May 14, 2020

Agile, data-driven strategy for managing the OR after COVID-19

By: Derrick Bransby, MBA
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As state authorities begin to ease restrictions imposed by COVID-19, physicians, nurse leaders, and administrators face a momentous challenge: resuming elective surgical procedures that have been postponed for several weeks or months. How will they accommodate the looming glut of elective surgery demand with limited infrastructure and staff who are already highly utilized under normal conditions?

Now is the time for organizations nationwide to take action to construct and revise recovery plans that address the backlog of elective surgical procedures. In the spirit of the cooperation and camaraderie that characterize many aspects of the COVID-19 response, this article offers insights into one such plan that can be adopted by other healthcare facilities. Through collaboration, ingenuity, and a little math, dedicated healthcare leaders will find ways to not only recover from COVID-19, but also increase the resiliency and performance of their staffs as our nation returns to a “new normal.”

An agile, data-driven approach to recovery


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Within hours of the Centers for Medicare & Medicare Services (CMS) issuing its recommendation to postpone elective and non-essential surgical procedures, perioperative leaders at Cincinnati Children’s Hospital Medical Center (CCHMC) in Cincinnati took decisive action. While physician and nurse leaders dealt with immediate concerns such as cancelling cases, taking inventory of personal protective equipment (PPE), and addressing staff concerns, others focused on the future. How would a department that routinely performs more than 100 cases per day manage the backlog created by performing only a handful of cases each day for weeks on end? With many unknowns looming, the team knew it must use data to focus its effort.

Brooke Mullett, MBA, is no stranger to evidence-based, data-driven decision-making. An industrial engineer with more than 10 years of experience in healthcare operations, Mullett is senior director of operations for perioperative and surgical services at CCHMC. She possesses the technical skill and operational acumen required to provide actionable, data-driven insight that guides decision makers through turbulent times.

Supported by engineers from St Onge Company in York, Pennsylvania, where I am senior manager of healthcare operations strategy and analytics, we developed a model that made best use of available data (eg, case logs, forecasts, etc). Adoption of an agile methodology—a method in which a project is broken into stages marked by continuous improvement and iteration—allowed our modelers to quickly bring situational awareness to the leadership team and remain in a near-constant state of collaboration with clinical stakeholders.

In the first stage, or “sprint” in agile terms, our team constructed a simplified model to test proposed operating parameters (eg, number of rooms, hours of operation, etc) and forecast a timeline for full recovery. In this iteration, constraints were relaxed to streamline workflows and quickly define a framework of key parameters. For example, we treated all minutes equally, distinguishing only between add-on and elective minutes. This allowed us to arrive at our first outputs within 48 hours.

Though simplified, the utility of this model was its ability to judge the relative feasibility of proposed solutions, and do so rapidly. In turn, outputs became defining parameters of an operations plan and modified schedule that made best use of rooms and staff available. For example, in this first iteration, we decided whether weekend hours were needed to achieve an acceptable timeline for recovery. In later iterations, we prioritized use of total available block time for divisions based on magnitude of their backlog as well as demand for future cases. After blocks were assigned, each division decided which cases to perform.

In subsequent sprints, modelers reintroduced constraints and integrated additional data for greater accuracy. While doing so resulted in less efficient use of resources within the perioperative system, it highlighted opportunities to think creatively about uses for underutilized assets and for performance improvement. The focus of such sprints included:

  • assignment based on room type and capabilities (technology, room size, etc)
  • protecting access for emergent (add-on) and inpatient cases
  • availability of beds and intensive care capabilities for patients admitted after surgery
  • integration of staff scheduling (nursing, anesthesia, surgical service, etc).

Output from each iteration of the “COVID Model” demonstrated value to the leadership team. “Even in its earliest iterations, the model helped us define the problem at hand in a concrete way. It started the conversation,” Mullett says. “In turn, its output facilitates meaningful dialogue among divisions and has helped prioritize our work and use of resources.”

As with any model, there is immense value in the ability to test alternatives, recognize key variables, and prioritize solutions without the need for trial and error. At CCHMC, the model has opened doors that go beyond traditional methods for increasing throughput in the OR, such as adjusting existing schedules based on observed duration and minimizing turnover time.

We believe the many challenges we face as a result of COVID-19 are also opportunities for transformative change. In Mullett’s case, that means the working with stakeholders to define a new block schedule that best accommodates the backlog of elective surgery demand and speeds the time to full recovery. “People are open to thinking differently,” Mullett says.

Tips for the journey to recovery

Our work at Cincinnati Children’s is ongoing, but it has uncovered several key themes we believe are worth consideration for anyone beginning the journey to recovery. Though the path ahead will almost certainly be unique to every institution, we hope these ideas might point you in the right direction.

Leverage a flexible, iterative approach

Break the problem at hand into “bite-size” portions; resist the urge to solve it in one fell swoop! Reintroduce constraints, refine inputs, and add detail over time to increase the resolution and realism of underlying plans. Recovery from the COVID-19 pandemic will require extreme flexibility as the situation evolves. As a mentor often reminds me, “maintain absolute rigid flexibility.”

Consider capacity on a system level

Consider available infrastructure of all types and in all locations. Think creatively about uses for underutilized assets—do not forget support services!

  • Can mobile equipment such as c-arms, microscopes, etc enhance existing room capabilities?
  • Is the distribution of instrumentation and equipment adequate to support additional volume?
  • Can cases be performed in a procedure room and/or at a surgery center or an alternate location?

Investigate and define a ramp-up schedule

Demand is not a light switch that turns on and off. In most cases, surgeons have had limited capability to see patients in the clinic, which has affected yield and the speed at which new cases are scheduled. However, this effect may not be immediately apparent if the pipeline of elective cases was full prior to the COVIC-19 pandemic. Consider the following:

*Have surgeons used telemedicine to see patients during quarantine, or has clinic ceased?

  • What, if any, elective demand will be lost (eg, patient seeks care elsewhere, decides to forgo the procedure due to financial pressure, etc)? What proportion will be deferred to a later date?
  • If deferred, how long might it be until that demand is realized? Will such deferral result in an elongated backlog of “new” elective cases or a peak in elective demand months from now?

Identify performance improvement opportunities

The COVID-19 pandemic is a deeply disruptive event, perhaps the most disruptive of our lifetime. It will likely provide a unique occasion to make otherwise difficult changes. Be unencumbered by past convention and think creatively. In many cases, the rules of the game have changed. Consider opportunities to modify and improve block schedules, address variability in scheduled vs actual duration, minimize turnover time, and even smooth demand. Marry best practices from the past with fresh ideas for the future.

Collaborate with central sterile and supply chain

The healthcare supply chain is under extreme pressure. Recognize that supply shortages may affect the ability of the OR to operate at or above capacity. Furthermore, it is likely the role of sterile processing will expand to include disinfection of PPE, such as N95 masks, given emergency use authorizations issued by the Federal Drug Administration. Such responsibilities will consume resources normally used to support the OR.

Anthony Fauci, MD, described our nation’s recovery in an interview: “It isn’t like a light switch, on and off. It’s a gradual pulling back on certain of the restrictions to try and get society a bit back to normal. Bottom line is, it’s going to be gradual. It’s not going to be all or nothing.”

We must treat our recovery in much the same way. Best of luck on your journey.

Derrick Bransby, MBA, senior manager of healthcare operations strategy and analytics at St Onge Company (York, Pennsylvania), specializes in application of industrial and systems engineering to perioperative systems in areas such as flow, scheduling, and capacity planning.

References

Linebaugh K. Dr Anthony Fauci on How Life Returns to Normal. Podcast. April 7, 2020. https://www.wsj. com/podcasts/the-journal.

 

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