DDBA 8561 Week 10 Elective Smoothing Proposal Example

Smooth the Elective Schedule and Ask Who Absorbs It: A Change Proposal Capping Daily Elective Surgical Admissions at a Teaching Hospital, With Most of Its Analysis Spent on the Block Schedule That Must Change to Make the Cap Work

Student Name

Walden University

DDBA 8561: Seminar in Managing Healthcare Delivery Systems

Instructor Name

Month Day, Year

Smooth the Elective Schedule and Ask Who Absorbs It: A Change Proposal Capping Daily Elective Surgical Admissions at a Teaching Hospital, With Most of Its Analysis Spent on the Block Schedule That Must Change to Make the Cap Work

The Change

Cap daily elective admissions to the surgical inpatient units at 39, the weekly average, so that no weekday exceeds it. Redistribute operating room block time so that surgical services can meet the cap without reducing their weekly volume.

The Problem

Lakemont University Hospital, a composite 640-bed teaching hospital in Missouri, admits about 195 elective surgical inpatients a week. The distribution is uneven: 33 on Monday, 49 on Tuesday, 47 on Wednesday, 41 on Thursday and 25 on Friday. Midweek, surgical units run above 95 percent occupancy, emergency admissions board for hours, and cases are canceled for lack of an inpatient or intensive care bed. On Friday and Monday, beds sit empty.

McManus et al. (2003) studied a pediatric hospital and found that variation in the elective surgical caseload, rather than in emergency demand, was associated with periods when the intensive care unit could not accept patients. Litvak et al. (2005) distinguished natural variability, such as the random arrival of emergencies, which cannot be eliminated, from artificial variability, created by an organization's own scheduling practices, such as elective cases concentrated on certain days, and argued that hospitals should manage the second rather than build capacity for its peaks.

How Smoothing Works

Elective admissions are scheduled weeks in advance, so their timing is a choice. Emergency admissions, about 60 a day to surgical units, vary randomly. When elective peaks coincide with random emergency peaks, the units overflow; when elective admissions are spread evenly, the same random emergencies meet a lower and steadier elective load. Capping at 39 a day would remove 10 admissions from Tuesday, 8 from Wednesday and 2 from Thursday, about 20 cases a week or one elective case in ten, and add 6 to Monday and 14 to Friday. Ryckman et al. (2009) described a children's hospital that smoothed elective surgical admissions and reported reductions in intensive care diversions and cancellations, which suggests the mechanism works in practice.

The Function That Absorbs the Change

The benefit falls on the inpatient units and the emergency department. The cost falls on the operating rooms and the surgeons, through the block schedule.

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Orthopedics bears the largest share because its joint replacement cases cluster on Tuesday and Wednesday, matching surgeons' clinic schedules. Moving two Tuesday blocks to Friday means two surgeons rearrange clinic days and that their patients, with typical three-day stays, are discharged on Monday rather than Friday. That shifts nursing workload and physical therapy into the weekend: surgical unit census on Saturday and Sunday would rise by about 14 patients, requiring additional weekend nursing and therapy staff, at an estimated $310,000 a year.

Anesthesia and operating room staff must also cover more Friday cases. Friday rooms are now often released early; under the proposal, they would run full.

Table 1

Weekly Elective Cases Moved by Service

What the Hospital Gains

If midweek occupancy falls from above 95 percent to about 88 percent, the hospital's model estimates about 300 fewer elective cancellations and about 1,200 fewer emergency boarding hours a year, and the ability to admit more emergency patients midweek.

Reading the Evidence Critically

The published results come from hospitals that chose to report successes, and they were led by enthusiastic teams. Effects at Lakemont may be smaller. The cap should be piloted for one quarter with orthopedics and general surgery before extending it.

Engaging the Surgeons

The proposal will succeed only if surgeons accept new block days. The chief of surgery should present the midweek cancellation data to each service, and services that move blocks should receive priority for any new operating room time.

Measuring the Pilot

The pilot should report midweek occupancy, elective cancellations, emergency boarding hours and weekend nursing hours each week, compared with the same quarter a year earlier, so that both the benefit and the absorbed cost are visible.

Limits

Surgeon cooperation is the main risk; block time is valued, and Friday blocks are less popular. Weekend staffing costs are estimates.

References

Litvak, E., Buerhaus, P. I., Davidoff, F., Long, M. C., McManus, M. L., & Berwick, D. M. (2005). Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. Joint Commission Journal on Quality and Patient Safety, 31(6), 330-338. https://doi.org/10.1016/S1553-7250(05)31044-0

McManus, M. L., Long, M. C., Cooper, A., Mandell, J., Berwick, D. M., Pagano, M., & Litvak, E. (2003). Variability in surgical caseload and access to intensive care services. Anesthesiology, 98(6), 1491-1496. https://doi.org/10.1097/00000542-200306000-00029

Ryckman, F. C., Yelton, P. A., Anneken, A. M., Kiessling, P. E., Schoettker, P. J., & Kotagal, U. R. (2009). Redesigning intensive care unit flow using variability management to improve access and safety. Joint Commission Journal on Quality and Patient Safety, 35(11), 535-543. https://doi.org/10.1016/S1553-7250(09)35073-4