A SWOT analysis was performed for surgical scheduling and utilization on MOR for FY Internal. External

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1 Main Operating Room (MOR) Surgical Scheduling/ Utilization Executive Summary A SWOT analysis was performed for surgical scheduling and utilization on MOR for FY SWOT Analysis Internal Strengths Abundance of OR personnel with a mixture of scholastic backgrounds, experiences, and skills Mission critical hospital in a pinnacle location Merge of (Army/ Navy) expands growth opportunities for the organization External Opportunities *Streamlining and standardization of products and equipment used in the different surgical specialties may improve efficiency and utilization Accurate accounting of service minutes will provide leadership data needed to advocate for manning and additional resources Limit number of master schedulers Offer more block time to those services booking the most TSAs *Same as last year Weaknesses Due to the size of the organization, fluctuations continually affect utilization (i.e. staffing turnovers, inaccurate service minute documentation) Merge of two branches of the military (Army/ Navy) still has growing pains for the organization Number of TSA procedures indicate inappropriate use of block schedule Threats *Hospital mission and staff availability dependent on current national and military missions (decreased staff due to soldier/sailor training, deployments, PCS and ETS) Too many people with master schedule privileges on S3

2 Current State of OR Utilization Block Schedule The MOR (Main Operating Room) is currently using block scheduling (see chart). The schedule is locked out 72 hours prior to day of surgery. At that point, the MOR scheduler and Anesthesia Medical Director are contacted to book additional cases. The numbers of other master schedulers have been limited to decrease booking issues. Once within 72 hours of day of surgery, cases are booked as TSA (Time and Space Available) and the MOR scheduler and Anesthesia Medical Director shifts those cases in their appropriate slots. Emergency cases are priority and bump all elective cases.

3 Daily Hours of Operation with Number of Rooms Utilized Time: Number of Rooms: M-F * M-F M-F M-F Sat-Sun ( ) 2 Sat-Sun ( ) 1 (*Plus 2 additional remote rooms: Urology- 1 RN 2x/week; OMFS- 1 RN on Fridays for Pediatric cases or PRN staffing shortage) Case Counts According to the Surgery Scheduling System (S3), there were cases performed in the MOR and 7254 cases out of the MOR, totaling cases during the 2014 calendar year; with 8007 outpatient and 9943 inpatient cases. Of the cases performed, 15017(83.66%) were routine, 264 (1.4%) were urgent/ semi-emergent, and 146 (0.8%) were emergent cases, plus 2523 (14.05%) TSA. Utilization per Service Utilization data gathered from S3 from January to December 2014; average utilization was 66%. Unscheduled cases such as TSA, emergencies, etc. were not included. Report: Service Block-Time Utilization Year-2014 Assigned Block Time UTILIZATION Assigned Used Time Used Time To Service (assigned) (unassigned) ttl % 5264 General Surgery % % % 3928 Neurosurgery % % % 2169 GYN Surgery % % % 1771 Ophthalmology % 7.9 0% % 1870 Oral-Maxillofacial Surg % % % 6652 Orthopedic Surgery % % % 3133 Otolaryngology % % % 370 Pediatric Surgery % % % 1298 Plastic/Recon Surgery % % % 3966 Urology/GU Surgery % % % 1452 Perip Vascular Surg % % % 1893 Cardiothoracic Surgery % % % 633 GYN/REI Surgery % % % 649 GYN/ONC Surgery % % % 366 Organ Transplant Svc % % % 508 GYN/URO Surgery % % % 1084 Neurosurgery-Telemedicine % % % 1840 WOUNDED WARRIOR 0.0 0% 0.0 0% 0 0% 0 Podiatry 0.0 0% 8.7 0% 9 0% 0 Hand Surgery 0.0 0% 5.8 0% 6 0% T O T A L S % % %

4 Turnover Times Turnover times from S3 for calendar year 2014; average turnover time was 48.3 minutes. The definition of turnover time according to S3 is the time from prior patient out of room to succeeding patient in room time for sequentially scheduled cases. Sequential cases must also be the same service to be counted. The goal for turnover time in the National Capital Region is 30 minutes. Report: Turnover Time Year-2014 Service Number of turnovers counted Average minutes per turnover Anesthesia Cardiothoracic 0 Anesthesia Neuromonitor 0 Anesthesia, Obstetric 0 Anesthesia, Regional 0 Cardiology 0 Cardiothoracic Surgery Dermatology Emergency Department 0 Gastroenterology General Surgery GYN Surgery GYN/ONC Surgery GYN/REI Surgery GYN/URO Surgery Hand Surgery 0 Hemo Oncology 0 Hepatology 0 IR Service 0 Medicine 0 MRI Services 0 Nephrology 0 Neurology 0 Neurosurgery Neurosurgery-Telemedicine Obstetrics 0 Ophthalmology Oral-Maxillofacial Surg Org Recy/Wash Consortium 0 Organ Transplant Svc Orthopedic Surgery Otolaryngology Pain Management Pediatric Cardiology 0 Pediatric Dental Pediatric GI 0 Pediatric Nephrology 0 Pediatric Neurology 0 Pediatric Pulmonary 0 Pediatric Surgery Pediatrics 0 Perfusion 0

5 Perip Vascular Surg Plastic/Recon Surgery Podiatry 0 Psychiatry 0 Pulmonary 0 Radiation Oncology 0 RRK PACU OVERNIGHT 0 Thoracic Surgery 'FBCH' 0 Urology/GU Surgery Vascular Surgery 'FBHC' 0 WOUNDED WARRIOR 0 WRAMC 0 Z Breast Center 0 Z Orthopedic Davila 0 Z Orthopedic Joint 0 Z Orthopedic Spine 0 Z TAMIS 0 TOTAL: Notes on this report: Definition of turnover time: Time from prior Patient Out of Room to succeeding Patient In Room Time for sequentially scheduled cases.

6 Backlog Report by Service (Unable to obtain from S3, IT notified on 13 th of February, 2015) The following was for FY 13 Service Total cases done Average daily backlog Total cancelled CardioThoracic General Surgery Gynecology Gyn/Onc Gyn/REI Gyn/Uro Hand Surgery Neurosurgery Neurosurgery- Telemedicine Ophthalmology Oral- Maxillofacial Org Recy/ Wash Consortium Organ Transplant Orthopedics Otolaryngology Pediatrics Perip Vascular Plastic/ Recon Podiatry Urology/ GU

7 Cancellations There were 1729 total cancellations from 1 January to 31 December Per S3, this was a 14% cancellation rate from the cases booked when the schedule was finalized (10778 cases done). The top five reasons given for the cancellations were: Schedule (moved to another day, with 274 cancellations) Patient (other explanation, with 208 cancellations) Other (enter explanation, with 148 cancellations) Surgeon (surgery no longer indicated, with 146 cancellations) Other (inclement weather conditions, with 137 cancellations)

8 Wait List GYN and PVS had the highest number of patients on the waiting list according to S3, which was accessed on 13 February Scheduled Scheduled Service Date<=30d Date>30d Wait list GENSURG NEUSURG 33 1 GYN OPHTHAL OMFS ORTHO OTO PEDSURG 4 PLASTIC 15 6 URO/GU PVS CT SURG 6 1 CARDIO 5 GYN/REI 13 GYN/ONC 5 TRANS 6 GYN/URO 7 NEUSURT Org RWC 1 Sustain: Limit number of master schedulers Limit the number of master schedulers and adhere to 72 hour lock out time with a limited number of personnel that can access the surgical scheduling system once within the 72 hour period. o Expected outcome-this may decrease the top reason for case cancellations (due to schedule; moved to different day). Continue using pagers to help with communication. Staff can respond to needs of leadership faster. o Expected outcome-team leaders/enlisted leadership can be paged to alert them when a room is coming down so they can assist with turnover.

9 Recommendations: Recommendation: Strategically hire key personnel that have clear cut impact on turnover and utilization. MOR leadership should reconfigure the Operating Room Business Team o Replace all military (except leadership position to provide overview) with civilian personnel for continuity in this team. This will decrease time and effort to train military personnel who have high turnover. Available military personnel could be used for MOR staffing or help with turnover. Expected outcome- More time will be spent on obtaining supplies and equipment to increase OR efficiency. Hire more housekeeping for turnover but continue to use staff to assist. Geography of MOR makes it difficult for circulating nurse and scrub techs to complete housekeeping duties and turnover in reasonable time. o Expected outcome-turnover time will decrease. Recommendation: Complete documentation with proper accounting of workload. Based on the utilization data gathered from S3, some services captured > 90% utilization while Podiatry and Hand Surgery had 0%. Proper accounting of workload will capture accurate utilization, may increase overall utilization and minutes of service in the electronic documentation system. S3 super users (MOR leadership, schedulers) should re-educate staff (via in-services for all shifts) on proper documentation of S3 times to ensure minutes of service is accurately reflected. Reassess progress after a month, report findings and praise staff for improvement. o Expected outcome- Proper accounting of workload will allow leadership to project future needs, to include adequate staffing and need for additional resources. Recommendation: Limit cancellations due to preventable issues. APU staff should identify preventable issues and address these in the preoperative evaluation process. o Expected outcome-this may decrease the second top reason for case cancellations, due to the patient (for various reasons). When reporting cancellation, identify exact cause/reason for better data collection. o Expected outcome- This will better identify top reasons for cancellation and allow you to develop strategies for curtailing cancellations. According to a study by Tulane University Medical Center (2009), hospitals are losing millions of dollars of lost revenue due to same day cancellations or no shows (McCook, 2012, para.1). Issues with transportation and not remembering when the appointment or date of procedure was the top three reasons patients did not show (McCook, 2012). These preventable issues should be focused on during the preoperative visit.

10 Recommendation: Monitor turnover times and reasons for delays. MOR leadership should consider the Perioperative Efficiency Tool Kit from the AORN website as a guide at o Expected outcome-the tool kit provides strategies that can be used by the perioperative team to optimize efficiency and patient flow, focusing on teamwork and communication, streamlining and standardization of processes (AORN, 2015a). Track delays due to each member of team. Schedulers can report these findings on a monthly basis to leadership to hold everyone accountable. o Expected outcome-decreased delay issues due to increased accountability. Recommendation: Identify a service with a history of poor turnover times and have a clinical workflow analysis done by WRNMMC Informatics Office and follow up with a multidisciplinary team using Lean. No manpower from the MOR will be needed to perform this workflow analysis. The informatics office will provide this service free of charge (next scheduled available time) and provide an analysis that is objective. (Richard Clark, MS, CNOR, Informatics Research Fellow, personal communication, 14 October, 2014). o Expected outcome-identified issues can alert leadership and key stakeholders of areas on what to improve that will result in a positive impact with room turnovers. Simon & Canacari (2014) found working towards decreasing turnover times using Lean requires buy in and participation from the key stakeholders (the multidisciplinary team); surgeons, anesthesia, nurses, technicians/technologists, housekeeping, administration, scheduler, central processing department, senior management engineer and various ancillary services such as x-ray, lab, etc. (p. 148). Thomas Jefferson University Hospital (who has 58 OR suites) used Lean process to decrease turnover time for ENT service from 73 minutes to 30 minutes (AORN, 2015b). Report prepared by Maj David Bradley, USUHS CNS Student 20 February 2015

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