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OPERATING ROOMS: How Mass General ramped up again after procedures were deferred during early days of pandemic

During the early days of the pandemic, hospitals were asked to defer non-essential surgery to free up resources for the care of SARS-CoV2 patients. Within 4 weeks, Massachusetts General Hospital (Boston) had deferred 6,500 surgical procedures – dropping to 15 percent of previous surgical volume. How the hospital devised an orderly methodology to triage surgical patients who were waiting to be rescheduled is described. This safe and swift methodology allowed the hospital to ramp back up from 10 to 58 operating rooms running each day – at 750 cases per week, a full schedule. How surgeons were assigned time as capacity changed is also discussed.

Source: Brumit, R. and others. Recovering an Operating Room Schedule During a Global Pandemic: A Method for Safe and Swift Increases in OR Volume During Times of Crisis. Journal of Medical Systems 45(12). Full text free here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787880/pdf/10916_2020_Article_1687.pdf

AMBULATORY CARE: How time of day affects quality of care and what to do about decision fatigue

Quality of care deteriorates over the course of the day due to the combination of shared cognitive biases, hurried visits, and mounting decision fatigue…”

Studies show that the quality of outpatient care decreases over the course of the clinic day. Patients seen later in the day are likely to have fewer appropriate services ordered and, also, more low-value inappropriate services ordered. A difference in diagnostic accuracy has also been found based on time of day. How to counteract this time-of-day trend by incorporating alerts into the electronic health record, by using social norm interventions, by optimizing use of telehealth and mail, and by changing payment models are discussed.

Source: Allison H. Oakes, and Mitesh S. Patel. “Time to Address Disparities in Care by Appointment Time.” Healthcare 9(1), (Mar. 2021). https://www.sciencedirect.com/science/article/pii/S2213076420301068

ORGANIZATIONAL INNOVATION: McKinsey consultants forecast what pandemic-driven change will look like

Business leaders tell us that the metabolic rate of their organizations has soared. Their companies have accelerated by adopting new ways to work.”

How much and in what ways will the pandemic push companies to adopt Silicon Valley-inspired nimble organizational concepts? What will the agile operational model look like in the near term? McKinsey thought leaders focus on change accelerations brought on by the pandemic and how things are changing more quickly than had been thought possible. A key set of three steps should be employed: to reflect, decide and then deploy at scale. Learnings from the pandemic will help organizations position themselves for greater uncertainty in the future.

Jost, Gregor, and others. “How COVID-19 is redefining the next-normal operating model.” The McKinsey Quarterly 1 (2021). Full text free here: https://www.mckinsey.com/business-functions/organization/our-insights/how-covid-19-is-redefining-the-next-normal-operating-model

OPERATING ROOMS: How much major surgery is infrequent? Is there an impact on costs?

Texas hospitals were studied to see how many inpatient major surgical procedures were not performed very often (once a month or less) at each hospital analyzed.  In this study of discharge data from 343 hospitals for the period late 2015 to early 2016, over half (54 percent)  of procedures were found to be uncommon (as defined above) for the hospital where they were performed.  These procedures accounted for 68 percent of inpatient costs.

Source: O’Neill, L. and others. (2017, September). Discharges with surgical procedures performed less often than once a month per hospital account for two-thirds of hospital costs of inpatient surgery. Journal of Clinical Anesthesia. 41, 99-103. Click here for publisher’s website: http://www.jcafulltextonline.com/article/S0952-8180(17)30659-1/fulltext   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

SPACE PLANNING: How to determine number of ORs needed

Tips for the planning process for a new surgical suite are given in this brief newsletter article by an experienced health care architect.  There are some interesting facts that are otherwise difficult to find in the literature:

  • What is the difference between an operating room and a procedure room?
  • What is a hybrid operating room?
  • How are some of the metrics used defined – room time, room turnaround time, throughput?
  • What is a target room turnaround time? (“…usually 15 to 20 minutes”)
  • How many hours are procedure rooms open? (“Most procedure rooms are available eight hours per day for a total of 480 minutes per day”)

Scheduling efficiency: A scheduling efficiency factor is multiplied by the annual minutes available per procedure room to account for periods of time that a case cannot be scheduled.  This factor may range from 70 percent for ORs or procedure rooms used for complex (and sometimes unscheduled) procedures — such as cardiothoracic, neurosurgery, and trauma/orthopedics — to 90 percent for an outpatient suite where all procedures are scheduled.”  (page 3)

Source:  Hayward, C. (2017, Winter). How many operating rooms? It’s complicated. Click here for newsletter: https://www.spacemed.com/newsletter/news101.html  Posted by AHA Resource Center (312) 422-2050 rc@aha.org

TEACHING HOSPITALS: What is the July effect? Is it real?

The “July effect” refers to the detrimental impact on patient care, efficiency and outcomes in teaching hospitals when a new class of residents comes on board each year in the summer.  This is not just scuttlebutt.  The authors note several research studies that found that patient care takes longer, is more expensive, or more likely to have errors when the patient is hospitalized in July.  What to do?  The authors, who are associated with the University of Michigan, suggest a multi-pronged plan to address the July effect.  The first steps involve identifying and incentivizing outstanding physician educators who are willing to serve as July-able attendings and also grooming senior residents to be ready for leadership and teaching responsibilities in July.  Academic health systems can also invest more in simulation-based training and improving communications.

Source: Petrilli, C.M., Del Valle, J., and Chopra, V. (2016, July). Why July matters. Academic Medicine, 91(7), 910-912.  Click here: http://journals.lww.com/academicmedicine/Fulltext/2016/07000/Why_July_Matters.12.aspx  Posted by AHA Resource Center (312) 422-2050, rc@aha.org


WORKAHOLICS: Why the “ideal worker” may not be

Sociologists define the “ideal worker” as one who is completely devoted to the job and who is available all the time.  In organizations that value this kind of worker, employees typically develop one of three strategies to cope with the pressure, by:

  • Accepting – and allowing other facets of their lives to wither
  • Passing – and devoting time to other pursuits but under the radar
  • Revealing – and being completely above-board about their outside interests, even to the point of negotiating for formal considerations related to hours and time off

The authors report on their findings based on cross-industry interviews with hundreds of professionals as far as the pervasiveness of the pressure to be an ideal worker and the coping strategies employed.  They then describe ways that organizations can focus more on the quality of work produced than on the sheer hours spent at the office.

Source: Reid, E., and Ramarajan, L. (2016, June). Managing the high intensity workplace. Harvard Business Review, 94(6), 84-90.  Click here: https://hbr.org/2016/06/managing-the-high-intensity-workplace  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

OPERATING ROOMS: What is the TORCZ zone technique?

A systematic process for setting up the operating room known as TORCZ – The Operating Room Circulating Zones – is described in this brief article.  There are six zones:

  • Patient care zone
  • 2 working zones
  • 2 viewing zones
  • Circulator zone

These zones are identified in a photograph that accompanies the article.  TORCZ was developed at the University of Texas MD Anderson Cancer Center.  It is a standardized approach that makes set up more efficient and less intimidating for new nurses learning how to circulate.

Source: Mathias, J.M. (2015, Nov.). Zones establish structure and routine for OR setup. OR Manager, 31(11). Publisher’s website here: http://www.ormanager.com/zones-establish-structure-routine-setup/ Posted by AHA Resource Center (312) 422-2050, rc@aha.org


What does “pull until full” mean?

This is an emergency department intake approach intended to have patients seen more quickly by a physician and spend less time in the waiting room.  Also known as no triage or straightback or triage bypass or immediate bedding, this approach involves taking a patient immediately into an ED exam room and having intake processes occur in parallel at the bedside.  Among the pioneers of this approach has been the University of California, San Diego.

Allnurses.com – the networking site for nurses – has an interesting discussion thread about pull until full triage that can be viewed here:  http://allnurses.com/emergency-nursing/pull-until-full-900834.html?s=ded182bfe6a271b0370397ebef0ce698.  I always enjoy this site because it has candid feedback from hospital nurses who talk about practices in their hospitals.  Some of the nurses on this discussion thread mentioned that this strategy works early in the morning and then the ED fills up.  These commentators also mention how nursing staff work together in the ED.

A recently-published article (Zocchi, et al., 2015) indicated that the “pull until full” approach was the most frequently implemented strategy to improve patient flow in the emergency department among a 42-hospital collaborative.


Welch, S.J. (2009, Mar.). Flow mapping for efficiency. Emergency Medicine Newshttp://journals.lww.com/em-news/Fulltext/2009/03000/Flow_Mapping_for_Efficiency.6.aspx

Welch, S.J., and Davidson, S. (2010, May-June). Exploring new intake models for the emergency department. American Journal of Medical Quality. 25(3), 172-180.  http://www.edbenchmarking.org/uploads/exploring-new-intake-models.pdf 

Zocchi, M.S., McClelland, M.S., and Pines, J.M. (2015, Dec.). Increasing throughput: Results from a 42-hospital collaborative to improve emergency department flow. The Joint Commission Journal on Quality and Patient Safety, 41(12), 523-541.  http://www.ingentaconnect.com/content/jcaho/jcjqs/2015/00000041/00000012/art00001  Posted by AHA Resource Center (312) 422-2050 rc@aha.org

OPERATING ROOMS: 60 percent of margin comes from perioperative services at better performing hospitals

These statistics come from the consulting firm Surgical Directions:

  • Over 68 percent of revenue comes from perioperative services at better-performing hospitals
  • 60 percent of margin from perioperative services at these better-performing hospitals

Most of this article is about tackling the challenge of staffing the surgical suite.  The consultants recommend establishing a SURGICAL SERVICES EXECUTIVE COMMITTEE (SSEC), which should include surgeons, nurses, hospital executives, and anesthesia providers.  The specific responsibilities of the SSEC are itemized.  It is recommended that the SSEC have a huddle each day to plan for surgical cases scheduled to take place over the next 3 to 5 days.  The OR staffing tool developed by the firm is also described.

Source: Mathias, J.M. (2015, Aug.). Predictive modeling helps match resources with needs. OR Manager, 31(8), 1, 7-9. Retrieved from http://www.ormanager.com/predictive-modeling-helps-match-resources-with-needs/ Posted by AHA Resource Center (312) 422-2050, rc@aha.org