An Evaluation of the Operating Room Scheduling System at
Wilhelmina Ziekenhuis Assen
Domingus Usmany Supervisor: dr. ir. D.J. van der Zee
MSc Technology Management Co-assessor: dr. ir. I. ten Have
MANAGEMENT SUMMARY
The changing healthcare environment forces the management of the Wilhelmina Ziekenhuis Assen to organize their processes more efficiently and effectively. Also the increasing competition between hospitals makes good quality service more and more important. An essential unit of focus is the operating room complex (OR complex) due to its high costs. However, the OR complex it is also a major profit making unit within the hospital. The performance of the OR complex is closely related to the operating room schedule (OR schedule). Constructing an OR schedule is a process that involves the organization of multiple persons and resources, this is referred to as the operating room scheduling system (OR scheduling system).
In the current situation there is no clear overview of the OR scheduling system. Next to the schedulers and the operating room day coordinator (OR day coordinator) it is unclear who can influence the OR schedule, and what their roles and interests are in the OR scheduling system. The current organization of the OR scheduling system makes it hard to understand why and by who certain scheduling choices are made within the OR schedule. Besides the fact that the organization of the OR scheduling system is unclear, it is also unclear what the performance is of the OR scheduling system. This research will provide a description of the OR scheduling system. Based on this description the performance of the OR scheduling system is evaluated by performing a performance scan. Based on the outcome of this performance scan suggestions are done about possible improvements.
Data for the description of the OR scheduling system is gathered by interviews, observation and documents of the WZA. The performance of the OR scheduling system is evaluated with a performance scan based on the “scheduling performance measures framework”. To perform this scan a stakeholder analysis is conducted. Data for the performance scan is gathered by a survey, interviews, observation and documents of the WZA.
The OR scheduling organization exists of two departments, the department Intake and Discharge and the OR complex. The OR schedule is constructed in two stages. The first stage is constructed by the schedulers of the department Intake and Discharge and the second stage is constructed a by the OR day coordinator. The OR schedule is constructed based upon OR scheduling criteria. These OR scheduling criteria consists of scheduling preferences of the various stakeholders and scheduling constraints with regard to staff and resources.
PREFACE
This master thesis forms the final step in the Master’s degree programme Technology Management at the University of Groningen. Having a technical background in mechanical engineering made me curious about the ins and outs of a non-technical organization. Therefore I chose to conduct my research project within a hospital, which is probably the complete opposite of a technical organization. This turned out to be a great experience. Not only did I gain a lot of insights about the ins and outs of hospitals, I also experienced the openness and kindness of a so called “people organization”.
I would like to thank a few people from the Wilhelmina Ziekenhuis Assen. First of all I like to thank Hans Holterman for his guidance throughout my research project, his enthusiasm and all the information he provided me with. I now know what happens behind the scenes of a hospital. I like to thank two people in particular, Jolanda Blesgraaf and Dick Hein, for all the information and time they put into helping me with my research project. And of course I like to thank all the people that were involved in my research project in whatever kind of way.
From the University of Groningen I like to thank my supervisor Durk Jouke van der Zee for his guidance throughout my research project, and the many feedback moments that definitely helped me to improve my research project.
Finally I would like to thank the people who made it possible for me to complete two studies. I like to thank my parents for their support and patience throughout my long years of studying. And of course I like to thank my girlfriend for all her support throughout the years, and her patience during two studies that lasted a bit longer than planned. I look forward to our future together.
Groningen, July 2012
TABLE OF CONTENT
1 INTRODUCTION ... 6 1.1 Company description ... 6 1.2 The OR complex ... 6 1.3 Patient pathway ... 7 1.4 Scheduling organization ... 8 2 RESEARCH DESIGN ... 9 2.1 Problem definition ... 9 2.1.1 Management question ... 9 2.1.2 Research goals ... 10 2.1.3 Scope of research ... 10 2.1.4 Research questions ... 112.2 Analysis and diagnosis ... 12
2.3 Plan of action ... 12
3 DESCRIPTION OF THE OPERATING ROOM SCHEDULING SYSTEM ... 13
3.1 Method... 13
3.2 Overview of the OR scheduling system ... 13
3.3 Patient characteristics ... 14
3.4 Operating room complex ... 15
3.4.1 Resource characteristics ... 15
3.4.2 OR Staff characteristics ... 16
3.5 Operating room scheduling organization... 17
3.5.1 OR blocks per specialism ... 17
3.5.2 Scheduling organization... 18
3.5.3 Support tools ... 20
3.6 OR scheduling process ... 20
3.6.1 Place patients on waiting list ... 21
3.6.2 Schedule patients for specific dates ... 21
3.6.3 Schedule patients ... 21
3.6.4 Determine patient sequence ... 26
3.6.6 Cancelation of patients ... 26
4 PERFORMANCE SCAN OF THE OR SCHEDULING SYSTEM... 27
4.1 Approach ... 27
4.2 Stakeholder analysis ... 28
4.2.1 Method ... 28
4.2.2 Analysis ... 29
4.2.3 Conclusion ... 32
4.3 Specification of stakeholder interests ... 33
4.3.1 Method ... 33
4.3.2 Specification of stakeholder interests ... 35
4.4 Performance of the OR scheduling product ... 46
4.4.1 Method ... 46
4.4.2 Performance scan: phase I ... 48
4.4.3 Performance scan: phase II ... 60
4.5 Performance of the OR scheduling process ... 62
4.5.1 Method ... 62
4.5.2 Performance scan ... 63
4.6 Influencing factors... 66
4.6.1 Organizational planning structure ... 66
4.6.2 Scheduler knowledge/skills ... 67
4.6.3 Information quality ... 67
4.6.4 Complexity and uncertainty ... 68
5 PROJECT PROPOSALS ... 69
6 CONCLUSION ... 71
7 REFERENCES ... 73
1
INTRODUCTION
The Wilhelmina Ziekenhuis Assen (WZA) is experiencing changes in the healthcare environment. This change is caused by the increasing demand for health care and increasing expenditures (Hans, Houdenhoven & Hulshof, 2011). Also the liberalization of the health care market leads to the fact that hospitals become more competitive and therefore good quality service is becoming more and more important. This forces the WZA to organize their processes more efficiently and effectively. An essential unit of focus is the operating room complex (OR complex) due to its high costs because of its expensive resources and staff (Vissers, 2005). However, the OR complex is also a major profit making unit that typically accounts for 40% to 75% of hospital income (Chen, Lin, Hou, Wang and Lin, 2010). Efficient utilization of the OR complex is therefore a widely discussed topic in research. The complexity due to multiple resources, preferences and wishes of staff and patients, and resource constraints makes it also interesting for research. The performance of the OR complex is closely related to the OR schedule as mentioned by Chen et al. (2010). Constructing an OR schedule is a process that involves the organization of multiple persons and resources, this is referred to as the OR scheduling system. The organization of the OR scheduling system, however is something that is almost not discussed in literature. In this research the OR scheduling system of the WZA is described. Based on this description the performance of the OR scheduling system is evaluated with a performance scan. The outcome of the performance scan is used to provide suggestions for possible improvements of the OR scheduling system.
1.1
Company description
The WZA is a medium size hospital that is located in Assen. The WZA has approximately 276 beds and 1200 employees. The mission of the WZA is:
“The WZA supports patient in Assen and surrounding with the satisfaction of his or her health care needs, delivers high quality health care and strives for continual improvement. The hospital is ambitious and innovative what leads to the best possible result in a people oriented manner. All this takes place in a safe and trusted environment by motivated employees.”
1.2
The OR complex
SPECIALISMS AT WZA Surgery
Urology Orthopedics
Oral maxillofacial surgery Gynecology
Otorhinolaryngology Ophthalmology Neurosurgery
Table 1. Specialisms at the WZA
The number of surgeries conducted in 2009, 2010, and 2011 are depicted in table 2. Approximately 8.500 surgeries of 2011 are elective surgeries. “Elective” is defined as patients that can be scheduled well in advance, so there is no need for immediate surgery (Guerriero and Guido, 2010; Gupta and Denton, 2008). Non-elective patients are emergency patients that cannot be scheduled in advance, but have to undergo surgery within a limited time, because their life or quality of life depends on it.
2009 2010 2011 Number of surgeries 9.542 9.723 10.185 Table 2. Number of surgeries
1.3
Patient pathway
Figure 1. Patient pathway
1.4
Scheduling organization
2
RESEARCH DESIGN
The research is structures by using the regulative cycle of Van Strien (1997). The research starts with a problem mess from which the research problem is derived. The management question of this research is defined in paragraph 2.1. Based on the management question the research goals, the scope of research, and research questions are determined. The analysis and diagnosis stage of the research are described in paragraph 2.2. In paragraph 2.3 the plan of action stage is described. The intervention and evaluation stages are not included in this research due to the timeframe of the research.
2.1
Problem definition
In this section the management question will be determined along with the research goal, the scope of research, and the research questions.
2.1.1 Management question
Management is forced to organize processes more efficiently and effectively, due to changes in the healthcare environment of the WZA. The OR complex is a key factor because this is a major expenditure of the WZA due to its expensive resources and staff (Vissers, 2005). At the base of OR complex performance lies the OR schedule Chen et al. (2010). In the current situation there is no clear overview of the OR scheduling system. Next to the schedulers and the OR day coordinator it is unclear who can influence the OR schedule, and what their roles and interests are in the OR scheduling system. The current organization of the OR scheduling system makes it hard to understand why and by who certain scheduling choices are made within the OR schedule. Besides the fact that the organization of the OR scheduling system is unclear, it is also unclear how the OR scheduling system performs. From this the following management question is derived:
2.1.2 Research goals
From the management question the following research goals are derived. The first goal is to provide the WZA with a description of the current OR scheduling system. The second goal is to evaluate the performance of the OR scheduling system based on the description of the OR scheduling system. The third goal is to provide suggestions for improvement based on the outcome of the performance evaluation of the OR scheduling system.
1.
Provide a description of the OR scheduling system
2.
Evaluate the performance of the OR scheduling system
3.
Provide suggestions for improvement of the OR scheduling system performance
2.1.3 Scope of research
The OR scheduling system is part of the more complex OR planning system the research is demarcated to get a clear scope. The scope is set with the “Framework for hospital production control” by Vissers, Bertrand and De Vries (2001) and the “Framework for health care and control” by Hans, Houdenhoven and Hulshof (2011).
Vissers et al. (2011) distinguish five levels of hierarchy: strategic planning, patient volumes planning & control, resource planning & control, patient group planning & control, and patient planning and control. Strategic planning is basically what ranges of services are offered within a time span of 2-5 years and is set by hospital management. This leads to patient volumes planning & control that involves the development of hospital activities in the next year with a time span of 1-2 years also set by hospital management. Based on the latter resources are allocated to patients groups and specialisms over a time span of 1 year. Thereafter specialist time is scheduled at patient group level. At the lowest level the individual patient is scheduled for OR. Hans et al. (2011) distinguish three hierarchical levels in an OR planning system: strategic, tactical, offline and online operational. Offline operational implicates the in advance planning of operations and deals with the detailed coordination of the current elective demand. Whereas online operational implicates reactive decision making due to the stochastic nature of health care processes, it deals with reacting to unforeseen or unanticipated events (non-elective demand). They also consider four different managerial areas with regard to planning: medical planning, resource capacity planning, materials planning, and financial planning. These two frameworks are integrated to get a comprehensive overview of the hierarchical levels of the OR planning system (figure 2).
activities of an operation. It is the construction of a detailed timetable that shows at what time or date jobs should start and when they should end”.
Resource Capacity Planning OR
Patient Volumes Planning & Control
Resource Planning & Control
Patient Group Planning & Control Strategic Level
Tactical Level
Strategic Planning
Patient Planning & Control Operational Level
Figure 2. Planning hierarchy (Vissers et al., 2001; Hans et al., 2011)
2.1.4 Research questions
To answer the management question the following research questions are constructed. These research questions are answered within the scope of research. The research questions are answered in sequential order in the following chapters.
Description of the OR scheduling system:
1. How is the OR scheduling system organized?
Analysis of the OR scheduling system:
2. Who are the stakeholders of the OR scheduling system?
3. What are the interests of the most relevant stakeholders?
4. What is the performance of the OR scheduling product?
5. What is the performance of the OR scheduling process?
6. What factors influence the performance of the OR scheduling system?
Suggestions for improvement of the OR scheduling system:
2.2
Analysis and diagnosis
In chapter 3 the OR scheduling system of the WZA is described. More specific, the patient characteristics, the operating room complex, and the OR scheduling organization are described. Data for this is gathered through interviews and observation.
In chapter 4 the performance of the OR scheduling system is evaluated by performing a performance scan of the OR scheduling system. This performance scan is based on the description of the OR scheduling system. In order to perform this scan first a stakeholder analysis is conducted. From the stakeholder analysis the most relevant stakeholders are determined and their interests are further specified. Data for the stakeholder analysis is obtained through interviews and a survey. Data for the performance scan of the OR scheduling system is also gathered through interviews and the same survey. The survey is constructed from interviews and conversations with different employees within the WZA, literature, and documentation of the WZA. The survey is checked for consistency and clarity by two day coordinators. The performance scan is divided in two parts: a performance scan of the OR scheduling product and a performance scan of the scheduling process. At last the factors that influence the OR scheduling performance are discussed.
2.3
Plan of action
3
DESCRIPTION OF THE OPERATING ROOM SCHEDULING SYSTEM
In this chapter a description is given of the OR scheduling system. First an overview of the OR scheduling system is given in paragraph 3.2. In paragraphs 3.3 to 3.5 the different parts of the OR scheduling system are discussed. In paragraph 3.6 the patient scheduling process is described. The following research question is addressed:
1. How is the OR scheduling system organized?
3.1
Method
Data for the description of the OR scheduling system is gathered through semi-structured interviews and observations. The interviews are conducted with two schedulers, one OR day coordinator. The observation is done by sitting next to a scheduler as she constructs the OR schedule of one OR day.
3.2
Overview of the OR scheduling system
Figure 3. Operating room scheduling system
3.3
Patient characteristics
The research is focused on elective patients these are patients that can be scheduled for surgery well in advance. The WZA divides patients into four categories:
• Rush (spoed): POP on the same or following day and surgery within 2 weeks. • Some rush (enige spoed): POP within 2 weeks and surgery within 4 weeks. • Regular (normaal): POP within 4 weeks and surgery within 6 weeks. • Waiting list (wachtlijst): POP within 6 weeks and surgery within 6 months.
Within this research elective patients are defined as patients from the categories regular and waiting list. The reason for this is the fact that schedulers schedule the rush and some rush patient with a different priority because of the short time span. They are usually scheduled the same or following day of receiving the Intake form, whereas the regular and waiting list patients are scheduled according to the regular scheduling process.
information down on the Intake form and the anesthesiologist notes the information on the Pre-op form. The data can be elaborated with additional research done at the laboratory or at the Rontgen department.
3.4
Operating room complex
The OR complex consists of resources and staff needed to perform surgery. First the patient routing at the day of surgery is discussed. Thereafter the resource characteristics and staff characteristics are discussed.
Patient routing at the OR complex
The OR complex consists of six OR’s, a holding room, and a recovery room. The patient routing at the OR complex is depicted in figure 4. The outpatient comes from the surgical day center whereas the inpatients come from the nursing department. At the holding room the patient is prepared for surgery by the anesthesiologist and anesthesiologist assistant. After preparation the patient is ready for surgery and is brought to the OR when it is available. After the surgery is finished the patient is brought to the recovery room to recover. Thereafter the patient is brought back to the surgical day center or nursing department.
Figure 4. Patient routing at the OR complex
3.4.1 Resource characteristics
The resources of the OR complex are: the OR’s, holding room and recovery room, instruments, and materials.
Operating rooms
patients are brought in with a wheelchair and thereby do not have to cross the whole OR complex. Also the equipment per OR differs and therefore certain surgeries need to be performed in specific OR’s.
Holding room and recovery room
The holding room has three beds and the recovery room has thirteen beds. Due to the low capacity of the holding room patients that need to be prepared are also kept in the recovery room.
Instruments
For each type of surgery a specific set of instruments is required. A limited number of these instrument sets are mainly in-house at the OR complex. This means that there is a certain limitation to the number of surgeries that can be performed, where the same instrument sets are required. However, there is the possibility to sterilize the instrument sets after surgery. It takes about four hours before the sets can be used again. The instrument sets that are required for each type of surgery are listed on Sharepoint. Also the number of instruments sets is listed on Sharepoint.
Material
For certain surgeries specific material is needed. Like for instance a special prosthesis. Standard material is in-house but special material has to be ordered. The specialist indicates on the intake form if material needs to be ordered.
3.4.2 OR Staff characteristics
The staff of the OR complex that are involved with or affected by the OR schedule are:
• OR day coordinator: Responsible for the overall state of affairs at the OR. This means that he has to keep track and control the OR schedule and has to handle emergency cases.
• Surgeon: The surgeon is the person that diagnoses the patient for surgery. Although the diagnosing surgeon mainly performs the surgery him or her-self it is possible that the surgery is performed by another surgeon in conformation with the patient.
• Anesthesiologist: Performs the anesthesia techniques and monitors the patient’s vital signs. • Anesthesiologist assistant: Assists the anesthesiologist.
• Surgeon assistant: Assists the surgeon with the surgery.
assistants, this team works from 9.00 hrs until 17.30 hrs. Besides these two teams there is a standby team, this team works from 14.30 hrs until 22.30 hrs. After 22.30 hrs the standby team is on standby for emergency cases.
3.5
Operating room scheduling organization
First the assignment and number of OR blocks per specialism are described. Thereafter scheduling organization, scheduling tasks, scheduling rules, and scheduling criteria are discussed. At last the support tools for OR scheduling is discussed.
3.5.1 OR blocks per specialism
On strategic level the number of OR’s is determined and the patient volumes are determined. At tactical level OR time is divided among the eight different specialisms. In contrast as mentioned by Vissers et al. (2001) and Guerriero and Guido (2011) that specialism OR time are determined on a yearly base, based on the expected patient volume, this is not the case within the WZA. The assigned OR time per specialism is constant no matter what the expected patient volume is. The scheduling method that is used with the WZA is block scheduling. In the case of block scheduling a set of OR time blocks is assigned to specific surgeons or specialisms. Every three months the OR day coordinator assigns OR blocks to the specialism in the scheduling system. The block schedule is derived from the amount of OR time allocated to each specialism (Santibanze, Begen and Atkins, 2007). This amount of OR time is determined in what Guerriero and Guido (2011) refer to as a cyclic timetable that is called a “OR block allocation table” or a “master surgical schedule”. An OR time block has an OR time interval of a half or a full day. The number of OR blocks per specialism are depicted in table 3.
SPECIALISM OR BLOCKS Surgery 17 Orthopedics 18 Gynecology 5 Urology 5 Ophthalmology 4 Otorhinolaryngology 7 Oral maxillofacial surgery 3
Neurosurgery 0,5
3.5.2 Scheduling organization
The OR scheduling system is a two stage scheduling system (figure 5). The OR schedule is constructed by two departments. At the first stage the OR schedule is constructed at the department Intake and Discharge. At this stage patients are assigned to OR blocks by the schedulers. At the second stage the patients in OR blocks are sequenced to optimize the utilization of staff and resources at the OR complex. This is done at the OR complex by the OR day coordinator.
At the department Intake and Discharge there are six schedulers that rotate on the scheduling job. Each day typically 2 schedulers are responsible for scheduling patients. The schedulers switch between different tasks at the department Intake and Discharge and the POP. At the OR complex the OR day coordinator is involved in scheduling patients for surgery. There are three people that switch between the function OR day coordinator, from these there are two main OR day coordinators. These two are the team leader surgery and team leader anesthesiology.
Figure 5. Two stage scheduling organization
Scheduling tasks
The scheduler is responsible for scheduling elective patients from the surgeon’s waiting lists into OR blocks of the specific surgeon. Also changes in the OR schedule are handled by the schedulers, for instance when a patient is sick on the day of surgery the scheduler has to remove the patient from the OR block and place the patient back on the waiting list. The scheduler also has to notify the patient about the scheduled OR date.
The OR day coordinator has to approve the OR schedule that is constructed by the schedulers to check whether the OR schedule is feasible. One day before OR date the OR day coordinator mostly in consultation with team the team leader anesthesiology determines the sequence of the patients scheduled within the OR blocks.
Scheduling rules
intake form is placed in the front of the surgeon’s waiting list in the surgeon’s dossier so they are scheduled first at the next scheduling session.
Scheduling criteria
There are a number of scheduling criteria that are used by the schedulers and OR day coordinators to schedule elective patients. These criteria are divided into scheduling preferences and scheduling constraints.
Scheduling preferences
Some stakeholders of the OR scheduling system have certain preferences with regard to the OR schedule. These preferences are certain aspects that a stakeholder likes to see in the OR schedule. Preferences can be for instance a specific sequence of patients in an OR block or specific patient mix. Per stakeholder the preferences differ because they all have different interests in the OR schedule. From the stakeholders mainly preferences of the surgeons are incorporated in the OR schedule by the scheduler and OR day coordinator. Per specialism the preferences differ because they all have specific patient groups that undergo specific surgeries. For instance Otorhinolaryngology performs many standard surgeries, whereas Surgery performs many non-standard surgeries with relatively high uncertainty. It’s not clear if all the preferences of the stakeholders are implemented in the OR schedule. The preferences are not listed but they are known for a part by the schedulers and OR day coordinators. The head of the surgical day center also has the possibility to mention her preferences with regard to the OR schedule. She does this by calling the OR day coordinator to discuss het preferred sequence of outpatients that are admitted at the surgical day center.
Scheduling constraints
Scheduling constraints determine the scheduling possibilities of the patients. The constraints are resource and staff related, related to choices made by management or set by regulations. The constraints for OR scheduling are mentioned below:
• OR resources (e.g. OR’s, instruments, material) • OR staff (e.g. surgeon, anesthesiologist)
• Third parties (e.g. guest operator, Rontgen personnel) • Patient specific (e.g. urgency, type of anesthesia, age)
• Treek norm1: 80% of the patients treated within < 5 weeks, maximum 7 weeks • IGZ Topzorg 1232: There are a number of official stop moments in the process
1
http://www.treeknorm.nl/ 2
• Topzorg predicaten: patients with a specific healthcare insurance and surgery need to be treated within a specific timeframe
3.5.3 Support tools
There are a few support tools that are used to schedule patients. To schedule patients in OR blocks scheduling software from Chipsoft EZIS (EZIS) is used. Patients that need to undergo surgery are registered in the clinical waiting list in EZIS. From this waiting list the patients can be assigned to OR blocks. From the Intake form patients are placed on the waiting list in EZIS. The Intake form is also used as a support tool. On this the patient’s data is with regard to the surgery is noted by the surgeon. Next to this data also preferences with regard to OR date are noted on the Intake from. Also the schedulers use the Intake from as a means to communicate special details about the patient by noting this on the form. Another support tool that is used is Sharepoint. On Sharepoint lists of instruments, lists of surgery types and type of laboratory research are available. It is also used as a means to communicate specific details with regard to OR scheduling between the schedulers because there are 6 schedulers that rotate each day which makes it difficult to keep track of specific details. This can be for instance the temporary preferences of a surgeon.
3.6
OR scheduling process
The OR scheduling process is described step by step with the Actor Activity Diagram3 in the following paragraphs. With this diagram the actors, activities, and information systems can be depicted and connected in a clear overview. An overview of the OR scheduling process is depicted in table 4. If a patient is diagnosed for surgery, the patient is placed on the clinical waiting list in EZIS. Patients with a preference for specific an OR date are scheduled a part from the regular scheduling process, however the scheduling process is the same. Regular OR scheduling is done eight days in advance of OR date, due to anticoagulant medicines that need to be stopped prior to the surgery. A day before OR date the sequence of patients in the OR blocks is determined. Cancellation of patients can be done from the moment the patient is scheduled up to and including the day of surgery.
3
Table 4. Overview of the OR scheduling process
3.6.1 Place patients on waiting list
The Intake form of the patient is brought to the department Intake and Discharge by the secretary of the polyclinic, the surgeon or the patient self. The patient data is entered in EZIS and the patient is placed on the waiting list. The scheduler checks whether the patient has a POP appointment and if not she makes one. The Intake form along with the Pre-op form is placed in the surgeon’s dossier.
3.6.2 Schedule patients for specific dates
Some patients are scheduled for a specific date. This can be due to preferences of the patient or preferences of the surgeon. The process of scheduling these patients is the same as the first two sub processes of the regular scheduling process as mentioned in paragraph 3.6.3.
3.6.3 Schedule patients
preference for a specific OR date that are scheduled. These patients are scheduled prior to the regular scheduling process. The scheduling process for these patients is the same as the regular scheduling process.
Figure 6. Scheduling process
Check scheduled patients
The first step in the scheduling process is to check the patients that are already scheduled for the specific OR date. There are several reasons why these patients are already scheduled this can be for instance the urgency of surgery or because of patient or surgeon preferences. The patients that are already scheduled are identified in EZIS and are their Intake and Pre-op forms are gathered from the dossier of scheduled patients. The scheduler checks if the patient is notified about the OR date this is noted on the Intake form by the scheduler that scheduled the patient. If the patient Intake form of a patient is at POP, for pre-operative screening, than a print of the POP appointment is made for the surgeon’s documentation. The patient is scheduled before pre-operative screening for instance because of the urgency of surgery. The process of checking scheduled patients is depicted in figure 7.
Dossier
Scheduled Intake form
Scheduler OR day
coordinator EZIS
Print POP appointment Identify scheduled patients
Gather Intake and Pre-op form of scheduled patients
Check if the scheduled patients are notified about OR date
Patients Intake form at POP
1
2
3
4
Schedule patients
Patients are scheduled in EZIS in the surgeon’s dedicated OR blocks from the surgeon’s waiting list (figure 8). The Intake and the Pre-op forms of the patients are kept in the dossier of the surgeon. From this dossier suitable patients are picked out. The patient is dragged from the waiting list in EZIS to the specific OR block in EZIS. When the patient is placed in an OR block the scheduler checks whether a patient has to give blood. This can be checked with a list on Sharepoint of surgeries that indicate which patients need to give blood, this list changes over time. Based on this a checkmark is checked in EZIS by the scheduler with regard to the letter for the patient. By checking this checkmark the patient is notified in the letter if he or she has to give blood and when. Thereafter the letter for the patient is printed with the needed information for the patient with regard to the admission for surgery.
Figure 8. Schedule patients
Schedule patients from other surgeons
16). The process of scheduling patients from another surgeon’s waiting list is the same as scheduling patients from the surgeon’s own waiting list (figure 8).
Complete the OR schedule
3.6.4 Determine patient sequence
One day before OR date the OR day coordinator determines the sequence of patients in OR blocks (stage 2). This is done before 15.00 hrs. The sequencing of patients in OR blocks is mainly done in consult with surgical day center. This sequencing is done by the OR day coordinator because he plans the OR resources: material, instruments, personnel and coordinates them on the basis of the OR schedule.
3.6.5 Inform patient about OR time
One day before OR date after 15.00 hrs, when the patients in the OR blocks are sequenced by the OR day coordinator, the patients call department Intake and Discharge for their surgery time and the time they need to be in the hospital.
3.6.6 Cancelation of patients
4
PERFORMANCE SCAN OF THE OR SCHEDULING SYSTEM
In this chapter the performance of the OR scheduling system is scanned. The scan is performed by using the “scheduling performance measures framework” of De Snoo, Van Wezel and Jorna (2010). To perform this scan first a stakeholder analysis is conducted. With this stakeholder analysis the most relevant stakeholders of the OR scheduling system are determined. When these are known the interests of these stakeholders are further specified. Based on this the performance of the OR scheduling system is scanned by scanning the performance of the OR scheduling product and the OR scheduling process.
4.1
Approach
The first step in performing a performance scan of the OR scheduling system is to identify the relevant stakeholders with a stakeholder analysis (paragraph 4.2). The respective stakeholders are then approached to participate in a survey. The survey consists of 33 OR scheduling criteria that are weighed on importance by the stakeholders. From these weighed criteria the interests of the stakeholders are further specified (paragraph 4.3). The research questions that are addressed:
2. Who are the stakeholders of the OR scheduling system?
3. What are the interests of the most relevant stakeholders?
After the relevant stakeholders and their interests are determined, a performance scan of the OR scheduling system is performed. The performance is scanned with the “scheduling performance measures framework” of De Snoo et al. (2010). De Snoo et al. (2010) divide the performance criteria of a scheduling system into three categories. For this research only two categories are used: the performance of the OR scheduling product (paragraph 4.4), and the performance of the OR scheduling process (paragraph 4.5). The third category “indirect scheduling performance criteria” is not considered because of the timeframe of the research. Besides these three categories De Snoo et al. (2010) mention five factors that can influence the performance a scheduling system. These influencing factors are used to explain the performance of the OR scheduling system in paragraph 4.6. The survey that is used to further specify the interests of the stakeholders is also used to scan the performance of the OR scheduling product, because the scheduling criteria from the survey are directly linked to the OR scheduling product. The three research questions that are addressed:
4. What is the performance of the OR scheduling product?
5. What is the performance of the OR scheduling process?
4.2
Stakeholder analysis
4.2.1 Method4.2.2 Analysis
The stakeholders are mapped in figure 10 the power and interests of the stakeholders are discussed below. The power refers to the ability of a stakeholder to influence the OR scheduling system. The interest refers to the amount of interest a stakeholder has in the OR scheduling system. The quadrants are:
• Manage closely: these stakeholders should be fully engaged in the OR scheduling system • Keep satisfied: these stakeholders should be kept satisfied about the OR scheduling system • Keep informed: these stakeholders should be kept informed about the OR scheduling system • Monitor: these stakeholders require only minimal effort and monitoring
Scheduler
The scheduler has mediocre power in the OR scheduling system. Although the scheduler is the one that constructs the OR schedule, the scheduler tries to implement the preferences of the surgeon, patient, and OR day coordinator. The surgeon can give his or her preferences with regard to the OR schedule and the scheduler than tries to implement these preferences. Also the patient can have preferences with regard to OR date or time and the scheduler also tries to implement these preferences into the OR schedule. But most patients need to undergo surgery within a specific timeframe and therefore do not have a strong preference about OR date or time. The fact that there is no specific policy with regard to patient preference with regard to OR date leads to the fact that patients can postpone their OR date. Some schedulers however try to convince a patient to agree with the scheduled OR date. The OR schedule that is constructed by the schedulers needs to be approved by the OR day coordinator. If the OR day coordinator does not approve the OR schedule the scheduler has to modify the OR schedule according to the feedback of the OR day coordinator. The scheduler has great interest in the OR scheduling system as OR scheduling is her core job task.
OR day coordinator
The OR day coordinator is the one that has to approve the OR schedule that is constructed by the schedulers. The OR day coordinator checks the OR schedule for feasibility in terms of OR constraints. When the OR day coordinator does not approve the OR schedule, the scheduler has to modify it according to the feedback of the OR day coordinator. The OR day coordinator is end responsible for the OR schedule and therefore has high power in the OR scheduling system. The OR day coordinator is directly approached by the anesthesiologists with affairs regarding the OR schedule, the surgeons in generally do not approach the OR day coordinator with regard to the OR schedule. The interest of the OR day coordinator in the OR scheduling system is very high, as he is responsible for the daily operations at the OR complex and therefore wants an optimal OR schedule with regard to OR resources and staff.
Surgeon
Anesthesiologist:
The anesthesiologist is a very important person with regard to the patient’s surgery. In the OR scheduling system however the anesthesiologist is almost not involved in the scheduling process. In fact the anesthesiologist is one of the last persons that looks at or has influence on the OR schedule. Although the anesthesiologist has the power to cancel surgery, his or her power in the OR scheduling system is relatively low. The anesthesiologist is responsible for the anesthesia and thereby the patient’s health perioperative, therefore the interest of the anesthesiologist in the OR scheduling system is high. Also because the daily activities of the anesthesiologist are directly determined by the OR schedule as he or she is the end-user of the OR schedule.
Surgical day center
The surgical day center is directly influenced by the OR schedule. Outpatients are taken in by the surgical day center and prepared for OR. After OR these patients return to the surgical day center and leave the hospital the same day. The head of the surgical day center has the opportunity to discuss the OR schedule with the OR day coordinator. This is done the day before OR date, when the OR day coordinator determines the sequence of patients. The preferences are only implemented if these are not in conflict with the performance of the OR complex. The power of the surgical day center is low because the patients in the OR schedule are already determined. The surgical day center can only try to influence the sequence but the efficiency at the OR complex is leading in the determining the sequence.
Anesthesiologist assistant and surgical assistant:
The anesthesiologist assistant and surgeon assistants have almost no power in the OR scheduling process. They are scheduled by the OR day coordinator. Sometimes they have preferences about participating with a specific surgery, and they ask the OR day coordinator if they can participate on the OR team that is scheduled for that procedure. The interests of the surgeon assistants in the OR scheduling system is low, because the way the OR schedule is constructed will not affect their daily activities in a major way. The anesthesiologist assistants however have more interest in the OR schedule, because this directly influences the workload they experience in their daily activities.
Patient
to the anesthesiologist when he or she is screened at the POP. So the patient has relatively more power in the OR scheduling system then the scheduler. The interest of the patient in the OR scheduling system is however lower, because the patient is mainly concerned about the OR date.
Nursing department
The nursing departments have no power in the OR scheduling system. They are not involved in the OR scheduling system at all. They however do have an interest in the OR scheduling system as this directly influences the activities at the nursing departments. Patients that stay overnight (inpatients) are taken in by the nursing department and prepared for OR. After OR the patients stay at the nursing departments for a specific time.
4.2.3 Conclusion
4.3
Specification of stakeholder interests
In this paragraph the interests of the most relevant stakeholders “manage closely” from the stakeholder analysis in paragraph 4.2 are further specified. The respective stakeholders are the scheduler, surgeon, anesthesiologist, and the OR day coordinator.
4.3.1 Method
The interests of the relevant stakeholders are further specified with a survey. The format of the survey comes from the Lean Operation Research Center4 where the format is used for the Lean monitor. All the six schedulers from the department Intake and Discharge participated in the survey. Two OR day coordinators participated in the survey. Four surgeons from the specialisms Otorhinolaryngology, Surgery, Gynecology and Oral maxillofacial surgery responded to the survey and two anesthesiologists responded to the survey.
The survey consists of 33 OR scheduling criteria that are obtained through interviews, WZA documents, and literature search. The interviews to obtain the 33 OR scheduling criteria were semi-structured and were conducted with: two schedulers, one OR day coordinator, head OR complex, patient ombudsman, two heads of nursing departments, and the team leader of the surgical day center. All these interviewees are involved in constructing or affected by the OR schedule. The WZA documents that are used are: Strategisch beleidsplan WZA 2011 -2014, Kadernota 2011, and Regelement OK complex 2004. The following literature is used to obtain the OR scheduling criteria is: Gupta & Denton (2008); Guerriero &Guido (2011); Sier, Tobin & Mcgurk (1997); Hamilton & Brewalski (1991, 1994); Vissers et al. (2001); and Cardoen et al. (2010). The OR scheduling criteria are weighed by the stakeholders according to their perceived importance on a 5 point scale that is defined as:
Totally unimportant = 1, Unimportant = 2, Neutral = 3, Important = 4, Highly important = 5
The 33 OR scheduling criteria in the survey are divided into six categories. The categories patient sequence and patient mix are sub-categories of the scheduling criteria patient sequence and patient mix under the category OR session. In table 5 the OR scheduling criteria are described. The survey is attached in appendix I.
4
OR SCHEDULING CRITERIA DESCRIPTION General
1 Topzorg predicaten Agreements with healthcare insurance companies about specific patients and surgeries
2 Treeknorm 80% of the patients treated within < 5 weeks, maximum 7 weeks 3 Safety Inspectie voor de Gezondheidszorg top 123
4 Reliability OR schedule Correct OR schedule, meaning no changes 5 Reliability surgery time Correct surgery time
6 Satisfaction OR personnel Satisfaction of anesthesiologist assistants and surgeon assistants Patient related
7 Short admission time OR Time from diagnose to surgery 8 Short waiting time on OR day Waiting time on the day of surgery 9 Patient preference OR date Patient preference for specific OR date
Efficiency departments
10 Efficient use OR Efficient use of staff and resources 11 Efficient use Recovery room Efficient use of staff and resources 12 Efficient use Holding room Efficient use of staff and resources 13 Efficient use nursing department Efficient use of staff and resources 14 Efficient use CDC Efficient use of staff and resources 15 Efficient use IC Efficient use of staff and resources
OR session
16 Optimal utilization Use of dedicated OR blocks by surgeons 17 Optimal occupation Filling of the OR block
18 Reducing late starts Reduce late starts of OR blocks 19 Reducing overtime Reduce OR block overtime 20 Reducing cancelations Reduce cancelations of patients
21 Enough room for emergency cases Enough room for emergency cases within the OR schedule 22 Patient sequence The sequence of the patients in OR blocks
23 Patient mix The mix of patients in OR blocks Patient sequence
24 Long/ short surgery duration Patient sequence of long and short surgery durations 25 High complex/ low complex Patient sequence of high and low complex surgeries 26 Adult/ child Patient sequence of adults and children
27 Anesthesia type Patient sequence of anesthesia technique 28 ASA class Patient sequence of ASA class
Patient mix
29 Long/ short surgery duration Patient mix of long and short surgery durations 30 High complex/ low complex Patient mix of high and low complex surgeries 31 Adult/ child Patient mix of adults and children
32 Anesthesia type Patient mix of anesthesia technique 33 ASA class Patient mix of ASA class
4.3.2 Specification of stakeholder interests
The outcome of the survey shows the importance of the OR scheduling criteria, from now on referred to as scheduling criteria, per stakeholder. The importance of the scheduling criteria is discussed per stakeholder group. Within the stakeholder groups the mutual differences and mutual similarities are discussed per category. The average importance and the range of importance of the stakeholder groups are determined. The range is the maximum score minus the minimum score of importance within a stakeholder group. The results are presented in a table which consists of scheduling criteria on the left side and the importance score per stakeholder on the right side. From the results the interests of the stakeholders are determined. The scheduling criteria that are weighed ≥ 4 on average are considered to be the interests of the stakeholders, because these are valued as important or highly important. At last the results of the different stakeholder groups are compared.
Schedulers
The results from the survey of the schedulers are shown in table 6. The results show a striking picture. There are large differences in assigned weights to the importance of the scheduling criteria among the six schedulers. The results show, except for 1 scheduling criterion, only mutual differences. The majority of the scheduling criteria show major mutual differences between the schedulers, meaning a range of ≥ 2, the most critical mutual differences with a range of ≥ 3 are highlighted in the table. The remaining scheduling criteria show minor mutual differences with a range of 1.
Within the category general the results show only two critical mutual differences of scheduling criteria [2 & 3]. Where four schedulers weighed the importance of scheduling criterion 2 a 5, the two other schedulers weighed this criterion a 3 respectively a 2. Scheduling criterion 3 shows a more diverse picture with the lowest weight of 1 and the highest weight a 5. The other criteria in this category only show minor differences.
Two of the three patient satisfaction scheduling criteria 7 & 9 show a minor mutual difference in the importance. The other criterion 8 shows a major range. This major range is caused by only one scheduler that weighed the importance of this criterion a 3, whereas the other schedulers weighed this 4 or 5.
The overall results of the criteria under the category efficiency departments show major mutual differences between schedulers of which three scheduling criteria [11, 12 & 15] show critical mutual differences in the importance between schedulers. The critical mutual differences show a very diverse picture of weighing among the schedulers with a range of 4.
mutual difference [23] shows a range of 4. Two schedulers weighed the importance of this scheduling criterion a 1 where three schedulers weighed this 5, the other scheduler weighed this criterion a 3.
The sub-category patient sequence only shows major mutual differences between the schedulers on all scheduling criteria. The assigned weight among schedulers is very diverse. It sticks out that two schedulers do not value any of the scheduling criteria important at all, however under the category OR session they weighed the importance of the patient sequence a 4.
The sub-category patient mix shows major mutual differences between schedulers. The results show that there are two schedulers that consider the criteria under patient mix. There is one scheduling criterion [31] that one scheduler weighed a 4, which is the highest weight in this category. The other schedulers do not consider the scheduling criteria in this category as they all weigh these criteria a 1. This sub-category also shows a difference of two schedulers between the assigned weights of scheduling criterion 23 under the category OR session and the assigned weight of the scheduling criteria under the sub-category patient mix. Where the two schedulers weighed the importance of these criteria a 5 for the scheduling criterion “23, they weighed all 1’s for the scheduling criteria under the sub-category patient mix.
Scheduler interests
From the average assigned weight the interests of the schedulers are determined, so the average weight of ≥ 4. Because the schedulers are the ones constructing the OR schedule instead of using the OR schedule, there interests differ from the end-users. They are not directly affected by the OR schedule itself. Therefore a complementary interview is conducted with a scheduler to determine their interests. The scheduler mentioned that the interest of the scheduler is to satisfy all the stakeholders of the OR scheduling system. This can also be seen in the results from the survey as they weighed scheduling criteria related to the patients [2, 7, 8 & 9], the OR [4, 5, 10, 16-22], nursing department [13] and surgical day center [14] a 4 or more. The criteria related to the OR are directly related to the users of the OR schedule, so the surgeon, anesthesiologist, but also the OR day coordinator. The schedulers do not focus on Topzorg predicaten, OR personnel, recovery room, holding room, IC and patient sequence and mix.
OR day coordinators
OR day coordinator interests
Table 6. Weighed importance of the OR scheduling criteria – schedulers S 1 S 2 S 3 S 4 S 5 S 6 A v e ra g e R a n g e General 1 Topzorg predicaten 1 1 1 1 2 2 1,3 1 2 Treeknorm 5 5 3 5 2 5 4,2 3 3 Safety 3 5 5 1 2 3 3,2 4 4 Reliability OR schedule 5 5 5 5 4 4 4,7 1
5 Reliability surgery time 5 5 5 5 4 5 4,8 1 6 Satisfaction OR personnel 3 3 2 3 3 3 2,8 1
Patient satisfaction
7 Short admission time OR 5 5 5 5 4 4 4,7 1
8 Short waiting time on OR day 5 4 3 5 4 4 4,2 2 9 Patient preference OR date 5 5 4 5 4 4 4,5 1
Efficiency departments
10 Efficient use OR 5 5 5 5 4 3 4,5 2
11 Efficient use Recovery room 1 5 2 1 3 3 2,5 4
12 Efficient use Holding room 1 5 2 1 3 3 2,5 4
13 Efficient use nursing department 5 5 3 5 4 4 4,3 2 14 Efficient use sugical day center 5 5 3 5 4 4 4,3 2
15 Efficient use IC 3 5 3 1 3 4 3,2 4
OR session
16 Optimal utilization 5 5 3 5 4 5 4,5 2
17 Optimal occupation 5 5 3 5 4 5 4,5 2
18 Reducing late starts 5 5 4 5 4 5 4,7 1
19 Reducing overtime 5 5 3 5 4 5 4,5 2
20 Reducing cancelations 5 5 5 5 4 5 4,8 1
21 Enough room for emergency cases 5 5 5 5 5 5 5 0
22 Patient sequence 5 5 3 4 4 4 4,2 2
23 Patient mix 5 5 3 1 5 1 3,3 4
Patient sequence
24 Long/ short surgery duration 3 5 2 1 2 1 2,3 4
25 High complex/ low complex 2 5 3 1 4 1 2,7 4
26 Adult/ child 4 5 4 1 5 1 3,3 4
27 Anesthesia type 2 5 1 1 2 1 2 4
28 ASA class 1 5 1 1 2 1 1,8 4
Patient mix
29 Long/ short surgery duration 1 1 3 1 2 1 1,5 2 30 High complex/ low complex 1 1 3 1 2 1 1,5 2
Table 7. Weighed importance of the scheduling criteria - OR day coordinators D C 1 D C 2 A v e ra g e R a n g e General 1 Topzorg predicaten 2 4 3 2 2 Treeknorm 2 4 3 2 3 Safety 5 5 5 0 4 Reliability OR schedule 5 5 5 0 5 Reliability surgery time 5 5 5 0 6 Satisfaction OR personnel 3 4 3,5 1
Patient satisfaction
7 Short admission time OR 4 4 4 0 8 Short waiting time on OR day 4 4 4 0 9 Patient preference OR date 3 4 3,5 1
Efficiency departments
10 Efficient use OR 5 5 5 0
11 Efficient use Recovery room 5 5 5 0 12 Efficient use Holding room 5 5 5 0 13 Efficient use nursing department 4 4 4 0 14 Efficient use sugical day center 4 4 4 0
15 Efficient use IC 4 4 4 0
OR session
16 Optimal utilization 5 5 5 0
17 Optimal occupation 5 5 5 0
18 Reducing late starts 5 5 5 0
19 Reducing overtime 5 5 5 0
20 Reducing cancelations 5 5 5 0
21 Enough room for emergency cases 4 5 4,5 1
22 Patient sequence 4 5 4,5 1
23 Patient mix 4 5 4,5 1
Patient sequence
24 Long/ short surgery duration 4 5 4,5 1 25 High complex/ low complex 4 5 4,5 1
26 Adult/ child 4 5 4,5 1
27 Anesthesia type 4 5 4,5 1
28 ASA class 4 5 4,5 1
Patient mix
29 Long/ short surgery duration 4 5 4,5 1 30 High complex/ low complex 4 5 4,5 1
Surgeons
The results from the survey of the surgeons are depicted in table 8. The results show that the surgeons have mostly minor mutual differences, and two mutual similarities. Only 9 of the 33 scheduling criteria show a major difference in the importance with a range of 2. The surgeons all agree upon the importance of the patient sequence and patient mix of high/ low complex cases.
The scheduling criteria under the category general show that, with the exception of one scheduling criterion [6], there are only minor differences in importance between the surgeons. A notable observation is that two surgeons did not know what is meant with “Treeknorm” [2].
The category patient satisfaction shows two major mutual differences [7 & 8] in importance and one minor mutual difference [9].
The results of the category efficiency departments show major mutual and minor mutual differences in importance. The surgeons show major mutual differences in the importance of three scheduling criteria [11, 14 & 15]. The other scheduling criteria show minor mutual differences between the surgeons
The category OR session show mostly minor mutual differences among the surgeons, three scheduling criteria show major mutual differences [19, 20 & 22].
The sub-category patient sequence shows mostly minor mutual differences among the surgeons. The surgeons agree upon the importance of one scheduling criterion [30] and only have one major mutual difference. The major mutual difference is the importance of scheduling criterion 26.
The sub-category patient mix shows only one mutual similarity [30] the other criteria all show minor mutual differences in importance between surgeons.
Surgeon interests
Anesthesiologists
The anesthesiologists have many mutual similarities and minor mutual differences as shown in table 9. There is only one major mutual difference [13]. This shows that there is a good mutual agreement among them with regard to the importance of the scheduling criteria.
The anesthesiologists agree on the importance of all the scheduling criteria under the category general. The category patient satisfaction shows only one minor difference [8].
The results under the category efficiency departments show minor mutual differences and one major mutual difference [13].
The category OR session shows mutual similarities and minor mutual differences.
Under the sub-category patient sequence there are three mutual similarities and two minor mutual differences, whereas under the sub-category patient mix there is only one mutual similarity and the other four scheduling criteria show minor mutual differences.
Anesthesiologist interests
Table 8. Weighed importance of the OR scheduling criteria – surgeons O R G S U R G Y N O M S A v e ra g e R a n g e General 1 Topzorg predicaten 3 3 4 3 3,3 1 2 Treeknorm 4 3 3 3,3 1
3 Veiligheid (IGZ top 123) 5 4 5 5 4,8 1 4 Betrouwbaarheid OK planning (juiste informatie, geen wijzigingen)5 4 4 4 4,3 1 5 Betrouwbaarheid duur ingreep 3 4 4 4 3,8 1 6 Tevredenheid OK personeel (chirurgisch assistent & anesthesie assistent)3 4 5 4 4 2
Patient satisfaction
7 Korte toegangstijd van diagnose tot OK 4 4 5 3 4 2 8 Korte wachttijd op dag van OK 2 4 4 3 3,3 2 9 Voorkeur OK datum patiënt 3 3 3 4 3,3 1
Efficiency departments
10 Efficiënt gebruik OK 5 4 5 4 4,5 1
11 Efficiënt gebruik Verkoever 4 3 5 4 4 2 12 Efficiënt gebruik Holding 4 3 3 4 3,5 1 13 Efficiënt gebruik Verpleegafdeling 4 4 4 5 4,3 1
14 Efficiënt gebruik CDC 4 3 4 5 4 2
15 Efficiënt gebruik IC 3 4 4 5 4 2
OR session
16 Optimale bezetting (wel of niet gebruiken aangeboden OK sessie)5 4 5 4 4,5 1 17 Optimale benutting (mate waarin bezette OK sessie wordt gevuld)4 4 5 5 4,5 1 18 Reduceren te laat starten OK sessie 5 4 5 5 4,8 1 19 Reduceren uitloop OK sessie 3 4 5 4 4 2 20 Reduceren OK annuleringen 5 4 5 3 4,3 2 21 Faciliteren voldoende ruimte voor acute ingrepen 4 4 5 5 4,5 1
22 Volgorde ingrepen 4 4 3 5 4 2
23 Case mix ingrepen 4 4 3 3 3,5 1
Patient sequence
24 Volgorde lange/korte ingrepen (tijdsduur) 4 3 3 4 3,5 1 25 Volgorde hoog complex/ laag complex 4 4 4 4 4 0 26 Volgorde kinderen/volwassenen 4 4 3 5 4 2 27 Volgorde anesthesie type 4 3 4 3 3,5 1
28 Volgorde ASA klasse 4 3 3 3 3,3 1
Patient mix
29 Case mix lange/korte ingrepen (tijdsduur) 4 3 3 4 3,5 1 30 Case mix hoog complex/ laag complex 4 4 4 4 4 0 31 Case mix kinderen/volwassenen 4 4 3 4 3,8 1 32 Case mix anesthesie type 4 3 4 3 3,5 1
33 Case mix ASA klasse 4 3 3 3 3,3 1
ORG = otorhinolaryngology SUR = surgery
GYN = gynecology
OMS = oral maxillofacial surgery
OR SCHEDULING CRITERIA
Table 9. Weighed importance of the OR scheduling criteria – anesthesiologists A 1 A 2 A v e ra g e R a n g e General 1 Topzorg predicaten 4 4 4 0 2 Treeknorm 4 4 4 0 3 Safety 5 5 5 0 4 Reliability OR schedule 5 5 5 0 5 Reliability surgery time 4 4 4 0 6 Satisfaction OR personnel 4 4 4 0
Patient satisfaction
7 Short admission time OR 4 4 4 0 8 Short waiting time on OR day 4 3 3,5 1 9 Patient preference OR date 4 4 4 0
Efficiency departments
10 Efficient use OR 5 4 4,5 1
11 Efficient use Recovery room 5 4 4,5 1 12 Efficient use Holding room 5 4 4,5 1 13 Efficient use nursing department 5 3 4 2 14 Efficient use sugical day center 5 4 4,5 1
15 Efficient use IC 5 4 4,5 1
OR session
16 Optimal utilization 5 4 4,5 1
17 Optimal occupation 5 4 4,5 1
18 Reducing late starts 5 4 4,5 1
19 Reducing overtime 5 4 4,5 1
20 Reducing cancelations 4 4 4 0
21 Enough room for emergency cases 4 4 4 0
22 Patient sequence 4 4 4 0
23 Patient mix 4 4 4 0
Patient sequence
24 Long/ short surgery duration 4 4 4 0 25 High complex/ low complex 4 4 4 0
26 Adult/ child 4 4 4 0
27 Anesthesia type 5 4 4,5 1
28 ASA class 3 4 3,5 1
Patient mix
29 Long/ short surgery duration 5 4 4,5 1 30 High complex/ low complex 5 4 4,5 1
Comparison between stakeholders
Table 10. Comparison of the weighed importance between stakeholders A v e ra g e S A v e ra g e D C A v e ra g e S U R A v e ra g e A R a n g e General 1 Topzorg predicaten 1,3 3 3,3 4 2,7 2 Treeknorm 4,2 3 3,3 4 1,2 3 Safety 3,2 5 4,8 5 1,8 4 Reliability OR schedule 4,7 5 4,3 5 0,8
5 Reliability surgery time 4,8 5 3,8 4 1,1
6 Satisfaction OR personnel 2,8 3,5 4 4 1,2
Patient satisfaction
7 Short admission time OR 4,7 4 4 4 0,7
8 Short waiting time on OR day 4,2 4 3,3 3,5 0,9
9 Patient preference OR date 4,5 3,5 3,3 4 1,3
Efficiency departments
10 Efficient use OR 4,5 5 4,5 4,5 0,5
11 Efficient use Recovery room 2,5 5 4 4,5 2,5
12 Efficient use Holding room 2,5 5 3,5 4,5 2,5
13 Efficient use nursing department 4,3 4 4,3 4 0,3
14 Efficient use sugical day center 4,3 4 4 4,5 0,5
15 Efficient use IC 3,2 4 4 4,5 1,3
OR session
16 Optimal utilization 4,5 5 4,5 4,5 0,5
17 Optimal occupation 4,5 5 4,5 4,5 0,5
18 Reducing late starts 4,7 5 4,8 4,5 0,5
19 Reducing overtime 4,5 5 4 4,5 1
20 Reducing cancelations 4,8 5 4,3 4 1
21 Enough room for emergency cases 5 4,5 4,5 4 1
22 Patient sequence 4,2 4,5 4 4 0,5
23 Patient mix 3,3 4,5 3,5 4 1,2
Patient sequence
24 Long/ short surgery duration 2,3 4,5 3,5 4 2,2
25 High complex/ low complex 2,7 4,5 4 4 1,8
26 Adult/ child 3,3 4,5 4 4 1,2
27 Anesthesia type 2 4,5 3,5 4,5 2,5
28 ASA class 1,8 4,5 3,3 3,5 2,7
Patient mix
29 Long/ short surgery duration 1,5 4,5 3,5 4,5 3
30 High complex/ low complex 1,5 4,5 4 4,5 3
4.4
Performance of the OR scheduling product
In this paragraph the performance of the OR scheduling product is scanned. The OR scheduling product in this case is the OR schedule. The scan is performed with the same survey used to further specify stakeholder interests and by conducting additional interviews with the relevant stakeholders.
4.4.1 Method
The performance of the OR scheduling product is scanned based upon the performance criteria from the “scheduling performance measure framework” of the De Snoo et al. (2010). For this scan not all the performance criteria from the framework are used to scan the performance of the OR scheduling product. The cost aspect is kept out of the scope of this research due to the limited timeframe of the research. The following performance criteria are used to scan the OR scheduling product:
1. Schedule errors
2. Fulfillment of constraints and commitments made to external parties
3. Fulfillment of preferences and wishes of employees using the schedules
4. Fulfillment of resource utilization constraints
5. Schedule robustness/ information completeness
6. Information presentation and clarity
Data for the performance scan is collected in two phases. In the first phase data is gathered with the same survey that is used for the further specification of stakeholder interests (paragraph 4.3). The OR scheduling criteria in the survey are linked to three performance criteria as shown in table 11. The stakeholders assigned weights to the implementation of the scheduling criteria in the OR schedule on a 5 point scale. The 5 point scale is defined as:
No implementation = 1, Some implementation = 2, Partial implementation = 3, Almost total implementation = 4, Total implementation = 5
An important note is the fact that the schedulers and the OR day coordinators are the ones constructing the OR schedule and therefore implementation for them implies to the degree in which they actually implement the OR scheduling criteria in the OR schedule. The surgeons and anesthesiologist however are the end-users and therefore the implementation for them implies the way in which they actually perceive the implementation of the OR scheduling criteria the OR schedule by the schedulers and OR day coordinators.
reviewed as groups, because they all have the same tasks and responsibilities. Within these groups the average and the range of scoring is discussed. The surgeons however are reviewed separately, because their work environment varies per specialism. Otorhinolaryngology for instance performs many standard surgeries so uncertainty with regard to the surgery is relatively low, whereas Surgery experiences higher uncertainties because of many special surgeries. Therefore the implementation of the scheduling criteria will likely differ per surgeon. At last the implementation of the OR scheduling criteria between the different stakeholders is discussed.
Performance criteria (de Snoo et al., 2010) OR scheduling criteria (survey) Fulfillment of constraints and commitments made to
external parties 1, 2, 3, 7, 8 and 9
Fulfillment of preferences and wishes of employees
using the schedules 16 - 33
Fulfillment of resource utilization constraints 10 - 15 Table 11. Link between the performance criteria and the survey
