IHP 640 Module 8 Milestone Three Example

Milestone Three: Improving and Holding Surgical Efficiency at Highland Valley

[Student Name]

Southern New Hampshire University

IHP 640: Measurement, Analysis, & Models for Performance Improvement

Module Eight Milestone Three

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Three: Improving and Holding Surgical Efficiency at Highland Valley

Milestone Two identified the specific causes of late first cases and prolonged turnovers at Highland Valley Medical Center, and the capacity modeling paper showed how recovery room holds could be reduced. This milestone completes the improve and control phases of DMAIC: it matches changes to causes, reports small tests, projects the effect on the aim and sets out how gains will be monitored and sustained.

Organizing the Work

Cima et al. (2011) organized their academic center's operating room improvement into parallel work streams, each led by clinicians and staff who did the work, and credited front-line ownership for the gains in start times, turnover and overtime they reported. Highland Valley will use four work streams: morning readiness, surgeon and anesthesia timeliness, turnover and recovery flow. Each has a clinician lead, a nurse or technician co-lead and the analyst's support.

Morning Readiness

Patients not ready caused 34% of late starts, mostly because of missing consents and history and physical documents. The change is a document review held two working days ahead of each operation, where a nurse confirms every required document and escalates gaps to the surgeon's office. A four-week pilot in orthopedics and general surgery cut readiness delays in those services by 58%. Monday cases receive a Friday check so documents are filed before the weekend.

Surgeon and Anesthesia Timeliness

Surgeons arriving late caused 22% of delays and incomplete anesthesia evaluations 14%. The surgeon change is transparent feedback: each surgeon receives a monthly report of personal first-case tardiness compared with peers, and the surgical chief discusses persistent outliers. The anesthesia change moves evaluations for first cases to the preoperative clinic or a phone assessment the day before. In a pilot month, surgeon-related delays fell 35% and anesthesia-related delays 50%.

Schedule Accuracy

Wachtel and Dexter (2009) showed that adjusting the operating room schedule, including better estimates of case duration and changes to case order, can reduce tardiness from scheduled start times throughout the day. Highland Valley will replace surgeon-estimated durations with estimates based on each surgeon's historical times for each procedure, updated quarterly. Simulated against last year's data, this would have cut median underestimation for orthopedic cases from 11 minutes to 3.

Turnover

Switching surgeon or service between consecutive cases was the strongest turnover predictor. Schedulers will group cases by surgeon and service within each room wherever possible. Instrument sets for the next case will be assembled and staged during the current case, and environmental services staffing will add one person from noon to 4:00 p.m., when prolonged turnovers cluster. A pilot in four rooms reduced prolonged turnovers from 13% to 7%.

Recovery Flow

Following the capacity model, surgeons in rooms with several short cases will place longer cases first, and new discharge criteria will allow phase one recovery to end once scoring thresholds are met rather than at a fixed time. If holds remain above 0.5 per day after three months, a midday recovery nurse will be added.

Projected Effect on the Aim

Scaling pilot results to the whole suite, with a discount for weaker performance outside pilot areas, projects the first-case on-time rate rising from 54% to about 78%, tardiness falling from 9.4 to about 4.5 minutes, prolonged turnovers falling to about 7% and overtime falling by about 28%, saving roughly $590,000 a year. These fall just short of the aim on some measures, so the teams will continue testing refinements.

Table 1. Changes, Pilot Results and Projected Suite-Wide Effects

Note. Composite pilot data; projections discounted for spread.

Staff Experience of the Changes

Pilots also tested how the changes felt to staff. Preoperative nurses reported that the readiness check added about twenty minutes per day but reduced chaotic mornings. Surgeons in the pilot group were initially skeptical of tardiness reports, but several said the comparison with peers prompted them to adjust clinic schedules that ran into operating room start times. Environmental services staff welcomed the afternoon position, noting that they had long been blamed for delays caused by understaffing. These reactions shaped refinements, such as shortening the readiness checklist and sending surgeon reports privately before sharing department totals.

The Control Plan

Improvement efforts often fade once attention moves on. The control plan names an owner for each measure, sets review frequency and defines the response when performance slips. Mohammed et al. (2008) recommend building control chart limits from a stable period and investigating points beyond the limits or unusual runs rather than reacting to every fluctuation. After three months of stable post-change data, new limits will be set, and signals will trigger a review by the relevant work stream within two weeks.

Monitoring Details

First-case on-time rate and tardiness will be charted weekly on a p chart and an individuals chart. Prolonged turnovers will be charted monthly, and overtime hours weekly. Same-day cancellations, the balancing measure, will be reviewed monthly. Results will appear on the surgical scorecard proposed in Module Five and on screens in the staff lounge.

Embedding the Changes

The readiness check will be written into the preoperative policy, historical durations built into the scheduling system, instrument staging into sterile processing standard work and the afternoon environmental services position into the budget. Surgeon feedback reports will be automated. Changes embedded in systems and budgets are less likely to erode than those that depend on reminders.

Risks

Surgeons may resist tardiness reports, the readiness check adds nurse workload and schedulers may find grouping cases difficult when block times are fixed. The surgical chief will sponsor the feedback, the readiness role will be funded from overtime savings and grouping will be applied where blocks allow, with results reviewed after three months.

Conclusion

Each major cause of delay now has a tested change, a clinical owner and a measure. Pilots suggest the suite can come close to its aim, and a control plan built on charts, owners and embedded systems gives the gains a chance to last, which earlier efforts never had.

References

Cima, R. R., Brown, M. J., Hebl, J. R., Moore, R., Rogers, J. C., Kollengode, A., Amstutz, G. J., Weisbrod, C. A., Narr, B. J., & Deschamps, C. (2011). Use of Lean and Six Sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. Journal of the American College of Surgeons, 213(1), 83-92. https://doi.org/10.1016/j.jamcollsurg.2011.02.009

Mohammed, M. A., Worthington, P., & Woodall, W. H. (2008). Plotting basic control charts: Tutorial notes for healthcare practitioners. Quality and Safety in Health Care, 17(2), 137-145. https://doi.org/10.1136/qshc.2004.012047

Wachtel, R. E., & Dexter, F. (2009). Reducing tardiness from scheduled start times by making adjustments to the operating room schedule. Anesthesia & Analgesia, 108(6), 1902-1909. https://doi.org/10.1213/ane.0b013e31819f9fd2