Prioritizing elective surgery volume

Hello. My name is Dr. Gary Smalto and I'm a practice partner with Optum Advisory Services, Hospital Performance Improvement team. I lead teams of consultants and clinicians to help organizations improve clinical efficiency, cost, and quality for many hospitals across the country. Today I'd like to follow up on a prior session that covered perioperative services efficiency to address how hot organizations are starting to tackle the return to normal operating room operations, if there will be a new normal.

What we've heard from many organizations is that after CMS introduced its guidance in March that they should delay elective cases, they've developed a backlog for the last approximately at least a month. Now on April 19th, CMS once again advised that organizations could restart their elective surgery programs as long as they met a number of different criteria that could be partially laid out by the state, possibly counties, but what they recommended was a number of gating criteria that they've outlined in some of their summary recommendations.

For this audience, we'd like to cover how organizations are starting to think about returning to normal operations. What we're seeing is that they are responding by creating plans before they open their doors. Now we think it's urgent that organizations focus on planning first so that when they open their doors, they don't either get: situation one, a rush of patients and surgeon demands for space; or two, a trickle of patients who are afraid to come into the doors of the hospital and not really understand how they're going to respond.

So what we're seeing organizations doing is setting in a four point plan.

The first part of this plan is to really use historical and surgeon office data to try to understand and parse through what types of cases are out there, what is the anticipated volume, what is the urgency for the case need, the patient situation, all the constraints that we have - and really gain a granular understanding of how they're going to organize this case volume against what their organization is able to actually do in the operating room.

So step two, they'll look to secondly to improve the capacity of their existing OR. Many organizations, if not most of them, according to our Surgical Profitability Compass colleagues, have very low actual OR utilization. When we think about OR utilization, it's the number of actual cases that we do during a staff day. Best practice organizations can boost that number up to anywhere between 75 and 80%, which means that they're humming along pretty smoothly and being very efficient. But most organizations really sit around 55 or 60%, which isn't going to be enough efficiency for them to actually do their possible post-COVID surgeon demand. So what these organizations are doing are saying, Hey, maybe we need to look at the way that we manage our capacity little bit differently. It may be that we need to suspend normal block use, add block time to surgeons that we know are going to be doing the highest priority cases, possibly we're going to increase time on the operating room day into nights, maybe we have to extend into weekends, or even open other procedure rooms to try to accommodate this known volume. So working with historical data around surgical volumes, surgeon office, anticipated demand, and then now knowing how we can manipulate our block schedules and our OR capacity to achieve 75 or 80% utilization, the next step is to actually prioritize those cases.

Organizations are going to have a number of constraints and they're going to be different by each hospital. Some organizations are going to be having an inability to accommodate inpatient cases or patients that need an inpatient bed after surgery because they are dealing with the aftermath of COVID. Other organizations didn't see much of a surge for COVID, yet they still have some capacity constraints due to some staffing layoffs or other problems on their inpatient side. This could also occur in their operating room. So organizations are saying, Hey, maybe we should prioritize ambulatory cases first, think about the ones that actually need an inpatient bed, create specialized non-COVID units for those patients, or any other strategy that's going to work for them to prioritize cases.

We think it's essential that they use their data, their knowledge of their surgeon's cases, their knowledge of their patients that they have to serve to create a great prioritization plan to actually organize those cases by surgeons so that you can have those surgeons operate very efficiently back-to-back in many cases in a block of time that's going to achieve a high volume of cases per surgeons that needed for their backlog.

The last step in this process is to actually finalize this plan. Up until this point, we've done a paper exercise using data and information we know about ourselves, about the surgeons offices, about the patients and their data.

We have to actually actualize this plan and create a final roadmap by working with our surgeon partners to help them understand why we're making decisions, how we're prioritizing cases, actually getting their input, getting their agreement, and then laying out a plan to stagger these cases in the correct way to respond to the volume needs and the elective case demand. So organizations then have a great plan in place to actually open the doors on a particular day of their choosing or whatever the states or governments are allowing them to do, and then start performing cases very quickly.

Now that organizations have created their final plan for reopening and organize their patients by surgeon type, case length, and ways that they're going to attack the case volume. They actually have to figure out how to implement eff iciently. Now, most hospitals have ORs that are culturally, possibly not well adapted to maximal efficiency.

On this next slide, what we show is the route to efficiency for most organizations. As you can see on the left, it requires really robust patient preparation so that on the day of surgery when a patient shows up, there's no delays due to things like missing lab elements or other signatures or consents that patients are going to require to come into the OR and actually be operated on without being canceled. In addition to these normal criteria, organizations are putting in some criteria such as a COVID test before patients are allowed to come in, or a regular temperature check both before and during the day of surgery, even before they'll let the patients in the doors.

Some organizations are considering whether or not they're going to have alternatives to waiting rooms so that they don't have patients together violating social distancing norms. Those things are all going to have to be worked out for each individual organization in guidance with its own state and county rules.

But what we're seeing is regardless of how you work out letting the patients in the door, there's going to have to be a very efficient operating room to actually perform all of these back-to-back type cases in an expedited timeframe and allow us to do the cases that we need to do in a prioritized way. So organizations are really going to have to focus on the middle part of the slide, which is day-to-day efficiency. And those things are roadblocks and barriers that come up all the time that will hinder performance. What we see some of the issues coming up are, if patients are not prepared, they will not have a robust first case on time start, which is going to delay the whole day. So we have to avoid that by making sure our processes are in place. And be highly efficient so that patients get into the room quickly and surgeons are able to operate fast.

Next is turnover times. If we have very lackadaisical turnover times or we're not well organized, we don't have good planning in place for our turnovers between certain types of cases, they're going to take too long. All those things are going to add up each day to delay our response to this elective surgery demand and it's going to push out the amount of time that we have to be operating this incident recovery mode.

So what we recommend is making sure that you plan well on the front-end for all of the priority and cases that you need to manage an efficient OR in the either four weeks, or eight weeks, or possibly 12 weeks it's going to take for you to work through all of your demand. But also focus on the basics and make sure that your teams are ready and able to execute well against first case starts, patient pre-op preparation, post patient discharge, whether they need to go to a PACU and then out the door at the hospital back home. How are we going to organize all of these things to make sure that the patient days are very smooth and that we're on top of all of the issues that are constantly going to be popping up.

So we see sort of this two-phased approach. First plan for this post-COVID "surge" of elective cases, make sure we understand how we're going to parse them out by surgeon and by case, by urgency, and by patient need. And then on the back-end make sure that we are going to be able to operate through all of any constraints so that they don't pop up as a barrier at the last minute and that we've planned well for all of that.

The next phase is that we have to actually implement smoothly. We have to have a very smooth process for pre-op patient preparation, a very smooth process for day of surgery operations, including first case starts and turnover times the equipment needs and supply management so that everything hums together on the day of surgery to allow us to manage this backlog well.

So those are some of the key elements that we're seeing organizations grapple with around the country right now. We're grateful for this time that you've given us to help outline some of these planning types and engagements that we're working with organizations to manage this type of response. We also hope that folks understand that they need to focus on bread and butter efficiency in their operating room. Without that good and smooth operation on the day-to-day operating room, they're going to really stumble and not be able to take care of the demand that they've done such a great job of planning for.

So once again, thank you very much. This is Gary Smalto for Optum in my home office, and I wish you all the best of luck in accommodating these cases.