In this session, we will complete our discussion of how to create leveled workflow. Operating rooms must manage both elective and urgent or emergent patients. The mixing of these two types of patients into the typical OR room schedule results in uneven flow and poor utilization of both operating rooms and personnel. Mayo Clinic of Florida published a study in 2013 describing how they improve OR utilization. The first thing they did is to slice and dice, separating the urgent cases from the elective cases and dedicating specific operating rooms for urgent patients and leaving the remainder of their ORs for elective surgery. They then required that elective patients be scheduled to achieve an occupancy rate of greater than 80% each day. To further smooth the work demand for urgent patients, they classified these cases into four categories: A) requiring surgery within 45 minutes; B) within two hours; C) within four hours; and, D) within eight hours. They then utilized mathematical modeling to determine the number of OR rooms that would be needed to be dedicated to urgent care to assure timely surgery. These changes resulted in a 27% reduction in work overtime, a 50 to 70% drop in unscheduled changes in the operating rooms, and increased OR occupancy by 5%. Net operating income increased by 38%, and most exciting to me, staff turnover decreased by 41%. These results were published in the Journal of the American College of Surgery in 2013, the references shown at the bottom of this slide. For patients being cared for on a hospital ward, the work of the bedside nurse can also be smooth by dividing patients into three groups: complex, A) patients with multiple problems and high nursing needs; B) moderately complex patients with intermediate nursing needs; and C) low complexity patients with low nursing needs. As I mentioned when discussing value streams, the ward on 64 and North has 34 beds and seven nurses, and on average, each nurse is assigned five patients. In addition, there is an eighth nurse, the charge nurse, that can help when demand becomes excessive. A production cycle chart can be used to guide how often each patient is visited by the bedside nurse. Each nurse is assigned one A patient, two B and two C patients. The frequency of visiting each category of patient is adjusted, and during a two-hour production cycle, the nurse is expected to visit patient A three times, patients B-1 and B-2, C-1 and C-2 once. Note there is an open slot to provide time for unexpected new workflow, such as patient discharge, an emergency blood draw, or a patient's unexpected deterioration. There are also three helpful strategies for smoothing unexpected flow. First, as we just discussed, an open time slot can be reserved to provide time for unexpected events. The frequency of open slots will depend on the pattern of demand for each operator. For example, we have estimated that unexpected demand can be compensated with a 15-minute open slot every two hours for our bedside nurses, while the patient care assistant or PCA should require a 15-minute open slot every four hours. A second way to smooth unexpected work is called baton passing. If the bedside nurse experiences an unexpected surge in demand, he or she can contact the charge nurse and hand off one or more tests. Or when a complex A patient requires excessive work, the nurse can call the PCA to manage two C patients for one two-hour production cycle. Finally, in some cases, bypass may prove to be the best approach. For example, if the bedside nurse's A patient requires additional work, the nurse could choose to skip a bedside check of the low-demand C patients for one production cycle. In summary, leveling creates even workflow, reducing stress, multi-tasking, and errors. This approach produces the right number of workers at the right time to respond to customer demand. For emergency patients, the number of workers needs to match the daily demand patterns. For elective patients, categorization by complexity and the creation of leveled production cycles can even the distribution of work. For unexpected demand, additional methods for leveling can be used such as an open slot, baton passing, and bypassing. Medical care badly needs to be leveled. The well being of providers and the lives of our patients are counting on it. Thank you.