Hospital slashes same-day surgery cancellation rates

Visually presenting performance data is key

Monthly performance improvement meetings didn’t have a great impact at Jamaica (NY) Hospital Medical Center, even though comparative data showed the facility had a 25% same-day surgery cancellation rate one of the highest among other New York regional hospitals.

The 365-bed independent facility began participating in the Healthcare Association of New York State’s Quality Improvement Project Data Performance Program in 1993. Each quarter, Jamaica and about 900 other New York state hospitals submitted data on numerous quality indicators and then used the comparative information to benchmark against other facilities.

Jamaica Hospital hoped its participation in the program would encourage clinicians and other hospital personnel to recognize weaknesses within their departments and motivate them to make positive changes. But rather than using the information to spark quality improvement initiatives, most employees accepted the information as it was presented and walked away feeling less motivated.

The reason behind the deflated morale had less to do with the information itself, and more to do with the manner in which it was presented, says Melba Talan, MPH, assistant director of performance improvement at Jamaica Hospital.

"We had monthly improvement council meetings where we [verbally] addressed our hospital’s performance in relation to other area [facilities]," she notes. "But we didn’t have an improvement team in place. Representatives from each department sat in on the meetings, but when we just told them how high our same-day surgery cancellation rates were, they just seemed to accept it. They were frustrated; they knew there was a problem, but they didn’t know what to do about it, and they didn’t want to hear it. It was like they said to themselves, This is the way it is.’ It was easier to blame everyone else, and as long as they felt that way, nothing was going to change."

^{Helping staff make a difference}

Cancellation rates at the hospital remained a challenge. But that was to change. In 1995, the hospital formed quality improvement (QI) teams and switched to visual presentations with detailed charts and graphs. The teams included an employee from the admitting area, ambulatory nurses who receive the patient from admitting, an operating room nurse, an anesthesiol- ogist, the vice president of professional and regulatory affairs, and QI staff.

The first reaction to the visual presentation was denial. Many staffers blamed the patients for the majority of cancellations, and some individuals pawned the problem off on other departments. For example, if clinicians weren’t blaming the patient, they were pointing the finger at admitting personnel and vice versa, she says.

"They also looked at the quality assurance people as the police," she says. "But once they realized we were working with them and could actually show them how many cancellations were caused by the patient and how many were caused by [hospital personnel], they had to start taking some of the responsibility.

"I’m not sure what happened, but it was like a cloud lifted all of a sudden," Talan explains. "When the information was put right in front of them like that, it made them really take a look at where we stood [against other New York hospitals]. It made them realize that we were off the mark on cancellation rates, and they knew they were the ones who could make a difference."

Because the New York state performance data only showed the total number of cancellations in relation to other regional hospitals, Jamaica Hospital had to gather its own data to determine which areas required the most work. The QI personnel put ambulatory surgery staff and operating room nurses in charge of data collection. The team, headed by an anesthesiologist, kept daily logs to track cancellation causes and used computers to monitor results.

"Over time, the teams provided much better communication between the departments, and everyone worked together instead of fighting one another," she says. "What we discovered was that we were the cause of more cancellations than the patient, so we started to make the changes there first."

The cancellation problem was twofold. First, employees rarely tracked the reason for cancellations, which made making changes next to impossible. Second, even when patients made the cancellations, the physicians were partly to blame, mainly because of improper communication between the two parties.

In 1996, 80% of Jamaica’s discharges were Medicaid and Medicare patients. Many of those patients were not educated properly about their surgeries, which was a direct cause of most cancellations, Talan says. To make matters worse, those instances were not properly logged, so hospital personnel could not learn from their mistakes.

"Some patients did not understand that they had to be seen for pre-testing, for example, and would show up on the day of surgery. Those surgeries would have to be postponed until they received medical clearance," she explains. "Sometimes, patients don’t take the surgery seriously, and it just slips their minds. But when we had these cancellations, they were usually logged in as patient cancelled,’ so we had no idea how to go about fixing the problem. We didn’t realize that just by being more detailed, we could have really cut down on our cancellations."

To tackle the problem, the teams carefully logged detailed reasons for missed appointments. Realizing that surgeons played a big role in the problem, the performance improvement team developed an ambulatory surgery information packet that helped patients gain a better understanding of the surgery process.

"Physicians see the patients and give them their expertise, but it’s not always enough. Many patients have other worries, such as who is going to take care of their children if they have surgery," Talan adds. "This [Medicare and Medicaid patient population] requires further education. This packet acts as a supplement to what physicians tell them because they can take it home and read it again. It spells everything out for them. They’ll know how to prepare for surgery, they’ll be reminded that they can’t eat before their surgery, and they’ll also be reminded of pre-surgery appointments."

Although patient education played a major role in missed appointments, it was not the only factor. Upon gathering internal data, Jamaica discovered that its operating room was understaffed.

"Before we implemented the program, we didn’t have any full-time surgeons on board. By 1996, we had two full-timers, which helped handle the patient load a lot more," Talan says.

Since the program began in 1995, cancellation rates fell by half, placing the facility well within the regional average. When 1997 data are compiled, the hospital expects those numbers to tumble to 6.5%. (See graph, above left.)

"There’s no telling just how far we can go with this program," she adds. "We’ve also started using it for all other indicators, including inpatient mortality and surgery site wound infections, even though we’re doing pretty well in those areas. I only wish we had started sooner."