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The right way to release and request block time webinar transcript


SANJEEV AGRAWAAL: Thanks, Sandy. Good morning. And good afternoon if you’re on the East Coast. Apologies, again, for the little hiccup this morning, but glad you could join us. So what we’re going to talk about today is part of a bigger webinar series we’ve been conducting. And today’s focus is on how you get the most out of your existing. OR capacity, specifically focused on one process, which is how to release and request time. And we’ll talk about that for the most part, today. As Sandy said, my name is Sanjeev Agrawaal. I’m the President of LeanTaas. 


And just to give you a sense of the full webinar series, there are five webinars as part of this series. And today, we’re on the third. If you can see my screen, the first one with an overview of how to get the most out of your existing OR capacity that covered all the topics in the webinars in this series. If you haven’t seen that and wanted to get an overview, it should be on our website. You can access that through Similar to the. September 13 webinar, where we talked about how to take block time away through the OR committee process that most hospitals have, how to right size block using a much better metric than block utilization, but focusing on collectible time that focuses on truly repurposable chunks of time that can be gathered and repurposed to put cases in. 


Today, we’re going to focus on another major inefficiency in the way time is left in the OR. And that has to do with how when a block owner cannot use their time, whether they know it or not, how do we get them to release it, and how do we make that really simple for others to access and put cases in. Two weeks from now, we’ll talk about how to engage with performance metrics in a way that surgeons and administrators can take decisions as opposed to just admire the problem, as we like to call it. And then, finally, in October the 11, we have a webinar on the right way to allocate time. Because fundamentally, we believe, these are the big issues. 


How to allocate time, how to take time away, how to release and request time, and how to measure and report the right things are the major reasons why time is left on the table in most ORs we work with. So let’s get into it. The last housekeeping thing I’ll tell you is that this webinar, along with all the others, is based on our experience working with almost 500 ORs now across 14 of the largest health systems in the country. Most of these you will recognize. So this set of knowledge was first built at University of Colorado Health. And then, these 14 health systems are somewhere along the process of deploying tools that we, as a company, has built. This webinar is not about those tools. 


It’s really about the thinking and philosophy and methodology behind the product called iQueue. As you can notice, it’s set of academic, community, small, large, across the CHR,. Epic, Cerner, MediTech, Paragon type institutions. Most of whom, you will recognize. In addition, we’ve had over 50 other provider conversations that have led to the creation of the IP that you’re going to see. So for those who’ve seen the previous webinars, this will be familiar. But if you haven’t, what is the basic problem we’re trying to solve? The basic problem we’re trying to solve is every OR in the country has allocated their time into some block and some open time as well as some trauma. But the way that block time is allocated has a fundamental underlying assumption in it. 


So if today, an OR committee meets and allocates blocks to various service lines and surgeons and groups, the underlying assumption they make is that whoever they are giving time to will be able to predictably fill the time they’re being given in a way that is consistent and uses that time well. Now, because we’re not making tennis court reservations, instead we’re predicting the volume of cases, the length OF cases. We’re predicting that we understand seasonality, for example, that never really happened. 


So let me start with a story of what happens when that doesn’t happen. So as a parent of two kids, I was at a Children’s Hospital a few weeks ago. Now, one of the surgeons there that if I brought my child in for an elective surgery, when they could fit my child in? And it was a hypothetical question and they said that they were fully blocked. Themselves had blocked time on Wednesdays. I happened to be talking to them on a Thursday. And they said, well,. I’m fully blocked out for the next six weeks. I have patients in my blocked time. I couldn’t fit your child in for a G7 weeks. So I looked at them and I said, seriously, you’re going to make me wait to get my kid into the OR seven weeks? And I know I want you at my kid’s surgeon because you’re the most awesome kid’s surgeon I know for the case that that I wanted my kid in for. 


And they said, yes. And so I said, well, if I walk through your ORs today with you, and tomorrow, and on. Monday, and all of next week, are you telling me that every. OR would be full all the time and will be being used by the individual or group that you reserve capacity for? And, of course, they laughed and they said, obviously, life doesn’t work according to a blocked schedule 100%. Einstein could build my block schedule and we’d still have issues with it because, you know, people have conflicts and they don’t have enough cases sometimes to fill their block. So the dilemma here for me, as a parent, was you’re telling me on one hand that for seven weeks you couldn’t fit my kid in. And on the other, you’re telling me that if we walk through the ORs today, tomorrow, and every day of the week, there is time left on the table. Especially, because OR time is so precious, if you do a back of the envelope calculation, every percentage point of increased utilization in the OR is worth anywhere between $50,000 and $300,000. 


So how can it be that on any given day I can’t find time and at the same time there is time on the table? So OR time is precious, but never available, yet reserve time is left on the table each day. So when we poke under the hood a little bit, we realize some of the same things I talked about at the beginning of the webinar. The fact is well our capacity is sacred. And when we allocate it and reserve it, we’re making a few assumptions that lead to this situation I described with my child. One is when you give long time away to any block owner, it becomes a rite of passage. Taking that time back is hard enough. Taking that time back if you use block utilization as a metric is almost impossible, because it’s just fundamentally the wrong metric. That was the last webinar. So I won’t spend time on that. 


Suffice it to say there is a much better metric called collectible time. Today, we’re going to talk about the fact that on the margin, even if we do a phenomenal job with the block allocation, six weeks a year, roughly, every block owner will have a conflict with the time that they have in reserved. Two weeks, everybody takes vacation. A couple of weeks, they’re out at conferences. Sometimes, they have teaching obligations. Sometimes, they have clinic conflicts. Sometimes, they don’t have enough of a book of business. And so when that happens, we have found that most hospitals we work with before, we start working with them have processes in place, where they can release time to a department, they can put it on outlook. If they don’t, then there is this auto-release mechanism in every EHR that allows you to take time away seven days or 14 days or 21 days before day off. 


With all due respect, most of those methods leave a lot to be desired. Most of those methods leave a lot of time on the table, mainly because tools like auto-release are a blunt instrument. They’re like taking a baseball bat to something that needs a surgeon’s scalpel. So today’s about what’s the right way to do requests and release of time. And like I said that these couple of webinars will be focused on engaging physicians with their data, how to allocate blocks right, and then one of case like deestimation. So just to backup what. I was saying earlier, let’s start with why exactly do we have this phenomenon, where when we allocate time there’s time left on the table on the margins. What you’re seeing here is real data anonymized across multiple hospitals we work with, where each of these lines on this graph is the volume of cases that an orthopedic surgeon has done. And obviously, if you add these up, you’ll get the total number of cases– sorry it’s minutes– it’s a number of minutes in the OR, which can be translated into a number of cases. 


But as you can see, it’s not a smooth line that’s either flat or going up and to the right. It is as you would expect a fairly jagged line. For some folks, it’s trending upwards. For some folks, it’s staying fairly flat. For some, it’s trending downwards. Because when we make block allocation decisions, we cannot, nobody on the planet, can very precisely and accurately predict exactly how many cases. If I’m the surgeon, I will do each day of the week. And by creating an artificial construct like Dr. Agarwal, I’m going to give you. Wednesdays forever, what you’ve done is you’ve assumed that my book of business into my clinic. How many of those patients will need elective surgery is highly deterministic into the future when it’s really not. And so, when life happens, you get seasonal trends, you get vacations, you get clinic conflicts, you get conferences, et cetera, et cetera. And that leads to an actual utilization that resembles these curves. I’m sure, if you were in a hospital, you’ve seen this for yourself. 


So one reason why this happens is that there’s variation in what we predicted the number of cases people would do versus the actual number of cases they do. The second big driver of why block allocation doesn’t work out quite as we always would want it to is the fact that the length of each individual case is also variable. Again, no new news to anybody. But if I plot how long the case took versus how long we thought it was going to take. So actual case lengths minus estimated case length, what you’re seeing here are three graphs for short, medium, and long lengths of cases. And as you would expect, they fall on a bit of a normal curve, meaning, in this case, at the top, 61% of cases are fairly tightly packed within 30 minutes, meaning if I expected the case to be two hours long, it was between an hour and 2 and 1/2 hours long. 


But then there are some times that cases take a lot less time and sometimes they take a lot more. So the second reason why time is left on the table is, again, Einstein couldn’t actually go ahead and predict precisely how long that specific case was going to take. But you could estimate the length of a case within the margin of error. But for a specific case there will always be the spectrum. So if we combine the fact that we cannot be completely accurate about how many cases someone’s going to do with the fact that we cannot possibly predict how long each case is going to take, the result of that is that time will always be less than on the table on any given day, which was my experience at this Children’s Hospital. 


So when you talk about creating open time, releasing block, and requesting block, the three fundamental problems are– one, when I need to pick up time, even if I’m a block owner I might need to pick up time outside my block because I see more patients than. I expected on the given day, and I need to do add on cases. Not necessarily trauma, but I have more cases that I have blocked time for. At the same time, there might be other block owners in the hospital who have blocked time who don’t, for seasonality reasons, or clinic reasons, or vacation reasons, not be able to use their time. So can we come up with a method that’s a little more 2018 than the process of letting my clinic scheduler know that he or she needs to release my time. 


On the other side, someone needing time, calling the OR repeatedly, and saying, give me time, give me time, give me time. So what we’re going to show you is a set of tools today that proactively help you create open time and a corresponding series of tools that allow transparency and visibility into the availability of that time in a way that is ubiquitous, in a way that is transparent and fair. So it boils down to three basic problems. One, in a world where blocked schedules are full in many hospitals, and building new ORs is really not an option by snapping our fingers, how do we make sure that no block is left behind? If I cannot use my time, people have significant future warning that I won’t be able to and can request that time. And second, how do we make these transactions happen in a way that doesn’t require human beings to play middle people? So if you think about the world outside the OR, no one makes restaurant reservations by calling 50 restaurants for the most part anymore. 


We call OpenTable, or we look at OpenTable online, and we see inventory of available time– open inventory of restaurants. Similarly, if we want to make travel reservations for a vacation, nobody calls a travel agent anymore. Yet in the OR, both to create open inventory and use open inventory, the number of phone calls and email and post-it notes and calls and people walking into our schedulers offices is remarkable that it still happens in this day and age. So let’s now talk about this notion of auto-release. Every hospital that we work with has an existing method where service lines and block owners let other people know that they won’t be able to use time. And if they don’t, they have a way of automatically taking that time away at a certain point in time before the day off. We’ve seen rules like as little as three days to as many as 14 days, whatever that auto release mechanism is. 


Now, the reason why that’s a myth, and you can do a lot better than that, is what you’re seeing on this page, which is also real data. What this is showing you, on the x-axis, is the number of days before the day of surgery that people have booked their cases. And what it’s showing on the y-axis is the percentage of cases that were booked at that point in time. So each colored graph is a distribution by block owner. We’ve picked for service lines in this case, but we could do this for every service line, every block owner, every surgeon. That if we look historically at when they book cases, how many of them they booked, how long before the day of surgery, it follows a certain pattern. The vertical bars are median, meaning this vertical bar says that there is one service line, in this case that happens to be OB-GYN that books 50% of the cases that they do about four days in advance, in the case of this particular hospital. 


Similarly, if I take the blue curve, which is general surgery, about 27 days. So what exactly does it mean to have this thing called a seven-day aut-release? What sense does it make? Because if I am one of these. OB-GYN surgeons that owns time or if my group owns time, then even 30 days before day off, if I own a block and. I put no cases in it, you have a pretty valid reason to look at that and say, you know,. Dr. Agarwaal, you tend to book your cases 40 days in advance on average. You have time 30 days from now. You don’t have any cases in the grid. Are you actually going to use your time or think about releasing it? Because you know what, there are many other people that could use that time. Much like a dentist’s reminder would come to you and say, hey, are you going to you going to show up. If not, there’s plenty of people in line waiting to use the slot that you cannot use. 


So a much finer grain analysis of booking patterns by block owner will reveal that there are many better opportunities than this auto-release mechanism. So let’s get into how this might work. Imagine a world where the ability to find open time in the OR was quite as easy as finding a table on OpenTable or being able to book a vacation through Kayak. All right. So imagine a world in which your clinic schedulers and your surgeons, but most importantly, the schedulers in the clinic, had access to both a mobile tool and a web tool, which resembles OpenTable. So let’s say, I am. Sandy’s clinic scheduler. Sandy is the surgeon that needs time the OR. And she asks me to go get time for her outside of block. 


Remember, this is all outside a block. And if I were to request time for Sandy, Sandy has privileges to do cases in multiple locations, in this case, at University of Colorado Health. She needs two hours and, in this case, she wants it in the afternoon. And what if I could go in and I could see a whole set of open inventory of at least two hours of time in the different locations that she had access to? And I know that Sandy is. OK going to [INAUDIBLE].. And I could request that chunk of time from the available inventory. And make a request, in this case, for an alarm, because she’s a fun surgeon as anybody in the ecosystem that needs to know that Sandy requested time gets notified. 


Now, let’s say, Sandy says that she insists some doing cases on one particular day. And there’s no open time available on that day. What if I could put an alert, and say, if this time opens up on that particular day in that particular OR, let Sandy or I know. Similarly, if sandy goes on vacation and forgets to release her time, what if I could go in and on her behalf, go ahead and pretty much release time into the future with two clicks of a mobile device? So this is, by the way, a mobile browser. It’s not an app or it’s nothing that you need to download. Clearly, there’s a lot behind it which we’ll talk about in a second. But this visibility and transparency over the top into open chunks of time being available in the OR is magical. 


The biggest reason it’s magical is before you provide tools like these, we would equate what happens in most ORs as the equivalent of doing a garage sale with time that you cannot use. If the process is I tell my clinic scheduler, I whisper to someone in my service line that my time will be available. Please go ahead and use it. That’s sort of like assuming that the thing I have in my garage that I cannot use will only be useful to people on my street, and so I put it out as a garage sale piece off. I put my old amplifier out for a garage sale. Well, instead if. I put it on eBay, there might be someone can burrows down who might need it and who might be willing to pay it, or pay for it. That’s what eBay did to the world of used or not usable things for the supplier, being made available to people that had demand for that same item. When this kind of capability works, magic happens. 


The clinic scheduler’s life goes from 1,000 phone calls to the OR asking for time. And the OR scheduler’s life goes from every possible mode of communication. Their phone ringing off the hook. I’ve been in clinic schedulers offices, and it’s a high stress job. I’ve also been in OR schedulers offices, it’s an even higher stress job, because you have 50 different offices. Sometimes, people walking into their office. Sometimes, people calling, emailing, texting. I’ve seen post-it notes. And I’ve always wondered do these post-it notes always make their way back into the EHR? When Sandy’s office calls to release a request time and I put it down in a post-it note, and I hang it off my wall, well, there could be a few occasions where. I forget because life’s tough. Many other people are calling at the same time. 


When this works, one of the other biggest benefits is, imagine, being able to give your new surgeons, who you couldn’t give block time to because you were fully blocked out, the ability to build a book of business by using this open time and showing I can do a lot of cases on Wednesdays and making a case to the block committee for getting Wednesday blocked. So all round of this capability works for new surgeons, for existing surgeons that have blocked time, for existing surgeons that don’t have block time, for the clinic schedulers, for the OR schedulers. It’s leaning out a highly manual, highly cumbersome process, and making it far more egalitarian for everyone to use. We’ll show you the results when we get through it. Now, there is an equivalent that you can do online. 


So imagine that the same capability to just sort through that web, through the mobile application on the browser, is available to be used on the web. So here you are seeing an interface online. And the URL is simply [INAUDIBLE].. Ignore that for a minute. Imagine if your clinic scheduler had access to a tool like this. And I’m showing you a real live website here. And I’m showing you, to all the tenants that are live on this, I’m showing you Metro Denver, which happens to be University of Colorado, where this was first developed, where they’ve been able to absorb 17 new surgeons now, and not given them block time but may help them by using this tool. Imagine as a clinic scheduler,. I could go in and do pretty much the same thing. I’m looking for time for Dr. Adams. 


In this case, let’s say, I need robot time. Let’s have a simpler example. Let’s say, I need three hours for Dr. Adams. Dr. Adams doesn’t care if it’s morning or afternoon. She just needs to fit in on it. And let me sign in. And in fitting that add on in, she wants to know where almost all the facilities that she has access to, she could get time, or I could get time on her behalf. So I need three hours of time for Dr. Adams. And I search for it. And now, I get a calendar view of all the times that are actually open. And like I said, it’s not surprising that almost every day in the OR, unless it’s a very specialized request for a robot’s room or some other kind of capability, I would find open time. We’ll also talk about how we create this open time in a second. 


Similarly, if I wanted to go release time that belonged to Dr. Adams, very same ability to do that indicate she’s not a block owner. And the beauty of this is because block owners can get access to open time as well, this makes it very surgeon-centric and makes a lot of non-block owners very, very happy. Now, what happens when a request is made? When a request is made and gets logged, as a series of tasks for the OR scheduler tends to then go process. As you can imagine, the OR scheduler needs to both take the releases that were made and go update Epic or. Cerner or Meditech, whatever the EHR is, to make sure that that time is shown is open, so it can show back into the application for others to use. If it is a request for time, let’s all look at all the pending requests, and then see what was requested. In this case, it was a transfer requested, which we will talk about in a little bit. 


But let’s say, it’s a simple request for time based on what’s available. You can go in and you can go ahead and approve or deny that request based on what was that for. Similarly, as the. OR committee, you can go in and see the status of who is being a good steward of their time, who is playing by the rules, and releasing or requesting time, what’s happening when time is being released or requested way in advance to the day of surgery. So one simple experiment we did with Ohio Health was we got their clinic schedulers in a room and we asked them to just release the time that they knew their surgeons and block owners were not going to use because they were going to be on vacation. 


This experiment was done in March before the summer. And most clinic schedulers knew exactly when their surgeons were going to be away, either for vacation or for conferences, et cetera. And simply by using a tool like this, more open time was created in a day than had been created for a long time before that. Almost a couple of years put together. And that time was then made available to multiple other block owners and non-block owners who could use it. So when you use tools like this, having the ability to audit everything, every block released, every chunk of time requested, is quite powerful. In addition to statistics, like how many releases and requests are happening, how far in advance of the day off is this happening, who are my most valuable players that are releasing time ahead of time, so their colleagues and their counterparts could use that time. And the reason they are doing this is that they know if they do it and they play by the rules, then when they need time, they can also go in and request open time for when they want to do add on cases. 


So the big point is that this tool, whether it’s mobile or web, creates a significant amount of open time and makes sure that the supply-demand matching for that open time happens over the air for everyone. How to create open time? Typically, when we walk into hospital situations, some of them have existing open time outside of trauma, but a lot don’t. Many are fully blocked out and so there isn’t much open time to begin with. The first exercise you can do is like we did at Ohio Health and see if you can encourage at least known vacation time to be put into the pot, or known conflicts like clinics and teaching obligations. The second level of where the predictive power of the tools comes in is if you look at the historical booking patterns, if you remember I showed you this chart on the left in a blown up version, based on the booking patterns historically, you can start sending these release reminders. 


And these release reminders are really simple message to clinic offices saying, hey, look, Dr. Agarwaal has time 30 days from now. He tends to book his cases 40 days in advance. Did he just forget to put a case on the grid? Are you planning to use the time? And if you’re not, please consider releasing it. Now, let’s say, I say, you know what, I’m the big and important Dr. Agarwaal. I’m not going to release time. You then in the application have access to the data that says, look, I keep asking you to release time. You keep ignoring me, Sanjeev. That’s fine. It’s your prerogative. But 8 out of 10 times when you get these released reminders, you should really go ahead and release this time. You know why? Because post-fact. 


I can just show you that your historical booking pattern was quite indicative of your normal practice. What ends up happening eight out of those 10 times is the OR has to scramble to put cases in. And by the way, patients, who are trying to get into the OR faster and other surgeons that might be able to use the time that you’re squatting on, would be much better off. And, oh, by the way, if you start playing ball and others start playing ball, all of us will benefit as a surgical team as well as the OR. So the proactive release reminders go a long ways. The flip side, the sister capability of that, is the ability, if you remember, to put your name on an Amazon wish list, to be able to say, I’d like to do cases on a very specific day. There is no open time currently on that day. Would you please let me know if time opens up? 


For a system, [INAUDIBLE] to go back, and then say, OK,. Dr. Smith wants time on the 28th of the month. There is no open time. Let me go to look at people that do have blocked time on the 28th, and who has no cases on the grid and should have had a case on the grid by now. And let me surgically go and only ping their offices, and say, are you going to use the time on the 28th? Because if you’re not, there is need for it. And we have found this little mini marketplace built on top of EHR goes a very long ways in encouraging people to do the right thing. The other big reason why it encourages people to do the right thing is all of this is time-stamped and gathered as auditable data. So you can go back and refer to it and say, what happened? Much likely, Amazon buyer and seller score or the eBay buyer and seller score, where you can’t hide if I told you I was going to ship something tomorrow and I didn’t, it’ll show up in my review as the guy said he’s going to ship it the next day, but didn’t. Or someone said a book was in good condition when it really wasn’t. 


So we live in a world where all of this outside is transparently made visible and marketplaces exist quite regularly. And the reason for OR to have this many marketplace is, again, going back to the fact that every slot of time that goes under utilized is potential capacity that could have earned us dollars, more importantly, could have accelerated patient access and got my child in, for example, sooner than I could at the Children’s Hospital. Now, as you saw on the website, but just to play a short video again, the last mile of decision-making still needs to be in the hands of an intelligent human being, for example, the OR scheduler. So that this tool would be different from an OpenTable is. 


This is not a commodity table for four I’m getting you at a restaurant. Remember, you asked for an OR, or you asked for the robot room, or you asked for a specific team to be working with. The OR scheduler is well aware of the constraints of the syste– is anesthesia available? Is the OR open? Is nursing available? Is this OR going to be available on that day depending on other surgeries that are going on? So this last mile check, or should I grant you time, or should I not grant you time, still is in the hands of the OR scheduler. But their life has gone from having in seven different modes of people communicating with them to one, which is this very simple set of reviews that they get to do of release and requested time and approve or deny it. That’s number one. The second is your EHR still stays your source of truth. So all this does is much like OR scheduler would do in today’s world– allow them to go change the. EHR based on their release and request made. 


So if Dr. Smith release his time, today they would go into the. EHR and show that’s open time. Tomorrow, they do the same thing, except the signal comes through this door. Similarly, if I approve time for Dr. Jones, then I go in and I put reserved that capacity for Dr. Jones. All the other supporting processes, the case form, the patient information, the case type, whatever your current is, if your clinics have access to the EHR in their offices, they continue to submit that there, they continued to or if they fax it, for example, and you require them to fax it within 24 hours, that’s what they do today. If they don’t fax it, then the time they have been approved gets rereleased and goes back into the system for iQueue, the tool, to be able to show other people that it’s still available. 


So really what’s happened is we’ve gone from a world where potentially any release time or open time could be a tree falling in a forest that everybody doesn’t see to one in which you can put some rules in place, but by and large, most of the open time is available to anyone wanting to pick it up. Now, September is a particularly crazy month for something like this because a lot of facilities hire new faculty or new surgeons over the summer and they start in September. And if you’ve gone through a massive process of trying to identify, can I give them block time can I not give them lock time. Using tools like these, you can actually delay that decision for a long time. And say, for a lot of the surgeons that are new, for whom I don’t know how much case volume they’re going to bring in. 


If you’re actually having to allocate time to them, again, you’re making a decision to give them expensive real estate without really knowing how much business they’re going to bring in. If you show them a tool that will always have up to 15% to 20% of OR time available, as open time, and leave the onus on them to be able to prove that they can bring a book of business that warrants a full block far better than making the case before the fact. So the reason why. OR schedulers– you can imagine lab test is that even in highly blocked situations, the ability to put time on hold should it open up. Clinic schedulers love it too because in a world where you do this manually, it is very, very difficult. 


The other reason why or directors perioeprative business managers love it is the fact that you get a very deep understanding of demand. And you get a very deep understanding of supply. You get to understand who is requesting time and using it well. Who is hoarding times. Who is requesting time and rereleasing it, putting in cases that aren’t always real? Who is requesting time for three hours but actually need five. And you knew that before. Now, you have data to prove it. Did the transaction actually consummate. Was the James Smith, that a particular office put in, a real patient. All of these things become completely transparent. So the audit trail of every single release and requests made through the application is like being able to go into, and look into your bank account and see every check your own and every ATM transaction you did. So there is no he said, she said, I thought, maybe. Dr. Smith says he released time, or et cetera, et cetera. It’s all there. There is a complete audit trail where you know you can’t fight the facts. Well, I guess you could, but not a good idea. 


The other reason– that the biggest reason that this creates value in the OR is the ability to do plan predictive case– predicted cases far into the future. So remember that this notion of 7-day auto-release, 3-day auto-release. If you have rules like that in place, chances that, that becomes your median release time is very, very high because everybody plays by that rule. If I don’t release my time, that’s fine. The OR will pick it up 7 days before the fact. Well, today, I know my. Thanksgiving schedule. Today, I know when my kids have winter break. Today, I know when I’m taking vacation over Christmas. By encouraging people to release time that far in advance without hurting my practice. If I release my time I’m not hurting my practice. 


Most of our customers have made the ability to see open time into the future as far ahead as 25 to 50 days. Imagine service lines that need a longer amount of time, a longer amount of lead time to get the patient ready, to get insurance paperwork done. Imagine I need the robot from. Robot surgery tend to be scheduled with a longer lead time, typically, the non-robot surgeries. All of these things become possible in a world where I see open time in all my OR way into the future because, as we said before, at least six to eight weeks a year every block owner will not be able to use time well, and we don’t know when they will not be able to use time well. So if we have 100 block owners or surgeons that have access to the block time. If we get 50% of the amount. They should be releasing into a pot. 


For each other and everybody to use, this kind of magic happens. These are real numbers of days in advance of surgery that I find open time. The robot is a special piece of equipment so let’s talk about that specifically. Through a tool like this, you can ensure that the robot room is only used for robot cases. If I’m into the surgical, or if I’m even you. You’ve got an expensive piece of equipment and you are currently putting it in a room or if its mobile, it’s mobile. But the fact is, it’s a travesty if the robot locker is being occupied for non robot cases. When in fact, people who need the robot on that day cannot get access to it. If that kind of thing is happening, imagine being able to use a tool like this to direct only robot traffic and shield robot availability into the future clearly and transparently. 


And this applies not just for the robot, but for any specific expensive piece of equipment or specialized room where you’d like to make sure that that room is maximized in the usage of the robot or that specialized piece of equipment. There’s a lot you can do in the back end, so many customers work with specialized teams where you know that you can only have three orthopedic rooms running at any given time. In the back end, you can set up the parameters of this capability. You say, I will only allow three neuro, or three ortho, or three cardio rooms to be running at once. Because if three cases are running simultaneously in three different rooms that require that special skill set, I just won’t show to that service line, or that those sets of surgeons the availability of open time. 


So it’s three neuro rooms are already booked, I can see that in the data. The application will just not show the availability of a full-term for neuro. So you can define which rooms can be released. You can define which rooms can be requested– specialized rooms,. GI suite, CVOR suites can be restricted to cases for that particular service line. And you can make this accessible to various types of surgeons and service lines based on their specific preferences. You can also– for example, if you’re staffed differently by day of week, you can decide how many rooms you want to run for each service line even if you have 20 OR. The only one to run 18 on certain days and make sure that no more than five of them are neuro rooms. You can easily set that up when you set capabilities like this. 


Now, you can do this by hand as well. Most people today are doing this by hand, but it’s a kind of a nightmare to do it during the day, during business hours as things change. While it’s sort of like, you know, using a physical map to navigate your way from place A to place B as opposed to Waze or Google Maps doing it for you in real-time. The many other features you can build into something like this. So for example, you could decide, I only want to give full-day blocks or half-day blocks to– as being the smallest unit of time, you can request a release. Or you can say I would like the hybrid ability. People should be able to pick up time just to do a case. People should be able to release smaller chunks of time. 


Because you know what, I might have cases up from 7:00 to 2:00 but between 2:00 and 5:00, I don’t. So I should be able to release 2:00 and 5:00 because that’s long enough for someone else to put a case in. And what the system does, is it puts some intelligent rules and play– rules in place to be able to take into account turnover, to be able to take into account prep time. And if you’re requesting 2 and 1/2 hours for example, gives you three hours. The tools also gives few of the ability for the scheduler to look at a case request and say, you know what you’re asking for two hours of time. There’s no way you’re going to get this done in two hours. I’m now looking at the paperwork you sent in for the exact case, this is going to take at least 3 and 1/2. 


To tell you what, sorry, I can’t give you this because it’s going to take more than the two hours that you requested through the door. I can give you 3 and 1/2 on this day because, in fact, it’s available or I can make a counter offer to you. There isn’t 3 and 1/2 hours available on the day you want it. But let me tell you, three days down the road, there is 2 and 1/2 hours available. So plenty of customization, plenty of rules that you can build in that make life easier for everyone. So at a very high level– if we were to summarize, the right way to release and request time is to try and make the process much smoother, much more 24 by 7, much more mobile and web, as if it’s a 2018 version of. Open Table for the OR than through a process of which is a fairly manual and cumbersome process what we’ve seen where blocks are being released, some people know it, some people don’t know it. 


They’re only being released and requested during business hours 7:00 to 5:00,. Mondays to Fridays. Unlike Open Table that. Saturday on a midnight, you could request a release. So the proof of the pudding, what happens when this works? What happens when this works is much like eBay, and OpenTable, and Airbnb. Marketplaces that work have high liquidity. Laws of supply, laws of demand, and transactions happening. So to give you some real numbers from the ORs where this is live. Like I said, this started at. University of Colorado Health first, where across the purpose of 42 ORs. In about two years, the team there across the board has requested 2,500 blocks roughly, of which 2000 have been approved. The high degree of fill rate of about 3,000 blocks released. In the world before 2, like this, and, yes, blocks would be released, but not nearly as many as these without the predictive release reminders. 


Not nearly as far in advance of the day off, so you might have found a third of these numbers of blocks released, and on average seven days before. Now, imagine three and blocks. Each block is worth $100,000. So if you look at the incremental number of blocks released, and far in advance of their surgery, that allows you to do magic like hire new surgeons, hire new staff. Be able to say, look, I know I’ll guarantee you there will be time available through OpenTable. In this case, it’s called exchange. And you don’t really need permanent block until you show me you can use the time well. That UCHealth, it’s an academic medical center. MultiCare is completely the opposite. 


Also in Epic, but it’s a community medical center where surgeons can split their time at MultiCare and in other facilities. One of the biggest draws for a community surgeon is to take their cases to places where they can easily get their cases in. So if you’re a community hospital, this works even better because this is kind of a marketing tool for you. This is your ability to say to surgeons, you know, yes, I know you can go down the road or you can bring cases to my hospital. If I made it really simple for your office to be able to grit their case, and reserve time into the future, far into the future, where do you think they would take their cases? 


To similar numbers from MultiCare, they’ve been live this year. You see how there’s been live a couple of years. But no matter where we go, Ohio Health and other large, very well respected community system in Columbus, Ohio near Presbyterians, Brooklyn Methodist Hospital. So wide-ranging set of hospitals near Pres happens to be on Cerner. The other three happened to be on epic, so it’s EHR independent because the IT part of it is fairly lightweight to get done, and we can talk about that if it’s interesting. But we’ve already seen some pretty significant benefits, which would be quantify, so let’s take UCLA. We quantified what this did for their ORs. If you think conceptually about what this did, it made plan-predicted cases into the future possible, which means being able to do more cases during business hours and to fill the gaps in the epic grid. 


So if you think about post-fact, how block owners were using time before, and when they started releasing it in advance, how others could get access to it. I equate that to filling in the gaps in Swiss Cheese. So if you lay out the epic grid, there’s a lot of Swiss cheese holes. On the same day that there are holes in the Swiss cheese during the day, there are people working between after hours between 5:00 and 11:00. So if you’re ever experiencing that issue, or I’ve got idle time for my anesthesiologists, and my nurses, and my staff during the day. All by the way, and. I’ll have 5:00 work between five and 11:00. A lot of that is because of the lack of visibility of future availability of time. 


A lot of cases become more than their margin cases even when they weren’t necessarily urgent to margin cases because, I, as a surgeon, don’t trust the system to give me time outside of my block. So if I see a patient today, and I have lost time on Friday, I’ll try and fit them in tomorrow. And so everyone’s going to work between 5:00 and 11:00 tomorrow night, but if. I knew that I could just go into a tool and look for time Monday, Tuesday, Wednesday and it would be available, chances that some of those add-ons didn’t have to be add-ons for tomorrow, much higher. So just as a quantification of some of the benefit, the CFO of UCHealth and the perioperative teams helped us put together the results of these numbers that you saw. And they quantified it in terms of how well their time was being used in business hours. So room utilization during business hours growing up by a significant amount, some of which, they said would be organic growth. It would have happened with or without. 


When we took even that piece out, they attributed very conservatively 4 percentage points of increase in utilization during business hours to a tool like Exchange because of the visibility and the transparency and the leaning out of the process for release and requesting of time. A big thing that happened is in all of these institutions is the relationship between the administration and surgeons, the belief that you are helping me get access to the OR when I need it, goes up a lot. My ability and desire to play as a team player and contribute my time because I know I will get it when I need. It goes up a lot. The ability like we said, to absorb new surgeons is a significant one, but the quarter quantified benefit is significant. Almost half a million dollars per quarter per year. 


Last couple of slides, and then we’ll open it up to questions if there are any. Clearly, when there is accountability for black ownership, this works better than when there isn’t. So the smaller the group of people that have their name against a block, surgeon groups work well, individual surgeons work well, as well. The point here is the more the system knows who is likely to use this particular chunk of time. Even if you have service lined blocks, oftentimes, people have gentlemen’s agreements or gentle people’s unspoken agreements that say, it’s John’s on. Monday, and it’s James on Wednesday to the extent that can be identified scale of leads through tools like your EHR. It allows the tool to send proactive release reminders to the right clinic. 


The problem with having completely collective responsibility across 50 surgeons is we don’t know who to send that release reminder to, for example. So even if you have service line lock to the extent that you can codify the unspoken agreements of who uses time on every day that they have lock, and it’s reflected in the EHR, allows the tool to know who to send, which clinic to send those release reminders to. That’s number one. The second best practice is there’s a lot of folding of the arms that happens where we say, if I am neuro, I’m only going to release time into neuro first. We understand why that happens. That, again, happens because we live in a world where we didn’t believe that if we gave time and to an open pool, ortho would do it too. And plastics would do it too, and urology would do it too. So we’ve created these little carpool lanes where we’re only willing to release time to our colleagues. 


With respect, this is something we see everywhere, and it’s just plain wrong. If you start creating open capacity above board for everybody to the extent that rooms are fungible or interchangeable, everybody will win. So if you’re willing to take the leap, great. There is a way to build this tool where you create artificial constraints, like for the first three days, I’m in general surgery. I’ll only give time for general surgery. You’re just belaboring the obvious efficiency in creating open time access to everybody. We can have a fight about this post this call tonight because I’m sure, this is a situation a number of you find yourself in. 


The third is take away all other forms of relief and request. Putting tools like this in place, in addition to allowing people to email and phone call and text and walk into the OR schedulers offices, just asking for trouble. You’re going to make their life even more miserable, so shut off other ways of accepting or releasing requests time. And create one single source of truth for people to use one process. And the last one, which by the way, should probably be number one, is only do it if there is enough pain and enough bored looking physician leadership that is willing to be early adopters and champions of this. Because just schedulers wanting this, or just periop leadership wanting it without the entire governance committee, saying, we need to do something different. We don’t have enough time in the car. We want accelerated oh our access for all our surgeons block owners and non-block owners is really key to making tools like this work. So when that happens, magic happens. 


A significant amount of capacity is unlocked. If you can do this, I’ll stop. Quick reminder that this was today, the right way to release and request blocked time. In two weeks, we’re going to talk about metrics. And what metrics makes sense to measure, and how we engage surgeons and administrators in a 2018 way of allocating time– of looking at their metrics and doing better. OK. So we apologize again for the technical issues at the beginning of this webinar. We do see that several of you still made it on to the webinar which we’re very grateful for. If you have any questions since there is no chat feature, you can just unmute yourself. And hopefully, one at a time, ask a couple of questions to Sanjeev. We did have a couple of questions that were emailed into us outside of this webinar platform, and we’re happy to take up those as well. 


SANJEEV SAGRAWAL: Any questions from anyone, please let us know. Else, you can email us or text us at the number here at the bottom of this page. You can also write to me directly at,. S-A-N-J-E-E-V Any questions at this point? 


SPEAKER 1: So one of the questions that was e-mailed in is, will this marketplace or tool only work in an academic setting, or could this also work in a community hospital? 


SANJEEV SAGRAWAL: Thanks, that’s a great question. We touched on some of it. It’ll work in both, and the reasons it’ll work in both are different. In an academic hospital setting, some community hospitals believe this will work better in an academic setting because all the academics usually employ their docs. And so they can tell their docs how to do things, and their clinics how to do things. We actually believe that, while that is true, for community settings, this is even more powerful because a lot of community settings have physicians that can take their cases to multiple places, and this becomes a pretty strong recruiting and stickiness tool. 


Like I was saying earlier, if I’m the only community hospital in the vicinity, that allows surgeons and clinics to see access to open time through tools like this, chances that I’ll be able to draw more of the cases in and bring more surgeons into my OR are much higher. And we’ve seen that practically at places like MultiCare and Ohio Health, and Dignity and other places. I think we’re out of time, Sandy, so– 


SPEAKER 1: Yeah, it does look like we’re out of time.

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