Main Operating Room (MOR) Surgical Scheduling/ Utilization Executive Summary A SWOT analysis was performed for surgical scheduling and utilization on MOR for FY 2014. 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
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.
Daily Hours of Operation with Number of Rooms Utilized Time: Number of Rooms: M-F 0700-1630 18* M-F 1500-1900 8 M-F 1900-2300 2 M-F 2300-0700 1 Sat-Sun (0700-1900) 2 Sat-Sun (1900-0700) 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 10696 cases performed in the MOR and 7254 cases out of the MOR, totaling 17950 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 3420.1 65% 665.9 13% 4086 78% 3928 Neurosurgery 1866.1 48% 193.4 5% 2060 52% 2169 GYN Surgery 1258.6 58% 72.5 3% 1331 61% 1771 Ophthalmology 1263.9 71% 7.9 0% 1272 72% 1870 Oral-Maxillofacial Surg 956.4 51% 67.9 4% 1024 55% 6652 Orthopedic Surgery 4800.5 72% 1443.0 22% 6243 94% 3133 Otolaryngology 2237.5 71% 111.3 4% 2349 75% 370 Pediatric Surgery 174.4 47% 45.7 12% 220 59% 1298 Plastic/Recon Surgery 782.4 60% 141.7 11% 924 71% 3966 Urology/GU Surgery 1927.5 49% 51.3 1% 1979 50% 1452 Perip Vascular Surg 780.4 54% 71.1 5% 852 59% 1893 Cardiothoracic Surgery 911.6 48% 39.1 2% 951 50% 633 GYN/REI Surgery 418.2 66% 47.1 7% 465 74% 649 GYN/ONC Surgery 452.8 70% 209.3 32% 662 102% 366 Organ Transplant Svc 137.5 38% 71.4 20% 209 57% 508 GYN/URO Surgery 399.5 79% 52.7 10% 452 89% 1084 Neurosurgery-Telemedicine 605.4 56% 89.5 8% 695 64% 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 22393 58% 3395 9% 25788 66%
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 12 66.4 Dermatology 1 52.0 Emergency Department 0 Gastroenterology 21 48.9 General Surgery 545 57.2 GYN Surgery 323 50.9 GYN/ONC Surgery 61 57.7 GYN/REI Surgery 86 58.8 GYN/URO Surgery 63 51.9 Hand Surgery 0 Hemo Oncology 0 Hepatology 0 IR Service 0 Medicine 0 MRI Services 0 Nephrology 0 Neurology 0 Neurosurgery 127 52.8 Neurosurgery-Telemedicine 57 50.3 Obstetrics 0 Ophthalmology 577 29.9 Oral-Maxillofacial Surg 90 47.9 Org Recy/Wash Consortium 0 Organ Transplant Svc 18 58.9 Orthopedic Surgery 907 51.1 Otolaryngology 385 44.4 Pain Management 13 47.4 Pediatric Cardiology 0 Pediatric Dental 21 50.1 Pediatric GI 0 Pediatric Nephrology 0 Pediatric Neurology 0 Pediatric Pulmonary 0 Pediatric Surgery 49 41.2 Pediatrics 0 Perfusion 0
Perip Vascular Surg 97 55.7 Plastic/Recon Surgery 110 50.2 Podiatry 0 Psychiatry 0 Pulmonary 0 Radiation Oncology 0 RRK PACU OVERNIGHT 0 Thoracic Surgery 'FBCH' 0 Urology/GU Surgery 123 51.4 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: 3686 48.3 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.
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 279 15 40 General Surgery 1858 330 240 Gynecology 515 140 48 Gyn/Onc 218 27 21 Gyn/REI 170 34 34 Gyn/Uro 159 74 12 Hand Surgery 3 0 1 Neurosurgery 721 351 159 Neurosurgery- Telemedicine 205 78 23 Ophthalmology 868 311 121 Oral- Maxillofacial 354 76 53 Org Recy/ Wash Consortium 3 12 1 Organ Transplant 118 2 38 Orthopedics 2452 1069 360 Otolaryngology 835 177 93 Pediatrics 223 31 33 Perip Vascular 460 53 116 Plastic/ Recon 347 100 32 Podiatry 1 159 0 Urology/ GU 942 385 134
Cancellations There were 1729 total cancellations from 1 January to 31 December 2014. 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)
Wait List GYN and PVS had the highest number of patients on the waiting list according to S3, which was accessed on 13 February 2015. Scheduled Scheduled Service Date<=30d Date>30d Wait list GENSURG 78 15 NEUSURG 33 1 GYN 57 14 4 OPHTHAL 47 43 1 OMFS 17 10 ORTHO 129 64 3 OTO 47 25 1 PEDSURG 4 PLASTIC 15 6 URO/GU 52 13 1 PVS 16 1 4 CT SURG 6 1 CARDIO 5 GYN/REI 13 GYN/ONC 5 TRANS 6 GYN/URO 7 NEUSURT 7 2 1 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.
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.
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 http://www.aorn.org/clinical_practice/toolkits/tool_kits.aspx. 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