Surgical Best Practices: Mayo Clinic

April 26, 2005

Phone interview between Douglas Wood and Dr. Mark Allen, Chief of Thoracic Surgery, Mayo Clinic

I had a long and very fruitful conversation with Dr. Mark Allen regarding the practices of surgery at Mayo Clinic in Rochester, Minnesota, focusing specifically on areas of leadership and culture. There were some dramatic differences as well as some similarities between our practices at the University of Washington Medical Center. The differences in leadership are potentially the most important and provide a window to the fundamental differences of practice between the University of Washington and Mayo Clinic.

Leadership

Operations and Oversight

  1. The Surgical Committee which oversees and is responsible for OR operations is made up of 20 individuals, 15 of whom are surgeons with 1 anesthesiologist and 4 other representatives who represent administration, nursing, etc.

Daily Functional Organization

2. The large physical operating facilities (55 operating rooms) are broken up into individual units, for example thoracic surgery and vascular surgery make up one unit that shares 4 or 5 operating rooms on a given day. The day-to-day leadership of this unit is solely delegated to the surgeon who leads that division. Frequently, if not most of the time, a head nurse who works with this surgeon functionally performs the details of scheduling and schedule adjustments within this group on a given day. There is the expectation that the departments of anesthesia and nursing will provide complete staffing to allow a running of the allocated operating rooms and are not directly involved in scheduling or triage decisions. (Note: I asked specifically whether this had any apparent negative impact on the nurses or surgeons but was told that there is a high morale in both groups as well high retention that symbolizes a satisfaction with this structural organization.)

3. Case Scheduling. Surgeons at Mayo Clinic can schedule cases on every second day. There is no block time. There is no deadline for scheduling or adding on a surgical case. There is no differentiation between regularly scheduled cases and “add on cases” – all are treated identically with a dominant culture of completing all of the cases by mid-afternoon. There is no limitation on how many cases a surgeons may schedule. A surgeon is expected to schedule as many cases as they themselves feel they can get done in a given day without oversight and without limitation. The nurse manager for that OR team, as delegated by the surgical division chief, then facilitates getting whatever cases are scheduled completed as rooms are available. For example, in thoracic surgery, on a typical day a thoracic surgeon could be anticipated to do 5 – 6 major thoracic procedures. Although these would sometimes start in one room this would often extend to two or even three rooms as the day progressed and as other portions of the schedule in that surgical team cleared. This is also with careful attention to Medicare compliance. In this thoracic surgery example, Dr. Allen reports that he is typically finished in the operating room between 3:00 and 5:00 pm each day and is virtually unheard of for him to be operating beyond 5:00 pm. In looking at the OR overall, he reports that 50% of their operating rooms are finished by 2:00 pm with approximately 20% still operating at 5:00 pm but that by 7:00 or 8:00 pm, that no operating rooms are still doing operations except for transplants or emergencies.

Teamwork

4. The Mayo Clinic has constructed strong surgical teams that work nearly exclusively within their group. These teams are able to be intact because of OR capacity during the day that allows virtually all of the surgical work to be done by the end of a business day. At a time when there is a meeting or other reason why there is expected low scheduling of surgery by a certain group, these rooms will be closed and the teams are provided with time off. Approximately half of the Mayo OR staff is unionized and staff may decide whether to take the days off or whether to continue to work on other teams at times when their own team is inactive.

5. When emergencies or transplants are necessary these never “bump” another case. The OR accommodates both the scheduled cases as well as the required emergency operations.

Incentives

Institutional

6. There are important differences between institutional incentives at Mayo Clinic and UWMC. At Mayo Clinic the institution is not only responsible for the OR operations and budget, but also pays salaries to the surgeons. In this system, the institution is invested in efficient use of surgeon time and maximizing opportunities for increased surgeon productivity. At UWMC, the hospital administration is responsible for the OR budget and operations, but has little or no investment in the professional staff which may lead to a disproportionate attention to operational efficiency with professional efficiency and morale being a lesser priority. Although operational efficiency may have the appearance of being the most fiscally responsible and conservative, one could argue that this may produce substantially less revenue in the long term because of barriers to surgeons scheduling and completing operations rather than providing easy access, open scheduling, and adequate capacity within the operating room that would encourage surgeons to schedule cases at UWMC. Greater capacity and access would likely stimulate and incent additional scheduling of cases by UWMC surgeons, as well as more efficient operations and patient safety, with the goal of accomplishing ALL of scheduled and add-on cases by 5:00 PM. This would result in teams staying together, more consistent processes, high patient and family satisfaction, and I would allege, an enormous boast in surgeon satisfaction and morale would follow. Given the Mayo experience, this effort to support efficient surgeon throughput does not seem to negatively impact other staff if appropriate personnel are provided, and appears to produce a high morale amongst nurses and anesthesiologists as well since teams stay together and there is a cooperative spirit of “getting the job done”.

Physician Staff

7. The professional staff are paid a salary at Mayo Clinic and do not receive an incentive based upon a number of cases performed. The surgeons and anesthesiologists are therefore incented identically. (It should be noted that surgeons who perform lots of operations do receive unofficial and ultimately official recognition and attain status and leadership positions within Mayo Clinic).

Nurses, HAs, Surgical and Anesthesia Technicians

8. There is no apparent incentive for increased work or performance and no standardized or institutionalized policy for recognition. However, certainly recognition does occur on many official and unofficial planes as in other work environments. It is felt that there is a “strong Midwestern work ethic” that drives an attitude amongst all employees “if there is work to do – let’s get it done.” There appears to be a high morale that also may relate to the consistent and close teams that are established.

Communication

9. There appears to be a high degree of respect in communication between the surgeons and anesthesiologists as well as the head nurses coordinating the schedule. However, Mayo Clinic performs a survey every 3 – 4 years and in the most recent completed survey there was “a low incidence of communication with mutual respect” on surveys from the OR nurses. This was somewhat of a surprise to the surgical leadership and is being addressed with an ad hoc committee to try to identify and improve this area of concern. In contrast, within the thoracic surgery service, the nurses responding on the thoracic surgery floor reported at a 90% level having a high degree of mutual respect in interactions and communications.