Every year, orthopedic and spine surgeons and their practices lose millions of dollars due to inefficient surgery case scheduling.
I've witnessed the impacts of poor scheduling firsthand across many practices and it is frustrating, to say the least. It's easy for surgeons to become complacent with mismanaged caseloads and cancellations when it doesn't seem like there are practical means to improve upon what have essentially become accepted deficiencies.
The good news is that solutions that address the pitfalls of inefficient case scheduling now exist, but to fully appreciate how they can help reverse these preventable developments, you must understand the reasons why these inefficiencies occur in the first place.
Here are seven of the most common causes.
1. Paper-based documentation
Though orthopedic and spine surgery is high-tech, many practices still rely upon low-tech processes for surgery scheduling, including some that are "no tech" (i.e., paper-based). Even in practices with electronic surgical orders, surgeons often still rely on paper-based surgical postings to communicate and delegate the tedious task of surgical order entry to their schedulers. Practices still using paper increase the likelihood that surgeons communicating complex surgical plans, timelines, and resource needs to their schedulers will lead to omissions, misinterpretation of instructions, and delays.
2. Case customization and complexity
Even when scheduling is backed by technology, systems often come up short in their ability to effectively support the level of customization and complexity required for optimal communication of planned surgical cases. Without this functionality, a surgeon must individually take time to construct customized cases (i.e., transfer their knowledge into a digital format) and share the essential details concerning the case, such as preferences, timelines, and resources. Any manual data entry increases the potential for errors, and more work by surgeons on completing documentation means less time spent with patients. Consequently, surgeons by necessity have grown accustomed to constructing surgical plans lacking detail, leaving much of the specifics to the discretion of operating room (OR) staff and their experience with the surgeon. This ultimately translates into inefficient ORs and poor resource management.
3. Scheduler burnout
Much of the surgical scheduling process rests on schedulers' shoulders. But what we are seeing is that the laborious, repetitive, and manual nature of the position, coupled with increasing administrative burden and sheer volume of work associated with a busy practice, is contributing to decreased staff satisfaction, productivity, and burnout. A fully engaged surgery scheduler may exchange 40-plus messages cumulatively with case assistants, OR managers, vendors, anesthesia, authorization teams, physical therapists, and others just to coordinate a single case. The manual, redundant nature of a scheduler's responsibilities contributes to errors and further delays in moving a case along the pipeline.
4. Overdependence on individual schedulers
Practices that rely heavily on manual documentation and paper-based communication for case scheduling also rely heavily on the practice- and surgeon-specific knowledge of individual schedulers. Their experience working with the practice's surgeon(s) is essential to knowing the steps required to effectively move processes along and identify when errors or missing information must be addressed.
The problem with depending so heavily upon single schedulers is the potential for substantial disruption in case scheduling continuity, documentation accuracy, and completeness if the scheduler is unavailable for a period of time, as has been the case for some practices during the COVID-19 pandemic. Schedulers brought on board to fill in for absent schedulers must attempt to quickly learn the manual and paper-based processes as well as surgeon workflow, preferences, and other requirements for successful scheduling. If a new scheduler has questions, they must usually ask the surgeon, which can lead to clinic interruptions and delays in moving scheduling forward. In this scenario, surgeons will need to take on an even greater role and workload in scheduling their cases until the absent scheduler returns or the new scheduler becomes comfortable with processes and preferences, which can take many weeks.
5. Missed problems
A significant shortcoming of paper-based processes and low-tech systems is that practice administrators will typically lack effective and efficient means to track pending, scheduled, completed, held, and canceled surgical cases; measure process performance; and diagnose problems in the case scheduling pipeline. What metric do you use to measure your surgery scheduler’s performance if your process is not tracked? While issues may eventually be discovered, as long as they remain undetected and unaddressed, damage is being done to the scheduling process and a practice's bottom line.
After digitizing its surgical scheduling process, one practice found that financial estimates produced later in the scheduling process was fueling attrition and last-minute cancellation of surgical cases. Using this insight, the onboarding process for surgery was revamped, providing financial estimates sooner. Almost overnight, the practice realized a 10% boost in surgical volume.
With paper-based processes, gleaning such intelligence is impossible. And during pandemics, with frequent surgery schedule revisions, mechanisms for tracking and following cases are more essential than ever before for surgical continuity.
6. Avoidable cancellations
Most practices only have the mechanisms to track day of surgery cancellations. However, in our experience, this grossly underestimates — sometimes as much as 10x — the total number of cases that do not present to ORs as originally scheduled. While we must accept that case cancellations will occur on occasion, we should not accept that they are always unavoidable. When surgeons and their teams understand patient- and case-specific risk factors, we put ourselves in a better position to recognize those patients who may benefit from interventions and extra attention concerning the completion of pre-surgical responsibilities (e.g., preoperative clearances, labs, medication regimen adjustments). Proactive efforts can decrease cancellations, reduce the risk for complications, and avoid patient satisfaction pitfalls.
7. Poor nurturing of undecided surgical candidates
The idea of surgery is stressful for patients. That's the case even before they meet with their surgeon to learn about the procedure, including discussion of the surgical experience, outcomes, recovery, and the pros and cons of alternatives. Unfortunately, busy and overwhelmed surgeons may only have a few minutes to engage directly with patients and have these critical conversations.
If patients leave the practice with any uncertainty about why surgery is right choice or whether a particular surgeon and practice is their best option, they may choose to postpone a procedure or seek an alternative provider. Even if the patient proceeds with scheduling the procedure, poor follow-up communications that fail to address questions, provide reminders, share words of encouragement, and keep patients apprised of their surgical timetable may lead to postponements and cancellations. Investing in curated content delivered for patients to consume at their convenience about their specific procedure can go a long way towards instilling confidence in the surgeon’s practice and decompressing the surgeon’s workload.
Achieving the "best-case scenario"
Inefficient surgery case scheduling has become so ingrained in many of our practices that it can be difficult to envision anything different. But I encourage you to push back on this notion and understand that you can take steps and implement solutions for your practice that will deliver tangible clinical, financial, and operational improvements. Now, more than ever, as we migrate to bundled payments, it is increasingly important to understand the total episode of care, capturing every step of the patient’s surgical journey.
Imagine surgeons with more mind space for patients, free from tedious paperwork and supported by solutions that expertly transfer their case knowledge. Imagine patients ushered on their surgical journey with just-in-time personalized text cues that inspire confidence in their surgical decision and adequately prepares them for their surgery. Imagine schedulers relieved of performing repetitive, manual, non-clinical tasks, free to focus on patient care. Finally, imagine practice administrators in control of the surgical case pipeline with access to the data and metrics needed to identify problems before they cause significant delays or cancellations. When surgeons make improving their case scheduling a priority, these possibilities can become realities.
Ashvin Dewan, MD, is a fellowship-trained, board-certified orthopedic surgeon serving patients in the Greater Houston area. His special interests include sports-related injuries of the knee, shoulder, elbow, ankle, and hip. Dr. Dewan is the co-founder of CaseCTRL, a modern surgical case management platform that allows any electronic medical record system to harness artificial intelligence and automation to improve and accelerate surgical care delivery.