of Immediate Angioplasty with Thrombolytic Therapy for Acute Myocardial Infarction,” The New England Journal of Medicine, March 11, 1993.

Instituto Modelo De Cardiologia Privado SRL Instituto Modelo De Cardiología Privado SRL has been operating in Cordoba, Argentina, for more than 40 years. The institution was the first cardiovascular center in the city, and now includes more than 40 specialties. With more than 300 physicians and 72 licensed beds, the institution annually cares for more than 6,500 annual admissions and more than190,000 annual outpatient visits. The institution began a cardiac rehab program in 1974 (the first in the country outside of Buenos Aires). In January 1988, the institution performed primary percutaneous transluminal coronary angioplasty (on an acute myocardial infarction), approximately five years before the practice was publicized in The New England

Journal of Medicine.1 The institution retains a strong cardiovascular focus — including coronary artery bypass graft surgery, transcatheter aortic valve replacements, and heart transplants — and has one of the best cardiology residency programs in Argentina. It is accredited by ITAES, a non-governmental organization for quality and safety accreditation in Argentina that is recognized by ISQua (International Society for Quality in Health Care).

https://go.osu.edu/AEH


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Physicians Focused at AEH Dr. Sala-Mercado was attending an American College of Cardiology Accreditation Services (formerly Society of Cardiovascular Patient Care) meeting in May 2016 when he heard about AEH and met Beth Miller, Program Director. The institution submitted a request for and received an AEH scholarship, and five physicians were trained at OSU in July 2016 — Sebastian Balestrini, Chief of Cardiac Catheterization laboratory; Javier Blanco, Chief of Perioperative Services and Vascular Surgery; Walter Quiroga Castro, Chief of Cardiovascular Post-Surgical Care; Felix Zelaya, Chief of Heart Failure; and Sala-Mercado (Adjunct CMO and COO as well as Adjunct Assistant Professor at Wayne State University in Michigan). AEH coach Susan Moffatt-Bruce — MD, MBA, PhD, and OSU Wexner Medical Center Chief Quality and Patient Safety Officer — served as the continuum improvement coach and engaged in working with the Argentinean-based physicians. “It was very important for us to have physicians involved because, traditionally, our minds are not set up to improve processes, but [rather] to study about medicine, different devices, and different medications,” says Dr. Sala-Mercado. “We don’t look to improve processes… It was very important to get out of the institution to be able to spend all of the time thinking about processes. The only thing we had to think about was what we were doing at the academy.” Despite communicating regularly at the institution, the physicians usually are focused on their own businesses and specialties; getting out of the country and together at AEH offered them the opportunity to explore the methods and merits of process improvements. During the training at AEH, the physicians learned about and improved their understanding of lean tools and techniques, such as process/value-stream mapping, the DMAIC (define, measure, analyze, improve, and control) improvement cycle, Five Whys analysis, 5W1H (what, why, who, where, when, and how) proposals/planning, and root-cause analysis. The institution physicians reported their initial findings from the two improvement projects to AEH in October 2016. Team members also have presented their findings to various departments and functions at clinical conferences at the institution “for people to start to understand that this is something that is here and will stay forever,” adds Dr. Sala-Mercado. “Change and continuous improvement is going to be part of the institution from now on, and lean methodology is going to be what we’re going to use.” Optimizing OR Utilization Since the institution’s founding by physicians, who are still board members, it has had a patient-centric philosophy, says Dr. Sala-Mercado, and there has been a desire to provide the best care possible without constraints of bureaucracy. An inability to fully utilize the OR, which was delaying OR care for some patients — was counter to institution’s mission.

Optimizing OR Utilization Improvement Team

• Javier Sala-Mercado, MD PhD

• Javier Blanco, MD

• Walter Quiroga Castro, MD

• Felix Zelaya, MD

• Sebastian Balestrini, MD

• Susan Moffatt Bruce MD, MBA, PhD



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A multidisciplinary OR committee was formed in July 2014, which consisted of members from the board of directors; the OR surgical chief; chiefs of OR personnel, administration, ICU, anesthesia, and the medical review panel; and three surgical department chairs. This group began reviewing practices and performance in the OR in late 2014, initially believing the primary problem was flow within the OR. The committee instead realized that the extended process, from the moment a patient identifies the need for surgery and including pre-surgery work, contributed to OR utilization. So the committee spent the first 18 months optimizing all processes involved in the pre-surgical period. The entire committee examined factors that affected the patient experience and the institution’s ability to increase the number of surgeries. This included patient feedback about scheduling surgeries and pre-surgery instructions (too much paper handling between specialties and OR services). Once pre-surgical processes were reengineered, the committee focused inside the OR, per se. For this latter effort, staff mapped the overall OR process, identifying seven steps prior to, during, and after surgery (see Surgical Process Map). The committee reviewed the map of OR patient flow and the physicians took their findings to AEH, where they continued to evaluate the process by working through the five stages of the DMAIC cycle: Surgical Process Map

Source: Instituto Modelo De Cardiología Privado SRL



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Define To define the problem, the physicians examined the OR processes and used the Five Whys approach to get feedback from frontline OR staff and surgeons, which also served to get them involved in the improvement project. Reviewing staff and physicians’ feedback, they found that scheduling of surgeries and pre-work was not standardized. For example, patients did not always arrive with signed consent forms; patients could not be transported to the OR if the consent forms were not with the medical records. In some cases, the physician planning for surgery was the same one that had kept the form. In addition, they also found that physicians had individual preferences for patients’ pre-surgical preparation (no standardization per surgical procedure) and, thus, had their surgeries delayed and the OR went unused for that period. Another problem that diminished OR utilization was that “either the surgeons were not in the OR when they needed to be, or the OR was not available to them when they needed it because scheduling was not organized,” says Dr. Sala-Mercado (see Causes of OR Delays). Measure The team began detailed tracking and measuring of OR-related metrics, including pre-surgical process times, OR availability, OR scheduling times, block assignments per surgical teams, utilization of assigned blocks, and patient flow prior to and within the OR. Dr. Sala-Mercado says that prior to investigating the problem, none of these data were available. Analyze The team examined the data and metrics they began to collect, feedback from staff, and insights gained from mapping the seven steps of patient flow within the OR — from patient wheeled into surgery to wheels out of surgery. This effort enabled them to develop an understanding of OR turnover time as well as total OR utilization time, surgeries per month and per department, timeliness of first-case starts, surgery durations by surgical groups and per physician, and changes to surgery volumes. With this information, the team set improvement goals:

• Increase patient evaluation/administrative capacity and eliminate scheduling delays • Increase surgeon OR availability • Increase OR utilization to 75 percent • Increase first-case on-time starts to greater than 90 percent • Improve staff satisfaction.

Causes of OR Delays




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Improve The improvement team’s efforts to optimize OR utilization have touched many facets of the institution, both in and outside the OR. Some improvements began prior to AEH, others while at AEH and upon return to Argentina, and many are still underway and/or expanding with Dr. Moffat’s continuum support. One early action by the OR committee was to develop a brochure for patients prior to surgery. “We used samples from the U.S., and several other institutions provided me with their samples,” says Dr. Sala-Mercado. “We made changes that were applicable to our patients and our culture.” The information addresses frequently asked questions by patients, such as what to do with dentures, use of medications prior to surgery, and whom to call if the patient has doubts or concerns. The institution also created a digital tool so that surgeons would not have to give so many papers and verbal instructions to patients, which then needed to be turned over or told to an OR services secretary. Even though ambulatory patients at the institution have electronic medical records, some physicians were not using the computerized approach. With the new tool, a physician is presented options for the procedures he or she wants to have in the OR, and that gets sent to purchasing, which orders supplies for those procedures. The team developed a tool to log and measure OR patient flow for the seven steps. The tool has led the team to more refined data and a better understanding of the process by surgical teams, such as too much free time between surgeries, overly long transport times, and open OR time but no personnel available to staff the OR at those times. One significant finding from this data tracking was that OR blocks — days and hours — which had been assigned only to cardiovascular surgeons, but not to other specialties, often went unused. Cardiovascular surgery blocks were a remnant from when the institution was solely a cardiovascular facility. “The last 20 years we started adding the other specialties, but they had to wait for the cardiovascular surgeons to decide if they were to use their blocks or not,” says Dr. Sala-Mercado. Institution leadership recognized that block assignments only for cardiovascular surgeons was not sustainable. Dr. Sala-Mercado says that cardiovascular surgeries are decreasing across healthcare and at the institution, which is why many of the blocks went unused. By measuring OR block utilization, the institution could present data to physicians and make the case for other departments and specialties securing blocks. The improvement team researched surgeon interests, such as days of the week and hours per day they wanted to conduct surgeries. The surgeons provided three options — three different days and indicated morning, mid-afternoon, or afternoon preferences — and the team was able to recommend a block schedule that accommodated all surgeons. The team assigned 75 percent of OR available time to blocks and kept 25 percent available for emergencies. In addition, if a surgery was not scheduled within a certain period of time prior to the arranged block per specialty, then the block would automatically be freed for others to schedule a surgery. After a sufficient period of measurement, if surgical teams fail to use their block times, they will relinquish them or have them reduced, and other teams will be assigned longer or more blocks of time.



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The data will help the institution to align OR staff times with demand and further analyze activities from patient registration to OR wheels in. Control The team’s collection of data over three months offered insights into where permanent changes could be made. For example, first-case on-time starts were 73 percent, resulting in 338 minutes of lost time for 108 surgeries. The OR utilization was only 32 percent, and block utilization was just 52 percent by day and 30 percent by hour. By tracking the seven steps in detail, the team also was surprised to find that each patient required on average 24.3 minutes of transport time to wheels in, and there was a turnover time of 143 minutes. Results and Next Steps After the AEH report out in October, the improvement team planned to collect another three months of data prior to hardwiring changes to surgery scheduling and OR utilization processes. For example, of the 22 departments assigned surgery block times, the initial three-month data indicated that seven departments should lose their block times and many others should have block times decreased or reassigned. With another three months of data, the team was confident that surgeons will buy into new block assignments and support the changes. “[Tracking OR measures] had to be friendly and fast, so we developed the tool to collect the information,” explains Dr. Sala-Mercado. “With that tool, in seconds we can get all the information about which group is using their own block, or which group is using another’s block. With that data we’re able to analyze if we need to make changes to increase a surgeon’s OR availability due to their necessity” (see OR Utilization — Interactive Data Display Sample). OR Utilization — Interactive Data Display Sample




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In December 2016 after six months of data collection, a smaller OR committee (three surgeons and a board member) that meets monthly reviewed the metrics and prepared to make block changes based on the data (see Block Utilization Results, Six-Month Data Review). Dr. Sala-Mercado says, “The chief surgeon, Dr. Blanco, is sitting down with each of the departments, showing them the data, and showing them why their blocks are being changed or reduced, and why others at the same time are able to increase it.” In addition, Dr. Blanco has started to implement best practices visual-management tools learned by the team during a gemba visit to Cardinal Health, which occurred in October while reporting back to AEH. They have implemented boards to register safety and quality defects and measure the time taken to resolve them. The OR improvement team is also examining ways to streamline pre-OR processes — e.g., patient registration, transport to inpatient, medical history, nurse preparation, and transport to OR (noted earlier in Causes of OR Delays). With higher optimization of the OR, the team believes it can decrease the time the OR is open and staffed and, thus, decrease costs associated with the OR without any negative impact to patients. The OR previously was open from 7:00 am to 10:00 pm, not including emergency services that occur at other hours or during weekends and holidays. The target is to close the OR at 6:00 pm, which also will help achieve the goal of 75 percent OR utilization (the volume of OR usage stays the same or increases, while staffed but unused OR time is reduced). Block Utilization Results, Six-Month Data Review

Block utilization divided by % usage of days, hours assigned, and hours used outside their block




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Improving Discharge Times The institution’s work to optimize OR utilization identified causes that occurred well beyond OR activities. Issues were surfaced with the institution’s discharge process: patients not being discharged in a timely manner prevented patients from having surgeries on time because no bed was available prior to or after the surgery. In fact, some physicians who had planned surgeries could not perform them because they had not discharged their own patients in a timely manner. The institution formed a separate improvement team, and began a project to improve discharge times while institution physicians were attending training at AEH. Dr. Quiroga Castro and Dr. Zelaya led the discharge-project improvement team at AEH and have been instrumental in making progress once back in Argentina. To better grasp why discharge delays occurred and the probable causes, the team mapped the discharge process, including patient admissions; prior-day announcement of the discharge to patients, families, and administration; morning rounds; involvement of specialties; executing discharge orders; and actual discharges. The improvement team’s mapping also began to track precise times for the following activities:

1. Discharge order: When the discharge order is decided, during the physicians’ rounds.

2. Administrative discharge: An administrative employee registers the discharge in the system, which begins the process of the patient being cleared by the insurer.

3. Patient communication: The resident provides discharge instructions and recommendations to the patient.

4. Effective discharge time: The patient has exited the room, and the room gets ready for another patient.

“When we started this project, we did not have any measures for three of [the four discharge activities],” says Dr. Sala-Mercado. “The only one that we had was the administrative discharge because it was already in the computer.” The improvement team established a discharge database, and built six months of data prior to full implementation of recommendations so it could compare the performance to what occurs three months after implementation. But, adds Dr. Sala-Mercado, “as it always happens, once we started measuring the four precise times, things got better over time.” The important first step in the discharge process is rounding. Rounds previously had occurred at the institution twice per day: one from 8:00 am to 10:30 am and the other from 5:00 pm to 7:00 pm. A round team consisted of six physicians (board-certified cardiologists, interninsts, and intensivists) and 11 medical residents, who take care of every ICU patient and inpatient.

Improving Discharge Times Improvement Team

• Walter Quiroga Castro, MD

• Felix Zelaya, MD

• Sebastian Balestrini, MD

• Javier Blanco, MD

• Eduardo Conci, MD, ICU

• Mara Isa, MD, ICU

• Mauro Quiroga, MD, ICU

• Fernando Vichi, MD, Chief of

Residents

• Silvina Serra, Administrative staff

• Javier Sala-Mercado, MD Ph.D.

• Susan Moffatt Bruce, MD, MBA, PhD



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Morning rounds occurred in large group meetings in a room away from patients; as the institution expanded and patient volumes grew through the years, bedside rounds with physicians and residents became impractical and were only performed during the afternoon rounds. A round could address as many as 65 patients, and only when all patients were discussed would physicians begin discharge orders. The training at AEH began to open physicians’ eyes to the problems associated with batching of discharge orders. Due to the manner by which rounding was completed, patient discharges frequently took place late in the day. Some home-discharges were dependent on the completion of tasks by specialties (e.g., traumatology, general surgery), while other ICU discharges were simply delayed or blocked due to lack of beds, as patients left for home late in the day. Initial analysis of the discharge process prior to AEH training revealed that from January through July 2016, only 45 percent of patients were discharged prior to 12:30 pm, and 57 percent were discharged prior to 2:30 pm (see Monthly Discharge Times on the next page).“Our discharge processes were not standardized,” says Dr. Sala-Mercado. “We were not looking at the time the patient was leaving the room, and we were just waiting for the patient to go home after we gave the instructions.” In addition, as previously mentioned, some surgical groups reviewed their patients for potential discharge at random times, often late in the day when the physician’s schedule opened up. Dr. Sala-Mercado says he got together with these surgeons and told them how they were causing their own delays by discharging patients a day later than anticipated: “The same bed was scheduled for the patient that you had [planned for] surgery today. You are stepping on your own toes.” By identifying problem areas on their process map and with the use of a benefits/effort matrix, the improvement team recommended that the morning rounds be divided into three groups, which would reduce the time to round. Each group would check on approximately 20 patients at the patient’s bedside, and all morning rounds would be completed by 9:00 am. After performing a baseline analysis, goals and objectives were initially selected by the team for the administrative discharge (the only measure being tracked prior to AEH). As data was established for the other three measures, the team defined its objectives and set goals for the effective discharge time:

• 40 percent of the discharges before 10:30 am • 60 percent before 12:30 pm • 80 percent before 2:30 pm.



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Results and Next Steps After redesign of rounding and discharge procedures, the effective discharge times were dramatically improved (see Monthly Discharge Times):

• Before 10:30 am: 8 percent January through July to 35 percent October through December. • Before 12:30 pm: 45 percent January through July to 71 percent October through December • Before 2:00 pm: 57 percent January through July to 82 percent October through December.

The team’s work effectively moved discharge times to earlier in the day, concentrating them as early as possible (see Percentage of Discharges by Hour on the next page). There were unanticipated benefits, similar to a Hawthorne effect, by improving discharge times. The increased interaction of physicians with patients at bedside rounds also improved quality of care, reducing length of stay and complications. Dr. Quiroga Castro says physicians are more likely to find early in the day that a patient scheduled for discharge has regressed or that another patient may have improved faster than expected and can be discharged in the morning rather than in the afternoon or the next day. Other unanticipated benefits have included improved patient satisfaction, as every patient in the hospital has been seen by a staff member in detail by 9:00 am; more time available for residents to devote to patient care during the morning and more time available to attend clinical conferences held at noon; earlier dispatch orders to other departments for studies to be performed for inpatients, which has led to earlier results being available for decision making. As expected, there also were more opportunities for surgical patient flow improvement because physicians were getting their own patients discharged sooner and opening up beds. The improvement team has continued daily control of discharges, which involves discussing goals, analyzing monthly discharge data, and posting the monthly controls and statistics for visual management. These meetings were expanded to other physicians groups involved in the discharge process, such as general surgery, traumatology, gynecology, etc. Institution physicians have been working on procedures to identify patients or families that could pose problems with discharges, as well as communicating with non-surgical specialists, such as pulmonologists/neurological rehabilitators, to expedite special needs after discharge (e.g., home care, oxygen therapy, neuro rehabilitation).

Monthly Discharge Times

January-July administrative discharges (prior to AEH) vs. September-December effective discharges (after AEH)

For latter-day periods, the improvements surpassed the team’s targets.




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Percentage of Discharges by Hour


In late 2016 the discharge-improvement project was focused on:

• Ensuring data registration for all discharges that take place at the institution • Exploring additional root causes, such discharge delays by department and/or physician and

non-medical causes of discharge delays • Implementing a high-quality improvement plan based on increasing patient information about

pathology, treatment, and home care • Creating standardized information to give to patients (e.g., brochures about medical care post-

discharge and follow-up care at the institution).

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DISCHARGES DAILY DISTRIBUTION JANUARY - JULY 2016

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DISCHARGES DAILY DISTRIBUTION SEPTEMBER - DECEMBER 2016

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DISCHARGES DAILY DISTRIBUTION SEPTEMBER - DECEMBER 2016

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DISCHARGES DAILY DISTRIBUTION JANUARY - JULY 2016DISCHARGESDAILYDISTRIBUTION"LEFTSHIFT"

(Jan-July,green/Sept-Dec,blue)



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The team has also reviewed discharge data relative to readmissions, and for January through July readmissions were 3.17 percent. After the discharge-process improvements were implemented, readmissions fell to 2.84 percent for September through December (data for August was not included because it was a transition month during which implementation of changes took place). The discharge-improvement team also is interested in improving the quality of discharges, and will implement a patient-satisfaction discharge survey to gauge patient perspectives of the changes that have been made. AEH Commentary The two Instituto Modelo De Cardiología Privado SRL projects illustrate the impact that engaged physicians can have on improving healthcare processes — both the degree of improvement and the speed at which improvements can be made. The institution’s projects also highlight the importance of a leadership perspective when examining and solving healthcare problems. Many healthcare process problems are interconnected — such as discharge delays impacting OR optimization. Without a high-level view of these issues and the power to make changes across departments, improvements can run into silos and roadblocks. The institution’s physician leadership, on the other hand, has taken the initiative to seek out any problem that impairs healthcare excellence at the organization and has the power to remove obstacles. The institutions leadership and its board of directors (all physicians) have enthusiastically provided full support to develop these types of process improvements in Argentina — investing the time and resources necessary for change.



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About AEH The Academy for Excellence in Healthcare blends in-person class time with hands-on project work, interactive simulations, and recurrent coaching, all aimed at helping healthcare teams spark actionable change at their organization. At the heart of this program is a real-world workplace problem each participant team selects and commits to solving through five intensive days on campus, followed several weeks later by two days of project report-outs and lean leadership training.

Optimizing Operating Room Utilization

and Improving Discharge Times

• Javier Sala-Mercado

MD, PhD, Adjunct CMO, Adjunct COO

Instituto Modelo De Cardiología Privado SRL

54 351-485-8597

[email protected]

• Susan Moffatt-Bruce

MD, MBA, PhD, CQO

The Ohio State University Wexner Medical Center

614-293-9806

[email protected]

• Margaret Pennington

Faculty Director The Academy for Excellence in Healthcare The Ohio State University 614-292-3081 [email protected]

For Program Information

• Beth Miller

Program Director The Academy for Excellence in Healthcare The Ohio State University 614-292-8575 [email protected]

mailto:[email protected]






optimizing operating room utilization and improving ... · some improvements began prior to aeh,...

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