The Hidden Obstacles of Surgical Scheduling

WHEN HOSPITAL STAFF AND ADMINISTRATORS lie awake at night thinking about overcrowding, most of them have visions of the Emergency Department filled to capacity, with ambulance diversions, long wait times, and no end in sight to the problem of bed scarcity. Since half of all hospital admissions come through the ED, it is the most obvious cause of patient throughput bottlenecks.

However, research has shown that scheduling of elective surgeries, though only responsible for about a third of hospital admissions, is actually as much if not more responsible for admission bottlenecks.

Scheduling Influences Capacity

The work of Boston University's Eugene Litvak, PhD, has uncovered the cause of this hidden obstacle, which he calls "artificial variability." To avoid capacity issues, hospitals would ideally staff all departments at a high enough level to handle all peaks in demand; however, the high cost of this solution causes hospitals instead to staff for the average level of demand. Natural variability in the arrival of patients through the ED or emergency surgery means that on busy days, hospital capacity will be strained.While these sources of variability are random and cannot be planned for, there is another major source of variability in patient demand that is entirely avoidable. Elective surgeries, which are scheduled at the surgeon's convenience, create major peaks in demand that strain hospital staff and resources.

Eliminating the block scheduling of surgeries is a daunting task for any hospital, as it can inconvenience the talented surgeons on whom the hospital depends. However, it accomplishes the goals of getting more surgeries done, and making sure they do not have to be suddenly cancelled due to competition with emergency procedures. When all staff members are focused on these goals, demand can be smoothed, easing the strain on the ICU and step-down units, and producing benefits throughout the hospital.

Crothall's Impact

Reducing demand is an important key to improving throughput. But there are other processes just as important to the steady flow of patients through the process that may go unseen. The responsiveness and productivity of the support services staff facilitating these processes must be a focus. Crothall's experts have identified several points in the patient flow process in which our services make an impact. For example, between case cleanings of surgical suites are imperative to insure that diseases are not spread from one patient to the next. This process must be performed thoroughly, as well as quickly and efficiently; otherwise, backups will occur despite any improvements to scheduling.

Transporting patients from surgery to the ICU can be a logistical challenge. Quickly discharging patients and turning the room around for the incoming patient recovering from surgery is vital. To free up a bed in one area, often several other patients must be moved as well. The thought process is similar to solving a slide puzzle, in which movement of a piece is dependent upon shuffling other pieces to free up space. One tool that Crothall has at its disposal is a new partnership with Awarix, a next generation patient care visualization tool that provides all hospital departments with real time graphical information about all patients throughout the hospital. By giving staff at-a-glance access to patient status, the pieces of the puzzle are easier to see, and patient transports can be scheduled in the most efficient manner.

In some of the more forward-thinking hospitals, Crothall is able to use flexible staffing solutions to meet demands. At Virginia Mason Medical Center, a status board is updated throughout the day with several key indicators, such as census, number of scheduled surgeries, and staffing shortages. If these indicators rise above certain thresholds, Crothall able to alert support department staff that they are in a "Red" status, and temporary staff can be called in until the demand calms down. This system has made real strides to reduce throughput bottlenecks. Dana L. Nelson-Peterson, RN, Administrative Director of Hospital Operations, says: "I'm particularly impressed with Crothall Leadership's willingness and eagerness to learn and engage with our management method, the Virginia Mason Production System. In fact, they have actually embraced the concepts of the VMPS and are leading the way, incorporating key principles into improving visual control of their work areas, level loading their staffing volumes to allow them to respond to surges in our system, and building transparencies into their work processes. Their work has definitely had an impact on our ability to maintain patient flow throughout our hospital."