2. Web Link for Resources: www.ihi.org/ihi/sitemap.aspx

6. Run Chart of Delays ©VUMC2001

7. Process Flowchart The flowchart was very large and complicated, but this is how the whole process ended-having the final inspection just as the patient is ready to go to the OR!

8. Cause and Effect Diagram ©VUMC2001 OR Start Delays PEOPLEPROCEDURES EQUIPMENTPOLICY Surgeon Late Anesthesia late Patient complications Consultation not done Consult notes not in chart No pre-op education Meds not given Tests not done H&P not done Nursing evaluation not done Anesthesia evaluation not done Test results not in chart Double booked Instruments not ready Not available Medical record missing Instruments not available No patient consent No authorization Registration not complete No pre-op check list Data were collected on all these causes to see which contributed most to the delays.

9. Pareto Chart A tool to prioritize the first improvement. # of errors Cum Freq Cum. Freq. ©VUMC2001

10. Sources of Delays A: Tests not ordered or results no posted.

11. Sources of Delays A: Tests not ordered or results no posted were greatest cause of delays. So let’s study why the tests are not being ordered or posted, right? But… are all the tests necessary?

15. The perception was that anesthesiologists sometimes delay surgical cases in order to conduct further patient testing, with the results that surgeons have learned to order various tests simply as a precaution against such delays. The upshot is unnecessary testing.

16. Develop disease and surgical procedural testing guidelines for: -laboratory testing, -electrocardiography -chest radiography in adult surgical patients

17. Team Anesthesiology (Chair) Otolaryngology OB-GYN Cardiology Pathology Internal Medicine Pediatrics Urology Radiology Facilitator

19. Cycles of Change Guidelines developed Dr. Higgins educated the surgeons on the guidelines Test ordering patterns were monitored Quarterly reports sent to surgeons and to the specialty Results amount to approximately $200,000 annual cost savings.

20. ©VUMC2001