OR Smoothing The Value of Analytics - IHI Home...

OR SmoothingThe Value of

AnalyticsFrederick C. Ryckman, MDProfessor of Surgery / TransplantationSr. Vice President – Medical Operations

Cincinnati Children’s HospitalCincinnati, Ohio

James Anderson Center for Health Systems Excellence

I have nothing to disclose

Hospital Flow Seminar

April 2016

James M. Anderson Center

For

Health Systems Excellence

Key Drivers for Capacity Management

Management of

Variability

Predictable Care

Delivery

Capacity

Prediction

Capacity

Management

Optimization of

Flow Delivery

Flow:Safety

Matching

Identify Patient Streams – Inpatient/Outpatient/OR

Manage System Variation

Evidence Based Best Practices, Analysis of ALOS and outliers,

Standardize then Customize, Eliminate unnecessary care

Integration of simulation modeling and planning

“Environmental Impact” Reports for growth programs

Simulation for design and patient placement

“Environments Impact” Planning

Placement initiatives – D:C Matching plans

Discharge prediction and planning,

Home Care, Parent Initiatives

Flow Failure Analysis, GARDiANS

IHI Drivers CCHMC Initiative Operations Possibilities

D/C

Match

System

Re-Design

Shape /

Reduce

Demand


For


Surgical Streams of Care

• Urgent / Emergent Surgery

• Predictable and Measurable – Natural Variation

• Possible to Model

• Can be managed within the System with resource allocation

• Delay Increased risk and worse outcomes

• Elective Surgery

• Unpredictable – Whim of Surgical Schedule

• High variability over time

• Delay Case specific risk

• Initial Design around Urgent Needs

• Goal – No urgent cases in Block Time

• Allocate “Block” for Urgent Needs


For


Traditional Block

• Reactive System

• Urgent Emergent Cases

placed within Block Time as

needed

• Elective Case Plan disrupted,

prolonged waiting time for

elective patients

• Inefficient (Unsafe) Access for

Urgent Cases

• Push complex Elective Cases

into the late hours

• Overtime

• Wrong Team in OR

Not

Ideal


For


Scheduling Guidelines – A to EGUIDELINES FOR SURGICAL CASE GROUPING DIAGNOSES/PROCEDURES

(guideline only: medical judgment required)

Acute Life and Death Emergencies

A < 30 MinutesAirway emergency(upper airway obstruction)

Cardiac surgery postop bleeding with tamponade

Cardiorespiratory decompensation (severe)

Liver transplant postoperative emergency

Malrotation with volvulus

Massive bleeding

Mediastinal injury

Multiple Trauma-unstable or O.R. resuscitation

Neurosurgical condition w/imminent herniation

Urgent C < 4 HoursAbscess with sepsis

Airway (non-urgent diagnostic L&B, flex bronch, non-symptomatic foreign

body)

Appendicitis-with sepsis/rapid progression

Biliary obstruction non-drainable

Cardiac ventricular assist device placement

Cerebral angiogram for intracranial hemorrhage

Chest tube placement in patient w/unstable vital signs, increased work of

breathing and decreased O2 saturation

Contaminated Wounds-Multiple Trauma

Diagnostic/therapeutic airway intervention

Hepatic angiogram w/suspected vascular thrombus

Hip Dislocation

Intestinal Obstruction-no suspected vascular compromise

Kidney transplant (ORGAN AVAILABLE)

Liver laparotomy

Massive soft tissue injury

Nephrostomy tube placement in patient w/sepsis

Obstructed kidney (stones) with sepsis

Older child with bowel obstruction

PICC placement where patient has no access but needs

fluids/medications urgently

Progressive shunt malfunction

Traumatic dislocation-hip

Unstable neurosurgical condition

Add-on case to elective schedule

E < 24 HoursNeeds to be done that day, but does not require the

manipulation of the elective schedule,

pyloromyotomy

Broviac

Closed reduction

Eyelid/canalicular lacerations

Facial nerve decompression

Femoral neck fracture

Liver biopsy

Mastoidectomy

Open fracture grade I/II

Open reduction of fracture

PICC placement-has other IV access

Retinopathy of prematurity treatment

Unstable slipped capital femoral epiphysis

Emergent, but not immediately life threatening

B < 2 HoursAcute shunt malfunction

Acute spinal cord compression

Bladder rupture

Bowel perforation, traumatic

Cardiac congenital emergencies w/hemodynamic or pulmonary

instabilities

Compartment syndrome

Donor harvest

ECMO cannulation

Ectopic pregnancy

Embolization for acute hemorrhage

Esophageal atresia with tracheoesophageal fistula

Gastroschisis/omphalocele

Heart, heart/lung, lung, liver and intestinal transplants

Incarcerated hernias

Intestinal obstruction with suspected vascular compromise

Intussusception-irreducible

Ischemic limb/cold extremity (compromised arterial flow)

Liver/Multivisceral/SI Transplant (when organ available)

Liver transplant with suspected thrombosis

Newborn bowel obstruction

Open globe

Orbital abscess

Pacemaker insertion for complete heart block

Replant fingers

Replant hand or arm

Spontaneous abortion

Semi-Urgent D < 8 HoursAbscess drainage

Appendicitis-stable/elective

Caustic ingestion

Chest tube in patient w/stable vital signs

Chronic airway foreign bodies

Closure abdomen-liver transplant

Coarctation repair in newborn

Esophageal foreign body without airway symptoms

GJ tube/NJ tube placement with no other nutrition access

Hematuria with clot retention

I & D abscess without septicemia

Joint aspiration or bone biopsy prior to starting antibiotic therapy

Kidney transplant (ORGAN NOT YET AVAILABLE)


For


Options from Simulation

# Cases Included # Rooms Average Waiting

Times (minutes)

Probability 1 Or

More Rooms

Will Be Available

Utilization

Rate

Recommendations/Considerations

1 A, B, C, D, “missing”

treated as B

1 A: 45

B + missing: 53

C: 72

D: 101

60% 40% NOT RECOMMENDED

Mean wait for A cases would exceed stated limit

2 A, B, C, “missing”

treated as B

1 A: 21

B + missing: 24

C: 30


Low utilization rate

3 A, B, C (No “missing”) 1 A: 17

B: 19

C: 22


Low utilization rate

Ignores “missing” cases

4 A – E, divided;

“missing” treated as D

2 rooms:

1 room for A- C,

1 room for D,E, &

missing

A: 18

B: 19

C: 24

D + missing: 70

E: 162

A – C room: 80%

D – E room: 43%

A – C room:

20%

D – E room:

57%

NOT RECOMMENDED

Low utilization rate in A – C room

Some cases with missing urgency codes may be more urgent than D

5 A – E together;

“missing” treated as

B

2 rooms that would

take any A – E case

A: 7

B + missing: 8

C + D: 9

E: 17

83% 42%, each

room

RECOMMENDED

Very good waiting times (Wait for A cases would exceed stated limit about

1X/112 weekdays (21.4 weeks ))

Treats missing cases conservatively

Highest utilization rate

Not very sensitive to small increases in case duration or case volume


For


Block with Urgent Access Assured

Predictive system

Urgent Cases in

Defined Rooms

with Scheduled

Teams

Resources needed

can be modeled

Care based on

Urgency / Medical

Need


For


B-E Case Access - % Successful

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ju

l 20

06 (

n=

278)

Sep 2

006 (

n=

290

)

Nov 2

006 (

n=

239

)

Ja

n 2

00

7 (

n=

217)

Ma

r 2

007 (

n=

263

)

Ma

y 2

00

7 (

n=

262)

Ju

l 20

07 (

n=

285)

Sep 2

007 (

n=

282

)

Nov 2

007 (

n=

227

)

Ja

n 2

00

8 (

n=

242)

Ma

r 2

008 (

n=

231

)

Ma

y 2

00

8 (

n=

244)

Ju

l 20

08 (

n=

42)

Sep 2

008 (

n=

104

)

Nov 2

008 (

n=

102

)

Ja

n 2

00

9 (

n=

191)

Ma

r 2

009 (

n=

227

)

Ma

y 2

00

9 (

n=

227)

Ju

l 20

09 (

n=

216)

Sep 2

009 (

n=

236

)

Nov 2

009 (

n=

206

)

Ja

n 2

01

0 (

n=

245)

Ma

r 2

010 (

n=

183

)

Ma

y 2

01

0 (

n=

262)

Ju

l 20

10 (

n=

275)

Sep 2

010 (

n=

277

)

Nov 2

010 (

n=

229

)

Ja

n 2

01

1 (

n=

142)

Ma

r 2

011 (

n=

192

)

Ma

y 2

01

1 (

n=

194)

Ju

l 20

11 (

n=

276)

Sep 2

011 (

n=

275

)

Nov 2

011 (

n=

173

)

Ja

n 2

01

2 (

n=

228)

Ma

r 2

012 (

n=

199

)

Ma

y 2

01

2 (

n=

319)

Ju

l 20

12 (

n=

205)

Sep 2

012 (

n=

281

)

Nov 2

012 (

n=

212

)

Ja

n 2

01

3 (

n=

169)

Ma

r 2

013 (

n=

221

)

Ma

y 2

01

3 (

n=

244)

Ju

l 20

13 (

n=

216)

Sep 2

013 (

n=

184

)

Nov 2

013 (

n=

196

)

Ja

n 2

01

4 (

n=

147)

Ma

r 2

014 (

n=

184

)

Ma

y 2

01

4 (

n=

263)

Ju

l 20

14 (

n=

284)

Sep 2

014 (

n=

116

)

Nov 2

014 (

n=

75)

Ja

n 2

01

5 (

n=

40)

Ma

r 2

015 (

n=

73)

Ma

y 2

01

5 (

n=

77)

Ju

l 20

15 (

n=

342)

Sep 2

015 (

n=

208

)

Nov 2

015 (

n=

185

)

% o

f "B

-E" C

as

es

pe

rfo

rme

d w

ith

in 1

5%

of

the

ir

ac

ce

pta

ble

tim

efr

am

e

Month

Add on Access to OR within Accepted Timeframe

"B-E" CasesPopulation: Base Hospital Add-on Cases

% Cases Center Line Control Limits

*NOTE: Current Control Limits set from 1/2011 - 8/2012.

Last Updated 2/1/2016 by E. McDaniel, James M. Anderson Center for Health Systems Excellence

OR Renovation

1 Add-On Room Closed


For


“A” Case Access Times – Target 30 Minutes

0

30

60

90

120

150

180

210

240

270

Jul 2006 (

n=

3)

Se

p 2

006

(n=

6)

Nov 2

006 (

n=

16)

Jan

2007 (

n=

6)

Ma

r 20

07 (

n=

7)

Ma

y 2

007 (

n=

6)

Jul 2007 (

n=

7)

Se

p 2

007

(n=

3)

Nov 2

007 (

n=

1)

Jan

2008 (

n=

3)

Ma

r 20

08 (

n=

3)

Ma

y 2

008 (

n=

7)

Jul 2008 (

n=

0)

Se

p 2

008

(n=

0)

Nov 2

008 (

n=

2)

Jan

2009 (

n=

2)

Ma

r 20

09 (

n=

2)

Ma

y 2

009 (

n=

4)

Jul 2009 (

n=

2)

Se

p 2

009

(n=

5)

Nov 2

009 (

n=

1)

Jan

2010 (

n=

2)

Ma

r 20

10 (

n=

0)

Ma

y 2

010 (

n=

1)

Jul 2010 (

n=

2)

Se

p 2

010

(n=

4)

Nov 2

010 (

n=

2)

Jan

2011 (

n=

1)

Ma

r 20

11 (

n=

2)

Ma

y 2

011 (

n=

1)

Jul 2011 (

n=

0)

Se

p 2

011

(n=

0)

Nov 2

011 (

n=

3)

Jan

2012 (

n=

2)

Ma

r 20

12 (

n=

2)

Ma

y 2

012 (

n=

2)

Jul 2012 (

n=

3)

Se

p 2

012

(n=

4)

Nov 2

012 (

n=

3)

Jan

2013 (

n=

4)

Ma

r 20

13 (

n=

4)

Ma

y 2

013 (

n=

1)

Jul 2013 (

n=

2)

Se

p 2

013

(n=

3)

Nov 2

013 (

n=

2)

Jan

2014 (

n=

3)

Ma

r 20

14 (

n=

3)

Ma

y 2

014 (

n=

2)

Jul 2014 (

n=

0)

Se

p 2

014

(n=

0)

Nov 2

014 (

n=

0)

Jan

2015 (

n=

0)

Ma

r 20

15 (

n=

3)

Ma

y 2

015 (

n=

1)

Jul 2015 (

n=

6)

Se

p 2

015

(n=

7)

Nov 2

015 (

n=

0)

Ave

rag

e W

ait

Tim

e (

Min

ute

s)

Month

Add on Access to OR within Accepted Timeframe

Wait Time for "A" Cases Population: Base Hospital Add-on Cases

Wait Time (Minutes) Center Line Goal Control Limits

Source: CPM/EPICLast Updated 2/1/2016 by E. McDaniel, James M. Anderson Center for Health Systems Excellence


For


Resources

• Nursing and Anesthesia allocated by system

• “We know they are coming, we don’t know their names”

• Surgeon Availability

• SOD – Surgeon of the Day

• DOOD – Doctor of Orthopaedics of the Day

• ENT – Available resources

• PLA, URO, OPH, Dental, NSg, GYN – Herd Immunity

• Cardiac – Special Resources

P


For


Take Away Thoughts

• Leadership sets the course – Priority Judgments

• Analytics tell you what you can do

• Execution allows it to happen

P11

OR Smoothing The Value of Analytics - IHI Home...

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