Three Rooms First, Five Rooms Later: An Implementation Plan and a Stepped Evaluation That Could Prove the Start-Time Program Wrong
Student Name
American College of Education
HLTH5693: Capstone Experience for Healthcare Administration
Module 5 Assignment
Instructor Name
March 5, 2029
What Is Being Implemented
Module 4 recommended four changes for the composite 196-bed hospital's first cases: obtaining consent in the surgeon's office, allowing credentialed physician assistants and nurse practitioners to complete the day-of history and physical update, a day-before readiness check by a preoperative nurse and a revised measurement system with multiple delay codes, step timestamps and badge sign-in. Together they carry a one-time cost near $13,000 and a yearly cost near $65,000. Two require formal approval before they can start: the consent policy needs medical staff and legal approval, and the practitioner update requires a bylaws amendment approved by the medical executive committee and the board.
The implementation plan is built around those dependencies. The measurement changes come first, because the evaluation needs a clean baseline in the new format before anything else changes. If the measurement system changes on the same day as the process, no one will ever know which one moved the numbers.
Phases, Owners and Dates
Phase 1, April through June 2029, prepares. The perioperative informatics analyst configures multiple delay codes and step timestamps by April 30 and badge sign-in by May 15, so that May and June provide a baseline in the new format. The perioperative services director takes the consent policy to the medical staff and legal counsel in April. The chief medical officer takes the bylaws amendment to the medical executive committee in May and the board in June. The preoperative nurse manager posts and fills the half-time readiness position by June 15.
Phase 2, July through September, pilots all four changes in the three rooms used by orthopedics and general surgery, the services with the worst performance and the rooms that run long enough for savings to occur. The readiness nurse covers these rooms' first cases only. Surgeons in these services receive a meeting with the perioperative services director and the chief medical officer before the start, explaining the findings and the changes. Phase 3, October through December, extends the changes to the remaining five rooms if the pilot shows no safety problems, with adjustments from the pilot. The operating room committee reviews results monthly throughout.
Why a Staggered Rollout Makes a Fairer Test
A simple before-and-after comparison would be weak. On-time rates vary by season, and a project that draws attention to start times can improve them briefly on its own. Interrupted time series designs, which compare the level and trend of an outcome before and after a change using many time points, are among the stronger quasi-experimental approaches for evaluating interventions that cannot be randomized (Lopez Bernal et al., 2017). The staggered rollout strengthens the design further. For three months, three rooms operate under the new process while five continue as before, in the same building, season and staffing environment. If on-time rates improve in the pilot rooms but not in the others, the improvement is much more likely to reflect the program than a general trend.
The comparison is not perfect, because the rooms differ in service mix and some staff work in both groups. The evaluation will therefore compare each group with its own baseline as well as with each other, and will report both.
Preparing People for the Change
Each group affected by the changes gets preparation matched to what it must do differently. Surgeons' office staff receive a short procedure and a checklist for obtaining and sending consent forms, delivered by the scheduling office in a visit to each office in June, since the office staff, not the surgeons, will do most of the new work. Physician assistants and nurse practitioners who will complete updates are credentialed through the medical staff office and receive an orientation to the preoperative area and the documentation template. The readiness nurse is trained by the preoperative nurse manager and given a script for patient calls reviewed by the privacy officer. Circulating nurses are trained on the new delay codes in two short sessions at their staff meetings.
Resistance is most likely among surgeons who see office consent as work moved onto their practices and among preoperative nurses who may view the readiness nurse as a judgment on their work. The first is addressed by showing each surgeon their own start-time data privately and by pointing out that the change saves them time on surgery mornings. The second is addressed by presenting the readiness check as a response to a system problem found in the analysis, not to anyone's performance, and by involving preoperative nurses in writing the checklist.
Measures
Process measures show whether the changes are happening: the share of first-case consents received two days before surgery; the share of day-before readiness checks completed by 3 p.m.; the share of history and physical updates completed by 7:10 a.m. and by whom; and the share of late cases with at least one delay code. Outcome measures show whether starts improve: the weekly on-time rate; the median delay among late cases; and, following Tiwari et al. (2018), the interquartile range of start times, since a program that works by making the process consistent should narrow the spread as well as raise the on-time rate. Secondary outcomes include overtime in the three long-running rooms and elective case volume by surgeons with block time.
Balancing measures watch for harm: day-of-surgery cancellations, in case earlier consent leads to more patients changing their minds late; consent discrepancies, where the procedure performed differs from the signed form; preoperative nurse overtime; and practitioners' reported workload. Weekly on-time rates will be displayed on control charts, which distinguish ordinary variation from signals of real change (Provost & Murray, 2011). With about 42 first cases a week, a single week's rate will vary widely by chance, so the evaluation will look for sustained shifts rather than individual good weeks.
What Would Count as Success, Failure or No Answer
Deciding in advance what the results would mean protects the evaluation from being read to suit its authors. Success is a sustained shift in the pilot rooms' on-time rate to at least 65 percent, with a narrower spread of start times, while the comparison rooms show no similar change, and no increase in balancing measures. Failure is no sustained shift after three months in the pilot rooms, despite process measures showing the changes were carried out; that would mean the analysis misidentified the cause. An inconclusive result is one in which the process measures show the changes were not carried out as planned, in which case the program was not tested and implementation must be fixed first. A shift in both pilot and comparison rooms would suggest a general effect, perhaps attention, and would need the longer time series to interpret.
Sustainment is part of the test. Phieffer et al. (2017) reported that a program that reached 92 percent on-time starts settled at 78 percent a year later, so the evaluation will continue monthly for twelve months after full rollout and will judge the program by where it settles, not by its peak. An evaluation that cannot show a program failed cannot show that it worked either.
References
Lopez Bernal, J., Cummins, S., & Gasparrini, A. (2017). Interrupted time series regression for the evaluation of public health interventions: A tutorial. International Journal of Epidemiology, 46(1), 348-355. https://doi.org/10.1093/ije/dyw098
Phieffer, L., Hefner, J. L., Rahmanian, A., Swartz, J., Ellison, C. E., Harter, R., Lumbley, J., & Moffatt-Bruce, S. D. (2017). Improving operating room efficiency: First case on-time start project. Journal for Healthcare Quality, 39(5), e70-e78. https://doi.org/10.1097/JHQ.0000000000000018
Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.
Tiwari, V., Ehrenfeld, J. M., & Sandberg, W. S. (2018). Does a first-case on-time-start initiative achieve its goal by starting the entire process earlier or by tightening the distribution of start times? British Journal of Anaesthesia, 121(5), 1148-1155. https://doi.org/10.1016/j.bja.2018.05.043
How this HLTH 5693 Module 5 example is structured
HLTH 5693 Module 5 typically designs implementation and the evaluation that would test it; your classroom's instructions decide the evaluation methods and level of detail. This example sets out the phases and dependencies first, with owners and dates, then the evaluation design, explaining why a staggered rollout gives a fairer test than a simple before-and-after comparison. Measures are grouped as process, outcome and balancing, each with its data source. A final section states in advance what results would count as success, failure or an inconclusive test.
HLTH5693 Module 5 questions, answered
What does HLTH5693 Module 5 usually ask for?
HLTH5693 Module 5 typically asks students to design how their capstone recommendations would be implemented and how the results would be evaluated. Many sections expect a timeline with owners, measures and an evaluation design that could show whether the changes worked. Your classroom's instructions decide the methods.
Why use a staggered rollout for evaluation?
Starting a change in some units before others creates a comparison group in the same setting and season. If results improve only where the change was made, the improvement is more likely due to the change than to general trends or attention.
What are balancing measures?
Balancing measures track possible harm or side effects of a change in other parts of the system, such as cancellations or overtime. They show whether an improvement in one measure was achieved at an unacceptable cost elsewhere.
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