PERI-OP GOVERNING COUNCIL ST. LUKE’S HOSPITAL CEDAR RAPIDS IHS Leadership Symposium April 17, 2012

Background Operating room is a significant driver of net revenue and cost in the hospital > 10,000 inpatient and outpatient cases annually Limitations to hospital resources Skilled specialty specific staff Rooms Specialty equipment Inefficient scheduling system contributes to unintended competition for resources Surgeons have limited understanding of the management of those resources beyond their schedule

Peri-Operative Governing Council (POGC) Established 2008 Aim: To create a shared governance model comprised of hospital administration, peri-operative service mgmt, surgeons, and anesthesiologists Purpose: Engage physicians in operational decisions that affect them  To keep physicians abreast of peri-operative initiatives  To identify opportunities to increase physician satisfaction and ease of practice  To support initiatives to improve the efficiency and effectiveness of the OR

POGC Structure Original Charter Advisory capacity Physician membership assigned and approved by St. Luke’s administration All physician members had voting privileges in determining recommendations referred to responsible hospital personnel & medical staff committees as appropriate Other medical staff attendees invited as topics dictate

POGC Business Identified and discussed operational issues affecting OR flow On time starts, first case of the day Definition of "start time“ Scheduled time vs. actual time Anesthesia schedule management Epidural block placement prior to surgery Ease of adding on cases Turn-over times The Flood - our response and what we learned ED to OR patient throughput

Surgical Services Assessment Built political capital through engagement and communication Took time for due diligence Educated physicians POGC selected external consultant for surgical services assessment (Sullivan Group) Physician participation in assessment interviews Communication, Communication, Communication

2010 – Assessment Conclusion and Action plan The Peri-Operative Governing Council has worked to establish an organizational foundation that will allow the peri-operative program to function in a high quality, patient-centric, customer-focused, and cost-effective manner A primary goal is to get the appropriate resources to the surgeon, including skilled help, the right equipment, and anesthesia services, so that he/she can give the best care to the patient in a timely fashion Many surgeons unintentionally compete with other surgeons for the same resources at the same time in the same hospital by way of past scheduling practices It is beneficial for everyone to improve scheduling processes and define elective block schedules that are site specific so as to reduce the unintended but frustrating competition for resources

A Platform for Change Recognize : This is a political process There are multiple stakeholders Foundational changes required to affect real change The importance of communication and deliberation

Presentation to St. Luke’s BOD Oct 2010 History of POGC – Aim and Purpose Peri-operative stakeholders Proposed improvements in peri-operative services Request to advance from an advisory council to a governing council Governing Council supported by BOD

2011 –Surgery Executive Committee Director of Surgery, Anesthesia Director, COO, Director Surgical Services Effective governance structure is essential to a well-run surgery program Structure: subset of the POGC Purpose:  Educate, develop, support physician leaders  Charged with operational responsibility and authority for all aspects of the surgical program, including: development, implementation, and enforcement of all policies related to surgical services’ operational issues including block scheduling and patient throughput responsible for creating the monthly agenda for the POGC examine educational opportunities for physician leaders

2011 – POGC Business Update charter to evolve from:  Advisory capacity to Governing capacity  Physician membership assigned and approved by St. Luke’s administration to membership selected and approved by POGC  All physician members had voting privileges in determining recommendations referred to responsible hospital personnel & medical staff committees as appropriate to voting privileges extended to creating policy  Other medical staff attendees invited as topics dictate Universal Block Scheduling Policy Add-on classification system Communicate Council activity to physician colleagues

2011 – POGC and Block Scheduling POGC oversight of transition from city-wide block scheduling system to a hospital-based or site- specific system to be completed January 2012 Collaborative effort between the hospital, anesthesia services and multiple surgeons and offices Issue surgeon and specialty-specific blocks Define scheduling terms Develop and implement Universal Block Scheduling Policy Develop and review block utilization reports

Elective vs. Add-On Principle: A well managed elective schedule along with clinically driven prioritization of add-ons can reduce wait times for urgent/emergent volumes.

Elective vs. Add-On Must be Managed Separately Wait times and other delays are key drivers in both patient satisfaction and clinical quality. The most effective organizations will address patient flow issues through “changing the production process” via operational management techniques from private industry. Variability in the elective schedule is the main driver in OR delays. The elective schedule is totally schedulable and within our control. Proper management of an elective schedule improves physician/patient access to patient-driven peaks in demand (add-ons). Elective and non-elective volumes are different and must be treated separately.

Results Operations / Flow: Variability – Hours of elective vs. hours or add-ons per day On-time starts first case of the day Block utilization Matching OR staffing to volumes OR staff overtime and Extra Hours Incentive OR rooms open after 1530, 1730 and 1930

Block Utilization Report Summary Total OR Blocked Hours Utilization Quarter Block Hours Scheduled Time Scheduled Time UtilizationActual Time Actual Time Utilization Out of Block Time Q % % Q % % Q3 1, % % Q4 1, , % % Key: Total , , % 1, % > 80% Utilization Jan. 1, % % % Utilization Feb. 1, % % < 60% Utilization Mar 1, % %

On Time Starts – 1 st Case of the Day

Overtime and Extra Hours Incentive

Rooms Open after 1530, 1730, 1930