A Kaiser Permanente So. Cal. Study in 2011

Implementation of the Clockwork Operating Room Efficiency Model (CORE) to Improve First Case Start Times - A Prospective Study Pharmacy Call Center Optimization - A Kaiser Permanente So. Cal. Study in 2011

Alex Ortiz1 Gregory McFarlin2

Summary

Kaiser Permanente in Southern California has a pharmacy call center that receives almost one (1) million calls annually, providing service to both members and physicians. This call center is in charge of performing the clinical screening on refill prescriptions that will be filled in a central refill center. Many of the services provided by this call center deal with issues of patient safety, and involve the clinical expertise of pharmacists and knowledge of other pharmacy staff.

Pharmacies are becoming more operationally complex as technologies and patient sophistication advance in tandem. These pharmacies are constantly struggling to manage phone calls in addition to the multitude of other competing priorities. All of these distractions could potentially affect patient safety and increase stress levels at the pharmacy. Given these issues, pharmacy call centers assist outpatient pharmacies in focusing not only on patient safety, but enhancing the working environment.

Traditional Industrial Engineering tools were used to optimize the operation of this call center (e.g., time and motions analysis, queuing, staff balancing, etc.). Major findings and recommendations relate to better management and control of the staff and recommended changes in the current telephony and computer systems. Recommendations are:

1 Industrial Engineering, 2013, University of Southern CaliforniaMS Industrial and System Engineering, BS in Chemical Engineering

2 Health Administration, 2013, University of Southern CaliforniaMBA PMP Green Belt LSS, Project Manager for Pharmacy Consulting Services

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 1 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] First Step: Quick hits. Reduction of 10% of talk time by the adoption of best practices of how to handle calls and minor changes in the IVR system (telephony integrated voice recognition system).

Second Step: Proper supervisor and proper quality control of the staff have an additional savings of 1/3 of the original talk time. Adoption of best practices in how to manage staff in a call center environment.

Third Step: System changes. Investment in improving current telephony and computer systems to improve efficiencies.

This study shows how to optimize a pharmacy call center to maximize service, quality and manage cost.

Project Overview

Background: Call Center Department Overview

The pharmacy call center is a mail order processing center and call center which serves all Southern California Kaiser pharmacies and its members.

Primary Duties: Answering calls and processing mail order prescriptions.

Receiving prescription orders via automated refill system, internet, electronic refill authorization and by mail.

Working on multiple reconciliation reports.

Talking to different departments to resolve prescription order issues (e.g., membership services, pharmacies, members, delivery services).

Screening of drug interactions.

Identified Issues: Discussions with call center management identified some issues that include:

Incomplete pharmacy prescription orders, creating manual work (i.e., multiple error logs) and longer phone calls.

Credit card issues (e.g., expiration dates not being identified until days later).

Phone capacity (e.g., not enough phone lines).

Telephony system unable to record calls (this could potentially help improve accountability).

Poor communication between computer systems.

2 Need for added space for staff.

A staff-to-supervisor ratio over 30:1.

Fig 1. Processing of a Filling of a Prescription Flow

Description & Purpose of Project

The purpose of this study was to identify the potential opportunities for the Kaiser Permanente Pharmacy Call Center to improve process flow, systems, re-engineering and use of new technology.

Project Deliverables

The primary deliverables of the project were:

Identify and document staff tasks and responsibilities.

Identify and document the current workflow, and develop time standards and processes to optimize overall workflow.

Determine staff utilization based on current volume, and estimate proper staffing levels and balance according to the expected service levels.

Provide an estimation of total improvement opportunities with high-level estimations of time and investments.

Identify system improvements that will improve efficiencies within Kaiser Permanente pharmacy call center.

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 3 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] Construct a simulation model that will be used to study alternative scenarios to improve productivity and reduce waiting times.

Recommend changes to workflow, systems, or other areas where efficiencies can be achieved.

4 Project Approach

Scope The scope of this project included the inter-workings of Kaiser Permanente pharmacy call center in relation to:

Staff workflow and processes.

Phone systems.

Other systems that are used to manage each call.

Study Approach This study included several approaches to achieve the deliverables as described. The project was divided into four general phases. These phases are general in scope and may overlap.

Orientation of the management to the study.

On-site observations and data collections.

Data analysis and development of recommendations.

Writing the report and presenting the findings to the client.

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 5 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] PHASE I: Orientation of Management to the study

The first study phase involved informal orientation and discussion sessions with the management. Project objectives, basic methods that were used in achieving objectives as well as any data collection that was required was discussed during these sessions and throughout the course of the project

PHASE II: Observations and Data Collection

Phase II involved detailed observations of the methods and procedures used by the staff. These observations and discussions with the staff formed the basis for later recommendations.

Data was collected during this phase to determine individual task times, task volumes, frequency of occurrence, and relative time required to perform each task. During this phase, time measurements of tasks performed by the staff were taken. Data of current departmental staffing levels was also collected during this phase. This data was used to determining sufficient staffing levels for the department.

PHASE III: Data Analysis and Development

Phase III involved compiling Phase II data and forming recommendations based on observations and discussions with staff. Specific recommendations were developed during data analysis phases for improving work processing functions and for increasing staff utilization. The data and recommendations generated during this phase were presented to management as the study progressed.

PHASE IV: Presentation of the Findings and Writing the Report

This phase required systematic coordination of findings and recommendations into a final presentation format that served as the topic of discussion and review at a meeting with call center management. Basic findings and recommendations were presented, and suggestions were discussed and revised.

Analysis Considerations

Optimization of Kaiser Permanente Pharmacy Call Center

Evaluation of service centers/call centers

- Cost analysis of benefits of service centers/call centers

Evaluation of workforce productivity systems

- Implementation of productivity standards

Evaluation of skill mix

- Reduction or elimination of manual activities for pharmacists and assistants

Evaluation of space and phone capabilities

6 Findings and Recommendations

Phone Call Activities:

Finding: Low level of direct supervision. Ratio is 1:35

Recommend:

Increase supervision ratio. Recommended industry standard is 1:16 (based on internal and external benchmarking findings of call center facilities).

Change escalation and troubleshooting process from supervisors to lead pharmacists to allow more time for supervision.

Finding: No formal training of staff

Recommend:

Hire training/quality assurance supervisor.

Use external vendor or Call Center-centric trainers to help with immediate training of staff.

Incorporate the UBT (Unit Based Teams) for suggestions and ownership.

UBT: Teams are composed of union staff and management to address work-related items together

Finding: High variation of call times for same type of calls

Recommend:

Immediate improvements (without hiring extra supervision and trainer/QA staff): Implement quick fixes (can reduce talk time by 20 seconds).

Complete improvements: Reduction of total phone call duration time by 48 seconds (a 21% improvement).

Training from Training/Quality Assurance Supervisor.

Charge UBT Teams to propose better scripts for each type of call.

Finding: Low service levels due to:

All issues described in point 1 to 3 above.

Unmatched demand with staff scheduling.

Unmatched demand with current staffing levels.

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 7 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] System issues – extended time due to price checks or status checks.

Recommend:

All recommendations described in point 1 to 3 above.

Scheduling staff according with excel queuing model for desired service goal.

Use non-phone call activities as much as possible as fillers to increase staff productivity (total projected staff utilization of 85%).

Address system issues.

Finding: Interactive Voice Response (IVR) quick fixes could improve operations

Recommend:

Improve IVR system to handle many of the calls such as: fixing current credit card validation process, accepting 10 and 11 digits, etc. Estimate 5% savings in call time due to these improvements.

There is a 20-seconds-per-call savings by the IVR pre-populating calls with MRN (Medical Record Number) info.

(Estimated reduction of incoming caller traffic and reduction of phone call time is equal to $0.3 million in savings per year).

Finding: Quality Assurance (QA) for efficiency levels are not up to standard from recommended levels

Recommend:

Analyze the information that we currently get from standard reports and find a way to fix this issue.

Improve QA levels and include the results in the standard monthly reports for Kaiser Permanente pharmacy call center stats.

Non-Phone Call Activities:

Finding: Over 18 assistants are processing 23 reports (across 6 systems) due to rework based on current system and process issues

Recommend:

Invest in improving IVR, Foundation, KP.org, and PIMS systems (can reduce by 10.5 FTE).

Relocate/add printers to reduce travel times of staff.

Obtain a current list of phone numbers of physicians to reduce pharmacists by at least 1 FTE.

8 The findings and recommendations can be addressed in steps rather than all at once. Figure 2 below indicates the areas where the improvements can be obtained during the overall improvement process.

Conclusions

Puja Trivedi, DO, Anesthesia Resident Physician Riverside County Regional Medical Center David Ninan, DO, FAOCA Anesthesia Department Chair Riverside County Regional Medical Center Hector D. Ludi, MD, FACS, Surgery Department Vice-Chair Riverside County Regional Medical Center Louise O’Rourke, RN, BSN, NM, OR Manager Riverside County Regional Medical Center David Belson, PHD, Professor USC Viterbi School of Engineering Daniel J. Epstein, Department of Industrial and Systems Engineering Abstract

An exponentially increasing patient population, diminishing medical funding, and uncertainty regarding the economic ramifications of recent healthcare reform have resulted in an emphasis on hospital economics in terms of efficiency, productivity, and cost containment. The operating room (OR) is a critical component of an institution’s ability to generate profit while simultaneously accounting for

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 9 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] significant expenses. At the core of OR efficiency is how well an institution matches its resources to demands. Riverside County Regional Medical Center (RCRMC) is a 439-bed teaching hospital with Level II adult and pediatric trauma services and nine main OR’s. RCRMC’s nine ORs were experiencing significant delays in beginning cases at their scheduled start times based on data obtained from a pilot study from 2006 to 2007. Collected data showed that only 40% of all scheduled elective first cases started on-time resulting in significant inefficiencies. RCRMC formed a Clockwork Operating Room Efficiency (CORE) subcommittee consisting of physician leaders, hospital managers and key OR staff members who created and implemented a formal workflow model to assist in the immediate identification and rectification of delay causes. An additional objective was to encourage individual accountability, responsibility, and value as responsible individuals offered delay prevention insight and suggestions for improvement. Through implementation of the CORE model, the CORE subcommittee enlightened our institution to a large area of unnecessary expenditure, developed and implemented an easily reproducible workflow model, and ultimately resulted in positive changes on multiple levels. Staff morale and patient satisfaction all subsequently improved and surgeons preferred to operate at RCRMC as opposed to other local facilities due to its predictable first case on-time starts.

Introduction

An exponentially increasing patient population, dwindling funds, and uncertainty regarding the economic future of healthcare have resulted in an emphasis on healthcare economics in terms of efficiency, productivity, and cost containment without sacrificing quality of care. Recent healthcare changes may adversely impact healthcare models providing care to underserved areas. California’s safety-net hospitals, the core of the state’s public healthcare system including county and academic medical centers, are fighting to keep up with increasing patient demands with a tighter budget and fewer resources than in the past [1a]. The only way for these healthcare models to survive is by a complete reengineering of its infrastructure. An area of focused interest is the operating room (OR), a critical component to an institution’s ability to generate revenue while simultaneously accounting for its greatest expenditure. High overhead costs are attributed to the need for highly specialized physicians; a large volume of trained and certified personnel; expensive equipment with associated costs of repair, sterilization, and periodic upgrades; and OR maintenance including cleaning, airflow management, specialized OR tables, and supplies.

At the core of OR efficiency is how well an institution matches its resources to demands. The planned allocation of resources during a defined time frame makes up the organization’s fixed cost. If the OR is utilized significantly outside of the allocated time, the institution’s variable costs increase and are often significantly higher due to overtime pay [3]. Immeasurable costs of delayed cases include patient dissatisfaction with extended waiting without nourishment, surgeon aggravation when scheduled to follow another surgeon, and staff frustration when asked to work beyond scheduled hours. This ultimately poses a risk to revenue as surgeons choose to operate elsewhere and patient dissatisfaction negatively impacts hospital reimbursements. Cases scheduled later in the day may be cancelled which impacts patients, surgeons, and society due to the increased burden of costs associated with additional length of hospital stay and delayed return to the workforce [3].

10 One solution lies in an application of management engineering principles and techniques to streamline healthcare systems. Dr. Belson, an award winning engineering professor, had successfully applied management engineering methods to improve productivity and efficiency at some of the world’s largest manufacturing corporations. He understood that similar to manufacturing, the flow of a patient in surgery is a sequential process with multiple steps and areas for potential breakdowns to occur (a). In 2007, the California HealthCare Foundation commissioned Dr. Belson, faculty and students from the USC Viterbi School of Engineering Daniel J. Epstein Department of Industrial and Systems Engineering to demonstrate the application of management engineering principles to safety-net hospitals. One of the selected safety-net hospitals, Riverside County Regional Medical Center (RCRMC), is a 439-bed safety net hospital with Level II adult and pediatric trauma services and nine main ORs. Analyzing data from the hospital’s information system, Dr. Belson quickly identified that the average turnaround time at RCRMC was well above industry benchmarks. Dr. Belson and colleagues applied the following five basic steps of management engineering: (1) problem identification, (2) measurement, (3) analysis, (4) design of solutions, and (5) intervention. The result was a reduction in turnaround time from 49 minutes in November 2007 to 39 minutes in July 2008. Additional areas of process improvement included a redesign which improved patient flow, better use of technology and information services, improved asset utilization, use of checklists with communication checkpoints along the way, and data tracking which served as a motivational tool helping to change the existing culture into one more responsive to patient needs.

Based on the success of reduced turnaround times, RCRMC formed a process improvement group to focus on first case start times as its next management engineering project. RCRMC’s nine ORs were experiencing significant delays in starting cases as scheduled based on data collected during a pilot study from 2006 - 2007. Collected data showed that only 40% of all scheduled elective first cases started on- time. The delay had a domino effect as succeeding cases were also delayed resulting in over 18 hours per month of lost OR time. RCRMC created a subcommittee of OR staff members with diverse roles and hospital managers to apply learned management engineering principles to improve on-time starts while still maintaining a high level of patient care. Together they created an initiative entitled Clockwork OR Efficiency (CORE) to assist in decreasing first case time delays. A consistent theme during literature review of OR management was how inefficiency stemmed from departmental divisions, lack of understandings of what OR efficiency means, ineffective communication, and that the need for teamwork was necessary for sustained change [4,5,6]. Therefore, the participation of key OR staff members was a crucial component in the development of our model. The majority of research in the field collected data on causes for first case delays and retrospectively attempted to determine the cause or individual [7]. Our initiative involved early identification of individuals responsible for delays in first case start times and early intervention to correct areas of inefficiency by asking responsible individuals to take responsibility for the event and offer suggestions as to how the event may be prevented on both the individual and hospital management level. This contributed to a supportive environment where staff members felt valuable as their feedback resulted in immediate change and helped to unite staff under a common goal of improving patient satisfaction and care. Through this initiative, elective first case time

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 11 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] improved, lost OR time decreased, and most importantly staff morale, patient and surgeon satisfaction greatly improved.

Methods

A CORE subcommittee was formed consisting of the Assistant Hospital Administrator, Anesthesiologist (Chair), General Surgery (Chair), OR Nurse Manager, and Quality Management Overseer. Data was collected from scheduled first cases performed in the nine main OR suites. A case was considered a “first case” if it was scheduled by noon one working day prior to surgery. Analysis was limited to scheduled workdays and excluded holidays. Trauma, emergency, and obstetric procedures were excluded.

The following protocol was implemented to reduce first case delays by promoting personal accountability, creating a supportive environment to encourage communication, bringing value to responsible individuals by allowing them to provide input, and allowing the formation of an OR team with the same universal goal of patient care despite departmental divisions. First, a patient had to be in the preoperative area a minimum of 30 minutes prior to the scheduled start time [Workflow 1]. If they arrived late, a reason was listed by the OR Nurse Manager and reported to the CORE subcommittee. The next timed measure in the protocol was that a representative from the surgical team and the circulating nurse had to sign off on the patient 15 minutes prior to the scheduled start time. If either member failed to sign off in a timely manner, the OR Nurse Manager or Surgery Division Chair evaluated the situation and reported this back to the CORE subcommittee for review. The final measured step was for the anesthesia care team to bring the patient into the OR suite at the prescheduled time. If they failed to do so, the Anesthesia Chair evaluated the circumstances and reported to the CORE subcommittee.

The CORE subcommittee held weekly meetings and adhered to the following procedures for notifying physicians and nonmedical departments of all first case delays attributed to their service or department:

1. Physicians received a delay notification memo by email requiring 10-business day turnaround response.

2. If no response, the chief of the service received a second memo by email requiring a 5 day response.

3. Subsequent failure to respond to second notification resulted in formal reports to the chief medical officer, the CORE subcommittee, Performance Improvement Committee and the Medical Executive Committee.

4. Non-medical departments were required to appear for an in-person response at the monthly CORE subcommittee meeting to address departmental issues identified from the prior month’s case delays and how said delays will be resolved to prevent repetition in the future along with any additional suggestions for possible improvements.

12 Workflow 1: Clockwork Operating Room Efficiency Model

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 13 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] The Clockwork Operating Room Efficiency Model provides an algorithm which can be easily followed through each time-measured step. Endpoints include an on-time start, an appropriate turn around response which is recorded, or no response resulting in a formal report being sent to the chief medical officer, CORE subcommittee, Performance Improvement Committee, and Medical Executive Committee.

Project results were displayed in key locations within the OR suite using graphs and charts of first case delay outcomes and progress for all OR staff to review.

Results

During the two-year study, 3,936 cases were scheduled to start at 7:30 a.m. on Monday, Tuesday, Thursday, Friday and 8:30 a.m. on Wednesday. In 2008, 1,908 out of 1,968 cases were in compliance resulting in a 97% on-time start rate. This number slightly improved to 1,930/1,968 in 2009 resulting in a 98% compliance rate [Table 1, Graph 1]. The most commonly reported reasons for delays included a lack of appropriate patient preoperative preparation (including lab work, surgical consent, updated history and physical), wrong equipment, patient tardiness, and surgeon unavailability.

Table 1: Percentage of First Case On-Time Starts by 3 Month Quarters Post Intervention

14 Percentage of First Case on-time Starts

2008 2009

QTR QTR QTR QTR QTR QTR QTR QTR Quarter 1 2 3 4 Year 1 2 3 4 Year

Rate 96% 97% 98% 98% 97% 94% 100% 99% 99% 98%

Numerator 470 475 483 480 1908 462 491 488 489 1930

Denominator 492 492 492 492 1968 492 492 492 492 1968

Numerator: number of cases that had the patient in the room by 7:40 a.m. Denominator: total number of scheduled cases per quarter Table 1: The number and percentage of on-time first case starts was recorded in 3 month quarters for the year 2008 and 2009 after the institution of CORE measures

Graph 1: Percentage of First Case On-Time Starts by 3 Month Quarters Post Intervention

Graph 1: A bar graph was created based on the number of cases with on-time first case starts to visually display side-by-side quarterly improvements in the year 2008 and 2009 after institution of CORE measures from a baseline based on a pilot study.

Discussion

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 15 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] RCRMC made measurable progress surpassing the CORE subcommittees expectations in OR efficiency by auditing causes of first case delays, creating an effective workflow model, determining the individual whose actions were at the root of the delay, brainstorming ways the delay can be avoided in the future through ideas from both the individual and as a subcommittee, and displaying delay data in highly visible hospital staff locations. RCRMC achieved an improvement in elective first case start times from 40 to 95%. Lost OR hours decreased from 18 hours to 5.2 hours per month, a 72% decrease in delayed hours. The number of delayed cases from a baseline of 131 cases dropped to 7 cases per month. By holding individual physicians and staff members accountable for OR first case start delays and having them feel involved by being open to his/her suggestions, intangible improvements were made in the areas of personal responsibility, accountability, and communication. Regular meetings with OR staff members with diverse roles and under different departments led to an improved team atmosphere and the OR staff began to act as a cohesive unit to promote an appreciation for hospital efficiency while still maintaining a high level of patient care and safety.

In looking at the applicability of the results it is important to highlight the definition, measurements taken, and identify challenges to implementation. The start times were defined as when the patient was physically in the operating room. So while the initiative was highly successful in improving this time it did not necessarily correlate with improved operating room utilization. Presumably this improvement would trickle down to efficiency and this was our anecdotal experience, however it was not part of this initial study.

Another potential confounding variable resulting from our definition was the availability of attending physicians to begin the procedure. Like many academic training sites at RCRMC, resident physicians are primarily responsible for the steps necessary to get the patient into the operating room. At times there were delays in the arrival of the Anesthesia/Surgery Attending to the operating theatre. This confounding variable as pertains to anesthesia has been previously described by Epstein and Dexter [8] and our experience was similar. There could be significant delays if an Anesthesia Attending was supervising two patients and was busy inducing one patient, while the second patient was waiting in the operating room. Similarly there were delays if the Surgery Attending was busy outside of the operating room and not immediately available after induction. This potential for delay was unmeasured since the patient was considered an on-time start as long as they were physically in the OR. This potential contribution to increased length of surgery is an area needing further study and is currently being investigated at our institution.

As an academic institution, an important emphasis is placed on the instruction and development of competent residents. The months of June and July, a time notoriously known for a steep learning curve as new interns and residents enter both the anesthesia and surgical arenas of the OR, was included [8]. Based on the quarter totals, no significant increase in delays was noted during quarters 2 and 3, a fact likely due to the greater involvement of attending and senior residents to ensure all necessary steps are taken in a timely manner to allow smooth OR case flow. Upon achievement of the goals set forth by the CORE task force, all aspects of the CORE workflow model were abandoned and no measure had been instituted to evaluate long-term sustainability. A recent survey of on-time starts for scheduled first cases

16 has fallen to pre-intervention levels. By not building in assessment measures to continue evaluating progress post-intervention, critical trends in delayed start times were missed and it became increasingly difficult to determine what factors contributed to a reversal of the progress achieved under the CORE workflow model.

Additionally, a 10-minute leeway was allowed in OR start times, for example a patient entering the OR at 7:40 a.m. was still considered “on-time” and did not constitute a delay. Potentially even something as short as a ten minute interval multiplied over multiple operating rooms has the potential to rapidly become significant.

In implementing the CORE workflow model, unanticipated challenges emerged which need to be highlighted as it is very likely these hurdles exist in all hospital models to varying degrees. As most operating staff members were paid based on shifts, it became more challenging to keep staff motivated and actively facilitating efficiency as it approached the end of shift time. For example, efficiently getting a case into the operating room at 2:30 p.m. often resulted in a staff member having to stay overtime to complete additional patient charting if their shift ended at 3:00 p.m. More importantly, staff may want to avoid a handover as a surgery begins to avoid miscommunication, potential errors, and ensure patient safety. It was also found that there was a lack of uniformity in the ways policies were understood and executed on multiple departmental levels which may be avoided by ensuring staff receive the same department specific training by the same supervisor and are observed periodically to ensure compliance to policies/clarify misunderstanding. It was interesting to observe the dichotomy between operating room personnel in terms of what efficiency meant, i.e. a Surgeon may think of efficiency in terms of the cases he/she completes within a set time period versus an Infection Control Nurse who would put more emphasis on efficiency as the number of post-operative infections. Despite formal patient outcome measures, it became impossible to reconcile different thoughts on what efficiency meant to each staff member but this discrepancy must be acknowledged especially when it becomes difficult to implement a new policy. Job security fears made it difficult to obtain accurate data at times as employees were scared of being blamed inadvertently if they revealed the source of delay while visiting/travelling staff were more likely to ignore warnings. Communication fall outs continued to occur despite formal organized meetings.

Although OR start time is only one factor in OR efficiency, by focusing on an easy-to-measure parameter with limited influence by external factors (case takes longer than scheduled, turnover, etc.) and developing a formal workflow to assist in the immediate identification and rectification of delay causes, we were able to enlighten our institution to a large area of unnecessary expenditure which has promoted positive change. Staff morale and patient satisfaction all subsequently improved and surgeons preferred to operate at RCRMC as opposed to other local facilities due to its predictable first case on- time start.

References

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 17 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected] [1a]. Belson D, Mary KS, and Overton L. “Improving Efficiency in the Safety Net: Management Engineering Practice and Cases.” California Healthcare Foundation; March 2010.

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[4]. Girotto JA, Koltz PF, Drugas G. “Optimizing your operating room: or, why large, traditional hospitals don't work.” Int J Surg . 2010; 8(5):359-67. Epub 2010 May 15.

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[12]. Koenig T, Neumann C, Ocker T, Kramer S, Spies C, Schuster M. “Estimating the time needed for induction of anaesthesia and its importance in balancing anaesthetists' and surgeons' waiting times around the start of surgery.” Anaesthesia. 2011 Jul; 66(7):556-62. Epub 2011 May 13. [13]. Masursky D, Dexter F, Isaacson SA, Nussmeier NA. “Surgeons' and anesthesiologists' perceptions of turnover times.” Anesth Analg. 2011 Feb; 112(2):440-4. Epub 2011 Jan 6. [14]. Mazzei WJ. “Operating room start times and turnover times in a university hospital.” J Clin Anesth. 1994 Sep-Oct; 6(5):405-8. [15]. McIntosh C, Dexter F, Epstein RH. “The impact of service-specific staffing, case scheduling, turnovers, and first-case starts on anesthesia group and operating room productivity: a tutorial using data from an Australian hospital.” Anesth Analg. 2006 Dec; 103(6):1499-1516.

18 [16]. Truong A, Tessler MJ, Kleiman SJ, Bensimon M. “Late operating room starts: experience with an education trial.” Can J Anaesth. 1996 Dec; 43(12):1233-1236.Pharmacy call centers employ pharmacy assistants and pharmacists with expertise in triaging calls and p

Rocessing prescription orders. The pharmacy call center agents not only optimize the member’s experience but also maximize the physician’s use of time in managing their medication-related messages. Therefore, there is an increasing need for a pharmacy call center as patient volume continues to grow. Implementing the recommended changes will allow the pharmacy call center to better adjust to the projected growth in membership as well as improve upon the current service that is provided to the members daily.

Alex Ortiz Alex has been with Kaiser Permanente for 27 years in health care operational consulting roles.

Gregory McFarlin Gregory has been with Kaiser Permanente in Pharmacy for 6 years. Gregory has over 17 years of Operations, Management and Project Management experience combined.

version 0910.1927.20123

Implementation of the Clockwork Operating Room Efficiency ModelPharmacy Call Center Optimization - A Kaiser 19 Permanente So. Cal. Study in 2011 Journal of the Society for Healthcare Improvement Professionals © 20123 515 South Figueroa Street, Suite 1300 • Los Angeles, CA 90071 • Phone +1-213-538-0700 • [email protected]