1. Surgeon, Surgical Team, and Surgery-Recovery System Knowledge Generation and Learning in a Hospital Nile W. Hatch Marriott School – BYU Nile W. Hatch Marriott School – BYU David W. Moore Care Flow Institute David W. Moore Care Flow Institute INFORMS - Seattle Nov 4, 2007 INFORMS - Seattle Nov 4, 2007

2. Surgeon, Surgical Team, and Surgery- Recovery System Learning Economics of Hospitals Dynamic and growing pressures against strategic pricing in hospitals –Insurance, government, customer choice Rising costs in all dimensions High fixed costs in facilities CEO perspective: Hospital as Middleman Surgeons, Patients = Customers Operating room and related process efficiencies key to attracting & retaining top surgeons, key to providing high level of patient care, so key to overall economic performance of hospital Dynamic and growing pressures against strategic pricing in hospitals –Insurance, government, customer choice Rising costs in all dimensions High fixed costs in facilities CEO perspective: Hospital as Middleman Surgeons, Patients = Customers Operating room and related process efficiencies key to attracting & retaining top surgeons, key to providing high level of patient care, so key to overall economic performance of hospital

3. Surgeon, Surgical Team, and Surgery- Recovery System Learning Knowledge, Learning & Performance As OR and related upstream & downstream processes improve, less frustration and more delight for surgeons and staff, so hospital increasingly able to attract top people Concentration of better surgeons and staff  higher states of knowledge and rates of learning  more process improvement Process efficiency, process improvement rate = measurable expressions of hospital knowledge Improved (degraded) process efficiency, or hospital knowledge, may enhance (diminish) the performance and learning rates of surgeons and staff As OR and related upstream & downstream processes improve, less frustration and more delight for surgeons and staff, so hospital increasingly able to attract top people Concentration of better surgeons and staff  higher states of knowledge and rates of learning  more process improvement Process efficiency, process improvement rate = measurable expressions of hospital knowledge Improved (degraded) process efficiency, or hospital knowledge, may enhance (diminish) the performance and learning rates of surgeons and staff

4. Surgeon, Surgical Team, and Surgery- Recovery System Learning Knowledge, Learning & Performance Surgeon and Staff Learning  Higher case volume per OR- day (given demand by patients)  faster learning by staff and surgeons Higher case volume  more cases per fiscal year over which to depreciate infrastructure and equipment Increased operational effectiveness  greater margin per case  more investment in infrastructure, information technology, process improvements, policy refinements, management, staff and incentives  reinforced advantage First-mover advantage with surgeons, especially locally All the above is synergistic, magnifying the advantage; knowledge maybe the only long-run source of sustainable competitive advantage…(Sastry ?, ?) Surgeon and Staff Learning  Higher case volume per OR- day (given demand by patients)  faster learning by staff and surgeons Higher case volume  more cases per fiscal year over which to depreciate infrastructure and equipment Increased operational effectiveness  greater margin per case  more investment in infrastructure, information technology, process improvements, policy refinements, management, staff and incentives  reinforced advantage First-mover advantage with surgeons, especially locally All the above is synergistic, magnifying the advantage; knowledge maybe the only long-run source of sustainable competitive advantage…(Sastry ?, ?)

5. Surgeon, Surgical Team, and Surgery- Recovery System Learning Surgery as Craft Mastery requires continued practice and development for both surgeons and staff Keeping doctors happy requires keeping doctors busy –Operating room management –Procedure time Repetition of craft maintains and/or improves speed Idleness risks loss of knowledge and skill Speed (controlling for level of care) is an important measure of performance for hospitals, surgeons and staff Keeping doctors happy requires keeping doctors busy –Operating room management –Procedure time Repetition of craft maintains and/or improves speed Idleness risks loss of knowledge and skill Speed (controlling for level of care) is an important measure of performance for hospitals, surgeons and staff

6. Surgeon, Surgical Team, and Surgery- Recovery System Learning Surgery as Craft Mastery requires observation and interaction with other masters Surgeons observe other surgeons in the OR Surgeons have other surgeons observe them in the OR Surgeons, staff and unit managers may visit and observe surgeons, staff, managers and processes at other hospitals (benchmarking) Observing and being observed is an important mechanism in the OR and the hospital for both growing and spreading knowledge Surgeons observe other surgeons in the OR Surgeons have other surgeons observe them in the OR Surgeons, staff and unit managers may visit and observe surgeons, staff, managers and processes at other hospitals (benchmarking) Observing and being observed is an important mechanism in the OR and the hospital for both growing and spreading knowledge

7. Surgeon, Surgical Team, and Surgery- Recovery System Learning Surgery as Craft Mastery requires teamwork among specialists Anesthesiologist, surgeon, surgeon’s assistant, circulating nurse and (scrub) technician work together to complete each case –Setup room; anesthetize & prepare patient; operate; transition patient to post-operative care Dedicated team performs best Shared nurses, technicians and assistants can be counter- productive from an efficiency standpoint in a given OR Turnover of surgeons and staff = loss of knowledge  diminished performance New surgeons and staff = new knowledge  enhanced performance Anesthesiologist, surgeon, surgeon’s assistant, circulating nurse and (scrub) technician work together to complete each case –Setup room; anesthetize & prepare patient; operate; transition patient to post-operative care Dedicated team performs best Shared nurses, technicians and assistants can be counter- productive from an efficiency standpoint in a given OR Turnover of surgeons and staff = loss of knowledge  diminished performance New surgeons and staff = new knowledge  enhanced performance

8. Surgeon, Surgical Team, and Surgery- Recovery System Learning Knowledge and Learning in Surgery Experience - Overall - By procedure - With team Experience - Overall - By procedure - With team Behavior change Behavior change Organizational performance -Surgeon -Team -Recovery Unit -Hospital Organizational performance -Surgeon -Team -Recovery Unit -Hospital Tenure in organization Tenure in organization Knowledge Time between procedures Time between procedures Process change Process change Visits, Visitors, Benchmarking Visits, Visitors, Benchmarking Team composition, experience Team composition, experience

9. Surgeon, Surgical Team, and Surgery- Recovery System Learning Data and Methods 6 years of surgery performance data for one hospital –13 ORs (main), 21 Pre-operative beds, 20 PACU beds, 10 beds each in Intermediate Care Unit, Intensive Care Unit –Multiple floors for in-patient care –10 ORs plus 1 minor room (ambulatory, out-patient surgery) –Over 295 surgeons –Over 861 different procedures –Labor and delivery, plastic, bariatric, cardiatric, spine and nerve, urology, general, vascular, breast, orthopedic, lung, etc. Initial focus on orthopedic cases –18 surgeons (20 active, 2 ignored due to low volume) –15 procedures (covering ~2/3 of all ortho cases recorded) 6 years of surgery performance data for one hospital –13 ORs (main), 21 Pre-operative beds, 20 PACU beds, 10 beds each in Intermediate Care Unit, Intensive Care Unit –Multiple floors for in-patient care –10 ORs plus 1 minor room (ambulatory, out-patient surgery) –Over 295 surgeons –Over 861 different procedures –Labor and delivery, plastic, bariatric, cardiatric, spine and nerve, urology, general, vascular, breast, orthopedic, lung, etc. Initial focus on orthopedic cases –18 surgeons (20 active, 2 ignored due to low volume) –15 procedures (covering ~2/3 of all ortho cases recorded)

10. Surgeon, Surgical Team, and Surgery- Recovery System Learning Orthopedic Procedures and Surgeons 4 – 9 procedures analyzed per surgeon (16 surgeons), sample sizes vary from 27 - 890 0 procedures analyzed for two surgeons (part of group) 15 procedures analyzed for the ortho group as a whole, 14567 instances, sample sizes vary from 42 - 4025

11. Surgeon, Surgical Team, and Surgery- Recovery System Learning Data and Methods Performance variables –Time in OR / Time in procedure / Time in PACU Estimation of learning curves for surgical team, surgeon and PACU (surgery-recovery system), controlling for –Tenure, procedure heterogeneity, environmental changes, team composition, visits and visitors, forgetting, degree of case planning, recovery destination (Home, ICU, IMC, PACU)… Performance variables –Time in OR / Time in procedure / Time in PACU Estimation of learning curves for surgical team, surgeon and PACU (surgery-recovery system), controlling for –Tenure, procedure heterogeneity, environmental changes, team composition, visits and visitors, forgetting, degree of case planning, recovery destination (Home, ICU, IMC, PACU)…

12. Surgeon, Surgical Team, and Surgery- Recovery System Learning Conclusions We’ll have some once the analysis is complete!