2. Surgical Directions © 2015 Issue Surgeons complain about turn over time and same day cancellations Most hospitals are afraid to address case time 2 BUT Cost per minute: $20 - $60

3. Surgical Directions © 2015 Issue Hospital for joint disease has limited capacity Has initiatives to grow volume 3 BUT Reducing case time is KEY to delivering strategic objectives

4. Surgical Directions © 2015 Objections No one should tell a surgeon how to perform a case. This is interfering with the practice of medicine. Our patients are more complex and sicker. This will never work. 4

5. Surgical Directions © 2015 Morbidity “Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making.” Hardy, K.L. Anesthet Surg J. 2014. 5

6. Surgical Directions © 2015 Complications Blood Loss SSI’s DVT’s Deep Tissue Injuries Increased Pain All leading to increased LOS and increases in readmission rates! 6

7. Surgical Directions © 2015 Getting Started Physician Champion Information Monthly Dashboard Process Improvement Leadership needs to both demonstrate change and address outliers! 7

8. Surgical Directions © 2015 Physician Champion Physician Champion essential to reduce case time OrthopedicAction Chairman of Orthopedic Surgery -12 joints per day -National reputation Commitment demonstrated by being in room for turn over CardiacAction Chairman of CV SurgeryCommitment demonstrated by review of case time by surgeon daily

9. Surgical Directions © 2015 Process Improvement Team Members: Orthopedic Leadership Anesthesia Leadership Nursing Business Development / Analytics Goal: Identify opportunities to reduce case time Provide transparent information Identify and remove barriers Monitor progress Celebrate successes 9

10. ORCHESTRATING STANDARD WORK 10

11. Surgical Directions © 2015 Designing Workflows 11

12. Surgical Directions © 2015 Pre-Hospitalization Workflow Anesthesia Driven Pre-Admission Testing (PAT) and Medical Clearance (optimization) Process: Evaluation and testing 4 weeks prior to scheduled procedure Anesthesia and medical clearance process aligned to minimize cancellations ASA 1 and possibly ASA 2 patients may not require preoperative outside medical clearance other than going through PAT process via telephone Chart completion 72 hrs. prior to scheduled procedure

13. Surgical Directions © 2015 Pre-Anesthesia Testing Effective PAT Medical Director Telephone Questionnaire Single Pathway Scheduling Risk Management Strategies Testing Protocols Systems to treat patients with co-morbid conditions

14. Surgical Directions © 2015 Day of Surgery Workflow Governance – Surgical Services Executive Committee (SSEC) Standard order sets Electronic Dashboards Daily Huddles with multidisciplinary teams Defined roles and responsibilities Parallel processing

15. What is the Huddle? PROBLEM/OPPORTUNITY LIST: 1)Recap of previous day 2)Total cases for next day and 5 days out; PAT and scheduling completion 3)Review of schedule 4)Total number of anesthesia providers to start day 5)PAT problem review 6)Antibiotics review 7)Review Pending Action items

16. HOW TO MEASURE CASE TIME Surgical Directions © 2015 16

17. Surgical Directions © 2015 Case Time Data Driving Organizational Change Patient In Anesthesia Ready CutClose Patient Out

18. Surgical Directions © 2015 Physician Scorecard

19. Surgical Directions © 2015 Physician Scorecard (cont’d)

20. Surgical Directions © 2015 OR Case Time Variance by Procedure 20

21. Surgical Directions © 2015 Addressing Variances Transparency of Data Comparisons of Anesthesia Techniques Comparisons of Surgical Technique Observing Procedures Crucial Conversations 21

22. Surgical Directions © 2015 10 Most Successful Techniques to Reduce Case Time Turnover teams Anesthesia Preference cards Reduction of items on Preference cards/Standardization Flip room based on case volume and case time PA for complex procedures with technology PAT Protocols Daily Huddle Anesthesia rounds on inpatients the night prior to surgery Anesthesia agreeing on metrics Leadership addressing outliers 22

23. Surgical Directions © 2015 Outcome Impact: Reduction in case time 9% increase in case volume over prior year in HJD National recognition: Increase in US News and World Report ranking for HJD of 4 from 8 in two years

24. Questions

25. Surgical Directions © 2015 Surgical Directions Information 25 For questions or comments, please contact: Surgical Directions 541 N. Fairbanks Court Suite 2740 Chicago, IL 60611 T 312.870.5600 F 312.870.5601 www.SurgicalDirections.com

26. Surgical Directions © 2015 Appendix: Notes for Slide 12 26