Alpha Consulting Group, Inc.

Alpha Consulting Group, Inc. updated their address.

One of the most frequent problems in the operating room is maintaining on-time starts. The percentage of on-time starts has varied from a low of 3% to a high of over 90%. Typically, the percentage averages 50% or below.

Several factors can contribute to late starts, but the main causes in order of frequency are as follows:

Late Surgeon
Late Anesthesia Provider
Incomplete Documentation
Pre-admission Screening Issues
Patient Late

We normally track about 20 indicators, but the first two on the list account for about 70 to 80 percent of all delays. It becomes a vicious cycle of the surgeon claiming the patient was not ready when they arrived and the anesthesia provider claiming, “Why should I come in on time, the surgeon is going to be late?” Many issues can be solved with a solid pre-admission assessment program, but the first two are both politically and operationally challenging.

Here are a few things that can be done to achieve improved on-time start performance:

Clearly define the start time so that all parties are informed.
Increase communication between members of the operating room team.
Strive for pre-admission screening of patients at 100%.
Determine when the anesthesia provider and the surgeon must arrive to ensure an on-time start. Typically, it is about 30 minutes for the anesthesia provider prior to the patient entering the room and 15 to 20 minutes for the surgeon.
Offer financial incentives when negotiating contracts with anesthesia providers and surgeons, if applicable, to include on-time starts as part of an overall quality program.
Identify and recruit a physician champion to assist with changing the perception of reasons for delay.
Routinely report on-time start performance in surgical committee meetings and post the results in the department.
Make on-time performance one of the indicators to determine if a surgeon maintains or receives block time.

If these measures do not help to improve your on-time performance, call Alpha Consulting Group, Inc. We can help!

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Perioperative Interim Management
By Paul Wafer, BS, MBA, RN

According to the Bureau of Labor Statistics’ Employment Projections 2019-2029, The Registered Nursing (RN) workforce is expected to grow from 3 million in 2019 to 3.3 million in 2029. The Bureau also projects 175,900 openings for RNs each year through 2029 resulting from the need to replace workers who exit the profession or retire.
A recent issue of Modern Healthcare stated that over 1 million nurses plan on retiring by 2030, leaving a shortage of 70,000 nurses per year. Consider how this will impact the experience level of the remaining pool of nurses. Who will train and mentor the next generation of leadership to ensure that the quality of care provided to future patients will meet or exceed today’s standards? This information combined with the fact that the shortage of leadership in the specialty of perioperative services is even greater than most other specialties, hospitals are facing a critical situation. On average it is taking our clients 6 months or longer, to replace a vacancy in perioperative leadership. Frequently it takes more than a year to find an acceptable candidate. Is it feasible to leave a highly technical, labor intensive and costly department rudderless for that long while trying to find a replacement?

Over the last 16 years Alpha Consulting Group, Inc. has been providing interim directors and managers strictly for the perioperative environment. Today, more than ever, hospitals are turning to interim leadership to maintain and improve their nursing departments. One may ask what makes one company better than another with interim leaders. Is it strictly a pricing issue? A timing issue? A trust issue? At Alpha Consulting Group, Inc., we believe it is a knowledge issue. As a perioperative consulting firm, we have provided services from coast to coast and throughout the United States in small, rural hospitals to major medical centers. We are the company you can trust to ensure that your perioperative areas remain in good care. Our interim leaders have more than 10 years of leadership experience and have been thoroughly vetted by our highly experienced perioperative management team.

The next time you need assistance within your perioperative leadership team, call us, we can help.

Flipping OR Rooms
“To Flip or Not to Flip, That is the Question”
By
Paul Wafer, BS, MBA, RN

For those of you unfamiliar with the term, flipping rooms means providing a surgeon with 2 rooms so that they can start the next case without down time for room turnover. Typically this means 2 teams of nurses and 2 anesthesia providers. The surgeons really love it, but is it economically feasible? I am frequently asked whether or not it makes sense to flip rooms for a surgeon. The answer to this question is a definite “it depends”! Below are a few tips to help you determine whether or not you should consider flipping rooms for a surgeon and what criteria it should be based upon.
1. Rule 1-require a minimum volume of cases scheduled in a day in order to get a flip room. One of the most important variables is how many cases can be done in a day, and how consistent the surgeon is in bringing enough volume to fill a day.
2. Rule 2-The amount of time for the procedure must be consistent and predictable. How consistent the surgeon is with the time it takes to do the procedure(s) must be well understood.
3. Rule 3 - The time it takes to do the procedure from incision to closure should be close to the amount of time it takes to get the patient out of the room, get the room turned around, the next patient in the room, anesthetized and positioned. For example, it can take over an hour to close, turnaround , prep and position a total joint patient in a room and the procedure itself can take an hour to hour and half with an efficient surgeon. A cataract turn-around can take 15 to 20 minutes, the same time it takes to do the procedure. You do not want a room and a team sitting around waiting to get started!
4. Rule 4-You need to have enough instruments and equipment to be able to furnish both rooms through the day. If you have to move equipment back and forth between rooms, or compromise sterility through immediate use sterilization, it is better to stay in the same room.
5. Rule 5 – There must be a qualified assistant that can close the incision in one room and assist with getting the patient into PACU. While the assistant is finishing up, the primary surgeon can be checking the next patient and helping to get them position properly, etc.
6. Rule 6-The criteria for flipping rules must be written, communicated and consistently enforced.
The bottom line is that room flipping can provide a level of efficiency that can be quite impressive and assist both the surgeon and the hospital make the best use of available resources when managed properly. If not done properly, room and resource utilization will be compromised.

Consulting Firm vs. Recruitment Firm: Which should you use for your interim management needs?

By

Paul Wafer, BS, MBA, RN

The healthcare industry today is more complex and competitive than ever. The demand for efficiency and consistent positive results has never been greater. At the same time, the industry is facing major disruption from a worldwide pandemic, an aging workforce, and experienced healthcare leaders in nursing and other clinical areas are reaching retirement at a rapid pace. The need for competent interim management for hospitals has never been greater. Interim leaders can provide support to an organization for a period of time while a permanent replacement is identified and vetted for the position.

Where does a healthcare organization go to find interim leaders and support? There are several ways, but the recent trend is to either utilize a healthcare management consulting firm (HCMCF) that provides support in the form of interim management, or to enlist the aid of a recruiter, i.e., a permanent management recruiter that also places interims.

A HCMCF, often staffed with experienced professionals coming from a clinical background, can assist in selecting and supporting the interim staff at your facility (support may have an additional cost) to ensure a smooth transition, while a recruiter or executive placement firm may or may not have staff with a clinical background, but has the capability of offering a wide variety of potential applicants and supports many of the HR-related functions of your search.

The question becomes, "Which should you use for your interim management needs? The short answer to this question is "it depends."

Below are some questions and answers to help you make that decision.

1. How well is the department currently running?

If your financial performance indicators are near or meeting their targets and you have a quality program in place with minimal errors, then utilizing an interim from a recruiter may make sense. However, if this area is an ongoing challenge to your organization, a HCMCF backing an interim may provide you with a better solution to the problem.

Is there business growth within the area, and if so, is there a structure in place to ensure a smooth assimilation of the new business? The interim provided by a recruitment firm may have the expertise to provide you with volume and labor projections for the future , but if they don't, they have no one to turn to in order to provide you with the service. Most HCMCFs will have that expertise in house and be able to provide you with that information.

2. Are the patients satisfied with the service provided?

How have you scored on your most recent HCAPS survey? Are your patients satisfied with the service that is provided? What about your physicians? Are they satisfied with the care that their patients receive? Are they happy with the service provided by the affected department(s)? If your patients and physicians are happy, then you may not even need an interim, but if you want to ensure that someone is minding the department while the search is underway, using a recruiter to provide an interim to maintain satisfaction makes sense. If your service levels are not meeting the expectations of your end users, an experienced HCMCF could provide you with a rapid assessment of the area along with the interim leader so that a plan of correction can be developed and implemented during the interim’s tenure.

3. Are the department staff satisfied?

Are the employees in the affected area(s) motivated and professional? Has there been sufficient professional development? Are their competencies and evaluations up to date? Do they have the maturity to stay focused on their work while waiting for a new leader? Today there are so many mandatory education requirements that it is sometimes a challenge to ensure that the departmental education and competencies are current and documented. A recent client faced rapid turnover in a leadership position which left a gaping hole in the staff competency documentation. Our firm was able to bring in a swat team to review all of the staff files and identify what was lacking in each file and develop a plan to get everyone into compliance. This could be a difficult task for someone working without additional support while still trying to manage the daily operations of a unit.

4. Are you planning any politically sensitive changes to the area?

Is the leadership or staff turnover in the affected areas greater than the average turnover for the hospital? This could be an indication that you have a real problem in the area. It could mean that there is lateral violence among the staff or unreported disruptive behavior occurring. This can be a very politically sensitive area to be addressed and it must be done with the utmost skill and attention. A solo practitioner coming in through a recruitment firm may have difficulty if they have not dealt with this type of issue in the past unless you have a strong Human Resource Department to assist with this challenge.

Are there personnel or program changes that need to be made? If not, an interim from a recruiter is an easy choice. If there are sensitive changes in the offering, it may be better to have a resource team available to address additional, unanticipated needs that may arise. Make sure that the recruitment firm or HCMCF is aware of this and make sure they have the skill set and/or additional resources if the need does arise.

5. Are the costs of operating the unit under control?

The costs of many units within the hospital are largely based on labor. There are a few (for example, the surgery and cardiac catheterization lab) that are both labor intensive and supply intensive. If you have an issue with keeping the labor costs under control, it may make sense to have leader that has productivity experience to implement necessary changes before the permanent director or manager joins the organization. Some interim directors do not have substantial expertise in productivity development or adjustment. In this case it would be very important to specify the need for this experience during the interim hiring process whether using a placement firm or HCMCF. A supply chain expert, or a seasoned director with supply chain experience would be able to identify and address supply cost issues.

6. Are you anticipating the implementation of any new initiatives or product lines in the near future?

Does the affected department have a new product line that is under development or about to be rolled out? A recent client purchased a $2 million surgical robot right as the director resigned. Can you afford to let a $2 million investment sit idly by while waiting for someone new to join the organization before you initiate a program? When something like this happens, it may require multiple resources to address the situation in a rapid fashion and get the department back on track.

7. Is there an imminent regulatory review?

Are you confident that all of the regulatory requirements for the area are in place? Does the staff in the area know what is expected of them during a survey? Has the area been free of any sentinel events during the last survey cycle? If you are confident that the department is well prepared for survey, an experienced director providing interim service from a recruiter would be a good choice. If you are not confident that the department is well prepared, a HCMCF could provide additional resources at the beginning of the engagement to improve chances that you are in compliance by the time the surveyors enter your facility.

For example, a recent client had a short time frame before their triennial survey when their perioperative director resigned. Not only were we able to provide an interim director, we were able to assess the department's preparedness for the survey. Potential issues were identified quickly by the team so that resources could be allocated correctly and the interim could focus on the management of the department. While a director from a recruitment firm would most likely identify the same issues, it may have taken longer for them to surface.

8 How do you want to structure the interim staffing agreement?

Generally, there are two ways to structure an interim agreement. You can "hire" the interim leader on a temporary basis and pay a recruitment fee, or you can contract with the agency for services provided and pay an agreed upon fee for the service. The first arrangement can put the hospital at risk if the interim does not work out and has to be terminated; the second arrangement puts the risk with the agency. Make sure that your agency has the insurance required for this type of contractual arrangement.

9 How long do you anticipate the need for the interim staff member to be engaged?

Do you believe that you will be able to attract a strong candidate for the position within a 1 to 3-month period of time? Have recruiters told you there is a large pool of candidates for the affected area that are available? Are you using the same recruiter for both permanent and interim placement at your organization? How are they addressing the fundamental conflict of interest that exists? What is the incentive to fill the position quickly if they are making a profit from the interim leader? If you are confident that the recruiter will find you a leader your unfilled need quickly, then a recruiter may be fine. If not, at a minimum use separate firms for interim and permanent placement.

10. Are there any internal candidates capable of taking on the role?

Have you identified anyone within the department that has the potential to take on the position permanently if mentoring is provided? Do you have someone within the organization that can provide the mentoring on an ongoing basis after the initial advancement and training? A HCMCF can assist with mentoring an individual into a management role and assist them in the transition for a number of months, both on site and remotely. Typically, the relationship will end with an interim placed by a recruiter once they leave the premises.

While any one of these issues may be enough for you to decide to use a consulting firm versus a recruiter, there may be other factors to consider. For example, is the area “high profile” within the organization and what financial impact does the area have on the overall performance on the organization? In those instances, a HCMCF that has additional resources available may be the more appropriate answer.

The decision to utilize a recruitment firm versus a healthcare management consultant firm for interim staffing needs is a critical one that can have a tremendous and long-lasting effect on a hospital’s bottom line – at financial, administrative and HR levels. Regardless of the direction you go, make sure you ask yourself and the firm, all the right questions.

If you are having trouble with your interim management needs, call us, we can help!

Needless to say, we have experienced more disruption in healthcare in the last few months than any other time in history. Historical costs, length of stay and case mix have gone out the door. Hospitals had to suspend elective surgery, just in case there was a surge in Covid 19 patients. Thankfully, in many places, social distancing and stay at home orders prevented a large surge from occurring. Today we are starting to see many parts of the country begin to re-open and with that, the slow ramp up of elective surgery.

There will be multiple variables impacting a hospital’s ability to ramp up their elective schedule. Initially that will primarily be done by following the joint statement of the American College of Surgeons, American Society of Anesthesiologists and the American Organization of Perioperative Registered Nurses. Additionally, there will be individual state mandates requirements and a slew of operational, fiscal and supply chain related barriers to address. Most facilities will have a backlog of cases to address. How will they be able to address that backlog in the most efficient and cost-effective manner while staying within all required guidelines, and what impact is that going to have on their ability to make up lost revenue from the crisis?

For the last several weeks we have been working with a team from the global consulting firm, Aarete, to develop an analytics tools with their data scientists, in an effort to design a tool to help hospitals in their decision making when ramping up the elective surgery schedule. The tool is powerful and customizable, and allows hospitals to determine how to adjust their schedule to maximize utilization, efficiency and profitability while also accounting for limiting factors related to supply chain, human resources, patient census and other clinical variables.

Once the crisis has past, this tool will allow the OR operations committee to perform “what if” analysis of the surgical block schedule to determine what impact changes will have on the profitability of the department.

If you would like to see a demonstration of how this product works, please email [email protected] or give us a call at 888-632-5742, or contact Luke Henderson at [email protected] or 214-914-0476. Call us, we can help!

Alpha Consulting Group, Inc. updated their business hours.

The World Health Assembly has named 2020 as The Year of the Nurse and Midwife in honor of Florence Nightingale’s 200th birthday. Here in the US, nurses are practicing in so many different settings, e.g., hospitals, schools, ambulatory centers, public health, military, research and so many other areas! In times like this, when we are facing health threats such as the potential outbreak of the Coronavirus world-wide, it highlights the importance of the nurse’s role in the world. Nurses frequently must take risks when caring for patients with a communicable disease, caring for violent patients with uncontrolled mental health issues and helping our injured troops in military outposts, just to name a few.
One of the ways that Alpha Consulting Group has been paying it forward is the annual Alpha Consulting Scholarship. Over the last 10 years we have provided over $20,000 in scholarships through the Association of California Nurse Leaders. We are very proud of our record of supporting life long learning to our nursing colleagues. This year is no exception. We would like to congratulate Charise Lyn Tabotabo, MSN, RND-NIC for being awarded the 2020 Alpha Consulting Scholarship! Charise is currently an advanced clinician and charge nurse at Sharp Mary Birch Hospital for Women and Children. Charise is currently working on her DNP in Health Systems Leadership at The University of San Diego. We are very proud of Charise’s accomplishments and scholarship award and ask you to join us in wishing her continued success.

Last month I wrote about strategies for increasing utilization of surgical blocks. This month I would like to talk about strategies to increase overall room utilization even further. Generally, most hospitals with block scheduling programs have a policy on “release time”. Basically, if a surgeon is going to be away on vacation or at a meeting, or just having a slow week, they must call the scheduling office before a certain time frame. If they do this, they are given “credit” for the time, and it does not count against their block utilization at the end of the month.
Frequently this release time is just a few days, or up to a week. Additionally, this release time is generally the same for all practices and specialties. When the release time is less than a week, it is often difficult to fill the block with other physicians’ cases which leads to gaps in the schedule.
We believe that the release time given to a specific practice, or physician, should be based on the type of practice and/or specialty. For example, if a practice, or specialty, frequently covers the emergency room, that practice should have a shorter release time. Both general orthopedics and general surgery may fall into this category. There are also a number of practices that are typically scheduling elective surgery that may be scheduled several weeks in the future. In that case, the release time could be 2 to 3 weeks prior. This method gives the hospital sufficient time to fill the scheduling gaps, and the ability for those surgeons with a busy ED practice to schedule their patients in a timely manner.
We believe that these release times should be assigned by the governing body empowered to oversee blocks and that all block participants should have release times. However, we do not believe that these practices or surgeons should get “credit” for this time in their monthly utilization results. Our rationale for this is 2-fold, first, we think that blocks should be reviewed on a quarterly basis, not monthly. Even if time is released in one quarter, there should be enough volume over the quarter to meet utilization goals. Secondly, we have seen some surgeons that are very good at releasing block time weekly. We have observed a surgeon whose block utilization report cited a 75% utilization rate, due to time released, when actually the surgeon only utilized 25% of their time. The ultimate goal of blocks is to improve the overall utilization of the OR by rewarding those physicians that consistently use their time.
If you are having trouble achieving this ultimate goal, call us, we can help!

We all know that “Turnover Time” is the most discussed performance indicator in the Perioperative arena. This is the time from one patient leaving the room until the next patient enters. In our experience in acute care hospitals, the average turnover time for all cases runs about 23 minutes. This overall average can mask performance issues if not watched carefully. One high volume specialty with exceptional turnover times may bring down the average, leaving inefficient specialties unchecked. Turnover by specialty should also be reviewed. Other factors such as case mix, staffing, department design and a variety of other operational processes may also affect turnover time. However, this is only one of a number of indicators that should be examined and tracked on a monthly basis. Below are a few others that your perioperative leadership should be reporting:

1. Physician Turnover Time, aka, Turnaround Time: This is the time from closure on one case to incision on the next case. This can be impacted by a number of factors including turnover time, anesthesia department readiness, case cart preparation, patient positioning, and surgeon availability in the department. The overall average for this time should be in the range of 45-48 minutes, but can vary significantly based on the complexity of the procedure. This is the time most concerning to the surgeon and why there is often variation between what nursing reports and what the surgeon claims to be turnover time.
2. First Case on Time Starts: This indicator can identify a number of process deficiencies that can affect department performance throughout the day. For example, there can be problems with patient preparation prior to entering the OR, there can be issues with the accuracy of preference lists and case cart development, and there can also be issues with instrument reprocessing. In our practice, we see the main reason being the timeliness of physician arrival as the key reason, but this can be masking all of the other items previously stated. We have seen several hospitals with on time start percentages less than 30%. We recommend a goal between 80-90% and believe it is achievable when the whole team works together to make it happen.
3. Room Utilization: This is based on the hours that the rooms are used divided by the number of hours the rooms are staffed. We prefer to determine room utilization without including turnover time because a long turnover can make it look like the rooms are being utilized appropriately. We like to see the department functioning between the 60-70% range. This provides for some flexibility and leaves a little room in the schedule to bring in new surgeons. Once your utilization is greater than 70%, it is probably time to either open or build additional OR rooms. The maximum utilization rate is typically 85%.
4. Block Utilization: Blocks are meant for high volume surgeons who can fill a room. It should be a “reward” for consistent utilization. Blocks should be utilized at the 85% rate. If physician blocks are consistently underutilized, they must be addressed. In hospitals with low block utilization, we recommend a target in the 60-70% range and adjust it higher as compliance improves. Physicians with low utilization must be addressed in an objective fashion. Depending on their current utilization, they should either have their number of days reduced, or completely eliminated. We have found that by reducing low utilizers, you can free up more space for first come, first served cases. This can reduce the overall demand for blocks and actually improve overall utilization of the rooms.
5. Cases by Day of the Week: By tracking daily patterns of room usage, adjustments can be made to the number of rooms and staff available by day of the week and improve efficiency. You should also do this another way by tracking
6. Cases by Hour of the Day: This will help determine the appropriate number of rooms to be available by shift to optimize staffing and utilization. This can also help determine the right time of day to shift to on-call status.
7. Department Productivity: In the OR it is typically tracked by hours worked per hour, or minute, of surgery time. We see wide variation in this number across the country, but typically recommend between .12 and .13 hours per surgery minute to allow for adequate staffing and time for staff development.

If all of these indicators are in alignment, there is a good chance that you have a well- functioning operating room. If they are not in alignment, give us a call, we can help.

Since beginning my long career in the perioperative environment in 1977, I have seen many changes. Many for the better, but also a few that kept me up at night. There is no doubt that the technological changes that have occurred in the last 40+ years were unimaginable when I started, and the results are undeniably amazing. The cataract patient that stayed in the hospital for multiple days in 1977 is now in and out in about an hour. That is progress! The numerous minimally invasive surgery procedures that allow patients to go home the same day as their surgery, did not exist. Robots and computers were seen on Star Trek, not in the operating room.
All of this new technology comes at a cost. Some cost is in purchase and servicing, some may be due to the additional personnel needed to operate, purchase supplies, and provide proper cleaning and maintenance for it. Financial costs aside, I believe new technology has led to a focus on the technology itself rather than the patient.
There are multiple patient related steps that must be completed in the OR, to ready the case for start. Consider these processes: check and open supplies, assemble medications and sutures retrieve positioning equipment, perform an initial count, bring in the patient, apply grounding pad, DVT prevention and warming device, assist with anesthesia induction, position and prep the patient, perform a time out and verification of the patient and procedure, check and balancing the video system, cautery system and other procedure specific equipment. While all of this is being performed, there may be a surgeon standing there complaining about how long the turnover took! I have not even mentioned the computer for charging and charting!
This is what keeps me up at night. Why? I am frequently asked to provide guidance on productivity in the OR. I agree that there are reasonable standards of productivity that we should strive to achieve, but there are a number of factors that can have an impact on the achievability. I have written many times on the factors, from personnel included in the cost center, inefficient processes, architectural layout, and facility culture.
So, this brings me back to the patient. We get so wrapped up in meeting performance targets that the patient becomes an afterthought. We have to strive for balance in achieving realistic goals with personalized care. That is what Alpha Consulting Group, Inc. tries to achieve with every client.