Last Updated December 7, 2024
Webinar Transcript
Ayla Ellison:
Welcome everyone to today’s webinar, unlock Hidden Value: How to Leverage Your OR Data to Drive Financial Performance and Sustainable Change. I am Ayla Ellison with Becker’s Hospital Review. We will begin today’s webinar with the presentation and we’ll have time at the end of the hour for a question and answer session. You can submit any questions you have throughout the webinar by typing them into the Q&A box you see on your screen. We are looking forward to hearing your questions. Today’s session is being recorded and will be available after the event. You can use the same link used to log into today’s webinar to access the recording. At this time, I am pleased to introduce our presenters for today’s webinar. Brian Watha is Associate Vice President of Consulting at Services Directions. We also have Michael Besedick, Consulting Manager at Surgical Directions. At this time, I’m pleased to turn the floor over to Brian to begin today’s presentation.
Brian Watha:
Thank you, Ella. Good afternoon everybody. Appreciate you taking this afternoon to spend with Mike and myself. Just a little background, I started my career at a very sophisticated organization, but as sophisticated as they were, they were not immune to the politics associated with the surgical space. And I would say one of my biggest achievements early in my career was the developing reliable metrics that both surgeons and administration could make decisions on. That being said, when the Affordable Care Act in 2009 passed, the rate and adoption of EMRs went up tremendously. You can see that while hospitals’ adoption of EMRs went up, that data complexity increased tremendously. One of the things I did when I started here at Surgical Directions, my first hire was not necessarily an OR person. It was a data scientist. So that way we could hardwire some of these metrics into an easier to digest reporting platform so that decisions can be made more reliably and more trustworthy. So you can see that the cleaning and manipulating of the shifting through large data sets requires talented multidisciplinary teams, which is why we have Mike here with us. Mike, want to introduce yourself?
Michael Besedick:
Yeah, so my name’s Michael. Thanks everyone for joining us as well. I think particularly hospitals that we’ve partnered with are facing a lot of challenges, not necessarily just with their data, but in positioning themselves strategically in the market and consolidating their data when there’s rapid consolidation in the industry is another really complicated thing to navigate for institutions, particularly ones that are trying to synergize various EMR systems that they may have brought on when they were still a burgeoning community hospital. It is just a challenging space to navigate. Incorporating feedback from surgeons that are going through this integration adds additional layers of complexity. So what we try to do when we engage hospitals is make sure that there’s trust in the numbers that surgeons are seeing, particularly when in a surgical services environment and also ushering in changes that are happening in the industry like hospital-acquired conditions, various penalties that are happening in Medicare, bundled payment strategies. There’s a massive shift the way in a lot of research being put into how hospital systems are compensated throughout this shift. So we’re trying to pay attention to both the operational but also the institutional and cultural changes that are happening and using data to transition us into something a little bit more understandable.
Brian Watha:
And I think that’s the key point is that again, having data is one thing, but being able to convert that data into intelligence so that people can make thoughtful decisions in a reliable format that’s recurring is some of the things that we find is tremendously valuable, particularly in the surgical space because in the surgical space that does for more often than not represent 60% of high-performing hospitals’ revenue. Almost everywhere we go, we know that it’s not just surgical space, but it’s the procedure areas that generate the majority of the revenue for the hospitals. And many of those physicians or those surgeons are independent practitioners. They get to come and go as they please and without having trustworthy data that says whether or not they’re being judicious stewards of your OR; whether or not the quality metrics on the backend actually makes sense. It’s the time for hospitals to make thoughtful decisions as to whether or not these surgeons are the people we want here. And how do we hold them accountable by actually having the data. But again, if they don’t trust it, if it’s not reliable, then it’s a non-starter. So again, a lot of what we do is make sure that we come up with the appropriate definitions. And going back to what Mike was talking about in this new world of merger and acquisitions, we’re seeing many institutions that are getting larger through acquisitions but then have disparted IT platforms. So now I have six different ways of defining something. So the same surgeon works in multiple facilities, it gets very convoluted as to how we define and how we measure performance.
Michael Besedick:
There’s sort of a two-pronged approach. There’s an integration and reconciliation period, but there’s also learning how to survive with the variety of metrics that continue to pop up. In surgical services in particular while being a major driver of revenue, there’s also enormous direct fixed costs that you incur running surgical services, including a ballooning materials cost. It can cost anywhere… there’s a recent study put out by JMA surge that it costs 36-$37 per minute for surgical minute, which is enormously expensive. So finding ways to drive your margin and drive success in the OR is of critical importance. So I think the way that we wanted to tee this up is sort of talk through a specific case where we were able to help an East Coast academic medical center, relatively large, 22 ORs, around 600 beds, sort of navigate these waters. A community hospital that had recently become a part of a larger system. They were experiencing a lot of challenges. They were on three different health record platforms. Their surgical services, EMR was relatively dated. So they had a lot of challenges. One of those challenges was surgeons would constantly feel pressured when they’re trying to schedule cases. They couldn’t find any time in the operating room. The OR was almost always 95% or more blocked, meaning there was no way to get on the schedule; yet, in the afternoons, surgeons would walk out of the room and see all this capacity with all this staff still hanging around. And I think Brian can give some context because he spent a lot of time.
Brian Watha:
Yeah, and to that point, this was a facility that was 95% blocked. They had about 5% open time, which didn’t give any non-block surgeons really any access to the OR. The other challenge when you’re 95% blocked is those surgeons hold onto that block time until the very, very last minute. So they can just kind of reserve access for themselves. And this particular facility, their block utilization hovered around 45% when we started. However, their OR utilization was around 60 to 75%. Really it was closer to 70% by day a week. So they actually had a volume problem. They had a lot of people trying to get into the facility but didn’t have an ability to give them access because there were so many people that were hoarding block time. Above and beyond, that there wasn’t a real thoughtful process at which block time was allocated or given out. So a lot of times when surgeons requested block time, it always felt like it was a very political process. I mean: You’re giving favors to this person or this person. Why is this person get this time? I asked first. There wasn’t a very clean process which created some disharmony. And then I would say beyond that, when you have a disparted EMR platforms, there was no reliable data whatsoever for them to make any decisions. So even having a conversation with a surgeon regarding block time, the numbers weren’t relevant or didn’t validate with the surgeon. It was like I said, a non-starter. So one of the first things we did when we went on site was to kind of create this collaborative governing body held by peers. So this is kind of our surgical service exec committee. Really what we do here is, again, we need to make sure that we all agree to the rules of engagement and what the definitions are. But I can’t as a consultant or as anybody else go into a hospital and say, this is your rules, this is your definition. So we pull together some of the highest performing surgeons, at that respective facility. Make sure that we have representation from not just surgeons but administration, nursing, anesthesiologists, and we could together collaborate on what is the appropriate definition, how do we want to measure things, making sure they’re in line with best practice. And then from there we’re able to help start the transition from making decisions based on who is yelling the loudest at that point in time, to really data-driven, this is your utilization, here’s your readmission rate, here’s your performance metrics, here’s your first case on time starts to hold, I guess our providers a little bit more accountable to what’s important to the hospital. So it does change the paradigm where we are doing everything we can to accommodate physicians to bring their volume where we’re now asking them: We need this to occur so that way we can make sure that we’re maximizing our resources and our opportunity to make revenue.
Michael Besedick:
In addition to the structural policy and process endeavors that we had when we formed this exec committee, I think a really important component of this is that this committee was viewing data regularly. It’s often the case where block utilization data takes weeks and usually it’s one person assembling this. You need faster, more real-time feedback in order to make sure that you’re controlling your day-to-day operations. So what helped in having a platform built that reconciled this information is that gave this committee the ability to review their data in a more real time way. And also I think another consistent challenge that we experience is a lot of the operational metrics that hospitals themselves to or operating rooms sold themselves to is they assume that the metric that they’re reporting on is contained within the name of the metric itself. I think the classic one is first case on time starts. But if you ask a surgeon or if you ask a nurse or if you ask an administrator what first case on time starts means, and you were to throw up an intraoperative record in front of them, you could come up with widely different results for how frequently you’re starting on time. So it was important to get into the gory detail of what the definitions were that the surgeons were going to be held to in order to maintain their block time. So it was a matter of handling the exceptions like any surgical minutes that happened outside of block time are accounted for separately. Meaning they don’t necessarily account for, they’re not accounted for in your overall utilization. We know that they happen, but that doesn’t necessarily mean that you get credit for them. And the analogy that we like to use was, it’s sort of like the goalpost when you’re kicking a field goal, you can’t just move it around according to what your preferences for work time are.
These are the goalposts and if you kick it outside of the goalpost, we know that it happened, but it doesn’t necessarily contribute to your ability to obtaining more block time or having higher productivity. Same thing with turnover. Surgeons that are in flip room type environments are going from case to case quickly. How are we crediting them? How are we crediting turnover minutes between cases? How are we accounting for the fact that there’s excessive turnover within the institutions? So, handling these kinds of definitions on a case-by-case basis is really important. The other really critical one that was effective at this institution is that we didn’t permit partial block releases. And maybe Brian can talk about why the SSEC decided to do that.
Brian Watha:
Well, this was a facility that initially when, so initially their surgeons, you’ll kind of see it in some of our other slides in the future, is without measuring utilization the way we have defined here, minutes of surgery during a sign block plus turnover divided by allocated minutes minus proactive release days. Now without ever measuring utilization in a thoughtful way that actually the surgeons could trust, no one ever released their days. And then when we decided that this was the direction we were going to move, the surgeons had decided that if I schedule six hours of surgery in my eight hour block, I’ll release the last two hours. Guess what? I’m a hundred percent utilized. So I mean they are smart individuals. They will find a way to game the system, what I mean, but you’ve got to have some controls on this thing, which is why we cited partial blocks release would not be permitted. There is a very formal process by which the surgeon’s office has to actually submit their block release in advance of their natural release. So we have structure and process around this, but again, no one really cared before because the utilization metrics that they were using were the ones that were regenerated out of their EMR. And I know many facilities across the country use EMR-based utilization metrics. And to be frank, they’re almost always flawed. Part of the reason why our company exists is because we’re able to provide more thoughtful analytics than what a lot of the other out-of-the-box EMR platforms provide. But going into our next snapshot, it’s kind of a larger snapshot of the utilization view that we provide for this facility. So here is a adjusted block utilization for a surgeon. They’re hovering around I think 40-something percent, but what we actually are able to provide as well is a block release report, which is one of the most powerful tools that we were able to provide this hospital.
So this respective group block had block time on, I believe it was Monday, Tuesday, and Friday. But what we can do is we are able to account for the total number of block days that this group was allocated over the Q3 and Q4 of last year and actually see whether or not they showed up for a case and whether or not they actually released their block. So I know that they had a total of, I think 23 or 26 Fridays allocated over the course of Q3, Q4, and actually only showed up for 10 of them. Okay, there’s 16 other blocks that they did not release. Having this at my fingertips makes it very easy for me to have crucial conversations with these block holders regarding what their block line needs are. Furthermore, below you can kind of see or usage report that kind of gives me insight into what days of the week each surgeon is using, which is very, very powerful because in this group block, instead of me chasing each surgeon, I’m going to the block owner and then they’re holding their surgeons accountable, but then I’m giving them this data for them to go have crucial conversations with their colleagues.
Michael Besedick:
And what is at times particularly challenging with group and or service blocks is a block can not be meeting its utilization targets, but it’s difficult when there’s diffuse accountability. So what we try to understand from the data are patterns of usage. And what we were able to discern is that there was one particular surgeon that just so happened to operate consistently on Fridays and just so happened to also be the surgeon that was not showing up relatively intermittent. So Brian can kind of highlight.
Brian Watha:
Yeah, so I think we talked about this a little bit. We kind highlighted the utilization overall being around 40%. Here’s the snapshot we just talked about the unused days actively being measured, and again, the lack of proactive management of their block days obviously drives their poor overall utilization. However, and we’ll show you a little bit the surgeon’s perspective is when I’m in the OR I am working all day long, the surgeon’s perspective is they are busy. Okay? This snapshot doesn’t reconcile from a surgeon view. So, this snapshot would say that they are very underutilized, but from a surgeon perspective, they’re not considering that my a 100 percent utilization plus my 0% utilization actually equals 50%. And then we can actually see here is kind of us capturing that surgeon that Mike was referencing. So we know that Friday is a very underutilized day by the surgeons, but we also know which surgeons actually allocated to that Friday. So we see them doing a little bit on Monday, a little bit on Tuesday. Is their ability for them to consolidate their volume on Friday or do I take this Friday volume and move it to Monday, Tuesday and recoup that Friday block? These are all the conversations we’re able to have with this block group because we are able to have this data at our fingertips and you can kind of see that Friday block that that surgeon is utilizing. But again, this is very powerful, particularly for academic physicians where those blocks are allocated at a service level, orthopedics, ET, so on so forth. Or like I said, any group blocks for any private practice.
So over the course of Q3, Q4, there was approximately what 2,000 blocks allocated, a little bit more than that. But of those 2,000 blocks allocated, we had about 25% or over 500 blocks that went unused. And when we say unused, we mean that the surgeon did not proactively release it and they did not show up to do surgery on that day. So basically they waited till the last minute, let it go, and I have surgeons who are breaking down the door requesting time, but unfortunately we are not able to give them an elective case time until two or three days when the block release. So one of the things we did do was adjust release time, but here as well, now that we actually have utilization analytics, we’re able to kind of push harder on them releasing their time a little more retroactively.
Michael Besedick:
And again, this speaks to the disparity that existed between OR utilization and their block utilization. Of course, if there are surgeons busting down the door to get into the OR, they eventually find a way. But I guess the question that we ask the institution is, is this the world that you want to live in?
Brian Watha:
Yes.
Michael Besedick:
Do you really want over 4,000 hours over a six month period of suboptimal usage? You’re scrambling almost every day to make sure that your staff has cases to work on. I mean there’s enormous labor cost perspective, there’s revenue that’s at stake. There are a lot of implications of surgeons having blocked time and not showing up until the last minute. This hospital was in a unique position in that it had a backlog of cases that could come in and sort of come to expect. But these kinds of behaviors, I think, because of the fact that there was not accurate data to reconcile this disparity in operational usage, just let it continue for years and years without doing anything.
Brian Watha:
And I’d say what’s really important here as well is this is a facility that’s very fortunate and they are very well regarded in the community and a lot of surgeons want to work there, but most other facilities, if I am a surgeon that requests the case and I am not told when my case is going to be scheduled until two or three days before the actual day of surgery, I’m calling another facility. And to be frank, more often than not that is what’s going on. We tend to find that growth occurs when you actually make it easier for different surgeon’s office to schedule at your facility. And this respective location, they actually were very challenged by that because there was no time for anyone to actually get in. So being able to kind of free up that time in a more proactive way, holding surgeons accountable to be more judicious with their block time, afforded the opportunity for them to be able to add more cases and increase volume by we’ll say a percent.
Michael Besedick:
And I think from a surgeon recruiting perspective, surgeons—when they want to come work for an institution—want guaranteed block time. If you tell a surgeon, Oh, well you can book into our 5% open time hope that you can build the case volume so you can start building your practice and then we’ll offer you block, it’s not as appealing. They’ll just go down the road to a facility that appropriately manages their block. So this is an important market differentiator for hospitals as well, looking to recruit active surgeons. I mean this is a great example in and of itself. They were 95% blocked, yet 25% of their blocks over the course of a six month period were suboptimally used. That’s easily a busy surgeon slotting into that time, if not numerous busy surgeons that could occupy that time as a recruitment tool.
Brian Watha:
And what we find often is that there are surgeons who are filling in that time, but they’re spreading their volume over three or four days because trying to find any space in the OR they can, but if we could actually recoup this time and give it to them and make things more predictable, not just for the OR, but for the surgeon and for the patients. But I want to go back to what we talked about before with regards to release time. When we looked at the utilization before we were hovering off 40%, but again, the surgeons who work in the OR, they do not believe they’re 40% utilized. They don’t believe they’re 40% utilized because when they are working, when they are actually in the OR, they show up, they’re there from 7:30 and they don’t leave till 5. You know what I mean? So they feel that this number may be underrepresented mean, but what we were able to do is say, Hey, listen, if you were actually able to proactively release your block, if I were to actually give you credit, going back to our definition of utilization being minutes plus turnover over reallocated time minus proactive release, if I were to give you credit for all that proactive release, then yes, you’re right, your utilization would be 89%, but you sir or ma’am need to manage your time. We’re asking you to be a judicious steward of the time we allocate you as opposed to being just accommodating any surgeon whim at the expense of the hospital operation productivity and resource management.
Michael Besedick:
I think that these simulations are a really powerful way of demonstrating both the capacity that’s available and the potential for greater productivity within blocks, either just for surgeons or for services and groups. This simulation was an effect of the effect of proactive release, but we can also show the effect of reducing average turnover between cases or flip rooms and what effect that would have on your utilization. Those are key things that surgeons sort of wonder, What would my day look like if this happened? Well, these simulations are a really powerful way to do that and are not necessarily available in your run-of-the-mill block utilization report. So this is definitely a way to sort of dangle the carrot so that surgeons can see what’s in store. And can convince this surgeon, I’m really productive when I’m in the operating room. Look at all these cases I have. Yeah, you probably need more block time if you were to release your block more proactively and in a predictable way.
Brian Watha:
And again, I think we’ve talked on this before, people aren’t going to change unless you measure it. I worked with a nurse and she used to always say, don’t expect it until you inspect it. And the reality is that we can make all these rules about what our expected target utilization is. We can have rules about when surgeons need to show up for cases, but if I don’t actually have a thoughtful mechanism to actually have data that surgeons can agree and to make decisions on, it becomes very, very loose. And this scenario, while the surgeons held onto block time because it was their way of hoarding access to the OR, the fact that they know that they’re being monitored, they’re more concerned now being publicly shamed because we do put these numbers out publicly, these utilization numbers by block, so other people know what days may be available. And what we do on a monthly basis is we look at all the blocks that are at red, that are at risk, and we also have you can comment on a block request form by day a week. So we know in advance of our quarter review, what I mean, who may be losing time, who actually should earn that time. And we cover through a couple different lens making sure we’re looking at active of admission or margin. There’s a couple different things that we look at, strategic priority for the facility, but at least we actually have a governing body that does that and actually holds these respective physicians accountable. Like I said, without something like this, it gets very, very loose. And then you’re at the mercy of surgeons wanting to run a very, very, very horizontal schedule, which I’m sure many people on the phone or on the call have experienced at some point or another.
Michael Besedick:
So this had a dramatic effect on overall block utilization. We were able to see improvement in overall OR utilization as well as block utilization throughout the facility. And this is just one example of how an effective release policy and practice tracking it, measuring it, was able to garner improvements for the hospital. I think that there’s an additional effect of a lot of the other simulations that were run in terms of getting people in the room on time, making sure that turnover was tracked appropriately and simulating the effect of shorter turnover and how that would help a surgeon fit into their block as well. So what we ended up with was a load-balancing effect. People could access the OR a lot better and improve overall utilization, which was obviously enormously gratifying to the administration as well.
Brian Watha:
So again, I think this is very important while we have the data, honestly, we couldn’t have done it without governance. But the governance can have done it without the aggregated. So there’s this reciprocal relationship between the two that is essential for really the judicious use of your OR, and I think a lot of people on the call, the experience, I mean we’re running inefficient, we’re running more rooms than we need to. We’re running more rooms late than we should. They’re asking for Saturday elective cases, you know what I mean? There has to be a limit to what we’re willing to accept, but without having the appropriate body in place to make those rules, and without giving them the data so they can actually make thoughtful decisions. I mean honestly, it becomes, like I said, very, very loose and you’re really at the mercy of your providers, because nobody wants to say no to volume.
We’re all trying to grow volume, but it’s can we do it in a thoughtful way? Can we do it based on what makes sense to the organization? I mean growing volume just to grow volume doesn’t make sense, but at least through governance, through the supportive accurate data, we’re able to help guide organizations on the path, whether it’s regionalization of cases in the acquisition world or simply something as simple as, Hey surgeons, we’re going to measure you. We need you to release your time. And through that, we’re able to create enough space for another 8% cases in our existing footprint.
Michael Besedick:
And I think a big part of this is even knowing what can be tracked, the culture of accountability is fortified by our ability to create metrics that answer the right questions. And I think one of the looming questions specifically in this example is, I can’t get on the schedule yet. I walk around in the afternoon and there’s all this open time. It is incredibly inefficient, and it seems really easy while I’m in the OR to get on the schedule. And it wasn’t until we started this release reconciliation process and understood who was responsible for using a resource and at what time that information would’ve never been gleaned out of your standard or utilization report. That’s a block schedule that exists in your EMR and you tally up the minutes and you call it a day. So I think that there needs to be a lot more robustness in the accounting process, more robustness in defining, and of course, the governance and the teeth to support making decisions like that.
Brian Watha:
And really just going to speak a little bit more on those governance though, you can kind of see we have those four players, surgeons, administration, anesthesiologists, and nursing. Our recommendation is always to have a peer-to-peer model. So when we do this, we always bring a physician to bear to have those crucial conversations with physicians because we know that that’s where they’re going to respond better. Nursing, we will bring in a OR director to talk to the OR director at the hospital, and then we’ll have this conversation with administration or the business managers of that facility so that not only are we able to share this insight, but we can actually help make it sustainable so that once we’re gone, they don’t fall back into a world of I’m going to yell really loud and get what I want, or the CEO says, Hey or circumvent a process. Oftentimes the only way to prevent that is by making sure you have a robust enough process in place that people trust it to start. And that begins here with governance.
I think we wrapped up a little bit early, but guess we have a little more time for questions, so we’re happy to take anything.
Ayla Ellison:
Great. Yeah, thank you. Thank you Brian and Michael for that fantastic presentation. We will now begin today’s question and answer session. So just as a reminder, please submit any questions you have by typing them into the Q&A box you see on your dashboard, and we’ll try to get through as many questions as we have time for today. We’ve already had several questions come through throughout the presentation, so we’ll go ahead and get started with those. And Brian and Michael, I’ll just pose the questions to both of you and either one of you or both of you can chime in as you’d like. So the first question that we have today is about how you track surgeon utilization. So this person’s just asking, how do you track surgeon utilization when operating not on block time?
Michael Besedick:
Yeah, it’s a great question. So like we mentioned earlier, we’ve put together an algorithm that accounts for basically every surgical minute that we see across the intraoperative record. And the advantage of doing that is surgeons see themselves as revenue drivers, as rainmakers, in the operating room. And when those minutes that show up outside of their block time go unaccounted for, it presents a serious issue. Like Brian mentioned, when a surgeon was in the OR working, they thought that they were gangbusters despite the fact that they had 40% utilization. So we don’t necessarily use a utilization metric to track that productivity, but we do account for the minutes and we group them into different variables like out-of-block time, which for instance would be minutes that spill over after their block or minutes where they were operating, maybe they were on-call of the day of their block the night before or something. We would count those minutes into a separate bucket. We would also count non-block. So another example, if they were doing ED call and they had a case put a case on, but we’re operating on one of their non-block days that would be accounted for in their non-block minutes and they get a report that shows essentially, okay, here’s how much of your time is spilling over into non block time. Here’s the time that’s falling onto your non-block days. So that they know that they’re getting credit and we’re seeing those cases happen, but they’re not essentially going missing.
Brian Watha:
Now, I’m going to go back a little bit when we look at this chart here. So you see the utilization, you see block release we have here is the OR minutes by day a week. So if these surgeons, so the good thing about this block is they use Monday, Tuesday through Friday. They’ve only done cases Monday, Tuesday, Friday. Now, if I saw a lot of volume on Thursday, I would’ve had a crucial conversation. It would’ve fell in this data, I would’ve seen that they are using a non-block day. It would’ve been highlighted here. So in addition to, hey, you’re underutilized, you’re not releasing your block, would’ve another conversation about you’re also not, you’re also using non-block days that would improve utilization on Monday, Tuesday, or Friday. We understand if you’re only looking at block usage, you’re missing another snapshot. They may be 35% utilized on Monday because maybe that’s not the day they’re really available and they’re doing all their cases on Thursday. But from a utilization perspective, you’re missing a lot of what they’re brought to the hospital. I hope that answered the question.
Ayla Ellison:
Yeah, thank you both so much. Thank you for the clarification and it’s super helpful to have the diagrams throughout the presentation as well to reference. The next question that came through for you two is do you find that your efforts to increase utilization differ between contracted and employed physicians?
Brian Watha:
Yes. There isn’t a different utilization target. The utilization target is the same. We don’t have rules specific to this group for that group. That being said, I will tell you physician self-select where they want to work based on the kind of lifestyle they want. And some physicians who become employed maybe don’t have the same volume targets, you know what I mean, or ambition. So we do at the end of the day, still track utilization the same way we would track anyone else. Now, I will say though, at a respective facility, if organizationally they’re looking to create a new medical group and they want to bring that volume in-house, and strategically they’re trying to give more time to their medical group as opposed to some other private guys. Or vice versa, they’re trying to ate all their medical group volume to another centralized hospital and they want to repurpose this facility for private guys, we work with the respective hospital strategic plan and use that in governance because again, without governance, it’s a free for all. And through that mechanism we’re able to say, well, we’re blocking it this way. These are the things that we’re aligning ourselves with the hospital priorities mean. But yes, it is different in terms of how we manage it, but ultimately, we do measure it the same.
Michael Besedick:
And it is the challenge. And to Brian’s point, it’s very important that it’s measured the same because some private surgeons that may have been working a community hospital for the past 20 years or so, see a new employee physician group getting propped up and having access to block time and feel like they’re being edged out. It’s important that everyone is held to the same standard so that there’s not a disparity in expectations amongst the providers. I think how physicians are compensated is also a big driver. A lot of employee physicians are compensated on an RVU basis, which can present other issues and the 3 o’clock or 5 o’clock witching hour, hang up their hat and are ready to transition out, which is not necessarily great for bolstering the top-end of your utilization curve, if you will.
Ayla Ellison:
Great. Yeah, thank you for that clarification there. I think it’s really helpful for everyone listening to hear about the differences, but also how they’re measured the same. The next question that we had come through, this person’s asking, how do you get surgeons out of their offices for urgent cases when you have available time, but they want to start in unstaffed hours?
Michael Besedick:
There’s a spectrum of ways to handle it. And I can remember not specifically on a project I’ve worked on, but hearing about a project about an orthopedic surgeon wanting to start their cases at midnight, not necessarily relevant to urgent cases. This is elective cases, but I think you want to be accommodating to surgeons in order to grow volume. But like Brian mentioned, you also want to grow sensibly and finding staff to help handle that case and making sure that everything goes smoothly and off hours that is very challenging.
Brian Watha:
And I would say one of the biggest issues we have with this is the definition of urgent and emergent.
Michael Besedick:
Yes.
Brian Watha:
So if a surgeon calls and says, I have an urgent case or emergent case, emergent to me means within an hour. That’s in my mind, within an hour. Okay. A urgent case within two to three. I mean, so again, governance, we’ll establish the respect of policies for what an urgent/emergent definition is. I’m never going to argue with a surgeon when they call that case, if they call an emergent case within an hour, we’re going to do our best to get that case within an hour. I will do a respective review on those cases that are called emergent, and they made the surgeons more accountable to whether or not they really were emergent. But if a surgeon tells me that I have an urgent case and in my mind that’s within three hours, but I need to go at 5:00 PM today at 7 in the morning, I’m challenging designation of urgency. But again, who does that challenging? It should be an anesthesiologist. It should be a clinical person who’s going to have a crucial conversation with that physician. And I mean, putting the nurse in the middle of this is always a little bit messy, but again, having this through governance and having it formalized, it gives some kind of insulation for the people who have that conversation because not going there and just saying, No, surgeon, you’re doing something wrong. You’re saying, Per the policies of our governing body, and I mean this would not be considered an urgent emergent case, or this is when we do our urgent emergent cases.
Michael Besedick:
And there needs to be peer-to-peer accountability. And I think that there have been policies that are passed or ratified through the SSEC that talk about this thing. The other particularly complicated part in handling this is relating to block time and who gets bumped and who follows who after block time. And this is really challenging. So making sure that surgeons are having a conversation. If you’re going to be bumping a surgeon, you have to call that respective surgeon and explain why they’re getting bumped. And we find that particularly opinionated surgeons that are getting bumped definitely don’t like it. So there has to be a process in place that ensures things go smoothly. It can be sticky for sure.
Ayla Ellison:
Yeah. Thank you both so much for blocking us through that process a bit. We’ve had several more questions come through. The next one builds off of what you all were talking about earlier on physician or the engagement strategy for hospital-owned versus contracted. So how does the employment status factor into your engagement strategy and just the differences between hospital-owned versus contracted physicians?
Michael Besedick:
So we’ve worked in all different kinds of situations. I think that we’ve worked with hospitals on the west coast that are predominantly all employed and with a handful of private surgeons that were highly productive. And I think it’s a matter of balancing that governing body, and we sort of touched on this earlier, but there are going to be disparities. It’s a matter of making sure that the metrics that you hold someone to are consistent and fair, because even if there is a perception that there is any kind of unfairness, it causes the governing body to disband.
Brian Watha:
And I would say we take our direction on this from the hospital in terms of what their strategy is and what their plans are. More often than not, their strategy is grow volume everywhere. So in that sense, what we want to make sure that we do is that when we have our governing body, that it’s not just made up of employed physicians, it’s not made up of just private physicians, that we do have a good mixed representation of the sort of providers we want in our OR doing volume, making thoughtful decisions on what’s going to impact them. Above and beyond that, I will say that there’s always a couple private practices that are very, very important to irrespective facility. So we will make sure that we work with our hospital partners. At the last place that I was at, it was an employed surgeon who was kind of in charge of the governing body. And together we actually went and had crucial conversations with some of the private groups and to make sure that they knew that we value them, that there was no preferential treatment, that we wanted to give them opportunities to have their cases done and really give them an opportunity to tell us what they needed so that way we can engage them as well.
Ayla Ellison:
Great. Thank you both so much. We’ve had so many questions coming through. It’s great to see. So just I’m going to continue to work through those for the rest of the time that we have here. The next question, this person’s asking for this type of ongoing analysis, do you provide scripts to hospital IT for the data extracts? Is this a subscription model? And are these analysis built into Tableau?
Michael Besedick:
Yeah, Tableau.
Ayla Ellison:
Okay.
Michael Besedick:
Yeah. We are developing a subscription offering where these metrics can be delivered at a pretty quick cadence. It’s a function of how quickly the hospital can provide us data. So we do have scripting. We don’t necessarily hand the scripting over, but we’ve developed sort of an analytics infrastructure that handles the data ingest, analyzes the data, processes it, and then visualizes it. Some of our clients are on Tableau or have Tableau as a BI tool within the organization, and we can build that through that visualization engine. But we’re also developing our own online portal for clients where it would be developed in sort of more open source visualization methods. So yes, a subscription offering is going to be available very soon.
Ayla Ellison:
Great. Thank you both so much. And also for helping with the pronunciation there. I don’t have all the terminology down quite yet. The next question we had come through is this person wants to know is anesthesia coverage and the number of coverage sites built into the modeling?
Brian Watha:
Absolutely. I mean, I can’t build a block grid unless I know how many rooms I’m running, how many rooms I’m running till 5, how many till 7, how many till 9, how many 24 hours. So our approach to this typically is again, in governance the first thing we’ll do is work with anesthesia and the hospital to what I’ll call a drawdown or a coverage model. What are the respective hours operations that we’re going to have for this respective facility? If we decide that of the 12 ORs you’re going to run, you’re only going to run 10, I really want to make sure 20% of your time is open. So that tells me I have eight rooms to block. Okay. So long as the governing body determines if that’s how they want to operate. So I start with 20% open time. And of those eight rooms, we would’ve had a determination working with anesthesia, how many late rooms, not anesthesia, but the hospital as well, how many of those eight rooms are going to go till 5, till 7? And then we work with surgeons. There are surgeons that really want, if I can give them a 10-hour day, they’ll take a 10-hour day, some want 12-hour days, some will work as late as you want. And what I really want to make sure is that those surgeons that are high volume surgeons that are willing to work late, that I’m able to give them a late room so that way I can also work with anesthesia and the hospital to staff that room late. So they feel that they have a dedicated team to them for that day. So we’re very thoughtful about making sure that we’re working with the hospital and anesthesia to develop what is the respective coverage model for this facility. And then we work within that box and we’re doing our allocation with the expectation that we’re going to try our best to provide that surgeon with their team to make their days efficient as possible.
Michael Besedick:
One of the tools that we use, it’s sort of a standard tool that we use almost everywhere, is our patent-pending heat map visualization tool. That way we’re able to design an efficient drawdown. We use it to inform staffing decisions. And what it actually shows is the probability of concurrency really at any given minute in the day so that anesthesia understands how many sites need to be covered. This includes the OR, this includes non-operating room anesthesia, this includes procedure rooms. Basically, anywhere that anesthesia touches can understand where their resources are. And I think one of the big challenges now that we see not necessarily related to just the OR is the growth in that non-operating room anesthesia volume. The interventions aren’t as serious, they’re not fully surgical interventions, but there’s still a demand for these services, like in GI or in interventional radiology, various places. So anesthesia needs to understand where the demand exists across the entire hospital, not just the surgical services suites. So what we do is use that to create parameters around where access to anesthesia coverage is optimal throughout the day so that they can provide that service both to the procedural areas, but also within surgical services.
Ayla Ellison:
Thank you both so much. It looks like we have a time for at least a few more questions before we wrap things up today. So wanted to try to get through a few more. And this person is just asking, did you measure how many cases you were missing because of scheduling inefficiencies? So just going back to if you had any measurement there as far as how many cases were being missed.
Brian Watha:
Well, we were able to do not necessarily from scheduling efficiencies, it was more of we can get a sense of what the OR utilization was based on by day a week based on what Mike said, our heat map and turnover time, so on and so forth. And then get a sense of, okay, if we made adjustments in different places, what would our volume tolerance be by day a week so we can get a sense of how much volume we can grow into each day? I will tell you that there were a lot of scheduling inefficiencies at this respective location, but a lot of them were tied to the fact that because this organization was 95% blocked, the scheduling office never really ever got time to schedule elective cases more than three days out. So when we relaunched the new block grid, they were still working within that world of scheduling left cases three days out, even though there was open time, we had to go back and work with the scheduling offices to kind of make sure that we enhanced their processes to make sure that they were, if there’s requesting two weeks out and there’s an open block that we built into the grid schedule that case right now. So there was some work that we had to do. And then above and beyond that, we actually had some working sessions with all the surgeons’ offices so that they understood what our scheduling rules were to make it easier on them so that way we could improve utilization that way as well. But yeah, there were some inefficiencies in scheduling that we had to address to make sure that we could actually get the cases that were backlogged onto the grid as soon as possible.
Michael Besedick:
And I think we didn’t necessarily quantify the precise volume, but we’re able to discern based upon the heat map visualization, also the parameters that we used to block the facility, how much capacity could be available on a particular day of the week depending on how busy they were or how inefficiently they were scheduling.
Ayla Ellison:
Great. Thank you both so much. We have one more question before we wrap things up today. And this person is just wanting to know if either of you or Surgical Directions will be attending the HIMSS conference in March?
Brian Watha:
Yeah, we’ll be there. Yeah, we love learning about new technologies. It’s probably one of just our nerdy interests. So I mean, we’re going to be there looking at all the new stuff out. So I mean, if anyone’s interested, find us on LinkedIn and know we’re happy to connect with you guys. We’re out there.
Michael Besedick:
Yeah, we won’t, won’t necessarily have a booth, but we will be in attendance.
Ayla Ellison:
That’s great to hear. And we have your information here available so anyone can reach out to you and hopefully you’re able to connect at the conference. That is all the time that we have for questions today. But I want to once again thank Brian and Michael for their excellent presentation, and Surgical Directions for sponsoring today’s webinar. Please enjoy the rest of your day and we really look forward to having you join us for future webinars.
Michael Besedick:
Yeah, we appreciate it. Thanks everyone for joining. And we actually just, we’re going to be publishing a blog around this information. I know that you’ll have the presentation to take home, but it gives a little bit more illustrative detail on how the governance body was set up and specifically what questions we were trying to answer with our dashboards. So if you would kindly subscribe to our blog, it’s blog.surgicaldirections.com, and you can see that article coming up soon.
Ayla Ellison:
Great. Thank you both so much and to everyone who’s called in today. Thank you so much and please enjoy the rest of your afternoon.
Brian Watha:
Thanks everybody.
Michael Besedick:
Thanks everyone.
