Society for Health Systems ConferenceFebruary 20 – 21, 2004

A Methodology to Analyze Staffing and Utilization in the Operating Room

For questions about this report, please call Mary Coniglio, Director, VHA’s Consulting Services at 610-558-9646.

Agenda:

Review case study of Operating Room AssessmentProvide project approach that can be duplicated “back at the ranch”

Consulting Approach:

Shared consulting resource provides 600 hours of consulting per year Focus on process improvement and cost reduction.Dedicated staff for labor/process and for supply expense reductionHospitals and consultants jointly select project areasSatisfaction and savings impact monitored after each project is completed

Project Background: Hospital administration requested consulting support because . . .

Manual scheduling process.Surgeon’s unable to get surgery slots when wantedNursing incurring overtime while not being fully utilized during the regular hoursIncreasing number of add-ons to the scheduleDelayed start time for procedures/difficulty locating surgeonsNewly appointed VP Nursing wanted quantified review of the Operating Room – not just anecdotal scenarios

Approach/Methodology:

Conducted interviews. Reviewed existing data reports (not much available!!)Collected one month of case-specific data from the OR patient record to quantify room and surgeon times. Conducted data comparison with Solucient databaseValidated data and assumptions with managers.Prepared and presented report.

Project Objectives:

Conduct an evaluation of the operating room (excluding supplies).Review current room utilization.Quantify individual surgeon use by time of day.Determine whether current block allocations are appropriate.Conduct external data comparison.Provide recommendations for improved processes.Develop data collection methodology to quantify surgeon and room utilization and to document delays on an ongoing basis.

FINDINGS:

Delays: There were 107 documented delays.23 cases,or 17% of the first cases were delayed greater than 10 minutes. The most frequent reason for first case delay was tied with between “surgeon late” and “nursing”.

First Case DelaysNursing 7 30%Surgeon Late 7 30%Anesthesia 2 9%Lab delays 1 4%Missing Consent 2 9%Other 4 17%

23

Operating Room Delay Summary

FINDINGS:

Delays: 84 of the cases that followed were late.The two primary reasons for “to follow” cases to be delayed were, 49% nursing, and 23% the prior case was late. The nursing category is the default when a reason is not given.Delays less than 10 minutes are not captured.

All Case DelaysNursing 52 49%Prior Case Late 25 23%Surgeon late 12 11%Lab delays 1 1%Same Day PAT 1 1%Missing Consent 3 3%Anesthesia 3 3%Other 10 9%

107

Operating Room Delay Summary

Recommendation #1 Delays:Delays: Operating Room

Further quantify the reasons contributing to “nursing delay”. Develop more detailed tracking form to better quantify why delays are occurring. Provide timely statistics to surgeons on average surgery time and delays.Address repeat outliers according to departmental guidelines. Consider “to follow” for a surgeon working within their block time when scheduling back-to-back cases.Quantify average case time per surgeon for top volume procedures to improve accuracy of scheduling.

Recommendation #1 Delays:Delays:

Example “Reasons”. Patient Issues: Insurance problems, patient arrived late, patient ate/drank, abnormal lab values.Practitioner Issues: Needs more labs, incomplete/incorrect consent, physician arrived late, prolonged setup time, nursing short staffed.System Issues: Test results unavailable, blood unavailable, patient not ready on floor, transport delay, previous case ran late, equipment unavailable/malfunction, X-ray tech unavailable.

FINDINGS: Comparative Data: Use external database or trend internal performance . . .

Comparative Data Review: Solucient Data BaseOvertime Hours % of Total Worked Hours Worked Hours per OR Patient Worked Hours per OR HourSalary Cost per OR PatientSalary Cost per OR HourSupply Cost per OR PatientSupply Cost per OR Hour

** Concentrate on worked not paid hours **

FINDINGS:Staffing: Operating Room Comparative Data

Staffing levels are 2.56 – 4.39 FTE’s higher than the comparison data base when compared on a per case basis. 50th percentile is 12.28 hours per patient.Staffing levels are 3.50 – 8.62 FTE’s lower than the comparative data base compared on a per hour basis. 50th

percentile is 7.68.The hospital OR hour per case is 2.14 versus 1.49.The time per case is high, while acuity is not, indicating thereare patient throughput issues. Overtime as a percentage of total worked hours was 7.2%. The 50th percentile is 3.2%

FINDINGS:

Staffing: Operating Room UtilizationThere were three days in June when a room was not open due to lack of anesthesiology resources.Data was sorted by room by day to quantify utilization. Time between patient in room and incision is 33 minutes.

Date Day Room # Time IN Incision Time

Time Between In and Incision Time Out

Scheduled Time Case Time Surgeon

3-Jun Mon 1 8:18 8:30 0:12 8:52 8:00 0:34 MI3-Jun Mon 1 9:11 9:21 0:10 9:45 Add-on 0:34 MI3-Jun Mon 1 11:00 11:15 0:15 11:45 10:30 0:45 T3-Jun Mon 1 12:10 12:40 0:30 13:05 Add-on 0:55 MI3-Jun Mon 1 13:36 14:00 0:24 14:30 13:30 0:54 C3-Jun Mon 2 7:45 8:04 0:19 9:34 7:30 1:49 S3-Jun Mon 2 12:51 14:24 1:33 17:35 12:00 4:44 L3-Jun Mon 3 13:20 13:48 0:28 14:45 13:00 1:25 MA3-Jun Mon 4 20:45 21:00 0:15 21:40 Add-on 0:55 MA3-Jun Mon 6 9:00 9:25 0:25 10:45 9:00 1:45 O'C3-Jun Mon 6 11:00 11:27 0:27 12:10 10:30 1:10 O'C3-Jun Mon 6 12:30 13:04 0:34 13:30 12:00 1:00 O'C

Operating Room Utilization Information - By Day

Findings: Room Utilization

Review non-regular hour coverage and utilization to validate that the schedule hours are necessary.One hospital averaged a 5% night shift utilization rate.

Average Total Room Time in Minutes 82

Average Between Case Set-Up Time @ 30 Minutes/Case 30 Average Total Time in Minutes that Rooms are in Use 112

Staffed Room Time in Minutes (2.5 FTE's for 8 hours) 1,200

After Hours Room Utilization (Based on Staffing)

Mondays

Recommendation #2 Staffing:

Staffing: Operating RoomConsider shortening the available hours for surgery on specific days to reflect actual hours being utilized.Avoid “same hours each weekday” mentality.Establish improvement team to determine why the time per case is significantly longer than the comparison. Revise staff start and stop times to coincide with actual surgery hours.Align staffing patterns to better meet surgeon volumes and practice patterns as determined by review of the block allocations, open times and utilized times.

FINDINGS:

Block Allocation: Operating RoomOnly 3 surgeons have been assigned block time. Several surgeons without assigned blocks consistently use time.The block time allocation does not match actual surgeon practice. Block time utilization is not routinely monitored and revised to reflect actual practices.

FINDINGS:

Block Allocation: Operating RoomOperating Room Utilization Information - BY PHYSICIANDr. "M"

Date Day Room # Time IN Incision TimTime Out Scheduled Case Time # of CasesTime Per

Case5-Jun Wed 3 12:45 12:55 13:20 11:30 0:357-Jun Fri 1 10:00 10:10 11:56 10:00 1:567-Jun Fri 1 17:45 17:54 18:55 Add-on 1:107-Jun Fri 2 14:45 15:08 16:55 14:00 2:10

10-Jun Mon 3 17:30 18:00 19:30 Add-on 2:0013-Jun Thurs 2 16:00 16:21 18:45 Add-on 2:4514-Jun Fri 3 7:47 8:00 8:30 7:30 0:4314-Jun Fri 3 8:55 9:07 9:35 9:00 0:4014-Jun Fri 3 10:05 10:39 13:35 12:00 3:3014-Jun Fri 3 14:10 14:27 14:40 Add-on 0:3014-Jun Fri 3 15:22 15:50 17:15 Add-on 1:5317-Jun Mon 1 7:40 8:15 9:25 7:30 1:4517-Jun Mon 1 9:50 10:15 10:45 11:30 0:5517-Jun Mon 1 11:05 11:45 17:05 Add-on 6:0024-Jun Mon 3 7:50 8:08 10:35 7:30 2:4524-Jun Mon 3 10:55 11:22 12:30 10:00 1:3524-Jun Mon 3 13:00 13:16 13:50 13:00 0:5019-Jun Wed 3 10:46 10:46 11:30 10:30 0:44

32:26:00 18 1:48:07

Recommendation #3 Block Utilization:

Utilization: Operating RoomUse actual surgeon time to revise current block allocations including additional surgeons. Adhere to established block rules.Consider changing block release time from 2 weeks to 48 hours to allow surgeons to schedule within their own block and not use open time.

Recommendation #3 Block Utilization:

Operating Room: The following surgeons are recommended to have block time.

Physician Monthly Hours Block Hours Needed In to Out Monday Tuesday Wednesday Thursday Friday Per Week

A 30:35:00 PM AM AM 7:38:45B 25:11:00 AM AM AM 6:17:45C 49:04:00 AM & PM AM 12:16:00D 43:14:00 AM & PM AM 10:48:30E 28:50:00 AM & PM 7:12:30F 31:25:00 AM 7:51:15G 23:22:00 AM AM 5:50:30H 45:59:00 AM PM 11:29:45I 29:20:00 No pattern 7:20:00J 35:04:00 PM 8:46:00

Block Recommendation

Block Time Recommendations for Physicians - SUMMARYBased On Physicians Utilizing More Than 20 Hours in June 2002

Finding: Room Utilization

Operating Room utilization ranges from 67% to 90%.

June 2002 Monday Tuesday Wednesday Thursday FridayTotal for Month

Average Per Day

Available Hours Total 4 Rooms 117.3 117.3 117.3 117.3 117.3Hours Used includes 30 Minutes Turnaround 98.5 70.4 92.7 78.6 105.6Unused Hours 18.8 46.9 24.6 38.7 11.7

Room Utilization 84% 60% 79% 67% 90%

Average Case Time - Patient In to Patient Out 2.2 2.2 2.2 2.2 2.2Total Time Per Case - Includes TAT 2.7 2.7 2.7 2.7 2.7

Projected Number of Additional Cases 8.5 21.3 11.2 17.6 5.3 64.0 3.2Projected numer of Cases Includes TAT 7.0 17.4 9.1 14.3 4.3 52.1 2.6

Inpatient Operating Room UtilizationAvailable Hours Compared with Utilized Hours Per Day

Utilizated Hours Reflect Cases Performed Only During The Available Hours

Recommendations:

Summary of Revenue Opportunity

Option I: Increase Surgery Volume While Maintaining Current Rooms and Staffing

Adjustments to the block schedule and policy changes will give the department the opportunity to increase the case volume with the current staffing levels Additional Annual Cases * Additional Potential Net

Revenue **Main OR 624 $ 159,214

* Based on achieving utilization during 85% of total available OR time. ** Gross per minute charge $5.25 per OR minute. Potential Net Revenue calculated at 30% of gross charges.

Increase number of cases by 52 per month.

Recommendation # 4 Room Utilization

Operating Room:

OR, flex staff schedules to reduce the number of FTE’s by 2.6.

Monday TuesdayWednesdaThursday FridayRN hours per OR hour 3.19 3.19 3.19 3.19 3.19Worked But Not Used Nursing H 59.87 149.67 78.58 123.48 37.42Total for Month 449.02Annualized Hours 5,388.3FTE's 2.6

Recommendation

Option II: Maintain Current Surgery Volumes and Adjust Staffing Requirements

Excess Capacity in

OR Hours per Day

Worked Hours per

OR Hour *

Excess Worked

Hours per Day

Annual Excess

Worked Hours

Potential Annual

Labor Expense

Reduction **

Main OR 6.7 3.19 21.4 5,388 $155,174 * Based on 50th percentile of RN worked hours per OR hour for the “national hospitals between 201-300 beds” compare group in the Solucient ACTION database, ** Includes benefit expenses estimated at 20% of payroll.

Recommendation # 4 Room Utilization

Operating Room:

Implement ongoing data collection method to concurrently quantify room utilization, turnaround time, and delays.

Scheduled MD Arrived Anesth Room # In Anest MD Incision MD Out Procedure Staff TOT/DelaysTime Holding Area Staff Time Ready Arrival Time Out Time

8:30 M 7:40Thornton/Vender 1 8:40 9:10 9:10 9:19 11:35 11:48 Carotid endartPS/FB H&P needed

12:00 M 11:10Thornton/Vender 1 12:15 12:35 12:35 12:44 15:20 15:29 Carotid endartPS/FB PC

7:30 G 6:50Thornton/Hanna 2 7:45 7:50 7:50 8:00 8:30 8:41 Bx. Bladder la DS Surg. Late

9:00 MI 8:30Thornton/Hanna 2 9:20 9:20 9:20 9:30 9:40 9:55 Exc. Arm mas DS/KB H&P needed/PC

Operating Room Data Collection SAMPLE

Conclusion:

Reduce DelaysImprove Patient ThroughputReduce Schedule DowntimeStaffing/Hours AdjustmentAdditional Case VolumeImprove Surgeon and Case Scheduling

? ? ? Questions ? ? ?