Improving Mott Hospital Post-Operative Processes Program and Operation Analysis Submitted To: Sheila Trouten, Client Nurse Manager, PACU, Mott OR Jesse Wilson, Coordinator Administrative Manager of Surgical Services, Mott Hospital Submitted By: Maxwell Booth IOE Senior Gunjan Sud IOE Junior Raj Vashi IOE Senior Date Submitted: February 2, 2008 1
Table of Contents Introduction... 3 Background... 3 Goals and Objectives... 4 Project Plan... 4 Key Issues... 5 Project Scope... 5 Proposed Approach: Data Collection and Analysis... 5 PACU Observations... 5 Literature Search... 5 Random Beeper Study and Worksheet Collection... 6 Current Data Set Review...6 Nurse Surveys... 6 Recommendations... 6 Expected Impact... 6 Project Team and Experience... 6 Support Required from Operating Entities... 7 Schedule and Key Dates... 7 Estimated Team Hours Required... 7 Approval... 8 2
Introduction University of Michigan s Mott Hospital is currently operating at capacity in many departments. Specifically, the Post-Anesthesia Care Unit (PACU), which is the first stop for patients after exiting surgery, is overcrowded and faces a bed shortage. As a result, patients are frequently unable to move directly from the Operating Room (OR) to the PACU. Since the patients and the operating staff have to wait in the OR until the patient can proceed to the PACU, surgeries are often delayed or canceled. However, because surgeries are only scheduled during working hours, the PACU is generally empty during the nighttime. To alleviate the congestion in Mott Hospital as a whole, the nurse manager and the hospital board would like to implement a 23-hour PACU. The 23-hour PACU would employ the PACU as a general recovery space during non-peak hours for 23-hour patients who are having outpatient procedures, but must remain for observation for less than 24 hours. Using a variety of techniques, the team will collect data regarding PACU usage and capacity, and will analyze PACU processes to reduce the delay in surgeries and determine the method to best execute the 23-hour PACU. The team will convey these recommendations to Mott PACU staff. The proposal outlines steps the team will take to collect and analyze data, and to provide recommendations to Mott hospital staff. Background Mott Hospital, a leading children s hospital, is part of the University of Michigan Health System. The hospital performs 3.5 times more cases per bed as the general hospital. There are three types of patient operations in surgical services: Inpatient patients are already admitted to the hospital on day of surgery Admit day patient (ADP) patient is admitted on the day of their operation, and stays more than 24 hours Outpatient patient arrives in the hospital on the day of surgery, and stays for less than 24 hours The 23-hour Patients are a subset of the outpatient category and must stay for observation beyond the normal outpatient recovery time, but stay for less than 24 hours. The Mott PACU is broken into two phases: Phase I, where patients resume consciousness, and Phase II, where patients meet their families, and nurses prepare patients for discharge. Except in special cases (mainly ICU patients), patients are brought to the PACU immediately after surgery. The process begins when the OR Circulating Nurse notifies the PACU Charge Nurse that the surgery is complete. As capacity dictates, the Charge Nurse assigns the patient to an available space in Phase I, and the anesthesiologist brings the patient from the OR to the PACU. The anesthesiologist then extubates the patient, and the patient returns to consciousness. When a patient returns to consciousness, he or she moves depending on patient-type: Outpatients proceed to PACU Phase II to meet their families and to prepare for discharge Inpatients and ADP proceed to the ICU or to their room in the main part of the hospital (the floor) 3
Although the majority of Phase II patients recover in the Blue room, which is dedicated to Phase II, these patients are occasionally moved to the Maize room, which is mainly used for pre-operative processes. Since the Maize and Blue rooms are similarly outfitted, and their occupancy rates peak at different times, the Maize room is under consideration as an outlet for excess PACU patients. Phase I is limited to 8 beds, with an enforced 1:1 nurse-to-patient ratio. Phase II has 11 recovery spaces, 4 of which are chair spaces. The nurse-to-patient ratio for Phase II is 1:3. Though the PACU has an extremely high occupancy rate during peak periods of the day, the department is empty or nearly empty in the evening and night hours. Due to this trend, housing 23-hour patients in the PACU at night is a possibility. Three to five procedures performed daily by Mott Surgical Services are 23-hour cases, and these patients are given rooms in the main part of the hospital, where space is extremely limited. Implementing a 23-hour PACU will help control space issues on the main floor. Goals and Objectives To determine the sources of inefficiency in patient flow from the OR to the PACU, the team will accomplish the following tasks: Develop overall picture of occupancy rates for Phase 1, Phase II (Blue room), and the Maize room Conduct quantitative analysis of collected data to identify process bottlenecks and reduce total process time Conduct series of studies of post-operative processes Quantify waste Identify sources of redundant work Issue surveys to nurses/administrative staff in order to garner feedback on potential sources of inefficiency and potential solutions With this information, the team will develop recommendations to: Decrease patient time in Phase 1 and Phase 2 Determine the viability of a 23-hour PACU Eliminate redundant work/process waste Project Plan The team will evaluate the post-operative processes at Mott and will regularly interact with the PACU charge nurse, the interim PACU nurse manager, and the Administrative Manager of Surgical Services. The primary parties affected by the outcome of the project are the patients at Mott, the charge nurse, the PACU nurses, and the administrative staff. The nurses and the administrative staff will implement the recommended process and will have to accommodate possible staffing changes. The patients will benefit from an efficient process that reduces surgery delays. The secondary parties affected by the project are the patients families and the surgical staff. 4
Key Issues There are certain constraints that limit how Mott Hospital can respond to overcrowding in Phase I and Phase II. Some of the factors that contribute to the problem are: A space constraint limits the number of beds in Phase I and Phase II and the possible layouts for these areas; the space constraint will remain a problem until the hospital moves to a new facility in 2011. Wait times in the O.R. lead to delayed or cancelled surgeries. The American Society of PeriAnesthesia Nurses regulates nurse to patient ratios for the PACU. Required time for patient recovery determines the shortest amount of time a patient must stay in the PACU. The team must be mindful of these limitations when making recommendations. Project Scope This project is limited in scope to the post-operative process at Mott Hospital. The process analyzed by the team begins when the OR Circulating Nurse requests a bed and ends when the patient departs from the PACU. Any task not related to the post-operative process will not be included in this project. Therefore, any pre-operative or intra-operative processes will not be considered. However, the team will collect occupancy data about the pre-operative Maize room to determine whether there is space available for Phase II or 23-hour patients. OR scheduling is outside the scope of this project, but the group may provide general recommendations for scheduling 23-hour patients. In addition, the project will not include recommendations regarding changes in the number of beds, which will remain fixed (although room layouts will be studied). Conversely, changes to staffing levels, PACU-specific processes, and PACU operating hours will all be considered. Proposed Approach: Data Collection and Analysis To improve processes at Mott PACU, the team will collect both qualitative and quantitative data. They will analyze the data to make recommendations to reduce process time and implement the 23-hour PACU. PACU Observations First, the team will spend three days observing the Mott PACU layout and process flow. The observation will provide the information needed to create a flowchart, which will help highlight areas causing bottlenecks, stations with excess capacity, and redundant processes that can be shortened or eliminated. Literature Search Since the point in recovery when families are able to see the patient may affect recovery time, the team will conduct a literature search to find a relationship between the two factors. The results of the literature search will serve as a recommendation for the optimal time to bring in families to 5
see patients. This will help standardize the PACU process since nurses currently use subjective estimates, which can lengthen the total process time to move through the PACU. Random Beeper Study and Worksheet Collection To collect data on Maize Room occupancy, the team will conduct a random beeper study for three weeks. The team will distribute worksheets to a nurse in the Maize Room; the worksheets will ask for the number of patients in the room at the time the beeper buzzes as well as the number of Phase II patients in the Maize Room. This will allow the team to quantify occupancy by time of day and day of week. The team will also give a PACU clerk a worksheet to collect data regarding wait-time to enter the PACU Monday through Friday throughout the day. The clerk will enter whether there is a delay every time the surgical staff requests a room. This data will give information on the frequency and length of delays to get into the PACU. Current Data Set Review The hospital currently collects data about each surgical case, including the duration of a patient s stay in Phases I and II; the dataset contains 14,000 patient entries and will be broken into process times by time-of-day, day-of-week, and surgery type. The information will be used to decrease total process time in Phase I and Phase II. Finally, the data will provide information on the feasibility of a 23-hour PACU. Nurse Surveys The team will survey the nursing staff to identify their perceptions of the problem as well as ideas for possible solutions. The surveys will Recommendations After the collecting and analyzing data, the team will present the findings and recommendations during an oral presentation and in a written report. Expected Impact The recommendations that the team will provide must meet the outlined goals and objectives. Specifically, the recommendations should have the following impact: Decrease wait-time to be admitted into PACU from the OR Reduce time surgeries are delayed and the number of delayed and cancelled surgeries Determine whether the Maize room should be used on a regular basis for PACU patients Determine how best to implement a 23-hour PACU Ensure patients receive required recovery time in Phase I and Phase II Project Team and Experience The following team members will work closely towards the completion of this project. Project Client/Manager Sheila Trouten: Interim Nurse Manager, PACU Sharon Lanzetta: Nurses Manager, PACU (Effective Feb. 11, 2008) 6
Project Coordinator Jesse Wilson: Administrative Manager of Surgical Services, Mott Hospital Project Team Maxwell Booth: Senior IOE student (See resume in Appendix A) Gunjan Sud: Senior IOE student (See resume in Appendix A) Raj Vashi: Senior IOE student (See resume in Appendix A) Support Required from Operating Entities The project client, the Nurse Manager of the PACU, will communicate requirements, expectations, and any relevant data/information to the team. She will also act as a liaison between the team and Mott employees, patients, and other individuals of interest for the project. Meanwhile, the project coordinator will help foster the relationship between the team and the client while also offering assistance in each phase of the project analysis. He will provide both data (spreadsheet data on patient turn-around times) and data collection tools (i.e. beepers for random beeper survey), as well as periodic feedback as the project progresses. Schedule and Key Dates The following dates represent the most important project activities. For a detailed Gantt chart, see Appendix B. Observe PACU processes and layout Perform random beeper study in Maize Room February 4 18, 2008 Analyze existing occupancy data February 1 18, 2008 Deliver interim report March 3 or 10, 2008 Perform survey of PACU nurses March 3 10, 2008 Analyze qualitative and quantitative data March 3 24, 2008 Develop recommendations March 17 31 Deliver final report April 14, 2008 Present final presentation By April 14, 2008 The team will also meet with the client every Friday from 10:30 to 11:30 am, and with the coordinator every Thursday from 12:00 to 1:00 pm. Estimated Team Hours Required The team estimates that this project will require 380 to 500 team hours, or 9 to 12 hours per week per team member. 7
Approval Approved by: Sheila Trouten (Client) Interim PACU Nurse Manager Jesse Wilson (Coordinator) Administrative Manager of Surgical Services Maxwell Booth (Student) Gunjan Sud (Student) Raj Vashi (Student) 8
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14- Jan 21- Jan 28- Jan 4- Feb 11- Feb 18- Feb 25- Feb 3- Mar 10- Mar 17- Mar 24- Mar 31- Mar 7- Apr 14- Apr Due Date Estimated Hours Task Team Members Responsible Max Gunjan Raj Meet with Jesse Wilson A ll 14 14 14 Meet with Sheila Trouten/Sharon Lanzetta All 14 14 14 Tour Mott facilities All 2 2 2 Proposal Draft All 8 8 8 Proposal Meeting (Mary Lind) All 1/31/08 1 1 1 Proposal Presentation All 2/4 or 2/11 6 6 6 Proposal approval All 1 1 1 Analyze existing datasheet Gunjan, Max 10 10 Prepare datasheets for nurses Gunjan 5 Distribute datasheets to PACU nurses Raj, Max 4 4 Conduct random beeper study in Maize Room All 5 5 5 Observe Phase 1 and Phase 2 Operations Al l 10 10 10 Create flowchart of PACU processes All 5 5 5 Draft survey for nursing staff Al l 3 3 3 Analyze data from beeper study Al l 3 3 3 Distribute survey to nursing staff Raj, Gunjan 4 4 Literature Search: Patient Recovery Time Raj 6 Make graphs/understand distribution of PACU occupancy rates Max 4 Prepare interim report and presentation All 6 6 6 Interim report meeting (Mary Lind) Al l 2/21/08 1 1 1 Interim report presentation Al l 3/3 or 3/10 5 5 5 Compile quantitative data Al l 6 6 6 Compile qualitative data Al l 6 6 6 Analyze viability of 23-hour PACU Al l 4 4 4 Determine best staffing configuration All 4 4 4 Determine whether to use Maize room for Phase 2 patients All 2 2 2 Prepare recommendations All 5 5 5 Compile results and recommendations in final report draft All 31-Mar 10 10 10 Create final presentation draft All 31-Mar 4 4 4 Final report meeting (Mary Lind) All 4/3/08 1 1 1 Complete final report All 8 8 8 Deliver final presentation to class All 4/7 or 4/14 1 1 1 Deliver final presentation to PACU staff All 4/14/08 1 1 1 154 155 150 Total: 459 10
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