Adding-On without Subtracting Quality

It’s no surprise that ORs in hospitals of all sizes often — even daily — have add-on surgical cases. Emergencies happen. Patients’ conditions worsen and they require urgent attention.

But at a hospital in the northeast, the daily add-on rate was 30 percent. So every day, OR staff and managers struggled to handle the caseload. Some days, chaos reigned. Something had to be done.

Sullivan Healthcare Consulting teamed up with the hospital to tackle the problem. A task force was formed involving stakeholders in each of the departments and disciplines from all over the facility. The executive sponsor of the project, the Director of the Campus, said, “All task force sessions were inclusive of necessary and diverse personnel representatives encompassing scheduling, fiscal services, physician, nursing and other staff departments.”

The challenge: to come up with a way to review add-on cases to determine whether they were truly urgent or emergency cases… or whether they were cases that could be scheduled, but were being shoehorned in. Staffers who ran the surgical scheduling board were at a disadvantage because they were being asked to accommodate the add-ons though they didn’t fully understand patient requirements and surgeon necessity.

The task force came up with a new, consistent process for handling add-ons that focuses on patients and the true urgency of cases. There was a great deal of discussion and planning around the categories of patient classification, how the process would impact physician practice as well as patient care. Input was sought about the best way to implement the system.

After perioperative leadership okayed the plans, new procedures were communicated to all those affected. Logs were developed. Staff members were educated. Reports were generated that would support and document the new policies. And two crucial roles were identified: Anesthesia in Charge and Control Desk Manager. These roles work to ensure good collaboration between anesthesia, nursing and the surgeon for effective, efficient daily operations and the overall success of the surgical program.

The Operating Room Executive Committee (OREC) is responsible for the day-to-day operations of the overall surgical program, including policy enforcement. The hospital’s Urgent/Emergency Policy defines the urgency of the situation. A surgeon or designee assigns add-on cases a priority triage level, depending on whether the case is life-threatening, and whether delaying surgery could cause complications. The patient and surgeon must be ready within the timeframe set, and if the patient’s condition changes, the surgeon can change that patient’s triage level.

The system works well. “The initial implementation went well and compliance was very high,” the Director of the Campus said. “As time went on and new physician personnel came on board, it was recognized that each one needed to be educated on the system, how to access it and how to make it most effective. The largest problems fell on the night shift as new residents attempted to schedule their patients to fall first on the add-on or emergency roster. The effectiveness of the Medical Directors made this an addressable problem and the Service Chiefs held responsible.”

Sullivan Healthcare Consulting helped the hospital define a permanent, maintainable system for regulating the influx of urgent/emergent patients to the operating room and put personnel in place to enforce the system and address any problems that arose. The Medical Directors (one Anesthesia and one Surgeon) as well as the Nursing Director formed an effective team, addressing problems and adjusting the system as needed. Now, the added caseload is well in hand, and emergent cases are handled effectively. An OR function that once was chaotic has turned into a well-honed process that upholds timely patient care and OR efficiency.

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