Anesthesiology and Perioperative Services Best Practices by 0I7T01


									Anesthesiology and Perioperative Services Best Practices: Cleveland Clinic

May 5, 2005

Phone interview: Zed Ibrahim (Cleveland Clinic Anesthesiology) and Alan Artru


Operations and Oversight

OR Committee - ~8-10 members – Surgeon is chair – other members are nurses (2),
anesthesiologists (2), administrators (2), transport services (1), and IT services (1) – the
Clinic is highly IT dependent for efficient presurgical evaluation and OR function – may
also have CQI person on OR Committee

Daily Functional Organization

50+ operating rooms for noncardiac surgery plus additional operating rooms for cardiac –
broken up into individual units (ambulatory, eye, colorectal, ENT, urology, general
surgery and liver transplantation, minimally invasive surgery, neurological surgery,
OB/GYN, orthopedic, and vascular; there is an anesthesiology “section” for each of these
units) – general leadership/scheduling of all operating rooms by anesthesiologist and
nurse – once day is underway the individual units have some autonomy over scheduling
the rest of the day within their unit – decisions within a unit are made cooperatively with
the anesthesiologists, nurses, and surgeons in that unit – all cases are scheduled into block
time – block is relinquished 7 days in advance if no cases – for rooms incompletely filled
(for example, if a service only has half a day’s worth of surgery for a particular room),
remaining block time is relinquished 2 days in advance – vascular and general surgery get
a “special break” of retention of 0.5 room even if unfilled 2 days in advance – liver
transplants don’t have own room but are placed into released room – as the day
progresses there is a staggered decrease in total room capacity with “critical times” of
1530, 1730, and 1930 – most rooms are filled on most days – on a busy day 20-25 rooms
run into the 1730 to 1930 time period (about 40% of the Clinic’s noncardiac room


Teams of nurses, surgeons and anesthesiologists are organized according to the units
outlined above – the team approach is used until 1700 at which time the nurse and
anesthesiology staffing becomes “general” (i.e., the expertise of specialized teams is no
longer available) – each team member does not necessarily stay until 1700; in some cases
a team member leaves at 1530 and is replace by another team member with similar
specialized skills who is working a shift that ends later than 1530 – interestingly, the
problem of “foot dragging at 1500 by persons who know they will leave at 1530” is a
problem, particularly with transport personnel (the physical point of entry for patients
having surgery is quite far from the OR so patient transport is a major rate limiting step in
patient flow at the Clinic) – as mentioned above, emergencies are placed into finished or
released rooms – I didn’t ask if it ever happened that emergencies “bumped” elective
cases in block time


All individuals (including nurses, surgeons, and anesthesiologists) are on salary – there is
no financial incentive for productivity – highly productive individuals and individuals
with many years of service to the Clinic realize incentives such as is usual for many
companies and private or public institutions: status, titles, administrative positions within
their specialty, “special treatment”, and etc – one incentive for highly productive
surgeons or surgeons with many years of service is the assistance of surgical fellows – an
unfortunate outcome of having surgical fellows is increased case duration when fellows
perform portions of the surgery that could be done more quickly by the senior surgeon
and increased case duration when surgeons are allowed to run two operating rooms with
the senior surgeon in one room and the fellow in the other room


Within established teams, communication is respectful and efficient – when usual team
members are not available (such as before 1700 when team members are not scheduled to
work that day or after 1700) communication within the operating room is not as
respectful and efficient – despite good communication, delays often occur in bringing
“to-follow” cases into the operating room because some individuals want the room to be
“entirely ready” before the patient is brought in – one method used by team members to
keep track of each patient’s status (such as just checked into Clinic, en route to OR, in
preop holding, in OR, in phase one recovery, and etc) and actual physical location of their
patient is via “Navicare” system; simple click on any of a multitude of computer screens
available throughout perioperative area provides that patient tracking information;
“Navicare” also used to modify assignments to operating rooms during the day as the OR
schedule unfolds

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