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OR Management: It's the Variability

 |  By HealthLeaders Media Staff  
   May 21, 2009

Crowded emergency rooms, ambulance diversions, and bed capacity issues in hospitals have created a crisis that politicians, administrators and patient advocacy groups are scrambling to address. For the most part, hospitals try to fix these problems by improving processes in or expanding the emergency department (ED), or by building new inpatient beds. In some cases, these are the right approaches. But in many others, the solution lies elsewhere.

Surprisingly, one of the main culprits causing both ED overcrowding and inpatient capacity issues is the operating room schedule. Although it seems counterintuitive, research shows that the elective surgery schedule is the primary source of the peaks and valleys in hospital census. In contrast, emergency admissions to the hospital, although randomly occurring, are often more predictable on a day-to-day basis than elective surgical admissions.

The variability in admissions caused by the elective surgical schedule causes capacity constraints for inpatient beds and the ED on days with heavy surgical volume. As the hospital fills with scheduled cases, the flow of emergent/urgent cases competes with the scheduled surgical cases for the few remaining inpatient beds, causing unpredictable nurse-patient ratios, slowed admissions from the ED, equipment conflicts and patient placement on inappropriate inpatient units during peak census. During the valleys, beds are empty, operating rooms (OR) run at low utilization rates, and staff is sent home.

The keys to solving these problems are to eliminate the peaks and valleys in patient flow caused by the variable volume in scheduled surgical cases, and to develop the ability to predict and manage the emergent/urgent volume. By actively managing patient flow, hospital leadership can increase the effective capacity of the hospital, the OR and ED, improve patient outcomes, increase staff morale and retention, reduce costs, and improve quality of life for both patients and caregivers.

The Problem of Peaks and Valleys
Looking at Block Scheduling
The OR schedule is the primary driver of the hospital's inpatient census. Examination of the block schedule will help identify the sources of the peaks and valleys in elective case volume throughout the week. Block scheduling for elective surgery is usually based on surgeon preference or requirements, history, convenience and utilization. Rarely is a block schedule designed to smooth case volume throughout the week or to optimize a patient's placement on an appropriate nursing unit post-surgically.

Most ORs have peak days in the surgery schedule, usually on Tuesday or Wednesday. Surgeons who perform complex cases with longer lengths of stay want to do them early in the week so patients can be discharged before the weekend, minimizing the need for cross coverage and rounding on the weekend.

As a result, inpatient bed capacity is filled early in the week, leaving fewer beds available for emergent/urgent patients. Not only does this tax the hospital's resources, but it also creates competition between the OR and the ED for available inpatient beds. When inpatient beds are full, the ED becomes overcrowded, extending wait times and potentially compromising quality of care and patient safety.

Peak days also require more expert OR staff and equipment. This can lead to resource conflicts and excessive use of flash sterilization. The peaks may result in longer turnover times, case delays and cancellations. Patients may be held up in the post-anesthesia care unit (PACU) waiting for beds or worse, held in the OR waiting for available PACU space. Boarding in the OR causes delays, cancellations, and excessive and unnecessary costs.

A hospital in this situation must make tough decisions. The elective surgery schedule must be delayed or cancelled, and/or the ED must divert ambulances. In some communities with few hospitals, diversion may not be an option. Then the surgery schedule suffers because canceling elective cases becomes the only alternative for relieving the bed crunch. Limiting or canceling cases too often may permanently damage referrals, managed care contracts, and the hospital's financial viability. To avoid canceling or delaying cases, the hospital might place patients in the first available bed—not necessarily in the right bed or unit—which can lead to extended stays and safety risks.

Steps to Actively Manage OR Volume
Separating Flows of Patients
In order to reduce competition between the ED and the OR for inpatient beds, the flow of elective cases must be separated from that of urgent/emergent cases. This is best accomplished in the OR (or any procedural area) by determining the volume, arrival patterns and acuity of urgent/emergent volume, as well as the clinically appropriate timeframe for treatment. Using a queuing theory, data analysis, and an objective clinical classification system with waiting times associated with each type of case category provides the information necessary to determine how much capacity is required to accommodate this volume.

Once the capacity requirement for this volume is known, space and staffing resources must be allocated to meet the demand. Establishing separate staffed capacity for urgent/emergent cases ensures that these cases have quicker access to the OR and that elective case volume is not bumped or delayed in order to accommodate the urgent/emergent volume. The separated flows thus allow better access to the OR, fewer delays, and more predictability for both urgent/emergent and elective volume.

Smoothing Elective Surgical Volume
The next step to improving flow is to smooth the flow of elective admissions into the hospital. One way to accomplish smoothing is to provide consistent OR block time by surgical service throughout the week based on OR utilization, as well as the patients' appropriate inpatient destination units. This requires accurate data on surgeon and surgical service utilization of the OR, and accurate and clinically-based admission and discharge criteria for the destination units for surgical patients. Data should also include accurate case duration times, defined as patient-in-room to patient-out-of-room time. Utilization is defined as case duration plus turnover time divided by the allocated block time or primetime as defined by the hospital.

While smoothing the available block time across the week is a start, the real path to sustainable smoothing of the elective admissions begins with understanding how patients are placed in the downstream inpatient units. By identifying the clinically preferred destination unit by service or physician, as well as the average length of stay for these patients, the hospital is better able to allocate both block time and inpatient beds to ensure that patients are placed in the most appropriate bed the first time and every time.

This is best accomplished with simulation modeling so that a variety of block scenarios can be evaluated in order to determine which scenario provides for the best utilization of the OR, as well as the best patient placement on the preferred inpatient units. For example, if general surgery and urology share an inpatient unit and the average length of stay for both services is 1.5 days, the OR manager and physician leadership should be careful not to schedule these services on the same days in order to assure adequate bed availability for all patients who require that inpatient unit.

Assuring adequate inpatient bed availability
Once the variability in the elective surgical volume has been smoothed and the urgent/emergent cases optimally managed, the hospital can determine its true bed needs. Using simulation modeling and taking into account the strategic goals of the organization, the hospital can effectively allocate the number of beds needed for areas such as medicine, telemetry and surgical service. This further assures that patients are placed in the right bed with the nursing staff best trained to care for them, thereby reducing length of stay, risk of error and adverse events and improving overall patient, physician and staff satisfaction.

Collaboration and Trust Prove Critical
Actively managing surgical volume will, at times, require some surgeons to change operating days or times, as well as office or clinic days, in order to smooth the surgical volume across the week. In order to make this work, a high degree of physician and hospital collaboration and trust are crucial. To help build that trust, the following are necessary:

  • Collecting accurate data and conducting analyses in order to ensure transparent and objective decisions
  • Encouraging trails to cement the collaborative relationship, address issues and enable rapid-cycle improvements
  • Making hospital leadership fully aware and urging them to be supportive of this initiative
  • Choosing the right physician champion
  • Having physician and hospital leadership work together to ensure that issues are heard, goals are established and progress is made
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This collaborative approach is the only method for implementing the smoothing strategy successfully. The gains in quality, patient safety, improved revenue, capacity and throughput are tangible and irrefutable.


Christy Dempsey, BSN, MBA, CNOR, is senior vice president for clinical operations at Patient Flow Press Ganey. She may be reached at cdempsey@patientflowtech.com.
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