Unanticipated cancellations of scheduled surgeries pose a major problem in effective operating room (OR) utilization. These cancellations lead to patient dissatisfaction, lower staff morale, and impose a large economic burden.1–4 In 2006, Argo et al1 demonstrated that cancellation of elective surgical cases in Veterans Affairs Medical Centers (VAMC) costs an estimated loss of over 32 million dollars. Mandates for change within the healthcare system and decreased funds have impacted the delivery of healthcare. For example, reduced funding for essential OR staff at our institution has led to unwanted surgical case cancellations (SCCs), causing a delay in patient care and wasted OR time. Facility factors such as reduced numbers of OR staff, administrative or scheduling errors, and facility environment have been shown to be responsible for 20% of all SCCs and 19% of ophthalmology case cancellations in a study looking at 120 VAMCs nationwide.
Public and private sectors both face challenges from unanticipated SCC, but the unique population, organizational structure, and fixed allocation of the VAMC provide additional challenges to decreasing the SCC rate.5,6 The VA patient population is older, of a lower socioeconomic status, and have a poorer health status, with a higher disease burden and case mix index than the general patient population.5,7 This results in more patient factors contributing to the SCC rates.1,6 The Veterans Health Administration is the largest provider of integrated eye care in the country.8 Despite this, problems with access to care can lead to missed appointments and added expense for family members who miss work to spend time in traveling and caring for their loved one.
The VA hospitals are structured to funnel patients who need eye surgery directly into a centralized location where clinic slots fill quickly and wait times are frequently long. In our state, Veterans from across the state must travel, many by coordinated transportation, and some for hundreds of miles, to complete preoperative evaluations, surgery, and postoperative care at our institution. Medical examinations before surgery also take place in a centralized location, followed by final confirmation of the surgical schedule. Historically, many months could pass in between initial surgical evaluation and medical clearance examination appointments. This structure lends itself to a high cancellation rates due to changes in health status. A higher volume of patients paired with a high frequency of SCC led to further investigation on how to study and better use OR time within the ophthalmology section, while maintaining the highest quality of care.
A quality improvement project was initiated by identifying contributing factors within the facility and making changes aimed at lowering the rate of SCC. The purpose of this study was to implement facility changes to improve OR utilization and measure the effect on decreasing rates of scheduled SCC.
This study was approved by the IRB of our institution. In 2016, we began with a retrospective chart review of VAMC ophthalmology SCC from 2013 through 2015. Before the study period, high SCC rates were noticed, and changes were made with the goal of decreasing SCCs. After these interventions, we decided to examine the impact in more detail and initiated this quality improvement study. For every month from January 2013 to December 2015, the number of completed ophthalmology cases and those canceled within 24 hours of surgery were obtained from OR performance reports. Monthly SCC rates were calculated from the total number of cancellations and the total number of scheduled cases that month. Cancellation reasons, as documented by OR staff, were then categorized into either preventable or unavoidable causes of cancellation. A fishbone diagram was constructed to help identify and categorize specific facility factors that were sources of SCCs, which were likely impacted through interventions for quality improvement (Figure 1). Categories included methods/procedures with a focus on scheduling, and policies with a focus on preoperative testing, patient factors, and facility/physician/staffing factors.
Interventions took place between September 2014 and March 2015 as a result of clearly high cancellation rates noticed before our study. Seven main interventions were used (Table 1). First, the surgery schedule was reorganized into specific subspecialty days. For example, cataract surgery was scheduled on Mondays and Fridays, and glaucoma surgery and retina surgery on Tuesdays, to streamline attending coverage. As every case required attending surgeon supervision, each operative day was assigned a set supervising physician rather than relying on trainees to find attending coverage. The prior paper-based scheduling system was replaced by an electronic schedule, easily accessible and viewable by VA staff to improve coordinated care. Optical biometry was initiated during this time period to improve efficiency during preoperative cataract surgery measurement acquisition. A back-up attending schedule was constructed to place priority on VA cases such that no available OR time was left unfilled, and the preoperative template in the electronic health record was updated to include better screening for systemic and intraocular diseases that could require additional preoperative workup. Finally, a trial period was temporarily instituted one additional day per month for only topical cataract surgery without anesthesiology team involvement in the operative case, to compensate for a short-term anesthesiology provider shortage. Of note, the total number of OR minutes remained unchanged throughout the duration of the study period.
Further data retrieval and analysis were performed for 2 separate 3-month periods before and after the 7 interventions to identify patient-specific factors for SCC and to determine how the interventions impacted SCC. A chart review was performed for surgical cases scheduled between October and December 2013, and October to December 2015. If the patient's surgical date did not match the originally scheduled date indicated on their preoperative assessment, further data collection was performed for that patient. Data collected included patient demographics, type of surgery, reason for cancellation or rescheduling, number of active medical problems, time from the original surgical evaluation to the reschedule/cancellation decision, and time to final completion of the surgery.
Differences in cancellation rates and proportions of preventable and unavoidable issues between the preintervention (October–November, 2013) and postintervention (October–November, 2015) periods were estimated using analysis of variance. Patient characteristics between these same periods were compared using the chi-square test for categorical variables and the Wilcoxon rank-sum test for continuous variables. In addition, a segmented time series analysis was performed to identify changes across time. The segmented time series analysis allows us to statistically model the interrupted time series data (our predata and postdata) to draw more strict conclusions about the impact of the implemented interventions.9 Finally, a Cochran-Armitage trend test was conducted on the number of surgeries completed each year from 2013 to 2015 to determine trends significance.
Two hundred sixty-nine ophthalmology SCC of 1,736 cases total occurred from January 2013 through December 2015. Characteristics of the preintervention and postintervention patient populations included in the study, obtained from 75 in-depth chart reviews, were similar with no statistically significant difference between gender, race, age, and active medical problems (Table 2).
A statistically significant decrease in SCC rates was seen during the intervention period. In the preintervention months of October–December 2013, of a total of 170 scheduled cases, the average SCC rate was 35%. In the postintervention months of October–December 2015, of a total of 202 scheduled cases, the average SCC rate was 7% (p = .014). Preintervention and postintervention mean case completion rates were 66% and 93%, respectively; also, a statistically significant change was observed (p = .014) (Table 2). A segmented time series analysis comparing preintervention and postintervention SCC rates showed no significant month-to-month changes in cancellation rates before intervention (p = .090). However, the time series method confirmed a significant reduction in the SCC rate (p = .028) during the postintervention period when compared with the preintervention period.
The average monthly proportion of scheduled cases that were canceled due to preventable causes decreased significantly from 28% to 5% (p = .005) and those attributed to unavoidable causes decreased from 5% to 2% (Table 3). The most frequently documented reason for cancellation within 24 hours of surgery was scheduling errors, which accounted for 9% of all scheduled cases during the preintervention period. Cancellations were categorized under “scheduling error” when they were over posted or incorrectly posted to the wrong day or attending. Scheduling errors declined significantly as a cause of SCC to only 0.5% of total surgical cases scheduled in the postintervention period (p = .001). Other statistically significant decreases in preventable reasons for SCC include no-show to preoperative appointment that declined from 8% to 1% (p = .034), and staffing issues that declined from 2% to 0% (p = .001). The other causes of SCC listed in Table 3 did not change significantly in the postinterventional period.
In addition to decreased rates of SCC, overall OR utilization increased. Although total OR minutes remained the same, surgical volume increased during the study period. From 2013 to 2015, annual case completions were 485, 502, and 749, respectively. Using a Cochran-Armitage trend test, a significant positive trend between year and completion of surgeries was identified (p < .001).
The impact of decreased cancellations was finally examined in reference to various time landmarks. The scheduled wait time of canceled cases from surgical decision to the original surgery date was 75 days in the preintervention period and 61 days in the postintervention period. The overall time until surgery completion in patients who had rescheduled or canceled ophthalmology surgery decreased from a median of 127 days to 106 days after interventions were implemented. Although these decreasing trends were noted, all the decreased waiting times mentioned were not statistically significant.
As the nature of quality improvement projects is aimed at rapid cycle process improvement and interventions with small subsets of population data, our study is limited by a small sample size, making it difficult to interpret the lack of statistical significance between the preintervention and postintervention changes for individual SCC categories. However, overall rates were reduced. In addition, because interventions were not implemented in a true stepped wedge fashion, it was not possible to separate the effect of each individual intervention to identify which intervention was more effective. The topical surgery day trial was limited with only 2 dates and a small number of cases, so no individual analysis could be performed for this intervention. This was also a retrospective study, with multiple staff contributing to documentation of reasons for SCC, and therefore, interrater reliability could not be evaluated. Finally, this study only evaluated data at our VAMC. Therefore, our findings are not necessarily generalizable outside the VAMC system and the ophthalmology section. However, the process of evaluating an OR using quality improvement techniques and metrics may be generalizable.
In this study, interventions aimed at improving surgical scheduling, preoperative screening, and attending coverage were examined in an attempt to target and decrease preventable reasons of SCC. The resulting postintervention data showed a significant decrease in SCC and, as expected, a significant increase in OR utilization. Notably, the proportion of SCC attributed to preventable reasons decreased dramatically. As a result, a larger portion of the postintervention SCC were attributed to unavoidable reasons. However, both the total number of preventable and unavoidable causes of SCC decreased in the postoperative period, whereas number of cases scheduled and completed increased significantly. Of all the reasons identified, SCC attributed to scheduling errors decreased the most which was expected, given that most interventions were targeted at the scheduling process. A decreasing trend was seen for original surgery wait time and overall time until surgery completion following cancellation, although this was not a primary end point.
Surgical case cancellation rates are indicative of the efficiency and functionality of a facility's OR and the preceding preoperative process. High SCC rates may indicate ineffective use of valuable health resources leading to higher costs and lower patient satisfaction.1–4,10 No consensus exists on what an appropriate SCC rate is, with studies citing a range of less than 5% to less than 20%.11,12 This may be because establishing benchmarks for SCC rates has been strongly discouraged in an effort to avoid creating potential administrative pressures to not cancel a case when a legitimate medical reason exists.1 However, it is still important to evaluate facility performance through SCC and case completion rates so that areas for improvement can be addressed.
Previous VAMC studies cite SCC rates ranging from 12.4% to 19.7%.1,11,13 In the months before intervention, SCC reached 35% on average in our VAMC ophthalmology section, indicating a need for evaluation and intervention. The heightened preintervention SCC in our study was mostly attributed to higher scheduling errors, staffing issues, and preoperative appointment no-shows, which ultimately prompted a quality improvement project and the targeted interventions described in this study.
With SCC being a multifactorial problem, it is important to determine what issues contribute most so that interventions may be implemented with the highest likelihood of making and sustaining meaningful change. In this study, we collected and reviewed monthly SCC rates before intervention and performed root cause analysis to determine that scheduling methods, and facility, physician, and staffing factors were the best areas to aim our interventions. Pollard and Olson13 also determined that focusing on system issues such as scheduling and staffing could result in a measurable improvement of SCC rates in the VAMC setting. Facility issues have long been recognized as a major reason for high SCC.1,3 Using the standardized cancellation reason categories described by Argo and colleagues, facility factors (i.e., scheduling error, staffing issue, emergency case, and equipment not available) contributed to approximately 39% of our preintervention SCC, making up 14% of total scheduled cases during that time frame at our VAMC. This is higher than other previous VA studies (20–23%).1,11,13 However, following our interventions, facility factors responsible for SCC dropped to 7.14%, making up 0.5% of scheduled cases in the postintervention period. This was attributed to only one patient experiencing a scheduling error leading to SCC out of 202 scheduled surgeries. There were no issues with staffing or equipment during the studied postintervention period, likely attributed to the staffing and electronic schedule interventions we performed. This suggests that quality improvement interventions targeted at scheduling can have the highest impact on improving SCC attributed to facility factors.
In addition to the unique patient population, VAMCs have other unique challenges related to organizational structure. With a larger and sicker patient population, one hurdle to efficient and timely healthcare at VAMCs is the funneling of patients into one centralized location for surgery, perioperative care, and postoperative follow-ups. Extended wait times compound the problem when a cancellation occurs, given that the surgical schedule is already full in the immediate rescheduling period. This leads to an exaggerated wait time until a patient can be rescheduled, along with requiring repeated preoperative medical testing and surgical clearance.
In this study, the overall time until surgery completion for patients with SCC decreased from 127 days to 106 days. However, this decrease was not statistically significant, likely because our interventions were targeted at reducing cancellations rather than reducing the rescheduling time. If these cancellations were prevented, patients would have waited 75 and 60 days for their surgery in the preintervention and postintervention periods, meaning cancellations caused an additional wait time of 52 and 46 days, respectively. A previous review by Hodge and colleagues revealed that patients who receive cataract surgery within 6 weeks (42 days) experience better visual and quality of life outcomes. In general, waiting times of 6 months or longer have been shown to be considered excessive to patients and have been associated with more negative outcomes such as increased rates of falls during the wait period.14,15 Of note, quality improvement data subsequent to the study time period reveal the surgery wait time further reduced to under 40 days by June of 2017, indicating a possible delayed fruition for some of the benefits derived from the study interventions.
Some patients experienced multiple cancellations before the competition of their surgery. These subsequent cancellations were most commonly due to medical reasons, which may suggest that SCC and a longer preoperative waiting period allow for more medical complications to arise resulting in higher likelihood of multiple cancellations. In addition, preoperative medical clearance guidelines that use extensive routine ancillary laboratory testing could have also contributed. We are actively adopting more current preoperative medical clearance guidelines for low-risk ocular surgery, the impact of which is a target for future study.16
The timely treatment of patients is associated with a higher level of patient safety and quality care. This has been linked with hospital organizational cultures that promote group culture and less hierarchy.17 Techniques to ameliorate detrimental effects of hierarchical organizations such as polices to distribute authority have been shown to transform rigid centralized control into a more flexible system.17 By implementing electronic scheduling viewable to any surgical staff member, we attempted to distribute the ability of all staff to help patients with questions regarding appointments and scheduling. Steps in this direction should be continued as maximizing the use of information technology, and scheduling software has been shown to contribute to the success of institutions with low SCC rates.18
Our findings suggest that quality improvement–guided interventions are effective in specialties susceptible to SCC secondary to preventable facility factors.
Implementation of interventions, especially those aimed at reducing surgical scheduling errors may significantly reduce the rates of SCC at VAMCs and other medical facilities where surgical procedures are scheduled and performed.
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Valerie J. Dawson, MD, is a recent graduate from the University of Maryland School of Medicine in Baltimore, MD. She is currently completing her preliminary medicine year at Mercy Medical Center in Baltimore City following which she will be starting her Ophthalmology Residency at the University of Colorado in Denver, CO, in 2019.
Jordan Margo, MD, is a board-certified cornea and external disease specialist. She has a strong interest in patient safety and quality improvement.
Natalia Blanco, PhD, is a healthcare epidemiologist. She completed a Master of Public Health (MPH) at Tulane University School of Public Health and Tropical Medicine and a doctoral degree (PhD) in Epidemiology at the University of Michigan School of Public Health. She currently works as a postdoctoral fellow at the University of Maryland School of Medicine, Baltimore, Maryland.
Wuqaas M. Munir, MD, is the chief of ophthalmology at the Baltimore VA Medical Center. He is also an associate professor and the director of the Cornea, External Disease, and Refractive Surgery Service at the University of Maryland School of Medicine, Baltimore, MD.