The Crimson Press Curriculum Center

First Page and the Assignment Questions:
I'm really exasperated, Jim! I can't get my cases booked during my scheduled OR sessions because the hospital tells me there isn't enough time. I can get the emergency cases on the schedule, but the patients who need non-emergency surgery have to wait longer than they'd like. Then I have to wait around for over an hour between cases. I don't get it. The schedule isn't that tight, but we can't get cases booked!

To Dr. James Stevens, the Planwide Chief of Obstetrics and Gynecology (OB/GYN) at New England Health Plan (NEHP), Dr. Julia Hartman's complaint was familiar: the surgeons did not have enough operating room (OR) time to schedule their patients' surgery. Non-emergency surgical cases were placed on waiting lists because there was no available time. These patients were waiting two months for surgery, sometimes longer, and even though these waits did not affect their health, Dr. Stevens believed the delays lowered patient perception of service quality.

To top off his morning, no sooner had Dr. Hartman left his office than Dr. Gordon called. Dr. Gordon, the Chairman of the Surgical Care Committee, told Dr. Stevens that he had been watching the OB/GYN OR utilization:

Jim, your OR utilization is way too low! You tell me your service needs OR time and then your doctors don't book it. There are other services that need the time more than OB/GYN apparently does. Use it or lose it! I'll see you at the Surgical Care Committee Meeting in three days. You can tell us your plan then, but at this point I can't think of any reason not to re-allocate 20% of OB/GYN's operating time to specialties that will use it.

Dr. Stevens wondered how there could be low utilization and long waits at the same time. It just didn't make sense. He looked around his office. His desk was buried under stacks of papers, his inbox was full of work he needed to sort through, he had a full afternoon schedule of patients booked at the Health Center, and he was due in the OR in 20 minutes.

Dr. Stevens had been Planwide Chief nearly one year and was still struggling to find enough hours in the day to practice medicine half-time and to deal with his new administrative responsibilities. He spent hours each week in meetings with the three Associate Medical Directors to whom he reported and with the Health Center Chiefs who reported to him (See Figures 1 and 2). He was actively trying to recruit new doctors and was trying to keep the ones already on his staff satisfied with their NEHP practices. Dr. Stevens had known that the OR was a problem - but there just hadn't been time to analyze the situation. Now he had to find the time. He leaned back in his chair and thought to himself, "Maybe Dr. Gordon's right. We aren't using the OR time and other doctors need it. Are the OB/GYN doctors just griping, or are their complaints legitimate?"

HEALTH MAINTENANCE ORGANIZATIONS

In March 1989 the Health Centers Division of NEHP was New England's largest staff model Health Maintenance Organization. HMOs became popular in the late 1970s and early 1980s with increasing public and private concern over rapidly rising health care costs. In 1989, one fourth of Massachusetts residents belonged to an HMO and NEHP's share of the Massachusetts HMO market was 27 percent.