The Magic and Mystery of Time in Healthcare Transformations Gaines - - PowerPoint PPT Presentation

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The Magic and Mystery of Time in Healthcare Transformations

Gaines W. Hammond Jr. MD, FACS

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Depart ment of S urgery and Urology Baylor S cot t and Whit e

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Time to change is fleeting and requires momentum and consensus

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Magic when it works - Time is critical Mystery when it doesn't - Time is critical “Space between the notes makes the music and coordination of the individual musicians makes a symphony”

Magic and Mystery

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Types of Transformation Leadership Styles Healthcare Transformation Uniqueness

Reasons for Failure

Transformation Basics

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Style Method Impact Transactional Dictatorial Force and demand Short Term Distributive Bargaining One Time Transformative Integrative Working together Trust Common Vision Long Term

Pick Your Style Pick Success or Failure

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Texas coach Charlie Strong was hired to bring an immediate change to the Longhorns' football fortunes. He is wasting no time in creating a culture of discipline and responsibility.

Charlie Strong Demanding Change in Texas Football

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Transformational Leadership

“When engagement in a group results in leaders and followers raising one another to increased levels of motivation and morality”

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Transformation requires understanding of how people work alone and together

Negotiate Strive Compete Incentivize

People Skills

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Transformation Challenges in Healthcare

Physicians are not followers Impatient Usually not team players Lack Vision on a Global perspective Overburdened with time commitments

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Patient’s View

The time between events in healthcare is often

• verlooked by providers and institutions

They feel as if “not at the table for change” Anxious and focused on issues at hand not global change agenda items Intimidated by the entire healthcare process

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Value - Perception vs. Science

Perception of value is in the eyes of the patient Outcomes based on facts is science but may not be perceived as value by the patient Outcome science and perception / time to resolution

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Surgeon’s Office Surgical Services Medical Device Innovation

Transformation Projects

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Escape Velocity is the speed at which the sum of an object's kine It is the speed needed to “break free” from the gravitational att

Escape Velocity

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Escape Velocity Status Quo

Transformation vs Status Quo

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Start Abandon

The chance of success is inverse reciprocal to time

Time Sustainable Success

Time and Success

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Time Works Against Success

Do not start until execution can be accelerated Define needs for Transformation Study Issues, Components, and Constituents Impacted Measure Perception of Problem Define Steps for Execution Begin Transformation Project racing against time

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Surgical Office Transformation

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Define Process of Triage Understand Service Define Time Efficiency Define Time Flexibility Execute

Surgical Office

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Problem Define/DX Call Reason for Visit #1 #2 #3 Appt Time ( #1 now) Information to Triage #1 #2 #3 Visit Smile Problems DX Stones CT CMP UA Hematuria Gross with Clots CT‐ Cystoscopy Microscopic UA CS CMP Cysto CT Cytology Elevated PSA / Nodule Rectal‐ Repeat PSA II ‐ Pus Bx Infection Complicated ‐Back pain‐fever‐chills CT r/o obstruction ‐CS Uncomplicated UTI ‐ no fever or back pain UA CS Cysto optional Retention Prostate PVR‐UA‐PSA‐CMP‐ Neurogenic Urodynamic‐ Post Op transient Incontinence UA‐PVR‐ Exam‐UDS

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Urology Office Schedule Template 6:00 Rounds 15 6:15 Rounds 15 6:30 Rounds 15 6:45 Rounds 15 7:00 Surgery 15 7:15 Surgery 15 7:30 Surgery 15 7:45 Surgery 15 8:00 1 1 2 2 3 3 6 8:15 1 2 3 3 4 8:30 1 2 2 8:45 Open 9:00 1 1 2 2 3 3 6 9:15 1 2 3 3 4 9:30 1 2 2 9:45 Open 10:00 1 1 2 2 3 3 6 10:15 1 2 3 3 4 10:30 1 2 2 10:45 Open 11:00 1 1 2 2 3 3 6 11:15 1 2 3 3 4 11:30 1 2 2 11:45 Open 12:00 Surgery 15 12:15 Surgery 15

14:00 1 1 2 2 3 3 6 14:15 1 2 3 3 4 14:30 1 2 2 14:45 Open 15:00 1 1 2 2 3 3 6 15:15 1 2 3 3 4 15:30 1 2 2 15:45 Open 16:00 1 1 2 2 3 3 6 16:15 1 2 3 3 4 16:30 1 2 2 16:45 Open 17:00 Surgery 15 17:15 Surgery 15 17:30 Surgery 15 17:45 Surgery 15 18:00 Surgery 15 18:15 Surgery 15 18:30 Surgery 15 18:45 Surgery 15 19:00 Surgery 15 Surgery 15 min blocks 21 315 Rounds 15 min blocks 4 Category 1 28 2 28 3 28

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Surgical Services Department Transformation

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Symptoms of current processes

• Late Surgeons
• High Rate of Add on cases
• Case Juggling
• Holes in Schedule
• Extended Preoperative LOS
• Decreased Morale: pressure on overtime
• Extraordinary demand to be “first case”
• Block Schedule with vague metrics, policy and processes
• Difficult to Add cases on for emergent (non trauma) cases
• Perceived need for more anesthesia coverage
• Cancellation rate being discussed

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Capital Responsibility and Operational Overhead Burden

Quality of care is economically imperative All Constituent Groups must understand the community responsibility to be good stewards

• f capital.

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Goal: High Level Long Range Goals:

Process from start to finish that works for the benefit of outpatients Strive to be and maintain the best Surgical Services as perceived by:

• Patients and their families
• Surgical Physicians
• Anesthesia Providers
• Surgical Department Staff

Surgical Services Task Force

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Surgery Capacity and Fixed Overhead

Expense OR Suite 1 10 20 $ Minute 40 40 40 $ Hour 2400 24,000 48,000 $ Day 57,600 576,000 1,152,000 $ Month 1,728,000 17,280,000 34,560,000 $ Year 20,736,000 207,360,000 414,720,000 Capacity 24 hours/day 24 240 480 Utilization 1 10 20 100% 24 240 480 50% 12 120 240 10% 2.4 24 48 Cases Time Cost 1 2,400 1.5 3,600 2 4,800 3 7,200

4 9,600 5 12,000

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Surgical Services Transformation

OR Capacity Total minutes per day available for procedures/ room 24 hr 60 min 1440 minutes per OR/day Fixed Expense $40/min $57,600 per day /per OR 10 Main OR 4 HSC 4 Endo 3 Labor and Delivery 21 total venues. = 30,240 minutes each day $1,209,000 per day fixed expenses $36,286,000per month fixed expenses Late starts, delayed starts, slow turnover are significant loss of opportunity impacting negatively the entire Institution.

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Perception Metrics Pre Pilot Project 1 good Patients wait a minimum period of time prior to start of surgery 1 2 3 4 5 Surgeries start on time 1 We cancel few cases on the day of Surgery 1 2 We practice “Truth in Scheduling” 1 2 We have adequate nursing staff support 1 2 3 We have adequate technician support 1 2 3 4 We have the ability to add non-elective procedures 1 2 3 4 We have short turnaround times between cases 1 2 3 4 We have reliable high quality equipment and supplies 1 2 3 4 5 Surgeons are on time 1 Anesthesiologists are on time 1 2 We get the required instruments properly cleaned and on time 1 2 3 4 5 We have reliable communication mechanisms across the OR 1 2 3 4 5

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Clearance on the following objectives ฀ Ability to investigate and understand anesthesia incentive options, concerns and issues ฀ Evaluation/recommendation of leadership techniques and support ฀ Physician specific plan to bring incremental volume - extrinsic and intrinsic ฀ ASC Anesthesia Designee for 3 month periods. ฀ How to incorporate financials as part of OR expectations- Capital demands and constraints ฀ Allowing viewing access to daily surgery schedule to all physicians ฀ Options and awareness in matching up anesthesia to surgeons preference (anesthesia preference for s ฀ Best way to solicit feedback and increase physician engagement without pitchfork (negative and emoti ฀ Best way to get feedback to Jim and Glenn ฀ Orient the OR to patient and surgeon service as a priority – to all physicians regardless of flag ฀ What’s the process for communicating, tracking, evaluating equipment needs for surgery? ฀ Outline the difference in Task force and ASC committee-determine future of ASC

• ASC goals still unclear-physician goals, capacity, how to bring incremental volume, how equipme

Clearance on the following objectives ฀ Ability to investigate and understand anesthesia incentive options, concerns and issues ฀ Evaluation/recommendation of leadership techniques and support ฀ Physician specific plan to bring incremental volume - extrinsic and intrinsic ฀ ASC Anesthesia Designee for 3 month periods. ฀ How to incorporate financials as part of OR expectations- Capital demands and constraints ฀ Allowing viewing access to daily surgery schedule to all physicians ฀ Options and awareness in matching up anesthesia to surgeons preference (anesthesia preference for s ฀ Best way to solicit feedback and increase physician engagement without pitchfork (negative and emoti ฀ Orient the OR to patient and surgeon service as a priority – to all physicians regardless of flag ฀ What’s the process for communicating, tracking, evaluating equipment needs for surgery? ฀ Outline the difference in Task force and ASC committee-determine future of ASC

• ASC goals still unclear-physician goals, capacity, how to bring incremental volume, how equipme

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Surgeons We practice truth in scheduling 1 2 3 4 5 Our patients are properly prepped for surgery 1 2 3 4 5 Chart Completion is properly performed 1 2 3 4 5 Surgeries start on time 1 2 3 4 5 We have short turnover times between cases 1 2 3 4 5 We have reliable communication mechanisms 1 2 3 4 5

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Surgeons Response Anesthesia

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Anesthesia Surgeons Response

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Anesthesia Surgeons Response

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Surgeons Response Anesthesia

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Surgery ฀ Start times Metrics for ฀ Surgeon present ฀ Pt in Room ฀ Induction time ฀ Cut Time ฀ Turn Over Time Metrics Current cases per month Pre op screening percentage Charts complete prior to DOS First Case Starts Understanding (7:00) ฀ Surgeon Arrival Time 6:55 ฀ Wheels in time 7:00 ฀ Induction Time 7:10 ฀ Incision Time 7:15 ฀ Wheels out time PACU LOS

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On the Clock Card

Phone Calls Time Signature Called for patient (Location: _________) Called surgeon ‐ Ready?

YES ‐ will be here by ____________ NO ‐ not ready ______________________

Anesthesia Team

(Interview/Intervention Complete)

Time Signature MD CRNA Surgeon Arrives Time Signature Check in time

*Our goal is to have the patient in the OR within 10 minutes of this time.*

OR Times Time Signature In Room Cut Time

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Scope of efforts defined – Global Objectives- Need a Surgical Services Business Plan and Long Range Strategic Plan

• a. Need a plan to restore transparency and communication in OR

i.Scheduling ii. Transparent process to track equipment needs and request

• b. Improving on time starts
• c. Reviewing block utilization policies

i.8 hours ii. 75% utilization iii. Create 20% availability for add- ons- Rules to operate this iv. Possibility of evaluating financial viability

• d. Increased coordination with Anesthesia and Surgeons

i.Evaluating surgeon opportunities to streamline pre-op requirements ii. Evaluate holding area process iii. Coordinating surgeon preference anesthesia with right physicians

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Establish Surgical Services Executive Committee - SSEC

• 6 Surgeons
• Anesthesia
• Director of Surgery
• Administration

Communicate Program to All Constituents

• Survey Baseline

Surgical Services Process Improvement Steps

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Metrics for Success

• On time starts greater than 90% at 7:00 and

later schedule on time starts at 63.5%.

• Day of cancellations less than 2%
• % of patients screened 72 hours before

surgery

• Turnover time IP (20-30 minutes) and OP

(10-20 minutes)

• Improvements in surgeon perception of

OR-survey baseline

• Add on availability at 20% with goal of
• ffering a 2 hour start from call.

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Focus Priorities Goals Pre Op Screening Prior to Day of Surgery All cases (excluding emergent scheduling) First Case Start Times 90% (within 5-7 minutes) Block Schedule Process and Policy Review 8hr blocks (75% utilization or at risk) Add on Emergent Case Strategy 20% of capacity for emergent add on cases Cancellations <1% Turnover Time - In Patient 20-30 minutes Turnover Time - Out Patient 10-20 minutes

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Phase 1 – Processes relating to start of first Surgery of Day Phase 2- Processes for Block scheduling, Mixed Block and open schedule Phase 3- Monitor, review and revise to remain excellent. Review current metrics, policy, and perceptions

• Scheduling
• Pre-Op Process
• On time starts
• TOT
• Block Schedule
• Add On Process
• Post Procedure

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Administrative Definition of OR Status and Efficiency Poor vs. Good Excessive Staffing Costs >10% vs < 5% Start time tardiness >60 min vs <45 min (mean sum of tardiness of start times for elective cases per OR per day) Case cancellation rate >10% vs < 5% PACU admission delays OR holds >20% vs < 10% (% of workdays with at least 1 delay of >10 min in PACU admission because PACU is Full) Contribution margin (mean) per OR hour <$1000/hr vs >$2000/hr Turnover Times >40 min vs < 25 min (TOT are defined as the time from when one patient exits the OR until the next patient enters th Prediction bias >15 min vs < 5 min (Bias in case-duration estimates per 8 hr of OR time Prolonged Turnover delays >25% vs < 10% (% Of turnover lasting more than 60 minutes)

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Execution Steps Survey of Issues – complete Review Case Utilization Metrics 13 month period ‐ done Review Block Utilization Metrics – done Establish Surgical Services Executive Committee – in place On the Clock Cards‐ completed Review Block vs add on needs Interview Surgeons and Office Staff ‐ complete

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Scheduling and Pre Op and Offices All Charts are complete prior to day of surgery

• Offices engaged in the process
• Schedule accuracy
• Appointment for Pre-Op screening by phone or in person
• Anesthesia reviews and green lights the case
• Chart complete prior to day of surgery

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Administrative Definition of OR Status and Efficiency Poor vs. Good Excessive Staffing Costs >10% vs < 5% Start time tardiness >60 min vs <45 min (mean sum of tardiness of start times for elective cases per OR per day) Case cancellation rate >10% vs < 5% PACU admission delays OR holds >20% vs < 10% (% of workdays with at least 1 delay of >10 min in PACU admission because PACU is Full) Contribution margin (mean) per OR hour <$1000/hr vs >$2000/hr Turnover Times >40 min vs < 25 min (TOT are defined as the time from when one patient exits the OR until the next patient enters the same OR. (Average setup and cle Prediction bias >15 min vs < 5 min (Bias in case-duration estimates per 8 hr of OR time Prolonged Turnover delays >25% vs < 10% (% Of turnover lasting more than 60 minutes)

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Define Goals Assemble Metrics and Perceived Metrics Pilot Project Communication to all constituents and agreement Prior to Day of Surgery

• Offices will relay the plans for surgery information
• Patients are properly informed as to their requirements
• All charts completed prior to Day of Surgery
• Patients appropriately screened to avoid delays and cancelations by Anesthesia

Day of Surgery

• Surgeons agree to show up and check in on time at 6:55
• Anesthesia agree to screen patients prior to DOS and ready to go at 7:00
• Staff ready for case to begin at 7:15

Pilot Project Goals

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Implementation Policy Guidelines for Schedule Easy – Done New Schedule Template – “Schedule Easy” – Open Range Allocate Rooms based on types of cases and timing of scheduling

• 7:00-5:00 elective hours
• 7:00-7:30 add-on- hours

Relocate appropriate service lines – January 1, 2014 “Add on Coordinator” for all add on cases – one call and in charge Establish Service Lines and start Scheduling Process Lean Schedulers Retreat with offices

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Transformation of Creativity from Concept to Commercialization

Medical Device Development Process Transformation

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Prototype Prototype Patent Patent Capital FDA FDA Biomedical Practice 1998-2010 13 Prototypes

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Concept 3D Printing Prototype Concept Validation Concept Validation Clinical Evaluation Biomedical Engineer Biomedical Engineer Regulatory Capital Intellectual Property Intellectual Property Commercialization Commercialization

Austin Texas 2015

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Medical Innovation Labs

Compress time from idea to commercialization Concept Validation Prototype 3D Printing Modification Clinical Evaluation Intellectual Property Capital Regulatory

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With a goal of improvement in these technologies and their availability to all, Medical Innovation Labs is open to clinicians, entrepreneurs, and medical researchers in all fields. It is through this type of modified crowd‐sourcing that they hope to create an environment in which accelerated development can benefit as many people as possible as quickly as possible.

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• n Labs Launches; Announces Development of World‐Class 3D Printing and

Healthcare‐focused innovation hub debuts with plans inting and rapid prototyping lab for clinicians, researchers, engineers, and e

Austin, TX (PRWEB) October 14, 2014

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Chief Technical Officer for the lab, Professor Joseph Beaman of The Cockrell S

“The goal of the lab is to provide the resources to accelerate proof of concept through These capabilities will reduce time‐to‐market for innovative devices and ensure near‐

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“Medical Innovation Labs accomplished in 3 months more than 12 years of prior development work.” Developer of Austin Catheter Platform Gaines W. Hammond Jr. MD, FACS

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Medical Innovation Labs is a perfect example of the specialized labs and communities we need to establish within Austin’s Innovation Zone,” said Texas State Sen. Kirk Watson. “This organization will not only bridge the gap between idea and marketplace to foster medical innovation, but also provide a window to technologies from around the world that will improve patient care.”

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Medical school transformation begins to spread

12/11/2014, 2:46 PM Share: Two new medical schools are opening within the University of Texas system, and they’ve tapped the consortium of medica “We are a brand new school developing an entirely new curriculum,” said Clay Johnston, MD, PhD (pictured lef Faculty from some of the 11 schools in the AMA’s Accelerating Change in Medical Education initiative met in A

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All Projects must overcome a “Time Barrier” to achieve Sustainable Success The Mystery is understanding the Time to Execute Barrier for each Project

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The Magic of Transformation is how to create a culture of shared vision ac The True Magic is imparting the Transformative Leadership Skills to others

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Time to change is fleeting and requires momentum and consensus