Two in-bins and a lot of sweat. That's all it took for us to improve our pre-admin process and reduce our hospital's elective surgery cancellation rate from 17 percent to less than 1 percent in a little more than two years. Hospitals often get paperwork from a surgeon and wait for patient information to trickle in. We don't wait. We take it upon ourselves to make sure surgeons and patients complete paperwork and turn it in before surgery. Here's how our system works.

Contact early and often
Once we receive notice from the surgeon's office that a patient is scheduled for surgery, we add the patient's name to our phone call checklist. We then work down the list and call every patient, making sure patients:

• have their primary care physicians' names and numbers, and
• are aware that they need to schedule a pre-op evaluation.

We go so far as to have them call us back after they make an appointment. That sets a time frame for a follow-up call to the patient, and also lets us know when we can contact the primary care physician for the information we need.

Our staff starts initial phone calls up to six weeks before surgery. They spend seven hours to eight hours a day on the phone and make about 800 calls per month. It's a lot of work, but establishing early contact with patients develops a key relationship. Even the brief conversation we have with patients puts them at ease; we're often the first contact they have with the facility that will perform their procedure.

Whoever calls the patient leaves her name and contact information, telling the patient to call with questions or concerns. We have many people coming from out of state, so we also provide local hotel and hospital shuttle information. Patients appreciate the little bit of effort we put into being accommodating and are more apt to call us with problems that arise before surgery, making us aware of issues that could cancel or jeopardize the case.

Prime primary care
When a patient calls to let us know that he's scheduled a visit to the primary care physician, we fax to the doctor's office a sheet that denotes the name of the patient who'll have surgery and the pre-op test results we'll need. We fax the sheets at least two weeks before surgery and again seven days pre-op if we don't receive a response.

If the primary care physician's office is still unresponsive, we make follow-up phone calls every day up to three days before the scheduled procedure. At the three-day cutoff, we solicit help from the surgeon's secretary or the patient himself. You'd be surprised how quickly the results of the pre-op evaluation come in when a patient facing a cancelled case calls the office of the primary care physician.

To expedite the information-gathering process, we also schedule annual breakfasts (we'd actually like to meet more frequently) with the primary care physicians' administrative staffs we deal with regularly. Over bagels and juice, we discuss the process for clearing a patient for surgery - both their responsibilities and ours. There's a lot of idea sharing and relationship building at the meetings, and that's invaluable when trying to collect patient information at a later date.

The famous bins
Once we've collected the pre-op evaluation results, we put all the information in the patient's chart, and place the chart in a bin labeled To Be Reviewed. The bin sits - along with a second bin labeled Needs Further Workup - against one of the walls in our office. Both bins have become the symbols of our department, and are known throughout the hospital.

I pull each chart out of the To Be Reviewed bin for an initial review and call the primary care physician, a specialist or the patient if I see something that's missing. If the chart is incomplete, I'll make a note of the missing info on a post-it, and stick the note on the front cover of the chart before placing it in the Needs Further Workup bin.

For instance, if I notice a patient needs a stress test before surgery, and the results are missing, I'll first contact the patient. Most times, patients are aware of the test, and inform me as to when it will occur. I'll write that on a sticky note (patient having stress test on July 5). Every couple days I'll pull the folders from the Further Workup bin, review the post-its and follow-up to obtain the information we're missing (on July 6, I find out if the patient had her stress test). On any given day, six or seven folders sit in the Needs Further Workup bin, a few pieces of their puzzles missing.

Bind the information
The checking and re-checking of post-its continues until we've gathered all the pre-op information. At that point, we move the patient's chart from the Further Workup bin and put it in a three-ring binder that is divided into sections for specific paperwork: h/p, admission, lab reports, physician orders, medications, and anesthesia and surgery notes (surgical history, including notes from previous procedures).

We give the binders to the anesthesia department for review before surgery; the anesthesiologist assigned to the case reviews the chart and adds his paperwork to the binder. After approval from anesthesia, we send the binder to admissions; the binder will follow the patient through the surgical process.

Each binder has a plastic sleeve on its cover, which we use to hold a color-coded sheet of paper: purple denotes the patient is in for same-day surgery; blue means the patient is scheduled for a short stay (23 hours) and green designates the patient for same-day admission (usually used for joint replacements, bariatric cases or urology procedures). With a quick glance at the binders - which are always placed at the foot of the patient's stretcher - the OR staff knows exactly what type patient they're dealing with and where they need to go during the surgical process.

From pre-op to post-op, each segment of the surgical team has its own section for making notes and adding paperwork. After surgery, the binder comes back to our department, the paperwork is removed and the information is added to the patient's permanent medical record. The empty binders are then ready for a new patient.

We purchased 40 three-ring binders (one-inch size). Each surgical department has a three-hole punch to make adding paperwork a simple process. In a hospital with various types of cases and patients cycling through its ORs, we've found the color-coded binders are a great way to organize and track patient information.

Worth the effort
Our early intervention with patients helps them to understand what they need to have completed before they come to the hospital for surgery. The constant phone calling, follow-ups with primary care physicians and information tracking is hard work, but lowering our case cancellations is worth the extra sweat we put into our pre-admin process.