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3 Key Priorities in the Perioperative World

Posted by Matthew Smith on May 18, 2017 10:48:47 AM

By Nehal Koradia, RN, MBA, and Ryan Treml, GE Healthcare Camden Group

As has been the case for many years, hospital organizations continue to look to perioperative services to be one of the most important financial engines for the institution – consistently looking for ways to maximize the utilization and efficiency of the department.

As reimbursement declines, new payment models are being explored, and hospitals continue to consolidate, organizations are expanding on and moving beyond past methods to drive improvement. Here are key priorities in the perioperative world that healthcare leaders should keep in mind:

1. Be more deliberate and detailed in linking the strategic plan to perioperative services.

Evaluate volume against capacity. Volume has historically solved most problems. However, with reimbursement changing towards value-based payment, volume has to be analyzed much more thoroughly. The days of adding volume without first understanding the total capacity available and the corresponding costs – labor, equipment, supplies, etc. – are gone. Organizations are tackling this challenge by becoming more specialized in their elective volumes – creating centers of excellence to combine specialty services and procedures in a common location to drive extremely efficient day-to-day processes. In addition, they are increasing their focus in shifting outpatient volume to ambulatory surgery centers, embracing the ability to utilize technology and new techniques to transition traditionally inpatient cases to an outpatient environment. Advanced institutions are also making the tough decision to truly rationalize their capabilities – thoroughly evaluating their market and understanding what the community truly needs and can support long-term. All of these options attempt to maximize the organizations utilization of their highly specialized resources.

Match recruitment to the strategic plan. As noted above, forward thinking organizations are pursuing surgical volume that matches their strategy. Similarly, as these organizations evaluate or recruit potential new surgeons, they are taking much more time than they have historically to consider capacity variables. Equipment and staffing capabilities are usually considered when making offers to surgeons, however rarely does an institution evaluate the inpatient capacity needs for the new surgeon joining and determine the optimal day to allocate block time to both maximize OR and IP Capacity. In order for the entire organization to run efficiently, there has to be a good match between the new providers' needs and the access the organization can provide.

2. A refined focus on operational processes and cost.

Embrace systems-thinking and advanced analytics to inform process improvements. It is well known that the elective surgical schedule typically accounts for more variation in inpatient census than ED admissions. Managing that variation is extremely difficult – very few institutions have been able to create a surgical schedule that maximizes OR utilization while also efficiently smoothing the downstream IP volumes. However, it's becoming more common to utilize simulation and forecasting tools to appropriately match inpatient resources to the demand created by surgical inpatient volume. Nursing, support personnel, ancillary services, etc. are being staffed with much more flexibility to allow for the daily, weekly, and monthly variation in inpatient surgical volume. In addition to these dynamic staffing concepts, organizations are focusing on inpatient operational processes to ensure that downstream capacity is not a limiting factor in growing surgical volume. Units are being re-purposed, the benefits and risks of specialization vs. generalization are being analyzed in detail to ensure that beds are available and utilized in the most efficient manner.

Make difficult decisions regarding supply cost. Organizations have always reviewed surgical supply cost and understood that there were opportunities to streamline/standardize, but the most advanced have taken the difficult step in convincing their surgeons to work with them to manage cost. This requires a very detailed dissection of case cost information while balancing it with quality and utilization measures. Often, the supply opportunity is only viewed from the cost perspective, and decisions are made that can impede utilization, extend case lengths, and impact outcomes. High performing organizations understand these situations and include the information into a surgeon's balanced scorecard – often driving change through awareness rather than forced decisions.

3. Establish governance, don't just talk about it.

Use the governance structure to execute strategy. Governance of perioperative services has typically been a term associated with policy development and enforcement. The problem is that it quickly becomes detached from the consistently changing healthcare environment. Surgeons that sit on committees such as Surgery Executive or Block Management are asked to manage with a set of policies that are infrequently reviewed or refreshed. They are asked to align with strategic imperatives and plans, but are not included in the development discussions. Organizations have realized this is not an effective structure to drive true governance and are incorporating these key strategic decisions into their surgical committees. This drives better alignment with the surgeon community, shortens the adoption of key changes, and actually makes policy enforcement much easier.

Hire a Chief Surgical Officer (CSO). To build on the concept of incorporating strategy into governance, hospitals are hiring a surgeon to drive the surgical portion of the strategic plan. This role is different than the chief of surgery – the CSO is part of the executive team and is involved in the development of the strategic plan, drives the recruitment of new surgeons, and balances the wants of the surgeon community with the needs of the hospital system. This role helps buffer the often contentious relationship between surgeons and the administrative suite – complementing the Chief Medical Officer.

Even though many organizations recognize that these changes need to occur to ensure future success, many have difficulty implementing these strategies due to the complex environment in perioperative services. But overcoming the difficulties and implementing even one to two of these strategies can increase revenue and/or decrease cost significantly for an organization, making it well worth the effort.


KoradiaN.jpgMs. Koradia has been leading healthcare organizations through transformation initiatives for over nine years. Ms. Koradia has worked with many large academic centers and community hospitals to transform their operating rooms, decrease readmission rates, and increasing early morning discharges and reducing ER wait times by utilizing simulation modeling, Lean, Work-Out®, and CAP® methodologies. These initiatives have allowed organizations to improve access for patients, streamline operations and improve financial performance, while creating a culture of continuous improvement. She may be reached at [email protected]

 

treml.jpgMr. Treml is a manager with GE Healthcare Camden Group, with 12 years of management consulting experience. He has led a broad range of engagements including: improving perioperative service departments through scheduling optimization and specific process improvements, developing comprehensive capacity strategy plans for high occupancy institutions, implementing electronic event reporting tools, streamlining discharge planning processes, and increasing throughput in diagnostic imaging departments. He may be reached at [email protected]

 

Topics: OR Optimization, Hospital Operations, Nehal Koradia, Ryan Treml, Perioperative Services

Hospitals are Not Hotels: Examining the "Discharge By Noon" Strategy

Posted by Matthew Smith on Aug 25, 2016 10:11:15 AM

By Dominic Foscato, Senior Vice President, and Nehal Koradia, RN, MBA, Manager, GE Healthcare Camden Group

Most healthcare organizations have goals of shifting care from acute to ambulatory settings while maintaining or improving quality and satisfaction. That goal has not led to a drop in occupancy rates in every geographic market. Inpatient volumes continue to increase in many markets due to demographic changes, Medicaid expansion, and physician recruitment and consumer engagement projects.

Managing consistently high inpatient occupancy has created many ingenious tools/processes across the country. Healthcare providers have tried many approaches to solve inpatient capacity problems, but many have failed due to poor communication, lack of prioritization, fragmented approaches to change management, misaligned stakeholders, or unclear objectives. Not all of those ideas will solve the main problem (bed shortages) and some may negatively impact cost, quality and other desired outcomes.

Capacity_challenge.pngGE Healthcare Camden Group helps organizations design and implement new approaches to managing capacity/throughput challenges. Clinical leaders often ask our team to conduct three-to six-month studies to model their operations in a virtual environment while posing 3-4 key strategic questions and developing a macro capacity model using the following framework:

  1. Define specific objectives and create leadership committees responsible for the engagement decisions, timeline, and communication
  2. Analyze one-to-two years of available data from various sources to create a simulation model
  3. Create workgroups consisting of staff, department leaders, and clinicians to validate the model and assess potential impact of process or volume changes

One of the key strategic questions that we are asked to model is whether or not ‘Discharge by Noon’ or similar measures may inadvertently create more challenges than it solves. We typically find the following to be true:

  • Optimal patient flow dictates that beds are available when needed
  • Focus must be on the “occupancy overlap” when census spikes for 2-3 hours quickly followed by large numbers of discharges
  • There is a need to reduce ‘empty/unused bed time’--particularly when there is demand
  • Manage to ‘discharge order response’ times
  • Ideal flow would have discharge curve about 90-120 minutes ahead of bed request curve by type of bed needed
  • Achievable goals drive results
    • Generic ‘Discharge by ‘X’ as a house-wide goal often have higher observed/expected LOS ratios and rarely earlier discharges
    • Alternatively, we analyze which nursing units or hospital services need inpatient beds and then focus the care team on prioritizing activities to produce timely discharges

Cumulative_Discharges.png


Discharge_line_graph.png


But remember, it is not just about discharging a certain number of patients before noon when thinking about patient flow/throughput. If your organization already has a goal for discharge time, or is considering setting one, we recommend performing a thorough review by asking these types of questions:

  1. To prevent congestion, how many beds do you need? When do you need these beds?
  2. Which units or services need more beds? Which have too many?
  3. How will you design solutions that align the care team around designation, communication, and execution so that a patient can successfully be discharged in the morning?

Our most successful clients take a very structured approach to answering these questions and defining their capacity strategy. They balance the use of advanced analytic modeling with feasibility studies. The outputs from this process allow them to establish clear goals and expectations that motivate their entire organization. By setting reasonable and achievable unit/service level goals that contribute to solving organizational objectives (i.e., lower LOS, higher quality/satisfaction), the implemented changes have a higher impact and are more sustainable.

Inpatient Occupancy Planning


Foscato.jpgMr. Foscato serves as a senior vice president with GE HealthcareCamden Group responsible for the overall design andimplementation of solutions, thought leadership and solution development. Mr. Foscato has deep domain expertise in improving clinical operations, implementing enabling technologies, optimizing revenue cycle and patient access functions for healthcare providers to deliver more effective patient care and financial performance. He also assists clients with activating strategy leveraging GE’s world-renowned management and leadership systems. He may be reached at [email protected].

 

KoradiaN.jpgMs. Koradia is a manager with GE Healthcare Camden Group. She has been leading healthcare organizations through transformation initiatives for over nine years. Ms. Koradia has worked with many large academic centers and community hospitals to transform their operating rooms, decrease readmission rates, increase early morning discharges, and reduce ER wait times by utilizing simulation modeling. She may be reached at [email protected].

Topics: Dominic Foscato, Nehal Koradia, Hospital Discharge, Occupancy Overlap, Inpatient Occupancy Planning, LOS, Priority Discharge, Hospital Occupancy, Length of Stay

Initiative Governance: Is Your Team Organized to Drive Decision-Making, Make Change, and Improve Culture?

Posted by Matthew Smith on May 2, 2016 11:59:25 AM

By Vesna Gernot, MBA, Vice President, and Nehal Koradia, RN, MBA, Manager, GE Healthcare Camden Group

The term “Governance” will lead some to think of their Board of Directors or the dozens of committees that some organizations have collected over time. We use Governance more broadly—as the foundation for a focused transformational effort and the engine to sustain performance gains. Initiative Governance is a critical component to any group of people working together to drive change—it nurtures or reshapes the culture and ultimately affects how work gets done.

In this context, Governance applies to an enterprise initiative, program, service line, or functional area. And the need for Initiative Governance is growing with new payment models driving integration across groups that, in the past, have individually provided direct care for the patient but have never had to be truly, directly accountable to each other – such as bundled payment programs or patient experience across the care journey.  

For illustration purposes, surgical services is a great example of how individual politics and incentives might cause misalignment. Most surgical service lines or OR departments have had a committee structure for years, but leaders commonly acknowledge that surgeons don’t attend, meetings are infrequent, real decisions aren’t made, and the “committee” becomes a forum for turf wars and complaints. The unintended results can be mounting frustration over inaction and overall distrust. (Click here for a related post on surgical services.)       

In order to avoid this frustration, organizations must set up an Initiative Governance structure instead of a committee structure. The difference is governance includes meetings that have a clear agenda aligned with key priorities, a cross-section of leaders that makes decisions, utilization of validated, transparent data, and an equitable approach to holding all parties accountable. It may seem like common sense—but not common practice because sustainable improvement and cultural change requires investment beyond a recurring calendar hold, dashboard, and an individual manager to run it all.

Here are questions we ask our senior executives and physician leaders to consider:

  1. Do we have the right people actively involved? Is our governance inclusive of management, physicians, and clinical staff? For physicians, do we have balanced representation of specialties, employed and independent, long-term and new, protagonist and antagonist? Based on strategic priority, do we have a senior executive sponsor that actively and consistently participates?
  2. Do we have the right structure in place or do we need to refresh it based on the times? Is there an operating structure, charter, and established guiding principles?
  3. When did we last review the guiding principles? Do our principles inform the policies and procedures? Does everyone know and have access to these? Who on the current committee was directly involved in their development?
  4. What data analysis have we done to clearly identify our strengths and improvement opportunities? Are we looking at the right measures, and do we know where we should be? Have we walked the committee through this data—is it understood by all and when it isn’t, do we do more socializing through one-on-one discussions?     
  5. Are we using the right metrics to track progress? Are we using data and the policies to make timely, consensus-driven decisions? Or do one-off anecdotes and silo’d views still create bias?
  6. Are we consistently transparent with the data? Do we break down this information by physician, service line or functional area to drive accountability?     
  7. Do we prompt immediate operational implementation? Do we have sub-committees in place to create focus in key areas and empower bottom-up continuous improvement?   
  8. Do we position formal and informal change leaders? Do we equip them with data and change management tools to know when and how to lead productive peer-to-peer conversations?
  9. What is our communication plan for goals, actions, and progress—for our committee, the broader service line or organization, physicians and staff, and related executive committees?  

Lastly, when we invest in this type of governance and it works as intended…

  1. Is senior leadership ready and aligned to address opportunities and barriers that are raised? Are they willing to empower this governance structure to make decisions?

GernotV.jpgMs. Gernot is a vice president with GE Healthcare Camden Group and works with health system executives to improve operational and financial performance through focusing on care delivery efficiency, strategic capacity planning, enterprise strategy activation, and change management. She is responsible for helping clients design enterprise performance initiatives and leading GE engagement teams to deliver. She may be reached at [email protected].

 

 

KoradiaN.jpgMs. Koradia is a manager with GE Healthcare Camden Group. She has been leading healthcare organizations through transformation initiatives for over nine years. Ms. Koradia has worked with many large academic centers and community hospitals to transform their operating rooms, decrease readmission rates, increase early morning discharges, and reduce ER wait times by utilizing simulation modeling. She may be reached at [email protected].

 

 

Topics: Payment Models, Vesna Gernot, Surgical Services, Initiative Governance, Nehal Koradia

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