Improving Quality and Performance in Procedural Areas

By: Gil Amoray, Partner, Tefen USA

Procedural areas are the heart of hospital operations. Surgical cases are a major contributor
to the hospital net patient revenue. Total number of surgeries – inpatient and outpatient –
equates to approximately three-quarters of the total number of admissions. This number
increases when including other procedural areas, such as cardiac catheterization labs,
electrophysiology labs and other areas performing small (or large) procedures outside the
Operating Rooms.
Most procedural areas are battling similar concerns: on-time start performance is sub-
optimal; surgeons’ satisfaction level is mediocre; capacity challenges result in long wait
times to schedule a case and long wait times during the day of surgery, which leads to low
patient satisfaction. Such challenges, in an environment that poses major quality risks, are
an alarming call to hospital executives.
Opportunities to improve quality and performance in procedural areas can be grouped into
three categories: activities that may be streamlined prior to the day of procedure;
improvements during day of procedure; and scheduling improvements.
Improvements Prior to the Day of Procedure
The typical check-in process on the day of procedure is cumbersome, lengthy and frustrating
for a patient already concerned with their upcoming surgery. Registration, consent forms,
insurance and other financial liability documentation are just part of what a patient is
encountering upon arrival to the hospital. Inpatient procedures involve less documentation,
but still require administrative attention. Completing these tasks prior to the day of service
will save time and divert attention towards the medical process. Patients may complete the
paperwork on their pre-surgery consultation visit, on-line, or using a call center service
complemented with kiosks, resulting in reducing administrative burden on the day of
service.

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Health and physical exams may also be completed prior to the day of procedure. Patients
may provide this information during their consultation visit, followed by a short verification
on the day of surgery.
Pre-procedural testing is a major cause for delays. Surgeons are waiting for labs, radiology,
and other tests before starting the case. Most hospitals choose to ask the patients to arrive
early enough to allow sufficient time for testing. However, phlebotomy, lab, and radiology
workloads during peak hours make it challenging to meet turnaround time targets and result
in idleness of critical resources – surgeons and procedural suites. The answer? Move
applicable tests to a day (or a few days) prior to the procedure. They may be performed at
the hospital or at a local or with national service providers.
Arrangements for logistics and transportation often handled AFTER the procedure. Case
management-related questions may be asked ahead of time, flagging cases where special
arrangements are necessary, and proactively addressing. An elderly patient entering a hip
replacement surgery with no domestic support is likely to require transportation and
logistical help upon discharge – and this may be anticipated and coordinated in advance.
Improvements During Procedural Day
Continuous care by the same nurse responsible for pre-op to support the procedure
eliminates hand-offs during this critical day, improves the quality of care and enhances
patient experience, who is more comfortable meeting the nurse supporting their procedure,
especially if they are under general anesthesia.
Tracking and monitoring of on-time start performance, coupled with root-cause-analysis to
address reasons for delays increases visibility and awareness and helps drive a culture of
on-time start.
Room setup and turnaround time are a major room utilization detractor that can be easily
addressed, by improving communication practices and performing applicable activities
“offline”, outside the room while the previous case is in-progress.
Material management contributes to an effective and efficient system in procedural areas.
Standardization of supplies across ORs, and adjustments of par levels to match demand and
prevent staff from breaking scrubs to search for supplies outside the procedure room, are
two examples of practices to improve.
Scheduling Improvements
Procedural areas have tremendous impact on hospital census. Consideration of census and
LOS to spread procedures across the day-of-week can minimize inpatient bed variation.
Every procedural area handles emergent and urgent cases. While the name of the patient is
unknown, the pattern of arrival (times of arrival and type of cases) can be predicted based
on historical data, and allow schedulers to reserve sufficient capacity to account for those
cases.
Case lengths vary by the type of procedure and physician performing it. Acknowledging this
variation allows allocation of appropriate durations for cases, reflecting the Truth in
Scheduling.
Starting the day with the least variance case improves the changes of running schedules on
time. Similar to airlines, on-time performance for the first flight minimizes delays later in the
day. To support this, schedulers need to know all cases scheduled for that day. A good

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practice is giving a patient, upon scheduling, a time window within the day, without
indicating specific start time. Schedulers can then arrange the schedule three days prior to
the day of service, and advise patients for their start time within that block.
A combination of improvements made prior to the day of procedure, during that day, and in
scheduling are powerful and can greatly improve operations in procedural areas. Taken
together, these can streamline flow across the hospital and ultimately improve patient
satisfaction.

About Tefen USA

Tefen USA works with hospitals and health organizations to make sustainable improvements
in the areas of business strategy, operations excellence, project management and
organizational development by applying LEAN, Six-Sigma, and related operations strategies
to improve the cost, quality, and access performance of healthcare organizations.