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With an OR schedule that was 95 percent blocked, Central Maine Medical Center (CMMC) could not add surgeons to meet growing demand. Yet the OR suites were being utilized less than half the time. Cases were starting late and delays were common. Surgeon and staff frustration was mounting.

By reconfiguring block scheduling and creating strict governance policies, 100 hours per week of capacity were freed up, and utilization rose to 61 percent. Volume has increased 10 percent yet the OR has not had to add staff, and overtime is down 28 percent.


Background

CMMC, located in Lewiston, serves about 400,000 residents. At a time when many healthcare organizations are contracting, this 250-bed medical center is growing. Fed by community and critical access hospitals, patient volume has increased over the last ten years since the Central Maine Heart and Vascular Institute opened.

This growth has afforded its share of growing pains. As healthcare reform continues to demand greater overall efficiency, The Medical Center has had to rethink scheduling and workflow practices within perioperative services in order to create room for more surgeons and accommodate the growing demand.

“The crisis point came in October 2013,” says Bruce O’Donnell, CRNA, who is the hospital’s Chief Anesthetist and acting director of the perioperative department. “We hired five new surgeons to come on board in early 2014 and we had no block time to offer them.”

The problem was that the surgical schedule was totally blocked – all available time slots for the 11 OR suites were already allotted to the surgeons on staff. Yet, the surgeons were utilizing less than half the capacity. In addition to the clogged schedule, the OR had process efficiency issues. Case delays and slow room turnover were throwing schedules off on a daily basis, impacting patient convenience, while ratcheting up surgeon and staff frustration.

“Recruiting new surgeons to grow the service line was a very high profile initiative. Trying to do that when you don’t have block time – how are you going to keep people? And why would these surgeons want to stay when everything was so inefficient?” says Tina Legere, President of CMMC.

“The most striking thing to me was how miserable everyone was – physicians, techs, nurses,” says Susan Horton, DNP, APRN, Vice President of Perioperative Services. Horton, who joined CMMC to head the new cardiac surgery program, was tapped to also oversee the general OR service line. “We had great people who were devoted to the institution; they just hated the working environment. They wanted a change, but didn’t know how to make it happen,” she says.

It was at this point that CMMC engaged GE Healthcare Camden Group to analyze the scheduling and workflow issues and recommend changes to unlock latent capacity and create a more productive and positive working environment in the OR.

Our Approach

REALITY-BASED SCHEDULING FREES CAPACITY

CMMC was facing an operational challenge common to many hospitals: it was operating below capacity but had virtually no room on the schedule to add surgeons and cases. GE analysis of 12 months of surgical case documentation pulled from the hospital’s database revealed that only 55 percent of the available surgical capacity was being utilized.

The GE consultants met with each of the 30 surgeons, and their practice managers, to discuss the findings and learn about their scheduling needs. The team used GE’s Block Optimizer™ modeling software, in conjunction with historical data and physician preferences, to develop alternative scheduling scenarios to unlock this latent capacity. In reconfiguring the schedule, surgeon time was re-allotted according to the utilization data and within full-day blocks.


“We learned from GE that you cannot over-communicate. The physicians felt that people were truly listening to them and would make process changes that worked well for them.” Susan Horton, DNP, APRN Vice President of Perioperative Services, CMMC


For example, if Surgeon A had 16 hours reserved across two days, but was only using 8 hours on a consistent basis, he was allotted 8 hours in a full-day block on the new schedule. Full-day blocks (typically 8 hours) are preferred from an efficiency standpoint since they typically accommodate more cases than two shorter blocks and minimize downtime required by a different surgeon room changeover. They can also decrease frustration for afternoon surgeons that otherwise are left waiting for morning cases to wrap up before getting started.

“As long as the surgeons could keep the time they were actually using, they were okay with the change,” says O’Donnell. “They appreciated and responded to the data-driven approach.”

The key was working directly with the surgeons, says Horton.

The optimized schedule freed 100 hours of incremental capacity for new surgeons, surgeons who did not qualify for block time, and urgent/emergent cases. Capturing even half of the open availability created potential for an additional 20 cases per week. Utilization rose from 55 percent to 61 percent.

A BETTER START TO THE DAY

At the same time, the GE team was tackling two troublesome operational indicators in the OR: on-time first case starts and room turnover time. Only 18 percent of first cases were starting on time, and room turnover time (wheels out – wheels in) was averaging 35 minutes.

GE process improvement consultants worked with the OR staff to optimize and standardize workflow processes – from patient admission to discharge – and clarify expectations and accountability. Among process changes implemented: establishing expected arrival times for staff, surgeons, and anesthesiologists; clarifying procedures and staff roles for room turnover; and standardizing patient flow.

For example, analysis of the same-day surgery check-in process revealed that each of the three registrars had a different approach. From a workflow perspective, it was determined that escorting the patient directly from check-in to the prep area, bypassing the waiting room, yielded the greatest efficiency. Room turnover processes were similarly ambiguous. Now, staff members clean the operating rooms according to designated zones, with one staff member having ownership for timely completion of each zone.

The results have been significant. Within a few months:

• On-time first case starts improved from 18 percent to 83 percent

• Room turn-around time fell from 35 minutes to 27 minutes

PHYSICIAN-LED GOVERNANCE MODEL

A strong governance structure was created to sustain the new policies and procedures guiding OR operations. Three provider-led bodies – the Perioperative Services Steering Committee, the Block Management Committee, and the Perioperative Practice Council – meet regularly to review, enforce, and modify (if necessary) the policies.

“Provider governance is critical,” says O’Donnell. “The surgeons, anesthesiologists, and nurse anesthetists are making the policies, monitoring the schedule, and enforcing the rules. If surgeons want time on the schedule, they have to go through the process. Arrive late too many times and you’re subject to losing block time. There are no longer any special arrangements and workarounds,” he says.

According to the center’s Chief of Anesthesiology, a key driver of the initiative’s success was the approach of the GE consultants. “They truly listened to everyone’s perspective,” says Dr. Kevin Morneault. “They contoured a strategy to our unique culture and secured buy-in on all levels, beginning with the physicians and, in particular, the surgeons. The process created, enforced, and reinforced expectations for success.”


“If it’s not a physician-driven experience, it’s not going to happen,” agrees Horton. “The surgeons were committed to making things better here. The time was right and everyone was committed to a change.” Susan Horton, DNP, APRN Vice President of Perioperative Services, CMMC


TRANSPARENCY THAT LEADS TO DIALOG

“We’re much more efficient now. Everyone is focused on getting here on time and getting their work done,” says O’Donnell.

At 3 p.m. every day there is an OR huddle, typically including the VP of Peri-Op Services, OR Director and Manager, Charge Anesthesiologist, Managers from Same Day Surgery and PACU, and OR Specialty Team Leaders. They meet to discuss first-time starts and turnover ? what worked, what didn’t, and the reasons why. A report on their findings and explanations for variances is emailed to more than 70 people – who often email back to correct or explain something.

In addition, executive rounds and a weekly newsletter keep operational issues top of mind. Bulletin boards recently installed in the department are meeting places for surgeons and staff to see announcements, read “kudos” on positive outcomes, and discuss more improvements.

“We’ve created a culture in which everyone has ownership for the outcomes,” says Legere. “There is real transparency and openness, and that has created a forum for dialog.”

Results

MORE PATIENTS, MORE SATISFACTION

In the year since CMMC began the OR optimization project, surgical volume has risen over 10 percent (additional 703 cases), equating to $2.9M in incremental margin yet the department has not had to increase staff and, in fact, overtime has decreased 28 percent. OR staff turnover is down as well.

As a result of all the changes instituted In the OR, “there is pride in ownership now,” says Horton. “People want to come to work. They’ve got smiles on their faces and pep in their step. Our commitment to quality and improving operational efficiency helps us focus on what really matters – improving care outcomes and the patient experience.”

Legere agrees. “Cases are no longer getting bumped or delayed. Patients and their families don’t have to wait in same-day surgery for hours. That’s the number one priority. We have focused on the patient being at the center of what we do to provide the highest quality, safe care and improving the patient experience.”


“Our surgical volume has increased and the surgeons we’ve recruited are, in turn, recruiting their colleagues to come here. That’s testament to the progress we’ve made” Tina Legere President of CMMC


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