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Novel OR scheduling and staffing boosts efficiency

Major Finding: During the first year, surgical cases rose 4%, overtime fell 27%, staff turnover fell 8%, and hospital margin rose 5%.

Data Source: The first-year experience of new operating room staffing and scheduling procedures at one U.S. hospital.

Disclosures: Dr. Smith said that he had no disclosures.

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Changed surgical culture focuses on patients, needs

At my institution, Johns Hopkins, we recently moved into new operating rooms, and we wanted to change the way we did things in the department just like at Mayo.

In general, the way surgeries are scheduled at U.S. hospitals is a mess. As a resident at UCLA, I would sit outside the OR at 6 a.m. to get a case scheduled for that day.


Julie A. Freischlag

The key element we identified for the changes we made at Hopkins were preparation and buy-in from all the staff: nursing, anesthesia, and surgery. We needed champions in each of these areas, and we had to stay focused on what was best for patients. Before this, the way we ran our operating rooms – and the way most hospitals still run their ORs – is based on what is best for the surgeons. Changing the culture in OR scheduling to focus on patients is essential for making the operation efficient.

We now do a great deal of negotiation on whether a patient needs surgery right away. This requires transparency about the real urgency of a case.

Redesigning the culture and eliminating block time was painful. But we now do six to eight additional cases each day, and we have seen reductions in costs and gains in efficiency similar to what Dr. Smith reports happened at Mayo. Fewer elective cases get interrupted, while the urgent cases still get scheduled.

Once we began this effort, our elective ORs increased to greater than 80% use, and now we are up to 95%. We still offer block time, but once OR usage falls below the 80% level, we take block time away; some surgeons on our staff believe that I am evil because I took away their block time. We also have five emergency ORs that run with about a 50% usage rate.

We now find that we run out of beds for the postsurgical patients before we run out of available ORs. Our next challenge is how to discharge postoperative patients faster.

Dr. Julie A. Freischlag is a professor and chairman of the department of surgery at Johns Hopkins University, Baltimore. She made these comments as a designated discussant for Dr. Smith’s report. She had no disclosures.


 

AT THE ANNUAL MEETING OF THE SOUTHERN SURGICAL ASSOCIATION

A more realistic approach to scheduling elective surgeries, and the staffing of operating rooms to support more efficient use, led to increased surgery volume but with less overtime, better staff satisfaction, and ultimately an increased margin for the hospital, according to the recent experience at one mid-size U.S. hospital.

The result was a surgical schedule that became "more predictable and reliable," and led to "increased capacity without increased operational costs," Dr. C. Daniel Smith said at the meeting.

"The issue is predictability and reliability, so that we can adapt [staffing and operating room needs] appropriately," said Dr. Smith, professor and chairman of the department of surgery at the Mayo Clinic in Jacksonville, Fla.

Dr. Smith and several other staffers at Mayo began by identifying a few shortcomings in the surgical scheduling methods at their hospital, a 214-bed facility that opened in 2008 with 21 operating rooms, 28 ICUs, and about 12,000 surgeries done each year. Operating-room volume was highly variable, fluctuating between 35 and 62 cases per day. "That’s a huge day-to-day variability. If you staff for the average you’ll be chronically understaffed or overstaffed each day," he noted.

Another big problem was that the schedule had no way to easily insert the inevitable emergency cases without severely disrupting elective cases. "As emergencies showed up, [elective] cases got bumped past 5 p.m. We had on average five cases a day where everything [scheduled] got changed. Surgeons no longer could operate with the team they expected."

When they began their self assessment in 2009, they found that their operating rooms had less than 65% utilization during prime-time hours, they routinely paid overtime for 15 full-time equivalent employees, and they had low levels of surgeon and staff satisfaction with OR management and efficiency.

They set out in 2010 to revamp their OR scheduling and staffing with the goal of increasing case volume, reducing overtime, and maintaining emergency surgeries without disrupting the elective schedule. Their strategy included designating some ORs that would handle only emergency and urgent cases. They also did not allow elective cases to be scheduled if they would finish later than 5 p.m., unless it was for a group of surgeons who consistently were used to working until the later time.

"We told surgeons [who wanted to schedule an elective case late in the day] that they would need to move the case to another day," Dr. Smith said. "The surgeons we struggled with the most were the high-volume, academic surgeons who try to handle 12 months of cases in 9 months. They run two rooms and a clustered bay. We told them that they could no longer bleed out into other rooms. They could no longer book a room that ended at 10 a.m. and then show up that morning and pound their fists and say they wanted more empty rooms to push their cases out to.

"That was a big cultural change, and it’s been hard," Dr. Smith said.

Another, ongoing facet has been to "reengineer flow out of the OR and into the hospital," he added. The goal is to "have a streamlined path from entry into the surgical practice to the postop bed and then out the door as quickly as possible."

During November 2010 to October 2011, the first year after full implementation of the revamped scheduling process, the number of surgical cases increased by nearly 500 patients, a 4% rise; prime time OR use rose from 61% to 64%; the number of overtime full-time equivalents fell by two staffers (27%) – a cost savings of more than $111,000; daily elective room changes fell by 69%; staff turnover, considered a measure of satisfaction, dropped from 20% to 12%; and the total net margin to the hospital rose by nearly $5 million, a 5% increase. That happened despite the addition of 15 full-time equivalents to the surgical staff, which boosted payroll by nearly $800,000, because the number of cases rose while the costs per case remained unchanged.

Despite these successes, Dr. Smith had a warning for any surgery department considering similar changes because of the substantial cultural change it involves: "We spent a year planning this before implementation, and that wasn’t enough time. There is never enough time. You need to take your time, find a group that likes this, get early wins, and build on that. It will take years to fully effect this; take it one step at a time."

Dr. Smith said that he had no disclosures.

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