Smoothing OR flow

How to change the surgeon’s practice of first half of week elective cases to smooth inpatient volume?

We have the issue common to hospitals that have a significant surgical volume; namely high elective OR volumes early in the week which gobbles up inpatient beds Monday through Thursday. This leads to the boarding of patients in the ED on Monday through Wednesday. Add-on cases are also delayed due this. My hospital will not mandate that the surgeons utilize the end of the week for elective cases because they can easily move their surgical practices to a competitor in town.


Alignment with all clinical departments.

Participant comments on Smoothing OR flow

  1. A couple of thoughts.

    1) Is there the opportunity to move some of the elective cases to outpatient or extended recovery and having those go first each day. While this would require “recovery” space it would help decompress the inpatient side. With joint replacement now being reimburse as an outpatient by Medicare the traditional LOS for many elective cases should decrease. Concerns with patients having issues once home could be alienated with a “at home/post discharge” visiting nurse program or an option where patients send in key vitals to the EHR for servalance. For high volume cases having a pre-surgical “boot camp” setting this expectation with patients and making sure they know how to set themselves up for success before they have surgery to make the discharge to home easier.

    2) Increasing bed compliment – expensive but always and option

    3) Create a clinical decision unit / observation unit. If observation patients are mixed in with full admits they will be managed by the doctors and staff as if inpatient increasing the length of stay. Even shaving .25 off the LOS of obs patients can increase throughput.

    4) Also have a goal for all discharges to be determined by 9 am so patients leave by 11 am. Establish a discharge lounge for patients who can’t leave at 11 due to social issues. Again creating more capacity.


  2. EMDO,

    This is really a problem that all hospitals seem to share, isn’t it? Last year, I gave a talk about the IOM’s Quadruple Aim with 3 other speakers I was discussing Population Health. The speaker who gave the lecture about Reducing Costs was an architect by training who now works as a Healthcare Systems Engineer and she had some great observations about patient flow in a hospital. She described a case study by Peter Viccellio that was presented at the Hospital Flow Seminar of the American College of Emergency Physicians in 2017 (Viccellio, MD, FACEP, Peter. (2017, May). Introduction to the Problem and Discussion of Full Capacity Protocol. Presentation at the Hospital Flow Seminar of ACEP, Boston, MA). One of her slides was a graph of elective vs. emergency hospital admissions by the day of the week. Emergency admissions are actually quite predictable and vary only slightly throughout the week (Saturday and Sunday are slightly lower). Elective admissions, on the other hand, vary greatly.

    I would be happy to share the slides with you and wonder if they could help you make your case to hospital administration. I understand the leverage these surgeons have with their ability to move their case volume to another institution if your hospital does not cater to them. I wonder if there are other benefits hospital administration would be willing to offer that might induce at least a few of the surgeons to move their cases to a different day.


  3. This is a problem in all operating rooms. I don’t know what you have tried already but perhaps offering some non-fiscal benefits to certain surgeons who might be willing to operate later in the week. Perhaps the availability of more than one room or staggered cases to allow greater productivity. Or consider a block time system where certain surgeons who have trouble getting enough OR time can get guaranteed OR time but later in the week. Or perhaps more first assistants on Thursdays or Fridays, or more PA/NPs helping to write orders and take care of patients periop. Also, never underestimate the power of free food on Fridays.

    Another equation to consider is if the implementation of a smooth operating system would be worth the risk of losing some surgeons? From your post sounds like you do not think that would be a profitable trade-off. May be worth looking at the numbers.

  4. Another idea of how to incent the behavior desired is by showing improvement in things like recovery room delays, OR delays and floor delays by demonstrating how smoothing would benefit the surgeons and would reduce these delays. The frustration of an inefficient operating room is one of the greatest dissatisfiers for surgeons so improving these delays by aligning and smoothing the schedule and showing the surgeon how this benefits them may help change behavior.

  5. Certainly as David suggested, surgeons should be motivated to alter their OR utilization if they understand that the various delays that they experience would be minimized. Extensive communication with the surgeons is necessary for them to understand the benefit of altering their OR utilization patterns. Surgeons may actually appreciate that they are being consulted to find solutions to this issue – and thereby less likely to move their practices to a competitor hospital who may not value surgeons’ opinions as much as your institution.

  6. I agree! As a surgeon myself, if the hospital came to me and asked me to switch my day I would say no. But if they presented the whole case and provided some concessions on the things I want I would be more likely to help them find a solution together.

  7. Transparency should be able to state how important is to all to better distribute cases all over the week. The insitution defines OR agenda, not surgeons. YOu offer them slots they could book surgeries not the other way around. if they want to have the best time schedule they have to fit your strategy. Kind of a fidelity program. If they do what you need, they get the best times on OR schedule, but simple rules may state no days in a row, for example…

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