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In a busy L&D unit, patient though-put is critical.  A downward trend in physician satisfaction caused by the inability to schedule patients for procedures, begin cases on time or have patients admitted timely led the management team to brainstorm solutions for improvement.  This team identified opportunities to streamline processes, decrease variation in practice, improve communication with physicians and patients and therefore improve patient flow and patient satisfaction.

Communication Issues – “me first”
The setting for performance improvement was rich with opportunity.  The physicians were consistently complaining about the inability to obtain desired timeframes for scheduled procedures.  In addition, rarely did a scheduled procedure such as a cesarean delivery occur on time.  There was no measurement of timeliness or no goal other than wheels “near” the room somewhere around the scheduled time.  This served to frustrate the physicians who wanted to get their work done and get on with their day and frustrated the patients who were anxious to meet their new arrival.  Also, the delays caused the families distress because they equated delays with the fear that something had gone wrong with their loved one.  All of this led to a great opportunity to drill down the  broken processes in the throughput designs and a chance to redesign the work flow.

Collaboration  Required – “Whose side are you on?”
The first step in  process improvement was determining the operational definitions to be used.  Many steps were put into place to ensure the staging process of scheduled labor and delivery patients could be streamlined. In order to be successful, collaboration with other departments such as the lab, blood bank, patient registration,  and anesthesia was critical.  Another initiative involved creating a telephone Pre Admission Testing (PAT) process to obtain patient history, determine the need for physician consults,  begin establishing relationships with the patients prior to arrival, and expedite the admission  process.  The PAT was expanded over time to include initial patient education  and an SBAR report sheet from nursing to anesthesia when clinical issues were identified.  Standardized pre-operative order sets were developed to decrease variation in practice and facilitate a smooth admission process.  The last phase involved the development of an OR team to assist in staging the patient and in driving the notification of the physician and expediting the movement of the patient to the OR prior to the scheduled case time.

Coordination – “Let’s get together”
Working with other members of the healthcare team, the strategies set in place led to rapid improvement from 0 % on time start for first case of the day to 30% on time start.  In addition, the team moved beyond measuring first case of the day only and focused on on-time starts for all scheduled c-section cases and is now seeing 75% on time or started within 30 minutes of the scheduled start time.  The labor and delivery team has been able to also implement other initiatives with success such as the World Health Organization OR checklist focusing on patient safety.