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KSR Publishing, Inc.
Copyright © 2016

         Clinical intelligence for supply chain leadership



February 2014

Operating Room

Outpatient Connection

Most frequent reasons for readmission related to patients’ underlying chronic conditions

Researchers cite identification and monitoring of known underlying chronic medical conditions as opportunities to reduce readmission rates and improve patient safety.

Not only are hospital readmissions a costly problem for patients and for the healthcare system, with studies showing nearly 20 percent of Medicare patients are readmitted to the hospital at an annual cost of $17 billion, but they also pose a significant opportunity for improved patient care and safety.

They also represent a complex, multi-faceted issue that still needs to be better understood. In new findings from Brigham and Women’s Hospital (BWH), researchers find that the most frequent reasons for readmission were often related, either directly or indirectly, to patients’ underlying chronic medical conditions (comorbidities), providing a new opportunity for focus in reducing readmission rates. This research is published in the British Medical Journal.

"We know that the reason for readmission is often different from the reason that the patient was initially hospitalized. Our research shows that the five most frequent reasons for readmission were often related to patients’ existing chronic medical conditions, underscoring the need for post-discharge care to focus attention not just on the primary diagnosis of the previous hospitalization but also on these comorbidities," said Jacques Donz, MD, MSc, a research associate in the Division of General Internal Medicine at BWH and lead author of the new research.

Researchers evaluated the primary diagnoses and patterns of 30-day readmissions and potentially avoidable readmissions according to seven of the most common comorbidities in medical patients (chronic heart failure, ischemic heart disease, atrial fibrillation, diabetes mellitus, cancer, chronic obstructive pulmonary disease, and chronic kidney disease).

Among the potentially avoidable readmissions, the overall three most common reasons for readmission were infection, cancer and heart failure. Heart failure and infection were the two most frequent main readmission diagnosis for the seven chronic medical conditions studied, accounting for 21 to 34 percent of all potentially avoidable readmissions. Interestingly, almost all of the top five diagnoses of potentially avoidable readmissions for each comorbidity were possible direct or indirect complications of that comorbidity.

Particularly important, researchers note that patients with cancer, heart failure, and chronic kidney disease had a significantly higher risk of potentially avoidable readmission than those without those comorbidities.


Blocked and loaded

OR workflow optimization carves out order from chaos

SIS surgery dashboard

by Jeannie Akridge

Spend any amount of time behind the scenes in the perioperative suite, and you’ll likely find yourself amidst a whirling dervish of activity and chaos. You might even begin to wonder how surgical cases are ever successfully completed with all of the starts, stops and delays that happen during the course of the day, whether awaiting surgeons, supplies, test results or even patients. Indeed, the complexity of the OR is matched only by the variety of cases and surgical techniques performed.

Explore this area further and you’ll discover why scheduling is just one tiny piece of optimizing perioperative workflow. Intuitive systems help improve patient safety and meet quality goals, provide comprehensive data analysis and benchmarking capabilities to help improve OR utilization, increase throughput and surgical case volumes, as well as bolster physician, staff and patient satisfaction. At the heart of all these systems are real-time communication tools such as scheduling dashboards, HIPAA compliant family messaging display boards, automatic status updates, safety checklists, reporting tools and more.

Four executives from companies offering perioperative workflow management solutions talked with Healthcare Purchasing News about what makes an OR tick.

HPN: Describe the challenges that can cause bottlenecks, delays and inefficiencies in the perioperative setting.

"The challenges lie in the extreme degree of variability in workflow practices, surgical techniques, equipment used, not to mention physical space constraints. Ineffective coordination of these physical and staffing resources with patient clinical and logistical workflow causes bottlenecks, delays, and inefficiencies. What exacerbates these challenges is that most hospitals use manual workflow processes and communication methods (whiteboards, pagers, and individual staff observations) to make decisions that can adversely impact operational efficiency and patient safety in attempts to impact perioperative performance."

– Jeff Robbins, CEO, LiveData Inc.

"There are a multitude of factors that can impact perioperative efficiency, such as ineffective approaches to patient scheduling, sub-optimal OR staffing, completing paperwork, or turning over the OR between cases. To address these factors at a macro level, we believe one of the biggest ways to improve efficiency in the OR is by improving knowledge about how and where resources are used, aligning clinical and operational goals, and ensuring OR staffing that is geared to maximizing throughput and quality. "

– Lars Thording, Vice President of Marketing
and Public Affairs, Intralign

"Surgical scheduling is complex and has unique needs. Key challenges contributing to bottlenecks and delays include inaccurate scheduling of case duration, incomplete pre-admission testing, lack of availability of specialized, required equipment, and lack of communication among team members.

"Additional key challenges [include]:

  • Inaccurate scheduling of case duration wreaks havoc on efficiency and patient throughput in the perioperative environment. When case times don’t consistently match the schedule, perioperative departments often face patient satisfaction issues due to delays and cancellations, higher staff overtime costs, and disgruntled surgeons, anesthesia providers, and caregivers who expect a predictable day.

  • When patient appointments for pre-admission testing and surgery are out of sync, required tests may be incomplete on the day of surgery and important data such as patient history and problem details may not be immediately available to providers.

  • Lack of availability of specialized equipment — such as a c-arm that is used only for a small portion of a procedure but is often booked for the entire case — can mean that other cases must be delayed or rescheduled. This inefficient use of resources can significantly impact costs in the OR.

  • Delayed case starts — due to a myriad of issues from staff and patient delays to poor communication and space availability — can produce a domino effect in the surgery schedule, ultimately causing later cases to be delayed or cancelled."

– Ed Daihl, CEO, Surgical Information Systems (SIS)

"The perioperative department and OR scheduling are dynamic systems dependent upon many factors. Bottlenecks, delays and inefficiencies can and do frequently occur due to lack of patient visibility and staff communication throughout the department.

"Examples include:

  • Surgical cases taking longer than anticipated

  • Patients arriving late the day of surgery (admissions or patient floors)

  • Patients eating or drinking after midnight the day of surgery

  • Physicians or Staff may arrive late for scheduled cases

  • Emergency cases may take precedence over scheduled cases

  • Add on cases can impact scheduled cases for the day

  • Patients may be missing key labs, tests, or other requirements needed the day of surgery (history and physical, EKG, X-ray, surgical consent, orders, etc.)

  • Patient labs may be out of scope the day of surgery, requiring interventional treatment and/or surgery cancellation

  • Patients with chronic health management issues such as respiratory diseases (asthma, emphysema, etc.) may require management the day of surgery prior to scheduled surgery or cancellation

  • Surgical room delays involving turn over times

  • Room cleaning time delays and/or staff awareness rooms need to be cleaned prior to add on or emergency cases

  • Missing or incorrect equipment delays

  • Multiple phone calls and over head pages interrupting patient workflows

  • Surgical Instrument sets not arriving (or incorrect, missing or broken instruments) in time for surgery cases to start on time

  • Loaner surgical trays unavailable for add-on or emergency cases

  • Missing or incorrect implant(s) in surgical room prior to surgery

  • Unexpected changes, exceptions or delays within expected workflows within the perioperative department (patient and/or staffing)."

– Randy Tomaszewski, PeriOperative Solutions Marketing Director,
STERIS Corporation

What are some of the most common factors affecting perioperative workflow?

Robbins: "Lack of real-time awareness and visibility (patient, OR, clinician, equipment status, etc.) and team communication regarding patient workflow are the two most common factors affecting perioperative workflow."

Daihl: "The biggest factors affecting perioperative workflow are lack of communication and limited access to information. When care providers aren’t aware of key patient information or a patient’s status in terms of important milestones in the care process, they can’t easily do their part in facilitating an efficient workflow process.

"For example, without a way to communicate that a patient’s preop assessment has been completed and the patient is prepped for surgery, the patient may not be transported to the OR for an on-time start. Without a method to communicate a patient’s allergies, the OR suite cannot be appropriately set up with the right supplies, often delaying the procedure and causing anxiety and dissatisfaction with the patient."

Tomaszewski: "Some of the most common factors affecting perioperative workflow are unexpected delays, exceptions or changes in the surgical schedule from the original schedule. This is often due to managing add-on and emergency cases, as well as lack of patient visibility and staff communication throughout the department.

"For most surgical departments, within the first few hours of the day, the original surgical schedule is no longer usable as originally planned due to patients arriving late, the addition of emergency or add-on cases, or surgical cases taking longer than anticipated. These delays have a ‘domino effect’ on the OR schedule, impacting other surgical cases scheduled ahead of these cases. Other negative contributors can be patients and/or staff, physicians or equipment arriving late to the surgical suite or case the day of surgery."

STERIS RealView Command Center

What key components must be in place in order to maintain a smooth-running and efficient OR?

Robbins: "The dynamic nature of the perioperative environment needs communication and management tools that can keep up with the pace and support optimal resource utilization. Automated workflow, real-time situational awareness, interactive resource management tools, and integrated communications methods support dynamic management of the OR. Additionally, the availability and use of in-depth comprehensive analytics impacts the future of perioperative performance."

Tomaszewski: "Continuous visibility, communication and automatic updates for OR management, physicians and perioperative staff. This includes real time patient workflows, locations and most recent patient data to optimize patient care. Continuous awareness, updates and perioperative visibility across departments are key to smooth running and efficient ORs. Immediate alerts to exceptions provide key perioperative leadership and staff with the ability to take proactive actions, make room and staffing adjustments, to address changes and maintain patient flow throughout the daily OR schedule. The ability to quickly identify bottleneck sources of inefficiencies at the source, communicate these factors to management, physicians and staff, help to drive these inefficiencies out of the perioperative process, promote and optimize lean processes continuous improvement."

Daihl: "To maintain a smooth-running and efficient OR, employ scheduling tools that enable the creation of a consistent and repeatable scheduling process based on accurate information for the most common procedures. By putting your perioperative data to work for you, you can better coordinate scheduling and provide a more predictable day for your surgical teams.

Focus your scheduling process improvements on the procedures your facility performs daily.

Use analytics to better understand historical procedure times so that you can schedule case times more accurately.

Use the 80/20 rule to create scheduling templates and standards — including staff, equipment and space — for the most common procedures.

On the day of surgery, use information collected throughout the care process to communicate important milestones to the entire care team."

Thording: "There are three components we see as key to effectively managing efficiency throughout the entire episode of care:

Using data as a basis for decision-making. To achieve this, you must create a system and culture for gathering, storing, and most importantly, utilizing data.

Change management to create holistic, co-developed and sustainable process improvement based on operational and clinical practice guidelines — to reduce variability in utilization and resource consumption and to create efficiencies throughout the system.

A specialization of clinical labor that optimizes surgeon involvement without sacrificing quality of care."

How can improving intraoperative workflow management help in aligning with quality goals and a move towards value-based care delivery?

Thording: "A move toward value-based care delivery is highly challenging. Change-oriented hospitals need to look for solutions that can affect real (substantial and sustainable) change. A focus on the intra-operative space allows the hospital to concentrate on one of the facility’s biggest resource consumers. Intralign services help providers advance efficient intra-operative care delivery by managing the change process, while balancing staff resources between surgeons and highly-skilled physician extenders.

"As reform continues to evolve our healthcare delivery system, we believe more efficient care demands will require further clinical labor specialization that optimizes surgeon involvement and enhances quality of care. With half of the Association of American Medical College’s anticipated physician shortfall of 91,500 by 2020 estimated to be surgeons and specialists, we believe an increase in the employment of highly trained [surgical first assists] SFAs in the OR is inevitable and we’ll be ready to fill that need."

Daihl: "Perioperative departments with a comprehensive perioperative information system including analytics are positioned to meet the requirements of value-based care delivery and the on-going requirements for continual improvement."

Robbins: "[LiveData] PeriOp Manager employs real-time auditing tools and alerts to assist clinicians in delivering care with the focus paid to SCIP and Value Based Purchasing process metrics."

Tomaszewski: "[STERIS] Real View eliminates many of the common distractions for healthcare providers that otherwise take them away from bedside patient care (such as answering phone calls and overhead pages), as well as the time searching for missing patient information. Real View automatically updates and enables perioperative staff to spend more quality time with each patient. More attention at the bedside optimizes both patient care and patient safety in a value-based care delivery system."

What cost savings opportunities are available through improved management of the intra-operative space?


"Improving efficiencies of scheduled cases within prime time. By identifying bottlenecks, delays and inefficiencies that tend to push the daily surgical schedule into extended times and eliminating these bottlenecks, unplanned overtime (OT) can be significantly reduced (typically by 50% or more). This includes improvements in room turn over, surgeon turn around times, First Case On Time Starts and to follow On Time Starts.

Hospitals can improve recognition of revenues earlier in the calendar by successfully allowing surgical cases to be scheduled earlier than previous based upon daily improvements in OR efficiency, to schedule surgical cases earlier (while also keeping these surgical cases within prime time).

For those hospitals that are aspiring to grow surgical programs and case volumes, greater efficiencies within the perioperative department and patient throughput can also improve surgical case volumes. Steady efficiencies made in patient handling and throughput will also help drive long term surgical revenues by adding more surgical cases to the bottomline.

RealView provides more time for care providers with their patients and families, also enhance patient, family and staff satisfaction. Patient satisfaction improvements positively impact HCAPHS scores. Therefore, hospital reimbursement revenues can be optimized for Health and Human Services (HHS) i.e. Medicare and Medicaid reimbursements.

Retention and recruitment of key surgeons and perioperative staff are also key and based in large part upon their satisfaction in working for and with the hospital, [to] secure and drive future revenues and growth."

Robbins: "Cost savings can be achieved through reductions in unplanned overtime and surgical complications. Revenue can be increased through additional surgical cases handled in a day by creating useable OR blocks of time during the normal business hours of a given hospital’s OR."

Thording: "Our SFAs’ ability to reduce surgery time and increase surgeon throughput allows our customers to be able to schedule more procedures, which can potentially lead to better care economics for the hospital. In fact, in a recent survey measuring the satisfaction and opinions of our customer base, 87 percent of respondents said that the level of impact their SFA has on increasing the number of procedures that the hospital/surgeon has capacity for was either a positive impact or significant impact. Additionally, from a hospital-wide perspective, SFAs also help decrease costs by avoiding reimbursement barriers and lowering administrative tasks."

Daihl: "Areas of cost savings opportunities include increased OR utilization, reduced per case costs, and reduced overtime. Robert Wood Johnson University Hospital reports the following benefits of the SIS Solution:

  • Improved first case on-time starts to 85%,

  • Increased OR utilization by 7% resulting in $3.5 million in additional revenue;

  • Increased block utilization by 10%;

  • Increased surgical volume by 1%; and

  • Reduced overtime by 47% resulting in a savings of $563,000.

"Factors including an aging population and more insured Americans are driving the anticipated increase in surgical volume in the coming years. In addition, more and more surgical procedures are moving to outpatient departments and surgery centers. This adds complexity to the scheduling and overall perioperative process and increases the pressure on healthcare organizations to be able to maximize throughput, while continuing to deliver high quality, cost effective care. Removing the bottlenecks with an advanced perioperative system and using perioperative analytics provide a foundation for meeting these needs today and in the years to come."

Editor’s Note: For more information on the companies and solutions mentioned in this article visit the following websites:

Intralign (Intra-Operative Support) www.intralign.com

LiveData Inc. (PeriOp Manager) www.livedata.com

STERIS Corp. (RealView Workflow Optimization) www.steris.com

Surgical Information Systems (SIS Analytics) www.SISFirst.com