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The Right Way to Take Away Block Time Webinar transcript


SANJEEV AGRAWAL:. Thank you, Sandy. Thanks everyone for joining. For those of you who may have attended the last webinar, you may already know this, but if you don’t, this webinar is the second of a five part series of webinars. The entire set of webinars is meant to talk about how to get the most out of know OR capacity. And each of these webinars is going to address a specific topic within the broader umbrella. And in August the 23rd, we did one that did a broad overview of the four topics. The first of which we’re going to cover today. So if you do want to go back and refer to that, that’s also available online. If you missed that webinar and then coming up next week, we’re going to talk about the right way to release and request block time. On October the 4th, getting surgeons to engage and believe their performance metrics. And then on October the 11th, the right way to allocate block time. And this is part of the five part series we’re hosting. 


So very quickly, we’ll start today by doing a recap of the top reasons why ORs typically don’t use time and money, as well as they possibly could. One of which we’ll dive deep into today but we’ll touch on the other four as well. And the big focus of this webinar is once we’ve made capacity allocation, decisions, and done block allocation. How do we measure how effective that block allocation has been? And typically the metric that most all OR views is block utilization. So if you’re in love with that metric, I apologize at the beginning because we’ll beat up quite a bit on it because we don’t think that’s the right metric. And instead, we will introduce a concept called collectible time that we think is a much fairer, more transparent, and more surgeon centric metric that you can actually implement, and makes up for many of the deficiencies that exist in block utilization as a metric. 


So that is the focus of today’s webinar. We’ll also show you examples, real world examples of where people have changed their block policy from block utilization to collectable time. Talk about how they’ve done it, and then talk you through the results, as well as show you an application for how to do the scalability where these institutions are doing it. So this knowledge in this intellectual property, if you will is based on the work that we as the meantime have been doing with many, many institutions across the country. Specifically in the operating room, 14 large providers that currently are using or have used or will be using our products. The goal is not to talk about the products, but the experience around collectible time and around block utilization not being very useful has been based on a mix of academic and community large and small, each are independent set of customers across university of Colorado Health, New York. Presbyterian Brooklyn Methodist Hospital, Ohio Health, and all the other logos that you see on here. There’s about 500 ORs that we’ve worked with and implemented this process of changing block policy from block utilization to collectible type. 


So again, if you’ve attended the last webinar, a couple of slides of repeat just to frame the problem. What is it that we’re talking about? Let me start with a story. So I was at a Children’s. Hospital a couple of months ago, and I asked a senior surgeon a very simple question. I said, look, you guys are really busy. This is one of the top children’s hospitals in the country. If I brought my daughter in and I needed to get her operated on, and she had elective surgery needs, when could you operate her? And he looked at me and he said, look, we were very busy. I usually have Wednesdays. And blocked out for the next five Wednesdays. Maybe in six to seven weeks. And so I looked at him and I said, well, what if I walked around with you across your ORs today, and we looked at who was using the ORs versus who had capacity allocated for them. And will there be a one to one map between the people who have capacity allocated today, and the ones who are using it? And in fact, are you telling me across [INAUDIBLE] in their case 27 ORs? 


There is no downtime at all during business hours for you to fit my daughter in. And he said, well, you know, that’s not true. There’s always time in the OR, we don’t always know about it. And by the way, I’m just restricted to my slot. Which is kind of a surprising, right? When you think about it OR time is sacred. A single block of OR time is worth $100,000. So how can it be the case that on the very same day that my daughter cannot be admitted to get an elective case done, there is time available and no one doing it. Or even if someone’s not using it, it’s the OR running around trying to fill the rooms up, now the people who were granted capacity are not using it as well as they should. 


Now, if you think about the economic impact of something like that, any time that’s left on the table during business hours. And what’s worse is sometimes that time is made up for after business hours. So not only do we leave our. ORs open during the day, we actually then incur extra costs of keeping them open after business hours. So a 1% improvement in the use of the ORs, for a single OR over the course of a year, has a massive economic impact depending on your revenue per minute. More importantly from, a patient access, perspective getting my daughter into the OR quicker, that’s a huge, huge deal. And the problem is only going to get worse as the need for surgical cases goes up, which will because of all the macro issues we know about. 


And so OR time is precious and never available, yet reserved time is left on the table each day. And that’s sort of like saying, if I buy a ticket to the Super Bowl, and I pay $10,000 because I buy it last minute. I stand in line for six hours. And I show up at the game, and a third of the stadium’s empty, and that doesn’t seem very doing all right. So why does it happen and how can we change that? And here’s five reasons why that happens– again, a bit of a repeat for those who were here last time. The first is when we allocate capacity, we have an underlying assumption that if I gave Sandy Wednesdays and I gave myself Thursdays and I gave you Mondays, that the supply and demand will magically match. Sandy through our clinic will be able to get enough patients to exactly be able to do cases on Wednesday. And the length of those cases which will be such that she’ll be magically able to fit those tetris blocks exactly in the next 52 Wednesdays over the course of a year. 


The problem is we’re not planning the production of Toyota cars. We’re planning what is fundamentally a variable set of issues. How many patients is she going to see? When will they need to be scheduled for surgery? What will they be needed to be operated on? How long will those cases take? So in mathematical terms, that’s known as stochasticity activity or variability. All that means is all of those metrics– how many patients she will see, how many will be admitted to an a OR or need surgery, when they will need surgery– are only predictable to some extent. And when there is variability in the system, you end up with this situation that across 400 surgeons of whom we have given 50 block time and 350 are feeding off of open time or trying to get their cases in. By not being precise, we’re leading OR time on the table, much likely would if we took a highway and we made every lane of the highway a carpool lane reserve and capacity for an individual type of car. 


So in that situation, when we reserve capacity, there’s nothing wrong with reserving capacity. But then when we take capacity away, the problem is using metrics, like block utilization, make it very hard to then go make a case to Sandy and me. And we’ll talk about this a lot today. Because the metric we’re using to take time away, block utilization, doesn’t make sense. So that’s number 1. That’s the purpose of today’s webinar. Just to give you a sense very quickly, the other four topics of why capacity left on the table will be addressed in the next few webinars. The next one we’ll talk about releasing and requesting time. When Sandy cannot use her time or I cannot use my time, how is that released to others who can, far enough in advance for them to have visibility to get patients in? 


On October the 4, we’ll talk about why providers often don’t engage with data because they don’t believe it. They don’t understand it. And it’s not fed to them in way that it’s useful. On October the 11, we’ll talk about how do you create block capacity. How do you allocate block capacity to begin with even before you take it away? What is the algorithm we should be using to allocate capacity well? And then one thing that’s really interesting to us, which is item number five that is still being thought through, is we can do a lot better with the math around predicting the length of cases, far better than the mean, the median that EHR do. But how do you actually use it to develop better estimates of case length, and then use it to make a smoother day off in the OR? So that’s the focus of the next few sessions. 


But today, let’s talk about number one. So let’s dig right into it and talk about block utilization and the limitations of it as a metric. So now, let’s say, we have 20 ORs and we have five blocks per week per OR. And for 52 ORs, we take the total number of blocks we have and and we allocate some portion of them, or all of them, by department or block owner. And then post-fact, we measured our block owners on how well they have done in using that capacity. So, imagine, I am. Surgeon A. And I happen to be a hand surgeon or a sports medicine surgeon. And now, you’ve given me 10 blocks a quarter. And at the end of the quarter, you sit down with me, and this is my utilization pattern. The dark blue is wheeled into wheels out. I’m Surgeon A. And I happen to be a surgeon whose case lengths are not very variable. 


What does that mean? I do cataracts, I do hand surgery, I do sports medicine, which lends itself to the average or the median length of the case being reasonably tight. I’ll talk about that in a minute in more detail. And so let’s [INAUDIBLE] 7 and 1/2 days of capacity, I packed my ORs. And at the end, my block utilization is 75%, post-fact. So I have 2 and 1/2 days free. I can release two days or not use two days. No matter what, my block utilization is 75%. Now, you are Surgeon B. You happen to be a neurosurgeon. You happen to be a cardiovascular surgeon. You’re doing a highly complex cases that have much wider variability in terms of case length, meaning some days, you’re operating and opening somebody’s heart and doing a quadruple bypass. And the same patient might take 6 and 1/2 hours some day. And a patient with very similar conditions might take 5 and 1/2 hours another day. 


So there is more variability in case length. You end up using all 10 days. And on average, you use six out of the eight hours in the dark blue wheels into wheels out, so your block utilization is also 75%. So now, we look at this picture and we sit in OR committee, and go, oh, our targets block utilization is 80%. And so both Surgeon. A and Surgeon B should be giving off some time. That’s a complete fallacy. And the reason it’s a fallacy is we’re not building Toyota cars that we know will take 30 minutes or 45 minutes or an hour plus or minus 30 seconds. We’re dealing with variable length of cases. And I’ll show you some pictures to demonstrate that in a second, real data. 


The biggest mathematical fallacy is, what do you do with someone’s block utilization number? If my block utilization is 75%, what does 1 minus 75% represent? It represents absolutely nothing. In the case of. Surgeon A, it might represent being able to take 20-25% of my time. In the case of Surgeon B, there is no way you can take 20-25% of Surgeon B’s time, and still let them get all their elective cases done– if that’s the repetitive pattern of both Surgeon A and Surgeon B. That’s one huge problem that 1 minus block utilization is meaningless. The second is our block utilization targets. Where do they come from? How much should block utilization be? If I’m doing only hands or only cataracts and much more cookie cutter cases, maybe the target should be 95%? If I’m only doing neurosurgery, maybe it should only be 60%. 


So setting targets is very hard. And then when you don’t meet those targets in block utilization, taking time away is harder. That’s why there’s always a great excuse for why block utilization doesn’t make sense. Secondly, it’s not surgeon-centric. If I’m sitting at OR committee, Surgeon B has a very legitimate case for not giving up time. The third is if block utilization is what makes me a hero, as Surgeon A, I would keep releasing those bottom two blocks. And then look what my block utilization b, would be 75 divided by 80. That’s 92%. So, again, due to no fault of my own, as surgeon B, I look bad, because Surgeon A could release to block time– two blocks. So the fundamental reason for that, the underlying math to the extent that’s of any interest, is when you look at the spread of how long a take case actually takes versus how long you think it’s going to take through the best case length estimates out there will be three images are showing you are short cases that are less than an hour long. 


That was the prediction before the case was done– cases that 1-2 hours and then the cases that are more than two hours, this is for one specific institution. It always falls on a spectrum. If I was building Toyota cars, then everything would peak around zero, because the x-axis is showing actual length of case minus estimated length of case. So if my actual and estimated length of case were exact, then all my cases would peak at zero. I would see 100% at being a zero. So that’s sort of like if I were looking tennis courts to reason 100% of how long I use a tennis court for is equal to how long I estimated I would use a tennis court for. Because I was only given an hour to play tennis and then you showed up and kicked me out, because it was your court. 


Surgery is not like that. So whether it’s short case or medium-length cases or long cases, they fall on a spectrum. And the best physicists and mathematicians on the planet can only come up with a better estimate. They’ll never be able to come up with an exact number. So this is one of the underlying reasons of stochasticity or variability. The other reason is just the number and volume of cases that people will be able to do. When you give me– going back to the example, I have Thursdays and Sandy has Wednesdays– when you are granting me this time, you’re making that assumption that somehow I will have three patients of three hours each that I can fit in for the rest of the year– the 150 patients. And how do I manage that? 


Because patients don’t work like that. They show up when they show up. So this is the problem with reserving capacity without thinking through the basic nature of stochasticity. What this chart is showing you is that some service lines are more predictable than others in terms of case length. So not surprising, we took orthopedics, neurosurgery, and gynecology. And not surprising, the blue is orthopedics. Orthopedics cases being a little more tightly placed around the zero point, meaning they’re a little more predictable. But even there, there’s a huge spread. Relative to neurosurgery and gynecology is less of a spread, but it’s still a spread. So you can never say that a case is going to take 2 and 1/2 hours. It’s going to take a roughly 2-3 hours, for example. So now, how do you solve this problem? How do you take time away if block utilization is not a meaningful number? 


Instead of using a one-dimensional metric like block utilization that’s very hard to act on, we’ve come up with another metric that we call collectible time. And the way we’ve come up with this metric is to step back and ask from first principles, what problem are we trying to solve? The problem we’re trying to solve is we’ve given capacity and allocated capacity to service line surgeons and surgeon groups. And we expect them to be good stewards of their time. And we have a lot of data on how good a steward of their time they’re being. Currently, we’re measuring that how good using block utilization as the metric. But really, if you think about what we’re trying to achieve, what we’re trying to achieve is we’re trying to get more cases done in our ORs. 


So for a second, if you indulge me, I’m going to quote the Chief of Surgery at a very famous hospital in this country that is using this product, or using this tool, who said, you know what, the smallest unit of time in an OR that’s relevant to me is not a minute. The smallest unit of time that’s relevant to me in an OR is the smallest length of case I can add and put in. Now, that’s a very deep statement because the implication of that statement is that on a day like January the 3rd, where I started to find the surgeon on January the 3rd and I started my case late 30 minutes, it’s showing this gap, this little blue triangle of 30 minutes, and then wheels in to wheels out. What it’s saying is, let’s really ask ourselves the question if those 30 minutes are really relevant from an access perspective. 


Of course, from a patient experience perspective, from a patient satisfaction perspective, we should get first case delays down to zero and turn over time to be exactly what it should be. However, let’s say, I had started my case on January the 3rd exactly at 7 AM. What would have happened? There would’ve been a 30 minute gap at the end of the day. Now, what exactly where we planning to do it? So not all gaps in this Swiss cheese are equally important. And when we use block utilization, we conflate small grains of sand with large chunks of time, in which cases could have been put in. So if you look at the same grid that I showed you on Surgeon A and. Surgeon B, whether it’s Surgeon A or Surgeon B, if this is my usage of the order repeatedly, then for a second stop thinking about the little blue triangles. I know we’re all hugely focused on first case delays adn turn over time as we should be. 


However, if they are small delays– and we’ll define small in a second– let’s ignore. Instead there are these large red diamonds that are empty spaces from a block usage perspective that are big enough to put cases in. So if we believe that the smallest unit of time is the smallest length of case I can put in, then let’s start looking for first principles at three specific gaps. One, large contiguous portions of unused time that I repeatedly leave on the table when I have blocked time. For example, 1/10, I did a case in the morning, one in the afternoon. And in the middle,. I left a big chunk. We’ll define big chunk in a second. I use the morning well on 2/22, and I always use morning well on Wednesdays, but not the afternoons. Or the other way around on 3/1, where I use the afternoon well and not the morning. So large contiguous portions of unused time. The second is abandoned time. 


We know everybody has an auto-release policy. If you don’t have a case on the grid seven days from day off, release the block. Well, that’s using a blunt instrument. That’s using a baseball bat for something that needs to be looked at far more surgically. Because if I’m not manually releasing my time that you’ve given me– I know I’m going on vacation in August, and it’s May. I know I won’t be able to use that time. If I’m not really releasing it, and I’m expecting the OR to do whatever they do within a week before or whatever your policy is, that’s not good behavior. Because that is telling me that. I could well have released that time way into the future to let my colleagues use it within my [INAUDIBLE] outside, but I didn’t. 


The third is if I’m releasing too much time. So remember Surgeon A, the way. Surgeon A have looked awesome was Surgeon A would repeatedly release two blocks and block utilization was 92%. The problem is, if you’re getting close to capacity and, let’s say, you’ve given me two blocks a week– there was a time I was a prolific surgeon and I was doing a lot of cases to fill those two blocks– but now, I want to hang on to those two blocks until– I’d rather pass those two blocks onto my kids as my legacy than give it back to the OR. But the way I look good on paper is I keep releasing one block all the time. So you’ve given me 100 blocks a year, I release 50 of them. Well, maybe releasing 20 of them is OK. But beyond a certain threshold, I am just not doing justice to the amount of capacity you’ve given me. 


So if you define collectible time as the sum of three things, large contiguous chunks of timing left on the table– we’ll define large in a minute– abandoned time that. I did not manually release, and large portions of release time beyond a certain threshold, then if you go back and look at Surgeon A or Surgeon. B or Surgeon C or Surgeon D, it doesn’t matter. A chunk of the OR time is a chunk of OR time. Now, how do you operationalize this? If you buy this logic, this logic is very, very powerful. You brought all these timestamps in your EHR. And if you run them through a machine learning algorithm, and that’s just a complicated way of saying pattern matching algorithm, that says, let me go look at every block owner and how’ve they use time in the last week, the last month, the last year, et et cetera. And then let me just define two pieces. 


So actually I’m going to jump in to a website. And on this website, there are many, many things. There are other modules that we’ll talk about in future webinars and that we talked about last time. But let me show you a section of this page just to orient you called collectible time. Because we’re focused entirely on how do you calculate collectible time and what you do with it. So if you take your data and you run it through these algorithms, the first thing you get to do, back to the discussion we were having, is to define how much manually release time is considered acceptable. So this goes back to the example you’ve given me two blocks a week, I’ve honored them for a year. 


You know what, life happens. And so you can’t be so stringent, and say, I can never release time. In fact, I’m doing the OR a favor by releasing time. But there’s a threshold of release time that makes sense. If I’m releasing 50%, it is much. But you can set how surgeon-centric you’re going to be, and say, let’s say 20% of time. So 20 blocks out of 100 that you gave me, if I release, are not really something you’re going to hold me accountable for. But if I release 50, the other 30 are I’m releasing too much if I’m doing that over and over again. The second is, how much continuous time do you consider collectable, meaning what’s the smallest length of case you can do? For orthopedics, it might be two hours. For neurosurgery, it might be five. So you get to define it. 


So in a tool like this, and the only purpose of showing you this tool is to show you a scalable way of doing this again and again– if I had every block owner that own block time here, and I did this analysis on them by getting data on a nightly basis and refreshing it every day, then on any given DAY you could go into a tool, and say, by block owner, by day of week, by location– especially if you have multiple locations– I can see how much of allocated time is collectable. And unlike block utilization where 1 minus block utilization means absolutely nothing, collectible time by definition means– remember those holes in the Swiss cheese– if I’d taken all holes away that were large enough to fill up [INAUDIBLE],, nothing would have happened to the surgeons, to the block owner’s ability to get cases done. And so without hurting my practice, how much time can you take away is the question, for whom the answer is collectible time. 


So if I’m going to sit down, say, I’ll just pick a particular block owner. I’ll pick UCH Cardiac. And we’re saying that between that group, or that sort of line, has 26 blocks on Tuesday in one location, 26 blocks a quarter of two blocks a day every Tuesday for 13 weeks in a quarter– that’s 26 blocks– and we’re making the case that they could get all their cases done in 20 blocks. Now, the way we make this case, because that difficult conversation that’s going to happen at OR committee or with the head of this department, in the world where you were taking block utilization to them, it’s very hard to win with that. But in a world where you say, tell you what, it’s hard to argue with facts. 


So let me show you some facts. Let me show you the 26 Tuesday blocks that you’ve been given. And how you have used every minute of time in the OR in all 26 blocks, this quarter, last quarter, last year, the last five years. And let me take the most favorable quarter that shows you in the best light. This is the most favorable quarter that shows you in the best light. Then let me actually give you credit for all the time that you’ve used that is wheels in to wheels out, meaning you actually have a patient in the OR, plus credit for all those little blue triangles. I’d give it up on the world, where first case delay delays and turn over time, and if you’re an efficient surgeon, and you end 30 minutes early, I’m not going to penalize you for that. 


In fact, here, I’ll show you time you use well. I’ll give you full credit for it right here. I’ll also show you where you left some time on the table, but this wasn’t useful time for me. As a peri-op owner, I couldn’t have done anything with this. So you know what, have at it. You’ve left less than 3 and 1/2 hours that I could actually do something with. Instead I am actually only going to focus on the large red diamonds. Those large red diamonds are gold. So, first of all, let’s have a conversation about the fact that you often leave entire blocks unused. Not that the OR doesn’t fill them up, but the OR has to go through all kinds of gymnastics to fill them up. So you’re not being a good steward of your time, and not releasing this time. I’m only going to focus on this. 


Let’s not conflate this with the 30 minutes, the first case delay. And I keep coming back to that because it goes in block utilization when you don’t distinguish between little blue triangles and a large red diamonds, you cannot have a fact-based discussion that surgeons will believe. Because Surgeon B will always have a good reason why the block utilization number doesn’t make sense. But if this is Surgeon. A or Surgeon B, can you explain to me why you don’t use your entire block? Whether it’s Surgeon. A or Surgeon B, if you’re leaving large chunks of time on the table, can you explain to me why you’re leaving large chunks of time on the table. Maybe you need a halfday block. Maybe you can play the game of Tetris and fit– you have eight blocks– and maybe you can fit everything in six. And that we can demonstrate to you. 


It is like when– this analogy may or may not work, but back in the day when the imperial system was used to measure length, the reason it worked was we were trying to build roads and what we needed to fit was horses. And so you could start by saying, how big is a horse? What’s the average size of a horse? And if I could fit three horses in, it’s a three horse street. Well, you want to send a person to the moon, that’s not a great metric. And that’s why the metric system was invented, where we’re looking at what is a meter. Well, the meter is based on the wave length of light when it’s emitted, when a [INAUDIBLE] atom goes from one energy state to another. That doesn’t change over time like the size of a horse. 


And so, when we look at collectible time, this is a standard metric that is saying, no matter whether it’s. Surgeon A or Surgeon B, no matter whether it’s hospital. A or hospital B, if you’re leaving enough time that can be repurposed and used by someone else and you have the liberty to define what the smallest length of that time is, then you’re able to answer some really strategic questions. I’m trying to hire someone who can only do cases on Wednesday. I need to give them luck. What is the lowest hanging fruit of time– who amongst my current owner of block can I take a Wednesday away from without hurting their practice, which is the definition of collectible time, and still open up time for others to use?


Second, if I’m not hiring people, and there isn’t enough volume in my market to justify it, am I running too many ORs? Every OR I go into in this country– I’ve talked to hundreds ORs– everybody says they have a nursing and anesthesia shortage. Well, maybe some days we’re running too many ORs. Maybe some days we have too much idle time during business hours, because we’ve got a lot of holes in our Swiss cheese. But we’re still working from 11 PM. So the same anesthesiologist that really was expecting to do eight cases during the day. And start the first one at 7:00, and the next one at 9:00, is not doing that, has idle time, but is staying over. So some of the reasons why the staffing shortage gets accentuated is we’ve got collectable time that we’re not filling. 


How many ORs should I be running by the week? Which surgeons has the most excess time? The biggest thing that this analysis does though is to give you a bulletproof argument to go talk to block Owners so when you go to Dr. Dyer, and say, on Mondays, you have x amount of time, And? You really need 80% of that, and I’m going to take one or two blocks away from you, you’re no longer having a debate about small blue triangles. You’re now talking about a very defensible way of showing all the three components of collectible time and diving right into EHR time-stamped data, which is irrefutable. Sure, I mean, you can argue with facts, but then you argue with facts. If you tell me the sun’s going to rise on the west side tomorrow, there’s not much I can do if that’s what you believe. But if I show you the facts, again and again and again, this is what you’re not using. And if I reclaim it, it wouldn’t have hurt you last month, wouldn’t have hurt you last quarter, wouldn’t have hurt you last year. It’s a little bit of an airtight argument to try and fight back against. 


So the punch line really is if we’re trying to increase block utilization, block utilization is the worst metric to look at. In order to improve block utilization, we should focus on repurposable chunks of time that doesn’t hurt any existing block owner, yet opens up enough time and can be collective to put cases in that someone else can do. So reducing individual block owner collectable time will increase overall block utilization, because then, when you free up capacity– first of all, there’s another concept in operations theory, which is don’t confuse freeing up capacity with monetizing capacity. So if I took this list of 100 blocks that I could capture, don’t wait until you have something you can do with those 100 blocks to take them away. Because you can close OR. You can give them to existing surgeons that need time. You can hire new surgeons. 


You can put it into an open market, which we’ll discuss next time when we talk about exchange, to be able to let people use it. That’s called monetizing capacity, how you make money from it. Freeing up capacity requires thinking we believe along the lines of collectible time, which is a much better way of taking away time once it’s been granted. Otherwise, it’s going to go into a trust fund for my kids. Because if you give me time once, I’m going to hang on to it because this argument of block utilization is never going to work. Now, the proof is in the pudding. Multiple large systems, some I showed you at the beginning of this talk, has been using this methodology. Well-run institutions, academic, on Epic, on Cerner, community, large, small, all of them have 15% to 20% of time that is collectable. And it kind of makes sense folks. 


When we give permanent capacity to people with the best of intentions and they accepted with the best of intentions, everybody says, yes, I’ll be able to fill this time up. But it’s a mathematical impossibility that everybody you give time to, today, will be able to predict for the next 52 weeks how many cases they’ll be able to do and how long they’re going to take. But if you look at the last 52 weeks and the 52 weeks before that, you can get a pretty damn good idea of how well they’ve been using that time and how much of that time, if you had taken away from them, wouldn’t have hurt them and yet it helps to allocate to others. So just to make these numbers real, for each of these institutions– the smallest is 18 OR, the largest is 42– there are over 100 collectable blocks per quarter. Just think about that for a second. 


How many of us have plans to build more OR? How many of us have surgeons coming to us all the time saying, I need more time? How many of us feel like we can’t hire surgeons or faculty because we have no block time to give them? How many of us feel that we sit in OR committee meetings and they become check meetings? Because it’s very hard to make decisions based on block utilization. And at the very same time, these 100 blocks being collectible really means we have airplanes that are sitting idle. Our OR capacity is like, it’s a perishable commodity. if I don’t use my art today, I lose the $50,000 or $100,000 I can make. So 100 blocks a quarter, even if a small percentage of them were reclaimed, and either you shut the ORs or reuse by even just getting to someone else, at a fraction of their capacity– meaning if you took 25% of 100 blocks each quarter and use them at 60% utilization– can you imagine how much, how many more patients my daughter could’ve been seen much sooner, for example? How much more revenue you could bring into the hospital? 


And so, collectible time is a much more strategic way of balancing your portfolio. One that’s hard to argue against, much more surgeon-centric and actionable. So we did a study. We went to all the institutions we work with. And we asked their process improvement teams, their [INAUDIBLE] sigma teams, their OR teams, and said, what are the things you’re focused on by way of increasing access? And pretty much the answers fall into a few buckets. We want to reduce first case delays– a very, very good goal. We want to reduce the number of cancelled cases, or at least predict comedy cancelled cases will happen better. We want to make turnover time precisely what our targets are 15 minutes, 30 minutes after the orientation, or whatever it is. We want to be able to estimate our cases better, so we allocate the right amount of time to each case. And so, there isn’t too much time left over in the OR. And those are the things we’re focused on. So we said, OK, let’s do this. 


Let’s go and look at block time, how it’s been used. And when it’s not being used, let’s tag the reason why it’s not being used. Is it because it was a little blue triangle representing a first case delay? Was it a little blue triangle representing a turnover delay? Was it a little blue triangle, because Dr. Smith said, this case is going to take six hours, it took 5 and 1/2? He was more efficient and left 30 minutes. Let’s back it all those into– actually, that’s [INAUDIBLE] overestimation. The first two, turnover delay, first case delay, let’s bucket those into delays. Then let’s bucket case length over estimation. I said it was going to take seven hours, it only took six, so an hour’s left on the table. Let’s bucket that is the case length over estimation. Then for everybody complaining– or some of our surgeons are just there’s too many cancelations going on. 


When cancelations happen, a case was [INAUDIBLE],, wasn’t done. And therefore, there was time left over on the table. Let’s look at that. Well, turns out, across these systems, most systems have actually done a pretty good job of reducing first case delays and turnover time. So only 14% of the total amount of lost time being left on the table could be attributed to delays. Now, the 11% of case length overestimation, it goes back to the fact that life is stochastic, folks. You cannot get too much better. The fact that only 11% of the time was from case length overestimation means most cases estimates are that bad. And the problem is the few times they are the only time that sticks in our mind. 


So it’s when the airline is late, we always say United sucks. Well, you know what, even [INAUDIBLE] on time arrival is like about 90%. So if getting 90-95% cases estimated reasonably well, that’s not the reason why you’re leaving a lot of time in the OR. Cancelations, because of the nature of the hospitals we were working with when the study was done, were reasonably high. But it’s the large blue pie, chunk of the pie, called schedule downtime or collectible time. And the reason we don’t go after that is that it’s hard to have an argument based on block utilization. Because it’s easy to measure cases like overestimation. It’s easy to see delays. It’s easy to understand cancellations. But now, when someone is not being a good steward of their time, that’s where we’re looking at block utilization to say, I’m going to take time away from you. 


That metric is squishy, and when you use that, you can never have a good. OR committee discussion around taking time away. So scheduled downtime is equal to collectable time that we can actually, through a tool, help on a daily basis show you where the opportunities are for you to do what you want with. So when you go through this process, the way to go through this process is you need to understand how your current allocation is truly performing, and identify usable capacity, not unusable capacity. Not the five minutes plus three minutes plus nine minutes capacity. The data driven recommendations to take away block time have to be one where you can defend collectable time in those three buckets. 


If you’re going to use this, if this is appealing to you, you have to have a discussion at OR committee. Show this to your surgeons, who, from at least our experience, I can guarantee you will find this a much more palatable way to look at capacity than block utilization. But then you have to enforce it by saying our block policy, which had a rule– turnover has to be 15 minutes, or first case delays have to be at least– first case on-time starts have to be 95%. Keep all those. Those are great. In addition to that, don’t make block utilization as the basis for rightsizing blocks. Make, if you believe this, then collectable time should be your basis for rightsizing blocks. The number of block utilization reports I have seen over the last three years that truly cannot be acted upon is magnificent. 


Going back to surgeon. A and surgeon B and surgeon A releasing time. And so, if you can get the right knights of the round table– surgeons, anesthesiologists, periop directors, periop VPs, nursing leaders– into a room, maybe that is your OR committee, your chief operating officer, and talk through this. You have a shot at bringing an imperial system metric into a metric system way of measuring. And then what you do with that unlocked capacity is really dependent on your market conditions. Are you trying to grow? Are you in a catchment area where you can actually get more patients and surgeons? 


If you are, instead of building another OR, you’ve got plenty of OR capacity to assign to them. Your chances are, you hired surgeons over the summer, and they’re just starting out now in September. You may not have given some of them block time. Their volumes may be rising. Maybe they deserve blocks. Maybe you gave them open time and they’re building a bit of business, and they’re thirsty for blocks. And so, all of these are different ways you can use that time. But this is how we would recommend you doing it. If you do this right, your block utilization goes up, your room utilization goes up, your collectable time comes down, there are– we can talk about add-ons next time, because exchange impacts add-ons a lot– but from your– from the soft benefits perspective, you can delay when you need to build a single new OR. 


We work with many highly urban area institutions that are landlocked. There’s no way to build more ORs. So being able to squeeze another block in, and give it to somebody, is huge. And your CFOs are not very excited about ponying up more capital without knowing that their current ORs are being used very well. From a certain satisfaction perspective, when everybody knows I’m being treated fairly, transparently, using a metric that makes sense to me, it’s much more likely to be adopted. And then people will care about the reports. People will care about their numbers. If you’re in a situation– I’m not suggesting you are, but many institutions are– where we have a lot of reporting, but I call that admiring the problem, there’s a ton of block utilization reporting going on. But because no one can be held accountable based on that, why do I care? 


Because, yeah, you can show me my block utilization, but nothing’s going to happen. And when you move to a fair metric, people will start to care more. So that was really it. It’s a quick preview. There’s a lot more discussion we can have. As I mentioned, this is the second of a five part series. The first one describes all these issues, and the next three are going to get into three other specific issues and how you can use your OR capacity better. If you’d like more information, and some if you happen to be going to OR Manager next week, we have a booth at OR Manager. We’ll email you the booth number if you’re interested. 


And then please come visit us, the folks at– and we have this presentation, and many others, because we’re offering CE credit at our booth as well. And so you will have practitioners who are implementing this come talk about this. You’ll be able to see some of these tools in action. We also have a conference where about 20 large healthcare institutions are coming in October in Austin. If you’d like information on that, we can also include it in the packet of follow up emails that we send you at the end of this call. But that’s the collectable time story. Please go ahead and put questions in into this Q&A box. There are three that I see already. Let me start with those. 


The first one that I see is, how often do block changes happen in the systems you work with? So, the interesting thing is we work with a lot of systems which haven’t been able to change block for a long, long time, and others that try and do it based on block utilization every quarter. No matter which situation they find themselves in when they start out, it’s always a very tough conversation. When they move to collectable time, they could have the luxury of deciding what cadence makes sense. Does it make sense once a quarter to review this, which will show patterns of seasonality? Or does it make sense to do it more often? Changing block allocation more often and changing the block schedule more often is hard. 


You have to go and reprogram your EHR, you have to do– you have to change people’s processes, but at least once a quarter is probably a pretty good way of looking at things, much like you would your financial portfolio. Once a quarter, make sure that you have the right balance of stocks and bonds, and depending on what happened in the last quarter, re-balancing your portfolio makes sense. So typically, we end up in a situation where every 10 to 12 weeks, people review collectable time. How do you handle certifying group blocks to identify collectable time? So I just go back into the tool. 


Remember, the collectable time analysis is done by block owner. It doesn’t have to be an individual. So I could look at the entire department, or I could look at a certain group, or I could look at an individual surgeon, depending on how you’ve allocated blocks. So cardiac has a set of blocks, but so does Dr. [INAUDIBLE],, Dr. Chong– but there’s a group, the ortho spine group. And so whether it’s a group, whoever the block owner is, that’s the unit of reallocation of time. How do you account for showing collectable time of surgeons who use two rooms? Much the same way as we would when they use one room. Because really, when you dive into the tool itself, you can go in and when you show people’s collectable time, when they’re using one room well, but not the second, that’ll show up as collectable. 


Because unless you’re an electron, you can’t be in two places at once. And that is something that I’ve always wondered about people using two rooms. Sometimes it’s a bit efficient, but a lot of times, one room is used really well, and the other, not so well, and that’ll surface when you do the collectable time analysis. Any other questions that came up? 


MODERATOR: If you have any other questions, you can enter them into the Q&A widget to the right hand side of your screen. Not seeing any more coming through. I know that we had at least one person that had a little trouble seeing the slides. We will send a recording that includes the slides. Sanjeev was using screen share for this webinar, which meant that his slides were visible in the media player widget, which does require Flash. So we will send out a recording. Sorry for those issues. Thanks again for joining us for today’s webinar, and have a great day.

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