SIP 1

Team Leaders: Judy Canfield

Dr. Laurie Amundsen

CharterScope: From patient’s decision of having surgery until 00:01 on the day of surgery.

In Scope: Patient scheduling of surgery; Pre-Anesthesia, Lab – including day of surgery; Discharge Planning; Financial Clearance; patient packet; interface to: Med Consult, Radiology, Pathology, Cardiology, Lab appointments; Scheduling Systems: scheduling coordination with PL’s; Communication of special needs – implants, ICU beds, bariatric equipment, etc.; In-patient preparation

Out of Scope:

Preparing instruments, supplies, and equipments;

Outcome Deliverables1. Document current state process(es)2. Document best industry practices3. Value analysis using LEAN methodology

a. Identification of optimal patient flow (patient experience)b. Identification of optimal information flowc. Identification of essential variability

4. Design future state process(es)5. Develop project plan and timeline

a. Identify short and long term projects6. Develop metrics and key indicators7. Short and long term project completion8. Strategy for ongoing Performance Improvement

Essential Metrics– Patient ready upon arrival– All resources ready upon arrival– Block time utilization– Planned schedule same as actual schedule

Where the team has focused its efforts due to the need for integration of all teams for Patient Preparation and Document Management

Condensed Process Map

Patient Decides to Have Surgery

Physician Initiates

Documentation

PCC Notified by Department

PCC Gathers Patient Data:

DemographicsSpecial NeedsSurgery Date

Availability

Physician IDs Case Type &

Duration

Pt. Calls PCC For

Next Steps

PCC Calls Pt. For Next

Steps

PCC Meets with

Pt. @ Decision

Time

Assists with

PMD if Needed

Refers to MSW

if Needed

Reg Process

?

Insurance Auth?

Pt.

PCC

MD

Yellow Packet

Yellow Packet Started

YP Not Started

Worksheet Possibly Started

Separate Ordersheet

Possibly Started

CPT/ICD9 Case

ID

Case ID By Name

Time Assigned

By Computer Estimate

Case Time Overridden

MM

PCC Enters Phys, Case Type &

Duration into ESI

PCC Gathers Addtn’l Data:Mindscape

Essential Tests

PCC Coordinates Visits

Pre & Post-OP

Phys. Order for Essential Services

Clinic RN/MA

Schedules

Data Available

& Scheduled

RN

Test Results Not Tied to Yellow Packet

Data Not AvailableSearch

Data Available

& Scheduled

Data Not Available Case in

TBA

Case AppropriateDetermined

Accurate Case ID & Appropriate Length

Yes

Consult RN3

Override Computer Estimate

MA

Special Needs in Comment Section

No

Interpreter Scheduled

Yellow Packet Initiated if not

Previously

A 49 Completed

Special Needs ID’d

Med Consult

Arranged

PAC Or Bypass

Determined

Referral Request if Necessary

Orders Started

Consent H&P

Orders Generated-Establish Follow-up

Dictation Completed & Printed?

PCC Returns Info to Referral Source

No Confirm

PSR

OR

Yellow Packet to PAC for Visit/

Bypass

PSR Reviews

YP

YP Checked

in For Visit

Yellow Packet Complete?

Yes

PCC

No

Patient Visits PAC

YP Ready Orders

Complete

RN Assembles

Loose Documents

Pt. Edu

Lab Draw, EKG, RN Assess

Assure Med

Consult if Needed

AncillaryF.U.

Determined

OR Runs ESI Build 2:30 Day

Ahead

Pt. to ED For AM Admit

Consent For Care

YP Prep Day of Surg

Check With OR Sched

For Case Type

OR Reviews Sched For Time Estimates & Site

All Case Items ID’d

Via PL

ESI Pick Ticket Produced

Check Pt On OR Schedule

Call Pt. With

Check-in Time

Patient Has Surg Time &

Instructions

Case Picking/Delivery Prioritized

Carts Picked one at a Time Via Pick

Ticket

Items Not Available

Shortage Documented

Enter Database

PM Crew Rechecks Completes

Carts

Continue?

No

Cancel

PCC Starts PAC Visit or Bypass

Yes

May FAX Info to PAC to

Determine Bypass

FAX H&P’ Health

Assessment Via Request

Form

Sets Up Pre-Surg

Appt.

PAC RN Determines Bypass/Visit

Core process

Key Areas of Improvement

• Scheduling Cases

• Preparing for Surgical Cases

• Accessing Patient Data

RPI Recommendation• Case Cart

• Patient Preparation

• Document Management

Patient Flow

Scheduling

PAC

SuppliesEquipment

Condensed Process Map

Patient Decides to Have Surgery

Physician Initiates

Documentation

PCC Notified by Department

PCC Gathers Patient Data:

DemographicsSpecial NeedsSurgery Date

Availability

Physician IDs Case Type &

Duration

Pt. Calls PCC For

Next Steps

PCC Calls Pt. For Next

Steps

PCC Meets with

Pt. @ Decision

Time

Assists with

PMD if Needed

Refers to MSW

if Needed

Reg Process

?

Insurance Auth?

Pt.

PCC

MD

Yellow Packet

Yellow Packet Started

YP Not Started

Worksheet Possibly Started

Separate Ordersheet

Possibly Started

CPT/ICD9 Case

ID

Case ID By Name

Time Assigned

By Computer Estimate

Case Time Overridden

MM

PCC Enters Phys, Case Type &

Duration into ESI

PCC Gathers Addtn’l Data:Mindscape

Essential Tests

PCC Coordinates Visits

Pre & Post-OP

Phys. Order for Essential Services

Clinic RN/MA

Schedules

Data Available

& Scheduled

RN

Test Results Not Tied to Yellow Packet

Data Not AvailableSearch

Data Available

& Scheduled

Data Not Available Case in

TBA

Case AppropriateDetermined

Accurate Case ID & Appropriate Length

Yes

Consult RN3

Override Computer Estimate

MA

Special Needs in Comment Section

No

Interpreter Scheduled

Yellow Packet Initiated if not

Previously

A 49 Completed

Special Needs ID’d

Med Consult

Arranged

PAC Or Bypass

Determined

Referral Request if Necessary

Orders Started

Consent H&P

Orders Generated-Establish Follow-up

Dictation Completed & Printed?

PCC Returns Info to Referral Source

No Confirm

PSR

OR

Yellow Packet to PAC for Visit/

Bypass

PSR Reviews

YP

YP Checked

in For Visit

Yellow Packet Complete?

Yes

PCC

No

Patient Visits PAC

YP Ready Orders

Complete

RN Assembles

Loose Documents

Pt. Edu

Lab Draw, EKG, RN Assess

Assure Med

Consult if Needed

AncillaryF.U.

Determined

OR Runs ESI Build 2:30 Day

Ahead

Pt. to ED For AM Admit

Consent For Care

YP Prep Day of Surg

Check With OR Sched

For Case Type

OR Reviews Sched For Time Estimates & Site

All Case Items ID’d

Via PL

ESI Pick Ticket Produced

Check Pt On OR Schedule

Call Pt. With

Check-in Time

Patient Has Surg Time &

Instructions

Case Picking/Delivery Prioritized

Carts Picked one at a Time Via Pick

Ticket

Items Not Available

Shortage Documented

Enter Database

PM Crew Rechecks Completes

Carts

Continue?

No

Cancel

PCC Starts PAC Visit or Bypass

Yes

May FAX Info to PAC to

Determine Bypass

FAX H&P’ Health

Assessment Via Request

Form

Sets Up Pre-Surg

Appt.

PAC RN Determines Bypass/Visit

Scheduling Cases Map

Scheduling CasesIssues

• Case selection, via PCC, is by procedure name.• Case selection drives the preference list that is chosen

for the case.• SCCA patients decide day ahead for surgery and

require intense coordination.• Each team member has different definition for surgery

time estimate. • Room scheduling is not standardized- Pavilion and

Main OR have different rules.• Cases are moved 24 hours ahead after review by

charge Anesthesia/Nurse staff for correct room assignment.

Patient Flow

Scheduling

PAC

SuppliesEquipment

Condensed Process Map

Patient Decides to Have Surgery

Physician Initiates

Documentation

PCC Notified by Department

PCC Gathers Patient Data:

DemographicsSpecial NeedsSurgery Date

Availability

Physician IDs Case Type &

Duration

Pt. Calls PCC For

Next Steps

PCC Calls Pt. For Next

Steps

PCC Meets with

Pt. @ Decision

Time

Assists with

PMD if Needed

Refers to MSW

if Needed

Reg Process

?

Insurance Auth?

Pt.

PCC

MD

Yellow Packet

Yellow Packet Started

YP Not Started

Worksheet Possibly Started

Separate Ordersheet

Possibly Started

CPT/ICD9 Case

ID

Case ID By Name

Time Assigned

By Computer Estimate

Case Time Overridden

MM

PCC Enters Phys, Case Type &

Duration into ESI

PCC Gathers Addtn’l Data:Mindscape

Essential Tests

PCC Coordinates Visits

Pre & Post-OP

Phys. Order for Essential Services

Clinic RN/MA

Schedules

Data Available

& Scheduled

RN

Test Results Not Tied to Yellow Packet

Data Not AvailableSearch

Data Available

& Scheduled

Data Not Available Case in

TBA

Case AppropriateDetermined

Accurate Case ID & Appropriate Length

Yes

Consult RN3

Override Computer Estimate

MA

Special Needs in Comment Section

No

Interpreter Scheduled

Yellow Packet Initiated if not

Previously

A 49 Completed

Special Needs ID’d

Med Consult

Arranged

PAC Or Bypass

Determined

Referral Request if Necessary

Orders Started

Consent H&P

Orders Generated-Establish Follow-up

Dictation Completed & Printed?

PCC Returns Info to Referral Source

No Confirm

PSR

OR

Yellow Packet to PAC for Visit/

Bypass

PSR Reviews

YP

YP Checked

in For Visit

Yellow Packet Complete?

Yes

PCC

No

Patient Visits PAC

YP Ready Orders

Complete

RN Assembles

Loose Documents

Pt. Edu

Lab Draw, EKG, RN Assess

Assure Med

Consult if Needed

AncillaryF.U.

Determined

OR Runs ESI Build 2:30 Day

Ahead

Pt. to ED For AM Admit

Consent For Care

YP Prep Day of Surg

Check With OR Sched

For Case Type

OR Reviews Sched For Time Estimates & Site

All Case Items ID’d

Via PL

ESI Pick Ticket Produced

Check Pt On OR Schedule

Call Pt. With

Check-in Time

Patient Has Surg Time &

Instructions

Case Picking/Delivery Prioritized

Carts Picked one at a Time Via Pick

Ticket

Items Not Available

Shortage Documented

Enter Database

PM Crew Rechecks Completes

Carts

Continue?

No

Cancel

PCC Starts PAC Visit or Bypass

Yes

May FAX Info to PAC to

Determine Bypass

FAX H&P’ Health

Assessment Via Request

Form

Sets Up Pre-Surg

Appt.

PAC RN Determines Bypass/Visit

Preparing for Surgical Case Map

Preparing for Surgical Case Issues

• All systems are manual, which is resource- and labor-intensive.

• Preference lists/ pick tickets are not frequently reviewed the day ahead, resulting in the wrong case cart.

• There is no standard for how information is received, reviewed and actions taken.

• PCCs are located in multiple sites.• Getting the patient access to essential services in

surgical preparation is difficult.• Anesthesia bypass process of the surgical patient is

complicated and inconsistent.

Condensed Process Map

Patient Decides to Have Surgery

Physician Initiates

Documentation

PCC Notified by Department

PCC Gathers Patient Data:

DemographicsSpecial NeedsSurgery Date

Availability

Physician IDs Case Type &

Duration

Pt. Calls PCC For

Next Steps

PCC Calls Pt. For Next

Steps

PCC Meets with

Pt. @ Decision

Time

Assists with

PMD if Needed

Refers to MSW

if Needed

Reg Process

?

Insurance Auth?

Pt.

PCC

MD

Yellow Packet

Yellow Packet Started

YP Not Started

Worksheet Possibly Started

Separate Ordersheet

Possibly Started

CPT/ICD9 Case

ID

Case ID By Name

Time Assigned

By Computer Estimate

Case Time Overridden

MM

PCC Enters Phys, Case Type &

Duration into ESI

PCC Gathers Addtn’l Data:Mindscape

Essential Tests

PCC Coordinates Visits

Pre & Post-OP

Phys. Order for Essential Services

Clinic RN/MA

Schedules

Data Available

& Scheduled

RN

Test Results Not Tied to Yellow Packet

Data Not AvailableSearch

Data Available

& Scheduled

Data Not Available Case in

TBA

Case AppropriateDetermined

Accurate Case ID & Appropriate Length

Yes

Consult RN3

Override Computer Estimate

MA

Special Needs in Comment Section

No

Interpreter Scheduled

Yellow Packet Initiated if not

Previously

A 49 Completed

Special Needs ID’d

Med Consult

Arranged

PAC Or Bypass

Determined

Referral Request if Necessary

Orders Started

Consent H&P

Orders Generated-Establish Follow-up

Dictation Completed & Printed?

PCC Returns Info to Referral Source

No Confirm

PSR

OR

Yellow Packet to PAC for Visit/

Bypass

PSR Reviews

YP

YP Checked

in For Visit

Yellow Packet Complete?

Yes

PCC

No

Patient Visits PAC

YP Ready Orders

Complete

RN Assembles

Loose Documents

Pt. Edu

Lab Draw, EKG, RN Assess

Assure Med

Consult if Needed

AncillaryF.U.

Determined

OR Runs ESI Build 2:30 Day

Ahead

Pt. to ED For AM Admit

Consent For Care

YP Prep Day of Surg

Check With OR Sched

For Case Type

OR Reviews Sched For Time Estimates & Site

All Case Items ID’d

Via PL

ESI Pick Ticket Produced

Check Pt On OR Schedule

Call Pt. With

Check-in Time

Patient Has Surg Time &

Instructions

Case Picking/Delivery Prioritized

Carts Picked one at a Time Via Pick

Ticket

Items Not Available

Shortage Documented

Enter Database

PM Crew Rechecks Completes

Carts

Continue?

No

Cancel

PCC Starts PAC Visit or Bypass

Yes

May FAX Info to PAC to

Determine Bypass

FAX H&P’ Health

Assessment Via Request

Form

Sets Up Pre-Surg

Appt.

PAC RN Determines Bypass/Visit

Accessing Patient Data

Accessing Patient DataIssues

• Information received from outside referral does not always make it to the chart.

• All document elements for the pre-surgical patient are not accessible to the requisite and appropriate staff.

• Yellow packet travels across sites, and is only accessible to the site where it currently resides.

• Records are lost causing case delays and errors.• Document completion is not standardized across

surgical clinics.

RPI – Case Carts

Yellow Packet to PAC for Visit/

Bypass

PSR Reviews

YP

YP Checked

in For Visit

Yellow Packet Complete?

Yes

PCC

No

Patient Visits PAC

YP Ready Orders

Complete

RN Assembles

Loose Documents

Pt. Edu

Lab Draw, EKG, RN Assess

Assure Med

Consult if Needed

AncillaryF.U.

Determined

OR Runs ESI Build 2:30 Day

Ahead

Pt. to ED For AM Admit

Consent For Care

YP Prep Day of Surg

Check With OR Sched

For Case Type

OR Reviews Sched For Time Estimates & Site

All Case Items ID’d

Via PL

ESI Pick Ticket Produced

Check Pt On OR Schedule

Call Pt. With

Check-in Time

Patient Has Surg Time &

Instructions

Case Picking/Delivery Prioritized

Carts Picked one at a Time Via Pick

Ticket

Items Not Available

Shortage Documented

Enter Database

PM Crew Rechecks Completes

Carts

Continue?

No

Cancel

PCC Starts PAC Visit or Bypass

Yes

May FAX Info to PAC to

Determine Bypass

FAX H&P’ Health

Assessment Via Request

Form

Sets Up Pre-Surg

Appt.

PAC RN Determines Bypass/Visit

Past and Current Activities

• Completed PCC ESI training• Reviewed and evaluated best practice scheduling

process from other academic medical centers• Reviewed literature• Created website for open and released block time• Established concepts for a best practice scheduling

process• Developed Best Practice scheduling process vision

(includes inpatient)• Established shared definitions• Developed standard physician worksheet• Created criteria/guidelines for scheduling TBA cases• Flexible scheduling process for cases that need 24 hour

turnaround of schedule (i.e., cancer, orthopedic injuries)

Best Practice Scheduling Process Recommendation

Patient and Physician determination of surgical procedure

Standard Worksheet completed – essential elements

MD determines and is accountable for procedure name, duration and preference list from data sheet with his/her specific cases and PLs

Process for scheduling is standard for both inpatient and outpatient cases by the PCC

Scheduler acknowledges work submitted

Information is entered into ESI and scheduled by PCC

Cases are scheduled to accommodate patient preferences and special needs

PCC reviews web site for released time

If no block is openPCC places case in block time

PCC places case in TBA schedule

If no released time available

48 hours before day of surgery – charge personnel checks surgery schedule for fit, moves TBA cases into open block and communicates these to services

Key Reality Checks• Will this make our scheduling process easier?  • Will it flow better and have more accuracy?  • Does our process give feedback to those using it?

Next Steps

• Develop future metrics• Develop implementation plan for new scheduling

process• Develop plan for elements not discussed (due to

time constraints) but of importance

SIP1 Team

Roles: Active Members: Team Leader Judy CanfieldTeam Leader Laurie AmundsenClinic Manager Nancy EberhardtPre-Surgery Clinic S. Deatrick/S. MossingPCC Manager Kathy HerigstadPCC Colleen MaraOR Scheduler Susan TracyInterpreter Services Linda GolleyCharge RN OR Donna AndersonOR RN3 Jackie WalkerSurgeon Ben GreerSurgeon Brandt OelschlagerSurgeon Ben AndersonSurgeon Neal FutranPL’s & Implants Bill AntonMaterials Management Sal Ramirez

Pharmacy Jim VelezProject Manager Michelle Agnew

Appendix

Comments/Questions from OR staff and department road shows

• Patients have lots of history but we cannot get/retrieve the record.

• PCCs have a lack of training in choosing the right PLs. Do we as the OR need to embrace training and collaborate with the PCCs?

• Because of the acuity of our patients, the day before the appointment in the Pre-Anesthesia Clinic is not enough lead time to prepare for the patient.

• Inpatients should be seen by the Pre-Anesthesia Clinic also.

• We are still getting incomplete instrument sets and wrong items in the case carts.

• Continuity of preop evaluation and on-site anesthesia management.

• Crisp definitions of time that make sense to the surgeons.

Review and Evaluation of Other Scheduling Practices

UCSF OHSU NYUMC Partners Who Schedules

Phys. Office/standardized form to relay the needed information (ICD code,procedure, implants needed, etc) for emergency/add-on cases either the surgeon or the resident calls to book the case - if the resdient calls we require the attending to call and approve the case before it is add to our "e" board

Phys. Scheduler Physician secretary.

Physician secretary-Schedule beyond block- into 3 virtual OR’s as wait list. 48 hours ahead of surgical day- all unused block time is released and the wait list cases are used to fill in time.

How to estimate times for cases

our surgery scheduling system averages case times (last ten cases by surgeon), for add-on cases we generally ask for a time estimate

Surgeon determines the cut to close case time and schedulers add the average turnover time for each site onto each scheduled case. Alternatively we use average case time aggregated in Ipath Surg. Scheduling system.

Computer system HBOC, ESI averages the time. When the schedule is reviewed the day before , times are reviewed. They are accurate 70% of the time.

Surgeon estimates the time within broad limits.

*Please note that this is only a small portion of the informal survey

Literature Review Sample• Schedule the Short Procedure First to Improve OR

Efficiency – Lebowitz, Phillip, MD, Oct 2003• What makes a well-oiled scheduling system? – OR Manager• Determining Optimum Operating Room Utilization – Tyler, D

et al., 2003• How to schedule elective surgical cases into specific

operating rooms to maximize the efficiency of use of operating room time –Dexter and Traub, 2002

• Optimal Sequencing of Urgent Surgical Cases, Dexter et al., May 1999

• Creating an Optimal Operating Room Schedule, Calichman, Murray, May 2005

• Applications of Queuing Theory, Vanaswala and Desser, Feb 2005

• Improving Operating Room Coordination, Moss and Xiao, 2004