Information Management

Increasing O.R. Utilization

Keith L. Long, M.D.
Associate Chairman, Department of Anesthesia
Winchester Hospital

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Increased Surgical Volume / Lack of Capacity

Winchester Hospital is a busy community hospital in suburban Boston. In 2000, the hospital experienced a significant increase in surgical volume. The caseload from surgeons on staff was already increasing. Suddenly and unexpectedly, several large hospitals in the area ceased operation. With few options, a large number of primary care providers moved into the Winchester Hospital network. Not surprisingly, the associated surgical specialists soon followed.

In the past, many surgeons with privileges at Winchester had diverted cases to other local hospitals complaining of a lack of access and capacity. In 2000, this was no longer an option. We were (and still are) one of only three facilities in our large catchment area. Clearly we were suffering from an "embarrassment of riches." Our internal caseload was increasing and a large and exploitable external market was developing. It was imperative that we solve the capacity problem. The question was how?

The Impact of Increased Surgical Case Volume

As one might imagine, the increased demand for surgical time placed tremendous pressure on the Winchester operating rooms. Wait times soared to almost six weeks, stressing patients and annoying surgeons. It became common to hear surgeons

complain that they had lost patients to competitors who could promise a more reasonable wait time. While the Hospital’s traditionally high consumer satisfaction ratings remained constant during the year, administrators worried that Winchester’s coveted 1 / 2 ranking might eventually suffer. The addition of a seventh operating room in February 2000 did little to alleviate the volume/capacity crisis. Staff morale declined as fourteen-hour days, once the exception, became the norm.

The Impact on the Anesthesia Department

The Anesthesia staff often bore the brunt of these long days and morale was conspicuously low. Paradoxically, staff felt that increased work time did not always translate into increased productivity. Hours were spent waiting for rooms to turn over or for surgeons to arrive. Downtime in the middle of the day meant that everyone stayed late.

The Anesthesia and Surgical Departments Working Together

Surgery had, in the past, relied on the Hospital’s internal information system to track and analyze O,R. data. Although adequate, it was far from optimal and often quite frustrating. Physicians had to rely on the Hospital’s IT department to generate required or requested reports. Lag time was long, often approaching two weeks. The disadvantage of entrusting surgical data to non-surgeons was sadly apparent. Much paper was wasted (and many arguments sparked) as clinicians consigned off-target reports to the scrap heap.

Despite numerous attempts, IT could never refine raw O.R. data enough to be useful. We could determine utilization for a room, say, but were unable to distinguish justified down time (room turnover) from unjustified down time (poor scheduling, inefficient O.R. crews). More troubling, though, was the system’s inability to effectively track and block the surgical day.

The Anesthesia Department had, at the time, been using the Deio Anesthesia Information System for over four years. We had recently installed the deioAnalyzer Reporting Module and decided to test its data gathering potential.

We asked the Hospital to provide us with some general information on our case mix. With a 73% outpatient to 17% inpatient split, we decided to first concentrate on our outpatient volume. To do so, we first compiled data on case count by surgeon and service and then noted at what time these cases were performed. We decided to continue scheduling surgeons on a first come – first served basis. This allowed all surgeons to compete equally for time.

Defining the Process

Once an objective case count by surgeon and service had been determined, we began to construct time blocks for our high producers. The theory was that a surgeon doing five cases a week would be most efficient doing them all in a single day. Given the skill of our surgeons, a seven case day was well within the realm of possibility, if room utilization could be improved.

During the initial six-week trial we were guaranteed sufficient staff to run all seven operating rooms from 7:30 a.m.-5:30 p.m., three rooms until 8:00 p.m., and one, if necessary, until 11:00 p.m. We elected to block a maximum of 60% of available room time per day and to set surgical turnover time at twenty minutes. We considered these parameters to be reasonable given the relative unfamiliarity of O.R. staff with block booking.

The Initial Results

We began using the Deio Anesthesia Information System and deioAnalyzer Report Module to track overall room utilization in October 2000. Given the rather limited scope of our first round of block booking, we set as our goals eight hours of utilization per 7:30-5:30 day, twelve hours of utilization per 7:30 a.m.-8:00 p.m. day and thirteen hours of utilization per 7:30 a.m.-11:00 p.m. day. What we discovered was enlightening. Rarely did any room approach maximum utilization. Even excluding the allowed twenty minutes per case turnover time, we left unfilled 20.9 hours of potentially lucrative O.R. time per ten-hour surgical day*. At best our utilization was a disappointing 67%.

Where did we lose time? Looking over reports created by the Deio systems, it became apparent that haphazard scheduling was the most likely culprit. Surgeons arrived late and/or failed to book enough cases to fill the surgical day. What happened during the middle of the day was, for us, the most telling. Winchester Hospital, like most community operations, traditionally booked multiple surgeons performing disparate procedures in each of its operating rooms. Considerable downtime is inherent in such a system. With most surgeons located off-site, it was difficult to capture and exploit time made available when cases finished early. The same was true of cancellations.

* To put it another way, over the course of our six week study, we wasted almost 710 hours of O.R. time., the equivalent of almost thirty days.

Implementing Change

Phase Two of our study involved expanding the range and scope of our block booking operation. During the months of April, May and June 2001, 85% of our surgeons were allowed to block book O.R. time. We did ask that they agree to certain ground rules, namely that start times be respected and that all allotted block time be filled. Adjustments were made throughout the trial period and were based on performance.

The Results

We discovered that by blocking surgical time we were able to increase case volume by more than 50 cases per month. Most new cases were scheduled between the hours of 7:30 a.m.- 5:30 p.m., a development applauded by both Hospital administrators and staff. Average surgical utilization increased to over 78%, with several surgeons approaching an astonishing 90%.

Changing the way in which we managed our O.R.s resulted in significant revenue for both Winchester Hospital and the participating physicians. We were delighted when several surgeons approached us with plans to add services to their practices, plans that the increased time and flexibility afforded by our blocks had allowed them to pursue. Patients saw a decrease in average surgical wait time from over six weeks to under four with an attendant rise in overall satisfaction. Perhaps most telling, though, is the effect of shorter, less frenetic days on staff morale. Most days we can count on being home in time for dinner.

The Next Step

On October 1, 2001, we expanded our surgical blocks to encompass 80% of available room time per day and enrolled 95% of the surgical staff. We elected to grant under-performing surgeons a three-month grace period, and expanded block time for those performing at or above 83%. Results are pending.

Goals

For this phase of the study, we set as our goals:

1. To increase average room utilization by 4% to a mean of 82%;
2. To expand blocks for those surgeons performing at 85% or above;
3. To decrease turnover time, and;
4. To increase objective evaluations of staff performance.

Discussion

Why does your O.R. Management Team need the better data definition provided by an Anesthesia Information System?

An efficient AIS can help you:

1. Generate accurate and objective data specific to your needs;
2. Generate reports required by Hospital administrators;
3. Give Anesthesia Departments the ability to more knowledgeably manage all aspects of the perioperative environment;
4. Objectively establish, manage and maintain surgical blocks, and;
5. Generate revenue increases for the hospital and the participating physicians.

But, remember,

1. An AIS is only as good as those who use it. The Anesthesia team must still track and analyze the data, and use it to promote change, and;
2. An AIS will always be a good investment for your O.R. if only for the improved definition of surgical process data it allows.
   

Last updated: 1 January 2002Created
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