Section IX Operating Room

Section IX Operating Room Summary of Recommendations Approach Data Collection and Synthesis Key Findings Perioperative Services Main OR & PACU Women s and Children s Ambulatory Care Center Central Processing Department Endoscopy and Cystoscopy Cardiac Cath Lab

Summary of Recommendations Improve suite utilization in both ORs and procedural suites. Design staffing plans to support revised available hours of operation and achieve targets. Perioperative Services: Governance: Evaluate effectiveness and desired outcomes of AIDE teams and charter a strong OR Governance Committee. Medical Director: Do not implement Medical Director of Perioperative Services at this time. Surgical Leadership: Articulate strategic plan, recruitment plan and program development for surgery to all surgeons. Nursing Leadership: Consolidate number of educators. Reassign responsibility according to proposed organization chart. Anesthesia: Optimize anesthesia technician and CRNA staff dependent of overall efficiency of ORs and coordination of other anesthetizing locations. Develop comprehensive cost containment/education program for residents and physicians. Information Services: Identify purpose for data collection/analyses and construct a Perioperative Dashboard. Case Scheduling: Charge OR Governance Committee with the complete revision and simplification of the scheduling policy. Modified Block Scheduling: Define/publish guidelines for a modified block schedule in P&P format and apply consistently to all participants. PreCare: Create a forum to consolidate, update and standardize all preadmission forms. Define value of PreCare to physicians and elicit their input to improve service. Section IX Page 2

Summary of Recommendations Main OR and Women s and Children s OR Utilization: Staff OR available hours/rooms to achieve OR suite utilization, w/o turn around time (TAT) of 70%. First Case On Time Start & Delays: Define Start Time performance expectations of anesthesia, nursing, surgeons and patients and achieve 95% of first case on-time starts consistently. Turn Around Time: Adopt TAT targets, established by specialty or type of case, and monitor consistently to ensure accomplishment and maintenance of targets. Staffing and Productivity: Consolidate cases in OR clusters to optimize nursing and anesthesia resources and reduce available hours to achieve target utilization support. Main PCS/PACU and Women s and Children s PACU Patient Flow: Capture essential patient information electronically to analyze problem areas. Achieve productivity target of 4.00. Collaborate with bed capacity management that directly impacts on PACU LOS. Staffing and Productivity: Evaluate current productivity against target, and adjust staffing patterns and overtime as aggressively as possible. Ambulatory Care Center (ACC) Utilization: Staff OR available hours/rooms to achieve OR suite utilization, w/o TAT of 75%. Turn Around Time: Adopt TAT targets, established by specialty or type of case and monitor consistently to ensure accomplishment and maintenance of targets. Staffing and Productivity: Evaluate current productivity against target, and adjust staffing patterns to achieve target of 9.00 worked hours per case. Section IX Page 3

Summary of Recommendations Central Processing Department (CPD) Staffing and Productivity: Evaluate current productivity against target, and adjust staffing patterns and overtime. Adult GI Procedures, Pediatric Endoscopy, Urodynamics & Cystoscopy Utilization: Reduce available hours in both units to achieve 75%. Cross-train staff to cover both units and consider redeployment of redundant staff following revision of available hours to Meadowmont. Evaluate consolidation Urodynamics and Cystoscopy without compromise to patient care and satisfaction. Staffing and Productivity: Consolidate pediatric unit with staff that cross-cover both Endoscopy and pulmonology. Cardiac Cath Lab Overview: Apply successful Impact Care methodology to achieve department s goals. [Portions of the Recommendations are confidential and have been redacted.] Section IX Page 4

Approach Case Case Scheduling Scheduling Precertification Precertification Patient Patient Preparation Preparation History History & Physical, Physical, Consents Consents Admission Admission Criteria Criteria Discharge Discharge Criteria Criteria Phase Phase II II Overnight Overnight Stays Stays ICU ICU Gridlock Gridlock On On Time Time Starts Starts Suite Suite Utilization Utilization Modified Modified Block Block Scheduling Scheduling Turn Turn Around Around Time Time (TAT) (TAT) Add-On Add-On Cases Cases & Cancellations Cancellations Section IX Page 5

Data Collection and Synthesis Unless otherwise noted, the completed models reflect patient level data for the period July 1, 2003 to June 30, 2004. The Main PACU data were manually collected and captured the months of October 2003 and February 2004. The data were defined as follows: Total Case Minutes Turn Around Time (TAT) Turn Around Time (TAT) Patient In Room Procedure Begin (incision) Procedure End (closure) Patient Out Room Room Ready Patient In Room Section IX Page 6

Key Findings Current UNCH Method Suite Utilization = 73% Recommended NCI Method Suite Utilization = 55% Includes Prime Time hours (7:30 AM 5:30 AM), weekdays only. Swing/hold room case hours. TAT of 40 minutes per case, including first and last cases of the day. Excludes All available hours outside of Prime Time, including evenings, nights and weekends. Swing/hold room available hours. Released block time hours. Includes All available hours, including Prime Time, evening, nights and weekends. 50 weeks of available hours, to allow for holidays. All case hours, regardless of time of day and day of week case completed. Excludes TAT. Call hours. Overtime hours. [Portions of the Key Findings are confidential and have been redacted.] Section IX Page 7

Key Findings Recommendation Suite utilization, in both ORs and procedural suites, may be improved in three ways: Increase case hours. Decrease available hours. Combination of both approaches. Other opportunities include: Establish Perioperative Governance Committee. Adjust hours of operation to achieve leading practice utilization. Revise modified block scheduling policy and block allocation. Revise staffing plans to support revised available hours of operation and achieve productivity targets. [Portions of the Recommendation are confidential and have been redacted.] Responsibility Dean OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 8

Perioperative Services Governance Medical Director of Perioperative Services Surgical Leadership Nursing Leadership Anesthesia Perioperative Services Information System Case Scheduling Modified Block Scheduling PreCare

Perioperative Services Governance There are three separate committees that touch Perioperative Services governance. Current committees perceived to be ineffectual by many physicians. Attendance fluctuates. Annual goals for committees absent. Extensive data collection rarely yields specific plans to achieve improvements. Many surgeons interviewed stated that no one drives Surgical Services too many agendas and no one is seeing the big picture. OR Management Committee Convenes monthly to consider OR staffing, scheduling and block time allocation. Membership includes: Vice President, Surgical Services Chair, Anesthesia COO (must approve of all recommendations) Chief of Staff (must approve of all recommendations) Vice President, Human Resources Section IX Page 10

Perioperative Services Governance Surgical Services Advisory Committee Held monthly with an open invitation to anyone interested in attending. Core membership described by Vice President, Surgical Services as high-volume surgeons. Lack of physician interest in assuming leadership role on this Committee precipitated the Vice President, Surgical Services assuming Chair. Some surgeons stated this Committee should be led by a physician. Described as the nuts and bolts of the OR. Primary responsibility defined as allocation of block time. Reported effectiveness of this Committee mixed, ranging from empowering surgeons, to a forum for analysis paralysis with no decisions and a gripe session. Issues frequently resurface, suggesting inadequate solutions or implementation. OR Policy Committee Meets monthly to consider policies that govern the OR. Per medical by-laws, Chair of this Committee is the Chair of the Department of Surgery. Committee members include Department Chairs and Perioperative Services nursing leadership. Perception of several surgeons that OR Policy Committee serves only to rubber stamp recommendations of Surgical Services Advisory Committee. This Committee s ability to enforce compliance with key policies reported as minimal. Section IX Page 11

Perioperative Services Governance Impact Care In addition to the three standing committees, AIDE Teams have been commissioned to focus on key processes that impact on the patient flow. Six Sigma methodology utilized. Extensive data collection and analysis conducted and reviewed by AIDE team members, which include physicians, nurses and other key stakeholders of process being studied. Recent AIDE teams include: Start Time Patient In to Skin Final report not yet released, leading some surgeons to speculate that report release was being delayed to avoid the discomfort of pointing fingers at responsible parties. Skin to Close AIDE Team reports are presented to Surgical Services Advisory Committee, OR Policy Committee and quarterly to every faculty meeting. Vice President, Surgical Services stated the veracity of data presented by the AIDE Team is never challenged. Some physicians described the AIDE teams as having no impact on process improvements, while being very time consuming for team members. Section IX Page 12

Perioperative Services Governance Recommendation Evaluate effectiveness and desired outcomes of AIDE teams. Conclude AIDE teams in progress and widely publicize final reports. Charter a strong OR Governance Committee to provide a consistent, organized process to help overcome operational obstacles and manage the resources of Perioperative Services. With this structure, Medical Staff will have a great sense of motivation and appropriate empowerment, and operational decisions must be data-driven and based upon leading performance targets. Implement OR Governance Committee to own operational improvement of all aspects of Perioperative Services. Charge OR Governance Committee with: Achieving an esprit de corps of working together collaboratively. Achieving monthly leading practice operational and fiscal targets. Include leadership from clinical, fiscal, IT and administrative realms on OR Governance Committee. Define annual goals for OR Governance Committee. Incorporate operational and fiscal Dashboard as a standing monthly agenda item for OR Governance Committee with necessary changes implemented quarterly in response to Dashboard. Responsibility Dean and Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 13

Perioperative Services Medical Director of Perioperative Services Chair of Anesthesia identified as current Medical Director of Perioperative Services, although there is no specific description for this position. Specific role and responsibilities have been under development for three years. Draft position description (based on example from University of Wisconsin), couples this position with role of Vice Chair of Clinical Operations for the Department of Anesthesiology. Details from draft position description include: Accountable to all department chairs for academic issues. Independent authority to enforce OR policy. Surgical Services Advisory Committee to provide link to both clinical enterprise and clinical departments of primary Perioperative stakeholders. Functional supervision will be exercised over all staff working within the OR suites (anesthesiologist, surgeons, nurses, support staff, etc.) Direct daily operations of UNCH ORs. Chair of Surgical Services Advisory Committee. Member of OR Policy Committee. In collaboration with management, develop policies/procedures relating to function of ORs. Implement and enforce established standards for Perioperative care. Establish practices that facilitate expeditious service to all customers of Perioperative services. Provide leadership in planning proactively to match resources and facilities to service demand in coordination with UNCH. Section IX Page 14

Perioperative Services Medical Director of Perioperative Services Recommendation Do not implement Medical Director of Perioperative Services at this time. Very specific and rare skill set required to successfully serve as Medical Director of Perioperative Services. Separate role and responsibilities for Vice Chair of Clinical Operations for the Department of Anesthesiology from Medical Director of Perioperative Services. Assign leadership role, possibly Vice Chair, on OR Governance Committee. Implement OR Governance Committee, rather than investing pivotal responsibilities in one individual. Responsibility Chair, Anesthesia Dean Timeframe Second Quarter 2005 Section IX Page 15

Perioperative Services Surgical Leadership [The is confidential and has been redacted.] Recommendation Articulate strategic plan for surgery to all surgeons, including recruitment plans and program development. Communicate clearly UNCH plans to correct bed capacity management and all associated processes. Engage surgeon and anesthesia leaders in OR Governance Committee. Responsibility Dean Chair, Surgery Timeframe Third Quarter 2005 Section IX Page 16

Perioperative Services Nursing Leadership Vice President, Surgical Services reports directly to COO. Multiple accomplishments of Vice President, Surgical Services reported by physicians. Accessible and responsive to surgeons. Desire to improve service evident. Overall more positive environment since her arrival. OR staff stabilized, although continued chronic use of OR traveler staff. Concern expressed by some surgeons that responsibility for Laundry and Linen, recently assigned to Vice President, Surgical Services, will diffuse her attention to Perioperative Services. Nursing management team appear collegial and supportive of each other. [Portions of the are confidential and have been redacted.] Section IX Page 17

Perioperative Services Nursing Leadership Organizational chart of Surgical Services Division reflects an atypical number of support staff, congregated in the Business Office. Staff of thirteen includes five educators, one of whom is assigned to special projects for the Vice President, Surgical Services. Two educators are assigned to the ORs, and two serve the PACUs. OR Scheduler uniformly identified by physicians as the most informed and involved in the day-today OR activities and efficient patient flow. OR Supervisors complete staff evaluations and ordering details. [Portions of the are confidential and have been redacted.] Section IX Page 18

Perioperative Services Nursing Leadership Recommendation Consolidate number of educators. Action will facilitate continued decrease of travelers in OR. Combine special projects for Vice President, Surgical Services with remaining educators responsibilities. One educator for OR needs and one to cover PACU needs. Consolidate OR Director and OR Scheduler positions. Consider current OR Scheduler to assume expanded role. Responsibility Vice President, Surgical Services Timeframe Second Quarter 2005 Section IX Page 19

Perioperative Services Anesthesia Certified Registered Nurse Anesthetist (CRNA) and anesthesia technician staff provided to assist in provision of anesthesia care in multiple locations. Positions are budgeted outside of the Department of Anesthesia and include: 40 CRNAs 30 anesthesia technicians 4 anesthesia workroom staff Anesthesia technician duties include set up of all fluids, calibration of monitors and twelve-point check of all anesthesia machines. Cost of drugs, gases, equipment and supplies reported as unknown to many anesthesia care providers, leading to an uncoordinated cost containment effort. Budget based on prior year s spend, not leading practice, so financial consequence of waste not readily apparent. Pharmacy will assume drugs used by anesthesia providers in FY05. PACU holds frequently require patients to be recovered in the OR, or in the PACU by the CRNA. [Portions of the are confidential and have been redacted.] Section IX Page 20

Perioperative Services Anesthesia Recommendation As with the anesthesiologists, optimization of anesthesia technician and CRNA staff dependent of overall efficiency of ORs and coordination of other anesthetizing locations. Develop comprehensive cost containment and education program to include residents and physicians. Ensure PACU staff are consistently communicating RN and bed availability to anesthesia providers to proactively determine and deliver appropriate level of patient care. Please see Section X, Anesthesia Services, for an in-depth review. Responsibility Chair, Anesthesia Vice President, Surgical Services Chief CRNA Timeframe Third Quarter 2005 Section IX Page 21

Perioperative Services Information System GE ORMIS system used in all operating suites. Implementation of 7.2 documentation upgrade in August and September 2004 completed with some difficulty. Data entry during the upgrade may have been temporarily compromised. Numerous reports produced on key performance processes, such as TAT, although effective changes not readily apparent. Dedicated FTE for Informatics resides in Surgical Services Business Office. Current reports are cumbersome and inconclusive. Recommendation Identify purpose for data collection and analyses, beyond generation of reports. Identify specific performance metrics with clear definitions to be measured and monitored monthly in order to construct Perioperative Dashboard. Consistently utilize accurate, timely analyses of data in the OR Governance Committee. Provide clear explanation for data-driven variances, if any, coupled with a correction plan. Clarify roles and responsibilities of dedicated FTE for Informatics to optimize position. Responsibility Vice President, Surgical Services Timeframe Second Quarter 2005 Section IX Page 22

Perioperative Services Case Scheduling Case Scheduling OR schedulers are located in the same office as the PreCare staff who are responsible for preadmission patient chart assembly. Next day s schedule closes at 10:00 AM day prior. Scheduling process reported by some surgeons as confusing, with multiple pathways for posting slips. Scheduling policy appears cumbersome and in need of revision. [Portions of the are confidential and have been redacted.] Case Length OR Managers expressed uniform concern over in congruency between actual case length and case length projected by surgeon. Vice President, Surgical Services identified wide variance in case length for same procedures, citing multiple reasons, including: Attending surgeon s presence at opening and close of case. Teaching skills and style of both the attending surgeon and anesthesiologist. Section IX Page 23

Perioperative Services Case Scheduling Urgent and Emergent Cases Definitions of urgent and emergent differed among interviewees. [Portions of the are confidential and have been redacted.] Surgeon Perceptions Some surgeons reported that it is very difficult to add-on cases. Surgeons are told there is no time available on the schedule and are placed on the add-on list. Management of the Daily Schedule Schedule Coordinator manages daily schedule for Main OR, W/C and coordination of cases from ACC. Anesthesiologist assigned daily to partner with Schedule Coordinator. Success in this role dependent on the individual. Section IX Page 24

Perioperative Services Case Scheduling Recommendation Charge OR Governance Committee with the complete revision and simplification of the scheduling policy. Standardize urgent and emergent definitions. Assess why cases are added to schedule: Inaccessibility of time during the day. Difficulty scheduling due to late release. Conflict with office hours. Compose criteria for add-on cases and evaluate financial impact of unlimited after hours volume. NCI Target: 5% or less of total cases should be add-ons, excluding elective cases. Responsibility Dean OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 25

Perioperative Services Modified Block Scheduling Current modified block scheduling by service, which administers block assignments internally. Average TAT is included in utilization calculations, as follows: Main OR 40 minutes W/C OR 30 minutes ACC OR 20 minutes Block utilization credit includes cases which begin within the block, but end afterwards. Example: Assigned block ends at 5:30 PM Case begins 3:30 PM Case ends 9:30 PM Block utilization credit is from 3:30 PM to 9:30 PM, not 3:30 PM to 5:30 PM. Block must be filled prior to booking into first come, first serve room, or swing room. Blocks are ten hours, from 7:30 AM to 5:30 PM, weekdays. Section IX Page 26

Perioperative Services Modified Block Scheduling Block allocation and utilization first reviewed by Surgical Advisory Committee. Consequences for low utilization nebulous it would be very unusual to have block time taken away. Recommendations of the Task Force on OR Block Time Allocation, prepared May 2004, included the following points: Service-specific TAT will be added to block utilization calculation. Warning or reduction in OR block time if utilization is below 67%. Offer for additional time if utilization is over 95%. No action to be taken if utilization is between 67% and 95%. Majority of available time is blocked, with minimal release times for all services. Main OR All Services Protected until 10:00 AM day prior to day of surgery Cardiac Protected until 5:00 PM day prior to day of surgery Ortho Protected until 6:00 AM day of surgery Section IX Page 27

Perioperative Services Modified Block Scheduling Majority of available time is blocked, with minimal release times for all services. W/C OR All Services Protected until 10:00 AM day prior to day of surgery Pediatrics Protected until 6:00 AM day of surgery ACC OR All Services Seven days prior to day of surgery GYN Protected 24 hours prior to day of surgery [Portions of the are confidential and have been redacted.] Section IX Page 28

Perioperative Services Modified Block Scheduling Recommendation Define and publish succinct guidelines for a modified block schedule in policy and procedure format and include: Minimum hours required for block time Block release times Short release times negate the usefulness of the room for case scheduling. Most patients cannot arrange to have surgery with only a few hours notice. Leading practice allocated block utilization time, without TAT, is 75%. Apply block guidelines consistently to all participants. Establish service specific block release times, for example: Orthopedics & ENT 7 days GYN & Urology 3 days General & Vascular 2 days Review block schedule utilization monthly and adjust quarterly by the OR Governance Committee. Discontinue inclusion of TAT in block utilization calculation as it falsely inflates utilization. Responsibility OR Governance Committee Timeframe Third Quarter 2005 Section IX Page 29

Perioperative Services PreCare Department s primary objective to to prepare patients form admission, surgery or anesthesia procedures. PreCare environment is patient-friendly, organized and modern. Patient care is provided weekdays, from 6:00 AM to 6:00 PM. Patient must be registered in PreCare no later than 5:00 PM in order to be evaluated. PreCare Manager identified several department objectives, including: Ensure patient wait time is less than or equal to one hour from arrive to entrance into exam room. Completed charts are reported to be available for physician review the night before. Chart carts are sent to physician workrooms and other appropriate areas. Minimum preoperative testing guidelines deemed unnecessary by anesthesia, according to PreCare Manager. Walk-in patients identified by PreCare Manager as biggest problem, confounding patient flow. [Portions of the are confidential and have been redacted.] Section IX Page 30

Perioperative Services PreCare Department of Anesthesia provides a Nurse Practitioner (NP) to evaluate specific patients, although criteria for patient selection is not available. NP sees an estimated four patients per day. Preanesthetic Patient Questionnaire developed by Department of Anesthesia to assist in patient evaluation for anesthesia consultation. Questionnaire currently being produced. PreCare Manager identified need for consistent coverage by an anesthesia provider. Several surgeons described PreCare process as unnecessary and of no value to patients. Required documentation perceived by some physicians as burdensome. PreCare Manager estimated 60 minutes is required to complete each patient chart, and 45 minutes is needed for patient evaluation. Recommendation Create a forum to consolidate, update and standardize all preadmission forms. Consolidate chart composition process and eliminate redundant documentation. Increase virtual preoperative preparation and evaluation. Define value of PreCare to physicians and elicit their input to improve service. Pilot Preanesthetic Patient Questionnaire without delay. Responsibility Chair, Anesthesia, Vice President, Surgical Services and OR Governance Timeframe Second Quarter 2005 Section IX Page 31

Main OR & PACU OR Utilization [Confidential] First Case On Time Starts TAT Staffing & Productivity (includes W/C and Business Office) Procedural Care Suites (PCS)/PACU LOS Staffing & Productivity

Main OR Cases in Progress, Average 25 OR Cases in Progress - Average Monday - Friday July 1, 2003 - June 30, 2004 20 Cases in Progress 15 10 5 0 12am 1am 2am 3am 4am 5am 6am 7am 8am Hours 9am of Operation 10am 11am 12pm 1pm 2pm 3pm Mon Average 4pm 5pm Cases 6pm in Progress 7pm 8pm 9pm 10pm 11pm Tue Average Cases in Progress Wed Average Cases in Progress Thu Average Cases in Progress Fri Average Cases in Progress Note: 13255 of 13296 cases included in analysis Wednesday is inservice day - all rooms open at 8:15am Section IX Page 33

Main OR Utilization [The is confidential and has been redacted.] Recommendation Staff OR available hours and number of rooms to achieve OR suite utilization, without TAT of 70%. NCI target is 70% due to Level I coverage requirements. Schedule cases in sequence, rather than concurrently to optimize suite utilization. Total number of first case starts driven, in part, by the elimination of scheduled gaps, such as lunch breaks. Schedule should be compressed both horizontally and vertically, while remaining as user- friendly to surgeons as possible. Compare NCI utilization calculations with current UNCH to understand reasons for variance. Staffed available hours should reflect what is expected to be open, that is, the staffing schedule made a month in advance, which ultimately drives the labor budget. NCI model considers the entire case volume and case hours, regardless of day or time case was completed, was accomplished within available hours. 52 weeks of case hours/50 weeks of available hours (to account for holidays). Responsibility OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 34

Main OR First Case On Time Start & Delays Start time defined as Patient In Room Time. Grace period defined as both greater than six minutes and ten minutes before a case is considered late. A grace period of ten minutes was utilized in the following analysis. Current performance demonstrates 67% of cases are considered on time. Late starts attributed to multiple factors, including: Missing patient consents. Delayed lab results. Late anesthesia. Late surgeons. Case cancellations. Estimate five per week, often due to undetected or changed patient condition. Specific criteria for being designated a late surgeon (frequency in a predetermined timeframe) not defined. Unknown consequences, if any, for a late surgeon. Delay codes are rarely and inconsistently used. Vice President, Surgical Services stated the ORMIS 7.2 version may include delay codes. [Portions of the are confidential and have been redacted.] Section IX Page 35

Main OR First Case On Time Start & Delays Recommendation Define start time performance expectations of anesthesia, nursing, surgeons and patients. Achieve 95% of first case on-time starts consistently. Communicate nursing and anesthesia assignments the day before to facilitate planning and smooth execution of the daily schedule. Complete and assemble all required elements for cases by noon the previous day including H&P, consents and financial clearance. Utilize delay codes for every case. Review delay data consistently with predetermined and well known consequences. Responsibility OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 36

Main OR First Case On Time Starts OR First Scheduled Case of the Day On Time Starts Monday - Friday May 1, 2003 - July 30, 2004 35% 30% 30% Percentage of Cases 25% 20% 15% 10% 22% 15% 13% 5% 5% 5% 2% 1% 2% 5% 0% Early or On Time 5 10 15 20 25 30 35 40 > 45 Minutes Start time defined as Patient-in time 10 minute grace period allocated before being considered late Current Performance: 67% of first cases start within 10 minutes of posted start time Target Performance: 95% of first cases start within 10 minutes of posted start time Note: 4333 of 13296 cases analyzed Section IX Page 37

Main OR Turn Around Time (TAT) TAT is a reflection of case complexity, with 25 minutes for the most instrument and equipment intensive cases, such as spinal surgery, total joint replacement and open heart surgery. Period from 2:30 PM to 3:30 PM identified by multiple surgeons as the slow down period for the majority of nursing staff. Parallel processing to begin cases reported by physicians as not in place, which delays patients from entering the OR. The following analyses consider the best case scenario (consecutive cases in the same room by the same surgeon). An average TAT of 25 minutes does not capture the extent of the problem. Over 60% of the cases analyzed had TAT of 25 minutes or longer, which is incongruent with the case mix. Leading practice suggests 15 to 20 minutes TAT for the majority of cases. Most ophthalmic, ENT and plastics cases should be 10 to 15 minutes. Vice President, Surgical Services estimated average TAT of 40 minutes, a critical metric, as average TAT is added to cases being scheduled and block utilization calculations. [Portions of the are confidential and have been redacted.] Section IX Page 38

Main OR Turn Around Time (TAT) 30% 25% 24% Main OR Turn Around Time Distribution Same Surgeon, Same Room, Consecutive Cases July 1, 2003 - June 30, 2004 Average: 25 minutes Percentage of Turnover Cases 20% 15% 10% 5% 6% 4% 6% 12% 17% 17% 14% 0% 10 or fewer 15 20 25 30 35 40 > 40 Minutes Current Performance: 60% of analyzed cases have TAT > 25 minutes Note: 3630 of 13295 cases anlayzed Section IX Page 39

Main OR Turn Around Time (TAT) - 50 45 40 35 30 25 20 15 10 5 32 32 34 35 34 Main OR Turn Around Time by Service - Average Same Surgeon, Same Room, Consecutive Cases July 1, 2003 - June 30, 2004 32 34 38 33 37 35 34 34 35 35 Section IX Page 40 11 35 35 25 25 PEDIATRICS PEDIATRIC DENTISTRY OVERALL AVERAGE Minutes OPHTHALMOLOGY UROLOGY OTOLARYNGOLOGY GENERAL-TRAUMA VASCULAR SURGERY GENERAL-PEDIATRIC SURGERY ORTHOPAEDICS NEUROSURGERY CARDIOTHORACIC SURGERY GENERAL-ABDOMINAL TRANSPLANT GENERAL-GI SURGERY GENERAL-BURN PLASTIC & RECONSTRUCTIVE SURGERY GENERAL-SURGICAL ONCOLOGY ORAL & MAXILLOFACIAL PSYCHIATRY ORAL MEDICINE Note: 3630 of 13295 cases anlayzed

Main OR Turn Around Time (TAT) Recommendation Adopt TAT targets, established by specialty or type of case. Monitor TAT consistently to ensure accomplishment and maintenance of targets. Initiate parallel processes to allow more timely movement of the patient into the OR. Communicate performance expectations to all staff members and monitor compliance. Responsibility OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 41

Main OR & W/C OR Staffing & Productivity Vice President, Surgical Services reported staff vacancies in all ORs. OR staff recruitment and retention described as a longstanding problem at UNCH. Effective team relationships also identified by Vice President, Surgical Services, as a challenge to filling existing vacancies. Ten traveler RNs utilized, in addition to four per diem contractors. Travelers primarily assigned lunch and early evening shifts. Salaries reported as competitive. Vice President, Surgical Services reported the following OR staffing realities: Five FTES approved off daily on first come, first serve basis Four FTEs call-in daily Surgeons described as appreciative of nursing with a high tolerance for new graduates in training. [Portions of the are confidential and have been redacted.] Section IX Page 42

Main OR & W/C OR Staffing & Productivity Specialty team nursing in place, as follows: Cardiac, transplant, vascular and thoracic. Plastics, burns, oral medical dentistry. Neurosurgery, ophthalmology. Orthopedics. General surgery, urology. Pediatrics/GYN (W/C). Specialty team call utilized on 11:00 PM to 7:00 AM shift. Call redesign under consideration. RN resident program conducted every six months. Currently, twelve RN residents occupy full-time RN positions. Scholarship offered with an 18 to 24 month commitment upon completion of program. Curriculum based on AORN 101 course. Skill mix of 65% RN and 35% surgical technologist close to leading practice of 60:40. Vice President, Surgical Services concurred with target of 6.00 Worked Hours per Case Hour and stated additional potential volume could be accomplished with current staff while maintaining the target of 6.00 Worked Hours per Case Hour. November 2, 2004, review of draft report with NCI. Section IX Page 43

Main OR & W/C OR Staffing & Productivity Main OR, W/C OR & Business Office Overtime as a percentage of Worked Hours. Current 1.33 NCI Target 2.00 Business Office reported higher overtime than ORs at 1.75%. Main OR, W/C OR & Business Office Productivity: Worked Hours per Case Hour. Current 6.06 NCI Target 6.00 FTE Opportunity 1.04 Recommendation Consolidate cases in OR clusters to optimize both nursing and anesthesia resources. Reduce available hours to achieve target utilization support. [Portions of the Recommendation are confidential and have been redacted.] Responsibility Vice President, Surgical Services Timeframe Third and Fourth Quarters 2005 Section IX Page 44

Main PCS/PACU Patient Flow Unit cares for both pre- and post-surgical patients. PCS has 15 private roomettes and one pediatric playroom. PACU has 27 bed spaces in an open ward and two private rooms for patients requiring isolation. Approximately three inmate patients served weekly, requiring some separation from other patients in this unit. All Main OR patients, including ICU admits, are recovered in this unit. Cardiac, transplant and intubated patients go directly to ICU from OR. Manual data (October 2003 and February 2004) were provided for analyzes. 62% of all visits exceed 90 minutes in October 2003. 65% of all visits exceed 90 minutes in February 2004. Average LOS decreased 28 minutes in February 2004, from 163 to 135 minutes. Discharge by both criteria and anesthesia sign-off. Anesthesia provides Medical Director for this area. Section IX Page 45

Main PCS/PACU Patient Flow PACU Length of Stay (LOS) Distribution October 2003 25% 22% Average: 163 minutes 20% 18% Percentage of Visits 15% 10% 15% 10% 9% 7% 14% 5% 4% 2% 0% 30 60 90 120 150 180 210 240 > 240 Length of Stay in Minutes Current Performance: 62% of PACU visits have LOS > 90 minutes Target Performance: LOS does not exceed 60-90 minutes Note: 947 of 949 visits analyzed Section IX Page 46

Main PCS/PACU Patient Flow 25% PACU Length of Stay (LOS) Distribution February 2004 21% Average: 135 minutes 20% 19% Percentage of Visits 15% 10% 12% 14% 11% 11% 6% 5% 4% 2% 0% 30 60 90 120 150 180 210 240 > 240 Length of Stay in Minutes Current Performance: 65% of PACU visits have LOS > 90 minutes Target Performance: LOS does not exceed 60-90 minutes Note: 815 of 822 visits analyzed Section IX Page 47

Main PCS/PACU Patient Flow In addition to Main OR patients, PACU will assist with conscious sedation reversal, patients recovering from anesthesia from other procedural areas and serves as a capacity management overflow area. Main PCS/PACU Manager estimated there are three to five overnight boarders in PACU weekly. Variance in practice among Anesthesiologists yields variance of LOS for like procedures. [Portions of the are confidential and have been redacted.] Recommendation Begin capturing essential patient information electronically, in order to analyze problem areas effectively. Patient PACU admission time. Patient ready for discharge time. Patient discharge form PACU time. Detailed reasons for delay (unit, person declining transfer and reason given). Section IX Page 48

Main PCS/PACU Patient Flow Recommendation Achieve productivity target of 4.00 through reduction of worked hours required to provide appropriate patient care. Assess all drivers of prolonged LOS and reduce or eliminate factors to achieve productivity target. Efforts must be coordinated with bed capacity management efforts. Discharge PACU patients by criteria, rather than waiting for anesthesia. Review practice variance in anesthesia that influence level and length of PACU care. Responsibility Vice President, Surgical Services Timeframe Third Quarter 2005 Fourth Quarter 2005 (overall Capacity Management effort) Section IX Page 49

Main PCS/PACU Staffing & Productivity Main PCS/PACU Overtime as a percentage of Worked Hours Current 2.53 NCI Target 2.00 [Portions of the are confidential and have been redacted.] Recommendation Evaluate current productivity against target, and adjust staffing patterns and overtime as aggressively as possible. Develop plan to adjust staffing to mirror anticipated improvements in bed capacity management. Responsibility Vice President, Surgical Services Timeframe Third Quarter 2005 Fourth Quarter 2005 (overall Capacity Management effort) Section IX Page 50

Women s & Children s (W/C) OR Utilization First Case On Time Starts TAT Procedural Care Suites (PCS)/PACU Staffing & Productivity

W/C OR Utilization [The is confidential and has been redacted.] Recommendation Continue to effectively manage case volume and available hours. Responsibility Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 52

W/C OR First Case On Time Start & Delays Start time defined as Patient in Room Time. Grace period defined as both greater than six minutes and ten minutes before a case is considered late. A grace period of ten minutes was utilized in the following analysis. Specific criteria for being designated a late surgeon (frequency in a predetermined time frame) not defined. Delay codes are rarely and inconsistently used. Vice President, Surgical Services stated the ORMIS 7.2 version may include delay codes. Current performance demonstrates 72% of cases are considered on time. [Portions of the are confidential and have been redacted.] Recommendation Define start time performance expectations of anesthesia, nursing, surgeons and patients. Achieve 95% of first case on-time starts consistently. Communicate nursing and anesthesia assignments the day before to facilitate planning and smooth execution of the daily schedule. Complete and assemble all required elements for cases by noon the previous day including H&P, consents and financial clearance. Utilize delay codes for every case. Review delay data consistently with predetermined and well known consequences. Responsibility OR Governance Committee, Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 53

W/C OR First Case On Time Starts Percentage of Cases 35% 30% 25% 20% 15% 10% 5% 0% 29% Early or On Time 26% 17% OR First Scheduled Case of the Day On Time Starts Monday - Friday July 1, 2003 - June 30, 2004 13% 3% 5% 2% 1% 1% 5 10 15 20 25 30 35 40 > 45 Minutes Start time defined as Patient-in time 10 minute grace period allocated before being considered late Current Performance: 72% of first cases start within 10 minutes of posted start time Target Performance: 95% of first cases start within 10 minutes of posted start time 3% Note: 1448 of 4888 cases analyzed Section IX Page 54

W/C OR Turn Around Time (TAT) TAT is a reflection of case complexity, with 25 minutes for the most instrument and equipment intensive cases, such as spinal surgery, total joint replacement and open heart surgery. Physicians interviewed identified TAT as a chronic problem. Anesthesia identified as contributor to delayed TAT, due to lack of proactive planning. The following analyses consider the best case scenario (consecutive cases in the same room by the same surgeon). An average TAT of 27 minutes does not capture the extend of the problem. Over 57% of the cases analyzed had TAT of 25 minutes or longer, which is incongruent with the case mix. Vice President, Surgical Services estimated average TAT of 30 minutes, a critical metric, as average TAT is added to cases being scheduled and block utilization calculations. Section IX Page 55

W/C OR Turn Around Time (TAT) 30% W&C OR Turn Around Time Distribution Same Surgeon, Same Room, Consecutive Cases July 1, 2003 - June 30, 2004 Percentage of Turnover Cases 25% 20% 15% 10% 5% 0% Average: 27 minutes 24% 21% 15% 16% 10% 7% 5% 1% 10 or fewer 15 20 25 30 35 40 > 40 Minutes Current Performance: 57% of analyzed cases have TAT > 25 minutes Note: 1931 of 4888 cases analyzed Section IX Page 56

W/C OR Turn Around Time (TAT) - 50 45 40 35 30 25 20 15 10 5 22 24 26 27 27 W&C OR Turn Around Time by Service - Average Same Surgeon, Same Room, Consecutive Cases July 1, 2003 - June 30, 2004 30 25 34 30 31 31 33 Section IX Page 57 31 32 26 27 OVERALL AVERAGE PEDIATRICS PEDIATRIC DENTISTRY Minutes OPHTHALMOLOGY UROLOGY OTOLARYNGOLOGY GENERAL-PEDIATRIC SURGERY ORTHOPAEDICS NEUROSURGERY PLASTIC & RECONSTRUCTIVE SURGERY ORAL & MAXILLOFACIAL GYN SURGERY REPRODUCTIVE ENDOCRINOLOGY WOMENS PRIMARY GYNECOLOGY GYNECOLOGY ONCOLOGY UROGYNECOLOGY Note: 1931 of 4888 cases anlayzed

W/C OR Turn Around Time (TAT) Recommendation Adopt TAT targets, established by specialty or type of case. Monitor TAT consistently to ensure accomplishment and maintenance of targets. Initiate parallel processes to allow more timely movement of the patient into the OR. Communicate performance expectations to all staff members and monitor compliance. Responsibility OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 58

W/C PCS/PACU Patient Flow Unit cares for both pre and post surgical patients. PCS has 12 private roomettes divided between a women s PCS and a children s PCS. PACU has nine bed spaces in an open ward and two private rooms for patients requiring isolation. Pediatric patients are admitted through the lobby due to the distance to W/C. One family member is allowed to carry pediatric patient into the OR. Family member is escorted by OR staff out of restricted area. Main PCS/PACU Manager estimated Phase I length of stay (LOS) to be 90 to 120 minutes. Manual data (October 2003 and February 2004) were provided for analyzes. 21% of all visits exceed 90 minutes in October 2003. 25% of all visits exceed 90 minutes in February 2004. Average LOS increased two minutes in February 2004 from 79 to 81 minutes. Discharge by both criteria and anesthesia sign-off. Anesthesia provides Medical Director for this area. Section IX Page 59

W/C PCS/PACU Patient Flow W&C PACU Length of Stay (LOS) Distribution October 2003 45% 40% 39% Average: 81 minutes 35% Percentage of Visits 30% 25% 20% 15% 14% 22% 10% 5% 0% 10% 4% 4% 1% 2% 30 60 90 120 150 180 210 240 > 240 Length of Stay in Minutes Current Performance: 25% of PACU visits have LOS > 90 minutes Target Performance: LOS does not exceed 60-90 minutes 4% Note: 474of 474 visits analyzed Section IX Page 60

W/C PCS/PACU Patient Flow 40% 35% 36% W&C PACU Length of Stay (LOS) Distribution February 2004 Average: 79 minutes 30% Percentage of Visits 25% 20% 15% 20% 23% 10% 5% 0% 9% 2% 30 60 90 120 150 180 210 240 > 240 Length of Stay in Minutes Current Performance: 21% of PACU visits have LOS > 90 minutes Target Performance: LOS does not exceed 60-90 minutes 4% 1% 0% 5% Note: 815 of 815 visits analyzed Section IX Page 61

W/C PCS/PACU Patient Flow Recommendation Begin essential patient information electronically, in order to analyze problem areas effectively. Patient PACU admission time. Patient ready for discharge time. Patient discharge form PACU time. Detailed reasons for delay (unit, person declining transfer and reason given). Collaborate with bed capacity management effort that directly impacts on PACU LOS. Responsibility Vice President, Surgical Services Timeframe Second Quarter 2005 Section IX Page 62

W/C PCS/PACU Staffing & Productivity W/C PCS/PACU Overtime as a percentage of Worked Hours Current 1.50 NCI Target 2.00 [Portions of the are confidential and have been redacted.] Recommendation Evaluate current productivity against target, and adjust staffing patterns and overtime as aggressively as possible. Develop plan to adjust staffing to mirror anticipated improvements in bed capacity management. Responsibility OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 63

Ambulatory Care Center (ACC) OR Patient Flow Utilization First Case On Time Starts TAT Staffing & Productivity PACU LOS Staffing and Productivity

ACC Patient Flow Self-contained unit combines preoperative preparation, intraoperative surgical intervention and PACU Phase I & II. Unit design includes: Four ORs Preoperative holding area with separate pediatric play/holding area Six monitored Phase I Bays Four Phase II Recliners Preoperative patient processing includes assessment, IV insertion and chart check/compilation. PACU Phase I and II combined LOS estimated to be 90 minutes by ACC Manager. Discharge by both criteria and anesthesia. Patients may not go into OR unless attending surgeon is physically present in OR. Section IX Page 65

ACC OR Utilization [The is confidential and has been redacted.] Recommendation Staff OR available hours and number of rooms to achieve OR suite utilization, without TAT of 75%. Schedule cases in sequence, rather than concurrently to optimize suite utilization. Responsibility OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 66

ACC OR First Case On Time Starts 30% 25% 27% OR First Scheduled Case of the Day On Time Starts Monday - Friday July 1 - June 30, 2004 Percentage of Cases 20% 15% 10% 20% 16% 17% 7% 8% 5% 0% Early or On Time 1% 1% 1% 5 10 15 20 25 30 35 40 > 45 Minutes Start time defined as incision time 10 minute grace period allocated before being considered late Current Performance: 63% of first cases start within 10 minutes of posted start time Target Performance: 95% of first cases start within 10 minutes of posted start time 3% Note: 705 of 3096 cases analyzed Section IX Page 67

ACC OR Turn Around Time (TAT) TAT is a reflection of case complexity, with target performance of 15 minutes for ambulatory surgery center (ASC) settings. Data included in analyses considered best case scenario: same surgeon, following self in the same room. Average TAT is 21 minutes, however, 24% of cases analyzed exceed 25 minutes. 25 minutes is the leading practice TAT for the most complicated and equipment intense case, such as an open heart case not the type of cases completed in the ACC. Surgeon perception of TAT ranges from satisfactory to very unsatisfactory. Length of room turn around reported to be dependent upon team in room and their attitude. Parallel processing to begin cases reported by physicians as not in place, which delays patients from entering the OR. The following analyses consider the best case scenario (consecutive cases in the same room by the same surgeon). Vice President, Surgical Services reported TAT of 20 minutes is included in block utilization calculation. Section IX Page 68

ACC OR Turn Around Time (TAT) 35% 30% OR Turn Around Time Distribution Same Surgeon, Same Room, Consecutive Cases July 1, 2003 - June 30, 2004 29% Average: 21 minutes Percentage of Turnover Cases 25% 20% 15% 10% 5% 5% 20% 22% 11% 6% 4% 3% 0% 10 or fewer 15 20 25 30 35 40 > 40 Minutes Current Performance: 24% of analyzed cases have TAT > 25 minutes Note: 1704 of 3096 cases analyzed Section IX Page 69

ACC OR Turn Around Time (TAT) - 40 35 30 25 20 15 10 5 20 22 19 OR Turn Around Time by Service - Average Same Surgeon, Same Room, Consecutive Cases July 1, 2003 - June 30, 2004 23 26 31 12 28 24 15 23 Section IX Page 70 19 27 22 21 OVERALL AVERAGE ANESTHESIOLOGY Minutes OPHTHALMOLOGY UROLOGY OTOLARYNGOLOGY GENERAL-TRAUMA ORTHOPAEDICS NEUROSURGERY CARDIOTHORACIC SURGERY GENERAL-BURN PLASTIC & RECONSTRUCTIVE SURGERY MEDICINE REPRODUCTIVE ENDOCRINOLOGY WOMENS PRIMARY GYNECOLOGY PEDIATRIC DENTISTRY Note: 1704 of 3096 cases analyzed

ACC OR Turn Around Time (TAT) Recommendation Adopt TAT targets, established by specialty or type of case. Monitor TAT consistently to ensure accomplishment and maintenance of targets. Communicate performance expectations to all staff members and monitor compliance. Responsibility OR Governance Committee Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 71

ACC Staffing & Productivity Pre and Phase II staff are cross-trained, and with the exception of one FTE, all Pre and Phase II staff members can also cover PACU Phase I. Two part-time RNs can cover all areas of ACC. ACC Overtime as a percentage of Worked Hours. Current 1.11 NCI Target 1.00 [Portions of the are confidential and have been redacted.] Recommendation Evaluate current productivity against target, and adjust staffing patterns to achieve target of 9.00 worked hours per case. Initiate additional cross-training to optimize staff flexibility. Responsibility Vice President, Surgical Services Timeframe Third Quarter 2005 Section IX Page 72