Economics of Reducing Turnover Times - …

1 This talk includes many similar slides Paging through produces animation View with Adobe Reader for mobile: iPad, iPhone, Android Slides were tested using Adobe Acrobat You can select View and then Full Screen First optimize your settings Select Edit, then Preferences, then Full Screen, and then No Transition Other PDF readers suitable if scrolling can be disabled Google Chrome PDF Viewer has Select Fit to Page, and then use the right/left arrow keysUpdated 06/26/20 2020 Franklin DexterEconomics of Reducing Turnover TimesEconomics of Reducing Turnover TimesFranklin Dexter, MD PhD FASAD irector, Division of Management ConsultingProfessor, Department of AnesthesiaUniversity of Financial Disclosure I am employed by the University of Iowa,in part, to consult and analyze data forhospitals, anesthesia groups, and companies Department of Anesthesia bills for my time, and the income is used to fund our research I receive no funds personally other thanmy salary and allowable expensereimbursements from the University of Iowa.

2 And have tenure with no incentive program I own no healthcare stocks (other thanindirectly through mutual funds)Why Focus on Turnover Times (Cleanup Time + Setup Time)? Lean manufacturing principles Value added time when labor is touching product, changing its form or function Non-value added activity is the opposite Times when patients are in or out of an OR No reliable and valid instrument and process to record Times of the start and stop ofvalue-added activity for most procedures Turnover Times can be measured reliably15:3015:3015:3008:0008:0008 HoursRegularOR ScheduleExtendedOR ScheduleRegularOR Schedule15:3015:3015:3008:0008:0008 HoursRegularOR ScheduleExtendedOR ScheduleRegularOR Schedule15:3015:3015:3008:0008:0008 HoursRegularOR ScheduleExtendedOR ScheduleRegularOR Schedule15:3015:3015:3008:0008:0008 HoursRegularOR ScheduleExtendedOR ScheduleRegularOR Schedule15:3015:3015:3008:0008:0008 HoursRegularOR ScheduleExtendedOR ScheduleRegularOR Schedule15:3015:3015:3008:0008.

3 0008 HoursRegularOR ScheduleExtendedOR ScheduleRegularOR ScheduleEconomics of ReducingTurnover Times Potential benefits of Reducing Turnover Times Increase OR efficiency on the day of surgery by Reducing over-utilized OR time Increase OR productivity by Reducing staffing, even if have under-utilized OR time each day Increase number of cases Focus not just on setup and cleanup Times , but also the frustrating prolonged turnoversEconomics of ReducingTurnover Times Potential benefits of Reducing Turnover Times Increase OR efficiency on the day of surgery by Reducing over-utilized OR time Increase OR productivity by Reducing staffing, even if have under-utilized OR time each day Increase number of cases Focus not just on setup and cleanup Times , but also the frustrating prolonged turnoversExample ofUnder-Utilized OR Time OR staffing is planned from 7 AM to 3 PM Yesterday, the last case of the day inOR 1 ended at 1 PM There were 2 hours of under-utilized OR time Under-utilized time was from 1 PM to 3 PMStrum DP et al.

4 Anesthesiology 1999 Example ofOver-Utilized OR Time OR staffing is planned from 7 AM to 3 PM Two days ago, the last case of the day inOR 1 ended at 5 PM There were 2 hr of over-utilized OR time Over-utilized OR time was from 3 PM to 5 PMPrecise Meaning of Maximize Efficiency of Use of OR Time Inefficiency of use of OR time ($) =(Cost per hour of under-utilized OR time) (hours of under-utilized OR time)+ (Cost per hour of over-utilized OR time) (hours of over-utilized OR time)Strum DP et al. J Med Syst1997 OR nurses & anesthesiologists full-time,hourly employees scheduled months ahead Staffing is planned from 7 AM to 3 PM There is estimated to be 9 hrof cases including Turnover Times Because of quick setup and cleanup Times ,OR finishes at 3 PM, instead of at 4 PM Has Turnover Times OR efficiency? Reducing TurnoverTimes on Day of Surgery OR nurses & anesthesiologists full-time,hourly employees scheduled months ahead On the day of surgery, the cost of anhour of under-utilized OR time isnegligible relative to the cost of anhour of over-utilized OR timeReducing TurnoverTimes on Day of SurgeryMeaning of Maximizing OR Efficiency on Day of SurgeryInefficiency of use of OR time ($) (Cost per hour of under-utilized OR time) (hours of under-utilized OR time)+ (Cost per hour of over-utilized OR time) (hours of over-utilized OR time)Dexter F, TraubRD.

5 AnesthAnalg2002 McIntosh C et al. AnesthAnalg2006 Meaning of Maximizing OR Efficiency on Day of SurgeryInefficiency of use of OR time ($) (Cost per hour of over-utilized OR time) (hours of over-utilized OR time)Meaning of Maximizing OR Efficiency on Day of SurgeryInefficiency of use of OR time ($) (Cost per hour of over-utilized OR time) (hours of over-utilized OR time)ConstantMeaning of Maximizing OR Efficiency on Day of SurgeryInefficiency of use of OR time ($) (Cost per hour of over-utilized OR time) (hours of over-utilized OR time) Implication Maximize OR efficiency on the day of surgeryby minimizing hours of over-utilized OR timeConstantMeaning of Maximizing OR Efficiency on Day of SurgeryInefficiency of use of OR time ($) (Cost per hour of over-utilized OR time) (hours of over-utilized OR time) Implication Maximize OR efficiency on the day of surgeryby minimizing hours of over-utilized OR timeConstantReducing TurnoverTimes on Day of Surgery Scenario Staffing is planned from 7 AM to 3 PM By Reducing Turnover Times , cases finishedin 8 hr instead of in the expected 9 hr Finished at 3 PM instead of at 4 PMReducing TurnoverTimes on Day of Surgery Scenario Staffing is planned from 7 AM to 3 PM By Reducing Turnover Times , cases finishedin 8 hr instead of in the expected 9 hr Finished at 3 PM instead of at 4 PM Reducing Turnover Times increasedOR efficiency by preventing 1 hr ofover-utilized OR time OR nurses & anesthesiologists full-time,hourly employees scheduled months ahead Staffing is planned from 7 AM to 3 5PM There is estimated to be 9 hrof cases including Turnover Times Because of quick setup and cleanup Times ,OR finishes at 3 PM, instead of at 4 PM Has Turnover Times OR efficiency?

6 Reducing TurnoverTimes on Day of SurgeryReducing TurnoverTimes on Day of Surgery Scenario Staffing is planned from 7 AM to 3 5PM By Reducing Turnover Times , cases finishedin 8 hr instead of in the expected 9 hr Finished at 3 PM instead of at 4 PMSameReducing TurnoverTimes on Day of Surgery Scenario Staffing is planned from 7 AM to 3 5PM By Reducing Turnover Times , cases finishedin 8 hr instead of in the expected 9 hr Finished at 3 PM instead of at 4 PM Reducing Turnover Times did notincrease OR efficiency by preventing 1 0hr ofover-utilized OR timeSame Implications of the two scenarios Impact of reductions in Turnover timesand delays on OR efficiency is highlysensitive to the staffing for each OR Efforts to reduce Turnover Times should betargeted based on the staffing for each ORDexter F et al. Anesth Analg 2003 McIntosh C et al. Anesth Analg 2006 Reducing TurnoverTimes on Day of Surgery Implications of the two scenarios Impact of reductions in Turnover timesand delays on OR efficiency is highlysensitive to the staffing for each OR Efforts to reduce Turnover Times should betargeted based on the staffing for each OR Staffing for each OR that minimizes theinefficiency of use of OR time generally arethe most important values to be calculatedusing local OR management dataReducing TurnoverTimes on Day of Surgery If OR has 3 cases and the first case of theday enters the OR 8 min late, that is sameas increasing mean Turnover time by 4 min Thus same principles applyMcIntosh C et al.

7 Anesth Analg 2006 Dexter F, Epstein RH. Anesth Analg 2009 Principles Apply toFirst Case of Day Starts If OR has 3 cases and the first case of theday enters the OR 8 min late, that is sameas increasing mean Turnover time by 4 min Thus same principles apply For scenarios involving more than 1 OR, such as anesthesiologist medically directing CRNAS, many decisions that increase % cases withon-time first case start reduceOR efficiencyDexter F et al. Anesth Analg 2007 Principles Apply toFirst Case of Day Starts Important for anesthesiologists supervising multiple ORs, because must use staggered starts ( 20 min) at first cases of the day for anesthesiologist to be present at inductions Otherwise 1:2 MD:CRNA, lapses > 30% of days Otherwise 1:3 MD:CRNA, lapses > 96% of daysEpstein RH, Dexter F. Anesth Analg2012 Principles Apply toFirst Case of Day Starts Let the surgeons know so that those withthe later starts are not waiting in the ORsKoenig T et al.

8 Anaesthesia 2011 Principles Apply toFirst Case of Day Starts Let the surgeons know so that those withthe later starts are not waiting in the ORs Yes, preferentially focusing on ORs with over-utilized time, since ordered priorities are first performing all the cases safely and second Reducing expected over-utilized timeDexter F et al. Anesthesiology 2004 Dexter F et al. Anesth Analg 2007 Principles Apply toFirst Case of Day Starts Let the surgeons know so that those withthe later starts are not waiting in the ORs Yes, preferentially focusing on ORs with over-utilized time, since ordered priorities are first performing all the cases safely and second Reducing expected over-utilized time Important to understand since fixation on first case starts is due to cognitive bias that starting late results in all cases being tardyDexter EU et al. Anesth Analg 2009 Principles Apply toFirst Case of Day StartsImpact of Staffing on Benefitof Turnover Time Reduction Outpatient Surgery Center with 6 ORs,all staffed from 7 AM to 5 PM Mean ORs in use before intervention2 PM 5 ORs 4 PM ORs3 PM 2 ORs 5 PM ORs Mean ORs in use after intervention2 PM 4 ORs 4 PM ORs3 PM ORs 5 PM ORs Increased OR efficiency?

9 Impact of Staffing on Benefitof Turnover Time Reduction1)Evaluate the OR allocation (staffing)Impact of Staffing on Benefitof Turnover Time Reduction Outpatient Surgery Center with 6 ORs,all staffed from 7 AM to 5 PM Mean ORs in use before intervention2 PM 5 ORs 4 PM ORs3 PM 2 ORs 5 PM ORs Mean ORs in use after intervention2 PM 4 ORs 4 PM ORs3 PM ORs 5 PM ORs Increased OR efficiency?Impact of Staffing on Benefitof Turnover Time Reduction Outpatient Surgery Center with 6 ORs,all staffed from 7 AM to 5 PM Mean ORs in use before intervention2 PM 5 ORs 4 PM ORs3 PM 2 ORs 5 PM ORs Mean ORs in use after intervention2 PM 4 ORs 4 PM ORs3 PM ORs 5 PM ORs Increased OR efficiency?UnchangedImpact of Staffing on Benefitof Turnover Time Reduction2)Evaluate the over-utilized OR timeassuming (and might be incorrect) that7 AM to 5 PM allocation minimizes theinefficiency of use of OR timeImpact of Staffing on Benefitof Turnover Time Reduction Outpatient Surgery Center with 6 ORs,all staffed from 7 AM to 5 PM Mean ORs in use before intervention2 PM 5 ORs 4 PM ORs3 PM 2 ORs 5 PM ORs Mean ORs in use after intervention2 PM 4 ORs 4 PM ORs3 PM ORs 5 PM ORs Increased OR efficiency?

10 Impact of Staffing on Benefitof Turnover Time Reduction Outpatient Surgery Center with 6 ORs,all staffed from 7 AM to 5 PM Mean ORs in use before intervention2 PM 5 ORs 4 PM ORs3 PM 2 ORs 5 PM ORs Mean ORs in use after intervention2 PM 4 ORs 4 PM ORs3 PM ORs 5 PM ORs Increased OR efficiency?Small& sameImpact of Staffing on Benefitof Turnover Time Reduction1)Evaluate the OR allocation (staffing) 2)Evaluate the over-utilized OR time No impact on OR efficiency, becausestaffing and over-utilized OR time are effectively the sameImpact of Staffing on Benefitof Turnover Time Reduction1)Evaluate the OR allocation (staffing) 2)Evaluate the over-utilized OR time No impact on OR efficiency, becausestaffing and over-utilized OR time are effectively the same Impact of intervention would be mostly anincrease in hours of under-utilized OR timeImpact of Staffing on Benefitof Turnover Time Reduction1)Evaluate the OR allocation (staffing) 2)