PROCEDURAL AREAS are the heart of hospital operations. Surgical cases are a major contributor to hospitals’ net patient revenue. The total number of surgeries – inpatient and outpatient – equates to approximately three-quarters of the total number of admissions. This number increases when including other procedural areas, such as cardiac catheterization labs, electrophysiology labs and other areas performing small (or large) procedures outside the operating rooms.
Most procedural areas are battling similar concerns. On-time start performance is suboptimal; surgeons’ satisfaction level is mediocre; capacity challenges result in long wait times to schedule a case and long wait times during the day of surgery, which leads to low patient satisfaction. Such challenges, in an environment that poses major quality risks, pose an alarming wake-up call to hospital executives.
Opportunities to improve quality and performance in procedural areas can be grouped into three categories: activities that may be streamlined before the day of procedure; improvements during day of procedure; and scheduling improvements.
Prior to the procedure
The typical check-in process on the day of procedure is cumbersome, lengthy and frustrating for a patient already concerned with an upcoming surgery. Registration, consent forms, insurance and other financial liability documentation are just part of what a patient encounters on arrival to the hospital. Inpatient procedures involve less documentation, but still require administrative attention.
Completing these tasks prior to the day of service will save time and divert attention towards the medical process. Patients may complete the paperwork on their pre-surgery consultation visit, on-line or by using a call center service complemented with kiosks. This will result in reduced administrative burden on the day of service.
Health and physical exams also may be completed before the day of the procedure. Patients may provide this information during their consultation visit, followed by a short verification on the day of surgery.
Pre-procedural testing is a major cause of delays. Surgeons often have to wait for labs, radiology and other test results before starting the case. Most hospitals choose to ask the patients to arrive early enough to allow sufficient time for testing. However, phlebotomy, lab and radiology workloads during peak hours make it challenging to meet turnaround time targets and result in idleness of critical resources – surgeons and procedural suites. This problem can be addressed by moving applicable tests to a day, or a few days, prior to the procedure. They may be performed at the hospital or by an outside provider.
Arrangements for logistics and transportation often are handled after the procedure. Case management-related questions may be asked ahead of time, flagging cases for which special arrangements are necessary and proactively addressing potential issues. For example, an elderly patient undergoing hip replacement surgery who doesn’t have domestic support is likely to require transportation and logistical help after discharge, and this can be anticipated and coordinated in advance.
During procedural day
Continuous care by the same nurse responsible for the patient from pre-op on eliminates handoffs during this critical day, improves the quality of care and enhances the experience of patients, who are more comfortable meeting the nurse supporting their procedure, especially if they are under general anesthesia.
Tracking and monitoring on-time start performance, coupled with root-cause analysis to address reasons for delays increases visibility and awareness and helps drive a culture of on-time starts.
Room setup and turnaround times are major room utilization issues that can be easily addressed by improving communication practices and performing applicable activities “offline,” or outside the room while the previous case is in progress.
Material management contributes to an effective and efficient system in procedural areas. Standardization of supplies across ORs, and adjustments of par levels to match demand and prevent staff from breaking scrubs to search for supplies outside the procedure room, are two examples of practices to improve.
Scheduling improvements
Procedural areas have a tremendous impact on hospital census. Consideration of census and lengths of stay to spread procedures across the days of the week can minimize inpatient bed variations.
Every procedural area handles emergency and urgent cases. While the name of the patient is unknown, the pattern of arrival (times of arrival and type of cases) can be predicted based on historical data, thus enabling schedulers to reserve sufficient capacity to account for those cases.
Case lengths vary by the type of procedure and the physician performing it. Acknowledging this variation enables allocation of appropriate durations for cases, reflecting the truth in scheduling.
Starting the day with cases likely to cause the smallest variances improves the chances of running schedules on time. Similar to airlines, on-time performance for the first flight minimizes delays later in the day. To support this, schedulers need to know all cases scheduled for that day. A good practice is giving a patient, upon scheduling, a time window within the day, without indicating specific start times. Schedulers then can arrange the schedule three days prior to the day of service and advise patients on their start time within that block.
A combination of improvements made prior to the day of procedure, during that day, and in scheduling are powerful and can greatly improve operations in procedural areas. Taken together, these can streamline flow across the hospital and ultimately improve patient satisfaction.
Gil Amoray is a partner in Tefen USA, which works with hospitals and health organizations to make sustainable improvements in the areas of business strategy, operations excellence, project management and organizational development.