UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
“Implementation Begins”
Present: Mike Alotis, Bill Anton, Alan Artru, Ross Beirne, Lisa Brandenburg, Peter Buckley, David Byrd, Judy Canfield, Mary Claire Cook, Karen Darnall, Shelley Deatrick, Karen Domino, Ben Greer, Paul Ishizuka, Vicki Sandeen, Mark Schierenbeck, Mika Sinanan, Ted Wagner, and Ed Walker.
Absent: Donna Anderson, Renae Battie, Sherri Del Bene, Julie Duncan, Bill Ellis, Laura Gerber, Susan Grant, Maria Hall, Kathy Herigstad, Brant Oelschlager, Gene Peterson, Jorge Reyes, David Saperstein, Dan Silbergeld, Kevin Smith, Mike Smith, Loretta Stesco, Trent Tredway, Terry Way, Ernie Weymuller, and Doug Wood.
Consultant: Joan Wellman
Support Staff: Virginia McClure
Surgical Improvement Project Mission:
· Make UWMC the First Choice for Patients seeking Excellence in Surgical Care.
· Make UWMC a Premier Practice and Work Site for All Members of the Surgical Team.
· Assure a Safe, Patient Centered, and Efficient Environment that Contributes to Fiscal Success for UWMC.
· Integrate Academic, Educational, and Service Roles of UWMC Surgical Faculty and Staff Seamlessly.
Balanced Commitments:
Balanced Commitments is a performance reporting and organizing system that enforces a balanced approach to achieving an organization’s strategic goals. Each goal set can be categorized into one of five Balanced Commitments areas.
Patient Safety, Access, Satisfaction, Cost, Outcome
Patient Safety – Provide the safest clinical care available
Access – Ensure timely access to our clinical services
Satisfaction – Surpass the needs and expectations of our patients, their families, the community, our referring partners, our faculty, and our staff.
Cost – Achieve budgeted operating margin and cash flow.
Outcomes/Other – Demonstrate the highest clinical outcomes. Maintain regulatory compliance through a robust compliance program.
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
Agenda:
Announcements/Calendar
5S #1, Report/Update
5S #2, Draft Charter Review
SIP Team 5 Update
Lean Education and Visioning Session
SIP Team 4 – Projects
Staff Survey
Appreciative Inquiry
Communication Strategies
Issues Log
Project Log
Handouts:
1. Agenda
2. Washington Post article, “Toyota Assembly Line Inspires Improvements at Hospital”
3. Literature Search, “Resource Management in the OR”
Report of Meeting:
Announcements/Calendar
Dr. Mika Sinanan welcomed the attendees and thanked them for their participation. He applauded the day’s implementation of 5S #1—Main OR Surgical Services OR Equipment, and explained the purpose of the June 17th Visioning Session, an all-day conference of Surgical Improvement Project members, designed to extract the essence of the work accomplished by the five SIP Teams to date and to develop a “skeleton vision of the near-term”. He concluded his presentation with an overview of the actions which will occur for implementation:
· 5S Project
· Rapid Improvement Projects
· Model Line (a prototype project designed to improve processes around a surgical practice, example: a group of surgeons)
· “Just Do It” (immediate implementation of change upon approval of the OR Management Team)
· New Resources (provision of immediate relief/resources from UWMC Administration)
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
5S #1, Report/Update
“After one day…the room is cleaned out…equipment will have one label, one name, one location,” stated Mary Claire Cook during her report. Much of the work of SIP 3 is dramatically focused on this 5S project. As Ms. Cook explained, search time has plagued the efficiency of OR operations, “…four people looking for one item for ten minutes”. The following key points developed from Ms. Cook’s report:
· A communication plan for proper notification regarding equipment that is out-of-service or out-to-repair is required.
· Even if not required for the entire length of a case, the present equipment tracking system allocates the item to that case for the full case time.
· “Hiding and hoarding” of equipment exacerbates the tracking of it. It was acknowledged that once a scarcity has been identified, a purchase may be initiated. Surgeons should be able to negotiate to determine priority.
· The OR nurse e-mail listserve should be employed to publicize the 5S project.
SIP Team 5 Update
“The right questions are more important than the right answers,” stated Dr. Ed Walker as he began his report on Strategic Planning. Recognizing the “ethereal, crystal ball approach” of the team he co-leads with Dr. Ernie Weymuller, Dr. Walker explained that SIP Team 5 is “calibrating the future”. He suggested two themes in the work of that team: 1.) No one can see the future, and 2.) What should be our long-term principles. Dr. Walker outlined the 13 “Principles that inform our vision”:
· Patient safety is our prime concern.
· Our care is compassionate as well as patient and family centered.
· We have a culture of collaboration, professionalism and justice.
· Resources are allocated according to our strategic goals.
· We exceed all appropriate benchmarks for safety, quality, efficiency and fiscal integrity.
· We consider and adopt all relevant best practices.
· We balance clinical efficiency and training.
· Our growth is planned and supported by proportional investment in infrastructure and essential services.
· We maintain high performing, well trained teams.
· We are stewards of our resources – nothing is wasted.
· We foster clinical innovation through research
· Compliance is integrated into what we do – it is easier to do the right thing.
· All necessary information is in the hands of those that need it when they need it.
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
Expanding on the thematic determinations of the Strategic Planning Team, Dr. Walker highlighted four key groupings of focus:
· The Right Rules
· The Right People
· The Right Resources
· The Right Processes
Dr. Walker noted that Team 5 assigned levels of intensity of need/attention/commitment to the key groupings. The levels are:
· Routine
· Straightforward
· Difficult
· Low impact
· High impact
· Urgent
The Right Questions were outlined under the following categories:
· Governance
· Standards
· Regulatory and payer environment
· Medical Staff
· Nursing/OR techs
· Patients
· Rooms
· Efficiency
· Existing Commitments
· Utilization
· Safety and quality
· Resident Training
26 Questions were developed by the Strategic Planning Team. They are:
1. What should be our strategic governance model?
2. What should be our operational management model?
3. What benchmarks (e.g. UHC, MCMA, AORN) should we use to target our goals?
4. What “best practices” for OR operation are available, and which should we select?
5. What regulatory issues (e.g., JCAHO and DOH) will affect our operations?
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
6. How will “pay for performance” affect how we choose to do our business?
7. How are surgeon and anesthesia recruitments coordinated with capacity?
8. What is the optimum model for anesthesiologists and CRNAs?
9. What are the correct ratios [nursing and OR techs] for their team membership?
10. How do we combine shift and non-shift team members?
11. What are patients and families demanding of us (e.g., web access, trends)?
12. How many rooms should we eventually open?
13. What will trigger new rooms opening or existing rooms to close?
14. How do we ensure that every surgical patient has a bed?
15. What are the correct ratios of resources (OR rooms, PACU, ICU beds, support services)?
16. What is the correct patient case mix for teaching and profitability?
17. What existing commitments have already been made (e.g., chair dowries, service lines)?
18. What is the most efficient way to schedule OR rooms?
19. What is the most efficient turnover process?
20. How do we balance emergent and elective cases?
21. How can we be the safest perioperative environment?
22. How can we improve team communication (e.g., CRM)?
23. What rate of perioperative infection rate will we accept?
24. What national quality standards will we adopt?
25. What are our supervision [of residents] policies and practices?
26. How do we balance clinical efficiency and training [of residents]?
Dr. Walker explained the influences that have and/or will be reflected in the Strategic Planning Team’s paradigm. Below are the topics and the names of the resources.
External environment scan:
· GME trends – Joseph York
· WSHA/AHA – Kathleen Sellick
· Technology – Rob Sweet, Richard Satava
· State/National Factors – Jackie Der, Barbara Perry
· Safety: Running Like an Airline – John Nance
· Quality Trends – Julie Duncan, Gene Peterson
· National Anesthesia, Surgery and Nursing trends
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
Internal environment scan:
· Capital Planning – Gretchen Hanna, Paul Ishizuka
· Department Outlook – Chairs
· Resident Training Issues affecting operations
· Patient and Family Issues
· Patient Flow Initiative
SIP 5 Presentations to date:
· History of UWMC Surgical Services – Judy Canfield, et. al.
· Standards Benchmarks and Practices – Judy Canfield
· Existing Commitments – Lisa Brandenburg and Ed Walker
· Medical Staff Workforce Outlook – Andy Bowdle and Ernie Weymuller
· Capital Planning Primer – Gretchen Hanna
Referring to a March 1, 2005 SIP 5 report, “Surgical Services—present state—and how did we get here” (developed by Renae Battie, Peter Buckley, Judy Canfield, Shelley Deatrick, Mark Schierenbeck, and Helen Shawcroft), Dr. Walker displayed three charts to highlight Surgery Caseload Forecast, “Like” Institution Benchmarks, and the UWMC OR Forecast. The Surgery Caseload Forecast (1997-2015) provides for a baseline forecast equaling 1% annual change. The high forecast is for 3.3%. The current fiscal YTD number for surgery caseload is reported at 14,653 cases. The baseline projection for ten years from now is for 15,449 cases—the high projection 19,944. The data from “Like” Institutions [no date provided for the data gathered] included reports from UW, Stanford, UCLA, USC, and UCSF. Below is a summary of the chart’s data:
Ranking by Cases: Stanford 23,000
UCLA 21,000
USC 17,000
UW 11,500
UCSF 10,000
Ranking by ORs: UCSF 450 [presumably an error]
UCLA 41
Stanford 33
USC 32
UW 19
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
Ranking by Cases/OR: Stanford 700
UW 600
USC 530
UCLA 500
UCSF 450
Ranking by % Outpatient: Stanford 59%
UW 47%
UCLA 43%
USC 24%
UCSF 21%
This chart included two other categories: IP Mins/Case and OP Mins/Case. The UW IP figure is 235; the OP figure is 113.
The last chart, which Dr. Walker referred to in this portion of his presentation, provided the UWMC OR Forecast from 1997 – 2015. The baseline forecast beginning with 22 rooms in 2005, goes to 23 in 2010, and 24 rooms in 2015--2 rooms in 10 years. The high forecast projects just short of 30 rooms in 2015.
Dr. Walker referred to another presentation, which Lisa Brandenburg and he provided for the Surgical Improvement Project on May 3, 2005 --“Existing Commitments”. The bulleted items below are from that presentation:
· UWMC’s program planning over the last 4-5 years has focused on promoting growth of the service lines.
· Therefore, existing UWMC commitments relate largely to supporting the growth and development of the service lines.
The Current Service Lines at UWMC are:
· Cardiovascular (UWRHC)
· Oncology – includes the SCCA
· Orthopaedics and Sports Medicine
· Organ Failure and Transplant
· Otolaryngology
· Neurosurgery
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
The reported criteria for these lines include:
· High-volume and/or High-charge Services
· Program Profitability
· Program Readiness
Dr. Walker referred to four charts to substantiate the service line concept: 1.) Why Support Service Line Growth? 2.) Essential Services, 3.) Payor Profitability – IP and OP, and 4.) University of Washington Medical Center Quarterly Volume Trends FY 2002 – 2005. Acknowledging that the first two charts were complicated, he concentrated on the remaining two charts. The Payor Profitability chart (FY04), reflects the percent of margin generated by Commercial payors (slightly over 250%) and the Medicare percent of margin generated (-150%). Medicaid/Healthy Options generates just under 50%. (Medicaid Other, Medically Indigent, General Assistance Unemployable, and Title 19 all generate negative percentages). The income from operations (listed in millions) shows a disturbing trend, which Dr. Walker correlated to an increase in regulation. The numbers, by quarter:
Mar, 2002 N/A Mar, 2003 8.7 Mar, 2004 1.0 Mar, 2005 1.4
Jun, 2002 7.8 Jun, 2003 3.6 Jun, 2004 7.3
Sep, 2002 6.6 Sep, 2003 5.0 Sep, 2004 0.5
Dec, 2002 7.8 Dec, 2003 3.9 Dec, 2004 2.0
The summary page of Dr. Walker’s Existing Commitments Powerpoint presentation states: “What have we learned? Service Lines are an important strategic priority. Can’t predict every issue that will surface as we try to grow various programs, but we could do better. New business planning process developed by UWMC Finance will seek to evaluate impact on related services such as Anesthesia, Radiology, Pathology, Lab, etc. and related departments.”
Highlighting another presentation, “Anesthesia provider deployment” by Dr. Andy Bowdle, Dr. Walker educated the committee on the impact of the rates for graduating AMG Anesthesiology Residents 1993-2004 and Graduating Nurse Anesthetists 1994-2005. The summary: “Anesthesiologists and CRNAs are in short supply. Available outcome data (which is scare) support the anesthesia care team approach (MD/Resident or MD/CRNA) with 1:2 ratio, at least for moderately complex patients. Under current conditions, any expansion of anesthesia service not accompanied by additional anesthesia residents results in greater financial losses for the Dept. of Anesthesiology and UWMC.”
UWMC
Surgical Services Improvement Project
Oversight Committee
Minutes
June 8, 2005
Dr. Walker’s final presentation, “Facility Master Plan & Financing Parameters”, provided the following information: “Background: Based on the outcomes of the facility master plan, UWMC developed a financial plan to assess how the plan would be funded. Two key questions addressed in the plan are: How much cash do we need to have? How much debt can we afford? The answers to these questions are predominantly based in profitability ratios, liquidity ratios (cash) and debt ratios.” The supporting documentation was a chart on Projected Occupancy, which indicates an “Ideal Occupancy Rate” static at just below 85% through FY15 and two projected indices, only one of which projects over 100% of current occupancy in FY13. Actual occupancy rates are not included for contrast on this chart.