Adopting "Flow Management" Improves Efficiency, Throughput, and Quality of Care in Hospital Surgery Units

Problem Addressed

• Capacity constraints leading to delays, cancelations, inefficiency, and unpredictability: The downsizing of hospitals and increasing numbers of emergency department (ED) and surgery patients vying for limited operating room (OR) resources result in surgical delays, case cancelations, and prolonged stays in postanesthesia care units due to the lack of available postsurgical beds in appropriate units.¹ This problem is compounded by inefficient and unpredictable OR scheduling systems for emergency and elective surgeries, which often result in patients waiting hours for operations.² 
• Net result is high costs and poor quality: Surgical bottlenecks result in unnecessarily high costs and poor quality of care. From a cost perspective, surgical bottlenecks are a part of a national problem that results in between 30 and 40 percent of all health care spending being the result of duplication, inefficiency, misuse, overuse, underuse, and general system failures.^2,3 On the quality front, the high prevalence of after-hours surgeries causes stress, fatigue, and sleep deprivation for physicians and nurses that can result in poor patient care and a high incidence of medical errors.⁴
• A local problem as well: St. John's Regional Health Center experienced many of the problems cited above, including the following: 
  • Inflexible scheduling of elective surgeries, which created difficulties in managing facilities and staff and controlling patient flow
  • Overloaded OR schedule, which left no flexibility to handle surges in surgical case load
  • Scheduling delays for elective cases (often until after 5 p.m.), as emergency cases took precedence
  • Midweek bed shortages on units, due to peaks in surgery and admissions, resulting in excess demand for postsurgical beds 
  • Excessive overtime costs for anesthesia, floor, nursing, and recovery room staff 
  • Excessive downtime for surgeons who were forced to wait for an available OR
  • Decreased revenues caused by canceled surgeries
  • Excessive costs due to the provision of duplicate, inefficient services²

Description of the Innovative Activity

• Analysis of patient flow: St. John's staff used principles of flow management to analyze the peaks and valleys in surgical cases. Use of the Hourly Patient Flow Analysis Tool showed that elective surgery was more variable than emergency volume. For example, urgent and emergency patients flow in at a steadier, more predictable rate than do elective surgeries, thus creating artificial peaks and valleys. Staff also modeled the effect of different ratios of scheduled and unscheduled surgeries on workflow, and found that when unscheduled surgeries comprise more than 15 percent of total volume, there is competition for limited surgical space and staff. Schedules cannot be maintained under such circumstances and diversions to other facilities may result. The analysis concluded that reducing artificial peaks and valleys can "smooth" the flow of patients and reduce stress on physicians, nurses, and staff.
• Comprehensive package of changes to improve flow: Based on the analysis described above, a comprehensive package of changes has been implemented to improve patient flow and throughput, as described below:
  • Establishment of "overflow" OR: A dedicated OR has been established to accommodate overflow for unplanned and elective surgeries. This OR had previously been reserved for use by trauma surgeons for cases scheduled after their on-call shifts ended for elective surgeries.
  • Elective surgeries booked every day of the week: Previously, elective surgeries were only scheduled during the middle of the week (Wednesday and Thursday are the most popular days), because surgeons were reluctant to conduct postsurgical rounds on weekends and preferred to work only 5 days per week. Now elective surgeries are scheduled 5 days a week.
  • Expanded rehabilitation schedule: Physical therapists and other personnel adjust their schedules to allow patients to receive rehabilitation therapy at the end of the week and on weekends. Staff previously worked Monday through Friday but now include Saturday and Sunday on their schedules.
  • Reallocation of bed and equipment: Equipment and other resources are allocated to allow staff to provide appropriate postsurgical care, including ensuring an adequate number of postsurgical beds in the proper intensive care unit (ICU), appropriate monitoring equipment, and a sufficient number of unit-appropriate ICU nurses to handle the case load. Simple paper and pencil charts are used to document bed and nurse shortages so that action may be taken to reallocate staff or beds.
  • Early bed control reporting to identify and address problems: To assist in the allocation process described above, bed control reports issued by house supervisors are usually reported at 10:30 a.m. daily meetings. Data are sometimes reported and discussed as early as 5:45 a.m. if there is a shortage of ICU or post-surgical beds. The house supervisor determines bed placement in such circumstances.
  • Committed teams to ensure timely post-surgical bed placement: To ensure ED and OR efficiency and case turnover, teams were developed to handle completion of operative and postsurgical procedures (case turnover) for orthopedic, gynecological, and neurological surgeries. Team members commit to staying the necessary number of hours (up to 16) to see the patient through to his or her postsurgical bed. 
  • Surgeon penalties for chronic tardiness: Surgeons who miss their surgical start times 10 percent or more of the time must meet with the perioperative committee to account for their tardiness. Possible penalties may include removal from early morning scheduled start times for a period of 1 month. Penalties have only been imposed three times in 5 years.

References/Related Articles

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Results

• More efficient use of ORs, leading to less overtime: The number of elective and unplanned surgeries rose by over 5 percent in the 7:30 a.m. to 1 p.m. timeframe. As a result, the need for OR capacity after 3 p.m. declined by 45 percent, and overtime hours for anesthesia, floor, nursing, and recovery room staff fell from 15 percent to about 3 percent, an industry low. 
• Increase in proper use of postsurgical beds: The number of patients placed on the most appropriate floor for postsurgical care (e.g., placing orthopedic patients on units with orthopedic nurses) rose to 96 percent after program implementation, compared to 83 percent before. 
• Increase in available block time and revenues for specialists: Orthopedic surgeons received almost 20 extra hours of OR block time per week, leading to more cases and higher revenues. Other surgical specialities gained significant increases in block time as well, due to better management of OR resources and scheduling. This reduction in downtime led to higher surgical volumes and enhanced revenues; trauma surgeons, for example, gained almost 5 percent in additional revenues.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Engaging a consultant: St. John's hired a flow expert who guided the hospital through analysis of the problem, development of potential solutions, anticipation of potential problems, and program evaluation. The consultant worked with the vice president of perioperative and emergency services at all phases.
• Analysis of current OR usage and schedule: Hospital staff evaluated current OR utilization, including ORs, surgical equipment, post-surgical floor beds, and other resources. Block schedules (i.e., dedicated blocks of OR time allocated for each surgeon or type of surgical service) were assessed to better understand peaks and flows in demand. In conducting the analysis, hospital staff kept in mind the fact that elective surgeries are nonrandom events that can be be controlled, and that even emergency surgeries (which tend to be random events) can be anticipated through better understanding of patient flow, including ED visit patterns. 
• Figuring out when "crunch time" occurs, and revising scheduling processes accordingly: Hospital staff used the analysis highlighted above to understand better when surgical backups tend to occur. Booking elective surgery patients during these times can result in backups that affect the timeliness of care and create overtime and stress for staff. St. John's quantified the current effect of crunch time on both staff and patients.
• Consideration of how altering schedules will affect other departments: The hospital evaluated how various proposals to redesign scheduling for elective surgery would affect other departments and services, such as rehabilitation therapy.
• Gaining buy-in from surgeons and staff through a "guarantee": St. John's committed to running several trials to test how the new system would affect various units. A "guarantee" was made to surgeons and staff that the old system would be reinstated if the new one did not result in improvements for all key stakeholders.  
• Enlisting physician champions: Hospital leaders identified and recruited a well-respected surgeon to serve in a leadership role in the project, working with peers to convince them of its merits.
• Estimating clinical and financial impact: Hospital staff set up the systems to gather necessary data to estimate the impact of the program on both patient care and hospital finances. 
• Training: Staff members learned of the new procedures during brief, informal training sessions in class sizes that were appropriate for the environment.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff schedules were adjusted in accordance with the new procedures. As noted, overtime hours declined as a result of the program.
• Costs: The major cost involved the hiring of an outside consultant to assist with the project. The resulting enhancements led to reduced overtime costs and increased surgical volumes and revenues that more than made up for the initial costs.

Funding Sources

St. John's Regional Health Center

Tools and Other Resources

Getting Started with This Innovation

• Pick the right physician champion: Ideal characteristics include credibility, good people and leadership skills, motivation to make system-wide changes, and capability of understanding and communicating the issues. 
• Pilot the program first to test its impact: Select a unit of manageable size to implement the flow redesign program. St. John's selected a small unit first, then tested the program again on a larger unit.  
• Involve and enlist support from all levels of the hospital: Administrators, surgeons, other physicians, and affected hospital staff all need to understand the various potential benefits before roll-out. Top-down directives from hospital administration are generally not well received. 

Sustaining This Innovation

• Monitor and communicate the impact of the program to all staff: Showing data that documents increased productivity, reduced waste, improved patient outcomes, and increased revenues for the hospital and surgeons tends to create a self-sustaining environment.
• Focus on reducing stress: Changes that reduce staff workload and hours create "on-the-ground" support for the new system. 
• Consider expansion to other units: Flow re-engineering can also be applied to medical units to increase the efficiency, safety and quality of patient care. 
• Adapt and customize specific program elements to meet local needs: What works for some programs may not work for others. For example, St. John's dedicated overflow OR made sense given the size and scope of its OR operations. The same might not be true for a smaller hospital.

Use By Other Organizations

• Carondelet St. Mary's Hospital, Tucson, AZ
• Hackensack University Medical Center, Hackensack, NJ
• Mission Hospitals, Asheville, NC
• North Hampshire Hospital NHS Trust, Basingstoke, Hampshire, UK
• Overlook Hospital, Summit, NJ
• Western Pennsylvania Hospital-Forbes Regional Campus, Monroeville, PA