key: cord-0727951-pu3qiv69
authors: Martin-Krajewski, Carie A.; Craig, Jason E.; Bledsoe, Jonathan M.; Wensink, Laurie J.; Crawford, Neal S.; Eberhardt, Angela M.; Grottke, Kara L.; Helmers, Richard A.
title: Regional Specialty Surgical Practice Efficiencies Gained as a Result of COVID-19
date: 2021-06-15
journal: Mayo Clin Proc Innov Qual Outcomes
DOI: 10.1016/j.mayocpiqo.2021.06.003
sha: a313d83c97f2fa7e3be854988434ad97a788c6f8
doc_id: 727951
cord_uid: pu3qiv69

Objective To identify the opportunities of discontinuing elective and non-emergent surgical cases in a regional surgical practice in response to COVID-19. Patients and Methods COVID-19 began to effect surgical practices across the US in March 2020. On March 17, 2020, all elective and non-emergent surgical care was deferred to prepare the Mayo Clinic Health System sites in northwest Wisconsin for an anticipated surge in COVID-19 patients. When the decision was made to reactivate the surgical practice, several major structural and operational changes were made to the regional surgical practice to optimize efficiencies. Results The structural and operational changes implemented during reactivation resulted in improved utilization of surgical resources including improvement in OR block utilization, increased available OR time, and increased case volumes. Conclusion Surgical and procedural leaders should consider a limited-time deferral of elective surgical cases to implement widespread OR efficiency strategies. The time selected for deferral of surgical cases should target a historically low surgical volume to minimize disruption to patient care and impact on overall OR functions.

Objective: To identify the opportunities of discontinuing elective and non-emergent surgical cases in a regional surgical practice in response to COVID-19.

Patients and Methods: COVID-19 began to effect surgical practices across the US in March 2020. On March 17, 2020, all elective and non-emergent surgical care was deferred to prepare the Mayo Clinic Health System sites in northwest Wisconsin for an anticipated surge in COVID-19 patients. When the decision was made to reactivate the surgical practice, several major structural and operational changes were made to the regional surgical practice to optimize efficiencies.

Results: The structural and operational changes implemented during reactivation resulted in improved utilization of surgical resources including improvement in OR block utilization, increased available OR time, and increased case volumes. 

The surgical and procedural practice in northwest Wisconsin has delivered high quality care to patients throughout the region for well over 100 years. The Eau Claire site serves as the regional hub site and is the only level 2 trauma center in the northwestern Wisconsin. The regional practice consists of ten surgical specialties which range from basic surgical services consisting of appendectomy, arthroscopic knee, and endoscopy to highly complex offerings such as transcatheter aortic valve replacement, craniotomy, and spinal fusion. The practice has 3 surgical locations in the region with operating room (OR) capabilities maintained at the hub site in Eau Claire and two critical access hospital (CAH) sites (Table 1) .

Annual targets and goals for the regional surgical practice are established by the Surgical and Procedural Subcommittee (SPS). The SPS is responsible for quality, the coordination of surgical and procedural resources throughout the region, accessibility, and expanding surgical services.

OR efficiency has been the focus of SPS for many years. This work identified key areas of improvement and opportunity throughout the regional practice. The two consistent themes within the initiatives were a mismatch of resources within the surgical services settings; and services misaligned to available space, staff, and equipment.

Surgical Practice Challenges -pre-COVID-19:

 The identified inventory of surgical cases needing to be scheduled was routinely inaccurate, not timely, and invisible to SPS leadership.

 The patient pre-operative evaluation process was not standardized, decentralized, and performed by several different departments which lead to case cancellations and lastminute order entry on day of case.

 Surgical robot transport waste. The region has one surgical robot which was routinely moved to multiple operating rooms depending upon specialty use and preference.

 Operating room assignments could be poorly matched to surgical case type (eg. room size, ability to accommodate specialized staff and equipment).

 Variable, and lower than desired, utilization of assigned surgical block time.

J o u r n a l P r e -p r o o f Historically, the team had been unable to make significant progress in addressing these inefficacies as solutions to each challenge identified required significant disruption to the current surgical workflow processes and offerings.

As COVID-19 began to effect surgical practices across the US in March 2020, the NWWI surgical practice was also impacted. In late March 2020 a decision was made to defer all elective and non-emergent surgical care to prepare systems of care to address COVID-19 patient surges.

Although well prepared, the NWWI region did not experience an influx of COVID-19 positive inpatients at that time. While the elective surgical practice was shut down, the regional leadership team discussed the challenges and opportunities associated with reactivating the surgical practice. It was recognized COVID-19 had in fact created an opportunity for the regional surgical practice to incorporate solutions to the long-term challenges as the region reactivated. The shutdown of the elective surgical practice created the perfect environment to implement process and structure changes within the surgical practice to achieve long-term strategic goals of the region.

In March 2020, the severity and effects of COVID-19 became more evident throughout the United States. On March 17, 2020 MCHS made the decision to defer elective, non-emergent, and non-urgent surgical care until further data related to safe COVID-19 practices could be understood.

In early April 2020, the SPS was charged with developing a regional surgical practice reactivation plan. The practice had been deferring elective and non-emergent care for three weeks and had a backlog of elective, non-urgent, and non-emergent surgical cases to perform.

The preliminary expectation for a reactivation timeline given to the subcommittee was two weeks, however it was clear that time was of the essence as hundreds of patients had experienced delays in receiving surgical care. As the SPS executive team evaluated reactivation options it became evident surgical titration due to COVID-19 had introduced several key opportunities to both address the current backlog of cases, and address long standing challenges within the regional surgical practice. Changes began with development and evaluation of the surgical case depot created to inventory the deferred cases and followed by additional key practice changes were implemented to address long term practice inefficiencies.

The creation of this depot and inventory was leveraged as the first surgical improvement opportunity throughout the region and presented the opportunity to more accurately inventory and identify surgical case scheduling in the future. A surgical depot was created in the electronic medical record (EMR) to inventory cases that were on the OR schedule, deferred during surgical titration, and rescheduled during reactivation. Surgeons and surgical practice leaders were notified that in order to have deferred cases rescheduled, they were required to identify patients and cases within the depot. Cases not inventoried in the depot would risk being lost and not be rescheduled in the future.

A pre-operative examination clinic (POE) was designed and launched at the three surgical locations in the region (Eau Claire, Barron, and Menomonie) to derive consistency in preoperative examinations, orders, evaluations, and manage COVID-19 education, screening, and results. Space was identified immediately adjacent to surgical areas in all sites, staff were J o u r n a l P r e -p r o o f identified with interest and expertise in this area, a physician leader was identified, and processes and procedures were developed by a work group over the course of two weeks. This improvement was based on past institutional learnings 1 and targeted to result in improved dayof-surgery scheduling accuracy as well as a favorable experience for the patient. Historically, case cancellations the day of surgery were a very rare occurrence, however case delays were a regular phenomenon due to inaccurate or missing orders. Finally, this approach offered additional capacity within the regional primary care practices who had previously been conducting these evaluations.

The practice of transporting the surgical robot between various operating rooms wasted 2 resources, reduced the available capacity of surgical robot time, and required additional 

Hand and cataract surgery cases were shifted from the regional hub to a Mayo Clinic Health System owned facility operated as a CAH site within the MCHS northwest Wisconsin region conveniently located 20 miles away located just off an interstate. The site selected (Menomonie, Wisconsin) provides simple travel for patients across the region. The high throughput and volume hand and cataract cases were easier to schedule at a site with fewer surgical service lines competing for OR time and resources. Before COVID-19, limited hand and cataract surgery had been offered at this CAH site. The lower than optimal case volumes at the CAH contributed to inconsistency of supporting these cases and the ability to retain and recruit a full-time surgeon at this site. While the CAH site was largely equipped to perform these cases and had ready capacity to support the additional cases being shifted, several key operational changes needed to occur in order to support the shift of hand and cataract cases. Specific surgical equipment, pharmaceuticals, and supplies needed to be transported between the hub site and the CAH site. Alterations to the EMR and supply software needed to be built to support patient care, billing and supply inventory. Operating room and surgical preparation and recovery staff travelled to the CAH to support the expanded volumes. The rapid shifting of J o u r n a l P r e -p r o o f resources was possible due to several key structural elements within Mayo Clinic Health System. First, MCHS has a standard pay and benefits structure in place, with an expectation for staff to support the surgical practice throughout the region which enabled these operational changes. Second, a single courier contractor provides service to all MCHS sites within the region. Alterations to the current courier service were necessary to support the practice change, but relatively simple to make as a result of existing routes between the sites. Thirdly, an integrated EMR supported the clinical practice with standardized documentation. Finally, the shift in this surgical case segment drove favorable reimbursement and patients benefited by being able to have their procedure at a smaller, easily accessible facility featuring parking at the door and easy wayfinding.

Moving hand and cataract surgery cases to the CAH created the opening for further consolidation of the operating room schedule at the hub hospital. Previously published findings indicate the effectiveness of lean and six sigma approaches to address surgical inefficiency 3 with several interventions focused on surgical schedule consolidation and reduction of variability. Applying these methods, historical block utilization trends by specialty were analyzed by SPS leadership and reallocated to each surgical practice. The individual surgeon assignment within the block was the responsibility of surgical and operational leadership of each specialty department. Reallocation and assignment of OR block time required a change management plan including townhall meetings, and open forums to incorporate surgeon questions and feedback. Weekly stakeholder updates were held to review data including block utilization by specialty and add on case trends. The reorganization and repositioning resulted in the closure of several operating rooms which maximizes efficient use of resources, utilization, and preserves space for future surgical growth.

May-October of 2020 were used as the months to evaluate reactivation optimization as there was a significant surgical titration in November-December 2020 in response to a COVID-19 surge in the region.

 For Eau Claire, average monthly available OR block hours increased 3% during COVID-19 reactivation and block utilization improved from 63% to 66% for an increase in utilization of 3%.

 In Menomonie, average monthly available OR block hours increased 7% and block utilization improved from 38% to 54%.

 Barron average monthly available OR block hours increased 5% and block utilization improved from 48% to 60% utilization.

In summary, both available OR block hours (figure 1) and utilization (figure 2) improved at all 3 surgical sites.

The reactivation of the surgical practice created opportunities to optimize surgical and procedural practices at the CAH sites. The data for the time of May -October 2020 compared to 2019 shows a shift of cases to Menomonie and Barron sites (table 2) .

 Eau Claire performed 80% of cases in NWWI in 2019 and during reactivation in 2020 performed 71% of the cases for the region.  In 2019, Barron did 6% of the cases for the region and increased to 8% of the cases post reactivation.

A major contributor to case increase is the shift of cataract cases to a CAH with an eye care center of excellence model. All cataracts, except for patients with medical complications, are performed at the CAH site.

In 2019, the hub averaged 116 cataract cases per month and there was an average of 17 per month at the CAH. In May 2020, during surgical reactivation, the cataract cases were moved to Menomonie except for patients with medical necessity. This move inverted the monthly average of cataract cases per month between the hub and CAH to average 22 cases and 86 cases respectively for the May -October 2020 (Figure 3) . A financial analysis on cataract cases done between June-August 2020 demonstrates favorable NOI per case performed at Menomonie versus the hub site.

Prior to the COVID-19 pandemic, the northwest Wisconsin region surgical practice had challenges quantifying surgical case backlog and cases pending, inconsistent pre-operative process, operating room utilization, service line location optimization, and efficient use of surgical robotic equipment. The ability to implement widespread changes prior to the COVID-19 pandemic was stalled due to physician concern regarding the long-term impacts of significant disruption to their practice. The resistance was largely related to surgical schedule interruption and how those changes would impact other areas of the practice such as outpatient clinic, and coverage of any inpatient hospital services. Over the course of a twoweek time period when elective surgical cases were deferred, regional teams assembled to create and implement a reactivation plan that addressed these issues and made structural changes to the practice that resulted in significant efficiency improvements. The experience of the surgical practice titration and reactivation in response to the COVID-19 pandemic led our team to conclude, if multiple structural and functional opportunities for improvement exist simultaneously in the operating room, leaders should consider a limited-time deferral of elective surgical cases to implement multiple changes. The selected time for deferral should be targeted during a historically low surgical volume to minimize the disruption to patient care and to minimize the impact on overall operating room functions. The bar graph reflects the number of cataract cases on the Y-axis and the site and date of case on the X-axis. The data depicts the shifting of cataract case volumes from the hub site to CAH during reactivation period of the surgical practice. 

Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center

The Application of the Toyota Production System LEAN 5S Methodology in the Operating Room Setting

Improving operating room efficiency through process redesign

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