1. Seth Christian MD, MBA Department of Anesthesiology Tulane University Hospital and Clinics

2. What is Operations Management?

3. PAT Online Urgent Emergent Admission Additional Testing OPS Info Holding Surgery Clinic Inpatient Surgery Clinic Preop No Surgery Recovery ICU Ward Discharge Regional

4. What is Operations Management? PAT Online Urgent Emergent Admission Additional Testing OPS Info Holding Surgery Clinic Inpatient Surgery Clinic Preop No Surgery Recovery ICU Ward Discharge Regional MRI OR7 OR2 Endo OR8 Endo OR9 OR3OR4OR1 OR6 SP OR5 OR10 Endo

5. “It is the responsibility of the OR directors and clinical managers to do any and all cases that can be done safely without compromising quality of care.”

6. “It is also the responsibility of the OR managers to provide surgeons with open access to OR time, to maximize OR efficiency, and to reduce overall patient waiting.”

7. Safety Open Access Efficiency Patient Waiting Professional Satisfaction

8. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

9.  Months to years before DOS  1st stage of OR allocation  Based on financial data  Allocate OR time to increase Contribution Margin  Involves changes in OR workload over months to years.  Weeks to days before DOS  2nd stage of OR allocation  Not based on financial data  Allocate OR time to increase OR Utilization  Matches staffing to existing workload Tactical DecisionsOperational Decisions

10. “In order to grow a specialty service, hospital administrators must tactically allocate more OR time by recruiting more surgeons, purchasing more equipment, expanding clinics, or increasing ward and ICU usage.”

11. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

12. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

13. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

14. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

15. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

16. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

18. Question 1 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many prime time minutes did CT surgery use on Monday and Tuesday? 1. 240 minute (4 hours) 2. 720 minutes (12 hours) 3. 840 minutes (14 hours) 4. 1080 minutes (18 hours)

19. Question 1 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many prime time minutes did CT surgery use on Monday and Tuesday? 1. 240 minute (4 hours) 2. 720 minutes (12 hours) 3. 840 minutes (14 hours) 4. 1080 minutes (18 hours) Explanation: On Monday, CT surgery utilized 4 hours of an 8 hour block. On Tuesday, CT surgery utilized all 8 prime time hours, plus 6 additional hours.

20. Question 2 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What was the prime-time utilization for CT surgery for Monday and Tuesday? 1. 25% 2. 50% 3. 75% 4. 100%

21. Question 2 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What was the prime-time utilization for CT surgery for Monday and Tuesday? 1. 25% 2. 50% 3. 75% 4. 100% Explanation: Although CT surgery operated for 18 hours, only 12 of those hours were during prime-time. CT surgery was allocated 16 hours. Therefore 12/16 = 0.75 or 75%.

22.  OR Utilization is just one of many factors influencing OR allocation.  OR Utilization alone is poorly related to patient waiting time, variable costs, and contribution margin.  Many times, increased utilization can decrease the profit margin (over utilization) and decrease surgeon flexibility.

23. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

24.  Over-utilized time (Over) – time that the OR is used and not staffed (“Overtime” = time and a half)  Under-utilized time (Under) – time that the OR is staffed and not used  Inefficiency of use of OR time (IU_OR)– the sum of the products of cost of under-utilized time multiplied by the number of under-utilized hours and the cost of over-utilized hours multiplied by the number of over-utilized hours.  IU_OR = Under + 1.5(Over)  Heavily dependent on the OR manager’s ability to minimize over-utilized time.

25. Question 3 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many under-utilized hours did CT surgery have for Monday and Tuesday? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours

26. Question 3 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many under-utilized hours did CT surgery have for Monday and Tuesday? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours Explanation: 4 hours of under utilized time on Monday and 0 hours of under-utilized time on Tuesday.

27. Question 4 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many over-utilized hours did CT surgery have for Monday and Tuesday? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours

28. Question 4 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). How many over-utilized hours did CT surgery have for Monday and Tuesday? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours Answer: 0 hours of over-utilized time on Monday and 6 hours of over-utilized time on Tuesday.

29. Question 5 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What is the inefficiency of use of OR time (IU_OR)? 1. 4 hours 2. 8 hours 3. 12 hours 4. 16 hours

30. Question 5 On Monday, CT surgery books a VATS that starts at 7AM and finishes at 11AM (4hr). On Tuesday CT surgery books 3 CABGs that start at 7AM and finish at 9PM (14 hr). What is the inefficiency of use of OR time (IU_OR)? 1. 4 hours 2. 8 hours 3. 12 hours 4. 16 hours Answer: 4 + 1.5(8) = 16. Ideally you would want this number to approach zero.

31. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

32. 20 minutes behind OR 1 OR 2 60 minutes behind What is the tardiness of OR 1? What is the tardiness of OR 2? 5 x 20 = 100 minutes 1 x 60 = 60 minutes

33. 1. Patient for Room 1 2. Patient for Room 2 Two ORs call for their next cases, but only one person is free to prepare the patients. Both ORs are 10 minutes behind schedule. The four remaining cases in OR1 are estimated to end at 2PM. The one remaining case in OR2 is estimated to end at 4PM. Staffing is planned from 7A to 6P. Which patient first?

34. 1. Patient for Room 1 2. Patient for Room 2 Two ORs call for their next cases, but only one person is free to prepare the patients. Both Ors are 10 minutes behind schedule. The four remaining cases in OR1 are estimated to end at 2PM. The one remaining case in OR2 is estimated to end at 4PM. Staffing is planned from 7A to 6P. Which patient first? Patient Safety – unaffected by decision Open Access – unaffected by decision OR Efficiency – unaffected by decision * OR1 is expected to have 0 over utilized hours. * OR 2 is expected to have 0 over utilized hours. Patient waiting – affected by decision * OR 1 expected total tardiness of 40 minutes * OR 2 expected total tardiness of 10 minutes

35. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

36. How do I optimize Prime Time Utilization, OR Efficiency, and Tardiness?

37. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

38. Which of these measures has the greatest impact on OR Efficiency? 1. OR Allocation (Staffing) 2. Turnover time 3. Case Duration prediction accuracy 4. First case start percentage 5. Clinician efficiency 6. Staff assignment 7. Staff scheduling

39. Which of these measures has the greatest impact on OR Efficiency? 1. OR Allocation (Staffing) 2. Turnover time 3. Case Duration prediction accuracy 4. First case start percentage 5. Clinician efficiency 6. Staff assignment 7. Staff scheduling Explanation: The principal determinant of OR Efficiency is OR Allocation or Staffing. OR Efficiency applies to the existing workload.

40. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

41. OR Allocation (Staffing) Months before DOS Tactical decisions determine increases in OR time allocation Operational decisions based on OR efficiency fill the OR time once the actual workload is known Dr. Thomas underestimates case durations and operates for 12 hours a day when the OR is only staffed for 8 hours. From an operational perspective, surgeons schedule cases on any future workday, regardless of OR staffing. The OR should be staffed for 12 hours for this surgeon. Over –utilized OR hours are reduced without increasing under-utilized hours. Every case scheduling conflict is a failure of OR allocation until proven otherwise.

42. First-case start percentage Clinician efficiency OR efficiency Case duration prediction accuracy Turnover Time Staff Assignment OR Allocation (Staffing) Staff Scheduling Tardiness Safety Open Access Efficiency Patient Waiting Professional Satisfaction Prime Time Utilization

43. First-case start percentage Clinician efficiency Case duration prediction accuracy Turnover Time “Working fast and efficiently is always a good characteristic, but if the OR managers do not allocate OR time appropriately, the benefits of working fast may be negated.” Case duration prediction accuracy is critical for matching the predicted workload to the actual workload. Hypothetical example: Today, Dr. Lancaster had the best day of his life. He was in the OR at 7:10 for his first case, a massive oncological disaster. Fiberoptic intubation, central line, a-line, and thoracic epidural all done by 7:30. Incision at 7:31. The case is predicted to last 6 hours, followed by a 1 hour port removal (+1 hour turnover time). The first case finishes 2 hours before the predicted case duration, and Dr. Mehl turns over the OR himself in 15 minutes. Because of Dr. Mehl’s awesomeness, the room finishes all of its cases 3 hours earlier than expected. From an operational perspective, did Dr. Mehl improve OR efficiency?

44. Wednesday 3/7/12 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 45678910141718E1E2 G/S/M 10+2 6 4 0 11 over5 under + ( 1.75) x = 24.25 inefficiency of use of OR time

45. Predicted Scheduled Workload Thursday 3/8/12 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 48910141718G1 Sp E2 E1XX 25 under

46. Predicted Scheduled Workload Thursday 3/8/12 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 48910141718G1 Sp E2 E1XX

47. OR Allocation (Staffing) Thursday 3/8/12 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 48910141718G1 Sp E2 E1 25 under + + ( 1.75) x = Inefficiency of use of OR Time ? over Caloia 7A-7P Call Rosen 7A-3P Martin 11-7P Bates Res. Mehl Res. Lanc Res. Weiss Res. Worle 11-7P Boudr 7A-3P St. Joh 7A-3P Rex 7A-3P Train 7A-5P Badon 7A-3P Palme 7A-3P Train 7A-5P Guilb 7A-3P Casey 7A-3P Guilb 7A-3P 19 under Murra 7A-3P Baker 7A-3P X2X5

48. PTU based on Allocated OR Time Thursday 3/8/12 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 48910141718G1 Sp E2 E125 #4 Fried Metz Block 4 of 8 50% PTU #8 FCFS Block 6 of 8 75% PTU #12 FCFS Block 8 of 8 100% PTU #10 ACS McGin Block 8of 8 100% PTU #14 U/E Block #17 Kandil Block 8 of 8 100% PTU #18 Lee FCFS Block 4 of 8 50% PTU #15 CV Releas 0 of 8 0% PTU OSL #2 Bellow Block 0 of 8 0% PTU #5 Hellstr Block 0 of 8 0% PTU OSL

49. StatYTD AvgTargetHCA Average 1 st Case on time starts 68%90%56% Scheduled Duration Accuracy 38%90%59% On time starts52%90%53% Prime Time Utilization 73%75%49% Average Physician TAT 47 min<35 minUnknown

50.  Surgeons are responsible for scheduling cases into block time and accurately estimating case duration.  OR Managers are responsible for allocating OR time to match the workload.  Departmental Conference Friday Morning  Two to One Resident Supervision  Resident Didactics on Thursday Afternoon

51.  OR Allocation is based on both Tactical and Operational decisions.  Tactical decisions are made by hospital administrators and use financial metrics such as contribution margin per OR hour to increase total OR allocation.  Tactical decisions increase allocation by increasing workload.  A doctor with low utilization may get more OR time allocated by administrators if he/she has a very high CM/OR hour.  Operational decisions adjust allocation to the existing workload to optimize OR efficiency.  OR allocation (staffing) has the greatest impact on OR efficiency.  Prime time utilization is a useful indicator, but must be interpreted in conjunction with other metrics.  Turnover time, case duration prediction accuracy, and clinician efficiency improve OR efficiency only if OR allocation is appropriate.  Operational decisions should always follow the ordered priorities 1. If the case can be done safely, it should be done. 2. Surgeons should have open access to OR time. Scheduling conflicts are a result of improper OR allocation until proven otherwise. 3. Operational decisions should minimize Inefficiency of use of OR time, which is heavily dependent on Over-utilized time. 4. Operational decisions should minimize overall tardiness. Case duration prediction accuracy, turnover time, and clinician efficiency can reduce variability responsible for increasing tardiness. 5. Physician satisfaction should only be considered after all other ordered priorities are satisfied. This relates to calling in teams to finish the day because of personal obligations, etc.