Re-engineering the Operating Room Using Variability Methodology to Improve
Healthcare Value
C. Daniel Smith, MD
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Healthcare Delivery Goals
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To provide the right care
To the right patient
At the right time
In the right place
VARIABILITY IS THE ENEMY
*Outcomes, Safety, Service
Variability in Operating Rooms
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• Peaks and valleys in day-to-day volume of surgical cases
• “No one wants to operate on Monday or Friday”
Day-to-Day
• On the day of surgery, changes to the OR schedule and resource allocation
• Emergencies, add-ons, delays, etc.
Within-Day
Day-to-Day Variability
StaffingHospital censusSupply chain…..
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Within-Day Variability
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Within-Day Variability
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Within-Day Variability
No.
Roo
m C
hang
esElective Rooms on Day of Surgery
2009-2010
SafetyPatient satisfactionTeamwork….
Variability Theory in Surgery
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Natural Variability•a result of naturally occurring processes•uncontrollable
Artificial Variability•a function of man made decisions•controllable
• Emergency or unscheduled Operations
• Uneven scheduling of elective cases
Within 48 hours
Urgent / Emergent (3)
Elective (16)Scheduled
Natural Variability
Artificial Variability
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Case Study Setting
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Mayo Clinic Florida
• 214 bed hospital (21 ORs, 28 ICUs) and outpatient practice within a single complex/campus – opened in 2008
• 11,900 admissions/ year: 55% surgical
• 12,000 operations/year – complex case mix (e.g., 150 liver transplants, 1,200 NS, 900 GISurg)
• 443,500 outpatient visits annually
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• Prime time OR utilization <65%
• 15 FTEs of overtime every pay period
• Low surgeon and staff satisfaction with OR management and efficiencies
• Concern about absence of specialty specific teams
• Frequent disruptions of elective cases by transplants and urgent cases
Baseline Data 2009
Proposal / Hypothesis
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Applying variability theory and methodology, we could
expand the capacity of our hospital’s operating rooms
and increase surgical throughput without adding
infrastructure or expense.
Goals for Variability Management Program
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Within 48 hours
Urgent / Emergent (3)
Elective (16)Scheduled
Natural Variability
Artificial Variability
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• 3 month prospective data collection
• Rooms reallocated based on real volumes/utilization
• Staff allocated to services (added 15 FTEs)
• Implemented November 1, 2010
• Impact assessed at one year
Operating Room Redesign
Results
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Pre- MVP Post-MVP % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.47 -41%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee increase adjusted) $93,929,569 $98,686,693 5%
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Pre- MVP Post-MVP % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.47 -41%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee increase adjusted) $93,929,569 $98,686,693 5%
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Pre- MVP Post-MVP % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.47 -41%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee increase adjusted) $93,929,569 $98,686,693 5%
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Pre- MVP Post-MVP % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.47 -41%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee increase adjusted) $93,929,569 $98,686,693 5%
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Pre- MVP Post-MVP % ChangeSurgical Cases 11,874 12,367 4%Surgical Minutes 1,757,008 1,844,479 5%OR Utilization (19 Room Model) 61% 64% 5%Number of Overtime FTE's (average) 7.4 5.4 -27%Staff Turnover (highest to most recent) 20.3% 11.5% -43%Daily Case Volume Variation 55.24 44.06 -20%Daily Surgery Minutes Variation 6,531 5,124 -22%Elective Room Changes (Average/Mon) 80 25 -69%Elective Room Changes (%) 8% 2% -70%
Salary Dollars (Adjusted for Salary Increases) Total $12,607,061 $13,395,997 6% Monthly $1,045,942 $1,115,646 7%
Cost/Case $1,062 $1,070 0%Cost/Minute of Surgery $7.18 $7.26 1%
Staff Turnover Cost (millions) $2.47 $1.47 -41%Overtime Cost Savings $111,488
Total OR Net Revenue (Fee increase adjusted) $93,929,569 $98,686,693 5%
OR Redesign - Summary
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• Increased volume of surgery
• Added 15 FTEs without significant increase in cost/case
• Prime-time utilization increased and overtime decreased
• The overall surgical schedule became more predictable and reliable
• Staff satisfaction improved as evidenced by decreased staff turnover
• Increased volume without added cost & cost avoidance resulted in improved financial performance
OR Redesign - Conclusion
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• Major cultural and operational change to operating room management
• Re-design around managing variability worth pursuing
• The increased capacity without increased operational costs may be important adjunct to tactics to deal with expected payment reductions accompanying healthcare reform
Re-engineering the Operating Room Using Variability Methodology to Improve
Healthcare Value
C. Daniel Smith, MD
Southern Surgical Association124th Annual Session
December 3, 2012The Breakers
Palm Beach, Florida
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