Author Archives: Brian D Gregory MD, MBA

About Brian D Gregory MD, MBA

Board Certified Anesthesiologist for 30 years. TOC design and implement for 30 years. MBA from U of Georgia '90: Finance, Data Management, Risk Management. Practiced in multiple US states and Saudi Arabia at KFSH&RC and KFMC Taught residents in two locations. Worked with CRNAs for 20 years.

Managerial Accounting Primer


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Root Causes of US Healthcare Design Conflicts


Single payer means single customer. If there is just one customer (no others exist) who no longer needs your services, or has an alternative to your services, then that customer, the single payer, can set the price just above the … Continue reading

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Is it all about Control?


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MIT news: “flexibility in resources drastically improves wait times”


From MIT news (August 6, 2013)—    From theory to practice “In work beginning with his master’s thesis, Xu has shown that having even a little flexibility in resources drastically improves wait times”: I blogged about this in January 2010 … Continue reading

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Finance Leaders Bemoan Talent Shortage


http://www3.cfo.com/article/2013/4/training_finance-function-training-skills-talent-corporate-executive-board-kruti-bharucha?utm_source=taboola Read the comments in the article.

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LinkedIn conversation…transparency discussion SCO (Surgery Center of Oklahoma)


Follow Mary Pat Oklahoma City hospital posts surgery prices online; creates bidding war kfor.com OKLAHOMA CITY – An Oklahoma City surgery center is offering a new kind of price transparency, posting guaranteed all-inclusive surgery… 9 days ago Unlike Comment Unfollow Flag … Continue reading

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Why OR staffing and scheduling is different than ER staffing and scheduling…


The OR case load has a very high daily variability of patient arrivals similar to an ER. However, unlike an ER patient’s arrival that normally may monopolize a single (or shared) ER nurse and room until the next caretaker (physician, … Continue reading

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Can engineers and physicians mix…from LinkedIn conversation


Follow David Can engineers and physicians mix? When doing and hearing about healthcare performance improvement it seems much is dependent on doctors and engineers collaborating. Yet this is difficult. Sometimes impossible when implementing. Are they too different to succeed? 7 … Continue reading

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Value Added rationale….Lean Six Sigma group from Linkedin


Follow Mike How do determine which steps are non-value added and which add? I specialize in precision cleaning prior to final assembly, an operation traditionally described as “non-value added.” The operation is obviously critical to the final product quality, yet … Continue reading

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TA vs GAAP (from a LinkedIn conversation)


Similar benefits for TA also apply to Lean Accounting and Marginal Costing.–me From Tony Rizzo: “Constraints-Accounting, that to which you refer as TA, is useful when one’s questions are designed to enable one to MAKE more money. The corresponding calculations … Continue reading

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What is the cost of a minute of intra-unit patient transport time….from LinkedIn conversation


Follow Brendan What is the cost of a minute of intra-unit patient transport time? The cost of a minute of time in patient transport is a questions we get asked quite often by acute care leaders. Is anyone aware of … Continue reading

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TA (throughput accounting) and TDABC (time driven activity based costing)….the fabric, the ‘warp and woof’ of healthcare accounting?


also see: throughput accounting…a natural for hospitals? Linkedin thread also see: throughput accounting (TA) vs activity based costing (ABC) also see: FTE vs cost accounting… when PUNs equal CUEs also see: When you’re lost, use a map… also see: Graphic Simulation … Continue reading

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Synergy of TDABC and Throughput Accounting…


SHS2013 poster presentation #107  “SHS2013 Clarifying OR Turnover Time Concept Graph” also see:  TA(throughput accounting) and TDABC (time driven activity based costing)…the fabric, the ‘warp and woof’ of healthcare accounting Poster #107 graphically hints how TDABC and Throughput Accounting, when … Continue reading

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big-data, gut-feelings, intuition


The argument comparing the usefulness of big data vs intuition needs some clarification of definitions and thought experiments. A thought experiment: “One picture is worth a thousand words”. Let’s suppose that the word is a an entry into a field … Continue reading

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Getting Dr. Able out of the OR before 4pm…


narration for SHS1013 poster presentations supports  #161 “SHS2013 Clarifying OR On Time Starts” supports #107 “SHS2013 Clarifying OR Turnover Time Concept Graph” supports #113 “Resolving Resistance to OR scheduling changes; Implementing a Multi-faceted Model” also see The effects of late surgeons … Continue reading

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OR Policy Comparative Results and PreOP Congestion


See also: “SHS2013 Resolving Resistance to OR Scheduling” “SHS2013 Clarifying OR Turnover Time Concept Graph” “SHS2013 Clarifying OR On Time Starts” Many PreOp holding areas have a large variance in their usage.  To keep PreOp from being a constraint (bottleneck) for surgery (surgeons … Continue reading

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Graphic Simulation Interactions of Constraint Theory and Lean


SHS2013  #107  “Clarifying and Using OR Turnover Time for Purpose and Advantage“ supports #161 “Clarifying the Definition, Purpose, and Effects of OR On-time Starts“ supports #113 “Resolving Resistance to OR scheduling changes; Implementing a Multi-faceted Model“ also see: predicting scheduled starts for … Continue reading

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The effects of late surgeons on other surgeons, overtime, Pre-Op, PACU, and patient waiting…


SHS2013 poster presentations supported supports #161  “Clarifying the Definition, Purpose, and Effects of OR On-time Starts“ supports #113 “Resolving Resistance to OR scheduling changes; Implementing a Multi-faceted Model“ also see  Getting Dr. Able out of the OR before 4pm… | ORTimes … Continue reading

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Strategy: Graphic examples of Orthopedic cases using PAs, Flipping Rooms, and Early Starts


 The necessary clinical experience and scheduling backend to implement these strategies is assumed. For comparison, two surgeons doing similar cases are used: Dr. Schlicter is flipping between two rooms which for visualization purposes are grouped together into the blue horizontal band … Continue reading

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Artificial Intelligence (AI), Simulations, and Experts…from Linkedin conversation


Artificial Intelligence, Simulations, and Experts I’m trying to get my head around how these all go together. For the sake of conversation, I’m posting a few statements (which may or may not be true) to get the conversation going. Any … Continue reading

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Linkedin converstion: “How will medical tourism insert itself into mainstream of US healthcare reform?”


MariaUnfollow How will medical tourism insert itself into the mainstream of U.S. healthcare reform? Under healthcare reform, employers are beginning to express interest in concepts and reform measures which have variously been labeled ―value-based, ―results-based, ―performance-based, or ―outcomes-based purchasing and … Continue reading

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Linkedin Medical Tourism excerpt: Major Diagnostic Category flaws


Medical Tourism for Group Health: Using Major Diagnostic Categories (MDCs) to Predict Medical Tourism Utilization – A Flawed Strategy that Can Lead to Unrealistic Expectations The MDC is a very commonly used term, and widely misunderstood. All diagnoses or illnesses … Continue reading

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Lawyer discussing complicated fine print (tax laws?)…


A few months ago, law professor Evan McKenzie wrote a short blog post called “The Fine Print Society” (December 2011): Quote: As I go over all the bills and statements and announcements and changes to this or that plan or … Continue reading

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Is Healthcare’s Insular Culture a Liability or Benefit? Linkedin thread started by Peter Hadras…


Is Healthcare’s Insular Culture a Liability or Benefit? Working recently in the healthcare industry, I keep being struck by the deep-seated culture that unless the solution or practitioner is from healthcare, then it cannot be applied to a solve a … Continue reading

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Canadian healthcare analyzed by Robert Gordon…


Robert Gordon • Alan P obliges me to comment on drug availability in Canada and on recourse to the US private sector for healthcare services. I comment first on DRUGS. In Canada, healthcare (“The Establishment, Maintenance, and Management of Hospitals, Asylums, Charities”) … Continue reading

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constraint theory and pareto optimals linkedin…


Constraint theory and Pareto optimals… We’ve been using Constraint theory (TOC) as a way to derive Pareto optimal solutions in the OR for a couple of years now, and briefly mentioned the approach at a recent Academy of Business Research … Continue reading

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throughput accounting…a natural for hospitals? Linkedin thread.


see also: TA (throughput accounting) and TDABC (time driven activity based costing)…the fabric, the ‘warp and woof’ of healthcare accounting?   Throughput Accounting— a natural for Hospitals? In my work with increasing OR productivity, throughput accounting quickly shows the benefits of … Continue reading

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constraint theory and Pareto Optimals…


Brian Gregory, MD, MBA • Wayne, good question. Healthcare is a funny animal–you have constraints within constraints. One of the main tenets of ToC is to pick what you want to be the constraint. In the case of the OR (ER, radiology, … Continue reading

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bad research…or bad reporting?


This is an example of the perils (morbidity, mortality, and financial) of mathematical manipulation of data by researchers in basing broad conclusions without more fully understanding the processes and externalities involved: Unnecessary anesthesia adds $1B to health spending – FierceHealthcare … Continue reading

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throughput accounting (TA) vs activity based costing (abc)…


see also: TA (throughput accounting) and TDABC (time driven activity based costing)…the fabric, the ‘warp and woof’ of healthcare accounting? from a Linkedin topic: Just thought I’d expand on some thoughts about Acitivity Based Costing (ABC) vs Thoughput Accounting (TPA): … Continue reading

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accounting and scheduling come together…


It took a few days (alright… quite a few days), but now my accounting software (great company-versatile software) collects accounting data in the standard cost accounting  manner, yet reports it in a Throughput Accounting or Activity-based Accounting way so that … Continue reading

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increase strategy to increase throughput: …data in context…lean in context…flipped rooms…


Why is this important? It can significantly increase total throughput and throughput as referenced by a particular agent (surgeon, anesthesiologist, hospital). Increased throughput can be converted into large increases in revenue. It can decrease cost for all agents. It can … Continue reading

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flipping rooms…get started


If you’re in charge of the OR, whether nursing or an anesthesia or surgical group, and want to decrease turnover time, risks, and costs while increasing revenue — you could greatly benefit from flipping rooms. With internet connectivity in your … Continue reading

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the art of flipping rooms…


– There are two main parts to flipping rooms: intra-case and inter-case. They are complementary and work together iteratively. – An analogy of this iterative type of scheduling –adjusting individual cases(intra-case) and schedule (inter-case) to make a good fit– is … Continue reading

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book recommendation: Models.Behaving.Badly by Emanuel Derman (Why Confusing Illusion With Reality Can Lead To Disaster, On Wall Street And In Life)


It’s nice to see one’s thoughts echoed by others who are much better known and established— even to the point of the same words and phrases used to categorize and clarify a universal problem and possible approaches to understanding and … Continue reading

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Healthcare Administrator-Physician divide


The following is an excerpt from an ongoing discussion in the Linkedin group ‘Healthcare Executives Network’. It broaches several problems and approaches that are necessary to understand before finding workable solutions, and could be taken as a preface for a … Continue reading

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a little data goes a long ways…


Although the expression –‘it’s not what you have, but how you use it’– is not entirely true, knowing how to massage whatever data you have can be very productive.  The data needed for this display is easily available from the … Continue reading

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unfounded confidence…anesthesiologists excluded :)


Don’t Blink! The Hazards of Confidence – NYTimes.com    

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Foldit….human pattern recognition trumps algorithms…


One of my tenets is that creating tools that help people recognize patterns can create better results than creating an algorithm than cannot take into account all the parameters of a situation.  Just like the saying “One picture is worth … Continue reading

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FTE, utilization, and cost accounting … when PUNs equal CUEs


also see: Graph of CRNA usage for optimized Surgeon Schedule also see: TA(throughput accounting) and TDABC (time driven activity based costing)….the fabric, the ‘warp and woof’ of healthcare — Cost accounting (whether standard costing or TDABC) is based on the concept … Continue reading

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not your father’s OR scheduler…


Want to know who’s doing what, when: With what?  What’s starting when? Who’s got to be there? How many whos? Can you let a few people off early?  Can you start a few people late?  How many people need to … Continue reading

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labor analysis of CRNA from collectible time data…


6:00 Labor Analysis 482 230 280 0.5809 150 102 14:02 The above shows information about the work of a CRNA during the day. The CRNA clocked in at 6:00 am and out at 14:02 for total Time-on-the-Clock wage minutes of … Continue reading

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conundrum…


After trying to modify the simulation part of my OR scheduler, and encountering various conundrums, I decided to try to formally clarify the source of the conundrums which led me to other realizations: To wit: The important parts of decision … Continue reading

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a box lunch to go…


It looks as though healthcare funding will be cut shortly.  Medicare will be on the chopping block soon, reimbursements for hospitals will be down.  Those who don’t think outside the box–who never saw the lid of  the box closing–will be … Continue reading

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Do Doctors run Hospitals better?


internet: http://ftp.iza.org/dp5830.pdf local: Who Needs an MBA   So which is better, an MD, MBA, or MD / MBA?

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‘risk vs return’ or ‘when the shit hits the fan’ in the OR


Taken from a Linkedin post of mine with the HFMA group: Sandra, The ‘general’ rule is that ASA 1-3 is ok for free standing facilities. That rule is effectively bent for rational reasons.  The ASA classification has a lot of … Continue reading

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OR scheduling concept map (concept diagram)…


A few years ago I diagrammed several concepts involved in scheduling an OR onto this graph.  The intent was to take advantage (or nullify disadvantages) of characteristics of individual surgeons and anesthetists. The interplay of these concepts and individual factors … Continue reading

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the dark side of hospital patient flow…Part 2


I received this email last week. Have you ever seen the drawings with the title ‘Where’s Waldo?’ Let’s play “Where’s the constraint?’ Think in terms of the discussion from my prior post ‘the dark side of hospital flow…Part 1’. Start … Continue reading

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the dark side of hospital patient flow… Part 1


Flow is defined as the quantity of some item (units of an item) passing by, leaving, or arriving at some point in a designated unit of time.  So, flow is defined by four parameters: units(1) of an item(1) , a … Continue reading

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getting your hands dirty…


Sometimes, to get what you want, you have to jump in and get your hands dirty… It’s been a month since my last post, a series of posts dealing with ‘what ifs’ and some simple simulations dealing with scheduling OR … Continue reading

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putting it all together…intra-case and inter-case….TOT and more


There are a thousand variations of the following examples, but I hope these four graphs will get across some ideas.  For potential economic effects, see:  Wasting $2.7 million dollars a year. Each of the following graphs has 5 bars. Each … Continue reading

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things you’ll probably never see…


Turnover Time (TOT) does not have an ideal value of  zero.  When you finally learn how to make it zero (or negative) you’ll discover the idiosyncrasies of your surgeon.  If fact, you will have achieved the proper TOT for your … Continue reading

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absolute loss of time…


In medicine, almost nothing is absolute.  Absolutes are strictly enforced, unless the person who decided that it was  an absolute changes his mind.  In the narrow world of OR throughput, this is an important factor why surgeons (and anesthesiologists) should … Continue reading

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clinical resolution of systems engineering scheduling in the OR…


No new graphs today…  Let’s discuss the resolution of a systems engineer in improving turnover time (TOT). In the last few blogs I showed the difference in TOT due solely to who sees the patient in the pre-op holding area, … Continue reading

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coffee and donuts…. time for a break


Oh what fun…       This is just one of many factors affecting turnover time  (TOT). For the sake of  smaller graphs and clarity, I’m showing only the times till anesthesia induces the patient to show the comparison of … Continue reading

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difficulties with start times and TOT in the OR…


The following are excerpts from a discussion concerning Turn-Around-Time (TOT) in the OR.  They relate to my recent posts on scheduling, and show the complexity/difficulty in defining the problems and solving them: ____ she: There are benchmarks out in the … Continue reading

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constraints, risk, and ego in OR start delays… simple example


First off, there must be a 100 different reasons for late OR starts.  Everything from surgeons, anesthesiologist, nurses, equipment, meetings, policies, traffic, school age children and equipment…to a mix of any of the above.  The trick is in understanding the … Continue reading

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predicting scheduled starts for surgery…


also see: Graphic Simulation Interactions of Constraint Theory and Lean This is getting to be fun.  Now, for a bit of applied constraint theory… In this simulation we’re considering the surgeon as the most important person…the constraint.  We don’t want … Continue reading

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micro real options in the OR…


One advantage of performing virtually identical cases—such as specialty ORs (cataract surgery would be an example) is that the room setup is virtually identical and a great deal of time can be saved (or avoided) by being able to put … Continue reading

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TOC in the OR visualized…


Ah….  theory of constraints… This is a visual representation to help with handling constraints in the OR.  For those who use TOC, be aware that the person represented by the green bar (‘Anes MD presence’) could be simultaneously supervising four … Continue reading

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