Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics

Seth Christian MD, MBADepartment of AnesthesiologyTulane University Hospital and

Clinics

PAT

Online

Urgent Emergen

t

Admission

Additional Testing

OPS

Info

Info

Holding

Surgery Clinic

Inpatient

Surgery Clinic

Surgery Clinic

Surgery Clinic

Surgery Clinic

PreopNo

Surgery

Recovery ICUWard

Discharge

Regional

PAT

Online

Urgent Emergen

t

Admission

Additional Testing

OPS

Info

Info

Holding

Surgery Clinic

Inpatient

Surgery Clinic

Surgery Clinic

Surgery Clinic

Surgery Clinic

PreopNo

Surgery

Recovery ICUWard

Discharge

Regional

MRI

OR7

OR2

Endo

OR8

Endo

OR9

OR3 OR4OR1

OR6

SP

OR5

OR10

Endo

“It is the responsibility of the OR directors and clinical managers to do any and all cases that can be done safely without compromising quality of care.”

“It is also the responsibility of the OR managers to provide surgeons with open access to OR time, to maximize OR efficiency, and to reduce overall patient waiting.”

Safety

Open Access

Efficiency

Patient Waiting

Professional Satisfaction

First-case start percentage

Clinician efficiency

OR efficiency

Case duration prediction accuracy

Turnover Time

Staff Assignment

OR Allocation (Staffing)

Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting


Prime Time Utilization

Months to years before DOS

1st stage of OR allocation

Based on financial data Allocate OR time to

increase Contribution Margin

Involves changes in OR workload over months to years.

Weeks to days before DOS

2nd stage of OR allocation

Not based on financial data

Allocate OR time to increase OR Utilization

Matches staffing to existing workload

Tactical Decisions Operational Decisions

“In order to grow a specialty service, hospital administrators must tactically allocate more OR time by recruiting more surgeons, purchasing more equipment, expanding clinics, or increasing ward and ICU usage.”



OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting





OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting





OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting





OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting





OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting





OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting



1. 240 minute (4 hours)2. 720 minutes (12 hours)3. 840 minutes (14 hours)4. 1080 minutes (18 hours)

1. 240 minute (4 hours)2. 720 minutes (12 hours)3. 840 minutes (14 hours)4. 1080 minutes (18 hours)

Explanation: On Monday, CT surgery utilized 4 hours of an 8 hour block. On Tuesday, CT surgery utilized all 8 prime time hours, plus 6 additional hours.

1. 25%2. 50%3. 75%4. 100%

1. 25%2. 50%3. 75%4. 100%Explanation: Although CT surgery operated for 18 hours, only 12 of those hours

were during prime-time. CT surgery was allocated 16 hours. Therefore 12/16 = 0.75 or 75%.

OR Utilization is just one of many factors influencing OR allocation.

OR Utilization alone is poorly related to patient waiting time, variable costs, and contribution margin.

Many times, increased utilization can decrease the profit margin (over utilization) and decrease surgeon flexibility.



OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting



Over-utilized time (Over) – time that the OR is used and not staffed (“Overtime” = time and a half)

Under-utilized time (Under) – time that the OR is staffed and not used

Inefficiency of use of OR time (IU_OR)– the sum of the products of cost of under-utilized time multiplied by the number of under-utilized hours and the cost of over-utilized hours multiplied by the number of over-utilized hours.

IU_OR = Under + 1.5(Over)

Heavily dependent on the OR manager’s ability to minimize over-utilized time.

1. 2 hours2. 4 hours3. 6 hours4. 8 hours


Explanation: 4 hours of under utilized time on Monday and 0 hours of under-utilized time on Tuesday.



Answer: 0 hours of over-utilized time on Monday and 6 hours of over-utilized time on Tuesday.



Answer: 4 + 1.5(8) = 16. Ideally you would want this number to approach zero.



OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting



20 minutes behind

OR 1

OR 2

60 minutes behind

What is the tardiness of OR 1?

What is the tardiness of OR 2?

5 x 20 = 100 minutes

1 x 60 = 60 minutes

1. Patient for Room 12. Patient for Room 2

1. Patient for Room 12. Patient for Room 2

Patient Safety – unaffected by decisionOpen Access – unaffected by decisionOR Efficiency – unaffected by decision * OR1 is expected to have 0 over utilized hours. * OR 2 is expected to have 0 over utilized hours.Patient waiting – affected by decision * OR 1 expected total tardiness of 40 minutes * OR 2 expected total tardiness of 10 minutes



OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting



How do I optimize Prime Time Utilization, OR Efficiency, and

Tardiness?



OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting



1. OR Allocation (Staffing)2. Turnover time3. Case Duration prediction accuracy4. First case start percentage5. Clinician efficiency6. Staff assignment7. Staff scheduling

1. OR Allocation (Staffing)2. Turnover time3. Case Duration prediction accuracy4. First case start percentage5. Clinician efficiency6. Staff assignment7. Staff scheduling

Explanation: The principal determinant of OR Efficiency is OR Allocation or Staffing. OR Efficiency applies to the existing workload.



OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting



OR Allocation (Staffing)Months before DOS

Tactical decisions determine increases in OR time allocation

Operational decisions based on OR efficiency fill the OR time once the actual workload is known

Dr. Thomas underestimates case durations and operates for 12 hours a day when the OR is only staffed for 8 hours.

From an operational perspective, surgeons schedule cases on any future workday,

regardless of OR staffing.

The OR should be staffed for 12 hours for this surgeon. Over –utilized OR hours are reduced without increasing under-utilized

hours.

Every case scheduling conflict is a failure of OR allocation until proven otherwise.



OR efficiency


Turnover Time

Staff Assignment


Staff Scheduling

Tardiness

Safety

Open Access

Efficiency

Patient Waiting






Turnover Time

“Working fast and efficiently is

always a good characteristic, but if the OR managers do not allocate OR time appropriately,

the benefits of working fast may

be negated.”

Case duration prediction accuracy is critical for matching the predicted workload to the actual workload.

Hypothetical example: Today, Dr. Lancaster had the best day of his life. He was in the OR at 7:10 for his first case, a massive oncological disaster. Fiberoptic intubation, central line, a-line, and thoracic epidural all done by 7:30. Incision at 7:31. The case is predicted to last 6 hours, followed by a 1 hour port removal (+1 hour turnover time). The first case finishes 2 hours before the predicted case duration, and Dr. Mehl turns over the OR himself in 15 minutes. Because of Dr. Mehl’s awesomeness, the room finishes all of its cases 3 hours

earlier than expected. From an operational perspective, did Dr. Mehl improve OR efficiency?

Wednesday 3/7/12

78910111213141516171819202122

4 5 6 7 8 9 10 14 17 18 E1 E2 G/S/M

10+2

6

4

0

11 over5 under + (1.75) x = 24.25 inefficiency of use of OR time

Predicted Scheduled WorkloadThursday 3/8/12

78910111213141516171819202122

4 8 9 10 14 17 18 G1 Sp E2 E1 X X

25 under

Predicted Scheduled WorkloadThursday 3/8/12

78910111213141516171819202122

4 8 9 10 14 17 18 G1 Sp E2 E1 X X

OR Allocation (Staffing)Thursday 3/8/12

78910111213141516171819202122

4 8 9 10 14 17 18 G1 Sp E2 E1

25 under + + (1.75) x = Inefficiency of use of OR Time

? over

Caloia7A-7PCall

Rosen7A-3P

Martin

11-7P

BatesRes.

MehlRes.

LancRes.

WeissRes.

Worle11-7P

Boudr7A-3P

St. Joh

7A-3P

Rex7A-3P

Train7A-5P

Badon

7A-3P

Palme7A-3P

Train7A-5P

Guilb7A-3P

Casey7A-3P

Guilb7A-3P

19 under

Murra7A-3P

Baker7A-3P

X2 X5

PTU based on Allocated OR TimeThursday 3/8/12

78910111213141516171819202122

4 8 9 10 14 17 18 G1 Sp E2 E1 2 5

#4FriedMetz Block

4 of 8

50% PTU

#8FCFS Block

6 of 8

75% PTU

#12FCFSBlock

8 of 8

100%PTU

#10ACS

McGin Block

8of 8

100% PTU

#14U/E

Block

#17Kandil Block

8 of 8

100% PTU

#18Lee

FCFSBlock

4 of 8

50% PTU

#15CV

Releas

0 of 8

0% PTU

OSL#2

Bellow

Block

0 of 8

0% PTU

#5Hellst

rBlock

0 of 8

0% PTU

OSL

Stat YTD Avg Target HCA Average

1st Case on time starts

68% 90% 56%

Scheduled Duration Accuracy

38% 90% 59%

On time starts 52% 90% 53%


73% 75% 49%

Average Physician TAT

47 min <35 min Unknown

Surgeons are responsible for scheduling cases into block time and accurately estimating case duration.

OR Managers are responsible for allocating OR time to match the workload.

Departmental Conference Friday Morning Two to One Resident Supervision Resident Didactics on Thursday Afternoon

OR Allocation is based on both Tactical and Operational decisions. Tactical decisions are made by hospital administrators and use

financial metrics such as contribution margin per OR hour to increase total OR allocation.

Tactical decisions increase allocation by increasing workload. A doctor with low utilization may get more OR time allocated by

administrators if he/she has a very high CM/OR hour. Operational decisions adjust allocation to the existing workload to

optimize OR efficiency. OR allocation (staffing) has the greatest impact on OR efficiency. Prime time utilization is a useful indicator, but must be interpreted in

conjunction with other metrics. Turnover time, case duration prediction accuracy, and clinician

efficiency improve OR efficiency only if OR allocation is appropriate. Operational decisions should always follow the ordered priorities

1. If the case can be done safely, it should be done.2. Surgeons should have open access to OR time. Scheduling conflicts are a result of improper

OR allocation until proven otherwise. 3. Operational decisions should minimize Inefficiency of use of OR time, which is heavily

dependent on Over-utilized time. 4. Operational decisions should minimize overall tardiness. Case duration prediction accuracy,

turnover time, and clinician efficiency can reduce variability responsible for increasing tardiness.

5. Physician satisfaction should only be considered after all other ordered priorities are satisfied. This relates to calling in teams to finish the day because of personal obligations, etc.

Documents

Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics