Reducing Cancelations on the Day ofScheduled Surgery at a Children’sHospitalJayant “Nick” Pratap, MB BChir, MRCPCH, FRCAa, Anna M. Varughese, MD, MPH, FRCAa, Patti Mercurio, MSN, RN, NE-BCb,Terri Lynch, RNb, Teresa Lonnemann, BSN, RN, CPNc, Andrea Ellis, MSN, RN, CPNb, John Rugg, MBAd, W. Ray Stone, MSd,Cindi Bedinghaus, MSN, RN, NE-BCd

abstract BACKGROUND AND OBJECTIVES: Cancelation on the day of surgery (DoSC) representsa costly wastage of operating room (OR) time and causes inconvenience,emotional distress, and financial cost to families. A quality improvementproject sought to reduce lost OR time due to cancelation.

METHODS: Key drivers of the process included effective 2-way communicationwith families, compliance with fasting rules, and decision-making on patientillness before the day of surgery. A multidisciplinary team conducted serialtests of change addressing the various key drivers. Interventions weresimplified, colorful, personalized preoperative instruction sheets and text-message reminders to caregivers’ cellphones, as well as a defined institutionaldecision-making pathway to permit rescheduling before the day of surgery incase of patient illness concerns. After initial smaller-scale testing, theinterventions were implemented across all patients and sites. Data werecollected from the hospital information technology system and analyzed byusing control charts and statistical process control methods.

RESULTS:Mean OR time lost due to DoSC was decreased from a baseline of 5.7 to3.6 hours/day in testing with a subset of surgical services at the hospital’sbase campus, and then from 6.6 hours to 5.5 hours/day when implementedacross all services at both surgical sites.

CONCLUSIONS: By applying quality improvement methods, significant reductionswere made in time lost due to DoSC. The impact can be significant byimproving institutional resource utilization.

Cancelation on the day of surgery(DoSC) represents a costly wastage ofoperating room (OR) time but isfrequent in children’s hospitals.1

Families suffer inconvenience, emotionaldistress, and financial cost.2 ReducingDoSC therefore improves OR utilizationand also reduces impact on families.Likewise, rescheduling in advance,where appropriate, facilitates reshufflingof the operative list and accommodationof add-on cases and minimizesdisruption to family life. Among thedimensions of health care qualityenumerated by the Institute of Medicine,

family-centeredness, efficiency, andtimeliness are all impacted.3

At the main campus of CincinnatiChildren’s Hospital Medical Center(CCHMC) lost OR time averaged 5.7hours each day (4.5% of total) by 2011due to DoSC. The 3 most frequentreasons were as follows: patient illness,“no show,” and violations of nil per os(NPO) instructions, togetheraccounting for 68.4% of lost OR time.These data are displayed in Fig 1 asa Pareto chart, which serves to directquality improvement (QI) efforts bypresenting reasons for process failure

aDepartments of Anesthesiology and Pediatrics, CincinnatiChildren’s Hospital Medical Center, University of CincinnatiCollege of Medicine, Cincinnati, Ohio; and bSame DaySurgery, cAmbulatory Services and dPerioperativeAdministration, Cincinnati Children’s Hospital MedicalCenter, Cincinnati, Ohio

Dr Pratap helped design the improvement projectand analyze the data, drafted and wrote the initialmanuscript, and revised the manuscript; DrVarughese, Ms Mercurio, Ms Lynch, Ms Lonnemann,Ms Ellis, Mr Rugg, Mr Stone, and Ms Bedinghaushelped design the improvement project andcritically reviewed the manuscript; and all authorsapproved the final manuscript as submitted andagree to be accountable for all aspects of the work.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-2418

DOI: 10.1542/peds.2014-2418

Accepted for publication Dec 29, 2014

Address correspondence to Jayant “Nick” Pratap,MB BChir, MRCPCH, FRCA, Department ofAnesthesiology, Cincinnati Children’s HospitalMedical Center, 3333 Burnet Ave, Cincinnati, OH45229. E-mail: jayant.pratap@cchmc.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

Copyright © 2015 by the American Academy ofPediatrics

FINANCIAL DISCLOSURE: The authors have indicatedthey have no financial relationships relevant to thisarticle to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors haveindicated they have no potential conflicts of interestto disclose.

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in decreasing frequency order.4 Wedescribe a QI project to reduce timelost due to DoSC, which forms part ofCCHMC’s value initiative aimed ata more productive use of resources.

METHODS

Ethical Aspects

As a QI project, this work wasclassified as nonhuman subjectsresearch not requiring informedconsent.

Setting

CCHMC is a 530–medical and surgicalbed, urban, pediatric academicmedical center that forms theprimary care facility for Cincinnatiand a tertiary care facility forsouthwestern Ohio, northernKentucky, and southeastern Indiana.CCHMC’s surgical services performed∼32 000 cases in fiscal year 2011.Approximately 40% of all casesconsist of ear, nose, and throat (ENT)surgery. One-third of patients havenoncommercial health insurance.CCHMC’s main campus conducted23 000 of a full range of surgeries infiscal year 2011. The geographicallyseparated ambulatory surgery centerundertook the remainder (shorterand less invasive procedures onpredominantly healthy children) but

was included only in the project’simplementation phase.

Improvement Team

The team consisted of 2anesthesiologists, a nurse from theSame Day Surgery (SDS) unit, 3 SDSnurse-managers, and an ENT clinicnurse. Two team members hadreceived formal QI training. A QIconsultant and 2 informationtechnology specialists providedtechnical support. The project startedin July 2011 and used the Method forImprovement.5

Planning the Interventions

Initial Analysis

To investigate underlying reasons forthe most common causes of DoSC(Fig 1), baseline data were collectedfor each of the top 3 causes. Amonga sample of 25 cancelationsspecifically for patient illness selectedrandomly from a 3-month period,only 20% had reported symptomsduring a routine preoperativetelephone call made 2 business daysbefore surgery by a registered nursefrom SDS; 40% had reported nosymptoms. Of the remainder, nurseswere unsuccessful in reachinga family member by telephone. Allsickness cancelations in the samplewere due to acute illness rather than

chronic disease. Potential thereforeexisted for advance rescheduling iffamilies would notify the hospital ofillness before the day of surgery.

The team investigated what happenedwhen SDS nurses discovered inadvance that patients had acutesymptoms. Many nurses felt theylacked authority to postponesurgeries, but anesthesiologists wererarely aware of concerns, perhapsbecause cases were not yet allocatedto individual anesthesiologists at thetime of the preoperative call. Thenurses therefore felt uncertain whomthey should contact. Most NPOviolations resulted from confusionover instructions given to families(Fig 2), in particular regarding “lightbreakfasts” and “clear fluids,”suggesting a need for increasedclarity and focused reminders.

While investigating no-showcancelations, we found that patientsof CCHMC’s 2 busiest surgicalservices, ENT and Urology, wereinformed of their designated arrivaltime only from the SDS preoperativephone call, rather than at the time ofscheduling like with otherdepartments. Thus, families knowwhen to arrive only if reached byphone by SDS; however, this contactwas successfully made in only 57% ofENT and Urology no-shows. Forothers, a voicemail message was left ifpossible. Some contact details in theelectronic medical record (EMR)appeared to be incorrect, buta separate QI project had recentlyaddressed this and senior leadershipfelt that further efforts would beunproductive. Our analysis, however,identified an additional opportunityto establish contact if caregivers wererequested to call the SDS nursesthemselves 2 days before surgeryrather than relying exclusively onfamilies being approached by SDS.

To identify further key drivers forimprovement we undertook botha simplified “failure modes andeffects analysis”6 and teambrainstorming sessions.7 These

FIGURE 1Pareto chart showing reasons for DoSC in a 6-month sample from April through October 2011.

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agreed-upon prerequisites forimprovement are outlined in Fig 3,along with appropriate interventions.

Ramp 1: “Steps to Surgery” InstructionSheet

Family education was the focus of thefirst set of interventions. A pared-down, single-page “Steps to Surgery”

sheet was designed to give step-by-step instructions for caregivers(Fig 4). To promote adherence,colorful graphics were used, andspace was left to personalize with thechild’s name and surgery date. Toprevent confusion resulting frominstructions for different age groupsbeing present on the same sheet,

entirely separate “Steps” sheets werecreated for infants and for olderchildren. Similarly, directions referredonly to the hospital’s main campus toprevent families from presenting tothe wrong site.

Previous analysis of NPO violations(Fig 2) influenced the text of theinstructions. Because the previouslypreferred phrase “light breakfast”was confusing, Steps sheets prohibitall solids after midnight for olderchildren. Because infants are athigher risk of hypoglycemia, andbecause such errors occurred rarelyin this group, solids were permittedfor them until 5 hours beforeadmission (usually 6.5 hours beforesurgery). A list of acceptable foodsreplaces the expression “lightbreakfast.” The sheet’s reverse sidedisplays examples of solids and clearsin pictorial form. Instructions alsorequest caregivers to call SDS 2business days before surgery toconsult with nursing staff and toreport any illness developingthereafter.

The sheet was reviewed first withfamily representatives and thentested with a group of 10 patientsundergoing surgery. We thenestablished a test with all ENTpatients over a 6-week period.

Ramp 2: Preoperative Text-MessageReminders

Because reminders improve processreliability,8 we sought to offer suchprompts to caregivers. Family councilmembers from an economicallydeprived neighborhood suggested theuse of text messages to cellphonesvia Short Message Service (SMS).They cited advantages of receivingmessages even if out of credit andconvenience in referring back toinstructions.

Software was developed forscheduling text-message reminders ofNPO and arrival instructions to bedelivered the evening before surgery.With the aid of the hospital’s attorney,a script was prepared for gaining

FIGURE 2Pareto chart showing root causes in a sample of NPO violations investigated. Information is availablefor determination in 22 of 37 cases between July 23 and October 3, 2011.

FIGURE 3Key driver diagram for the improvement project presenting the global and specific aims, theories(key drivers), and ideas for change (interventions). periop, perioperative; RN, registered nurse.

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consent for text messaging during theroutine preoperative telephone call.Technical issues were resolvedduring 3 rounds of tests with 10 to 15patients each. Text-messagereminders were then offered to allfamilies of children presenting forsurgery.

Ramp 3: “Check-In” Process

Because patient illness was the mostfrequent cause of DoSC (Fig 1) andSteps sheets encouraged families tonotify of illness in advance, we lookedto facilitate advance decision-makingregarding illness. Through testingwith 1 author (J.N.P.), then with theanesthesiologist assigned each day toconsult the clinic (which could be anymember of the physician group),

a standardized “check in” process wasestablished for SDS nurses to discusswith an attending anesthesiologistany illness concerns identified. Awritten call log was implemented toensure that all appropriate caseswere discussed.

Implementation

After the ramped small tests ofchange, senior OR stakeholdersagreed to support implementation ofthe “Steps to Surgery” sheets andtext-message reminders for allsurgical patients at both CCHMC’smain and ambulatory surgerycampuses. A second set of Stepssheets was created to incorporatedirections to the ambulatory center.The SMS software was rewritten to

interface directly with the EMR topermit automatic texting without theneed for nurse intervention.Following institutional policy change,responsibility for text-messagingconsent transitioned from SDS tosurgical clinic clerks. The check-inprocess for advance decision-makingon patient illness continued, but thetask of determining fitness forsurgery transitioned toa perioperative nurse practitioner,with an anesthesiologist allocated forfurther consultation if required.

Planning the Study of theInterventions

The project’s primary outcome wasdefined from its early phases as thetotal hours of OR time lost each day

FIGURE 4“Steps to Surgery” sheet providing clear and focused instructions in a colorful and personalized format, in this case for caregivers of infants attendingfor surgery at the hospital’s main campus.

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due to DoSC. This measure waschosen for correlating well with lostrevenue, given that improvedresource utilization was the team’smandate from senior leadership.

Data on scheduled and canceled caseswere routinely entered into the EMR(EPIC Systems, Verona, WI) byindividuals independent of ourongoing QI efforts. The primaryoutcome measure for eachnonholiday weekday was plotted ona statistical process control (SPC)chart for the project’s testing phase atthe main campus.9 Charts wereestablished to pull data automaticallyfrom the EMR. On a weekly basis, theQI team reviewed all qualitative andquantitative reports. Theimplementation phase was monitored

by using a similar chart but withweekly data from both surgicalcampuses.

Analysis

Charts permitted display and analysisof variation in the time-series dataand were used to evaluate theeffectiveness of interventions. Upperand lower control limits (63s) wereapplied to assess process stability.Special-cause variation was definedas the presence of any of thefollowing: (1) a “shift” of the mean orcenter line from $8 consecutivepoints below or above the center line(data points on the centerline neithermaking nor breaking a run), (2)a “trend” from 6 consecutive datapoints in either direction, (3) 14

consecutive data points alternatingabove and below the center line, or(4) a data point outside of upper andlower control limits.10 Any specialcause was investigated to learn aboutprocess properties; then, explanatorylabels were added to the chart.Project milestones were similarlyannotated. Where special causecoincides temporally with a plausibleexplanation, the process is regardedas having undergone change, anda new baseline is created.

RESULTS

Immediately after the project’s keyinterventions were tested, the controlchart of the primary measure showedspecial-cause variation, specifically

FIGURE 4Continued.

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8 consecutive points below thecenterline (Fig 5). In the .2 years forwhich EMR data are available,a special-cause variation “shift” hadnot previously occurred (data notshown). The mean OR time lost due toDoSC was reduced from a baseline of5.7 hours to 3.6 hours/day at ourmain campus (37% improvement).The mean total scheduled OR timewas 136.1 hours/day during theperiod depicted in Fig 5, although thistime includes inpatients andemergency cases not subject to theproject’s interventions. Over the next4 weeks, the only special-cause eventidentified was a single point abovethe upper control limit. Investigationrevealed that an all-day case had beencanceled due to failure of vital ORequipment, which was outside thescope of this project.

Two of the 3 interventions could notbe continued after the epoch depictedin Fig 5. Specifically, the text-messagereminders were discontinued becauseof changes in the hospital’sinformation technology

infrastructure, and the supply ofcolored “Steps to Surgery” sheets ranout. These instruction sheets were sofavorably regarded by ENT clinic staff,however, that, independently of the QIteam, black and white copies weredistributed to families even after theplanned “test of change” had ended.Several other surgical servicesbecame aware of the intervention andrequested to use the instructions aswell.

Although this initial successfacilitated “buy in” from perioperativeleadership, .12 months elapsedbefore securing funding forredesigned “Steps to Surgery” sheetsand new text-message remindersoftware. Figure 6 charts theimplementation across all services atboth of CCHMC surgical campuses.One week after SMS reminderscommenced, 9 points below thecenterline indicated special-causevariation. That the special-causevariation occurred 6 weeks afterinitially distributing “Steps toSurgery” sheets was unsurprising,

because surgery typically follows theclinic visit by several weeks.Widespread implementation of keyinterventions was associated witha reduction in mean OR time lostdue to DoSC from a baseline of6.6 hours to 5.5 hours/day (17%improvement). The mean OR timescheduled was 184.6 hours/dayduring the period depicted in Fig 6,although this time includes inpatientsand emergency cases not subject tothis project’s interventions. Morethan 5 months after theimplementation phase commenced,a special-cause event was notedthrough ongoing scrutiny of the SPCchart. Subsequent investigationrevealed that some larger surgicalclinics had run out of “Steps toSurgery” sheets and were unaware ofthe process for reordering.

DISCUSSION

Using the Model for Improvement,5

a multidisciplinary team devised,tested, and refined 3 sets ofinterventions to successfully reducetime lost due to DoSC at a largechildren’s hospital. Although a fulleconomic analysis is beyond thescope of the project, given ∼250working days/year and an OR chargeof $3000/hour, the potentialadditional revenue for OR time aloneis estimated at .$800 000/year.Although not specifically trackedduring the project, families’inconvenience and emotional distresswere likely also reduced.

Particular challenges may haveaffected the outcome. First, witha baseline DoSC rate of ∼5%, thepreoperative preparation process wasalready achieving high reliability.8

To further improve high-reliabilitysystems, disproportionate effort andsophisticated strategies arerequired.11 Also, unlike manyhospital-based improvement projectsthat focus on health care workers, theultimate target of 2 of the 3interventions was the behavior ofcaregivers and families within their

FIGURE 5Control chart showing total hours of OR time lost each day due to DoSC at the hospital’s maincampus. The solid red line represents the mean OR time lost each day. The dotted red linesrepresent upper and lower control limits, which correspond to 63s from the mean. Special causeis shown by the “shift” of the mean below the centerline. The horizontal span of the gray boxesrepresents the time period during which the stated interventions were in place. h, hour.

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own homes. Because theseindividuals had no knowledge of theimprovement project, any Hawthorneeffect was likely minimized.

The team was disappointed that thedegree of improvement was lessduring the implementation (17%)than during the testing phase (37%).The reasons are still underinvestigation and subject to furtherimprovement effort, but some themesare already apparent. For example,“roll out” of the “Steps to Surgery”sheets requires that they are stockedand distributed at all locations wherechildren are scheduled for surgery,which includes many outsidelocations and offices of privatepractice physicians undertakingsurgeries at CCHMC. Also, somesurgical services opted to distributeinformation sheets from theiradministrative offices rather thandirectly to families attending clinic.Fewer text messages were sent whenthe consent process transitioned fromSDS to clinics. Because the newservice forms part of a hospital-wideinitiative, a separate team took

ownership. Finally, because testingphases of the QI project werepresented in meetings with manyperioperative staff, we cannot excludesome Hawthorne effect.

The QI approach to DoSC wasfacilitated by the opportunity toconduct “tests of change” on largenumbers of individuals because ∼100children undergo planned surgery atCCHMC each working day. Thecorollary, that large amounts of datacan be overwhelming, was largelyobviated by the preexisting datacollection workflow. Because SPCcharts interfacing to the EMR werecreated at the outset, rapid learningfrom the response of the process tointervention was feasible.

Preoperative preparation offersmultiple intervention opportunitiesfrom the time of scheduling onward.This team benefited from includingfront-line representatives from manysteps in the process. The “Steps toSurgery” sheet is distributed in thesurgical clinic, but reminder textmessages are sent out the evening

before surgery. However,interventions early in the pathwaysuffer a lag effect before feedback isreceived due to the inevitable intervalbetween scheduling and surgery.Resulting effects will therefore exhibitramped onset due to variation in thislag between individuals.

From the outset, the project’s keyoutcome measure was lost OR timedue to cancelation for any cause. Thisselection was most meaningful tosenior decision-makers within theinstitution because of its correlationwith lost revenue. Clinicians generallypreferred to know the absolutenumber of families impacted, butmost also appreciated a sense of timewasted as meaningful. For families,cancelation of longer or majorprocedures might perhaps beregarded as more important.

Reductions in DoSC benefit patients,caregivers, and the hospital. Forfamilies, last-minute cancelationcarries emotional and practicalimpact. Tait et al2 found that one-third of mothers and over half offathers missed a day of work, whichwas unpaid in almost half of cases.Moreover, their average round tripwas .150 miles to the University ofMichigan Medical Center.Disappointment, frustration, andanger were frequently reported. Thecurrent study did not ascertainpsychological or practical impact, butit seems likely that the reduced DoSCalso improved patient and familyexperience.

Increased OR efficiency has beenreported to follow more accuratescheduling and alignment of staffingin the postanesthesia recovery unit.12

After a previous successful effort atCCHMC to reduce staff overtime costsby improving on-time day start andfinish times,13 DoSC was selected forimprovement. Although cancelation ismore common for children than foradults,14 few studies describe theproblem.15–19 Fewer still reportalleviating it.1,20 Patel andHannallah20 used a telephonic

FIGURE 6Control chart showing mean combined daily hours of OR time lost each week due to DoSC at both ofthe hospital’s surgical campuses. The solid red line represents the mean daily OR time lost. Thedotted red lines represent upper and lower control limits, which correspond to63s from the mean.Special cause is shown by the “shift” of the mean below the centerline. The horizontal span of thegray boxes represents the time period during which the stated interventions were in place.

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screening process to reduce DoSCfrom 14.8% to 9.7%. A similarapproach had already beenincorporated into our processes.Boudreau and Gibson1 instead useduniversal face-to-face preoperativeassessment. Similarities to our studyinclude the setting of a large tertiarychildren’s hospital and acute illnessas the most frequent cause of DoSC.Although no economic analysis waspresented, it seems likely thatconsiderably more resources wererequired to conduct the universalpreoperative assessment clinicdescribed than for the revised familyinformation sheet, automated text-message reminder system, andimproved internal communicationpathway used in the projectdescribed here.

CONCLUSIONS

We identified key drivers critical toreducing cancelations of children’ssurgical procedures on the scheduledday. Analysis-driven modifications topreoperative processes, tested andrefined by using the Model forImprovement, led to a significantreduction in cancelations at a largetertiary children’s hospital. Clear andfocused preoperative instructions,text-message reminders to caregivers,and a clearly defined internal decision-making process on patient illness allcontributed to the project’s success.

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DOI: 10.1542/peds.2014-2418 originally published online April 13, 2015; 2015;135;e1292Pediatrics 

Lonnemann, Andrea Ellis, John Rugg, W. Ray Stone and Cindi BedinghausJayant ''Nick'' Pratap, Anna M. Varughese, Patti Mercurio, Terri Lynch, Teresa

Reducing Cancelations on the Day of Scheduled Surgery at a Children's Hospital

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