With experience working with over 400 hospitals, Surgical Directions has observed the greatest opportunity in improving procedural care can usually be found in the process of scheduling and preparing patients for surgery.
Most patient preparation in the US is office-based, often last minute, inconsistent, and generally patient unfriendly. It should come as no surprise that in many hospitals day-of-surgery cancellation rates are high, often exceeding 5%. Of course, the surgeon and patient frustration from a cancellation can be significant, often with long-term consequences for the hospital. Additionally, the opportunity cost of every cancellation in lost time and materials is substantial, ranging from $2,000-$10,000[i].
In Surgical Directions’ experience, a cancellation rate exceeding 1% is a direct indication that a hospital’s scheduling and preparation process needs in-depth review and restructuring.
Patient preparation for surgery is a complex process and consists of many interdependent components:
- Scheduling: This should include an accurate and compressive booking document with all the necessary information required in having a prepared patient and operating room on the day of surgery
- Pre-authorization and financial counselling: This “admitting” process should start at the time of booking. By the time the patient arrives and enters the admitting process, all financial issues should be addressed.
- Patient preparation: Ideally, the patient begins the clinical optimization process in the office with plenty of lead time before the surgery. Best practice patient preparation is hospital-based, with consistent, universally agreed-upon work-up standards and algorithms. In this system patients have a review-of-systems phone screen.
- Patient education and communication: Eliminating patient frustration and confusion prior to admission should be part of the process. It requires a carefully designed patient-centric communication and education system. State-of-the-art hospitals are now incorporating patient engagement technologies the optimize interactive communication using the ubiquitous smartphone.
- Surgeon orders and a prepared operating room: A major part of the scheduling process, this should include an accurate and comprehensive surgery description with all necessary supplies and equipment provided well in advance of the procedure date.
Suggestions for monitoring and improving your cancellation rate.
First, make sure your cancellation rate is accurate and recorded daily. Often, cancelled cases and rebooked are not counted as cancelled cases. ALL cases that are booked and cancelled should be counted.
Once you have established accurate cancellation data and this data points to opportunity, begin a close examination and redesign of your system. Going forward, make sure your cancellation data includes cause.
Surgical Directions suggests this step-by-step process for reducing cancellation:
- First, any redesign effort of this magnitude must have the support and sponsorship of clinical leadership, surgeons, anesthesia, and nursing. Additionally, senior hospital leadership should be aware of and support this effort. (See SSEC blog.)
- Carefully choose a multidisciplinary team, representing all areas involved in patient preparation prior to surgery, to be a performance improvement team (PIT). Typically, this group would include representatives from:
- Pre-admission patient revenue preparation unit
- Select representatives of surgeon offices
- Pre-surgical optimization unit
- Data collection (I.T.)
- A designated team lead
- Initially, this team should meet regularly, usually weekly, or bi-weekly.
- Begin by breaking down your current process into its elements, patient optimization, scheduling, admitting/pre-authorization, etc. Team discussion should identify issues and processes that require intervention and redesign.
- Working in this collaborative environment, begin designing your new process, integrating all elements of the elective pre-op process into a streamlined, patient-friendly system.
- Once the “new” system is designed, make sure your leadership, both clinical and administrative reviews and agrees with the plan.
- Pilots are a must. Pick a surgeon’s office willing to participate. Carefully monitor this initial rollout, fixing “bugs” and issues as they occur.
- As the pilot matures and all parties are aligned with this new process, start a gradual rollout, continually monitoring data.
KEY Issues and Suggestions:
- KEY: Although this patient preparation overview may appear straightforward, choosing the appropriate participants and keeping this group focused and committed can be difficult. Choosing the right PIT leadership is a key element of successful implementation.
- KEY: The new process’s design must emphasize a more centralized, consistent, standardized and streamlined hospital-based approach to patient preparation. Additionally, anesthesia leadership should take an active role in establishing system-wide patient preparation guidelines.
- KEY: Build an accurate data collection system that is able to identify and categorize the cause of cancellation. At a minimum, this data should be reviewed monthly.
- KEY: Working closely with surgeons and especially their office staff throughout redesign and rollout is fundamental for success.
- KEY: The “new” process should emphasize and enforce scheduling elective surgery as early as possible. Working with our clients, Surgical Directions is recommending elective patients have all necessary elements of a chart, orders and preparation complete at least three business days prior to the day of surgery.
- KEY: Continual office, patient and hospital communication is a must. Developing a proactive and multidisciplinary, collaborative daily schedule review (CDR) (see blog) is an important part of this communication activity. Typically, this CDR reviews the schedule 3-5 days in advance.
If your cancellation rate is greater than 1%, you have opportunity. Moving traditional patient scheduling and preparation out of the surgeon’s office into a more patient-centric, hospital-based approach is key for success. Continually monitoring cancellation data that includes cause can help identify problems as well as solutions. Finally, high-level sponsorship and a daily CDR are important components of success.
[i] Data from internal SD client sources.