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Improving Hospital Flow Improving Hospital Flow to Increase Throughput, to Increase Throughput,
Improve Patient Improve Patient SatisfactionSatisfaction
July 14July 14, , 20052005
Niels K Rathlev MDVice Chair
Department of Emergency Medicine
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Maximizing throughput:smoothing
the elective surgery schedule
James M. Becker, MDKeith P. Lewis, MDJohn B. Chessare, MDEugene Litvak, PhD
Richard Shemin, MD
Gail Spinale, RNDemetra OuelletteAbbot Cooper
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Boston Medical Center
475 bed Level 1 trauma center 129,000 annual ED visits Safety net hospital in Boston’s South End ED provides 20% free care, 20% “self pay” 2 pavilions – East Newton cardiac center
Menino Trauma Center
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Variability
“Natural”: you can’t control it …you just have to manage it. # of patients coming to the ED Types and # of emergency surgeries
“Artificial”: you can control it & must eliminate “batching” it to create flow When the nuclear med lab reports stress
test results Types and # of scheduled surgeries
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Surgical smoothing
Smoothing elective vascular surgerySmoothing elective cardiac surgerySeparating elective from urgent surgery in the Menino Pavilion
• Creating reliable urgency data• Separating a room for urgent/emergent cases• Eliminating Block Scheduling
Smoothing elective cardiac caths (in progress)
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Should the ED care?
Each additional elective surgical case prolonged the mean LOS per ED patient by 15 seconds.
The median # of 48 elective surgical cases per weekday add 12.3 mins (5.2%) to the mean LOS per ED pt & 30.6 hrs to total ED dwell time
No association with diversions
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0.2
0.4
0.6
0.8
1
1.2
Abramson
Restucci
Madison
Sampson
Wong
Bed Need by Day of Week for Vascular Surgery (18 mos)
Progressive Care Unit
Volume
0
0.5
1
1.5
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2.5
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3.5
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4.5
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Volume
Vascular Elective PCU Cases by DayRandom Month July 2002
Vascular Scheduled PCU Cases - Weekdays Only (October 2003)
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2
3
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5
10/0
1/03
10/0
2/03
10/0
3/03
10/0
6/03
10/0
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10/0
8/03
10/0
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10/1
0/03
10/1
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10/1
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10/1
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10/1
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10/1
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10/2
0/03
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1/03
# o
f S
ch
ed
ule
d C
as
es
E6W Direct Nursing Hours per Patient Day
8.66
8.16
7.90
8.00
8.10
8.20
8.30
8.40
8.50
8.60
8.70
Prior to Vascular Smoothing
After Vascular Smoothing
Average Nursing Care Hours per Patient per Day By Week
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6.5
7
7.5
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8.5
9
9.5
10
9/29
10/610
/1310
/2010
/2711/311
/1011
/1711
/2412/112
/812
/1512
/2212
/29 1/51/
121/
191/
26 2/2
2/92/
162/
23 3/2
3/93/
163/
233/
30 4/64/
134/
204/
27 5/45/
115/
185/
25 6/1
6/86/
156/
226/
29 7/67/
137/
207/
27 8/38/
108/
178/
248/
31 9/79/
149/
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FY2003
FY2004
Mean CT Surgery Unscheduled Cases Weekdays
Average Scheduled CT Surgery Cases by Weekday
Cardiac Scheduled Cases Histogram January & February Non-holiday Weekdays Only
0%
5%
10%
15%
20%
25%
30%
35%
Monday Tuesday Wednesday Thursday Friday
2004
2003
March Daily PCU Census - 2003 vs. 2004
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2
4
6
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12
1-Mar
2-Mar
3-Mar
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6-Mar
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ar
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ar
2003
2004
2003 range 10 – 1 = 9
2004 range 7 –2 = 555% reduction in variability
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Boston Globe, June 2004
“Anybody who comes to me and says, I can’t do this, I’m going to send them to Boston Medical Center ”
Dr. Dennis O’Leary President, JCAHO
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Changes to the Menino OR Schedule
BMC has 2 OR Suites
Newton Pavilion
13 ORs
Menino Pavilion
8 ORs
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Menino Pavilion compared to
Newton Pavilion
Variable NP MP
# Rooms 13 8
# Cases Day 30-35 25-32
# Cases Year 8601 6608
Cancellation Rate 10% 20%
#Add Ons Per Day 1-2 5-12
#Weekend Cases 0-4 5-20
Unique Services Cardiac, Eye Pediatrics, Trauma, Gastric Bypass, OB
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Pre-change problems with the schedule –
Menino Pavilion
•Urgent/emergent bump elective cases•Overall 50% block utilization•Variable use of block (vacation, meetings)•Most cases booked 3-4 days out•33% of daily schedule is “add ons” •Variable release time between services•Cases can be lost waiting•People live in fear of losing their block
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Our Goals
Reduce bumped Cases– Reduce waste in rework– Improve patient satisfaction– Improve surgeon satisfaction– Improve scheduling staff
satisfaction Increase surgical volume
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Our Plan
Separate urgent/emergent from scheduled surgeries
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How many rooms should we set aside for urgent/emergent
cases?
Created a case classification and prioritization system:
• Emergent 30 minutes• Urgent 30 minutes – 4 hours• Semi-urgent 4 – 24 hours• Non-urgent >24 hours
Analysis shows that 1 room would be sufficient to have rarely bump an elective case
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The Question
Whose block time should we take away?
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Block scheduling
Surgeon or service “owns” blocks of time on the OR schedule
Allows surgeons to plan their time If utilization of the blocks
approaches 100%…everyone wins Requires redesign of block as
surgeons come and go or as demand changes
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Advantages of open scheduling model
•Gives surgeons flexibility in scheduling•Equal access for all surgeons•Promotes booking far in advance•Opens up free time for other surgeons•Not rigid and gives schedulers flexibility•No case will be refused
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“Concerns” regarding the open scheduling
model
•“It’s not what we are used to doing”•Gaming the system •Someone may take the time you want•Late booking may lose out•Fear of loss of OR access and income•Cases all over the place •The winner takes it all!
Menino OR New DesignApril 26, 2004 Urgent and Elective Flows
SeparatedNo-block Scheduling Begins
1. Open Scheduling (Open Scheduled/OS)Quantity: 5 Rooms
2. Orthopedic Scheduling (Block Scheduled/BS)Quantity: 2 Rooms
3. Day of Scheduling (Urgent/Emergent Schedule)Quantity: 1 Room
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Urgent room 5
•Monday – Friday 7– 3:30 PM•Fully staffed and ready to go•Open to all!•Case classification and prioritizing
Emergent 30 minutesUrgent 30 minutes – 4o
Semi-urgent 4-24o
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OR Executive Committee commitment
•Want to enhance volume for all•Want to prioritize and get to all emergencies•Dedicated schedulers•Tighten final schedule to maximize surgeon efficiency•No case will be denied•If it fails, we will reassess and change
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Separating urgent from elective
Before and after
BeforeApril – Sept 2003 157 emergent cases (M
– F) 7:00 AM to 3:30 PM
334 elective patients were delayed or cancelled
AfterApril– Sept 2004 159 emergent cases (M –
F) 7:00 AM to 3:30 PM 3 elective patients were
delayed or cancelled(1 cancelled, 2 delayed)
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Summary of open block & separating urgent from
scheduled cases
Eliminated bumping of elective cases (#3) Scheduling cases quicker More choice: both day and time Book consecutive cases More productive use of OR (fewer gaps) No need to notify scheduling for time off Minimal # of complaints
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What’s next?:smoothing elective cardiac
caths
We have competition for beds between adult cardiac and pulmonary ED patients and patients coming from the cath lab on our 6 North Unit
Do we have artificial variability in scheduling elective caths and if so, what can we do to smooth this?
E6N Tuesday Noon Census
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5
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5/30 6/6 6/13 6/20 6/27 7/4 7/11 7/18 7/25 8/1 8/8 8/15 8/22 8/29
Week of...
Cen
sus
Interventional
Other
Total
Interventional
Other
Total
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Smoothing elective caths
• We have just implemented a cap of 5 elective cath patients on Mondays and Fridays after studying the variability.
• It is too soon to see the effect of this change.
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Summary
There is much artificial variability in healthcare. We must do better to design systems to eliminate it. We can no longer afford this waste.
Separating the flow of urgent surgery from scheduled surgery reduces waste and rework
No-Block scheduling is a good way to help the surgeons, patients, and staff
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References
Leading Change; by John P. Kotter McManus ML, Long MC; Cooper A, Mandell J,
Berwick DM, Pagano M, Litvak E. Impact of Variability in Surgical Caseload on Access to Intensive Care Services, Anesthesiology 2003; 98: 1491-1496.
http://management.bu.edu/research/hcmrc/mvp/index.asp