Smooth operator

Five years ago, Ellis Knight had a problem. As Vice President of Medical Affairs at Palmetto Health System in Columbia, South Carolina, one of his responsibilities was to evaluate and carry out root cause analyses of significant adverse events that had occurred in the Palmetto Richland hospital.

“I wish you could snap your fingers and make the culture magically appear, where everybody says, ‘That’s the way we do things around here, and that’s the way we always have done them, and that’s the right way to do things.”

Invariably one of the first findings in each case would be that these events had occurred during times when medical staff had had to manage a large number of patients in a short period of time. The peaks and troughs in the hospital's case load were more than mere annoyances; they had the potential to cause serious harm.

Around this same time, Knight - who is now the health system's Senior Vice President of Ambulatory Services - and his senior management colleagues had signed up for a course in managing healthcare operations given by Eugene Litvak, President and CEO of the Institute for Healthcare Improvement. They came away inspired.

"The course took place over nine months with a few on-site sessions in Boston, and some coursework and activity projects in between," Knight recalls. "Over that time, we became quite enamored with his model for managing variability and helping patient flow throughout the hospital, and then, subsequently, made arrangements to work with his team at Boston University to come and help us implement some of that in our own organization."

Knight praises. Litvak's approach as "unique" and says it got to the root cause of a lot of the problems that his hospital - and indeed, many others - suffer from. These included long wait times in the emergency department, patient dissatisfaction, employee dissatisfaction, lower margins due to an inability to maximize volume and throughput, and most particularly, says Knight, a concern that these bottlenecks in flow were resulting in significant quality-of-care problems and potential patient harm.

Many hospitals faced with a similar challenge would solve it by building more capacity, but Knight believes that far from solving the problem, adding more space can exacerbate it.

"It seemed to us that by managing the flow, we would get more to the underlying cause of the dysfunction, as opposed to other measures which would simply put a Band-Aid, if you will, on those manifestations that we were seeing. For instance, with emergency department overcrowding, the first thing you think is, 'Let's build more capacity.'

"One of the genius aspects of Dr. Litvak's approach is that he can show both mathematically and also in many instances where it's been tried, that building new capacity doesn't alleviate the problem, and, in fact, can exacerbate it by creating more capacity and more problems with high flow or peaks. And often at a great deal more expense than what you would have to put into trying to adjust the more basic problem, which is the flow variability."

Smoothing flow

Knight and his colleagues decided that the best way forward for their institution was to implement Litvak's model for smoothing elective surgical flow through operating rooms. "We did that because - and this is one of the unique aspects of his design, I feel - he can show that the elective surgical flow is something in most hospitals that does come in peaks and valleys and does cause stress on the system, but fortunately it's something that, theoretically at least, can we can control.

"The flow to the emergency department is more what we call natural variability, and has to do with how many people become ill with contagious illnesses, or trauma, or whatever may be causing those peaks and valleys. But the variability in flow in elective surgeries is all due to something that we can control, and that's the desire of surgeons to operate on a certain day at a certain time and do certain cases.

"This approach was something we could get a handle on, and Dr. Litvak does a very good job of analyzing your own data and showing you that that would create significant benefits.

"We assembled a group of surgeons and began meeting on a monthly basis at the ungodly hour of 6 a.m., when surgeons can find time to get together. We did that for more than a year, and went through a very methodical process where we, first of all, separated the elective surgical cases from the emergency surgical cases, which of course are not under our control.

"We had to determine how much capacity we had to set aside for those emergency cases, and make sure that they were dealt with in a timely fashion and in a way that would not compromise patient care. That left us with this elective surgical volume that we could smooth out and therefore create a more even flow."

This was achieved through adjusting the block surgical time given on the schedule to certain surgeons that allows them to plan ahead and to know when they have time to operate. Knight and his colleagues looked at this block time closely to ensure it was being optimally used. "That's very valuable time, obviously," he says, "and we didn't want to have a significant amount of IT go to waste. Unfortunately we found it was being wasted, and so we had to reallocate that and make sure that the blocked schedules were being utilized in an optimal fashion."

The process of  separating of elective from non-elective cases and the reallocation of block times took about 18 months. The team were then left to deal with what Knight calls "the hard part": asking surgeons who may prefer to operate on one single day or a couple of days a week - when everybody else may want to operate, - to adjust their schedules and to smooth that out. This proved to be a sticking point, as Knight explains.

"Quite honestly, that was the point at which we got hung up. Our hospital has a large, independent private practice medical staff, and it was very difficult for us to work through those aspects of asking those surgeons to smooth their case schedules.

"The situation in most hospitals like ours is that the medical staff has historically been very independent and autonomous, and to try to engage them in an effort like this, where the motivations and rationale for this may not be aligned, is very difficult. That's not to say that they're wrong. It's just that they're operating in their own environment and according to their own desires and motivations, and they've got their own agenda, and their own agenda has to do with maximizing their own efficiency and their own schedules.

"It's difficult when you have those kind of parallel universes and they don't necessarily align, although we do have an opportunity to change that. We, like many hospitals, are employing more of our surgeons, and we plan on utilizing our employment relationship with those surgeons to facilitate those schedule changes that will have the effect that we want.

"We are also working with another organization that we've developed - an accountable care organization - that does include independent private physicians, as well as employed physicians."

Cultural difference

The existing culture of the hospital can also play a role in getting surgeons on-side. Knight points out that there are some long-established institutions, such as the Mayo Clinic, that over a hundred years or so, have developed the kind of culture that provides its own incentive for the hospital and physicians to engage and work together harmoniously.

He says it's more of a challenge in smaller or newer organizations without a 100 percent employed medical staff, and even though at Palmetto Richland the amount of employed staff is growing it will take a while to reach 100 percent, and even when it does, that type of culture takes a long, long time to develop.

In the meantime, says Knight, the reality is you have to rely on things like financial incentives or other types of rewards around increasing efficiencies to foster that sort of engagement and alignment. "I wish you could snap your fingers and make the culture magically appear, where everybody says, 'That's the way we do things around here, and that's the way we always have done them, and that's the right way to do things.'

"Unfortunately, you have to use a little bit more innovation in terms of how you incentivize that. I do think though that, especially in the era of healthcare reform, that will be an essential challenge for any healthcare system or hospital of any size to figure out, because I think the days when  physicians and hospitals can operate in these kind of independent, autonomous realms is long past and is not going to work in the future."

The hospital is also beginning to work on some clinical and cost initiatives that it is hoped will provide incentives to physicians to help motivate them and align them with the overall purpose of the prospect. Unless you can create those alignment structures, where both sides are equally motivated to produce that sort of difficult change, Knight says, it's a hard problem to address.

Other changes include the instituion of strict 7:30 a.m. starts and being firmer about not allowing people to delay cases so that they become backed up later in the day, all of which has paid significant dividends, according to Knight. He calls the outcome of the project's initial stage "very positive", even though they have not yet implemented everything they would have liked to.

Major benefits

As well as increased patient safety, the project brought Palmetto Richland significant financial benefits. Knight puts the figure at $500,000 in increased revenue realized from the measures they were able to implement, net of the cost of the services of Litvak's team.

The amount was raised through increased surgical volume and increased margin per surgical case achieved through the Litvak-inspired efficiencies. The projected financial benefits following implementation of the entire project - including the smoothing of surgical cases - in the range of $13 million to $14 million

Knight says that even the higher figure is probably an underestimation of the overall financial benefit to the organization from the downstream effect that not only increasing the surgical volume would bring in more revenue, but also in alleviating some of the associated problems of long wait times and patient dissatisfaction.

"The other benefit that we obtained was a significant increase in surgical satisfaction," he continues. "We had done a survey of 100 of our medical staff members for two years running previous to this project, and one of the biggest complaints from surgeons was around the prolonged wait times to do elective or emergent cases.

"After the project, we did another survey of our surgeons, and there was 73 percent satisfaction, with the ability to easily schedule emergent or urgent cases, so we felt that that was a significant gain, as well, and it resulted in a lot of improved satisfaction in our surgeon staff."

When asked whether he would recommend the process to other hospitals and healthcare institutions, Knight responds with an unqualified 'yes'. "I would certainly advise, and have on multiple occasions, other organizations to try this. Though it's not without its challenges, one of the main ones being how to achieve that alignment with your medical staff who have to buy in to this to make it work, and those kinds of political obstacles are the major difficulty.

"I do think, as I said before, that this is at the root of many, many problems that befall healthcare right now, and if any organizations to think they can manage this without addressing the variability and flow, I think they're mistaken. This is something that has to be addressed, and more people are realizing this because of the development of joint commission standards now to address it.

"Leapfrog Group has also announced that they're going to have a Leap added to their list of things that they advise and incentivize hospitals to do, which will specifically address Dr. Litvak's approach to surgical case smoothing."

Value focus

Litvak's methods certainly seem like to become increasingly prominent, aligning as they do with the current focus on value. "A very simplistic approach and one that I use often is value is quality per unit of cost," Knight says, "So the more you can improve quality and the more cost-efficiently you can produce that quality, the higher the value that you produce.

"Modifying the patient flow variability accomplishes both of those goals. There's good data in the literature that shows that the less stress on the system, with regard to volume of patients per provider, is a significant marker of quality and a way to avoid adverse outcomes.

"As I mentioned anecdotally, when I would do these root cause analyses, almost every one of those started with the phrase, 'It was an especially busy day, and that's why this happened.' There are other more quantifiable empiric data out there that prove that that actually does happen, and that one of the root causes of harm events in American hospitals is the peaks in patient flow that occur and put too much stress on the system, so that bad things happen.

"On the cost side, it's simply a matter of realizing that the American healthcare system is a fixed-cost enterprise. Therefore, the higher the volume that can be run through that fixed-cost model, the better the margins will be. We have opportunities there to improve significantly, and not only to do it in a higher volume fashion, but also to do it at a lower cost per case as that volume improves, which I think is also, when you look at things in a macroeconomic sense, one of the essential challenges of the future if we're going to really achieve true reform.

"Lastly, but certainly not least, you've got these reform initiatives that have come down the pike, where larger numbers of individuals are going to now have access to care through more insurability, etc., and so we've got to realize that one way to accommodate that population and that demand for increased access is going to have to be to smooth the flow and to accommodate that through application of these operational flow methods."

In Knight's opnion, just building more beds and more facilities and more equipment is not going to be cost-effective. In fact, it could be the opposite, both in terms of cost and escalating the already untenable inflation of healthcare costs in this country, and, secondly, in terms of having a magnet effect on patient volume, where demand is often drawn by the availability of healthcare resources.

"That has to do not only with patient demand," Knight says, "but also, unfortunately, I think it's a truism that healthcare providers create their own demand oftentimes in this country. Therefore, just providing more capacity and more beds, more facilities, more equipment is going to as a magnet for that sort of behavior."