title: Management implications for the perioperative surgical home related to inpatient case cancellations and add-on case scheduling on the day of surgery.
abstract: BACKGROUND
  The American Society of Anesthesiologists has embraced the concept of the Perioperative Surgical Home as a means through which anesthesiologists can add value to the health systems in which they practice. One key listed element of the Perioperative Surgical Home is to support "scheduling initiatives to reduce cancellations and increase efficiency." In this study, we explored the potential benefits of the Perioperative Surgical Home with respect to inpatient cancellations and add-on case scheduling. We evaluated 6 hypotheses related to the timing of inpatient cancellations and preoperative anesthesia evaluations.
  
  
  METHODS
  Inpatient cancellations were studied during 26 consecutive 4-week intervals between July 2012 and June 2014 at a tertiary care academic hospital. All timestamps related to scheduling, rescheduling, and cancellation activities were retrieved from the operating room (OR) case scheduling system. Timestamps when patients were seen by anesthesia residents were obtained from the preoperative evaluation system database. Batch mean methods were used to calculate means and SE. For cases cancelled, we determined whether, for "most" (>50%) cancellations, a subsequent procedure (of any type) was performed on the patient within 7 days of the cancellation. Comparisons with most and other fractions were assessed using the 1 group, 1-sided Student t test. We evaluated whether a few procedures were highly represented among the cancelled cases via the Herfindahl (Simpson's) index, comparing it with <0.15. The rate of scheduling activity was assessed by computing the number of OR scheduling office decisions in each 1-hour bin between 6:00 AM and 3:59 PM. These values were compared with ≥1 decision per hour at the study hospital.
  
  
  RESULTS
  Data from 24,735 scheduled inpatient cases were assessed. Cases cancelled after 7 AM on the day before or at any time on the scheduled day of surgery accounted for 22.6% ± 0.5% (SE) of the scheduled minutes all scheduled cases, and 26.8% ± 0.4% of the case volume (i.e., number of cases). Most (83.1% ± 0.6%, P < 10) cases performed were evaluated on the day before surgery. Most (67.6% ± 1.6%, P < 10) minutes of cancelled cases were evaluated on the day before surgery. Most (62.3% ± 1.5%, P < 10) cases were seen earlier than 6:00 PM of the day before surgery. The Herfindahl index among cancelled procedures was 0.021 ± 0.001 (P < 10 compared not only to <0.15 but also to <0.05), showing large heterogeneity among the cancelled procedures. A subsequent procedure was not performed for most cancelled cases (50.6% ± 0.9% compared with >50%, P = 0.12), implying that the indication for the cancelled procedure no longer existed or the patient/family decided not to proceed with surgery. When only cancellations on the scheduled day of surgery were considered, the cancellation rate was 14.0% ± 0.3% of scheduled inpatient minutes and 11.8% ± 0.2% of scheduled inpatient cases. There were 0.59 ± 0.02 OR schedule decisions per hour per 10 ORs between 6:00 AM and 3:59 PM (P < 10, corresponding to ≥1 decision per hour at the 36 OR study hospital).
  
  
  CONCLUSIONS
  The study hospital had a high inpatient cancellation rate, despite the fact that most patients whose cases were cancelled were seen by an anesthesia resident by 6:00 PM of the day before surgery. This finding suggests that further efforts to reduce the cancellations by seeing patients sooner on the day before surgery, or seeing even more patients the day before surgery, would not be an economically useful focus of the Perioperative Surgical Home. The wide heterogeneity among cancelled cases indicates that focusing on a few procedures would not materially affect the overall cancellation rate. The relatively low rate of subsequent performance of a procedure on patients whose cases had been cancelled suggests that trying to decrease the cancellation rate might be medically counterproductive. The hourly rate of decisions in the scheduling office during regular work hours on the day of surgery highlights the importance of decisions made at the OR control desk and scheduling office throughout the day to reduce the hours of overused OR time. These data suggest that efforts of the Perioperative Surgical Home related to inpatient cancellations should focus on management decision-making to mitigate the disruptions to the planned OR schedule caused by inpatient case cancellations and add-on cases, more so than on efforts to reduce inpatient cancellation rates.
authors.affiliation: From the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; and Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Epstein
authors.forename: Franklin
authors.initials: F
authors.lastname: Dexter
mesh_terms: D000046:Academic Medical Centers; D039602:After-Hours Care / Q000592:standards; D000761:Anesthesia Department, Hospital / Q000458:organization & administration / Q000592:standards*; D001071:Appointments and Schedules; D017598:Efficiency, Organizational; D006801:Humans; D007297:Inpatients; D007396:Internship and Residency / Q000592:standards; D009870:Operating Room Information Systems / Q000458:organization & administration / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration / Q000592:standards*; D010562:Personnel Staffing and Scheduling Information Systems / Q000458:organization & administration / Q000592:standards*; D015143:Philadelphia; D058996:Quality Improvement / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D013647:Task Performance and Analysis; D062606:Tertiary Care Centers; D013997:Time Factors; D057188:Workflow; D016526:Workload / Q000592:standards*