A Novel Think Tank Program to Promote Innovation and Strategic Planning in Ophthalmic Surgery

Abstract

Background:

Continuous quality improvement is a pillar of all surgical groups. Innovation is a critical aspect to continuously improve, but traditional staff retreats have several disadvantages which limit their utility in identifying needs and developing innovative solutions. To address these challenges, we designed the novel Think Tank Program to spur innovation and strategic planning for an academic ophthalmology department including the Kellogg Eye Center 6 operating rooms.

Methods:

The Think Tank program is a structured seven-phase program for faculty in small teams to identify, innovate, and implement meaningful change. Participants brainstormed problems and possible solutions to those problems, formed teams, acquired data, and implemented meaningful change in clinical care, research, education, and administration.

Results:

The program generated 19 novel proposals and significant faculty engagement and discussion in improving the department. A case example of improving the operating room (OR) utilization resulted in improved OR utilization from 63.8% to 74.6% over a 3 month period before and after implementation. It also resulted in a reduction of cancelled or rescheduled surgeries within 2 weeks or surgery from 29.8% to 15.2%. This resulted in an estimated positive financial margin of over $141,000 to the institution in addition to improvement in patient, surgeon, and staff satisfaction with the quality of care.

Conclusions:

Engaged faculty, critical data analysis, and value proposition analysis with data-driven metrics and accountability can result in a significant increase in OR utilization and reduction in surgical cancellations. Think Tank serves as a model transformative program to assist practices and institutions to best fulfill their mission while actively engaging and retaining their members.

INTRODUCTION:

Continuous quality improvement is a pillar of all healthcare organizations to improve our care of patients^{1, 2}. The American College of Surgeons mission statement states, “The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.” The American Board of Ophthalmology (ABO)³ emphasizes that continuous innovation and improvement are core principles for all physicians. To achieve this improvement, many institutions have traditionally participated in staff retreats to engender creativity around problems, discuss issues at a deeper level, and consider future directions for the institution. These retreats serve an essential role in the strategic planning and improvement of organizations.

It is critical to engage all members of an organization to make a meaningful difference when it comes to innovation, competitiveness, and ultimately quality improvement. People directly involved in performing activities might have a different understanding of needs that departmental leaders who might not be involved in directly performing activities. Traditional staff retreats have been often structured in a rigid, hierarchical manner. With few members involved in the decision-making process and agenda, individual faculty members are less invested and may feel less ownership of the innovation process. Increasing evidence^{4, 5} shows that hospitals that increase employee involvement in decision-making processes have more engaged, productive, and empowered employees with a sense of personal control over their work, all of which are essential for the best quality outcomes.

To address these challenges, we describe the development and implementation of a program called Think Tank. The Think Tank solution is a collaborative program implemented by the Michigan Medicine, University of Michigan Fast Forward Medical Innovation (FFMI), and Kellogg Eye Center (KEC). It is an innovative approach to achieving the Kellogg Eye Center’s purpose through the triple goals of improving the quality of research, teaching, and clinical care. After describing this Think Tank process at KEC, a specific group proposal of improving operating room utilization is described in detail as a case example.

METHODS

Two program managers from FFMI in June 2016 guided an organizing group of 10 KEC faculty members in identifying the main broad categories within patient care, education, research, and administration. The Think Tank program is a seven-phase, 9-month structured opportunity for faculty that followed the SQUIRE 2.0 guidelines for quality improvement studies.

Program Launch (Phase 1)

A program is described to allow innovation through focusing on current trends, areas of interest, and individual problems experienced firsthand. To focus our efforts, we chose four categories of interest aligned with the mission of the KEC: provide excellent clinical care, educate world-class physicians, conduct cutting-edge research, and be the best eye care center in the world. After narrowing our focus to these four areas, the steering committee laid out the broad areas at a faculty meeting kick-off of the 103 KEC clinical and research faculty members with the goal of piquing interest from faculty members to their teams. Faculty self-selected into one of the four broad categories.

Ideation and Team Formation (Phase 2)

Group ideation involves the transition from a board steering committee to smaller groups. These sessions were interactive and motivational to allow for ideas which served as a starting point for team projects. Flexible brainstorming sessions encouraged the generation of over 100 ideas, problems, potential solutions, or opportunities. Under the guidance of a lead instructor with expertise in innovation, biomedical technology development, and entrepreneurship, the group then prioritized ideas and reduced to a list of 19 ideas. Participants formed small working teams around the ideas which they felt a particular affinity for. Unlike the classical hierarchical structure, the Think Tank program is a flatter structure that empowers everyone in the organization to be involved in the decision-making processes. Multiple small units of four to eight faculty formed a team and decided to champion one of these 19 ideas and pitch it in front of FFMI’s judges and faculty peers.

Value Proposition (Phase 3)

As part of this process, each team created and validated a clearly defined value proposition for their proposed solution, participants were instructed to present the problem to be addressed, the critical stakeholder(s), the proposed solution or change, and the value provided by the solution.

Validation (Phase 4)

Validation is focused on validating the value proposition. The importance of data-based decision-making was emphasized. Teams validated their value proposition by collecting critical data and conducting interviews of key stakeholders from August 2016 to January 2017.

Pitch Presentation Development (Phase 5)

Each team prepared a short 5-minute oral presentation for FFMI’s judges and faculty peers followed by a 3–5 minute question period. Each project team delivered a draft version of their business pitch in anticipation of the final pitch. This structured event provided immediate constructive feedback from instructors and faculty colleagues so presentations could be refined.

The Pitch (Phase 6)

The Pitch was a structured as a competition hosted in February 2017 to showcase the 19 innovative projects listed in Table 1. Each team presented their final proposed solution in a 5-minute pitch to all ophthalmology faculty and a panel of 9 experts. The expert panel provided 7 minutes of question/answer followed by a critique of each pitch. After each pitch, all faculty audience members used anonymous electronic polling to provide constructive feedback. Each pitch was ranked on a scale of 1 to 4 based on potential value and appeal of solution (1= home run ready to implement, 2=priority problem but solution needs more work, 3=lower priority but like the change, 4=back to the drawing board for lower potential value and less appealing solution). The faculty voted on the relative importance of addressing each issue and whether the suggested solutions were viable. Figure 1 shows the priority that the faculty voted on each pitch. The department’s executive leadership evaluated each presentation and the faculty vote to determine departmental funding priorities.

TABLE 1.

Overview of Pitches in Think Tank

Area	Proposal	Pitch	Faculty		ranking
			priority (Percentage)
			1 Best	2	3	4
Clinical care	Increasing OR Utilization	Increase access to pre-op evaluation, create list of patients willing to have earlier surgery, improve tracking for cancellations and review same day case cancellations	38	59	1	1
	VA Hand Offs	Change the Veteran Administration (VA) care consult template in electronic medical record to be more specific in what is being requested	77	11	10	1
	Retention of PSAs	Create a patient service associate (PSA) recognition week to help improve PSA engagement and retention.	25	49	11	14
	Future of Personalized Medicine	Increasing departmental awareness and education of genetics and the potential of increasing genetic counseling staff	25	33	29	14
	Data Driven Clinic Resources	Bring data-driven metrics to improve the needs of individual practices and the department’s clinical performance	19	67	8	6
	Appointment Efficiency	Implement changes in existing workflow to improve appointment efficiency.	21	58	15	7
Research	Grants Dashboard	A web-based, refreshed grants dashboard securely provided to faculty to help ease application burden	42	23	27	8
	Lab Collaboration	Host seminars in other departments to highlight KEC research aimed to stimulate collaborations	34	36	19	12
	Digital Fundraising	Use crowdfunding and peer-to-peer fundraising to raise funds for research	58	21	18	4
	Clinical Research Support	Hire a clinical research recruitment specialist to implement best practices	17	47	16	20
	Diagnostic Testing for Retina	Develop a CLIA-certified lab to expand and improve on current tests and develop novel assays	55	6	21	18
Education	Flipped Classroom	Develop web-based “flipped classroom”	46	29	16	9
	Educational Value Unit	Create a value unit to recognize/incentivize effort for educational activities	24	49	12	15
	Out-of-Country Experience	Establish a set of international clinical experiences in which residents can participate	2	14	48	36
	Improving Residents’ Surgical Experience	Redesign the resident rotation. Create resident runsubspecialty clinics and emphasize residents are primary or first assistants on these surgical cases	9	59	9	23
Administration	Coding Confidently	Hire ophthalmology specific coding specialist to improve coding efficiency and accuracy	78	18	4	0
	Fiscal Workings	Create a virtual handbook guide on departmental financial information for transparency	51	14	32	3
	Expansion Analysis	Create a decision tree to guide the department’s clinical network expansion strategy	40	48	10	1
	Preparing KEC for the Future	Form a Kellogg 2020 team to evaluate and suggest best initiatives to pursue	38	37	12	13

Figure 1:

The percentage of priority that faculty voted of the Pitches in Think Tank.

After pitch implementation (Phase 7)

After feedback from faculty and the expert panel, the Think Tank groups with the highest priority scores sought to implement their pitches. After implementation, teams evaluated critical metrics monthly to ensure that the changes were having the desired effect. This was a critical part of the Think Tank and used the same quality improvement framework as the implementation.

RESULTS

Since the discussion of all 19 proposals is beyond the scope of this manuscript, this manuscript focuses on the improvement of operating room (OR) utilization. Only 1 proposal was withdrawn, and the other 18 have all been implemented and progressed. The team to improve OR utilization was a multidisciplinary group including 5 clinical ophthalmic surgeons, 1 OR nurse manager, and 2 anesthesiologists. This manuscript will describe the problem being addressed, the critical stakeholders, the proposed solution, the data before intervention, the value proposition analysis, and the post-intervention data for this project. A University of Michigan institutional review board (IRB) exemption was granted for this study (HUM00177114, Dept. of Ophthalmology Think Tank Strategic Planning Data, PI: Paulus). No patient consent was required since this was performed as a quality improvement study.

Problem

As the OR is an important source of revenue and cost, many hospitals are continuously striving to increase OR utilization.^{6, 7} In addition, cancellations can be costly to patients and their families. Cancellations can also lead to irregular and inconsistent surgical times for surgeons, nurses, and anesthesiologists. Cancellations, therefore, have an important economic as well as emotional and quality of life impact on patients, their families, and the entire staff in the operation room. Reduction in cancellations/rescheduling could increase the profit margin.

At the KEC, there are 6 eye-dedicated operating rooms that previously ran at 63.8% utilization during the 3 months initially evaluated (August – October 2016) whereas for the whole year the utilization rate was 67.26%. OR utilization was defined as the all case time total in an 8-hour block divided by the allocated block time. Oftentimes, cases at the KEC were cancelled or rescheduled at the last minute, making it difficult to fill in open slots despite long wait times for surgery. Data was evaluated for sameday and last 2 week cancellations for 3 months (August – October 2016) (Fig 3–4). Two weeks was selected because it is often possible to fill cancellations if performed more than 2 weeks before the surgical date. It is often hard to fill if less than 2 weeks from the surgical date. During these 3 months, 2,016 patients were scheduled for surgery, 29.8% (600) had their operations cancelled/rescheduled within 2 weeks of the surgical date. This indicates that cancelled/rescheduled of scheduled operations was a significant problem in KEC, just as it is in many hospitals^8–10.

Figure 3:

Reason for patient cancelling/rescheduling surgery within 2 weeks of the intended surgical date in 2016 and 2018. From 2018 to 2016, the percentage of total preventable reasons for cancellation has decreased from 52.2% to 38.8% while the inadequate pre-operative evaluation rate significantly declined from 15.2% to 3.3%, from the chart view, the cases which is unable to determine reason for cancellation has decreased from 42.8% to 19.0%.

Figure 4:

Comparison of the anticipated surgical duration from 2016 to 2018. The surgeries that are scheduled to be less than 45 minutes has decreased from 49.5% to 23.0% while that less than 30 minutes has significantly decreased from 14.3% to 1.8%. The cataract surgery cancellation/reschedule rate slightly decreased from 48.3% to 46.9%.

Electronic medical record chart review and interviews of the surgical schedulers were performed to investigate the primary reasons for cancellation/rescheduling. The reason was stratified based on preventable or non-preventable causes. The reason for cancellation was unable to be determined in 42.8% of cases. Among those cases with an identified reason for cancellation (Figure 3–4), preventable reasons were 52.2% of cancelled cases. These reasons included patient preference to reschedule the date (25.9%), inadequate pre-operative evaluation (15.2%), and so on. For the un-preventable reasons, we don’t describe them in Figure 3 in detail since it is too many categories of it so it will make the figure hard to read. The un-preventable reasons includes: medical and anesthesiology reason, symptoms resolved, insurance issue and surgery moved to another location.

Approximately half of the cancellations/rescheduling surgeries (49.5%) were scheduled to be less than 45 minutes, and 48.3% of them were cataract surgeries (Figure 4). Fast surgeries, particularly topical cataract surgeries, pose less risk to patients from an anesthesia perspective in addition to being logistically easier to squeeze into shorter time frames.

The project team members interviewed stakeholders and included surgeons, anesthesia, and nurses on the team to discuss and propose solutions.

Solution

Based on the data acquired about reasons for cancellation, a multi-pronged solution with 7 components was proposed to increase OR.

1. Surgical schedulers moved up patient reminder calls from 1 to 3 weeks prior. Secondly, a script was introduced to emphasize to the patient the importance of keeping their appointment by highlighting how other patients were also waiting for their procedures.

2. An additional physician assistant (PA) was hired in the pre-operative clinic to ensure patients had adequate history and physicals to reduce inadequate preoperative evaluation.

3. A database of flexible patients ready and willing to have earlier surgery was created to improve the ability to move up patients and fill any gaps that opened.

4. The pre-operative order set was modified to have a special section on anticoagulation use and the operative requirement to reduce the risk of cancellation due to anticoagulation use.

5. The surgical packet and surgical scheduling script were updated to highlight the importance of not eating or drinking the morning of surgery.

6. Improved tracking was instituted. Staff and surgical schedulers were instructed to appropriately document reasons for cancellation.

7. Every sameday cancellation was re-evaluated with a discussion between the surgeon, nurses, and anesthesiologists to determine the reason for cancellation.

The operating room committee was further charged with discussing and implanting all aspects of the proposal along with gathering feedback from the team members.

Pre- and post-intervention results

After implementation, the decision was made to evaluate the data at the same months as initially evaluated due to seasonal fluctuations in surgeries, and thus August to October of 2018 was evaluated. The same metrics as the number and characteristics of cancellations and rescheduling within 2 weeks during this period was evaluated along with the OR utilization rate.

In 2018, KEC ORs achieved a utilization rate averaging 74.6% for the 3 months evaluated, whereas in 2016 there was 63.8% utilization. The entire calendar years were also evaluated to ensure that evaluation of a larger group of surgeries demonstrated the same trend. The entire year data for January 1, 2016 – December 31, 2016, was gathered before Think Tank and January 1, 2018 – December 31, 2018, was gathered for after Think Tank. The entire year analysis confirms the 3 month data and finds that our intervention resulted in a statistically significant increase in the KEC OR utilization from 67.26% in 2016 before Think Tank to 73.29% in 2018 after Think Tank (Figure 2). The total number of OR cases at KEC increased from 6,065 in 2016 to 7,333 in 2018. Additionally, all surgical cancellations were tracked and reviewed for these three months. We evaluated the data in 2016 for sameday and last 2 week cancellations. During these same three months in 2018, 1,791 patients were scheduled for surgery, and 15.2% (272) of them canceled/rescheduled their surgeries within 2 weeks compared with 29.8% in 2016 (Figure 2).

Figure 2:

Comparison of OR utilization and cancellation rates in 2016 and 2018. From 2016 to 2018 in the 3 month analysis, the OR utilization has increased from 63.8% to 74.6%, *P<0.05 compared to utilization of OR in 2016, and the cancellation rate has decreased from 29.8% to 15.2%. For the entire calendar year, the OR utilization increased from 67.26% in 2016 before Think Tank to 73.29% in 2018.

Reasons for cancellation/rescheduling can be classified into preventable and non-preventable causes. The preventable reasons included physician and patient preference, inadequate pre-operative evaluation, patient eating on surgical date, and patient on anticoagulation. The non-preventable reasons were mainly composed of medical reasons and anesthesia reasons. Medical reasons refer to cold, flu, broken ankle, and other acute illness. Anesthesia reasons refer to patient conditions that are not suitable for anesthesia like high blood sugar or hypertension. Other non-preventable reasons included social issue, insurance issue, family issue, patient deceased, unable to get ahold of patient, surgery moved to another location, and patient deceased. Duplication of record refers to the surgery schedule was duplicated so the staff would cancel one. In particular, the Think Tank group proposal aimed to reduce the preventable reasons for cancellation/rescheduling. Comparing 2016 to 2018 (Figure 3), preventable reasons for cancellation/rescheduling in total decreased from 52.2 to 38.8%. In particular, inadequate pre-operative evaluation declined sharply from 15.2% to 3.3% of the causes of cancellations/rescheduling. Of those surgeries canceled/rescheduled, 19.0% of them in 2018 are unable to determine the reason for cancellation with the improved tracking system. This was reduced from 42.8% in 2016.

In evaluating the anticipated surgical duration, surgeries of less than 45 minutes decreased in cancellation rate from 49.5% to 23.0% from 2016 to 2018. Cancellations of surgeries scheduled less than 30 minutes decreased significantly from 14.3% to 1.8% (Figure 4).

Monetary value analysis

To estimate the value of the proposed intervention, the operating room utilization was evaluated at 63.8% and 74.6% (Figure 3) for each period. Taking the average of 2,087 work hours in an average year, utilization rates for each year resulted in an estimated 1,331.5 hours worked in 2016 compared to 1,549 hours in 2018. This was an increase in 218 work hours from increased utilization rate. The operating room has an estimated $650 positive margin per hour of operating (including indirect costs), which results a net gain of $141,488.20 for 2018 to the department.

DISCUSSION

This article details the design, implementation, and case example of the Think Tank program at the KEC. This collaborative, dynamic quality control initiative represents an improvement from conventional faculty retreats. It demonstrated several unmet needs and developed proposed solutions. This quality improvement program is unique in that it encourages active participation from all faculty and allows for data-based decision-making. Before discussing a problem and proposed solution, faculty members are given the opportunity to evaluate the data and analyze the feasibility of proposed solutions. During the pitch, the panel of experts and fellow faculty audience members cast their vote to provide constructive feedback and to make decisions from the executive leadership about projects to move forward.

Innovation is a critical aspect to organizational growth but traditional retreats have several disadvantages which limit their utility. Such factors include, top-down agendas, limited data, and small planning groups. Thus, in many cases, faculty and members of the organization are less likely to be engaged in the discussion or invested in decision-making. In addition, for ideas brought up by members outside of the leadership, there is often limited data or information to support or refute ideas.^{11, 12} With limited information, organizations are unable to use data to guide their decision making process.

In the Think Tank model, those directly involved in the day-to-day activities ideate and form teams to spur innovation. After implementation of an intervention, data gathering is necessary to ensure that the proposed solution has had the intended consequence. The decision-making process in Think Tank is driven by objective data to understand the cause of the problems and propose novel solutions according to the underlying causes. It represents a radical departure from conventional hierarchical organizational structures to one that is egalitarian.

Millennials comprise about 40% of today’s workforce and will account for 75% of the workforce in 2025.¹³ As stated in an opinion in JAMA,¹⁴ “millennials do not necessarily embrace the siloed communication typical of traditional academic departments” and embrace flat infrastructure promoting engagement. For millennials “purpose is paramount”. This is particularly important to millennials to allow them to feel more engaged in the decision making process. This engagement becomes essential to recruit and retain millennials in organizations. In the case example of improving the OR utilization, the OR utilization rate increased from 63.8% to 74.6% after intervention with the cancellation rate decreased from 29.8% to 15.2% (Figure 2). The reasons for cancellation were also more discernable and preventable (Figure 3). These interventions resulted in direct monetary gain to the institution in addition to improvement in patient, surgeon, and staff satisfaction.

Think Tank is garnering increased attention not only in ophthalmology but also in specific disease management.^15–17 Think Tank can transform the work environment and inspire faculty members to be engaged, proactive, and interested. Also, when working in an empowered environment, faculty members will have further opportunities to grow and can increase their self-confidence.18, 19

Continuous quality improvement is an important goal for all healthcare providers. Academic centers have multiple components to their missions, including clinical care, research, education, and administration. Michigan Medicine launched a research strategic plan in 2012 to develop an innovation and entrepreneurship program: Fast Forward Medical Innovation.²⁰ FFMI accomplishes its mission through programs on innovation, commercialization, and entrepreneurship tailored to the busy medical academician. The collaboration with FFMI was critical in the success of the Think Tank program at Kellogg. FFMI has successfully implemented programs for innovation and entrepreneurship in additional departments at the University of Michigan, including the Department of Surgery and the Michigan Institute for Clinical, Health Research.^21–23 The innovative Think Tank program is a transformative and powerful program that can be used by other practices and institutions around the country to fulfill their mission and better deliver quality care through active engagement.

CONCLUSION

FFMI and KEC provided a program called Think Tank to empower all of the faculty members in KEC to identify major issues and propose solutions to solve these needs. Think Tank can transform a work environment and inspire faculty to be engaged, proactive, and involved. A case example of operating room utilization is explored in detail. Engaged faculty, critical data analysis, and value proposition analysis are essential for an innovation and entrepreneurship program. Think Tank has served as a model transformative program to better assist practices and institutions best fulfill their mission while actively engaging and retaining their members.

Abbreviations:

ABO

American Board of Ophthalmology

FFMI

Fast Forward Medical Innovation

KEC

Kellogg Eye Center

OR

operating room

PA

physician assistant

PSA

patient service associate

VA

Veteran Administration