2. 1 SIP 3 Arrives at check in Patient Source (IP/PAV) Patient arrival in Pavilion PreOp PT Receptionist PreOp RN Check into HYPERSPACE Escorts Patient to room Place paperwork in Black file Patient may arrive at different time than specified May be called in earlier than anticipated Receptionist cannot enter Medicare info, must use paper Must get forms if left out of packet Confirms info Fill in forms Witness form Copies Insurance form Checks to see if patient has arrived Looks through window to see if patient arrived – no notification Confusion between Surgery Clinic and Pre- Anesthesia Clinic Receptionist cannot update insurance, Next of Kin info lacking Spelling names/birthdates wrong Case times change PSR – Home at 2 pm. No staff support later

3. 2 SIP 3 Pavilion PreOp Activities PT MA Surgeon PreOp RN Bag belongings Talk with family Nurse checks in several patients and may or may not be aware of MD visit After 5 pm Staff Verifies consent Allergy With RN Talks with surgeon Verifies site Checks pt into area Paperwork/Insurance Vital signs Instruct pt to Gown Checks Orders Talks with Patient Marks site Completes H&P IV start DOS Medications Marks Communication Board Documents in CIS Gets old chart Gets Yellow packet Gives Black Bag Changes clothes Opens curtain DOS Lab Instructs MA TED’s Answers phone determine pt ready or not Relays If pt not ready calls back when is ready Waiting in Pav Pre- op Area Surgeon looks for pt in main Pre-op or Pav Pre-op Blood Draw, EKG, Watches Hyperspace, Phone Pt for the Main OR, Surgeon performs activities in the Holding area Stop the patient until all paperwork is done *suggestion Expedited Cases No systematic “stopping the line” until all paperwork is done Switch care providers during critical times

4. 3 SIP 3 Patient Source (IP/PAV) Patient arrives in Pre- Op Main Calls pt source to check if pt is there & ready for transport Patient PreOp HA Front Desk OR RN Calls Transport HA Transport HA Mark Board Checks correct pt id Pick up gurney Pick up patient, chart, card, belongings, family Pre-Op RN calls RN in Unit Pre-op RN Anesth Waiting in Pav Pre-op Area Calls for Pt, Surgeon Surgical Resident Calls for Pt, Calls Circulator in the room to see if it is okay Unit/Floor RN unaware of TBA case start time (some for scheduled cases) Crosses of pt from board in PAV Pre-Op No specific person or time to call for next patient Front board is hard to interpret Unit/Floor does not have access to updated schedule/ESI

5. 4 SIP 3 Pre Op Hold (Main)Main Or Check pt in, H&P, consent,charts PT HA Anesth Pharmacy ??? PreOp RN Scrub RN Interpreter, EP staff, isolation, developmentally delayed, latex allergy – information not available until last minute (may change plan) Assistance as needed Talks to pt, marks site, H&P Exchanging anesthesia tray with An Tech, Dispensing drug box to Rooms, dispensing Rx per case RN Surg Circ RN, surg Rep Anes Rep, - no sequence Drop pt off & marks board; stamp paperwork Put pt belongings in back of PACU Call Anesth Call Circ RN Reviews plan, check pt plan,interviews pt, IV start, lines blocks 1stPt leaves room Patient may not have been seen by an Anesthesiologist, especially if In- Patient. Plan must be made Anesthesia may have seen the pt but different provider = different plan IV started in another area - maybe TBA’s may or may not be seen beforehand SIP1? – Surgeon has information but not sure who to provide the information to.

6. 5 SIP 3 Pre Op Hold (Main) – 1 st pt left OR, In Room activitiy after pt gone Main Or PT HA Anesth Scrub RN Anesth Tech Check next pt allergy, site marking, paperwork RN Surg Escorts to PACUPick up Op report Check next Case cart Clean instr and take to SIP Overhead pages for HA & A. Tech Turns specimen to Pathology, turn in X-ray 1000 item check Case cart location variable Bathroom break Cleans, replenish equipment, get drug tray, take out trash Lines, blocks etc Dump drug, get new drug, check equip, finish equip prep Restock linen, clean room, garbage, setting up operative bed, procuring equipment Receive pager message Talk to family, waits in room, bathroom break, dictate Sometimes, Write equip variation on board or talk to HA Highly variable When is OR ready for pt? How do we know when the OR is ready for pt? How does the surgeon know when the pt is in OR? Roll into OR Issues Go to room with Roll Royce (cleaning cart) Check with RN about Bed need for any other equipment Communication about room status and pt status labor intensive

7. 6 SIP 3 Intra-operative PT Anesth Scrub RN/ Surg Tech RN Surg Monitors blocks, lines, induces anesthesia Foley, cliper, position, etc. Surgeon appears Put on table- cir RN and Aneth Drape patient Surgery Time out Huddle Surgical Team must come to an agreement about when the pt should arrive in the OR Finish case prep with Scrub RN Assist moving pt to bed, safety strap Finish case prep Skin prep Pt asleep Someone pages surgeon ??? Assist moving pt to bed, safety strap Surg Res Expected to show up when pt arrives in room (indeterminate time) Surgeon appears Multiple phone communications on phone, wasted travel time, and search time

8. 7 SIP 3 In OR Patient arrival in Pavilion PACU PT RN Surg PACU HA PACU RN Surgery Enter PACU Goes to assigned spot Notifies PACU of est. arrival time to PACU No standardization of PACU notification. Potential gaming of system. No phone call Surgical team does not know where in PACU to place the patient Wheel in pt to PACU Look on window to see where pt is assigned Surgical team drops off patient. Not enough PACU staff