Patient Flow Enewsletter
Volume 1, Issue 8
Tuesday, November 16, 2004
Resources in this article: Every day in hospitals nationwide, patients arrive for routine, scheduled, elective surgeries. To their dismay, some of these patients will be waiting to go into the operating room only to be told at the eleventh hour that their surgery must be cancelled and rescheduled. Typically, it's because a patient in an urgent, life-threatening situation has arrived at the hospital's emergency department and must be taken into the operating room immediately. "It's very frustrating for people. Take the daughter who uses three vacation days from work to fly in from Denver and be with her mother, who is scheduled for gall bladder surgery," said John Chessare, MD, chief medical officer and senior vice president for medical affairs at Boston Medical Center (BMC). "As mother and daughter arrive at the hospital that morning, they're told that the surgery has been cancelled due to a serious motor vehicle accident." "In April - September of 2004, only two surgeries were delayed and one cancelled - more than 100 times fewer." Home to the largest Level 1 trauma center in New England, BMC is not alone in facing this challenge, but it may be alone in its unique approach to overcoming it - at least for now. Over recent months, BMC has embarked on an effort to better classify, distinguish and monitor urgent, emergent and elective surgeries - hoping that it may help to predict surgery volumes and ultimately reduce the number of elective surgeries that have to be cancelled. Dr. Chessare began working with Dr. Eugene Litvak of the Boston University Program for the Study of Variability in Health Care, Dr. James Becker, BMC's chief of surgery, Dr. Keith Lewis, BMC's chief of anesthesia, and Ms. Gail Spinale, BMC's director of Operative Services to separate the flow of elective surgeries from urgent and emergent surgeries. The first hurdle to get over was that BMC did not have a common definition of "urgent or emergent" surgery. The team created a four-level classification system and held schedulers accountable to collect the information when a case was called in. Armed with a few months of data, the team then calculated that it could almost always meet the daily demand for urgent / emergent cases by setting aside one room for them. It was then clear that since all of the rooms were allocated to surgeons via the block scheduling system that some surgeons would have to lose their block time to accommodate the change. Like many facilities nationwide, BMC for years has used block scheduling as a way of matching surgeon demand with operating room supply. In a common scenario, a particular surgeon would 'own' operating room four on Tuesday and Thursday mornings and would be responsible for filling up those blocks of time with his or her surgeries for the week. "In most instances of block scheduling, you never find complete happiness," said Dr. Chessare. "There are always surgeons with block time, but not enough cases to fill it. Then you also have surgeons with more cases than they have block." Such a system also requires excellent, ongoing communication, which isn't always possible in such a busy environment. For example, if a surgeon forgets to tell the individual managing the block schedule that he or she is going on vacation for two weeks, one of the operating rooms could sit empty during his or her scheduled blocks. Thus the team proposed an innovative concept - doing away with all block surgery scheduling and instead putting a group of schedulers in charge of assigning surgery dates and times as the cases were called in. Under this new system, each time a surgeon has an elective surgery, he or she calls the scheduling team and learns the next available time, then books the surgery for that time slot. The surgeons were assured that the schedulers would group their cases back-to-back whenever possible, and that if the end result was that fewer cases were done or that it was harder to get the cases done, the team would revert back to block scheduling. The results were astounding. Between April 1 and September 30, 2003, 157 emergent surgeries were conducted between the hours of 7:00 a.m. and 3:30 p.m. During that same time frame in the year 2004, the total number of such surgeries was 159. Even more surprising than learning the predictability of urgent and emergent surgeries were the results of the new surgery scheduling procedure. In April to September of 2003, 334 elective surgeries were delayed or cancelled. In 2004, only two surgeries were delayed and one cancelled - more than 100 times fewer.
Separating Urgent from Elective Before: After: Dr. Chessare feels strongly that the lessons the BMC team has learned by looking at data they'd never before collected are ones that can and should be learned at hospitals nationwide. "The fundamental laws of mathematics don't vary by geography," said Dr. Chessare. "Sure a 50-bed hospital may not do as many surgeries, but they don't have as many people arriving in their emergency department either. Every hospital can stand to benefit from reducing artificial variability." For more information about BMC's approach, Click here to download Dr. Chessare's full presentation, "Maximizing Throughput: Smoothing the Elective Surgery Schedule to Improve Patient Flow". (415 KB) To listen to an audio recording of Dr. Chessare's presentation from the November 11-12, 2004 conference titled "Perfecting Patient Flow: Proven Solutions to ED Crowding," Click here for more information. ----------------------------------- John Chessare, MD, MPH
Previously, such surgeries had not really been closely tracked, but had instead been written off as totally unpredictable. "We kept hearing that urgent and emergent cases were the cause of the hospital's variability, but when you looked at the data, that didn't make any sense," said Dr. Chessare. "Urgent and emergent cases are perfectly smooth by the day of the week. What was instead causing our variability were things like having the two highest volume surgeons operating on the same day of the week due to block scheduling - not the urgent and emergent surgeries that were arising in completely predictable volumes."
Chief Medical Officer and Senior Vice President of Medical Affairs
Boston Medical Center
Boston, MA
