Improving Surgical Flow at St. John’s Regional Health Center: A Leap of Faith

​It’s hard to say who was unhappier about the frequent late-night surgeries at St. John’s Regional Health Center: the surgeons or the patients. The high volume of surgical cases — about 25,000 per year ­— at this Level I trauma center in Springfield, Missouri, USA, meant that each day’s tightly packed surgical schedule could be — and often was — thrown completely off when urgent or emergency surgeries were necessary. It wasn’t unusual for surgical teams to perform surgery late into the night or in the wee hours of the morning to accommodate the day’s surgical patients.
 
That was “before,” says Christine Dempsey, BSN, CNOR, Vice President of Perioperative Services at St. John’s. Before they made some important changes to “the way things had always been done.” Before they discovered that taking a different approach to scheduling surgery would smooth the flow of surgical patients and result in:
  • A 5 percent increase in surgical case volume
  • A 45 percent decrease in surgeries performed after 3 PM
  • An all-time low in Operating Room (OR) overtime
  • A 4.6 percent increase in revenue
  • Improved staff and patient satisfaction
 
“What we did was counterintuitive,” says Dempsey. But when data revealed that the reason the surgery schedule got bogged down was not the reason anyone thought, it was clearly time to “think outside the box.”
 
“This is Crazy”
St. John’s Regional Health Center, part of the Sisters of Mercy Health System based in St. Louis, Missouri, USA, is an 866-bed acute care facility serving southwest Missouri and northwest Arkansas. As the only state-designated Level I trauma center in the region, St. John’s is a high-volume surgery center, where the 22 operating rooms are seldom unused. Therein lay the problem.
 
As members of IHI’s IMPACT network, staff at St. John’s are committed to achieving breakthrough improvements wherever possible. “We knew we had opportunities and needs to improve patient flow, so we decided to focus on that, and joined an IHI Collaborative on improving flow in acute care settings,” says Dempsey.
 
What she heard at the first Learning Session in Boston struck such a resonating chord for Christie Dempsey that she called the St. John’s trauma chief before she even boarded the plane for home. “I told him I had heard some really fascinating and exciting ideas, with compelling evidence, about how we can smooth the flow of patients into the OR, and that I wanted to talk to him about it when I got home,” she recalls.
 
The idea, she knew, sounded extreme, and would be hard for the surgeons to embrace. “I told him that we should set aside one OR for unscheduled surgery only,” she says. This meant that surgeons would have to give up the opportunity to fully schedule elective surgery cases in all available ORs.
 
Kenneth Larson, MD, a general and trauma surgeon and Medical Director of the St. John’s Burn Unit, remembers that phone call, and his reaction. “There is no way we are going to do this,” he recalls thinking. “We are already too busy and they want to take something away from us. This is crazy.”
 
But so was the way the surgery schedule had been working — or not working. Like most hospitals, St. John’s was using a block scheduling system, in which surgeons are given blocks of time in the OR based on their utilization. At St. John’s, the blocks were about 80 percent filled, so that every OR was scheduled with elective cases until mid- to late afternoon. Urgent unscheduled cases would be added on to the end of the day’s scheduled cases. Emergency cases would be taken immediately, pushing the rest of the day’s schedule later and later. With an average of 10 to 15 “add-ons” per day Dempsey says, “it was not uncommon for surgeons to be taking cases at 10 PM or later.”
 
But the idea of giving up an OR for just the “add-ons” was difficult to consider. “Everyone assumed that because the flow of unscheduled surgeries can’t be predicted, setting aside an OR just for ‘add-ons’ would be a very inefficient use of the space,” says Dempsey. Surgeons and staff alike worried that the room would sit idle when it could be used for elective cases.
 
But in fact, Dempsey was able to show that the prevailing assumption about variability was wrong. Using the Hourly Patient Flow Analysis tool for measuring variability [developed during the IHI Flow Collaborative], Dempsey demonstrated that “our elective surgery volume is more variable than our emergency volume.” Because elective surgery schedules reflect patient and physician preferences — many surgeons prefer Wednesdays and Thursdays, for example — artificial peaks and valleys appear in the schedule. Urgent and emergency cases flow in at a steadier rate, because unplanned surgery cases present at about the same daily rate.
 
“This goes against common sense,” says Eugene Litvak, PhD. Litvak is Director of the Program for Management of Variability in Health Care Delivery at the Health Policy Institute of Boston University, in Boston, Massachusetts, USA, and an IHI faculty member for the Flow Collaborative. “But in our work with hospitals we have found that elective surgery admissions are more variable than admissions through the emergency department.” Litvak says that when unscheduled surgeries comprise more than 15 percent of a hospital’s total surgeries, the resulting competition for surgical space and staff typically wrecks the schedule.
 
An Important Promise
Despite his skepticism, Larson was willing to listen to Dempsey’s sales pitch. Her proposal was this: since the trauma team would have to give up a block, their other blocks could be lengthened from 8 to 10 hours. In this way, they would not be giving up time, just moving it. All unscheduled cases — day and night — would go to the “add-on” OR.
 
In making her case, Dempsey made an important promise. “I told him if it didn’t work after trying it for 30 days, we’d go back to the old way of scheduling.”
 
Larson, convinced by Dempsey’s enthusiasm and the “compelling evidence” she had gathered from IHI, agreed that the idea was worth a try. Together, they presented their proposal to the hospital’s Perioperative Guidance Team, which includes five surgeons, an anesthesiologist, and the manager of each area in Perioperative Services (ambulatory surgery, recovery room, admissions, pre-admissions, and pre-anesthesia).
 
“This is a group with very strong physician leadership that helps determine the vision and goals for Perioperative Services,” says Dempsey. Hearing the proposal from a fellow surgeon was key to their willingness to consider it, says Dempsey.
 
Indeed, a strong physician advocate is essential when proposing change of this nature, says Robert Brodhead, FACHE, President of St. John's Hospital and Regional Vice President, St. John's Health System. “Don’t try this without a strong physician champion, and without a trial period,” he advises. “When you’re running a hospital, it’s not good to have unhappy surgeons. We guaranteed them we’d go back to the prior arrangements if this didn’t work. And now that they aren’t working late into the evenings, they are a lot happier.”
 
“Once we tried it we found it didn’t hurt as much as we thought,” says Larson. Not only did the late-night surgery load lighten considerably — “My wife’s happier because I’m getting home earlier,” says Larson — but the block schedule worked more effectively overall. Thirty days later, they decided to stick with the new system, and they’ve never looked back. “At three and six months, we saw an increase in revenues simply because we were more efficient, and were scheduling our blocks more fully,” says Larson.
 
Demspey says the “add-on” OR is currently used about 60 percent of the time. “We were already staffing that OR. It was initially uncomfortable to think about staffing a room that isn’t more fully utilized. Now the benefits are clear.”
 
Dempsey says the new arrangements do require on-call surgeons to respond immediately when they are needed. “When a surgeon is called at 9 AM to do a case, he can’t say he’ll come at 11 AM after he sees patients. The room is ready, the patient is ready, and the surgeon needs to be ready. It does require our surgeons to manage the expectations of their office patients and staff.”
 
Dempsey, who was recently promoted from director to vice president in part because of the success of this change, is already working with colleagues to spread the lessons learned about surgical flow to other hospitals in the Sisters of Mercy system. “We are proving that this works. Now it’s time to share what we’ve learned.”
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