Massachuse(s  General  Hospital  Center  for  Periopera6ve  Care  Re-­‐design  

Minakshi  Raj,  MPH;  Caroline  Horgan,  RN;  Kate  Riddell,  MD;  Eden  Brand,  MPH  Department  of  Anesthesia,  Cri@cal  Care  and  Pain  Medicine    

MassachuseCs  General  Hospital,  Boston,  MassachuseCs,  USA  

1.   Improve  Pa6ent  Experience  i.  Reduce  pa@ent  processing  @me  and  shorten  

@me  wai@ng  in  lines  ii.  Reduce  pa@ent  anxiety  on  the  morning  of  

surgery  2.   Reduce  Delays  

i.  Reduce  first  case  delays  resul@ng  from  prep  and  transport  delays  

ii.  Prevent  delays  in  later  case-­‐starts  resul@ng  from  first  case  delays  

3.   Increase  Nursing  and  Admin  Efficiency  and  Simplify  Process  

i.  Reduce  the  @me  OR  staff  spend  wai@ng  for  pa@ents  to  arrive  

ii.  Reduce  CPC  check-­‐in  staff’s  overwhelming  workload  between  5:30  and  6:30  

A  @me  and  mo@on  study  was  conducted  in  June  2015  to  iden@fy  boClenecks  in  the  current  process.  We  created  a  current  state  process  map  (see  Figure  4)  and  in  collabora@on  with  CPC  staff  and  leadership  developed  a  future  state  process  map.  In  the  pilot  a  CPC  administrator  checked  in  pa@ents  in  the  main  hospital  lobby  from  5:00-­‐5:25am  (see  Figure  6),  and  then  returned  to  the  CPC  main  desk  to  con@nue  checking  in  pa@ents.  Tools  to  support  the  CPC  admin  were  created  including:  instruc@ons;  conversa@on  scripts;  and  colored  pa@ent  instruc@on  cards.  Some@mes,  pa@ents  who  had  a  later  case  surgery  also  arrived  at  MGH  prior  to  5:30am.  To  ensure  that  the  check-­‐in  process  was  fair  and  @mely  for  pa@ents  who  were  scheduled  for  1st  case  surgery,  we  created  colored  cards  to  triage  pa@ents  who  checked  in  early  (see  Figure  5).  The  cards  ensured  CPC  staff  could  easily  iden@fy  pa@ents  based  on  @me  of  their  surgery.  Finally,  we  communicated  and  collaborated  with  mul@disciplinary  teams  throughout  the  hospital,  including  CPC  leadership  and  administra@ve  staff,  security  staff,  and  main  lobby  support  staff,  to  ensure  all  groups  were  aware  of  and  suppor@ve  of  the  pilot  and  redefined  process.  

60  

50.5  

40  

45  

50  

55  

60  

65  

Monday  

Time  (M

inutes)  

CPC  Processing  Time  from  Check  -­‐  In  to  Departure  on  Mondays  

Pre  -­‐  Pilot  

Pilot  

IT   Organiza6onal  Issues  

Pa6ent  Percep6ons  

Physical  Resources  

Hospital  Policies  Owned  by  Other  Groups  

Within  Scope  of  Control   Out  of  Scope  of  Control  

We  observed  the  greatest  reduc@on  in  processing  @me  on  Mondays;  on  average,  pa@ents  were  processed  9.5  minutes  faster  (see  Figure  7).    An  overall  average  reduc@on  in  processing  @me  of  4  minutes  was  observed  for  each  weekday.  An  average  of  eight  pa@ents  were  checked  in  prior  to  5:30am  in  the  main  hospital  lobby  each  morning,  allowing  the  morning  shib  CPC  staff  to  experience  a  smoother  workflow.  We  observed  a  number  of  addi@onal  posi@ve  outcomes  of  the  pilot,  including  a  reduc@on  in  @me  wai@ng  to  check  in.  An  improvement  in  pa@ent  sa@sfac@on  was  also  reported.  The  successful  pilot  process  was  suggested  by  a  CPC  staff  member,  and  our  adop@on  of  her  sugges@on  led  to  enhanced  job  sa@sfac@on  and  engagement  between  administra@ve  staff  and  leadership.  Feedback  was  sought  from  CPC  staff  resul@ng  in  collabora@on  throughout  the  development  and  implementa@on  of  the  pilot.  

Based  on  our  evalua@ons  and  results  of  the  pilot,  we  recommend  making  the  early  check-­‐in  process    standard  for  first  case  surgery  pa@ents.  We  suggest  designa@ng  a  member  of  the  CPC  staff  to  conduct  future  evalua@ons  of  the  CPC  process  and  to  reassess  the  impact  of  the  new  process  in  3-­‐4  months.  Other  boClenecks  were  iden@fied  during  the  ini@al  shadowing  process,  such  as  in  the  transporta@on  of  pa@ents  from  the  CPC  to  the  opera@ng  room.  These  boClenecks  can  be  targeted  next  as  areas  for  improvement.  Finally,  we  recommend  con@nuing  to  solicit  feedback  and  sugges@ons  from  pa@ents  and  staff  in  order  to  con@nue  improving  the  process  and  working  towards  achieving  our  goals  of  improving  pa@ent  experience,  process  and  efficiency,  and    reducing  delays  in  surgical  start  @me.  

First  case  pa@ents  arrive  at  MassachuseCs  General  Hospital’s    (MGH)    main  lobby  between  5:00-­‐5:30am  to  check  in  for  surgery  at  the  Center  for  Periopera@ve  Care  (CPC).  The  CPC  building  does  not  open  un@l  5:30am  (see  Figure  1).  Pa@ents  who  arrive  before  5:30am  must  wait  in  the  main  lobby  un@l  5:30am.  At  5:30am,  20+  pa@ents  and  their  families  proceed  to  the  elevators  and  wait  in  the  line  to  check-­‐in  (see  Figures  2  and  3).  Pa@ents  experience  very  long  wait  lines  to  be  processed  for  surgery,  and  CPC  staff  experience  an  overwhelming  workflow  un@l  the  majority  of  first-­‐case  pa@ents  are  checked  in  and  processed.    

Pa@ent  Experience  

On  Time  Surgical  Starts  

Improve  Process  and  Efficiency  

Figure  7.  Note:  Findings  were  not  sta0s0cally  significant  due  to  limited  sample  size  

Figure  3.  Pa0ent  View  of  CPC  Entrance  from  Elevator  

Figure  2.  Pa0ent  View  of  CPC  Hallway  

Surgical  

Check  In  

Desks  

Figure  1.  CPC  Check-­‐In  Desk  

Security  Staff  Desks   White  Lobby  Check-­‐In  Desk  

Wai@ng  Area  

Wai@ng  Area  

Figure  6.  Pilot:  Main  Lobby  Check-­‐In  

Background  

Evalua6on  

Goals  

Methods  

Challenges  

Results  and  Posi6ve  Outcomes  

Recommenda6ons  

Time-­‐Mo@on  studies  along  with  @me-­‐stamps  documented  on  EMR  were  collected  and  analyzed  .  Data  was  collected  for  eight  days  in  July  to  measure  current  state,  along  with  eight  days  of    data  during  the  pilot.  We  also  evaluated  the  success  of  the  pilot  based  on  visual  observa@ons,  for  example,  shorter  lines  at  5:30am  and  a  less  overwhelming  workflow.  Our  evalua@ons  included  feedback  from  staff  on  their  experiences  with  the  new  workflow,  and  from  pa@ents  on  their  sa@sfac@on.  

Figure  4.  Current  State  Process  Map  

Figure  5.  Colored  Card