Efficiency is often in the eye of the beholder. I was just talking to one of my colleagues the other day about working hard versus working smart, and I was making the case to him that I feel like I work as smart as I possibly can. Without that sense of efficiency and juggling as many projects as I can at once, none of them would ever get done. But that doesn't mean I'm necessarily right. If someone who knows what they're doing got into the science of how I work, I'd be willing to be they could find at least a few ways I could improve my work capacity.
Margaret Van Bree had a similar thought nearly two years ago as she took the reins as CEO of St. Luke's Episcopal Hospital, the flagship of the health system of the same name in Houston.
"We benchmark our performance against other hospitals, and we have a higher case mix index than many in the country," says Van Bree, who holds a doctorate in public health from Tulane. "But still, our length-of-stay was longer than it should be."
Not only that, but Van Bree is a firm believer that efficiency and quality in healthcare are directly related. Walking the halls, she says, the hospital seemed to be operating at capacity, only it wasn't.
"People were operating at this feverish pace," she says. "It wasn't like we were running at 95% occupancy and it had to feel like a fire drill. Yet people still had to use heroic efforts every day to keep up."
Decision-makers at St. Luke's were interested long term in building a replacement facility, but first, they wanted to make sure their current facilities were being used as efficiently as possible.
"We are contemplating a replacement facility and we don't want to build more beds to accommodate our inefficiency if there's a better way," she says. "If we could be more efficient, could we shutter units and operate on a smaller chassis?"
She adds that this question gained traction under the prospect of healthcare reform, where efficiency and quality is rewarded.
"We shouldn't put more into plants and operations than we need to."
That meant some extensive process re-engineering was in order.
St. Luke's is one of 14 hospitals (and three medical schools) which make up some of the 49 healthcare institutions that are part of the largest collection of clinical space in the world—Texas Medical Center in Houston. Even though the system has plenty of space for expansion outside the central downtown location of TMC, options for replacement and expansion are limited on the TMC campus. That forced them to make the necessary decision to improve processes to get more out of the space they already have, says Van Bree.
GE Healthcare Performance Solutions was brought in to consult about ways to optimize the space and time constraints at the hospital. The project, as you might guess, is heavily populated by physicians, who found their time spent at St. Luke's was less productive than it might be. Though there are lots of components in the exercise, big gains stood to be made by doing a better job of patient care management and block scheduling for the physicians, Van Bree says.
"Some of the initial work has been on smoothing out variability in the elective operating room," she says. "It's six times greater than in our emergency room."
Physicians there preferred the first come, first served nature of scheduling elective surgeries, she said, but that wasn't working very well at St. Luke's—even with 42 total ORs available. Implementing block scheduling, which allows them to do several cases in one block of time, wasn't perfect either.
"Rooms were blocked 91% of the time. Optimally it should be 48%," she says. "We had the ability to add 5,000 patients by freeing up these blocks."
Physicians agreed to help find a solution that worked for all of them, and the institution.
"When you're talking with physicians about block scheduling vs. first-come first-serve, those are really difficult conversations," she says.
You might guess IT was involved here, and you'd be right. A sophisticated modeling software tool was used to weigh surgical demand against required resources, evaluate hundreds of thousands of potential scheduling scenarios, and allocate block time in a way that meets surgeons' needs while also accommodating new cases and flex capacity.
A team of physicians looked at many of the possible scenarios that the software presented, and collectively decided upon the most time-efficient schedule for the surgeons and the hospital as an organization. That helped with culture change, says Van Bree.
"They are willing to partner because it gives them greater control and from a leadership perspective, causes them to 'own' pieces of this organization," she says.
Concurrent work is progressing on moving patients efficiently through the organization, which should be both an employee- and patient-friendly effort. As Van Bree notes, the hospital "felt full" but actually wasn't.
By re-engineering the best ways for patients to be moved through the system, the goal was to improve patient care and satisfaction, improve staff satisfaction, standardize employee roles, and improve communications across departments, hopefully yielding better decision making and financial benefits, among others.
For example, Van Bree says, care areas should be better able to prioritize how they take patients. An inpatient might have a final appointment with radiology before she's discharged. Yet she still has to wait in line with many others who are ahead of her in the queue, which might mean that discharge is delayed by hours, if not a whole day.
"If that patient goes first, we might be able to free up a bed," Van Bree says. "There's no way to tee that up right now, but a big part of this project is to take away that white space where we're really not advancing patient care."
Not only that, but this kind of work is likely going to lower the cost of any replacement facility that gets built, because the inefficiencies that exist now won't be baked in, she adds.
"If you are in an old plant you can't avoid the question of rebuilding, but there's an appropriate hesitancy for anyone considering big building projects right now. We're trying to make sure that we're getting improvements we need from operations and that we are not asking our board to fund inefficiencies in our system," she says. "If cost per bed is $1-2 million, the difference between a 750 and 650-bed facility…well there's a lot of difference."
Philip Betbeze is the senior leadership editor at HealthLeaders.