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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

Driving Surgical Services and the Tertiary Growth Engine

Posted by Matthew Smith on Feb 3, 2016 7:45:00 AM

By Vesna Gernot, GE Healthcare

Surgical services continues to be a key growth focus for health systems--fueling about half of a hospital’s total revenue today and forecasts for continued growth ahead. In fact, academic medical centers and tertiary providers are forecasted to benefit from an estimated 11 percent increase in tertiary care discharges over the next 10 years. Organizations are pushing to capture this high-margin growth opportunity by creating operating room ("OR") capacity and improving operations to effectively accommodate higher acuity, specialty cases, and ultimately to advance their regional and national destination brand. The environment has never been so complex with limited capital dollars forcing the maximization of existing investments, intense competitive pressures for staff and surgeons, and rising expectations from patients.

These organizations must optimize their surgical services platforms to drive profitable margins in this high-resource, high-cost care setting--meaning attracting more complex cases without adding ORs and staff or extending hours. But almost every executive we have talked to has assigned internal resources to the OR and experienced numerous, recycled improvement efforts with only incremental gains. ORs continue to be plagued by imbalanced case load across the week, a completely blocked schedule, low utilization of OR block time, frustrated staff, inefficient workflow, and long-standing operational practices by each silo – surgeons, anesthesia, staff, and support services.  

These projects are highly political where the stakes are high and part-time approaches typically do not work.   Achieving and accelerating meaningful outcomes, such as freeing up capacity for incremental cases or improving utilization, requires that organizations solve for the OR as a system as compared to the individual parts by executing three highly integrated components in parallel:

  1. Block Schedule and Scheduling Policies (e.g. allocations based on utilization, booking elective add-ons)
  2. Process and Flow (e.g. first case starts, room turnovers, pre-surgery testing)
  3. Governance and Culture (e.g. OR steering committee, data transparency, accountability)  

All three are critical, but here is a closer look into the block schedule and scheduling policies--a component regarded as the most strategic and one of the largest opportunities for improvement.

What Process and Schedule Changes Will Help Move the Needle?

Block schedules and scheduling policies are the most critical lever to optimal OR access, efficiency, and productivity. While process and workflow improvements contribute to overall efficiency, the schedule represents the most challenging but most impactful driver. For example, while shaving 5 minutes off of a room turnover is a surgeon satisfier, you cannot fill that time with an additional elective case or send staff home significantly earlier if the OR consistently runs 2 hours late. It is critically important to understand the return on effort for any changes proposed. 

Block schedules are a common approach to managing OR time and resources, however oftentimes they are not implemented as intended. In fact, many block schedules become 100 percent blocked over time and create an access issue, despite the fact that average overall OR utilization is between 50-60 percent. If not 100 percent blocked, existing capacity is scattered across less desirable, potentially smaller chunks of time, making it difficult to recruit surgeons or offer first case starts to current surgeons successfully growing their practice. These surgeons can operate late into the evening or their schedulers call around to other offices to identify unused time – an unsustainable process for retention and growth. Market competition demands that your system provides predictable, meaningful access.

Data Changes Minds

To unlock latent capacity, you could consider thousands of potential scheduling scenarios with a range of performance results, making it difficult to effectively solve for the best solution manually. The number of scenarios is driven by factors such as patient volume, procedure mix, procedure time, room turn, and staffing. These inputs are straightforward but there are many other strategic decisions that need to be included in optimal block schedule design.

Organizations need to understand the overall impact of key scheduling policies, such as:

  • Full day vs. half day blocks – What is the impact of the surgeon running early or late, such as a long case delay or idle gap in the middle of the day?
  • Elective vs. emergent/urgent – Particularly for trauma centers, how do you effectively accommodate unpredictable emergent/urgent volume while protecting capacity for scheduled cases?   
  • Blocked vs. open time – What is the right balance of blocked-to-open time based on factors such as growth plans and case mix?

Some scheduling decisions can be more political but have significant impact on overall results, such as:

  • Time allocations – Are surgeon or service level blocks most effective? Will the organization allocate time based on actual utilization?
  • Flip rooms – What is the volume threshold and case types when flipping makes sense? How much productivity does the surgeon and OR mutually gain?
  • Release times – What are the automatic and voluntary release times and when will a surgeon appropriately receive credit?  
  • Clinic – How will you align surgeon clinic schedules with the optimized block schedule?
  • Anesthesia – How will you align anesthesia resources with the OR schedule to address competition due to increasing demand from other procedural areas such as endoscopy?

Other scheduling decisions will have enterprise implications and should be aligned with enterprise goals:  

  • Level loading the elective schedule – What is the day-to-day and week-to-week variation of the block schedule? How does this impact optimal use of the ORs and staff across the week? How does this impact downstream inpatient capacity, process and resources?   
  • Acute care vs. ambulatory – What are the “right” cases to shift to ambulatory care settings based on lower acuity clinical needs, consumerism expectations and changing payment models? What is the downstream inpatient impact of backfilling this newly created capacity with higher acuity cases, including the PACU or critical care units?

All of these factors are in the data and can be modeled with advanced tools to make an informed decision about the option that best aligns with your organizational goals. This data is the backbone to a change management process, enabling surgeons and administrators to move from anecdotes, perceptions and tribal knowledge, to data-driven, objective assessment. In our experience, only advanced modeling tools and effective governance provide the horsepower to critically understand the net impact of the individual surgeons and parts, on the OR as a system.   

What Should I Expect?

We find consistently that a 10-20 percent increase in Prime Time minutes is achievable through taking a sophisticated approach that uses data and engages surgeons in the options available to improve performance.  An effectively implemented block schedule drives high performance, accountability, and positive financials for the organization and physicians.  

Here is an example of how a 16 OR tertiary facility improved their performance:

Example_OR_Schedule.png

In later articles, we will cover the need to address process and flow to create credibility with surgeons that warrant changes to the schedule and the role highly effective governance can play in engaging, aligning, and driving accountability with surgeons and staff.   

Case Study, Operating Room Capacity


Vesna_Genot.png

Ms. Gernot 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. Her experience in both planning and operations enables her to bridge strategy to execution. She may be reached at [email protected] or 312-909-2874.


 

Topics: Block Scheduling, Operating Rooms, OR Optimization, Scheduling Policies, Vesna Gernot, Surgical Services

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