Operation Management Massachusetts General Hospital’s Pre-Admission Testing Area (PATA)

Massachusetts General Hospital\’s Pre-Admission Testing Area (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Five anxious faces looked up at Dr. Jeanine Wiener-Kronish, chief of anesthesia at Massachusetts General Hospital (MGH), as she entered the conference room. It was June 2009, and the group before her was the task force for the Pre-Admission Testing Area (PATA). PATA had been struggling with inefficiencies and long patient wait times for over two years. Despite the group’s best efforts to fix these problems, a letter forwarded from the president’s office that morning highlighted that conditions in PATA were not getting better. Dr. Wiener-Kronish took a seat and read the letter aloud: Last week I brought my mother into the Pre-Admission Testing Area. We live almost 3 hours away and had to make a special trip for this appointment, which her oncologist, Dr. Paul Schneider, said was necessary to ensure a safe and successful surgery. When we arrived at the clinic, the waiting room was so full, it was five minutes before my mother and I could get two seats together. We sat there for a full half-hour before they sent us back to get her blood pressure reading. We then waited back in the waiting room for another 45 minutes before being moved to an exam room. It was 20 minutes before a nurse finally came in and she mostly just asked questions I had already answered on a form provided by the front desk. After the nurse left, it was almost another half-hour before the doctor finally came in and he also asked many of the same questions. The providers were very nice and apologetic, but of the almost 4 hours we spent in the clinic, only 11?2 hours of that was actually face time with anyone! Even more aggravating, while my mother was in surgery this morning, two families in the waiting room said their relatives never even had to have a PATA appointment. One even had the same condition as my mother so I’m not sure why our PATA visit was even necessary. This case was prepared by Kelsey McCarty, MBA Class of 2010, Jérémie Gallien, Associate Professor of Management Science and Operations, London Business School, and Retsef Levi, Associate Professor of Management, MIT Sloan School of Management. Copyright © 2012, Kelsey McCarty, Jérémie Gallien, and Retsef Levi. This work is licensed under the Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License. To view a copy of this license visit http://creativecommons.org/licenses/by-nc-nd/3.0/ or send a letter to Creative Commons, 171 Second Street, Suite 300, San Francisco, California, 94105, USA.

MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi I brought my mom from out-of-state because we were told that Mass General provides the best care in all of New England, maybe even the country, but that’s not at all what we experienced. I sincerely hope that we can expect more from our next visit to MGH. Dr. Slavin, president of MGH, had a dedicated department to process letters from patients, families, and friends. The majority of these letters were filled with overflowing gratitude for the quality of care delivered by the hospital and its employees. Therefore, when letters like this came across his desk, they were not taken lightly. Dr. Wiener-Kronish knew she needed to correct the problems in PATA quickly. Anesthesia at MGH Dr. Jeanine Wiener-Kronish began her career in anesthesia as a resident at the University of California at San Francisco (UCSF) and went on to become a skilled attending physician,1 researcher, and director of the Pre-Operative Program. In 1999, she achieved great renown for discovering a vaccine for an infection associated with prolonged ventilator usage. This infection was the leading cause of death in the intensive care unit (ICU). In 2008, ready for her next challenge, Dr. Wiener- Kronish accepted the position of anesthetist-in-chief at MGH, becoming only the fourth person to hold the prestigious position in the 70-year history of the Department of Anesthesia, Critical Care and Pain Medicine (DACCPM). Located in Boston, Massachusetts, MGH was founded in 1811, making it the third oldest hospital in the United States. With 907 patient beds across a 4.6 million square-foot campus and almost 23,000 employees, it was one of the largest hospitals in the country and Boston’s largest private employer. U.S. News & World Report consistently ranked MGH as one of the top five hospitals in the nation, and patients traveled from all over the country to receive treatment there. It was also home to the Ether Dome, an amphitheater that served as MGH’s first operating room (OR) and became the birthplace of anesthesia when ether was first publicly administered there as a surgical anesthetic in 1846.2 The DACCPM received its official charter in 1938 and since then has maintained its position as a leader in innovative anesthesiology research. The DACCPM was one of the largest clinical departments in the hospital with 278 physicians and 198 nurses, researchers and administrative personnel. This large work force was needed to support all stages of the perioperative3 patient flow: pre-operative assessment, intra-operative monitoring and care, and post-operative recovery. Due to the nature of the specialty, the DACCPM was also charged with administrative oversight in the ORs, the Post-Anesthesia Care Unit (PACU), the Pain Medicine Center, and the Surgical Intensive Care Unit (SICU). The department’s achievements across many areas of MGH, however, were being overshadowed by the persistent challenges in PATA. 1 Attending physicians have hospital admitting priveleges (the authority to provide patient care) and are primarily responsible for patient care. In contrast, interns, residents, and fellows are physicians in training and must receive attending approval for major patient care decisions. 2 Prior to the discovery of ether, surgeons had their patients drink whiskey or coat the surgical area with snow to numb the pain, even for amputations, which were common in the 1800s. 3 Pertaining to any aspects of a patientt care provided before, during, or after, and in connection to, surgery. January 3, 2012

2 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi The PATA Mission The risk of administering anesthesia had decreased significantly since the early 1990s due to major strides in research and technology. Risks were still present, however, and complications could result in permanent disability or death. Doctors, therefore, needed to know before surgery that a patient’s system was strong enough to endure anesthesia. All surgery patients were therefore required to have a “pre-admission work-up”. The PATA clinic was responsible for completing work-ups for all out- patients,4 which accounted for 43% of all surgical patients. Challenges in PATA PATA was an outpatient clinic with 12 exam rooms, a lab, and a waiting room. (See Figure 1.) Patients typically spent about 80-90 minutes of face time with providers in PATA, but even in the best-case scenario, appointments lasted at least two hours. The average appointment was two-and-a- half hours and many patients spent over four hours in PATA. Long waiting times were particularly troubling due to the goal of high quality patient- and family-focused care that MGH espoused. Many surgical patients at MGH came from outside referrals. PATA, therefore, played a big role in a patient’s first impression of the hospital. If referring physicians received enough complaints, they might start referring patients elsewhere. Figure 1 4 Out-patients (aka ambulatory patients) arrive from home to receive their care in contrast with in-patients, which are hospitalized. In-patients requiring surgery had their pre-admission work-ups completed on the hospital floor. January 3, 2012

3 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi PATA providers were equally upset. Not only were they concerned by the long wait times endured by their patients, but they also experienced direct impact. Both registered nurses (RNs) and medical doctors (MDs) were salaried with the expectation that they worked from 7:00am to 5:00pm every day; appointments, however, were rarely ever completed by that time. Staying until 6:00pm had become routine and sometimes providers were there as late as 7:00pm or even 8:00pm. Tensions were growing as waiting room patient pile-ups and long days persisted. Surgeons were the final stakeholders affected by the problems in PATA. They diagnosed the patient’s medical condition and determined exactly what type of surgery was needed. They were also responsible for booking their patients’ PATA appointments, which were required within 30 days of the scheduled surgery. Because of the limited capacity, there was a common understanding that the most complex cases had priority. The cases that fell into this category, however, were not well defined. This lack of clear guidelines plus variability in surgeon assessments often resulted in sick patients not being sent to PATA while young and healthy patients were scheduled. While there was both an RN and an MD who jointly oversaw clinic activities, ownership for the clinic was shared between several departments. In addition, the clinic did not bring in any revenue,5 which also made it even harder to justify additional resources. The problems associated with pre-operative assessment were not unique to MGH. There were many publications in medical journals dedicated to the topic, but these mostly focused on best practices or cautions for various parts of the process. None offered systemic solutions to fix the problems as a whole. Despite the operational challenges in PATA, the quality of care and concern for patient safety was very high. While it would have been easy to take short cuts under the pressures of decentralization, long wait times, OR delays, and grumpy patients and providers, the MGH staff remained committed to thorough pre-admission work-ups to ensure a safe and uneventful surgery. The Impact of PATA on the OR Due to limited capacity, the PATA clinic was only able to see about 65% of all out-patients. PATA, therefore, prioritized visits for patients with co-morbidities, long medical histories, or other potential complications (e.g., elderly, diabetic, or cancer patients). The remaining, typically healthier patients (i.e., a 30-year old who needed an ACL6 repair) received their work-ups in the OR on the day of surgery. The work-ups had the same requirements and were performed with the same degree of quality of care regardless of whether performed in PATA or the OR. The latter was not ideal, however, because performing work-ups in the OR often led to delayed surgery start times. There was, therefore, a clear desire to see all patients before the day of surgery. 5 Reimbursement for work-ups were bundled with surgery and anesthesia payments so PATA did not bill separately for its services. 6 A torn anterior cruciate ligament (ACL) is a common injury among athletes. January 3, 2012

4 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Each day at the MGH, it took hundreds of employees to undertake the formidable task of simultaneously coordinating 135 surgeries (34,000 surgeries per year) across MGH’s 52 operating rooms. Having to perform pre-admission work-ups in the OR put additional strain on the already overloaded surgical staff and resources. Incomplete and missing work-ups often led to delayed surgery starts. As everyone who worked in the OR was well aware, if the first cases were delayed, there would be an avalanche of problems and delays throughout the day. The OR director frequently had to make a tough call: go into overtime or cancel surgeries. Running the ORs into overtime was very costly but the impact on the staff was an even bigger problem. OR teams were asked much too frequently to cancel evening plans and stay late. On the other hand, cancelling surgeries upset patients and families who often came from long distances and had prepared many arrangements (transportation, time off from work, home nursing care, etc). There was also the physical component of having to fast for at least eight hours prior to surgery and the emotional component of mentally preparing for it. Asking a patient to go home (or stay an extra night in the hospital) and come back to the OR the next day was therefore not a favorable option. Fewer surgeries also meant less revenue. The OR director estimated that OR delays contributed to 57,000 minutes of lost productivity every year. The hospital could simply not sustain these losses. The PATA Task Force Many valiant efforts were made by the OR director and the DACCPM executive director to improve the pre-operative assessment process. DACCPM Executive Director Susan Moss was the most senior administrator in the DACCPM and she worked closely with Dr. Wiener-Kronish to manage the department (these types of relationships were sometimes referred to as “suits and scrubs”). In 2005, Moss, the OR director and other hospital leaders put together a proposal to build an additional PATA clinic. Space was available at the Mass General West (MG West) satellite hospital in Waltham, Massachusetts and market research showed this would be a preferred location for a significant proportion of PATA patients. Building a second clinic here would enable the hospital to see 100% of surgical outpatients and provide the freedom to try a new practice design without disrupting MGH culture. Despite the robustness of the proposal, PATA was still a cost center and ultimately the MG West site was allocated to another (revenue generating) department at MGH that also asked for the site. The group then moved to trying to include PATA fixes in larger projects aimed at improving the overall perioperative process. These broader-scope projects had insurmountable fiscal, political, and cultural hurdles of their own, however, and as a result never came to fruition. In 2008, because of her deep concern about the challenges in PATA and her experience as the director of the Pre-Operative Program at UCSF, one of Dr. Wiener-Kronish’s first actions as the new chief was to form an official PATA Task Force. Moss was asked to lead the team, which included Dr. Wiener-Kronish, the January 3, 2012

5 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi associate chief nurse of Patient Care Services, the PATA nursing director, the PATA medical director, and the OR medical director. Building on their lessons learned from past attempts, the task force focused only on solutions that would require changes internal to PATA. They considered improving triaging,7 providing online rather than in-clinic patient education about what to expect on the day of surgery, and switching from paper to electronic medical records. However, additional funding, personnel, and space would have been required to execute these ideas. In addition, while it was recognized that all of these efforts would certainly help, the task force knew they would not target the major source of the problems in PATA. Despite these obstacles, the task force continued to think creatively about ways to improve PATA. In May 2009, Moss added a seventh member to the task force, an MBA intern from the MIT Sloan School of Management who had been hired to conduct a current state assessment of PATA’s processes and performance. The clinic was run almost entirely on manual systems so data collection required several weeks of interviewing staff, shadowing patients and providers, conducting time studies, and mapping workflows. The data confirmed that most patients spent more time waiting than they did with an actual provider. (See Figure 2.) More broadly, the data revealed a complex system with significant variability, but also some hope for the future of PATA. 7 The process of prioritizing patients based on their medical needs. January 3, 2012

6 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Figure 2a PATA Patient Visit Detail, July 13, 2009 Patient # Time In Appointment Time Out Length of Service Exam 1st 2nd Time Visit Room # Provider Provider January 3, 2012 7 1 6:59 2 6:59 3 6:59 4 7:15 5 7:15 6 7:15 7 7:23 8 7:45 9 7:45 10 7:45 11 7:55 12 8:15 13 8:15 14 8:15 15 8:15 16 8:47 17 9:10 18 9:15 19 9:15 20 9:17 21 9:27 22 9:45 23 10:04 24 10:07 25 10:15 26 10:15 27 10:16 28 10:45 29 10:45 30 10:45 31 11:04 32 11:04 33 11:15 34 11:15 35 11:30 36 11:48 37 11:49 38 11:51 39 11:55 40 12:15 41 12:47 42 12:57 43 13:12 44 13:15 45 13:28 46 13:45 47 13:47 48 13:50 49 14:00 50 14:00 51 14:16 52 14:38 53 14:43 54 14:52 55 15:00 7:00 8:40 7:00 9:10 7:00 8:40 7:30 9:37 7:30 9:18 7:30 8:30 7:00 10:23 8:00 9:37 8:00 9:33 8:00 10:24 8:00 10:29 8:30 10:45 8:30 10:40 8:30 10:32 8:30 10:02 9:00 10:23 9:00 13:01 9:30 10:47 9:30 11:20 9:00 11:29 9:30 11:29 10:00 11:53 10:00 14:18 10:00 12:14 10:30 12:59 10:30 13:56 10:30 12:35 11:00 12:26 11:00 14:05 11:00 13:15 10:30 13:45 11:00 14:16 11:30 14:34 11:30 13:37 11:30 13:42 add-on 15:27 11:30 14:10 12:00 14:14 12:00 16:30 12:30 14:29 13:00 16:04 13:00 15:49 add-on 15:42 13:30 14:55 13:30 16:10 14:00 16:11 14:00 16:15 14:00 15:42 14:30 16:16 14:30 15:31 14:30 16:54 14:30 16:51 15:00 17:20 15:00 17:13 15:00 16:57 1:41 ORTH 7 2:11 ORTH 9 1:41 NEUR 5 2:22 ORTH 6 2:03 ORTH 4 1:15 ORTH 3 3:00 ORTH 12 1:52 ORTH 11 1:48 CARD 1 2:39 UROL 8 2:34 GYN 7 2:30 SONC 5 2:25 ORTH 10 2:17 UROL 4 1:47 SONC 3 1:36 GYN 9 3:51 NEUR 11 1:32 ORTH 2 2:05 UROL 3 2:12 CARD 1 2:02 GYN 6 2:08 OMF 9 4:14 GENS 7 2:07 UROL 8 2:44 GENS 3 3:41 TRNS 5 2:19 UROL 10 1:41 THOR 2 3:20 NEUR 12 2:30 SONC 6 2:41 OMF 4 3:12 GENS 9 3:19 UROL 5 2:22 OMF 1 2:12 UROL 10 3:39 SONC 11 2:21 GYN 2 2:23 NEUR 8 4:35 SONC 10 2:14 GYN 3 3:17 NEUR 4 2:52 GENS 1 2:30 ANES 12 1:40 PLAS 2 2:42 ORTH 6 2:26 GENS 9 2:28 SONC 11 1:52 GYN 3 2:16 THOR 5 1:31 ORTH 7 2:38 ORTH 2 2:13 THOR 1 2:37 NEUR 8 2:21 ORTH 4 1:57 NEUR 7 RN1 MD4 RN2 MD5 RN1 MD2 RN4 MD6 RN5 MD1 RN2 MD6 RN3 MD2 RN5 MD4 RN1 MD7 RN5 MD8 RN4 MD4 RN2 MD3 RN1 MD7 RN2 MD6 RN3 MD3 RN5 MD5 RN4 MD8 RN3 MD7 RN5 MD2 RN1 MD1 RN5 MD6 RN4 MD5 RN1 MD4 RN2 MD7 RN5 MD3 RN1 MD7 RN2 MD1 RN5 MD6 RN4 MD4 RN3 MD5 RN1 MD3 RN2 MD8 RN3 MD2 RN2 MD2 RN3 MD7 RN5 MD6 RN5 MD6 RN4 MD4 RN1 MD8 RN2 MD7 RN4 MD5 RN5 MD8 RN3 MD6 RN5 MD3 RN4 MD7 RN4 MD4 RN5 MD5 RN5 MD1 RN2 MD2 RN4 MD6 RN1 MD2 RN2 MD3 RN4 MD4 RN2 MD1 RN3 MD5

MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Figure 2b Definition of Surgical Services MGH Surgical Services Abbreviation Name ANES CARD EMER GENS GYN NEUR OMF ORTH PEDI PLAS RAD SONC THOR TRNS UROL V ASC Anesthesia Cardiac Emergency General Surgery Gynecology Neurology Oral and Maxillofacial Orthopedics Pediatrics Plastics Radiology Surgical Oncology Thoracic Transplant Urology V ascular Figure 2c PATA Patient Scheduling over a 3-week Period Date Day # of patients # of no # of add-ons # of patients scheduled shows seen June 19, 2009 June 22, 2009 June 23, 2009 June 24, 2009 June 25, 2009 June 26, 2009 June 29, 2009 June 30, 2009 July 1, 2009 July 2, 2009 July 3, 2009 July 6, 2009 July 7, 2009 July 8, 2009 July 9, 2009 July 10, 2009 July 13, 2009 Friday Monday Tuesday Wednesday Thursday* Friday Monday Tuesday Wednesday Thursday* HOLIDAY Monday Tuesday Wednesday Thursday* Friday Monday 53 2 58 3 59 5 59 9 50 4 54 3 60 5 59 4 60 6 51 5 — — 59 4 58 6 58 5 53 4 53 5 58 5 3 54 2 57 3 57 3 53 5 51 4 55 3 58 3 58 1 55 4 50 — — 3 58 4 56 3 56 2 51 4 52 2 55 Average 56.4 4.7 3.1 54.8 * The clinic does not open until 9am on Thursdays to accommodate Grand Rounds and other hospital educational activities January 3, 2012

8 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Overview of the PATA Clinic In PATA, a laboratory technician, a nurse, and an anesthesiologist saw each patient. The lab tech was responsible for obtaining vital signs, an EKG,8 and blood samples. The nurse completed a standardized nursing assessment form. The anesthesiologist assessed the patient’s overall health and obtained the patient’s consent for anesthesia. While all aspects of the appointment were conducted to ensure patient safety and quality of care, the nursing assessment form and anesthesia consent form were also required by law and had to be completed by an RN and an MD, respectively. The required pre-admission work-up was complete when each of these three providers had completed all the necessary exams, tests, and documentation. Each day the PATA nursing director scheduled five lab technicians, five nurses, and eight anesthesiologists. Patient Scheduling Clinic hours were Monday through Friday from 7:00am to 5:00pm. Four patients were scheduled every half hour beginning at 7:00am and ending at 3:00pm, except during the lunch hours when there were only two patients scheduled at 12:00pm, 12:30pm, 1:00pm, and 1:30pm. The appointments were managed with an MGH software program that allowed surgeons’ offices to log in and schedule patients for a PATA appointment. They could select any available date and time, as long as it was within 30 days of the scheduled surgery. Each day, including add-ons and no-shows there was a fairly consistent average of 55 patients per day. Check-In There were two front desk attendants in the PATA waiting room, one of which was assigned to greet patients, locate their medical chart, document their time of arrival, and give them a form to complete. This entire process took about two minutes. The attendant would then walk the patient chart back to the lab and leave it in a holding bin, signaling to the lab technicians that a patient had arrived. Sometimes, when several patients arrived at once, multiple charts would pile up on the front desk before the attendant had a free moment to walk them back to the lab. Nevertheless, charts were typically transferred within 15 minutes of a patient’s arrival. The other attendant was assigned to answer phones, enter data, and process paperwork. Vitals and EKG The laboratory was split into two services: 1) two stations to take patient vitals and EKG at the beginning of the appointment, and 2) three stations to take patient blood samples at the end of the appointment. Providers needed the vital signs and EKG to evaluate a patient’s health, which was why this step was done first. For about 10% of patients, the anesthesiologists needed to make amendments to the standard blood work order forms based on the patient exam. Therefore, to avoid sticking patients with a needle twice blood draws were done at the end of the appointment. A total of five lab technicians, trained to work at either station, were scheduled each day. When a lab tech saw a patient chart in the holding bin, they would call the patient back from the waiting room. They would take the patient’s vital signs first, which consisted of heart rate, blood 8 An electrocardiogram (ECG or EKG) is a diagnostic tool that monitors heart rhythms and conduction. January 3, 2012

9 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi pressure, height, weight, temperature, and room air oxygen saturation. Next, the patient would be asked to lay flat while leads were placed on the patient’s chest for the EKG. The EKG recorded cardiac rhythms, which were later reviewed by the anesthesiologists for any abnormalities. The entire process took an average of ten minutes9 per patient. When the technician was done, they would record the patient’s vital signs on an index card (Figure 3) and attach the card and the EKG printout to the patient’s chart. The patient was then escorted back to the waiting room and the technician would notify the charge nurse that the patient was ready for the next provider. Figure 3 PATA Appointment Tracking Card This card was used to track a patient’s PATA visit. The front desk stamped the reverse side with the patient’s name and medical record number (MRN) and then entered the date, appointment time, and arrival time on this side. Lab techs recorded the vital signs, which were later transcribed into the patient’s medical chart by the anesthesiologist. All providers initialed next to their provider type. At the end of the appointment, before the front desk let the patient leave, they verified that all steps of the appointment had been completed and wrote in the departure time. At one point, each provider recorded the time their session with the patient started (IN) and stopped (OUT), but those fields had not been used in a while. The cards were stored for two weeks after the appointment and then discarded. The Charge Nurse The charge nurse was the director of patient flow, an essential role in PATA. This person kept track of add-ons and no-shows, assigned patients to rooms, and providers to patients. Their role was to keep the patient flow through PATA moving smoothly at all times. Each morning, a printout of the appointment schedule was taped to the back wall where the charge nurse had the best vantage point to monitor clinic activity. Next to each patient’s name were empty columns for Room #, RN, and MD. (See Figure 4.) 9 Standard deviation for vitals and EKG time was 3 1?2 minutes. Index Card Key: BP: T: P: R: O2 SAT: HT: WT: Blood pressure Temperature Pulse Respiratory Rate % oxygen saturation of blood Height Weight January 3, 2012

10 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi Figure 4 PATA Appointment Schedule and Charge Nurse Flow Sheet* *All patient information shown is fictitious data to protect patient privacy and comply with privacy regulations but is similar to actual information posted in PATA. January 3, 2012

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Kelsey McCarty, Jérémie Gallien, Retsef Levi When evaluation of vital signs and the EKG were complete, the lab technician would place the patient’s chart in the charge nurse’s holding bin to signal that the patient was ready to be seen by an RN. The charge nurse would call the patient back from the waiting room and escort them to an empty exam room. She would then write the exam room number on the schedule under the “Room #” column to communicate the location of the patient. If all rooms were taken, the patient would remain in the waiting room until one became available. Regardless of appointment time, patients were seen in the order they arrived by whichever lab technician, RN, or MD was first available. After a patient was escorted to an exam room, the charge nurse would find an available RN to assign to the patient and then enter that provider’s initials under the “RN” column. When the RN had completed the exam, their initials would be immediately crossed out. This signaled that the RN step was complete and the patient was ready to see an anesthesiologist. The charge nurse would then find an available anesthesiologist and write their initials on the schedule under the “MD” column. Similar to the RN, when the anesthesiologist was done, their initials would be crossed out to signal that the exam was complete. The charge nurse would then highlight the patient’s information to communicate that the patient had left and the room was available. The charge nurse was also responsible for managing the lunch hour. In theory, the charge nurse would give providers half-hour lunch breaks that corresponded with ebbs in patient arrivals, but this alignment proved very difficult. Often, the charge nurse would send providers to lunch when the clinic seemed quiet, only to have multiple new patients walk through the door just as they left. The system basically came down to staggering the lunch breaks and “crossing fingers” that patients wouldn’t build up in the waiting room while providers were out. As a result, during the 12:00pm to 2:00pm lunch period, there was typically only one front desk attendant, one vital/EKG tech, two RNs, four MDs, and two blood draw techs on duty. Even outside of lunch breaks, PATA ran very unevenly. Sometimes multiple providers were ready and waiting, other times a patient might have to wait for an hour before they were seen. While the charge nurse’s schedule was helpful for tracking patients, rooms, and providers, there were several challenges with this system. If the nurse or a provider forgot to write in their initials, two providers might think they were responsible for seeing the same patient. Conversely, sometimes initials would be written in but the provider didn’t realize they’d been assigned. The first scenario led to redundancy and waste of previous provider time; the second left patients waiting for up to an extra 30 minutes. Another problem was that the system relied on providers informing the charge nurse when they were available. If no patients were waiting to be seen, providers would often leave to get other work done or take a break. When a patient did become available, the charge nurse then had to leave their station to find an available provider. This increased the time patients spent waiting and sometimes led to the charge nurse missing important patient flow events while away from the station (i.e., an RN completing an exam but not crossing out their initials). January 3, 2012

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Kelsey McCarty, Jérémie Gallien, Retsef Levi Registered Nurses Five RNs10 were on duty in the clinic each day. Their primary responsibility was to complete nursing assessment forms for all patients. The form consisted of a series of questions about the patient’s medical history, mental health, and social welfare. It was a regulatory requirement and could not be completed by the patient, a physician, or other third party. RNs would review the recent medical information in the chart left by the lab tech in the holding bin. Some RNs would also log into the electronic medical record system and review the patient’s complete history.11 These longer reviews could take up to 20 minutes for RNs who felt that this level of thoroughness was necessary to ensure quality of care. Other RNs felt that reading through the entire record was an invasion of privacy,12 not needed to complete the form accurately and a consumption of precious time that could be better spent seeing more patients. Across all RNs, the average chart review time was five minutes. Once in the exam room, completing the nursing assessment form took an average of 27 minutes per patient. After the appointment, nurses also needed some time to complete additional documentation and file the paperwork. On average, this took 11 minutes per patient. Anesthesiologists The process for anesthesiologists was similar to the RNs, but their assessments were more complex. More time was therefore required at each step – an average of 10 minutes for patient chart review and 17 minutes for post-exam documentation. Once the RNs left the exam room, the first available anesthesiologist was assigned. Since the MDs did not need the documentation or notes from the RN exam, they could enter the patient room as soon as the RN left. For the patient exam, the anesthesiologist began by entering the vital signs from the index card into the patient’s electronic medical record and reviewing the EKG from the lab. They then followed a medical history and physical exam interview protocol that included asking the patient about their medical history, surgical history, prior experience with anesthesiology, family history with anesthesiology, smoking, alcohol, and drug use, medications taken, allergies to medications or latex, and level of physical activity. They listened to the patient’s heart and lungs and examined the mouth, eyes, abdomen, and neck. They also explained the risks of anesthesia and what to expect on the day of surgery. Finally, they reviewed the blood work order form and added or removed tests as needed. If the anesthesiologist cleared the patient for surgery, the visit concluded with both the patient and the anesthesiologist signing the anesthesiology consent form. 10 An RN is the standard nursing degree. There are also many advanced training specialized nursing degrees that allow for an expanded scope of practice, which partially, or sometimes almost completely, overlaps with physician privileges. These include nurse practitioners (NP), certified nurse anesthetist (CRNA), certified nurse midwife (CNM), etc. 11 At the time of the case, MGH was in the process of switching to electronic medical records (EMRs). Since not all departments were using them yet, the most recent physician notes and test results were maintained in a paper chart. Older information could only be found in the EMR. 12 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 includes many patient privacy laws, including that providers may only access patient information if it is necessary to provide quality care. January 3, 2012

13 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi The length of the visit could vary wildly. Long medical histories, many medications, the need for a translator, missing diagnostics, or a patient who was a “talker” were just a few things that could add time to an exam. Exams ranged from 15 to 70 minutes, but on average they lasted 37 minutes per patient. There were many factors that contributed to variability for both nurses and anesthesiologists at other stages of the appointment as well. Phone calls, disorganized charts, or the need to consult with a colleague could all add time to an appointment. The time study, therefore, attempted to capture this variability, which was reflected in the standard deviation (21 minutes for RNs and 29 minutes for MDs13) for the collective three-step – the pre-exam chart review, patient exam, and the post-exam chart documentation – provider process. After the exam, the doctor would walk the patient back to the waiting room and give the blood work order form to the front desk. Next, they crossed their initials off the charge nurse’s schedule and entered their physician���s note with detailed observations of the patient, reasons why they did or did not clear the patient for surgery, and any special conditions that the OR anesthesiologist should know.14 The note, the completed nursing assessment form and a copy of the blood work order form were added to the chart, which was then deposited into a final holding bin and filed until the day of the surgery. Blood Work When the front desk received the blood work order form from the anesthesiologist, they immediately transferred it to the laboratory holding bin. As with the vital signs, patients were called back by a tech in the same order their blood order forms were received. Different tests required different tubes – some were coated with special chemicals, others needed to be stored on ice. The lab tech would draw the patient’s blood and prepare the required samples. This took an average of six minutes per patient .15 The patient was then sent back up front and the tubes were stored for pick up by another lab that did the actual testing. Check-Out After having their blood drawn, patients returned to the front desk with their index card. In addition to the patient’s vital signs, the card had the initials of all the providers the patient had seen. The attendants used these initials as a check that the patient had been through all the requisite steps of the appointment. If the card looked okay, the patient was finally free to leave. This last step took less than a minute, but most patients were so fed up with their PATA experience at that point, even that was too long. Occasionally, patients became so tired of waiting they simply left in the middle of the appointment. This was one of the reasons patients sometimes arrived for surgery with incomplete PATA work-ups. More often, work-ups were incomplete because surgeon offices didn’t forward patient records that 13 The average coefficient of variation for patient interarrival times was 1.0 for RNs and 0.2 for MDs, however these values could be much higher or lower when evaluating providers individually. 14 The anesthesiologist in PATA who cleared the patient for surgery was not the same anesthesiologist who cared for the patient in the OR during surgery. 15 Standard deviation is 2.0 minutes and coefficient of variation for patient inter-arrival times is 0.4. January 3, 2012

14 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi PATA physicians needed to complete their assessments. Several phone calls were often required to get the information, if it was sent at all, leaving physicians extremely frustrated by their general lack of control over the process. The June Task Force Meeting When Dr. Wiener-Kronish finished reading the patient letter, the team took a minute to take in the information, and then the ideas started flying. The PATA nursing director spoke first: “With four appointments scheduled every half-hour, the clinic is behind from the minute the day begins. We should extend the clinic hours until 6:00pm so we can increase the time between appointments to 45 minutes.” The PATA medical director had a different suggestion: “Longer appointments will mean longer days and the staff are already upset about being over-worked. What I consistently hear from my team is that the expectation to see 55 patients is just simply not reasonable. We need to either add more rooms, physicians and nurses or reduce the patient volume.” The OR medical director sympathized with the difficulty of managing a frustrated staff, but he did not completely agree with using another resource-intensive approach: “We can’t reduce our patient volume when we’re already only seeing 65% of out-patients and we’ve already tried several solutions that require asking for more people and more space and all of them have been rejected. If we really want to see positive changes in PATA, we’re going to have to figure out how to run the clinic better with the resources we already have.” Moss listened carefully and then commented: “Each suggestion seems reasonable in theory, but no one has presented methods for evaluating the actual expected impact on the clinic. Also, while improving the clinic without any additional resources sounds great, what would that actually look like?” The intern finally spoke up: “I could evaluate the impact of these scenarios using the data collected in the time study. (Figure 2) The review also highlighted some opportunities for increased efficiency that may be able to address your idea of improving PATA without more resources.” Whichever direction the task force would choose to go next, Moss knew that detailed analysis would be needed to guide and support the group’s decision and obtain buy-in from key members of hospital leadership: “Alright, let’s see what your analysis tells us. Let’s meet at the same time, same place next week. Everyone, be prepared to discuss what changes make the most sense in light of the new process analysis data. Take a really hard look at what has to be done, who can do it best, whether we are leveraging technology as much as we should, and let’s generally challenge all existing assumptions. Everything about this process should be on the table.” January 3, 2012 15 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 1 PATA Patient Intake Form January 3, 2012

16 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 2a Nursing Assessment Form (pages 1 and 2 of 6) January 3, 2012 17 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 2b Nursing Assessment Form (pages 3 and 4 of 6) January 3, 2012 18 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 2c Nursing Assessment Form (pages 5 and 6 of 6) January 3, 2012

19 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA) Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 3 Anesthesia Consent Form January 3, 2012

20 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 4 Surgical Consent Form January 3, 2012

21 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 5 Provider Variability (data collected over 10 days) p-values for two-sample t tests RN1 vs. RN2 RN1 vs. RN3 RN2 vs. RN3 0.0024 0.0046 2.05E-09 January 3, 2012

22 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi Appendix 6 Photos of PATA Upper left: A patient checking in at the front desk Upper right: A lab tech checking a patient’s blood pressure Bottom left: A lab tech preparing an EKG bed Bottom right: Hall to exam rooms 1 to 5 January 3, 2012

23 MASSACHUSETTS GENERAL HOSPITAL\’S PRE-ADMISSION TESTING AREA (PATA)

Kelsey McCarty, Jérémie Gallien, Retsef Levi Upper left: Patient exam room Upper right: The charge nurse station at the back of the clinic Middle left: Providers reviewing patient histories and writing up exam notes Bottom left: A lab tech labeling blood samples Bottom right: The blood work lab January 3, 2012 24 Integrated Case Brief • Think of this report as a consulting project – presented to the managing committee. • Paper Requirement: • The case analysis includes: • Overall, your task is to analyze the operations; discuss the specific problems and challenges and suggest operational processes (using various models that you have learned) that will provide solutions • Critically analyze (what you consider to be relevant and applicable to the case situation): 1. Layout design 2. People related challenges 3. Scheduling issues 4. Capacity utilization 5. Work-flow, troubleshooting, Maintenance 6. Bottleneck analysis 7. Compliance and controls monitoring 8. Can JIT & lean operations obliterate concerns 2. Challenges of operational issues while conducting business e.g. waiting times 3. Design solutions – going forward – to reduce the challenges 4. Strategies to make the business more successful 5. Lessons learned & Conclusion Include relevant and appropriate flow-charts and graphics – as you studied in the various chapters. 1. Challenges 2. Inventory / Scheduling / Troubleshooting / Compliance Mentoring / JIT & Lean Operations 3. Operation Challenges / Design of Solutions / Strategies / Lessons Learned This criterion is linked to a Learning Outcome Challenges 2. Operation Challenges / Design of Solutions / Strategies / Lessons Learned

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